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Coordinated Health Care Event 5/13/92 [OA 7573] [2]
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Coordinated Health Care Event 5/13/92 [OA 7573] [2]
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Records of the White House Office of Speechwriting (George H. W. Bush Administration)
Speech Backup Chronological Files
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Record Group/Collection:
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Speechwriting, White House Office of
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Chron File, 1989-1993
OA/ID Number:
13813
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13813-010
Folder Title:
Coordinated Health Care Event 5/13/92 [OA 7573] [2]
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PU1
05-09-92 09:50 AM FROM OLP
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05-09-92 09:50 AM FROM OLP
P02
STATEMENT BY
REVIN MOLEY
DEPUTY SECRETARY
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ON
S. 2077 - MEDICAID MANAGED CARE IMPROVEMENT ACT OF 1991
BEFORE THE SENATE COMMITTEE ON FINANCE
SUBCOMMITTEE ON FAMILIES AND THE UNINSURED
APRIL 10, 1992
05-09-92 09:50 AM FROM OLP
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INTRODUCTION
I am pleased to be here today to voice our strong support
for S. 2077, a bill aimed at tearing down the barriers which
preclude States from taking full advantage of the benefits
coordinated care can bring to the Medicaid program.
Let me take this opportunity to commend Senators Moynihan
and Durenberger, the authors of the bill, and to recognize
Senators Packwood and Roth, who are also cosponsors. we are
grateful for the opportunity to foster our continuing dialogue on
this and other key health policy issues.
Coordinated care systems have demonstrated their value to
communities all over the country through expanded access for
their citizens. To the many who take advantage of their
services, they offer continuity of care instead of the hodge-
podge of fragmented care. They can also offer improved quality
through preventive services, and in particular foster early
attention to problems that, if left untreated, could have serious
health effects. Coordinated care eystems can also offer an extra
advantage of less paperwork burden and administrative hassle.
This Administration believes that coordinated care offers a
proven, high-value choice for quality health care in the United
States. Coordinated care options are an essential building
1
05-09-92 09:50 AM FROM OLP
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block in the President's comprehensive plan for health care
reform. They are an integral component of a market-based,
competitive system and are key to cost control nationwide.
The Administration supports coordinated care as an essential
ingredient in any progressive movement toward health care reform
in general.
At the outset, let me express the Administration's general
support for S. 2077 and underscore our Willingness to work with
the Committee toward its enactment this year. We have some
concerns with the bill as drafted which we are currently working
to resolve in staff-level discussions. We are confident that
these concerns can and will be resolved to the full satisfaction
of both the Department and this Committee, and we will continue
to make passage of a Medicaid coordinated care bill a priority.
COMMENTS ON THE BILL
That being said, let me make a few brief remarks on the bill.
Advantages of Coordinated Care for Medicaid
Coordinated care holds special promise for State Medicaid
programs and their recipients. unable Bluntly stated, fee-for-service
medicine is increasingly failing to meet the needs of the
Medicaid population. Today's Medicaid client faces greater
2
05-09-92 09:50 AM FROM OLP
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difficulty accessing care through providers in the fee-for-
service system.
Coordinated care systems provide clients with a point of
entry into the health care system where their total health care
can be managed. Providers in a coordinated care system will know
the patient and the patient's medical history. This increases
the opportunity for appropriate preventive care to be started
before health problems get out of control.
Many Medicaid clients report using the emergency room
because they do not have a regular source of care. Having access
to a primary care provider through a coordinated care
organization is, without a doubt, a much better alternative for a
client than waiting in an over-burdened emergency room for care
from an unfamiliar provider. [A recent study by the HHS Office of
Inspector General indicates over one-half to two-thirds of
Medicaid emergency room visits are non-emergency. Moreover, our
IG found that treatment in an emergency room increases the cost
of the care from 3 to 5 times over the care received in a more
appropriate setting for the same condition.
State Flexibility and Freedom of Choice Waivers
The Department supports providing States greater
flexibility to manage health care for their Medicaid clients and
3
05-09-92 09:50 AM FROM OLP
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to take control of Medicaid costs. On average, States now spend
over 20 percent of their budgets on health care.
Health care
expenditures for Medicaid continue to grow. As States devote
more and more of their budgets to health care, they feel the need
for greater flexibility in controlling health care costs and an
obvious way to do this is to take advantage of high quality,
cost-effective coordinated care options.
The bill permits States to offer Medicaid clients a choice
among coordinated care options and eliminates Federal approval of
the "freedom of choice" waivers. Choices for Medicaid clients
would be between, at a minimum, two coordinated care plans, or a
coordinated care plan and a primary care case management
program. The one exception to this would be in an area where at
least two-thirds of Medicaid providers belong to the coordinated
care organization. In this case, the client would have a choice
among primary care providers participating with that particular
coordinated care entity.
Current law requires that, without the "freedom of choice"
waiver, Medicaid clients are to be given a choice between managed
care and the "unmanaged care" in the fee-for-service system.
This, as I already mentioned, often turns into costly trips to
the local emergency room for non-emergency care. States, where
the "freedom of choice" waiver has been granted, have been able
4
05-09-92 09:50 AM FROM OLP
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to increase access to care and many have also been able to reduce
inappropriate use of the emergency room.
Waivers to existing law are an appropriate process for the
Federal government to provide control and oversight for new
concepts where there is some uncertainty about what the economic
and behavioral implications might be for the programs and
beneficiaries for which we are accountable. Therefore, as HMOs
and other forms of coordinated care began to become part of the
delivery process for Medicaid clients, it was appropriate that
certain conditions be placed regarding the exclusive use of these
organizations.
Coordinated care is, however, no longer new. HMOS and other
forms of coordinated care have proven themselves on both the
quality front and the cost-effectiveness front, both in the
private sector and the public sector.
States that have extensively used coordinated care and
primary care case management report substantial successes.
For
example, Kentucky's primary care case management program reduced
infant mortality rates and, in the process, saved $25 million.
Arizona's exclusive use of coordinated care for Medicaid shaved
nearly six percent off of projected fee-for-service costs. HMOS
serving the Medicaid population in Wisconsin are able to pay
their primary care doctors more than Medicaid fee-for-service
5
05-09-92 09:50 AM FROM OLP
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rates due to savings from reductions in unnecessary emergency
services and hospitalizations. These HMOs cut expensive
emergency room use by a third and inpatient hospital days by more
than half.]
Despite the promise of coordinated care, 9.0f 10 89 percent of of
Medicaid clients continue to receive care through fee-for-service
systems
.]
New QA Requirements Replace 75 Public/25 Private Enrollment
Rule.
The bill also permits coordinated care entities specified in
this bill to serve a total Medicaid client base, eliminating the
requirement that 25 percent of the enrollees be private pay. The
actual effect of the 75/25 provision, as it is referred to, is
that coordinated care plans have significant difficulty in
meeting the private pay requirement, largely due to demographic
and geographic reasons. The disappointing, end result is that
fewer cost-effective, coordinated care options are available for
these clients.
The primary purpose for the 75/25 provision has been to
assure quality. Quality assurance is an area in health care
which evolves regularly with sophisticated advancements toward
measuring and improving quality. As this bill recognizes, the
6
05-09-92 09:50 AM FROM OLP
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75/25 requirement has not been that effective as a "proxy" for
quality. As a replacement for the 75/25 requirement, S. 2077
provides that coordinated care plans establish an extensive
quality assurance plan with state oversight responsibility and
meet specific standards that measure quality of care. While the
Department supports the replacement of the 75/25 requirement with
quality assurance standards, we would caution against imposing
burdensome standards that create barriers to managed care, or
place a managed care institution at a competitive disadvantage to
fee-for-service care.
Case Management
We are concerned with the language of Section 5 which
relates to case management. This section does not affect the
skipped
coordinated care portion of the bill. We are concerned that the
provisions of section 5 may be too broadly written and
interpreted. We will continue to work with the Committee on
drafting language in this and other parts of the bill so that
Federal spending would not increase thereby subjecting the bill
to the pay-as-you-go requirement of the Omnibus Budget
Reconciliation Act of 1990.
CONCLUSION
In closing, let me reiterate our general support for S. 2077
and for your efforts to improve the Medicaid program by fostering
greater use of managed care. This legislation both provides
7
05-09-92 09:50 AM FROM OLP
P10
States with the ability to control Medicaid expenditures and
offers a quality alternative to the more traditional fee-for-
service system that has poorly served Medicaid clients.
Consistent wf direction
Expanded use of coordinated care, as specified in S. 2077,
is at the core of the President's Comprehensive Health Care
Reform Program. It promises high quality cost-effective care to
all Americans. Thank you for the opportunity to comment and I
will be glad to answer any questions.
8
05-09-92 09:50 AM FROM OLP
P11
BILL SUMMARY
S. 2077 - MEDICAID MANAGED CARE IMPROVEMENT ACT OF 1991
S. 2077 would change the requirements for States operating
Medicaid coordinated care programs and also change some case
management requirements. The following description summarizes
the general provisions of this bill. In cases where the language
is unclear, an intent was assumed.
Coordinated Care:
HMOs, other prepaid health plans, and primary care case
management programs are all included in the definition of
coordinated care plans. In general, S. 2077 would provide States
more flexibility to develop coordinated care programs as an
optional Medicaid service. For example, this bill would:
O
eliminate the requirement that HMOs contracting with
Medicaid have at least 25 percent enrollment from persons
not eligible for Medicaid or Medicare.
expand the scope of the States current option to provide
guaranteed Medicaid coverage for individuals enrolled in any
coordinated care plans for one to six months, regardless of
whether the individual would otherwise become ineligible
during the guaranteed period.
allow States to adopt coordinated care programs as an
optional service in Medicaid, without the need to get
waivers from HCFA. For example, States would have the
option of implementing a mandatory managed care program if
recipients have a choice between two coordinated care plans,
a plan and a primary care case management program (PCCM) or
a choice among physicians if at least two-thirds of the
physicians are participating in the plan or PCCM.
o
allow the Secretary to continue any successful managed care
program operating under a waiver of section 1915 and under
granted. section 1115 authority without additional waivers being
o
eliminate the prior approval requirement that currently
applies $100,000. to Medicaid coordinated care contracts over
O.
require coordinated care plans to adhere to certain
standards for internal quality assurance (QA) programs.
05-09-92 09:50 AM FROM OLP
P12
require States to establish a number of external quality
assurance procedures, e.g. setting up toll free numbers for
recipients and establishing State-operated grievance
procedures.
add statutory language that offers the possibility of more
flexible rate-setting for capitated Medicaid payments.
require risk-based PCCM programs to meet insolvency and
auditing requirements similar to risk-based HMO contracts.
require the Secretary to convene groups and report on
criteria to be used to determine underutilization and the
feasibility of using encounter data.
Case Management
S. 2077 also includes some provisions that affect case management
programs operated as part of home and community based waiver
programs. The first provision that directly affects case
management services would add a general provision to section
1902(a) stating that Medicaid is not restricted from paying
another provider for services when similar services are provided
to a population by the State (or under contract) without charge.
While the intent of this provision is unclear, the effect is very
broad. Literally, this provision requires Medicaid to pay for
any covered services without regard to whether it is provided to
all other persons free of charge.
The second provision in this section of 8.2077 appears to exempt
case management and home and community based care waiver programs
from all freedom of choice requirements. The third provision
would allow case management agencies to pay case management
providers directly for Medicaid services.
of
THE TREASURY
THE SECRETARY OF THE TREASURY
WASHINGTON
1789
May 5, 1992
The Honorable Thomas Foley
Speaker
United States House of Representatives
Washington, D.C. 20515
Dear Mr. Speaker:
On February 6, the Administration published the
"President's Comprehensive Health Reform Program." The document
provides extensive detail on the President's plan for reforming
the health care system, including provisions addressing: market
reforms, universal access to affordable health care, cost
containment, administrative cost reforms, improved consumer
information and containment, and substantial reform of the
Medicaid program. Today I am transmitting the "Health Benefits
for Self-Employed Individuals Act of 1992," which implements the
President's proposal to extend the current twenty five-percent
deductibility of health insurance premiums for the self-employed,
and to raise the allowable deduction to one hundred percent of
the premium costs.
The Department estimates that this legislation will
reduce federal revenue by the following amounts:
Fiscal Year
($millions)
Total
1992
1993
1994
1995
1996
1997
1992-97
-58
-246
-544
-885
-1,292
-2,022
-5,047
These costs must be offset under the Budget Enforcement
Act of 1990. The President's Budget includes $5.5 billion in
mandatory outlay reduction proposals for fiscal year 1993 and
over $68.4 billion in mandatory savings proposals for fiscal
years 1992-1997. Any of these mandatory outlay reduction
proposals would be acceptable to the Administration as an offset.
More specifically, however, the Administration would propose to
finance this legislation by adopting reforms to: (a) place the
Medicare hospital update on a calendar year basis and (b) reform
payment of laboratory services by lowering the cap from 88% to
76% of the median, updated to reflect market factors. The
mandatory outlay savings from these two proposals in each of the
next five years exceed the costs of our proposal to expand the
health insurance deduction for the self-employed. These
- 2 -
proposals were included in the "Medicare Budget Amendment of
1992, " transmitted to Congress by Secretary Sullivan on February
21, 1992.
Thank you for your consideration. We look forward to
working with the Congress on this legislation.
Sincerely,
Tuck they
Nicholas F. Brady
Enclosure
102D CONGRESS
2D SESSION
To amend the Internal Revenue Code of 1986 to make the deduction for health
insurance costs of self-employed individuals permanent, and to provide for
a phased-in increase in the deductible amount of health insurance costs from
25 to 100 percent.
IN THE
May 5, 1992
introduced the following bill; which was referred to the
Committee on
.
A BILL
To amend the Internal Revenue Code of 1986 to make the deduc-
tion for health insurance costs of self-employed individuals
permanent, and to provide for a phased-in increase in the
deductible amount of health insurance costs from 25 to 100
percent.
1
Be it enacted by the Senate and House of Representa-
2 tives of the United States of America in Congress assembled,
3 SEC. 1. SHORT TITLE.
4
This Act may be cited as the "Health Benefits for
5 Self-Employed Individuals Act of 1992".
2
1 SEC. 2. PERMANENT EXTENSION AND INCREASE
2 IN HEALTH INSURANCE DEDUCTION FOR SELF-
3 EMPLOYED.
4
(a) IN GENERAL.--Paragraph (1) of section 162(1) of
5 the Internal Revenue Code of 1986 (relating to special rules
6 for health insurance costs of self-employed individuals) is
7 amended to read as follows:
8
"(1) IN GENERAL.--In the case of an individual
9
who is an employee within the meaning of section
10
401(c)(1), there shall be allowed as a deduction under
11
this section an amount equal to--
12
"(A) 25 percent in the case of taxable
13
years beginning on or before December 31,
14
1993,
15
"(B) 50 percent in the case of taxable
16
years beginning on or after January 1, 1994,
17
and on or before December 31, 1995, and
18
"(C) 100 percent in the case of taxable
19
years beginning on or after January 1, 1996,
20
"of the amount paid during the taxable year for insur-
21
ance which constitutes medical care for the taxpayer,
22
his spouse, and dependents."
23
(b) PERMANENT DEDUCTION.--Section 162(1) of such
24 Code is amended by striking paragraph (6) thereof.
3
1
(c) EFFECTIVE DATE.--The amendments made by this
2 section shall apply to taxable years beginning after Decem-
3 ber 31, 1991.
HEALTH
OF
DEPARTMENTOP
MUMAN SERVICES
THE SECRETARY OF HEALTH AND HUMAN SERVICES
WASHINGTON, D.C. 20201
USA
May 8, 1992
The Honorable Dan Quayle
President of the Senate
Washington, D.C. 20510
Dear Mr. President:
On February 6th, the Administration released the "President's
Comprehensive Health Reform Program." The document provides
extensive detail on the President's plans for reforming the
health care system, including the Administration's approach to
health insurance market reform, expanded access to affordable
health care, cost containment, and substantial reform of the
Medicaid program.
Today, I am transmitting the "Health Insurance Market Reform Act
of 1992," which implements the President's proposal to reform the
health insurance market to make coverage more secure, available,
and less costly for millions of Americans. In particular, the
bill will expand the availability of more affordable health
insurance products to all workers, but particularly to those who
are employed by small businesses.
This proposal has four major components:
All Americans will benefit from the increased
availability of health insurance, regardless of health
status. Coverage will be renewable and preexisting
condition limits will be eliminated for those who
maintain coverage. Workers can change jobs without
fearing they will be denied insurance coverage based on
their health status.
Coverage for individuals and small businesses, which
otherwise would face excessively costly insurance
because of their health status, will be more affordable
through broad risk pooling. Insurers will participate
in broad pooling arrangements to spread health risks
evenly across insurers and thereby allow insurers to
charge uniform premiums for the sick and the healthy.
On an interim basis, pending phased implementation of
this new system, insurers will be subject to limits on
their ability to vary premiums because of non-
demographic characteristics.
Group purchasing of health insurance by small employers
will enable small employers to have the same cost
advantage and market power enjoyed by larger employers.
They can pool their purchasing power through Health
Insurance Networks (HINs).
Page 2 - The Honorable Dan Quayle
Health plans will have increased flexibility to control
costs; they will be protected from mandated benefit and
anticoordinated care laws that drive up costs and
hinder designing cost-effective benefits tailored to
individual and family needs.
Section 4 of the "Health Insurance Market Reform Act of 1992"
could result in increased receipts to the Federal Government.
Therefore, the bill is subject to the pay-as-you-go requirement
of the Omnibus Budget Reconciliation Act of 1990. The Office of
Management and Budget estimates that the pay-as-you-go effect of
this bill would be less than $500,000 annually.
We are advised by the Office of Management and Budget that there
is no objection to the submission of the draft bill to Congress,
and that its enactment would be in accord with the program of the
President.
We urge the prompt enactment of the Health Insurance Market
Reform Act of 1992".
Sincerely,
Jouis W.Aullinan
Louis W. Sullivan, M.D.
Enclosures
LWS to South Carolina
Chamber rf Commerce
I am delighted to be here today to speak about a topic much
in the news recently and one that is vitally important to you as
business people -- that is, reforming the American health care
system. Specifically, I'd like to talk about the plan that
President Bush announced two weeks ago.
Theme
I need not remind you that the issues involved in health
care financing and delivery are very complex. Accordingly, the
President's plan is comprehensive. It includes 12 different
categories of proposals, each of which targets particular problem
areas.
But at the same time, these many separate proposals work
together in a coordinated way. For while details are complex,
the mission is clear: it is to provide affordable health
insurance, slow the growth in costs, improve access and
continuity of care, and make health insurance more secure.
We want to take what is fundamentally a good system, a
system that has set the world standard in health care, and make
it better. We want to preserve the benefits that the great
majority of Americans enjoy today
make those benefits more
affordable and safe for the future
and extend them to every
citizen of our country.
1
You have undoubtedly heard other proposals which may appear
simpler. But their apparent simplicity is misleading. If we are
to be responsible and realistic in confronting the problems of
our health care system today, then we must acknowledge at the
outset: there is no one simple answer, no panacea, no magic wand,
no substitute for sound analysis and hard work.
However, before we can select the particular paths, there is
a single, greater decision which must be made. It concerns the
fundamental direction we wish to take, and it is a decision which
must be made by our citizens as a whole.
The President put this decision succinctly in his recent
State of the Union Address. He said:
Really, there are only two options: We can move toward
a nationalized system -- which will restrict patient choice
in picking a doctor and force the government to ration
services arbitrarily
Or we can reform our own private
health care system -- which still gives us, for all its
flaws, the best quality health care in the world.
Let's consider each of the alternatives.
2
The Democratic Alternative
The proposals which have been put forward by Democratic
members of Congress -- whether called national health insurance,
or expanded Medicare, or Americare, or "Play-or-Pay" -- have this
in common: they would all lead us to a government-controlled
health care system. Some would do so forthrightly; others
attempt to conceal that end. But the truth is that each of these
proposals would ultimately put a government bureaucracy in charge
of health care financing and health care choices.
In contrast to those proposals, the President would maintain
the integrity of the private sector in the health care area. His
plan would strengthen the government's role in some important
respects:
it would expand the safety net for the uninsured and
those in need;
it would correct problems in the private insurance
market, making insurance more available and secure;
and it would strongly encourage the use of coordinated
care, which provides workable incentives for high
quality, with cost control.
3
The President's Plan
Fundamentally, however, the President's plan differs from
the Democratic plans because it would protect consumer choice and
private market mechanisms. And it is these private structures,
not government promises or wishful thinking, that are truly the
best hope for the future of our health care system. If we want
to achieve the right balance of cost, quality and access for our
citizens, then it makes sense to leave as much choice as possible
in our citizens' own hands, to make the decisions that are best
for their own circumstances.
Let me briefly re-cap some highlights of the President's
plan:
-- I'll start with the most important element for
businesses -- particularly small businesses. The
President's plan would revolutionize the way health
insurance is offered, establishing "risk pools," so
that smaller businesses and individuals can enjoy the
more favorable health insurance terms that larger
businesses enjoy.
4
We would do this through a mechanism called health
insurance networks. And we would eliminate those
burdensome state mandates imposed on health insurance
policies, which drive up the costs of premiums and
restrict competition.
-- Health insurers would be required to provide coverage
to all employers requesting it. Coverage would be
guaranteed, renewable, and no limits would be allowed
on pre-existing medical conditions. Insurance coverage
would be secure. And workers would no longer face "job
lock" -- the inability to change jobs for fear of
losing access to insurance.
-- Insurance affordablity would also be enhanced by limits
on premium costs. Altogether, the savings from small
market reforms will mean lower premiums for small
companies.
-- There would be new health insurance credits and a new
tax deduction would benefit more than 90 million
Americans. Together, these provisions would make
health insurance available to those with low incomes,
and make insurance more affordable for those with
middle incomes. For example:
5
If the tax credit were fully in effect today, a family
of four, with adjusted gross income up to $14,300,
would obtain the maximum credit, enabling them to buy
$3,750 of health insurance.
Likewise, a family of four, making $60,000 but without
employer-sponsored health insurance, could take the
full tax deduction of $3,750, providing about $1,050
that would help with the purchase of insurance.
-- States would be required to develop a basic health
insurance package which could be purchased with the tax
credit. At the same time, consumers would be free to
purchase alternative insurance, if they preferred.
-- Self-employed persons are helped in the President's
plan by being able to deduct 100% of the cost of health
insurance on their tax returns. Current law allows for
only 25%
6
-- The President's proposal encourages the use of
"coordinated" health care. Under this type of
arrangement, insured individuals will enroll in a
program in which they may choose their own personal
doctor, who, in turn, will coordinate the care they may
need by other medical specialists, or particular health
care facilities.
Not only has this method of service delivery proven
more affordable, it also enhances the concept of the
"family doctor" in medical practice.
-- The President's plan includes malpractice reform. It
also includes initiatives to reduce administrative
costs and insurance paperwork, and increase flexibility
for state Medicaid programs. In the 1993 budget
released two weeks ago, major expansions were also
proposed for clinics and providers in underserved areas
as well as new resources for disease prevention
activities.
-- Finally, we propose to improve consumer information.
The President's plan envisions "blue books" of
information comparing costs and quality of care
provided by physicians, hospitals, clinical
laboratories, and other health care providers.
7
Conclusion
These are the elements of the President's proposal. They
include fundamental reform of the insurance market to ensure
availability and affordablity. They provide access for all poor
families, and support for middle-income families in the purchase
of health insurance. And they encourage the growth of
coordinated care, with its incentives for quality plus cost
control.
Most importantly, they rely on the free market system to
continue to provide the finest health care in the world.
In the weeks and months to come, the United States will be
answering a fundamental question: Will we turn to government,
subjecting our health care sector to the whims and vacillations
of budgets and bureaucrats? Or will we maintain our mixed
private/public system, drawing on the best strengths of the
private market?
Stated another way, the question becomes: How many Americans
would turn in the private sector coverage they have today for a
government-run system? I believe the answer to that question is
self-evident.
And on that note, I would be happy to entertain some
questions from you. [Take Q&A -- presubmitted]
#
#
#
#
#
8
HHS ISSUE PROFILE
from the Office of the Assistant Secretary for Legislation
U.S. Department of Health and Human Services
No. 2/September, 1991
COORDINATED CARE
One of the major initiatives of HHS's Health Care Financing Administration
(HCFA) has been the development of a continuum of alternatives to its traditional
fee-for-service programs. This comes out of a belief that the Medicare and
Medicaid programs receive better value for their health care dollar, and that
Medicare and Medicaid beneficiaries receive better quality of care, when they enroll
in organized health care delivery systems that include networks of hospitals and
physicians which can coordinate the delivery of health care services - in short
"coordinated care."
Health Maintenance Organizations (HMOs) have been the foundation of
HCFA's coordinated care efforts, with over 2 million Medicare beneficiaries and 1.5
million Medicaid recipients now receiving care through these providers. By the end
of 1991, close to another 1 million Medicaid recipients will be enrolled in Primary
for-service features.
Care Case Management (PCCM) programs that combine coordinated care and fee-
These coordinated care programs typically offer more comprehensive
services than traditional fee-for-service, greater access to care, better quality care,
and more coordination of services. In Medicare, for example, coordinated care
generally permits many Medicare risk contractors to provide additional non-
at little or no added cost to beneficiaries. In addition, premiums for risk-based
Medicare covered benefits (e.g., eyeglasses, hearing aides and prescription drugs)
plans are often much less than those for traditional Medigap insurance policies. In
abuse, inappropriate hospitalization and inappropriate or delayed use of emergency
the Medicaid program, coordinated care reduces doctor shopping, prescription drug
room services by Medicaid recipients, while encouraging the use of primary and
preventive health services and increasing access to these services. When services
are coordinated, in either Medicare or Medicaid, the quality of care is better,
dangerous inefficiencies such as adverse drug interactions are reduced, and the
wasteful duplication of costly tests and procedures is curtailed.
A recent survey by the Health Insurance Association of America (HIAA)
found that HMOs are saving employers money, costing an average of 16.5% less
than indemnity plans. Costs are reduced through preventive care, non-duplication
of services, and coordination of treatment. Other studies have shown that
coordinated care programs are a proven strategy to provide quality health care.
Room 416G, 200 Independence Avenue, S.W., Washington, D.C. 20201 (202) 245-7627
The federal government (through both CHAMPUS and FEHBP), state governments,
and numerous corporations have turned to coordinated care techniques to manage
care efficiently. The HIAA study and many others have concluded that,
through these programs, costs can be lowered while the quality of health care is
maintained or improved.
The HMO, which represents the first generation of coordinated care models,
has grown and matured while many other alternatives have now been developed.
Preferred Provider Organizations (PPOs) and Exclusive Provider Organizations
(EPOs) have evolved from the HMO model to extend coordinated care and its
advantages to more people. HCFA is progressing with ways to expand the use of
HMOs in Medicare and Medicaid while several new coordinated care initiatives are
planned, including FY 1992 legislative proposals.
Recently, OBRA '90 authorized a limited version of the Medicare SELECT
option for beneficiaries as an alternative to traditional fee-for-service Medigap
plans. Under Medicare SELECT plans, full Medigap benefits generally would be
paid only when the service was provided by the plan's coordinated care network.
Medicare SELECT policies will be offered by private insurance companies in
essentially the same way that traditional Medigap policies are made available.
Beneficiaries who buy these policies are expected to be charged a lower premium
and plans. have better quality assurance than is available under the traditional Medigap
HCFA has also proposed a "Point of Service" option which will bring
coordinated care to all Medicare beneficiaries. It is a coordinated care option that
does not require enrollment. Instead, Medicare beneficiaries will make a decision to
receive the advantages of coordinated care at the time they actually need care. By
allowing a choice within a range of alternative health delivery systems, Medicare
beneficiaries are able to choose an option that best suits their health needs and,
more specifically, their financial situation.
Coordinated care is beginning to play a major role in reducing costs,
increasing quality of care, and providing greater access to care. The Health Care
Financing Administration wants it to play an even greater role.
For further information: contact either HCFA's Office of Legislation and Policy at
245-8220 or the HHS Assistant Secretary for Legislation's Office of Health
Legislation at 245-7450.
HHS FACT SHEET
from the Office of the Assistant Secretary for Legislation
U.S. Department of Health and Human Services
No.9\May, 1992
MEDICAID AND COORDINATED CARE
BACKGROUND
Medicaid, the Federal-state program which provides medical care to over 30 million low income people
annually in the United States, is increasingly turning to coordinated care programs as an option to fee-
for-service. Effective coordinated care programs improve quality and access, provide continuity of care
and help to prevent the delivery of inappropriate services to Medicaid patients. They also help to reduce
A
overutilization of health care services.
Presently, too many Medicaid patients rely on costly emergency rooms and doctors who may not know
their medical histories. Coordinated care programs allow Medicaid patients to have their care "managed"
by one doctor.
Promoting the use of coordinated care programs to serve the Medicaid population is an important
initiative on both Federal and State agendas. Faced with growing access problems, limited resources,
and the need to make their programs more efficient, an increasing number of States have found
coordinated care programs to be a viable alternative to traditional fee-for-service delivery systems.
Particular emphasis is being given to enrolling Medicaid-eligible women and children in coordinated care.
Over 10 percent of all Medicaid recipients are already enrolled in some type of coordinated care program
including Health Maintenance Organizations (HMOs), other pre-paid health care arrangements, and
primary care case management programs (PCCMs).
Coordinated care programs offer these distinct advantages:
o
Access
-
Capacity for on-call primary care access or referral 24 hours a day, 7 days a week
-
Sufficient number of primary care providers in a geographic area
o
Continuity of Care
-
A "Medical home" for recipients
-
Appropriate care in appropriate settings
-
Case management and care coordination
-
Reduction in inappropriate episodic care in emergency rooms
o
Quality
-
Emphasis on preventive care
-
Quality Assurance systems in place
o
Cost Efficiencies
-
Efficient management of health care resources
-
Reduction in costly inpatient stays
-
Increased ability to project expenditures
Room 416G, 200 Independence Avenue, S.W., Washington, D.C. 20201
(202) 245-7627
TYPES OF MEDICAID COORDINATED CARE PROGRAMS
Primary Care Case Management (PCCM) - A Medicaid program where States contract with primary care
physicians and/or clinics to be responsible for the provision of primary care and to coordinate referrals
for specialty care to individual Medicaid recipients. In exchange for case management functions and
around-the-clock coverage, States typically pay primary care coordinators a flat monthly fee of $3-$5 per
recipient.
Health Maintenance Organization (HMO) - a health care entity that accepts responsibility and financial
risk to provide a comprehensive set of health services to a defined group of enrollees during a defined
period at a fixed price.
Health Insuring Organization (HIO) - an health care entity that acts as a risk-assuming fiscal intermediary.
All HIOs pay for a defined package of services for a certain population in exchange for a fixed or per
capita fee from the State. Some HIOs, like HMOs, also arrange for the provision of care to enrollees.
Prepaid Health Plans (PHP) - usually an entity that contracts to provide a subset of services (e.g., acute
care services excluding inpatient services) on a prepaid, risk basis. Entities that contract on a non-risk
basis for a comprehensive set of services are also included in this category.
MEDICAID COORDINATED CARE ENROLLMENT AS OF JUNE 30, 1991
Type
Number of Plans
Number of Enrollees
Health Maintenance Organization
134
1,283,600
Health Insuring Organization
5
162,000
Prepaid Health Plans
50
419,400
Primary Care Case Management
32
805,200
Total
221
2,670,200
PROPOSALS FOR LEGISLATIVE CHANGE
Although Medicaid enrollment in coordinated care programs is increasing rapidly, growth in these
programs is still constrained by legislative barriers and States' need to obtain Federal program waivers.
The President's proposal for Comprehensive Health Care Reform and Senate bill S.2077 [introduced by
Senators Patrick Moynihan (D-NY), Dave Durenberger (R-MN), and Bob Packwood (R-OR)] both include
measures to eliminate legislative barriers to the use of Medicaid coordinated care programs and to
provide States with more flexibility.
For further information: contact either HCFA's Office of Legislation and Policy at (202) 245-8820 or the
HHS Assistant Secretary for Legislation's Office of Health Legislation at (202) 245-7450.
(Hinchliffe/Gershowitz)
May 7, 1992 12 p.m.
HMO Draft One
PRESIDENTIAL REMARKS: MANAGED HEALTH CARE EVENT
WEDNESDAY MAY 13, 1992
BALTIMORE, MARYLAND
I'm very glad to be here today -- up at Johns Hopkins, which
is not only on a summit in Baltimore, but is at the summit of
medical excellence. I've just had the chance to spend some time
eight blocks -- and another world -- away from here, in your East
Baltimore Medical Center. Before I get onto anything else, I
want to say that visiting a place like that, we feel grateful
that there are people like you devoting your lives to others.
The center's most impressive -- a terrific example the rest
of the country can follow. It's based on a special kind of
partnership between this medical institution; a private insurance
company; and the government. It's a problem-solving partnership
that heralds the future of health care in this country.
Thanks to this partnership, EBMC is the largest and fastest
growing Medicaid HMO in Maryland. It's terrific to see the
success of this innovative community-based HMO, because it proves
what I strongly believe -- that health care and insurance
industries can meet the challenge of controlling health care
costs while providing the finest quality service. I congratulate
you for the part you play -- for while this HMO saves members,
employers and government money, the health care remains first-
rate.
And the key to EBMC's success, especially for Medicaid
patients, is that managed health care makes creative approaches
2
possible. It provides coordinated, quality care at a lower cost,
while emphasizing prevention and extra benefits, like EBMC's free
dental work or Better Beginnings Program.
[ANECDOTE OR STORY]
I was excited to see so many successful pieces of my
comprehensive Health Reform Program already at work at EBMC. As
you know, I introduced this plan on February 6. In it, I set
about to address the twin challenges of expanding access and
containing cost -- while building on the strengths of our present
health care system. I was determined to treat the root causes of
our problems -- not just the symptoms. As medical professionals,
I think you can understand.
I'm appalled to think that in this -- the greatest, most
technologically advanced nation on the face of the earth -- one
out of every seven Americans has no health insurance. That is a
disgrace and we must not tolerate it.
What we must do to remedy this is clear -- and I've put it
into a comprehensive 4-part plan. Simply put: we will guarantee
every American universal access to affordable health insurance.
In this election year, it seems like everybody and his or
her brother has their own plan. National Health -- "Play or Pay"
-- the options are reproducing like rabbits, and they're just
about as deep. Look, it's easy. People want quality care they
can afford and rely on. We don't need to put government between
patients and their doctors. We don't need to shovel Americans
into another new level of federal bureaucracy. We need
3
commonsense, comprehensive health care reform and we need it now.
So I proposed my plan to dramatically reform our market-
based system. I was determined that it would put quality care
within the reach of every American family -- but be built on
choice. I was determined that it would keep costs down, access
up. I followed the words of British doctor Sir Frederick Banting,
who said: "You must begin with an ideal and end with an ideal."
Part one of my plan says we'll make health care more
accessible by making it more affordable. We'll give $3750 in
health insurance credit for low-income families -- and in tax
deductions for middle income families. This alone will bring
health insurance to almost 30 million uninsured Americans.
Part two says we'll cut the runaway costs of health care by
making the system more efficient. We'll call for innovative
approaches and provide incentives so that together we'll create
workable solutions to our health care challenges.
Part three says we'll wring out waste and excess by
reforming the system.
And part four says we'll control federal growth -- because
health care is the fastest growing part of the federal budget.
Our plan states that we can contain costs by encouraging
coordinated care programs in both public and private sectors; by
offering choice; and by associating state Medicaid programs with
coordinated care programs. These are precisely the areas where
EBMC excels today. It shows these ideas do work.
Well, we unveiled this plan more than three months ago.
4
During that time, we've moved ahead with our proposals, following
through step by step on everything we outlined in that historic
plan. Today, for instance, we're releasing regulations that will
make it easier for small businesses to join HMOs. [INSERT?]
What's most important is that we've put together a health
care legislative package. But, guess what. The ball's in
Congress' court. And they're not budging. Now's the time to see
if they're really interested in passing useful legislation --- or
just in the upcoming election. It's so frustrating, I can tell
you. We've got a great plan. It can lift the hearts and ease
the pain of literally millions of Americans who today are sick
and scared. All of the elements we've introduced can be enacted
immediately. Why isn't Congress moving? [INSERT]
Our plan does everything the government can and should do to
ensure the quality of life of each citizen of this great land.
It doesn't promise the moon -- it does something more important.
Its promises the future. We're not building dream castles. We
believe in the truth. We'll deliver what we say we can -- and
we'll deliver it proudly.
MAY 08 '92 09:35 PRUDENTIAL INSURANCE
ROBERT C. WINTERS
Chairman and Chief Executive Officer
The Prudential Insurance Company of America
Robert C. Winters became Chairman of the Board and Chief Executive
Officer of The Prudential in February 1987.
Before his election to Chairman, Mr. Winters had been Vice Chairman
since September 1984. In that capacity, he headed the Company's Central
Corporate and Financial Operations.
Mr. Winters joined the Company in 1953 in the Newark headquarters.
Subsequently, he held actuarial positions in both group and individual
insurance, as well as assignments in the Company's regional home offices in
Boston, Chicago and Fort Washington, Pa. In Fort Washington, he was Senior
Vice President in charge of The Prudential's Central Atlantic Operations
from 1975 to 1978. In 1978, Mr. Winters was promoted to Executive Vice
President and became a member of The Prudential's Executive Office.
Mr. Winters graduated from Yale University in 1953, and received his
M.B.A. from Boston University in 1963. Ha became a Fellow of the Society
of Actuaries in 1957. He was awarded the Chartered Life Underwriter
designation by the American College in 1977 and the Chartered Property and
Casualty Underwriter designation by the American Institute for Property and
1956. Liability Underwriters, Inc. in 1982. He served in the Army from 1954 to
Mr. Winters is a past President of the American Academy of Actuaries
and a former member of the Board of Governors of the Society of Actuaries.
Ha is a past Director of the Regional Plan Association and a Director of
the Life Office Management Association. Mr. Winters served as Chairman of
the United Way of Tri-State Campaign for 1989-90, and has served as
Chairman of the Board of the Greater Newark Chamber of Commerce.
Mr. Winters is Chairman of the board of the American Council of Life
Insurance and is on the board of the United Way of Tri-State. He is a
member of the Business Council, the Business Roundtable and its Policy
Committee, its Task Force on International Trade and Chairman of its
Health, Welfare and Retirement Income Task Force. Mr. Winters is a member
of the Services Policy Advisory Committee to the U.S. Trade Representative's
Office, the Committee for Economic Development, the Partnership for New
Jersey and the New Jersey State Chamber of Commarce. He 13 a member of the
Education Commission of the States, to which he was appointed by Governor
Thomas Kean. Mr. Winters also serves on the Board of Allied-Signal Inc.
Mr. Winters is married to the former Patricia Martini of Minneapolis.
They have two daughters and reside in Rumson, New Jersey.
2/7/91
former
Bob Winters Visits with President Bush
Other participants included representatives from Florida Health
discuss managed care as an effective cost containment strategy.
Mr. Winters met with the President on Friday December 13, 1991 to
Access and COSE, two small employer health care purchasing
coalitions, and Southwestern Bell.
White House.
attended the United Negro College Fund reception and dinner at the
Mr. Winters also met with the President on March 10, 1992 when he
Johns Hopkins
Medical Institutions
550 North Broadway/Baltimore, MD 21205
(410) 955-6680 / FAX (410) 955-4452
Office of Public Affairs
TO:
Editors, Producers and Reporters
FROM:
Marc Kusinitz
DATE:
May 5, 1992
SUBJECT: JOHNS HOPKINS BRIEFING ON DEVELOPMENT OF LOW VISION
ENHANCEMENT SYSTEM (LVES)
Date: Wednesday, May 13, 1992
Time: 10:30 a.m.
Location: Oncology Center Auditorium (Room 119, Wolfe Street entrance to Hospital)
Researchers at the Lions Vision Center of the Hopkins Wilmer Eye Institute will display
and demonstrate the latest prototype headset that compensates for poor vision by
displaying in front of the wearer's eyes real-time video images captured by a
miniature, built-in camera.
The LVES prototype to be displayed is the first of a line of similar devices that
eventually will be able to compensate for vision problems caused by diseases of the
eye.
Although designed to compensate for low vision, the system could be used by anyone
as a "home entertainment unit," and is expected to be the basis of a virtual reality
device in the future.
Hopkins researchers collaborated with the National Aeronautics and Space
Administration's John C. Stennis Space Center in Mississippi on the development of
the LVES.
EXCELLENT VISUALS AVAILABLE
To attend this briefing, contact Marc Kusinitz or Joann Rodgers at (410) 955-8665.
GETTING HERE IS EASY
JOHNS HOPKINS
DRIVING FROM THE NORTH
Outpatient Center
Traveling south on Interstate 83, follow the expressway to its termination
SECOND CENTURY OF JOHNS HOPKINS MEDICINE
at the traffic light at Fayette Street. Turn left on Fayette and continue
traveling eastbound to North Caroline Street, then make another left. Cross
over Orleans Street and look for directional signs to the Outpatient Center
parking garage.
Traveling south on Interstate 95, bear left on I-895, then exit at Moravia
Road to Route 40. Follow Route 40, traveling westbound, and bear right
onto Orleans Street. Follow Orleans to North Caroline Street, turn right and
look for directional signs to the Outpatient Center parking garage.
DRIVING FROM THE SOUTH
Traveling north on Interstate 95. exit at Russell Street. Follow Russell to
Pratt Street and turn right. Follow Pratt, traveling eastbound, through
downtown Baltimore to North Caroline Street and turn left. After crossing
Orleans Street, look for directional signs to the Outpatient Center
parking garage.
WOLFE STREET
The
Johns
Hopkins
Hospital
BROADWAY
Johns Hopkins
Outpatient Center
MONUMENT STREET
ORLEANS STREET
FAYETTE STREET
Outpatient
Center
Parking
NORTH CAROLINE STREET
JOHNS HOPKINS
Outpatient Center
SECOND CENTURY OF JOHNS HOPKINS MEDICINE
601 North Caroline St., Baltimore, MD 21287
For appointment information, call:
A PERSONAL APPROACH
Adults: 410-955-5464
Children: 410-955-2000
To HOPKINS MEDICINE
MAKING YOUR VISIT
A PERSONAL PRIORITY
From the time you call to schedule your
appointment, through the time of your visit,
the entire collective efforts of the Johns
Hopkins Outpatient Center staff focus on
efficient attention to your medical needs with
high regard for your personal time. We're
dedicated to delivering a positive patient
experience with minimal waiting.
When you visit, you'll find it conven-
ient to park and easy to register and
get to your appointments. Medical
tests and X-rays will be done quick-
ly and efficiently. Our friendly
staff will be there to help and to
answer your questions.
Most important of all, this
Center offers you quality Hopkins
medical care, with state-of-the-art diagnos-
tic facilities, imaging equipment and operating
rooms.
We are proud to introduce you to our
newest innovation in Hopkins medicine, the
Johns Hopkins Outpatient Center-a part of
our continuing commitment to be the best in
the world.
ADVANCE
WHAT TO BRING
opposite the main
REGISTRATION
On the day of your appoint-
entrance to the
Once you've scheduled an
ment you will need the
Outpatient Center.
appointment, a patient service
following:
If someone is
coordinator will call you in the
dropping you off or
your Johns Hopkins
evening to collect registration
picking you up, there is a
Hospital I.D. card, if you
information.
convenient four-lane driveway
have one
The purpose of advance reg-
in front of the building.
insurance cards and
istration is to collect necessary
forms
information while you are in
HMO/PPO referral
the comfort of your home, SO
forms
CHECK-IN
that we can shorten the regis-
medical cards
tration process when you ar-
As soon as you walk up to the
Social Security number
rive at the Center.
main information desk in the
of the person in whose
If you prefer, you can call us
first floor lobby, our staff will
name the insurance
at 410/955-2453 to complete
greet you and direct you to
is issued
the registration process. This
name and address
your destination.
brief phone call will save you
Four elevators are reserved
of that person's employer
time on the day of your ap-
for your use. In the elevator
pointment.
Also, when you make your
lobby on each floor is a direc-
Please plan to arrive 10 min-
appointment, you may be
tory of clinical departments to
utes before your scheduled
asked to bring medical re-
assist you in finding the loca-
appointment if you have pre-
cords, X-ray films, or prior test
tion of your appointment.
registered and 20 minutes be-
results, if you are being re-
fore your appointment if you
ferred to Johns Hopkins by an-
have not preregistered.
other physician.
AFTER YOUR VISIT
After you have seen your doc-
tor, you will meet with a
THE ROBERT M.
EASY ACCESS
CONVENIENT PARKING
patient service coordinator to
HEYSSEL BUILDING
order any lab tests or X-rays
You'll find directions to the
The Center is located in
you might need, or to schedule
Outpatient Center on the map
the Robert M. Heyssel
return appointments. Please
on the back of this brochure.
Building. The Trustees
be prepared to pay for your
of the Hospital and
Once you turn onto North
visit at this time. Insurance or
University dedicated
Caroline Street, look for the
referral forms will be collected,
and named the building
tall sign that directs patients
and we will send you informa-
in recognition of Dr.
and visitors to the Center.
Heyssel's distinguisbed
tion that you may require to file
service as director of
If you are driving, fol-
an insurance claim.
The Johns Hopkins
low the directional
Hospital from 1972 to
signs to the
1983, as its president
Outpatient Center
from 1983 to 1986, and
parking garage,
as president of both the
Hospital and the Johns
located directly
Hopkins Health System
from 1986 to 1992.
ADDITIONAL PATIENT SERVICES
X-RAYS AND
The Center's lobby
LABORATORY TESTING
Appointment
Benson Optical
offers a number of ser-
Referral Office - Assists
Superstore - A one-
Blood and urine tests, EKGs, and
vices for your comfort
patients who need an
bour service for eye-
chest X-rays are all provided in
and convenience.
appointment in find-
glasses (with more
the express testing area of the
CLINICAL SERVICES
Office of Patient
ing the appropriate
than 1,000 frames to
lobby. All other radiology ser-
Services - Assists
physician. Call
choose from) and
vices, including CT and MRI
LOWER LEVEL
international and
410/955-5464.
contact lenses.
scans, are also provided in the
- Outpatient Surgery
other patients with
Freedom Pharmacy -
Gift and coffee
building.
FIRST FLOOR
special needs, such as
A rapid-fill, complete
shops - Featuring
- Lobby Services
interpreter services,
prescription service,
magazines, cards,
SECOND FLOOR
travel, housing, and
which also stocks over-
and gifts, as well as
- Diabetes Center
billing. Please call
the-counter drugs and
gourmet coffees and
THIRD FLOOR
WE'RE HERE TO HELP YOU
410/955-8032 for
supplies.
baked goods.
- Imaging, including
assistance.
Our employees are knowledge-
CT, MRI and nuclear
Automated teller
able about your needs and our
medicine scans.
machine for your per-
services. They are eager to help
FOURTH FLOOR
sonal banking needs.
you if you have questions or need
- Radiology
- Breast Imaging
directions. Do not hesitate to ask
Center
for assistance at any time.
- Urology
FIFTH FLOOR
- Neurology
- Neurosurgery
- Orthopaedic Surgery
SIXTH FLOOR
- Otolaryngology
(Head & Neck
Surgery)
- Dermatology
SEVENTH FLOOR
- Adult Medicine and
Surgery
- Cardiology and
Cardiac Surgery
- Meyerboff Center
(Gastroenterology
& General Surgery)
EIGHTH FLOOR
- Pediatrics
- Gynecology &
Obstetrics
- Plastic Surgery
MEMORANDUM
TO:
"Interested Parties"
FROM:
Elaine Freeman
Joann Rodgers
DATE:
May 7, 1992
SUBJECT: Hopkins Background for Bush Visit
Attached is an assortment of materials about the Johns Hopkins
Medical Institutions and Johns Hopkins Health System President
Robert M. Heyssel, with an emphasis on information relevant to
health care reform, cost containment, delivery of services to the
urban poor and prevention.
The materials include descriptions of programs, research projects,
news releases, speeches, position papers and news articles.
From Hopkins' standpoint, several issues highlighted by the
materials stand out:
O The Johns Hopkins Hospital and Health System developed the
concept of a Medicaid HMO in Baltimore in 1984 when they took over
a small HMO in East Baltimore that went into bankruptcy. The State
of Maryland and Hopkins leadership and money "grew up" that HMO,
the Johns Hopkins Health Plan, to a 55,000 enrollee success
Prudential acquired the Plan in 1991.
O Keeping health care costs down and the quality up requires
appropriate levels of care for each patient and a regulatory system
that rewards cost savings. At Hopkins, Dr. Heyssel developed the
"vertically integrated" health care system that encompassed
neighborhood health centers and the opening this week of the $140
million Outratory care center to complement the tertiary care at
Hopkins Hospital, called the best in the nation by U.S. News and
World Report. In addition, he led the support for Maryland's
unique all-payors hospital reimbursement system that helped
guarantee fiscal stability and sensible planning of hospital
services in the state, while rewarding those institutions that
maintained a competitive edge without "dumping" patients.
o When Dr. Heyssel came to Hopkins 20 years ago, he inherited
a white enclave in a racially segregated environment. Since then,
he has built bridges with the minority community that surrounds
Hopkins, culminating with the Hospital-funded Office of Community
Health. This office runs health programs and supports minority
health career development with agendas set by community leaders,
not Hopkins.
O Preventive medicine is a tough sell in an academic medical
center where the focus is the advancement of cutting edge knowledge
to help the sickest individuals. Yet Hopkins made a substantial
commitment to preventive medicine and the cost effectiveness it
represents with such model programs as Heart, Body and Soul. HB
and S works with dozens of African American clergy to promote
health, offer screening programs and reduce death and disability
from heart and blood vessel disease. The School of Public Health
has numerous programs integrated with medical school and hospital
faculty and staff to advance the benefits of preventive medicine.
Johns Hopkins Medical Institutions
Office of Public Affairs
550 North Broadway / Baltimore, MD 21205 (301) 955-6680 / FAX (301) 955-4452
EMBARGOED UNTIL NOON, E.S.T.
NEWS RELEASE
WEDNESDAY, DEC. 11, 1991
HOPKINS TO COMBAT HEALTH PROBLEMS OF EAST BALTIMORE
The Johns Hopkins Hospital is launching a Community Health Initiative for
East Baltimore that vastly differs from numerous existing Hospital programs because
it asks the community to tell Hopkins what it wants and needs.
Based in a new Office of Community Health (OCH), the initiative has initial
funding of $150,000 from The Johns Hopkins Hospital.
"People in our surrounding neighborhood know what their most important
health concerns are," says Robert M. Heyssel, M.D., president and chief executive
officer of the Johns Hopkins Health System and The Johns Hopkins Hospital. "We
need to listen and learn from them where we should concentrate efforts at improving
health, and we need to make it easy and convenient for people to get involved and
share information.
"Further, we want to demonstrate with the community that measurable
changes can be made in community health in a broad population in cost-effective
ways, such as education, prevention and early intervention, which are a lot less
expensive than treatment later in the course of disease," Heyssel says.
A 12-member Advisory Board is comprised of representatives from East
Baltimore community groups, the Mayor's Office, and the Baltimore City Health
(more)
The Johns Hopkins Hospital
School of Medicine
School of Nursing
School of Public Health
Johns Hopkins Health System
JHMI--Community--Page 2
Department, as well as from The Johns Hopkins Hospital, School of Medicine and School of Public
Health. They will help in determining community health outreach priorities. The OCH then will
serve as a clearinghouse for information about all existing health-care programs in East Baltimore,
help groups seek financial support for needed projects, and will serve as an information and referral
source for groups and individuals.
Existing Hopkins-sponsored community health programs will continue, although they may be
expanded or improved based on community input.
The OCH will tackle many of the most difficult health problems the community faces. Based
on preliminary Advisory Board discussions, efforts are likely to focus in such areas as: reducing infant
mortality, increasing vaccinations, slowing the spread of AIDS, improving primary care, providing low-
cost mammography screening, reducing sexually transmitted diseases, promoting healthier lifestyles and
influencing many other entrenched problems. The Board will likely select three of these problems for
initial concentration.
Terisa James, who established and coordinated the Community Services Program for the Johns
Hopkins Oncology Center, has been named OCH'S executive director. Department of Pediatrics and
OCH Director Frank A. Oski, M.D., says James was selected because of her established ties and
credibility with community leaders and her longstanding commitment to improving the health of
people in the surrounding neighborhood.
(more)
JHMI--Community-Page 3
"We wanted someone who could relate to the needs of the community and not focus only on
what Hopkins perceives are health priorities," Oski says. Julia McMillan, M.D., deputy director of the
Department of Pediatrics, is the OCH associate director.
Advisory Board members include:
Pastor Marshall Prentice, president, Clergy United in the Renewal of East Baltimore
(C.U.R.E.)
Ralph Moore, director, Project RAISE II
Lucille Gorham, director, Citizens for Fair Housing
Lee Tawney, assistant to the Mayor
Councilman Carl Stokes, 2nd district, Baltimore City, the district surrounding The Johns
Hopkins Hospital
Thomas P. Coyle, director, Office of Policy and Program Development, Baltimore City Health
Department
Robert M. Heyssel, M.D., president and chief executive officer, Johns Hopkins Health System
and The Johns Hopkins Hospital
Catherine DeAngelis, M.D., associate dean for academic affairs, Johns Hopkins School of
Medicine
Bernard Guyer, M.D., M.P.H., chairman, Department of Maternal and Child Health, Johns
Hopkins School of Public Health
Diane M. Becker, Sc.D., M.P.H., director, Johns Hopkins Center for Health Promotion
Vanessa L. Bradley, residency program coordinator, Department of Pediatrics, Johns Hopkins
University School of Medicine
An additional seat for a community representative is still vacant.
The Office of Community Health is located across from Hopkins Hospital at 550 N. Broadway,
telephone 410/550-6524.
###
(For press inquiries only, contact Jan Shulman or Joann Rodgers at 410/955-8662.)
SELECTED EXISTING HOPKINS-SPONSORED
COMMUNITY HEALTH PROGRAMS
COMMUNITY HEALTH INITIATIVES
0
Clergy United in the Renewal of East Baltimore: Heart, Body and Soul
Program
(A community/church-based screening and education project that includes
screening programs for hypertension, diabetes and cholesterol, as well as a
smoking cessation program.)
The Johns Hopkins University School of Medicine
0
Breast and Cervical Cancer Screening Project
The Johns Hopkins Oncology Center, Community Services Program
(In collaboration with the Heart, Body and Soul Program)
0
Vision Screening Project
(Screens for cataracts, glaucoma and other vision problems.)
Dana Center for Preventive Ophthalmology
The Johns Hopkins Wilmer Eye Institute
(In collaboration with the Heart, Body and Soul Program)
0
Dunbar Middle School Clinic Initiative
(Assessment, intervention and referral of children -- includes physicals,
medical and mental health referrals and health education.)
The Johns Hopkins Children's Center
0
Hearing Outreach Program for Senior Citizens
The Johns Hopkins Center for Hearing and Balance
0
The ARK Project
(Free screening and physical exams for homeless women and children.)
The Johns Hopkins Children's Center
0
Pediatric HIV Program
(Comprehensive program for high-risk and HIV-infected children)
Johns Hopkins Children's Center
COMMUNITY EDUCATION AND HEALTH CAREER PROGRAMS
o
Alternative Careers Program
(Introduces high school students to career opportunities in the allied health
professions.)
The Johns Hopkins Hospital, Employment Services
0
Community Relations and Education Program
(Includes a free speakers' bureau and health career day.)
Johns Hopkins Children's Center, Child Life Program
o
The Dunbar High School/Hopkins Health Professions Program
(Offers assistance to students who select a health-track curriculum and offers
paid intern programs.)
The Johns Hopkins University
o
Professional Readiness Insurance for Minority Excellence (PRIME)
(Provides health-care job experience for qualified minority college students
with the goal of offering Hopkins employment.)
The Johns Hopkins Hospital, Employment Services
o
RAISE II
(Mentoring program for Dunbar Middle School.)
The Johns Hopkins Medical Institutions
COMMUNITY VOLUNTEER PROJECTS
o
Community Service Volunteer Work
(Students in Community Outreach class at School of Public Health are
required to perform two hours of weekly community service.)
The Johns Hopkins University School of Public Health
0
Community Health Fairs
(Offers cancer prevention education.)
The Johns Hopkins Oncology Center
EAST BALTIMORE GUIDE
DEC. 12, 1991
Hopkins Program Targets Eastside
Johns Hopkins Hospital has
most needed programs. One seat on
begun community health program
the board, reserved for a commu-
for East Baltimore based for the
nity representative, is vacant.
most part on input from the com-
Health issues most likely to be
munity, a rare foundation for hospi-
addressed include reducing infant
tal programs.
mortality, increasing vaccinations,
Robert M. Heyssel, M.D., presi-
slowing the spread of AIDS, im-
dent and CEO of the Johns Hopkins
proving primary care, providing
Health System and Hospital, said
low-cost mammography screening,
he hopes the project will emphasize
reducing sexually transmitted dis-
education, prevention, and early in-
eases, and promoting healthier life-
tervention, which are cheaper than
styles.
treating diseases later on. "People
Hopkins-sponsored community
know what their most important
health programs already in effect
health concerns are. We need to
will continue, and may be im-
listen to them, and also make it easy
proved upon depending on com-
and convenient for people to get
munity input, They include the
involved," Dr. Heyssel said. "We
Clergy United in the Renewal of
also want to demonstrate that
East Baltimore (CURE), a commu-
changes can be made in community
nity/church-based screening and
health in cost-effective ways."
education project. that screens for
The project was initially funded
hypertension, diabetes and choles-
with $150,000 from Johns Hopkins
terol; the Vision Screening Project;
Hospital, and is based in the Office
the Dunbar Middle School Clinic
of Community Health (OCH), 550.
Initiative, which includes physi-
N. Broadway, across from the hos-
cals, medical and mental health re-
pital. Terisa James, who coordi-
ferrals, and health education for
nated the Community Services Pro-
children; the ARK Project, which
gram for the Johns Hopkins
provides free screening and physi-
Oncology Center, was named
cal exms for homeless women and
OCH's executive director.
children; aand the Dunbar High
A 12-member advisory board, in-
School/Hopkins Health Profes-
cluding representatives from area
sions Program, which offers assis-
clergy, community leaders, city
tance to students looking for a ca-
government, and hospital officials,
reer in health care, and offers paid
was formed to help determine the
internships.
THE SUN
under
NOV, 1 4 1990
HMO's
prenatal
JHMSC Health Predential
program
VOUCHER, From A1
child care and be offered childbirth
education classes. She also will see a
pays off
voucher that she can cash at the
social worker once - more fre-
health center. She will get a voucher
quently if necessary - during her
each time she comes to a checkup
pregnancy.
and class.
Each patient could have as many
In addition to the regular check-
Have checkup,
2 15 appointments, Brodsky says,
ups, smokers who are referred to,
although she assumes the average
and attend, smoking-cessation clin-
get voucher
will be closer to 10.
ics will be given $10 for each class
The classes will stress health and
they attend. And women with drug-
Instrition, says Brodsky. As her preg-
or alcohol-abuse problems who com-
By Mary Maushard
mancy progresses, each woman will
plete detoxification classes will be
Evening Sun Staff
Frisit a pediatrician to learn about
given an additional $10 each time
A Baltimore HMO is paying
some of its patients to take care of
themselves. As part of a new prenatal health
program, the Johns Hopkins Health
Plan is giving $10 vouchers to ex-
pectant mothers, covered under the
state's medical assistance plan, for
having regular checkups and attend-
their drug screening is "clean,"
sky says. If a woman receives $150
ing bealth-education classes.
Brodsky says.
from the incentive program over the
The voucher system, which will
be extended to pregnant women who
Brodsky would not say how much
course of her pregnancy, "the money
money is budgeted for the incentive
will help her and will help her baby."
also drug-detoxification "incentive" nings, attend a prenatal part smoking health of programs, Better cessation and Begin- educa- is the or
program. At an average of $100 per
Caring for an infant with acute
patient ($10 a visit for 10 visits), plus
health problems can easily cost
more for smokers and drug and alco-
$50,000, Brodsky says. If predictable
tion program started by the health
hol abusers, the program would cost
problems can be avoided in only one
maintenance organization Nov. 1.
at least $30,000 to $35,000 annually.
baby, "the whole program will be
Better Beginnings is open to all
"The cost of the incentive pro-
worth it," she adds.
HMO members enrolled at the plan's
gram will be much less than the cost
There will be some savings, too,
four city offices, but only medical
of [caring for] a baby if it were born
in normal deliveries, Brodsky says.
assistance patients are "being of-
with serious health problems." Brod-
As part of Better Beginnings, moth-
fered that incentive to attend their
appointments," says Karen Brodsky,
program coordinator.
The four centers serve about 650
pregnant women a year. About half
of them are Medical Assistance pa-
ers who have uncomplicated, vagi-
they return home from the hospital
tients, she says.
nal deliveries and healthy babies
to be sure they are progressing and
And many of these patients are
will be able to leave the hospital
will make an appointment for the
teen-agers, whose age, education,
within 24 hours rather than 48 hours,
mother's six-week post-partum
eating habits and home situations
which is now the norm for most
checkup. "The home-health visit
put them at risk of having small and
mothers.
could be repeated, if necessary,"
premature babies. Better Beginnings
Brodsky says.
is intended to eliminate some of
Some women already leave the
HMO officials are hopeful that a
hospital in one day, and Better Be-
these problems.
woman who has had good health
Here's how the program works:
ginnings is hoping to increase that
care during her pregnancy would be
When a woman is scheduled for a
number by 20 percent.
encouraged to continue it for herself
regular prenatal checkup (once a
Through the program, a home
and her child.
month through most of the pregnan-
health care worker will visit the
"We really think it will make a
cy but more frequently in the eighth
woman and her baby the day after
difference," she says.
and ninth months), she also will be
acheduled to attend a health-educa-
tion class. If she has the checkup and
attends the class, she will get a $10
See VOUCHER, A5, Col. 1
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U Heann
PERSPECTIVES
August 19. 1991
TWENTY YEARS OF MARYLAND RATE REGULATION
For 20 years Maryland hospitals have operated under 8 tightly-controlled state-run payment system that
sets rates for all payers and all patients. As a result. payments are 8 percent below national average. So
why are administrators so happy? And. perhaps more Importantly. what can the rest of the nation learn from
Maryland?
When Maryland launched its "experiment" with all-payer rate-setting in 1971. hospital costs in the state
were among the highest in the nation. Calls were being heard in the state legislature to "sta-tionalize" the
industry, turning it into a sort of public utility. Providers naturally balked and the legislation was defeated.
But, recalls former Maryland Hospital Assn. President Richard Davidson. the debate set the industry to thinking.'
After all. state rate setting, if it were done correctly, would have some benefits to hospitals. Facilities would
have a steady income flow and would know exactly what they would be paid for each case. And, the system
guarantees access to hospital care for every resident, regardless of insurance.
So, rather than waiting for the next legislative battle to begin, Davidson gathered his troops and drafted
his own plan. After gaining support from a key legislator and Gov. Marvin Mandel. the proposal was approved.
featuring an active role for hospitals in the establishment of the rates and monitoring of implementation.
Operating under a federal Medicare waiver, Maryland's Health Services Cost Review Commission
(HSCRC) regulates rates to reflect the cost of operation for the state's 53 hospitals. As a result. Maryland
hospitals are the only ones in the nation not being paid under Medicare's DRGs.
IMPRESSIVE RESULTS
The results have been so impressive that state and federal policymakers who are desperately trying
to control health care costs are taking a second look at Maryland's system. The-National Governors' Assn.'s
new health reform proposal, for example, says that states might want to test rate regulation.
But while Maryland hospital administrators say the system works for them. many caution that it might
not work in other places. For one thing. Maryland is unique in the degree of cooperation among its hospitals.
And even with all of the good news. some serious potential problems - such as continuing cost increases
- loom on the horizon.
"The overall merits of the system from a public policy standpoint are very positive," says Jim Xinis.
CEO and president of Calvert Memorial Hospital in Prince Frederick County. "But it's not all peaches and
cream. The net income over operating expenses that hospitals have obtained has been less than the national
average. And the rates [that hospitals are paid] are not going up as fast as the cost of providing services."
John Colmers. executive director of HSCRC. agrees that profit margins are slim, but says the advantages
of rate setting far outweigh any drawbacks. "It's more rational, more equitable. and more predictable. And
it's saved money - that's the ultimate proof."
F&G
Christina Kent, Editor
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PERSPECTIVES. August 19. 1991
Some say the debate boils down to à philosophical argument: what is the best way to control costs.
the free market or regulation? The only answer that Maryland can give is that. in Maryland - so far -
regulation has worked.
Under its system. Maryland sets payment rates for all hospital-based inpatient and outpatient care. First.
hospitals inform HSCRC of their estimated costs for medicine. surgery. and other departments. Costs for
direct and indirect departmental expenses. uncompensated care. working capital. and buildings and equipment
are factored in. Those expenses are compared to the costs of a similar group of hospitals, under the theory
that like hospitals should have like costs.
HSCRC decides whether each hospital's estimates are reasonable or unreasonable. allowing hospitals
that believe they will have unusually high costs to justify them. If HSCRC believes that the proposed
expenditures are overstated, public hearings are held. Hospitals can appeal unfavorable decisions to the
Maryland courts. At the end, rates are set for individual departments.
Once a year. the rates are adjusted to take into account the inflation that occurred in salaries. fringe
benefits. food. supplies. and other expenses. Hospitals rarely undergo full rate reviews. relying instead
on automatic inflation adjustments. Although some hospital administrators criticize the automatic
adjustments for not providing enough of a profit "cushion." others say they increase stability throughout
the system.
Bad debt and charity expenses are included in the rate base: cross-subsidization among hospital services
is prohibited: most nonpatient revenue is used to offset patient care rates: rates include a markup for working
capital: and discounts are provided to Medicare and Medicaid. to patients who pay upon discharge, and to
third-party payers who, twice a year. accept all applicants.
UNIQUE FACTORS
For those who are looking to Maryland as the panaces for health cost inflation, there are enough
similarities to provide encouragement but enough differences to make the going slow. The system was launched
in the en v 1970s. in the midst of precipitous cost increases and a rise in the number of uninsured. The
early go. 5. was rocky. as the state sought to drive down costs. ys Spencer Foreman. CEO of New York's
Montefiore Medical Center and former CEO of Baltimore's Sin 1 Hospital. "No system that has as its goal
the reduction of resources is going to make people happy. and restrictions and cutbacks made relations
confrontational and very legalistic."
To aid in its effort. HSCRC interpreted the law's requirement that payments meet the "financial
requirements of a hospital" to mean meet the costs of an "efficiently and effectively" run facility. Those
were, of course, two very different things. Over the years. hospitals and HSCRC often have debated whether
hospitals were or were not efficient. and whether the standards that HSCRC applied were appropriate.
Hospitals have gone to court. arguing that HSCRC must accept a "reasonable" rate structure proposed
by hospitals and saying HSCRC does not have the authority to order refunds for rates that are above
approved rates. Industry also has challenged the budget review method as arbitrary and capricious. saying
the selection of comparison hospitals was subjective. Courts have upheld the principles that HSCRC is
solely empowered to determine rate structures and that hospitals may charge only HSCRC-approved rates.
Other rulings. however, have said HSCRC's ratings and methods must be supported by "competent. material,
and substantial evidence."
Hospital officials say that while they don't always agree with HSCRC. the regulators tend to be responsive
to hospitals' concerns. For example. about two and a half years ago, wage and salary increases began to
outstrip the inflation adjustments provided by HSCRC. In the first part of 1988. Maryland hospitals average
profit margins dipped to less than one-quarter of the national average. After hearing the case made by hospital
administrators, HSCRC agreed to a 1.5 percent across-the-board rate increase. which gave hospitals an
additional $45 million. Some say this one-time increase won't stave off future needs. however.
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PERSPECTIVES. August 19., 1991
THE RESULTS?
The system has plenty of admirers - and detractors. Robert Heyssel. MD. president of Baltimore's
Johns Hopkins Hospital and the Johns Hopkins Health System, says the all-payer method works 90 well
that the federal government should extend it to all hospitals - and physicians.
Rate setting contains costs, Heyssel says. For 15 consecutive years. Maryland hospital admission costs have
risen at rates below the national average. in 1990. costs per admission rose 8.7 percent, compared to a national
average of 8.96 percent. Rate regulation saved Marylanders $5.3 million in 1990. HSCRC says.
And the system factors "reasonable" levels of bad debt and charity expenses into the rates that hospitals
can charge. so those costs are distributed equally among all payers. In Maryland, hospital costs are marked
up an average of about 7 percent to cover uncompensated care. In unregulated states. private payers often
have their charges marked up by 20-to-30 percent for patients who can't pay. As a result. Maryland has
"not had the sort of dumping problems that you have elsewhere." Heyssel says.
The strategy is predictable. he adds. "You can make a good guess in January when you're preparing
your budget about what kind of rate change you will get. Who knows what the federal government will
do with Medicare from year to year?" And. the system has helped to lock in the status quo. Over the decade
of the 1980s. more than 800 hospitals closed throughout the country. In Maryland. the closure total was
three.
Those arguments are anathema to those who believe that rate regulation is wrong. both from a practical
and a philosophical point of view. "Maryland has been the least oppressive of the rate-setting states (because its
rates tend to be higher]." says Michael Bromberg, executive director of the Federation of American Health
Systems (FAHS). which represents for-profit hospitals. But even Maryland saves money by squeezing
profit margins, which means hospitals have few funds to invest in equipment and buildings. Bromberg
says. In 1990. Maryland hospitals had a total profit margin of 1.88 percent. compared to the 4.8 percent
margin of hospitals nationwide.
Bromberg adds that rate regulation doesn't really save money. A recent FAHS-sponsored study found
that regulated states had higher per capita hospital expenditure increases than states that are competitive (as
measured by high concentrations of health maintenance organizations). From 1986 to 1989. per capita
experiditures in six regulated states (MD. MA. NJ. WA. CT. NY) increased an average of 9.5 percent - -
compared to only 7.1 percent in five competitive states (MN, CA. OR, DE. CO). Maryland's per capita
expenditures rose 8.2 percent during that period.
Finally. rate regulation inhibits innovation in health care delivery, Bromberg says. "Once you have
the same price for everybody. the incentive to experiment, to take risks, evaporates."
HMOs too are not enamored of the all-payer system because it prevents them from negotiating discounts
with hospitals. Rate regulation "doesn't preclude our participation. but it doesn't allow us to give as affordable
health care as we could under other systems." says Geni Dunnells, executive director of the Maryland Assn.
of Health Maintenance Organizations.
CHANGES AROUND THE BEND?
While hospital administrators tend to foresee no major changes in the system in the near future. they
are worried about continually rising costs and dropping profits. "The rest of the country can shift costs to
private-pay patients." says Xinis. "We can't. It makes things more difficult."
Looming over officials is the potential loss of the Medicare waiver. which would make the all-payer
system a thing of the past. If Medicare costs per admission in Maryland at any time creep past the national
average. the state will have to design a new payment system and figure out a way to pay for uncompensated
care. which last year cost Maryland about $270 million.
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It's happened in other states. Only a few years ago. Maryland was one of four states operating all-
payer systems under Medicare waivers. But New York. New Jersey. and Massachusetts gradually have dropped
from the fold. Only Maryland and a six-hospital system in upstate New York have retained the waivers.
The consequences of losing the waiver can be devastating. New Jersey. for example, is currently paying
for uncompensated care by adding a 19.7 percent surcharge to hospital bills. which has sent insurance costs
rocketing upward. "Business and industry have notified us of their concern and the governor is trying to
get a payroll tax adopted [to take the place of the add-on)," says Pamela Dickson. assistant commissioner
for the New Jersey Health Dept.
Maryland officials say that such potential problems make them all the more committed to retaining the all-
payer system. "In the long run, I feel quite optimistic about the hospital industry in Maryland," Colmers says.
"There remains a very strong commitment among the political leadership and hospitals to keep the system going."
TAKING IT ON THE ROAD
Could portions or all of Maryland's system be transferred to other states or to the nation as a whole?
Some say the answer is "no." "I frankly do not think that it would work in larger states or [on a national
basis)." says Monteflore's Foreman. "The system requires that the regulators know a good bit about the
individual circumstances [of each hospital]. You can't do that when you have to meet national standards."
Nonsense. says Johns Hopkins' Heyssel. If necessary. the U.S. could be broken down into smaller portions
for purposes of regulation. in Eact. some say that Maryland's system doesn't go far enough. "The Maryland system
has stabilized costs, and uncompensated care is covered." says PhyMis Torda, of the consumer advocacy group Families
USA. "But it has the obvious weakness of only applying to hospital care - it doesn't guarantee access to physician
care." Torda and Heyssel advocate extending rate regulation to physician fees and hospitals around the country.
It may be that certain principles of Maryland's system. such as efficiency. solvency. and paying for
uncompensated care. could be incorporated into other systems. says Colmers. "But [the system) is not a panacea
for every state. Certain features work quite well in Maryland and would work well in other areas. I'm not a zealot
for having it copied. but I am in favor of states being given the flexibility to set up their own systems."
Davidson's recent elevation to the presidency of the American Hospital Assn. has turned a new spotlight
on the Maryland system and set some to wondering if the new AHA chief might be interested in exporting the
Maryland system to the nation. Definitely not. says Davidson. whose selection was generally greeted with cheers
but has some opponents of regulation nervous. Davidson says that Maryland's system works because the law that
set it up was written by hospitals and is not punitive. The basic question is not regulation versus competition.
Davidson says: "it is defining the appropriate relationship between government and hospitals." In Maryland. that
relationship is trust. and that trust would have to be transferred or created. if the "Maryland system" was to work
in other places, Davidson adds. "It works in Maryland because the hospitals want it to work-- it was their idea."
Still. members of Congress - Democrats in particular - are looking for ways to control costs in order
to case passage of legislation to expand access to care for the uninsured. A proposal (S.1227) by Senate
Democratic leaders would establish national expenditure targets for each segment of the health care system
and create an independent national board to monitor compliance. While that voluntary system upset some
providers. industry is more nervous about a proposal by Sen. Paul Simon (D-IL) to make the controls mandatory.
The Simon bill (S.1669) has the backing of organized tabor. And a plan (H.R.3205) by House Ways & Means
Committee Chairman Dan Rostenkowski (D-IL) includes mandatory spending targets as well. If federal Inwmakers
can convince providers that they seek a cooperative relationship - a la Maryland - a national rate setting system
could be just around the bend- CK
HEALTHCARE
Editorial:
Published as a supplement to Medicine & Health, 1133 Fifteenth
INFORMATION
Richard Serian, Executive Editor
Street, NW, Suite 450, Washington DC 20005. ©1991 Faulkner s
Janet Firshein. Editor, M&H
Gray, 106 Fulton SL. New York NY 10038. Reproduction in any form
CENTER
forbidder. Reprints of PERSPECTIVES are available to subscribers
Editorial Information, (202) 828-4148
at $5 each: $2 each for 5 to 50 copies: $1 each above that Price to
Fax: (202) 828-2352
nonsubscribers it $25 each for single copies.
** TOTAL PAGE. 005 **
DRAFT
While American congressmen and columists traipse all over the world in
search of 0 successful health care system, they are ignoring one right under
their noses -- in Maryland.
Since 1977 , Maryland has been "excused" from the federal formula for
hospital cost contairment. For the past 15 years, it has been the only state
exempted. Why? Because Maryland had o successful hospital cost containment
system in place before the federal government got into the act.
In every state but Maryland, Washington decrees the rates paid to
hospitals for treating patients covered by Medicaid and Medicare -- no matter
what the actual costs. In all other states, neither the federal government
nor non-goverment insurers, fran HVD's to the Blues, are compelled to share
in a hospital's cost of providing care to all patients, including the
uninsured poor. There is no pressure on the insurers to share in underwriting
high cost regional services, such as troumo centers or neonatal intensive care
units. They pay only costs related directly to the care of persons covered by
their policies.
The consequences are grim -- for the uninsured poor as well as for those
who treat them. Urban academic medical centers, the usual and most
sophisticated caregivers, are forced to dip into endowment until they, too,
are impoverished, unable to develop new programs or properly cover the cost of
old ones. Meanwhile, the poor are shunted from hospital to hospital as
institutions protect themselves from bad debts by durping poor patients on the
medical centers -- o modern variant of "hot potato."
By contrast, Maryland's unique hospital reinbursement system is the most
A
Johns Hopkins
Medical Institutions
550 North Broadway/Baltimore, MD 21205
(410) 955-6680 / FAX (410) 955-4452
Office of Public Affairs
rational and humane in the nation. Ours is the only state with on "all-payor"
system. This means that all insurers -- government or commercial -- as well
as all who pay their own way, must pay the same rate of o particular
hospital. The rate is set not by some distant federal bureaucracy's formula
but by 0 state commission with great flexibility: the Health Services Cost
Review Commission.
In o world-class display of common sense, the HSCRC adjusts each
hospital's rates to reflect that hospital's reasonable costs of providing
services needed by Marylanders. This means that hospitals treating more of
the uninsured poor get more leeway in rates than hospitals treating fewer
poor. And the rates reflect the true costs of keeping 0 state-of-the-ort
emergency room or intensive care unit staffed round the clock, as opposed to
costs of a first-aid station.
Through the HSCRC, Maryland's officials acknowledge that it is in the
state's best interest to mointain o healthy network of hospitals, including
institutions such as Johns Hopkins that offer the most advanced levels of
care.
There is, of course, o hitch. To maintain this rational system and
protection from the federal formula, the inflation rate in Maryland's
hospitals must be less than the national average for hospital inflation.
Through constant monitoring, the HSCRC guards this margin of freedam and asks
each hospital to make adjustments to keep it.
This year, for instance, our approved rates at Johns Hopkins were 9
percent above the average of the state's hospitals. The Commission agreed
these rates were needed to cover the costs of the care we provide.
Nonetheless, the HSCRC now has asked US to cut costs 2 percent o year for each
of the next two years as our part in lowering the state's overall hospital
Johns Hopkins
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Office of Public Affairs
inflation rate?
Belt-tightening won't isn't be easy, but it is a price we willingly pay to help
the State of Maryland retain its unique hospital reinbursement system.
Could other states do what Maryland does? The answer is "yes" if all
players, from hospital administrators to government insurers, are willing to
put something into the kitty. The gamble seems well worth it to escape the
current no-win system that hurts patients and hospitals alike.
#
Johns Hopkins
Medical Institutions
550 North Broadway/Baltimore, MD 21205
(410) 955-6680 / FAX (410) 955-4452
Office of Public Affairs
BUSINESS Baltimore JOURNAL
JUN 24 1991
BALTIMORE PROFILE
JOURNAL PHOTO BY TED HOFFMAN
Davidson to guide American Hospital Association into new era.
Health care's voice of reform
By Christopher J. Gearon
And while horror stories abound about hos-
pitals turning away sick people because they
Richard J. Davidson, the newly appointed
lack insurance, that isn't an issue here as
president of the American Hospital Associa-
Maryland hospitals have agreed to treat pa-
tion, has made some folks in the health care
tients regardless of their ability to pay.
industry nervous.
Even though Maryland saw Homewood
As president of the Maryland Hospital Asso-
Hospital Center close this spring - the first
ciation for the last 22 years, Davidson helped a
Maryland hospital to close in five years - the
hospital system that was one of the costliest in
state's 52 hospitals overall are stable finan-
the nation 15 years ago become one of the
cially because of a system designed to focus on
most efficient today - saving Marylanders
patient care rather than big profits. Not a lot
more than $1 billion.
Continued on page 33
JUNE 21-27, 1991
BALTIMORE BUSINESS JOURNAL
PAGE 33
D.C. "It sounds quite scary (to
idson said, especially since what both
Nation's hospitals watching as
them)."
want is so similar. But with the talk of
"It's a very strong dichotomy,"
a federal role in health care, hospitals
Marylander takes over association
Sorian said, when Maryland hospital
get nervous.
administrators praiseing the system to
"What you have out there is a terri-
Maryland's system, they are wary of
outside administrators, who'd rather
ble distrust of government," Davidson
Continued from page 1
of hospital systems can match that.
the means by which it's achieved -
distance themselves from increased
said of the nation's hospitals.
But while Davidson's appointment
private sector hospitals working with
government ties.
Within the last decade, as the fed-
in May to the 4,935-member organiza-
and depending on the state and federal
While Maryland's strong hospital-
eral government has reimbursed hos-
tion reportedly was greeted with en-
governments.
government relationship is in the back
pitals on a prospective payment sys-
thusiasm, there are some in the indus-
Maryland hospitals are heavily reg-
of health care executives' minds when
tem for the caring of Medicare
try that feel Davidson will back
ulated by the state, and Davidson is a
Davidson's name is mentioned, Sorian
patients, hospitals have been squeezed
national rate setting for hospitals.
big reason for that. In the early 1970s,
said that industry players are "very
continually by Washington. The fed-
Davidson, now in the forefront on
when the cost of admission in a Mary-
receptive to him personally because
eral government keeps racheting down
the debate of American health care re-
land hospital was quickly outpacing
he's very well respected."
its payback, making it tougher for
form, said he isn't planning to force
hospitals in other states, lawmakers
"There's a lot of anticipation about
hospitals to treat patients effectively
Maryland's system on the rest of the
and hospitals were concerned. Every-
what role I will play in (national
and maintain their viability.
one knew something had to be done,
health reform) discussion and debate,
Davidson will have his work cut out
country.
"A lot of people say, 'Davidson, can
and Davidson brought competing hos-
and it will be as an honest critic of
for him trying to convince all parties
pitals together convincing them that
what can and cannot work, and I
that. their interests are the same, and
you transport Maryland's system to
other states?' and my reaction is "I
their future was in working with the
wouldn't pretend for a minute that
an even tougher time trying to con-
don't think so,' the Severna Park
state.
what we do here can be replicated in
vince government and other payors
Through the years, hospitals sub-
other states," Davidson said.
that the long-term financial health of
resident said.
"What we do here is driven by a set
mitted to regulation so that they could
Davidson believes that the competi-
hospitals is not grounded in oppres-
of values," Davidson said of Mary-
concentrate on their mission of pro-
tive focus of the last decade distracted
sive cost containment.
land's hospital system. "We want to
viding care to those who needed it.
the nation's hospitals from their mis-
But Davidson said he's also con-
ensure care to those who come to our
And by 1975, the federal government
sion as care providers. Maryland
cerned about the Maryland hospital
door who don't have the ability to
and Blue Cross and Blue Shield of
didn't have that distraction.
system.
pay. I have an enormous sense of
Maryland were brought into what has
"The theme of the 1980s was health
"I think hospitals in the state of
pride to what's happening in Mary-
been dubbed as the "all-payor" sys-
care could compete like any other
Maryland will be continuously chal-
land."
tem. The system subsidizes hospital
business in selling a commodity. That
lenged with holding the payment sys-
On July 15, Davidson will land in
care for those who can't afford care.
kind of became the policy or mantra
tem together," Davidson said.
the middle of the health care reform
The hitch is that Maryland's hospi-
of a lot of people in health care," he
As the federal government contin-
said. "Hospitals changed in the '80s,
ues to cut payments to hospitals for
debate swirling in Washington as he
tal costs must stay below national hos-
moves the AHA president's office
pital costs or the system unravels.
but they got beat up in a lot of
providing care to federally subsidized
from the group's Chicago-based head-
Other hospital systems are petrified of
places."
patients, Maryland is not immune
quarters to the nation's capital. While
Davidson wants to emphasize col-
from these pressures.
such dependance on the government.
overseeing 850 staffers, the associa-
"Most hospital administrators out-
laboration, not competition, among
Even with Davidson leaving Mary-
tion's highest ranking staff member
side of Maryland
who don't un-
the nation's hospitals as the industry's
land's association to lead the national
will be meeting with the nation's lead-
derstand the Maryland system think
leading spokesman. Collaboration is
hospital association, Maryland's hos-
ers advocating ways to make the
it's the next step to communism," said
what takes place in Maryland. That,
pital system, like the rest of the na-
country's hospital system stronger.
Richard M. Sorian, executive director
he said, benefits the patients most.
tion's hospitals, will be depending on
And although hospital leaders
of the Faulkner and Gray Healthcare
Hospitals and governments need a
Davidson's voice during the turbulent
around the country are envious of
Information Center in Washington,
better working relationship, too, Dav-
debate on health care reform.
RCV BY JHMI
: 5- 9-91 :11:42AM ;
301 955 0825-> JHMI PUBLIC AFFAIRS: # 2
may y 91 10:43
0254 MEDICAL TECHNOLOGY
ICL 301-935-0823
The Johns Hopkins
1830 East Monument Street
Room 8068
Program for Medical
Baltimore, MD 21205
Technology and
Telephone: (301) 955-8294
FAX: (301) 955-0825
Practice Assessment
Earl P. Steinberg, M.D., M.P.P.
Director
Gorard F. Anderson, Ph.D.
Co-Director
The Johns Hopkins Program for Medical Technology
and Practice Assessment
The Johns Hopkins Program for Medical Technology and Practice Assessment
is a collaborative undertaking of the Johns Hopkins School of Medicine, the Johns
Hopkins School of Hygiene and Public Health, and the Johns Hopkins Hospital/
Health System. The Program draws together a multi-disciplinary faculty with the
purpose of defining clinical, management, and policy strategies that will contain
costs while preserving or enhancing quality of care. Program faculty and staff
include physicians, economists, health services researchers, clinical
epidemiologists, statisticians, and experts in health policy, decision analysis,
artificial intelligence and computer science, medical ethics and clinical
education. Program faculty have conducted research on the efficacy, cost, and
cost-effectiveness of new and established medical technologies and practices,
as well as the quality and outcomes of care. Recent technology assessments have
focused on low-osmolality radiographic contrast dyes, gallstone lithotripsy, the
impact of peripheral angioplasty on management of peripheral vascular disease,
and variations in the management of cataract. In addition, Program faculty are
currently involved in development and implementation of a new quality assessment/
quality assurance system for the Johns Hopkins Hospital.
The Program for Medical Technology and Practice Assessment is 0 collaborative effort of the Johns I lopkins School of Medicine, School
of Public Health, and Hospital. The Program is based within the Johns Hopkins Center for Hospital Finance and Management.
Johns Hopkins Medical Institutions
Office of Public Affairs
550 North Broadway / Baltimore, MD 21205 (301) 955-6680 / FAX (301) 955-4452
FOR RELEASE ON RECEIPT
HOPKINS HEART STUDY RAISES COST VS. CARE DILEMMA
NEWS RELEASE
A new Hopkins study of a common diagnostic procedure has put the spotlight
on the ethical dilemma of how to provide the highest-quality care while keeping costs
under control. In the study, Hopkins researchers compared two types of contrast dye
used to diagnose coronary heart disease, and found that the older, cheaper type of
dye works as well for most cardiac catheterizations as a widely used new one that
costs up to 20 times more. The results of the study are reported in the February 13
issue of the New England Journal of Medicine.
"This is a new breed of study that reflects the attention hospitals and
physicians are now giving to costs," says Earl P. Steinberg, M.D., M.P.P., principal
investigator in the study. "We're entering an era in which expensive innovations will
be very critically evaluated before we accept them."
In their study of diagnostic cardiac catheterizations in 500 patients, Steinberg
and his team compared reactions to two types of contrast dyes--an older, inexpensive
high-osmolality dye and a new, very expensive low-osmolality dye that has been
widely adopted by hospitals nationwide since its approval five years ago. The old type
costs about $8.00 per injection and the new, about $200.
The study found that patients injected with the old dye experienced slightly
more "nuisance symptoms," including nausea, vomiting or hives. They also showed
mild changes in heart rate and blood pressure three times as often than those
injected with the new one. But because there was little or no difference in the rate
(more)
The Johns Hopkins Hospital
School of Medicine
School of Nursing
School of Public Health
Johns Hopkins Health System
JHMI--Costs--Page 2
of severe reactions, the study concludes that using the new dye only in high-risk patients would be
more cost-effective than using it in all patients. "Using the new dye in all patients buys a very small
benefit at a very high cost," says Steinberg.
Cardiac catheterization, or angiography, is a routine diagnostic procedure that uses contrast
dye to detect blockages in coronary arteries. About 1.2 million are done in the U.S. each year.
Similar dye injections are used for the 10-12 million radiographic procedures done in this country
annually. According to Steinberg, using the old dye instead of the new for these procedures would
save $1 billion a year nationwide. For cardiac catheterizations alone, use of the old dye would save
$200 million.
Like Hopkins, many hospitals now employ a team of experts to regularly assess the costs and
benefits of adopting very expensive new medical technology. "With elections coming up, everyone is
talking about the need for affordable health insurance and cost control," says Steinberg. "But cost
control involves trade-offs. Our study is a good example of the cost VS. quality decisions hospitals now
have to make."
###
(For press inquiries only, call Rachel Wilder or Carol Pearson at (301) 955-6680.) 2/13/92
Note: Our area code is now 410 instead of 301.
THE NATIONAL LEADERSHIP COALITION
FOR HEALTH CARE REFORM
File
Arlington, Virginia
March-15, 1991
Robert M. Heyssel, M.D.
Thank you for letting me share my thoughts with
you today. What I have to say is a further
evolution of ideas presented in a lecture at the
IOM last April.
What I said then was that we need what will be
perceived by many as radical change if we are
to deal with the problems of cost, access and
quality in the health care system.
I implied that radical change included not just the
delivery system but education of professionals
as well, and that radical change will have pain in
it for everyone. I will add to that that the pain
2
will be greater and more expensive if piecemeal
changes are pursued.
Change had to have as a goal the betterment of
community health broadly bringing providers and
the community together in a new partnership to
bring about targeted and measurable
improvement in the health status of Americans.
I said then that we did not need more money. I will
qualify that by saying to obtain the change we
need we will have to spend more money up
front. We will recover it many times over if we
do it right.
And, finally, that organized systems of care --
organized delivery system -- or ODS's in your
3
new jargon -- is the mechanism through which
this can be done.
What I want to do is to get more particular
concerning the necessary elements to achieve
ordered change toward the objective of
community-based delivery systems.
Let me restate my premise, briefly, that addressing
equity of access alone (read financing for that)
without a clear vision of the shape of the
system that will result will frustrate our efforts
to control costs, achieve equity and provide
quality of care.
Quality of care is individual and measurable, and
quality of system services is also measurable in
4
the community as a whole. Organized Delivery
Systems that receive money for a broad array of
health services -- population- or enrollment-
based -- are necessary to develop the targets
and measures of success. The ultimate goal is
to allocate resources and hold organizations
responsible and accountable for the health of
populations within a framework of measurable
costs.
The statement made earlier that we do not need
more money in the long run is based on the
belief that much of the very expensive care we
now give is a result of misallocation of
resources. We do not have effective
community-provider interactions in prevention
and treatment. Instead, expensive power
5
centers of specialty care -- hospital and
physician controlled -- characterize the system
today.
The base of such a system must be primary care,
integrated with a tier of services from home care
to specialty care and care of those no longer
capable of independent living.
How do we change in practical terms and what are
the elements we need to put in place to bring
about change most rapidly?
First, we need to put in place through federal
government an action plan for universal health
insurance coverage. There must be an
important role for state, regional and interstate
6
or intrastate organizations in administration and
regulation. The bulk of the funding needed for
expansion of coverage to those unable to pay
and for subsidies to small businesses unable to
pay on behalf of their employees should be
federal. We would retain a private-public mix of
payment. The German sick funds are probably
the closest analogy to a restructured United
States system of health insurance rather than
the Canadian or United Kingdom system.
A basic set of benefits would be put in place for
citizens to include inpatient and outpatient,
preventive and catastrophic coverage.
Mechanisms which move away from experience
rating for groups to broader community rating of
7
premium setting must be achieved.
An option for individuals to supplement basic
benefits should be offered, but employers or
employees would not be able to take advantage
of tax deductions for benefits added above the
basic package.
There should be co-pays for individuals with a cap
on individual expenditures dependent on income.
Second and simultaneously, "all-payor" systems with
rate control for hospitals and physicians and
other elements of the delivery system should be
mandated by the Federal Government as an
exchange for federal funding. As indicated
earlier, these administrative agencies could be
8
state-wide, within states by regions or interstate
by state agreements, not federally administered.
They would not set insurance premiums, rather
negotiate rates for payment to providers.
Utilization review and other programs to control
rates of use of services would remain, but it is
assumed that, over time, quality measures
related to outcomes would supplant such
measures.
Third, and again simultaneously, capital pools by
region should be established. These pools
would have two purposes, to provide for annual
capital replacement, and to retire debt for
individual hospitals to make mergers and
consolidation of providers more attractive.
9
Allocation from the capital pools would be
through the agencies developed for rate control.
Again, capital allocation mechanisms may
disappear as competitive systems mature.
Fourth, government activity through the regional all
payors system agencies should stimulate system
formation by negotiating with existing systems
and by calling for the development of new
competitive systems. New systems will form in
response to opportunities to gain or protect
market share. Provider systems would delineate
their markets in concert with government
insurers and employers.
Federal antitrust laws would require revision. The
creation of competitive, public utility-like,
10
organized systems in health care would lead to
market concentration, but market concentration
with a purpose.
Incentives for hospitals, physicians, home health
agencies, and extended care facilities would
include among others:
- Access to capital.
- Incentive payments for the achievement of
defined goals.
- Risk sharing with insurers.
- Opportunities to expand their base of
patients.
Arguments that the regulatory agencies will be too
powerful are countered by two facts. First, they
11
are no less powerful and much more
accountable locally than a federally controlled
system. Second, they must be powerful to
succeed.
Arguments that systems will not form or are not in
sufficient numbers now are arguments against
any change at all. In fact, the HMO movement
grew by federal stimulus. In fact, incomplete
systems, including HMOs, are abundant now.
Arguments that there are too few primary care
providers nationally and in many local areas
ignore the power of incentives to change many
practice patterns of primary care practitioners
and specialists alike.
12
Finally, arguments that it will not work in under-
served urban areas or rural areas again ignores
the power of incentives for institutional
providers and individual practitioners. In fact,
the reason for regional and state systems is to
allow for local innovation and experimentation.
The argument for such an approach is that it is less
draconian and more consistent with American
political processes and, therefore, more likely to
be acceptable than other suggestions if we are
serious about solving the problems of cost,
access and quality.
Johns Hopkins Medical Institutions
Office of Public Affairs
550 North Broadway / Baltimore, MD 21205 (301) 955-6680 / FAX (301) 955-4452
FOR RELEASE ON RECEIPT
NEWS RELEASE
OUTPATIENT CARE: A $140 MILLION HOPKINS INVESTMENT
With the opening of a new $140 million Outpatient Center, Johns Hopkins will
relocate 10 specialty departments into a single building, providing a convenient,
"seamless" medical experience for an estimated 1,200 patients each day.
To identify bottlenecks in patient flow, Hopkins developed a computer model to
simulate up to 8,000 patient visits per week. Using this model, they were able to plan
the amount of staffing needed to meet their objective -- that patients spend as much or
more time with their doctor as on non-clinical activities, such as registration.
"We've tried to keep our patients' concerns first and foremost among all
considerations," says Steven H. Lipstein, executive director of the Johns Hopkins
Outpatient Center. "We've made it easy to park, we've introduced advance registration
to speed up flow on the day of appointment, we've worked hard on layout and
directional signage to make it easy to find your way. We've also grouped together
diagnostic testing areas so that patients can get through quickly and efficiently."
Some 300 physicians will provide specialty care (not emergency or general
medicine) in the new building, in areas such as obstetrics/gynecology, pediatrics, and
urology.
Discussions about building such a center at Hopkins began in the mid-1980s,
when, nationwide, advances in medical technology, the need to control costs, and
changing insurance practices created a shift toward outpatient care. By 1987, detailed
planning meetings were under way with physicians, nurses, and administrators.
Today at Hopkins, 55 percent of radiology and 39 percent of surgical procedures
are performed on an outpatient basis, and the rates continue to grow each year. Since
1982, in fact, outpatient surgery has increased 30 percent, and last year was a near-
record year at Johns Hopkins for total outpatient volume.
"Because many aspects of medical practice are shifting to an outpatient
environment, this building is essential to our future," says Lipstein, who has worked on
The Johns Hopkins Hospital
several pivotal projects at Hopkins during his 10-year career there.
School of Medicine
School of Nursing
(more)
School of Public Health
Johns Hopkins Health System
JHMI-Patient--Page 2
Room for growth was planned into the building, too. For example, while eight operating rooms
have been constructed on the lower level, only six will open at first. Shell space has been constructed
for expansion in radiology and for a Pain Treatment Center as well.
Lipstein emphasizes that this project is more than an investment in bricks and mortar. In
outpatient services, it also represents an investment in new information systems for patient registration,
appointment scheduling, ordering tests, and recording patient charges. Hopkins has mounted a major
orientation and training effort for non-medical personnel who provide essential services to outpatients.
About a dozen jobs registrars, receptionists, clerks, and a host of others -- have been collapsed into
a single job title: patient service coordinator, Lipstein says.
"I can't over-emphasize the important role of our patient service coordinators," he says. "They are
the first people to greet our patients, they are knowledgeable about patients' needs and our services and
can provide needed assistance. As wonderful as the new building is, the building won't make the
difference; our people will."
Nearly 800 employees throughout Hopkins have received training on the new computer
registration system. In addition, all patient service coordinators will receive training in job skills
(including the most up-to-date information on insurance regulations) and customer service skills. "It's
been a big success, but also one of our largest challenges," says Bill Kent, director of administrative
services for the center.
Patient service coordinators also will look the part in "career apparel" provided by Johns Hopkins.
Women will dress in business suits and men in gray or navy blazers.
"The career apparel program is part of our commitment," says Lipstein. "We're doing it so
patients recognize our employees and because we think it will increase the respect all employees are
due."
In a unique ownership arrangement, the Outpatient Center is being financed jointly by The Johns
Hopkins Hospital and University, which are two separate corporations. The building is owned as a
condominium with three separate units. Areas such as radiology and surgery are owned by the Hospital;
faculty offices and research labs by the University, on behalf of the School of Medicine. All other areas,
such as exam rooms, are owned jointly.
###
(For press inquiries only, call Carol Pearson or Joann Rodgers at (410) 955-5384.) Please note: Our area
code is now 410 instead of 301. 4/6/92
Johns Hopkins Medical Institutions
Office of Public Affairs
550 North Broadway / Baltimore, MD 21205 (301) 955-6680 / FAX (301) 955-4452
RELEASE
FOR RELEASE ON RECEIPT
OUTPATIENT CENTER AT JOHNS HOPKINS OPENS FOR BUSINESS MAY 18
A $140 million, eight-story Outpatient Center at Johns Hopkins will be dedicated
May 8, and will open for business on May 18. The 450,000-square-foot building is
designed to serve 1,200 patients a day, making it the biggest outpatient facility in
Baltimore, and one of the largest in the Northeast. More important than the physical
facility, however, the new Outpatient Center is expected to change the way Johns
Hopkins does business.
With the opening of the center, patients will preregister at home, cutting waiting
time on the day of their appointment. Upon arrival, patients will find nearby parking,
be greeted by uniformed personnel, and guided by talking elevators. If a blood test or
chest X-ray is necessary, it will be done in one convenient location. In addition to the
streamlined clinic visit, conveniences such as a pharmacy, optical store, bank machine,
and even a gift shop and coffee bar have been added.
It's all part of the "ideal patient experience," an idea culled from the suggestions
of patients and staff alike. "As wonderful as the building is, the building won't make the
difference, people will," says Steven H. Lipstein, executive director of the Outpatient
Center. "We want to give patients personalized attention, to make them feel important
and appreciated. They should spend more time receiving medical care than parking,
walking, waiting, registering, and looking for the right bank of elevators.
Intensive planning for the facility began in 1987 and has included input from
hundreds of people. In addition, Hopkins officials traveled throughout the United
States, from Phoenix to New Orleans to Rochester, Minn., gathering ideas from eight
centers. They borrowed the idea for advance registration from Duke University, for
instance, while "career apparel" originated with the Ochsner Clinic in New Orleans.
"Collaboration between the School of Medicine and the Hospital have sharpened
the Outpatient Center's focus on patient care and patient service," says Mark C. Rogers,
M.D., associate dean for clinical practice and chairman of the center's management
committee. "In developing this center, we have taken input from physicians, nurses,
The Johns Hopkins Hospital
School of Medicine
(more)
School of Nursing
School of Public Health
Johns Hopkins Health System
JHMI--Outpatient-Page 2
administrators, and the patients themselves. It represents our best thinking in the area of ambulatory
care."
To prepare for opening day, employees have been training for the last year. A new computerized
registration system called EPIC is now up and running in all of the clinics. A new job title, "patient
service coordinator," was created for the team of nonclinical personnel working directly with patients.
In addition to computer workshops, trainees will attend sessions to update knowledge of insurance
regulations and customer service skills. Refresher courses are mandatory every six months.
In all, 10 specialty clinics--from dermatology to surgery--will move their outpatient practices from
various locations inside The Johns Hopkins Hospital's 19 buildings to the new building located across
the street, on the west side of Broadway. With the move, some departments will as much as quadruple
their present space.
Designed by Payette Associates of Boston and built by George Hyman Construction Co., the
building includes 191 exam rooms organized in clusters or "pods." Eight operating rooms are designed
using the same pattern. The facility also is equipped with 68 procedure rooms, 28 radiology rooms, and
12 blood-drawing stations. A tunnel will connect the new building to the rest of the Hopkins complex,
as well as to the subway station planned for completion in the mid-1990s.
(For press inquiries only, call Joann Rodgers or Carol Pearson at (410) 955-5384.) Please note: Our area
code is now 410 instead of 301. 4/6/92
Johns Hopkins Medical Institutions
Office of Public Affairs
550 North Broadway / Baltimore, MD 21205 (301) 955-6680 / FAX (301) 955-4452
FOR RELEASE ON RECEIPT
JOHNS HOPKINS OUTPATIENT CENTER: THE ARCHITECTURE
NEWS RELEASE
The new 450,000-square-foot outpatient facility at Johns Hopkins, opening for
business on May 18, is the largest of its kind in Baltimore, and one of the biggest
outpatient facilities in the Northeast. Architects Payette Associates of Boston designed
the building to be convenient for patients, energy efficient, and historically relevant to
the Hopkins architecture it faces across Broadway.
Ground was broken by the George Hyman Construction Co. in January 1990, and
the building opens four months ahead of schedule. During the construction phase,
installation of the center's two MRI (magnetic resonance imaging) machines proved
particularly challenging. Since the machines were not placed on the ground level, as is
usually the case for MRI facilities, the building had to be structurally reinforced to hold
the extra weight. Each of the machines' 16.5-ton magnets were lifted by crane through
windows on the third floor with about six inches to spare. In addition, copper and steel
shields were constructed to provide two-way protection from the powerful magnets--
protecting people (and their credit cards and watches), as well as protecting the magnetic
images from outside interference.
A tunnel beneath Broadway connects the Outpatient Center to the main Hospital.
Last summer, four-escalators for the concourse were lifted, swung 200 feet in the air, and
then lowered into the tight space between the historic domed Billings Administration
Building and the Wilmer Eye Institute on the east side of Broadway. The escalators are
encased in a three-story, dome-shaped glass pavilion.
Inside the L-shaped, eight-story center, nearly 200 exam rooms are organized in
clusters of four to six rooms, a pattern repeated throughout the building, even in the
operating rooms. "We wanted use of the space to be flexible. For example, instead of
knocking down walls when someone must move, the 'cluster' concept allows for easy
conversion of office space to exam rooms and vice versa," says Anne Colevas,
construction manager for the center, whose biggest challenge has been keeping the $140
million project on schedule and under budget.
(more)
The Johns Hopkins Hospital
School of Medicine
School of Nursing
School of Public Health
Johns Hopkins Health System
&
Johns Hopkins
Medical Institutions
550 North Broadway/Baltimore, MD 21205
(410) 955-6680 / FAX (410) 955-4452
Office of Public Affairs
TO:
Writers, editors and producers
FROM:
Carol Pearson
DATE:
April 29, 1992
SUBJECT:
PATIENTS' WISH LIST COMES TRUE AT HOPKINS' $140M
OUTPATIENT CENTER
Critics call it the "malling" of American medicine, where health-care facilities become
"retailers" and patients "customers"or "clients."
At the new Johns Hopkins Outpatient Center, there's none of the above. Patients are still
patients and good medicine is not hustled like new cars. But there IS a new commitment
to seeing to it that patients and their families have the easiest time possible when they come
to this $140 million center for medical care.
That commitment means they'll find a quick, convenient place to park. They'll be able to
register ONCE for everything, get all their tests -- X-rays, blood tests in one place. They'll
be able to instantly recognize clerical employees by their attire, so they needn't hunt for
someone to point them in the right direction or answer a question. And they'll get all the
information they need before they even come for the appointment.
"The goal is a positive patient experience," says Steven Lipstein, director of the center. "We
know that we can go a long way to reducing the stress, anxiety and frustration that often
accompanies a visit for health care."
Lipstein and a team of planners, architects, engineers, health professionals and
administrators combed the nation's hospitals and ambulatory care programs for the best
ideas and brought them under one roof.
The Johns Hopkins Outpatient Center will be dedicated on May 8, at 2 p.m., and there will
be a ribbon-cutting ceremony for the employees of the Hospital and School of Medicine
May 11 at 2 p.m. The center will open its doors to the public on May 18. The enclosed
materials should provide you background on all aspects of the center. If you are interested
in an interview, a tour or other photo opportunities, please call me at (410) 955-5384 or
(410) 955-6680.
Johns Hopkins
Medical Institutions
550 North Broadway/Baltimore, MD 21205
(410) 955-6680 / FAX (410) 955-4452
Office of Public Affairs
TO:
Writers, editors and producers
FROM:
Carol Pearson
DATE:
April 29, 1992
SUBJECT: PATIENTS' WISH LIST COMES TRUE AT HOPKINS'
$140M OUTPATIENT CENTER
The Baltimore Orioles aren't the only venerable Baltimore institution moving to new
quarters this spring. One month after the opening of the new baseball stadium, Johns
Hopkins physicians and nurses are picking up their stethoscopes and scalpels and moving
across the street from The Johns Hopkins Hospital to the new building where they will see
300,000 outpatients a year. While the stadium cost $106 million, the price tag for the
Outpatient Center and its high-tech equipment is $140 million.
More important than the facility itself, however, is the philosophy behind the new center.
Its planners were committed to seeing that patients and their families have the easiest time
possible when they come to the center.
That commitment means they'll find a quick, convenient place to park. They'll be able to
register ONCE for everything, get all their tests -- X-rays, blood tests -- in one place. They'll
be able to instantly recognize clerical employees by their appearance, so they needn't hunt
for someone to point them in the right direction or answer a question. And they'll get all
the information they need before they even come for the appointment.
"The goal is a positive patient experience," says Steven Lipstein, director of the center. We
know that we can go a long way to reducing the stress, anxiety and frustration that often
accompanies a visit for health care."
Lipstein and a team of planners, architects, engineers, health professionals and
administrators combed the nation's hospitals and ambulatory care programs for the best
ideas and brought them under one roof.
The Johns Hopkins Outpatient Center will be dedicated on May 8, at 2 p.m., and there will
be a ribbon-cutting ceremony for the employees of the Hospital and School of Medicine on
May 11, at 2 p.m. The center will open its doors to patients on May 18. The enclosed
materials should provide you background on all aspects of the center. If you are interested
in an interview, a tour or other photo opportunities, please call me at (410) 955-5384 or
(410) 955-6680.
JOHNS HOPKINS OUTPATIENT CENTER
FACTS AND STATISTICS
0
About 67,000 tons of concrete and 540,000 bricks were used to construct the JHOC.
0
A piece of the Berlin Wall was mixed into the concrete for the building columns.
0
It cost $140 million to build, equip, furnish and finance the center, and connect it
to the Hospital with an underground concourse.
0
The possible names for the building were reviewed with patients, who preferred the
term "outpatient" to "ambulatory care."
0
About 1,200 telephones and 300 computer terminals have been installed in the new
building.
0
The center will house 500 permanent employees, in addition to 300 physicians seeing
patients in a typical week.
0
Approximately 1,200 patients will be seen there each day, or about 300,000 a year.
0
For conservation, the toilets in the center use only 1.6 gallons of water, compared
with the usual five.
0
At Johns Hopkins, 55 percent of radiology procedures and 39 percent of surgical
procedures are performed on an outpatient basis.
0
Outpatient surgery at Johns Hopkins has grown from 9 percent of all surgery to 39
percent since 1982.
0
The eight-story Outpatient Center is equipped with 191 patient exam rooms, 68
procedure rooms, 28 radiology imaging rooms, 12 blood-drawing stations, and
eight operating rooms.
0
The center houses two MRI (magnetic resonance imaging) machines, which are
unusual in that they were installed on the third floor, instead of at the ground level.
The building is structurally reinforced to hold the weight of the machines' 16.5-ton
magnets.
0
The Outpatient Center building is named for Robert M. Heyssel, M.D., president of
The Johns Hopkins Hospital and Health System, who is retiring June 30 after a 20-
year career at the Medical Institutions.
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American Hospital Association
z
AHA
Department of Media Relations
840 North Lake Shore Drive
Chicago, Illinois 60611
News Release
FOR IMMEDIATE RELEASE
CONTACT: Donna Gaidamak
312/280-6129
MOST SURGERY NOW OUTPATIENT
CHICAGO (April 21, 1992) - Of the 22 million surgeries performed in U.S.
community hospitals in 1990, for the first time more were performed on an
outpatient basis, rather than requiring a hospital stay, the American Hospital
Association said today.
In 1980, there were 3 million outpatient (same-day) surgeries and nearly 16 million
inpatient operations in hospitals. Ten years later, the situation dramatically shifted
with the greater portion of surgeries not requiring hospitalization. In 1990, more than
11 million surgeries were outpatient and slightly less were done as inpatient
procedures. These are some of the findings in "Ambulatory Care Trendlines: National
Trends in Outpatient Surgery," an AHA report released today.
Fueled by technology and changes in reimbursement, outpatient surgery has continued
to grow. "The development of increasingly sophisticated technology and the increasing
prevalence of managed care are major factors in the shift from inpatient to outpatient
surgery," said Irene Fraser, Director of AHA's Division of Ambulatory Care. "Managed
care provides incentives to serve patients In an outpatient setting wherever possible."
Another trend cited in the AHA report is the increasing amount of outpatient surgery
being performed outside the hospital. Hospitals performed more than 11 million of the
13.3 million outpatient surgical procedures performed in the U.S. in 1990, but their
share of the total number of outpatient surgeries is declining.
-more-
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Outpatient/2
In 1985, more than 90 percent of outpatient surgery was performed in hospital
facilities, in 1990 It was 83 percent. Nonhospital-owned facilities performed 710,000
outpatient surgeries in 1985, and 2,320,000 in 1990.
Significant growth of all freestanding surgical centers is partially due to the increase
of outpatient procedures that the federal government pays for under Medicare. In
1982, there were 450 approved procedures. This year, there are 2,500. Also, in some
states, nonhospital-owned facilities are not subject to the-same requirements that
hospitals face in opening similar facilities.
The AHA, a not-for-profit organization, serves as a national advocate for hospitals and
the patients they serve, provides education and information for its members, and
informs the public about hospitals and health care issues.
-30-
Editor's note: Copies of the AHA report are available for reporters and editors.
JOHNS HOPKINS OUTPATIENT CENTER
GUIDED TOUR
Lower Level: Outpatient surgery, including eight operating rooms, four preoperative exam
rooms, and 12 preoperative holding cubicles.
Concourse Level: Patient services, including Freedom Pharmacy, Benson Optical Superstore,
Gift and Coffee Shops, Meditation Room, and Express Testing, including six blood-draw
stations, two EKG testing stations, chest X-ray room, and glucose tolerance testing room.
Plaza level: Cafeteria, Diabetes Center.
Third floor: Imaging, including two MRI units, two CT units, and four nuclear medicine
scanners.
Fourth floor: Radiology, including special ultrasound and pediatric rooms, fluoroscopy, and
general radiography; Breast Imaging Center, including three mammography suites, mammo-
test room for breast biopsy; Urology, with 11 exam rooms, four cystoscopy procedure rooms
and urodynamics lab.
Fifth floor: Neurology/Neurosurgery, with 26 exam rooms, three EEG and four EMG rooms;
Orthopedic Surgery, with 16 exam rooms, two radiology procedure rooms, and a cast room.
Sixth floor: Otolaryngology - Head and Neck Surgery, including speech pathology rooms,
six audiology booths, two oral surgery exam rooms, and a hearing aid dispensary and repair
service; Dermatology, including 16 exam rooms and a phototherapy suite.
Seventh floor: Adult Medicine and Surgery, including the specialties of internal medicine,
endocrinology, genetics, nephrology, hematology, and kidney and liver transplants; Meyerhoff
Center for gastroenterology and general surgery; Cardiology, including clinics for both adults
and children.
Eighth floor: Gynecology and Obstetrics, offering services in general gynecology, obstetrics,
gynecologic oncology, reproductive endocrinology, and nurse-midwifery; Pediatrics, offering
diagnosis and treatment in 19 subspecialties, from allergy to speech pathology; Plastic
surgery, including special expertise in breast reconstruction, cleft lip and hand disorders.
BIOGRAPHICAL SKETCH OF
ROBERT M. HEYSSEL, M.D.
Robert M. Heyssel, M.D. is President and CEO of the Johns Hopkins Health System and
The Johns Hopkins Hospital. The Johns Hopkins Health System includes The Johns
Hopkins Hospital and Outpatient Center, The Francis Scott Key Medical Center, the
Johns Hopkins Geriatrics Center, a physician group practice which staffs some eighteen
(18) outpatient centers in the Baltimore region, and Home Health Care programs.
Dr. Heyssel has appointments as Professor of Medicine at The Johns Hopkins University
School of Medicine, and Professor of Health Policy and Management at The Johns
Hopkins University School of Hygiene and Public Health. He is a Trustee of the Johns
Hopkins Health System and The Johns Hopkins University.
Dr. Heyssel came to Hopkins in 1968 as Associate Dean and Director of Outpatient
Services. He became Chief Executive Officer of the Hospital in 1972. Prior to that he
followed a career in Hematology/Nuclear Medicine, serving for nine years on the faculty
of Vanderbilt University where he was a recipient of the U.S. Public Health Service
Career Development Award in medical research and Director of Vanderbilt's Radioisotope
Center and Division of Nuclear Medicine and Biophysics. He was a senior assistant
surgeon with the United States Public Health Service assigned to the Atomic Bomb
Casualty Commission in Hiroshima and Nagasaki, Japan, investigating the delayed effects
of radiation in humans.
Dr. Heyssel is a Fellow of the American College of Physicians and the International
Society of Hematology. He is a member of the Institute of Medicine of the National
Academy of Sciences, the Association of American Physicians and the Society of Medical
Administrators. He has served on numerous government and foundation sponsored
commissions and study groups in Baltimore, the State of Maryland and nationally. He
is a member of the Board of Directors of the Signet Bank Corporation and the Monsanto
Company.
Dr. Heyssel holds the Distinguished Alumnus Award of the University of Missouri and
an honorary degree of doctor of science from St. Louis University. Born in Jamestown,
Missouri, Dr. Heyssel received his B.S. degree from the University of Missouri and his
M.D. degree from St. Louis University. He took advanced training at St. Louis
University, Barnes Hospital, and Washington University School of Medicine in St. Louis.
He is married, and he and his wife, Maria, have five children and eight grandchildren.
Robert M. Heyssel, M.D.
Robert M. Heyssel, M.D., is president and CEO of the Johns Hopkins Health System
and The Johns Hopkins Hospital. As principal architect of the System, he guided the
formation of the vertically integrated health care organization that now comprises the 1100-
bed Johns Hopkins Hospital and Outpatient Center, The Francis Scott Key Medical Center,
the Johns Hopkins Geriatrics Center, a physician group practice which staffs 18 outpatient
centers in the Baltimore region and Home Health Care programs.
An expert in health system governance, Dr. Heyssel has been in the forefront of
efforts to reform, reorganize and financially streamline health care. He has chaired the
Commonwealth Fund Task Force on Academic Health Centers, the Association of
American Medical Colleges and served on numerous national commissions, bringing his
expertise to bear on quality assurance, decentralized managment, funding medical care for
the poor and elderly, the impact of new payment schemes on hospital management and the
interdependence of the teaching, research and patient care missions of academic medical
centers.
His cross-disciplinary skills are reflected in his appointments as professor of medicine
at The Johns Hopkins University School of Medicine, and of health policy and management
at The Johns Hopkins University School of Hygiene and Public Health. He holds
membership in the Institute of Medicine, the Association of American Physicians and the
Society of Medical Administrators. He is a trustee of the Johns Hopkins Health System
and The Johns Hopkins University and a fellow of the American College of Physicians.
Dr. Heyssel has sought and fulfilled broad roles in the Baltimore community in
parallel with his efforts as a national leader. When he first came to Hopkins in 1968, the
Hospital labored under the growing alienation common at that time to inner city institutions
and their neighbors. First as associate dean and director of outpatient services, then as head
of the Hospital, he made a commitment to forming long-term partnerships with the East
Baltimore Community. He made it forcefully clear that The Johns Hopkins Hospital was
a community hospital as well as a national center of excellence. With colleagues, he visited
virtually every physician in the community and helped establish the East Baltimore Medical
Plan to better meet the health care needs of the area.
An early and strong supporter of black cardiac surgeon Levi Watkins' decade-old
annual tribute to Martin Luther King, Jr., he assured the continuation of this program that
has brought Bishop Desmond Tutu, Zenani Mandela Dlamini, Coretta Scott King, Rosa
Parks and Stevie Wonder to address Hopkins employees.
Dr. Heyssel created the Clarence "Du" Burns Community Service Award honoring
Baltimore's first black mayor, who worked with Hopkins as an East Baltimore community
advocate and City Councilman. Dr. Heyssel marshalled the Jefferson and McElderry courts
Housing Development project to increase affordable housing for Hopkins' neighbors, and
committed $150,000 this year to a new Community Health Initiative pledged to take its
marching orders from community leaders.
Born in Jamestown, Missouri, Dr. Heyssel received his B.S. degree from the
University of Missouri and his M.D. from St. Louis University. His early career in
hematology and nuclear medicine earned him a U.S. Public Health Service Career
Development Award in medical research and appointment as director of Vanderbilt
University's Radioisotope Center and Division of Nuclear Medicine and Biophysics. He was
a senior assistant surgeon with the PHS assigned to the Atomic Bomb Casualty Commission
in Hiroshima and Nagasaki, Japan, investigating the delayed effects of radiation in humans.
A member of the Board of Dirctors of the Signet Bank Corporation and the
Monsanto Company, he and his wife, Maria, have five children and eight grandchildren.
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MICHAEL M.E. JOHNS, MD.
DEAN, THE JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE
Michael M.E. Johns, M.D., has been Dean of The Johns Hopkins University
School of Medicine and Vice-President for Medical Affairs at The Johns Hopkins
University since July, 1990.
He came to Johns Hopkins in 1984 from the University of Virginia to be
chairman of the Department of Otolaryngology-Head and Neck Surgery. Trained as a
head and neck oncologic surgeon, Dr. Johns received joint appointments In the
departments of oncology and neurological surgery. In 1986 he also was named
Associate Dean for Clinical Practice, with responsibility for managing and coordinating
the clinical practice activities of the entire medical faculty as well as the responsibility
for planning and developing the new outpatient center.
A specialist in the management of head and neck tumors, Dr. Johns has
achieved an International reputation as a cancer surgeon and for his studies of the
effects of a variety of treatments, including surgery, radiation therapy and
chemotherapy, on Improving the survival rates of these patients. He has made major
Innovative contributions to the field of skull base surgery and has published over 150
papers and chapters In scientific Journals and books on a range of issues dealing with
the epidemiology, diagnosis, staging, treatment and outcome of head and neck
cancer.
His honors Include the Young Surgeon Award from the Virginia Chapter of the
American College of Surgeons, the Annual Recognition Award from the Speech and
Hearing Association of Virginia, the Honor Award from the American Academy of
Otolaryngology-Head and Neck Surgery, and the Fowler Award from the American
Triological Society.
Dean Johns has served on the editorial boards of several scholarly journals,
including the Archives of Otolaryngology and the Journal of the National Cancer
Institute, and as a reviewer for the New England Journal of Medicine. He has recently
been appointed the Editor of the Archives of Otolaryngology-Head and Neck Surgery.
A governor of the American College of Surgeons, he is a member of the Advisory
Council for Otolaryngology, President-Elect of the American Society for Head and
Neck Surgery, a director of the American Board of Otolaryngology, and the executive
secretary of the Triological Society. He has served as president of the Society of
University Otolaryngologists and the Maryland Society of Otolaryngology-Head and
Neck Surgery. He has served on the steering committee of the Group on Faculty
Practice of the AAMC. He currently chairs the AAMC Ad Hoc Committee on Physician
Payment Reform. He has participated on numerous national committees.
After completing a Bachelor of Science degree In Biology at Wayne State
University In his hometown of Detroit in 1964, Dr. Johns went on to receive his degree
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with distinction from the University of Michigan Medical School. Following his
internship and residencies in surgery and otolaryngology in Ann Arbor, he joined the
Medical Corps of the U.S. Army and served as assistant chief of the Otolaryngology
Service at Walter Reed Army Medical Center while on active military duty from 1975 to
1977. From 1977 to 1984, when he moved to Hopkins, he was on the faculty of the
University of Virginia Medical Center in Charlottesville.
Mike Johns and his delightful wife Trina have been married for twenty-five
years. They have two children: Christina - a second first year student at The Johns Hopkins
University School of Medicine, and Michael - currently a pre-medical student at the
University of Virginia.
Preventive Medicine
Residency Program
<<<<<<<<<<<<<
PublicHealth! Public Health
STEPHANIE SHIELDHOUSE
The Magazine of
The Johns Hopkins
School of Hygiene
and Public Health
Winter 1991
Pat Chaulk,
Chief Resident
JEFF BRELAND
Pat Chaulk, chief resident in the Preventive Medicine Residency Program
"
ISEASE PREVEN-
college, took premed courses and en-
the company to offer day care services
tion and health pro-
tered medical school. He then com-
D
for employees. He also wrote
motion are concepts
pleted a pediatric residency at the
prevention-related stories for in-house
whose time has
University of Nebraska Medical Cen-
publications.
come," says Pat
ter, where he also received a grant to
He finished the practicum year
Chaulk.
study child day care issues. Through
through a rotation with the Depart-
"As we become more concerned
the grant, he developed health inter-
ment of Epidemiology helping to put
about rising health care expenditures,
ventions, which he promoted through
together an HIV-AIDS Surveillance
more and more people are looking se-
videos and other teaching aids.
Manual for mid-level field workers in
riously at ways that prevention strate-
He chose the Hopkins residency
Africa and developing nations. Funded
gies can help cut back these rising
program for many reasons but says he
by the World Health Organization, the
costs."
was attracted because he knew of Ka-
manual is to be tested in Rwanda,
Armed with the U.S. Preventive
ren Davis, Ph.D., chairman of the De-
Kenya and Malawi.
Services Task Force Report, which is
partment of Health Policy and
In June, he received the Burroughs-
the consensus on screening and coun-
Management, and other role models
Wellcome A.M.A. Resident Leader-
seling patients, "We've taken a large
who are involved in policy issues.
ship Award at the American Medical
step forward. Now the mindset of in-
After his M.P.H. year, Chaulk spent
Association meeting for his volunteer
surance providers needs to change to
four months working with the staff of
work in day care-related issues and
make 15 minutes of counseling a pa-
the Governor's Commission on Health
with the Maryland Committee for
tient reimbursable," says Chaulk.
Care Policy and Financing, which is
Children. His project included an as-
Right out of college, he worked on
examining ways to meet the health
sessment of the day care needs of the
Capitol Hill with Ralph Nader and
care needs of the uninsured. His next
Baltimore community.
spent seven years in a variety of policy-
rotation was with a Hopkins residency
related jobs concentrating on health
alumnus at a pharmaceutical company
and the environment. He returned to
in Philadelphia, where he provided
clinical care and suggested ways for
HMO
PRACTICE
MARCH 1992. VOL. 6. NO. 1
A JOURNAL FOR CLINICIANS AND CLINICAL MANAGERS IN GROUP PRACTICE HMOS
ISSN 08916624
Johns Hopkins Ambulatory Care Groups
A Case-Mix System for UR, QA'
and Capitation Adjustment
WEINER- A new ambulatory case-mix system developed by researchers at
Johns Hopkins University has potential for use in HMOs. In addition to
assisting with the analysis, financing and management of care, ACGs can also
be used in clinical areas such as utilization and quality management.
PAGE 13
SECTION EDITOR
CLINICAL/OUTCOMES RESEARCH
Edward H. Wagner, MD, MPH
Johns Hopkins Ambulatory
Care Groups (ACGs)
A Case-Mix System for UR, QA and Capitation Adjustment
JONATHAN P.
This paper describes a new ambulatory case-mix system developed at The Johns
WEINER, DrPH
Associate Professor, Health
Hopkins University and known as Ambulatory Care Groups (ACGs). ACGs categorize a
Policy & Management
person into one of 51 categories based on the diseases and conditions for which they re-
barbara H.
ceived treatment over a period of time, such as a year. ACGs can be used to describe the
STARFIELD, MD, MPH
"illness-burden" of a population and are up to ten times more predictive of ambulatory
Professor, Health Policy &
Management and Pediatrics
care resource use than age and sex alone. ACGs can be determined using a computer-
RICHARD N.
ized "grouper" software package based on ICD-9-CM diagnosis codes and demographic
LIEBERMAN, BA
information presently found in virtually all claims or encounter data systems. They were
Project Coordinator
developed and tested at four HMOs and a state's Medicaid program. This paper dis-
The Johns Hopkins University School
cusses the potential application of ACGs to analysis, financing, and management of am-
of Hygiene and Public Health,
bulatory care, specifically as it relates to utilization review (UR), quality assurance (QA)
Department of Health Policy and
and the adjustment of capitation payment within managed care settings. (Key words: Am-
Management, Health Services
bulatory care, Case-mix, Capitation, Utilization review, Quality assurance)
Research and Development Center
he structure of the American
vided. More specifically, payment increas-
T
health care system has created
ingly is pre-paid or pre-determined; HMOs,
strong incentives for providers
preferred provider organizations (PPOs), and
to develop and utilize advanced
private and public insurers are "managing"
medical procedures and services.
the provision of medical care, largely by
The positive impact of this is
profiling and monitoring physicians' prac-
undisputed. However, these advances have
tices. The locus of care has switched away
not occurred without
from the hospital and
undesired consequen-
has moved towards
ces, the most signifi-
ambulatory care.
cant of which are fi-
These trends have
nancial; costs have
led to an increase in
been spiraling out of
the importance of
control for the past
population-oriented
decade.
perspectives, particu-
Efforts to contain
larly as they relate to
the rise in health care
ambulatory care. In
expenditures and to
turn, this has led to a
achieve efficiency
demand for relevant
have taken many
case-mix measures
forms, including al-
that can assist in com-
tering the unit of pay-
paring groups of pa-
ILLUSTRATION ROBERT BYERS
ment, development of
tients in terms of their
utilization controls,
utilization experience,
and restructuring the
morbidity, or health
organizational frame-
care expenditures.
work within which
While approaches
health care is pro-
b)
have been applied to
HMO PRACTICE VOLUME 6 NUMBER 1
JOHNS HOPKINS AMBULATORY CARE GROUPS
13
adjust for case-mix differences in the provi-
Moreover, many analysts believe that with-
sion of hospital care (e.g., DRGs), similar
out such methods of case-mix adjustment,
approaches have been not been applied on a
the growth of prepaid and managed health
wide scale in the ambulatory care environ-
care approaches will be stymied by allega-
ment.
1,2
tions of inequities due to "biased" selection;
An effective ambulatory care case-mix ap-
that is, where it is perceived that the patients
proach can be expected to have many appli-
served by managed care plans are "healthier"
cations for payment, utilization review (UR),
than those receiving care elsewhere.
quality assurance (QA), and management.
OVERVIEW OF THE AMBULATORY CARE
GROUP SYSTEM
SECTION EDITOR'S COMMENTS
This article, targeted at clinicians and
managers, describes a new ambulatory case-
Clinical/Outcomes Research
mix measure and some of its potential appli-
cations for health care financing, UR, and
QA. The Johns Hopkins Ambulatory Care
Group (ACG) system, provides a conceptu-
This section has the audacious goal of trying to
ally simple, statistically valid, and clinically
change the way care is provided by the nation's leading
relevant measure useful in predicting the
HMOs, since these are increasingly being viewed as na-
need for ambulatory health care services.
tional models for innovation in health care delivery. We
ACGs are based on the premise that a mea-
hope to change care by presenting empiric evidence that
sure of a population's "illness burden" can
Edward H.
supports changes in care delivery. Such data will pertain
help explain variation in health care resource
Wagner, MD,
to both problems with current delivery approaches and
MPH
consumption. ACGs represent a simple
system successes (innovations). Successes include sys-
SECTION EDITOR
method for categorizing persons based on
tematic clinical approaches to providing care for specific
their age, sex, and ICD-9-CM diagnoses
health problems, new ways of generating and using information to man-
assigned during their contacts with the de-
age care, or changes in practice organization that contribute to improved
livery system.
outcomes. Key outcomes include (in descending priority) patient health
The development and validation of the
and function, patient satisfaction, provider satisfaction, and cost.
ACGs relied on the analysis of computerized
The "Clinical/Outcomes Research" section will give emphasis to pa-
encounter/claims data obtained from five
pers that present fresh data and use sound research designs and meth-
ods to generate that data.
separate large "enrolled" population groups
On first glance, it may seen odd to inaugurate a section devoted to
(total sample size 150,000).* Four of the
clinical research and changing care with two papers that will strike many
populations came from HMOs; the fifth
clinicians as dealing more with health economics than clinical care. Fur-
from the Medicaid program of the State of
ther reading will reveal that these papers describe efforts to make sense
Maryland. The test organizations included
out of the chaos of ambulatory care by defining subsets of patients shar-
the:
ing common clinical problems and care requirements. They also recog-
Columbia Medical Plan (Maryland)
nize groups of patients who are costly in terms of dollars and provider
Harvard Community Health Plan (Bos-
time where one might direct early practice improvement efforts.
ton)
Many clinicians and clinical trainees are finding ambulatory care to be
more and more stressful, and less and less satisfying. Ambulatory care,
Med-Centers Health Plan (Minneapolis)
especially primary care, tends to be reactive and unplanned, the day de-
Maxicare (Los Angeles)
fined by who happens to be sitting in the waiting room. Stressed provid-
Maryland Medicaid
ers are feeling the need to gain better control of care and provider satis-
faction, especially in "managed care organizations, "would be to manage
ACGs represent a methodology for clus-
care-i.e., plan and organize practice resources to better meet the
tering ambulatory ICD-9-CM diagnostic
needs of important patient groups. Although the objectives and methods
codes. The overall theoretical goal of ACG
of the papers in this section are quite different, the logic is similar. En-
assignment is to cluster similar conditions
rollee populations are clinically diverse, but clinical problems and geo-
based on their expected impact on health
graphic characteristics define groups requiring very different intensities of
care services resource_consumption. The first
care. The papers show how these groupings might be used to help man-
step in the grouping process is the assign-
age resources. They just might help manage patients as well.
ment of over 6,000 ICD-9-CM diagnostic
Submissions should be sent to the Editor, HMO PRACTICE, Health Care
codes to one of 34 clusters. These clusters
Plan, 900 Guaranty Building, Buffalo, NY 14202.
are termed Ambulatory Diagnostic Groups,
or ADGs. Table 1 displays examples of some
Dr. Wagner is the Director of the Center for Health Studies at Group Health
of the ADGs and some diagnoses commonly
Cooperative of Puget Sound and Professor of Health Services with the
University of Washington School of Public Health and Community Medicine.
Note: Other organizations have successfully applied HGs
since the development phase.
14
JOHNS HOPKINS AMBULATORY CARE GROUPS
WEINER. ET AL
VOLUME 6 NUMBER 1
PR TICE
assigned to them. The process was guided by
TABLE 1
clinical judgment and statistical analysis to
Examples of the 34
cluster different conditions into a single
ADG. In relative order of importance, the
Ambulatory Diagnostic Groups (.ADGs)
clinical criteria for assigning conditions were
as follows:
AMBULATORY DIAGNOSTIC GROUP
COMMON DIAGNOSIS
The expected persistence/recurrence of a
Time Limited: Minor
Dermatitis
condition over time;
Time Limited: Major
Synovitis
Likely to Recur: Progressive
The likelihood that the patient would
Diabetic Ketoacidosis
Chronic Medical: Stable
make a return visit to continue treatment
Hypertension
Chronic Medical: Unstable
for a condition;
Coronary Atherosclerosis
Psvchosocial: Chronic
The likelihood that a specialty referral
Depression
Signs/Symptoms: Minor
Headache
would be required;
Malignancy
Malignant Skin Neoplasm
The expected need and cost of diagnostic
and therapeutic procedures associated with
ested readers are referred to two more de-
a condition;
tailed descriptions of the ACGs and their
The likelihood that the patient would
development.
require hospitalization for a condition
To summarize, the ACG "grouping" pro-
during the near term;
cess involved four stages of categorization:
The likelihood that a condition would
1. ICD-9-CM-CM codes are assigned into
result in either short-term or long-term
one of 34 Ambulatory Diagnostic Groups
disability; and
(ADGs);
The likelihood that a condition would
2. Similar ADGs were "collapsed" into
lead to decreased life-expectancy, either
twelve Collapsed ADGs (CADGs);
over the short or long term.
3. Based on the combination of CADGs,
During a single year, a patients' diagnoses
the patient is placed into one of 25 mutu-
may place them into anywhere from 1 to 34
ally exclusive Major Ambulatory Catego-
distinct ADGs. That is, ADGs are not mu-
ries (MACs); and
tually exclusive and there are potentially as
4. Based on age, sex, presence or absence of
many different unique ADG combinations
certain individual ADGs, and number of
as there are combinations of the 34 catego-
individual ADGs, persons within some
ries (i.e., over a million). In order to develop
MACs were further partitioned.
a system for practical use, it is necessary to
Ultimately, each person was categorized
collapse this huge number of possibilities
into one of 51 mutually exclusive ACGs. (All
into a manageable number.
of this is handled automatically by a "grou-
The DRG development process served as
per" software program that runs either on a
a general model for the reduction of the data
PC or mainframe).
into ACGs. The 34 ADG categories were
At the five test sites multiple regression
collapsed into twelve "Collapsed ADGs", or
techniques were used to explore the ex-
CADGs. Each CADG is a group of ADGs
planatory/predictive power of the ACG case-
that is similar with regard to the likelihood
mix system. The results of these analyses
of persistence or reoccurrence of the diag-
allowed us to document the degree to which
noses within them. Based on the combina-
the ACGs (and their components) can be
tion of CADGs, patients are then assigned
used to explain the variation in ambulatory
to a clinically logical, mutually-exclusive
care resource consumption.
grouping that we termed Major Ambulatory
The summary of key multivariate regres-
Categories or MACs. These categories are
roughly analogous to the Major Diagnostic
TABLE 2
Categories (MDCs) used in the DRG sys-
tem.
Examples of some
After each patient was assigned to a single
Ambulatory Care Groups (ACGs)
MAC, the use of statistical variance reduc-
tion techniques resulted in the further split-
ACG 1
Acute minor condition(s) only, age less than two
ting of some of the MACs into one of 51
ACG 6
Likely to recur condition(s) and allergies
mutually-exclusive ACGs based on their age,
ACG 13
Psychosocial condition(s) only, but no major psychiatric diagnosis
sex, and combination of ADGs. Table 2
ACG 17
Acute minor condition(s) and chronic medical-stable condition(s)
displays several examples of ACGs. Inter-
ACG 43
Four or five different ADGs, age 17-44
TABLE 3
each model.
Summary of Explanatory Power of ACGs
The first model (model A) included only
and its Components by Type of Regression Model, Site,
age and sex of the enrollee as explanatory
Dependent Measures, and Year
(independent) variables. This model sug-
gests that for the three dependent measures,
DEPENDENT MEASURES
the variation explained by these commonly
Ambulatory
Ambulatory
Total
applied demographic variables is limited to
Visits
Charges
Charges
about 5%.
Year 1
Year 2
Year 1
Year
2
Year 1
The second model (model B) incorpo-
Model A: Age-group, sex
rated each of the 34 individual ADGs, age,
Columbia Medical Plan
.05
.05
.03
.03
and sex. The results across the two years
MedCenters Health Plan
.04
suggest that ADGs explain more variance in
Maxicare
.06
.06
utilization for the year in which they were
Harvard Community Health Plan
.03
assigned (i.e., up to 59%) than for utilization
in the subsequent year (i.e., up to 23%). The
Model B: Age-group, sex, ADGs
results also suggest that ADGs have a some-
Columbia Medical Plan
.59
.23
.46
.21
what greater predictive ability for visits than
MedCenters Health Plan
.52
.47
.19
they do for ambulatory charges. The ex-
Maxicare
.57
.49
planatory power for total charges is signifi-
Harvard Community Health Plan
.40
cantly lower (19%) but still almost five times
Medicaid
.48
.42
that of age and sex alone.
Model C: 51 ACGs
The final model (model C) shows the
Columbia Medical Plan
.50
.20
.38
.18
degree to which the mutually exclusive ACGs
MedCenters Health Plan
.44
.38
.15
explain variance. This suggests that ACGs
Maxicare
.45
.39
can explain up to 50% of certain resource
Harvard Community Health Plan
.32
use measures, or ten times the explanatory
Medicaid
.42
.34
power of age and sex alone.
The explanatory power of ACGs (model
(All figures represent adjusted R-square of linear regression equations.)
C) is somewhat lower than the model (model
Note: R-squares are roughly equivalent to percent of variance explained by each model.
B) using ADGs combined with age and sex.
This suggests that in developing the mutu-
sion analyses exploring the explanatory/pre-
ally-exclusive fixed ACG categories from the
dictive power of ACGs and their compo-
non-mutually exclusive ADG clusters, a pro-
nents is presented in Table 3. This table
portion of explanatory power was lost. This
summarizes the results of the statistical model
is to be expected given that the number of
that attempts to explain variation in annual
ACGs (51) is significantly smaller than the
ambulatory visit rates and charges at the five
millions of potential ADG, age, sex combi-
research sites. The dependent (outcome)
nations. Given that most non-research ap-
measures included:
plications of case-mix require a fixed num-
annual face-to-face ambulatory visits;
ber of categories (rather than multivariate
statistical technique) this modest loss in pre-
annual ambulatory charges-which in-
dictive ability should be considered a reason-
cluded all professional fees and ancillary
able trade-off. (It is suggested, however. that
costs; and,
applications relying on multivariate analyses
ambulatory charges as well as all charges
(e.g. regression) should use ADGs. age and
associated with inpatient care.
sex, rather than ACGs.)
At each site we attempted to explain these
three resource measures during the same
POTENTIAL APPLICATIONS OF ACGS
year (year 1) for which we determined the
Throughout the last decade, a great deal
independent (explanatory) variables. At one
of emphasis has been placed on analyzing
site (CMP) we were also able to use the year-
the utilization and cost of inpatient care. For
1 independent variable to predict the second
example, most methods used to assess illness
year's (year 2) resource use. Based on three
severity or predict resource consumption
models, Table 3 presents the R-squared
have focused on hospital-based services.
statistic for each of the resource variables
Hospital stays are much easier to categorize:
indicated. The R-squared can be considered
the episodes of care have discrete starting
roughly equivalent to the percentage of the
and ending points; the cost per episode is
variation in the dependent measure explained
relatively high; and inpatient databases are
by the independent variables included in
relatively well developed.
In contrast, the evaluation of ambulatory
TABLE 4
care poses numerous difficulties: there are
many more settings with many more provid-
\ Comparison of Actual Ambulatory Charges
ers; the endpoint is ill-defined; there are a
With Capitation Rates Calculated by Three Approaches
large number of units of services with rela-
HMO
tively small costs per unit of service; and
ENROLLEE
ACTUAL
ALTERNATIVE CAPITATION
defining an ambulatory episode of care, par-
GROUP
CHARGES
RATES FOR YEAR 2
ticularly when patients have multiple condi-
Year 1
Year 2
Community
Age-Sex
ACG
tions, is problematic.¹⁶ For these reasons,
A
$ 25
$ 221
$ 452
$ 417
$ 130
focusing an analysis only on the patient visit
B
133
291
452
433
310
usually will not yield meaningful results.
C
150
363
452
442
ACGs are designed to overcome many of the
441
D
420
480
limitations inherent in a visit-oriented as-
452
495
547
E
1055
860
sessment of ambulatory care by taking into
452
487
818
Plan-Wide Avg.
389
account the complete illness profile of a
452
452
452
452
patient across a period of time (e.g., one
year).
ACG-derived capitation rates to two other
Because they focus on persons and popu-
approaches. Table 4 presents the actual year-
lations (or beneficiaries), it is likely that
1 and year-2 ambulatory care charges and
HMOs, PPOs, and other public and private
alternative capitation rates for five enrollee
health insurance plans will have the greatest
sub-groups selected at one HMO. These
use for the ACG system. ACGs are particu-
groups were selected on the basis of their
larly well-suited to plans employing man-
resource consumption during year-one,
aged care methods or capitation payment.
where group "A" used the least services and
For example, health plans, or physician
group "E" the most. The three alternative
groups participating in them, can use ACGs
year-2 capitation rates for each sub-group
to evaluate care provided to the beneficia-
were calculated by using:
ries/patients they serve or tailor capitation
a "community rate," where the amount
or premium rates. ACGs will probably not
be useful for payment or analysis at the level
paid per-capita is equal across sub-groups
and is based on the previous year's HMO-
of the individual patient encounter or ser-
vice. Visit-based ambulatory case-mix and
wide average ambulatory charge (plus an
inflation adjuster);
severity systems such as Ambulatory Patient
Groups (APGs),⁷ Products of Ambulatory
an age-sex adjusted rate, where the sub-
Care (PACs),8 and the Ambulatory Severity
group's rate is based on the previous
Index (ASI),⁹ should be more applicable to
year's use within age/sex "class" (plus
this purpose. The next sub-sections describe
inflation); and
several potential applications of The Johns
an ACG adjusted rate, where rates are
Hopkins Ambulatory Care Groups.
calculated on the basis of the previous
year's use within ACG "class" (plus infla-
Setting Capitation or Premium Rates.
tion).
In the past, HMOs relied mainly on com-
Table 5 assesses how well each alternative
munity rating to prospectively determine
capitation rate (based on year-1 characteris-
premiums for member groups. In response
tics) predicted the actual year-2 charges. A
to pressure from employers and others, many
percentage of "100%" indicates that the
HMOs are increasingly applying alternative
rating mechanisms, such as community rat-
TABLE 5
ing by class (CRC) or adjusted community
rating (ACR). Both CRC and ACR rating
The Three Alternative Capitation Rates as a Proportion
attempt to prospectively adjust the commu-
of the Actual Average Year-2 Ambulatory Charges
nity rate by incorporating selected charac-
teristics of the group (such as age and sex) to
ALTERNATIVE CAPITATION APPROACH
be covered. The ACG system could be used
HMO Enrollee Group
Community
Age/Sex
ACG
as a basis of these and similar rating tech-
A
205%
189%
59%
niques to adjust capitation or premium rates
B
155
149
107
for the predicted morbidity of a population
C
125
122
113
of enrollees selecting a particular health ben-
D
94
103
114
efit plan or delivery site within a plan.
E
53
57
95
Tables 4 and 5 display a comparison of
(Figures Represent Capitation Rate Divided by Actual Year-2 Charges x 100)
HMO PRACTICE
VOLUME
6
NUMBER
1
JOHNS HOPKINS CARE GROUPS
WEINER
17
capitation rate was equivalent to the actual
columns of Table 6 represent:
charge. Table 5 shows that ACG adjusted
1. the average annual per person charge for
capitation rates, in general, are significantly
each enrollee sub-group;
closer to the actual year-2 charges than ei-
ther the community rate or age/sex CRC
2. the ratio of this sub-group's average to
approach. Both community and age/sex-
the unadjusted mean for all HMO enroll-
adjusted CRC ratings result in capitation
ees (which include enrollees outside these
rates that are highly skewed with respect to
three sub-groups);
many enrollee groups. It should be noted,
3. the ratio of actual charges to the ex-
however, that the ACG method is skewed
pected* age/sex adjusted average of each
for the "A" enrollee group; based on their
sub-group; and
year-1 experience, this group of very low
4. the ratio of the actual charges to the
utilizers were not, on average, categorized
expected* ACG adjusted average of the
into many "serious" ACGs. This regression
persons in the sub-group.
Note that ACG-adjustment (column 4) tends
TABLE 6
to bring the UR screening ratios closest to
An Application of ACGs as a Mechanism for Adjusting
1.00 (i.e., where the sub-group's use is the
Utilization Review Measures at an HMO
same as the HMO-wide average). Without
any adjustment (column 1), the patients in
(3)
Sub-Group
(4)
sub-group "C" appear to be receiving 2.71
(2)
Avg.
+
Sub-Group
times the average resources. After charges
(1)
Sub-Group
Age-Sex.
Avg. ÷
have been adjusted using age and sex, the
Avg. Amb.
Avg. +
Adj.
ACG Adj.
Charges
Actual
Expected
Expected
ratio indicates that these patients are receiv-
for Sub-Group
HMO Avg.
Avg.
Avg.
ing 2.49 times the expected average. After
Enrollee Sub-Group A
$ 133
.34
.36
.50
ACG adjustment, the ratio suggests that the
Enrollee Sub-Group B
420
1.08
1.06
.89
patients are receiving only 1.49 times the
Enrollee SubGroup C
1055
2.71
2.49
1.49
expected. These types of analyses could
readily be performed for populations cared
Overall HMO Average
389
for by a single physician, a panel of physi-
cians, or those practicing within a particular
to the mean is expected, since all members of
geographic location.
a "very healthy" group are unlikely to re-
main "very healthy" from year to year. It
Quality Assurance (QA)
appears that capitation rates for people in
Many quality assurance activities revolve
very low ACGs would have to be adjusted
around the development of profiles of pat-
upward to compensate for this.
terns of practice (i.e., process of care) or
patient outcomes associated with one or
Utilization Review (UR)
more disease entities. One stumbling-block
ACGs can be used as a method for adjusting
associated with this approach is the inability
utilization review measures across providers
to adjust for severity of illness across differ-
or organizations when there is question about
ent groups of patients. ACGs could be used
one cohort of patients being sicker than
to control, at least to some degree, for case-
another. For example, when profiling pro-
mix differences across groups of patients,
viders' patterns of practice (e.g., based on
particularly as they relate to varying disease
claims data), ACGs might be applied to
burdens or co-morbidities. For example,
adjust for differences associated with varying
when monitoring specific outcomes of care
morbidity levels across physicians' caseloads.
for diabetics across individual providers or
Table 6 displays such an application of
groups within an insurance plan, ACG ad-
ACGs. It compares unadjusted and adjusted
justment could assist in controlling for co-
UR screening ratios derived from practice
morbidities across the different patient co-
profiles. These "screens" are based on the
horts. Furthermore, as is sometimes done
average (per person) annual ambulatory
with inpatient severity measures, ACGs
charges (including both professional fees
might also be compared across two points in
and ancillary services) within three enrollee
time as a prognostic indicator of change
sub-groups at one HMO. Each of the three
within a population's morbidity status.
populations have different use patterns-
low, medium, or high-when compared to
The expected rates were determined by multiplying the num-
the overall plan average.
ber of persons in each age/sex or ACG "cell" tn the average
plan-wide charge for all persons with the same characteris-
For total ambulatory charges, the four
tics as persons in that cell.
Another potential-though untested-ap-
2. Smithline N and D. Arbitman (eds.). Ambulatory
plication of ACGs relevant to quality might
case mix classification systems. F Ambulatory Care
Management 11 (Summer 1988).
be as a prospective tool to identify patients
3. Weiner J. Starfield B, Steinwachs D. Development
with special needs. Individual primary care
and application of a population oriented measure of
practitioners or medical directors could use
ambulatory care case-mix. Medical Care.
1991;29:452-472.
the system to identify patients who are likely
4. Starfield B. Weiner J, Mumford L, Steinwachs D.
to require more attention (and resources)
Ambulatory care groups: a categorization of diag-
than others because of their high morbidity-
noses for research and management. Health Services
burden. Based on this selection approach, it
Research 1991;(26):54-74.
might be possible to better match patients to
5. Johns Hopkins Health Services Research and Devel-
opment Center. ACG "Grouper" Software, Balti-
clinicians or to offer special case manage-
more. Md. 1991.
ment. For example, primary care physicians
6. Weiner J. Ambulatory case-mix methodologies: ap-
specializing in patients with multiple or un-
plication to primary care research. In Grady, M.
stable morbidities would not be expected to
(edt.) Primary care research: theory & methods
USDHHS, U.S. Agency for Health Care Policy and
care for as many patients as physicians with-
Research, AHCPR Publ #91-0011, Rockville, MD,
out a preponderance of patients in such
1991.
"sicker" ACG categories.
7. Averill R. Goldfield N, McGuire T, et. al. Design
and evaluation of a prospective payment system for
ambulatory care. (Wallingford, Connecticut: 3M-
THE FUTURE OF ACGS
Healthcare Information Systems, Inc.), HCFA Con-
The Johns Hopkins Ambulatory Care
tract 17-C-99369/1-02.
Group methodology reported here repre-
8. Tenan P. et al. PACs: classifying ambulatory care
patients and services for clinical and financial man-
sents the culmination of years of research,
agement. F .Ambulatory Care Management
development and testing and involves input
1988;(11):36-53.
from many clinicians and researchers. None-
9. Horn S, Buckle J, and Carver C. Ambulatory sever-
ity index: development of an ambulatory case-mix
theless, assessing this measure's full poten-
system. J Ambulatory Care Management 1988;(11):53-
tial awaits continued application and testing
62.
in a wide range of health care settings. The
ACG system, which can be calculated on the
ACKNOWLEDGEMENT:
basis of existing computerized claims data,
The development of this work was supported, in part, by
will facilitate the application of case-mix
Grant # HS05505 from the US DHHS Agency for
adjustment to ambulatory care. We believe
Health Care Policy and Research. Other members of the
research team included Donald Steinwachs, PhD, Laura
that this new technology will allow providers
Mumford, MD. Colin Flynn, K.C. Hall and Michael
and insurers to manage health care resources
Fox. The organizations providing data to this research
more effectively and equitably than ever
effort are gratefully acknowledged. Some findings pre-
sented in this paper were published in two previous ar-
before.
ticles written by the authors (references 3 & 4).
REFERENCES
CORRESPONDENCE:
1. Gold M. Common sense on extending the DRG
Jonathan P. Weiner, DrPH, Associate Professor, Johns
concept to pay for ambulatory care. Inquiry
Hopkins University. 624 North Broadway, Room 605,
1988;25:281-289.
Baltimore. Maryland 21205.
Nursing Strategies for the '90s
Thinking Ahead, Acting Now
August 27-29, 1992, in Boston, Massachusetts. A nursing conference
with a difference. Be on the cutting edge of nursing in an age of managed
care, new practice models. A collaborative conference between Harvard
Community Health Plan, Beth Israel Hospital, Northeastem University,
Brigham and Women's Hospital, and Boston College. Call (617) 421-
2740 for more information.
INSIDE
Special four-page supple-
ment on health care to go:
Home Care, Med-Care, and
Social Work, p. 3-6
Cosby entertains Children's
Center patients, p. 2
Construction update, p. 2
$1 million park dedicated
at Bayview, p. 2
A PUBLICATION OF THE JOHNS HOPKINS MEDICAL INSTITUTIONS
VOLUME 40 NUMBER 4 SUMMER 1990
EXCLUSIVE
J.S.News
CRACKDOWN ON CABLE TV. CHARGES REPORT
BusinessWeek
U.S.News
Special tribute:
AMERICA'S
BEST
A Dean for 15 seasons, p. 7
SCHOOLS
SURPRISE
IOSPITALS
RATINGS
Star-studded "Dick Tracy"
premiero bénefits Hopkins,
p.8
Hopkins celebrates top hon-
ors earned in three national
surveys published recently
n'Business Week and U.S.
News & World Report.
HOPKINS
in two different surveys - one ranking
the country's graduate schools. Out of
the nation's hospitals and one compar-
America's 124 medical schools, Hopkins
ing medical schools. In these surveys,
ranked second in academic reputation
TOPS POLLS
both Hospital and Medical School re-
for producing outstanding students.
The Housekeeping Depart-
ceived some of the highest ratings of any
Harvard topped that list, and Duke
ment uses more than 6,000
medical institution in the country.
came in third. "I think the survey was
gallons of wax each year to
To rank the nation's hospitals, U.S.
wrong about us," says Richard S. Ross,
polish the Hospital's floors.
W
c came out on top in
News asked 100 doctors coast to coast to
M.D., dean emeritus of the School of
(See the department's new
survey after survey
name the 10 leading hospitals in their
Medicine. "We're number one in terms
director, p. 4.)
ranking the nation's
specialties. Fifty-seven hospitals (out of
of having the best balance between rc-
hospitals and medical
6,500) were mentioned often enough to
search, education, and good patient
schools for everything from academics to
make the final list of "the best of the
care."
quality of nursing.
best." Hopkins was number two.
The same graduate program survey
High marks come from such nation-
In addition, 10 of 12 clinical areas
rated our Biomedical Engineering De-
ally prominent sources as U.S. News &
were considered top notch by the spe-
partment as the country's very best. It
World Report and Business Week, as well as
cialists in the survey - a very close sec-
was number one on a list of five winning
Tons of Broadway dirt, ex-
government agencies. For example,
ond to Minnesota's Mayo Clinic, which
departments in that field, followed by
cavated for the Metro by
Business Week recently singled out Robert
had 11 clinical specialties recognized as
Duke and MIT.
the MTA, will be used In
M. Heyssel, president of the Hospital
construction of the new
outstanding by the doctors surveyed.
The experts who review U.S. govern-
and Health System, as one of the na-
stadium grounds at Camden
The Hopkins departments of ophthal-
ment grant proposals obviously are im-
tion's five best managers in the health
Yards (see Update, p. 2).
mology and urology received the highest
pressed with Hopkins, too. Our School
service field. The article, "Profiting from
praise. They were number one on their
of Medicine received more inoncy for
the Non-Profits," cited the lessons com-
respective lists, which means the doctors
research, training, and fellowships from
A HOPKINS FIRST
pany managers can learn from well-run
surveyed cited Hopkins more often than
the Alcohol, Drug Abuse and Mental
Thirty years ago, DOME re-
institutions like Hopkins.
any other hospital for excellence in those
Health Administration in 1989 than any
ported closed cardiac chest
One characteristic of a good manager,
areas. In fact, 92 percent of them listed
other institution. The Medical School re-
massage (now known as
says Business Week, is the ability to articu-
the Hopkins ophthalmology department
ceived the second-highest number of
CPR) was developed by
late clearly the organization's overall
as among the best - by far the highest
National Institutes of Health grants in
Hopkins physicians William
mission - a task that Heyssel puts high
score given to any department at any
1989 - more than Stanford, Yale, or
Kouwenhoven, James Jude,
on his agenda. "I'm happy to be in-
hospital in the country.
Duke, but behind UCSF.
and Guy Knickerbocker. Ac-
cluded on the list," he says, "but it's im-
Hopkins ranked among the top two
cording to the Journal of
portant for employees at every level to
Does this mean it's time to get smug?
institutions in the U.S. for treatment of
the American Medical Asso-
get the credit for making Hopkins a
Not yet, if ever, administrators agree.
AIDS and cancer. Other areas at
clation, the manuscript
place that knows where it's going and
"We've got to keep up the good work
Kouwenhoven and his col-
Hopkins that won special commendation
and look for ways to do even better,"
why - to provide the best patient care
leagues published describ-
from doctors surveyed were cardiology,
says Heyssel. Incoming Medical School
of any hospital here or abroad."
Ing their new technique
gastroenterology, neurology, otolaryn-
Dean Michael E. Johnstadds, "If our goal
"may have resulted in sav-
According to U.S. News & World Re-
gology, pediatrics, and rheumatology.
is to be better than the best, we've got to
Ing more lives than any
port, we're close to achieving that goal.
Hopkins was high on a list of bests in
top ourselves"
other medical manuscript
The magazine recently sang our praises
another U.S. News survey, this one rating
- Rachel Wilder
during the past century."
Photo Copy Preservation
THE CHILDREN'S CENTER
News
LOVES COSBY
Cosby - not the famous
comedian, but a Holland
Lop bunny - is the new
star of the CMSC 9 play-
room. Donated by local vot-
erinarian Mary Lee Lynch,
Cosby was Introduced on
CCTV's Bunny Show at
Easter. Now patients like
Tara Heuman (pictured) can
play with Cosby any time
the playroom Is open and,
on special occasions, Child
Life staff bring him In for
bedside visits.
A NEW GENERATION
JOINS THE HOPKINS FAMILY
Hopkins has been a household word since Amy
SUPER SECRETARIES
Margolis and Carol Coffey Burns were born. A
Nine secretaries and ad-
fourth-year student at the School of Nursing,
ministrative assistants were
Amy is the daughter of Simeon Margolis, M.D.,
tops In typing and spelling
Ph.D., associate dean of the School of Medicine,
CONSTRUCTION UPDATE:
contests held at a School of
and Mary Alice Margolis, who has worked in ad-
Medicine fair following Na-
minstration for the Department of Medicine for
MORE MUCK TO COME
tional Secretaries Week.
more than three decades. The daughter of
Winners were Sunny Robin-
Men and machines are burrowing under Broad-
son, Lisa Stronsky, Starleen
Donald S. Coffey, Ph.D., professor of urology, on-
way to build the east/west concourse (above) con-
Murray, Gary Lloyd, Brenda
cology, and pharmacology and molecular science,
necting the Hospital complex with the Outpatient
McKay, Barbara Izzo, Nola
Carol is an '89 SON graduate.
Center and other buildings west of Broadway.
Miller, Gall Schnelder, and
GOING FOR THE GOLD
Amy and Carol first met as undergraduates at
Meanwhile, construction of the 876-foot Metro
Lona Bannasch. Each had a
Janet Worthington (pic-
Susquehanna College in Pennsylvania. Hopkins
station - the longest in the system - is begin-
pick of prizes, Including
tured), editor of Hopkins
was the only nursing school either of them consid-
ning on Broadway between McElderry and
luggage and a popcorn ma-
Medical News, was all
cred. "I had heard my father talk about Hopkins
Madison streets, and a 22-foot machine from Wis-
chine. All participants on-
smiles when the magazine
all my life. It was the only school I wanted to go
consin has begun north-south tunneling for the
Joyed food, music, and
won a gold medal In the
to," says Carol.
Hopkins leg of the Metro. A compressor plant be-
workshops.
college magazines category
of the annual Council for
Drs. Margolis and Coffey are also enthusiastic
tween Jefferson and Orleans operates 24 hours a
the Advancement and Sup-
about their daughters' decision to follow them
day producing compressed air to stabilize the dirt
port of Education Recogni-
into health careers at Hopkins. Says Margolis,
around the tunnel and prevent water from leak-
tion Program. Hopkins pub-
Becoming the fulfillment of an ambi-
ing into it. Workers go through a decompression
Ilc affairs came out on top
tion Amy's had for a long time, and the School'
chamber when they and leave the tunnel.
In other catogories, recolv-
just the kind we need more of."
For your information, the dirt called-mucks
Ing a gold modal for the
Carol and Amy both plan to stay at Hopkins:
which is excavated is transported by muck trains
Centennial registration
Carol has been working in adult medicine since
to a muck pit and stored in a muck bin. Trucks
package, and bronze mod-
graduation, and Amy will begin work in psychiat-
cart the muck away to the construction site of the
als for the publications pro-
ric nursing after her graduation in May.
stadium at Camden Yards.
gram, "Pridol Pick It Up!
campaign, and Contennial
media campaign.
EVERY EMPLOYEE COUNTS
TWO FOR ONE SALE
IN THE 'HOPKINS CENSUS'
Over the past year, one of
every four to five couples In
Watch your mailboxes in late July for the
the in vitro fortilization pro-
"Hopkins census," a skills survey to be distributed
gram has gone home with at
to all employees by the Hospital's Human Re-
least one baby. Claire
sources Planning and Staffing Department. The
Stackhouse and Jim Banks
survey will ask employees about their education
went home with two. Stack-
and skills, and data collected will be used to cre-
house, a nurse In GYN/OB,
ate a skills inventory data base, which will assess
and Banks, a Hopkinspedia-
GOT A BEEF ABOUT
future training needs. The survey is strictly confi-
trician, are parents of Alex
SECURITY OR
dential, and individual data will not be made
and Maggie (pictured), now
TRANSPORTATION?
6 months old. Twins ac-
available. For details, call Sam Haggar, TT 5-1518.
count for 20 percent of the
Among your options is writ-
program's births, but a rec-
Ing a letter to the new Se-
ord has just been set: the
curity and Transportation
Committee created to serve
School of Nursing student Amy Margolis walks through
program's first triplets.
as a connecting link be-
Hopkins corridors with her father, Dr. Simeon Margolis.
HOSPITAL HOSTS HIGH
tween Hospital and Univer-
SCHOOL STUDENTS
sity administrators and stu-
HOPKINS-DUNBAR PROGRAM
dents, employees, and pa-
Thirty high school students
tients, according to Anto-
will volunteer time and tal-
CELEBRATES FIRST GRADS
Inette F. Hood, M.D., com-
ont to the Hospital for eight
mittoo chair. Send letters to
Thirty-seven Dunbar High School students were
wooks this summer. "They'll
Hood at 913-D Blalock or to
$00 state-of-the-art equip-
recently honored as the first graduates of the
any of the other committee
ment, help care for pa-
Hopkins-Dunbar Program, a cooperative effort to
members: John Bartgis,
tients, and learn In an envi-
prepare minority students for college and for ca-
David A. Blake, Ph.D.,
ronment which may load
recrs in medicine, nursing, and related profes-
Dorothy A. Brillantes, Mary
$1 Million Park Dedicated at Bayview: You'll find
them to choose health care
Brune, Patricia Charache,
sions. Eighty percent of the graduates are college-
a pond, fountain, walking paths and benches in the new
as a career," says Dobbie
M.D., Sydney 0. Gottllob,
bound, including Tanya Jeffries and Jonathan
$1 million community park recently dedicated at the
Bangledorf, acting Volun-
M.D., Richard Grossi, and
Johns, who will attend Hopkins this fall. Jeffries
Bayview Research Campus. The 6:4-acre park, which
foor Services supervisor.
Mumtax B.B. Kammerer. You
and Johns, along with classmates Marlo Price and
Students will work two to
borders Eastern Avenue, was developed by Baltimore City
can also address questions
Sadiq Russell, are each recipients of a $1,000
and the Dome Corp. "Il is a fine example of cooperation
four days a week in nursing
or concerns to the security
Hopkins Centennial Scholarship - a gift from
units and laboratories, and
between the city, the neighborhood, and private enter-
office (Tower, Room 109)
will attend tours and lec-
Hopkins employees. Hopkins Medical Staff re-
prise," says James D.M. McComas, president and CEO
and parking office (550
tures on AIDS, drug and
cently voted to continue to give a $1,000 scholar-
of the Dome Corp., which had promised the park to
Bldg., Room 104).
alcohol abuse, and teen
ship to a Dunbar student each year.
Bayview's neighbors.
pregnancy.
2
Photo Copy Preservation
Photo Copy Preservation
HOMING IN
ON HEALTH CARE
Extra
This Dome supplement will
Introduce you to some of
the patients, the employees,
and the services Involved
when the Hospital extends
Hopkins health care into
people's homes.
HOPKINS MAKES
HOUSE CALLS
Hopkins care doesn't stop when patients
leave the Hospital. That's where Social
Work, Home Care and Med-Care come
in. They work together to provide the
seamless sequence of quality care that be-
gins when a patient enters the Hospital.
OVERCOMING
POST-OP PROBLEMS
Sally Vorcacos noticed George Chin was feeling
depressed and she wasn't surprised. As senior
clinical social worker in otolaryngology head
and neck surgery on Meyer 9, Voreacos under-
stood and expected such a mood.
Because he had cancer of the larynx, the 62-
year-old retired chef had undergone radical neck
surgery, including a laryngectomy and a tracheot
omy. His vocal chordswere removed so normal
speech was Impossible, and he had a tracheotomy
tube coming out of an opening in his throat.
It was a day worth celebrating: Home Care primary nurse Kim Schonfeld congratulates cancer patient Becky Bailey
on her last visit for treatment at the Hospital.
Before Chin was discharged from the Hospital,
The regular routine of Becky's life, indeed the
a plan was made to take care of him at home with
lives of everyone close to her, was interrupted
the help of three departments whose job is conti-
when she was still a baby. She was less than a year
nuity of Hospital care: Social Work, Home Care,
old when a rare tumor was found lodged in her
and Med-Care, a subsidiary of Hopkins' Dome
abdomen against her spine.
Corp. Voreacos, his social worker, met with the
At the time, a course of radiation was begun to
in-hospital coordinator for Home Care and Med-
shrink the cancerous growth. Later, after surgery
Care and álong with Chin's physician - decid-
at Hopkins to remove the tumor, chemotherapy
ed how the services of each of these departments
began.
could be brought into play.
It was difficult for Becky and her mother, who
Teaching Chin to take care of himself was a
had other children at home, to travel from their
priority. His trach tube must be suctioned and
farm in Thurmont, some 72 miles west of Balti-
cared for daily, and he needs enteral feeding,
more, to Hopkins for the treatments. The solu-
since it's hard for him to chew and swallow.
tion to their dilemma - the Baileys call it "a god-
His primary Home Care nurse, Alice Gelcich,
send" - was a combination of Home Care serv-
came to his home three time a week, monitoring
ices and Med-Care resources, which allowed
his progress and continuing the teaching that was
Becky to be treated at home.
started at the Hospital. Now Chin cares for his
"Suzanne Vazzano and I have been taking
own trach, with the help of equipment supplied
turns going up to Thurmont four days in a row
by Med-Care.
once a month," says Schonfeld. "I sit and play
If Chin needs help between visits, Home Care
with Becky a while. Then I prepare her medica-
is ready. "Everyone here knows that if we get a
tion, and hook up the IV line to the catheter."
call and all we hear is tapping, it's Mr. Chin. Two
Vazzano and Schonfeld have taught Becky's
Senior clinical social worker Sally Voreacos provides
taps for yes, one for no," says Carol Sylvester,
mother to administer IV drugs to Becky, such as
moral support for George Chin, a patient in otolaryngol-
Home Care's nursing director. But not for long.
the sodium phosphate she needs to supplement
ogy head and neck surgery.
"Mr. Chin is learning to use an electrolarynx, so
her diet. Med-Care provides the intravenous
expecting him to say a few words the next
medicine, as well as dressings, syringes, and other
To help Chin change his outlook, Voreacos in-
time I see him," Voreacos says with a smile.
supplies needed for Becky's daily care.
vited him to a support group for people with
Even when Becky's course of chemotherapy
head and neck cancer. On a piece of paper he
ends, she will continue to be seen by Home Care
wrote that he would come, but only "to sit in."
FIGHTING CANCER
nurses and utilize Med-Care resources. "We'll
"He enjoyed the meeting very much," she rc-
continue to see her for blood work and follow-up,
members. "We talked about how people felt dc-
DOWN ON THE FARM
and she will have to continue the sodium phos-
pressed in the beginning, but how they could
"She has no hair and weighs about 24 pounds,
phate intravenously," Schonfeld says. "And of
learn to talk." Soon Chin was writing questions
but she's doing well," says Home Care primary
course we'll be at the party the Baileys are having
that Voreacos read aloud to the group. "Just talk-
nurse Kim Schonfeld about one of her favorite
to mark the end of her chemotherapy."
ing about his problems buoyed him up."
patients, 3-year-old Rebecca "Becky" Bailey.
Sharon Bondroff
3
Extra
HEALTH CARE
whole family, to refer them to the right services,"
says Vick, a 15-year Hopkins veteran. "We work
with dads at times, too. We can refer them for job
TO GO
placement."
Vick's main focus is counseling girls about their
relationships to parents or boyfriends and help-
Social workers, Home Care nurses,
ing them with parenting, while giving them emo:
tional support. After four years, when mother,
pharmacists: they're on the team that can
and child graduate from the clinic, Vick makes
deliver Hopkins health care right to our
sure they have a place to go for health care.
patients' doorsteps after they leave the
Seventeen-year-old Laquitta Butler knows
Hospital.
about the program firsthand. "I was a mother at
13. The program lent me a helping hand. It has
people who care about people. It taught me to
become a better parent and how to better myself,
CARRIE VICK,
Butler says.
SOCIAL WORKER
"Most people see teen-agers as parents who
don't make it. There are many who do," says
Vick. Butler and her now 4-year-old son Darren
It happens all the time. "A girl comes in, says
are about to graduate from the TAC clinic. Butler
there's no milk, or she has no place to go, or she's
also graduated from Dunbar High School this
had:a,fight.with her mom," says Carrie Vick, sen-
ior clinical social worker, who works
June with honors, and plans to attend college in
the falland learn to be an emergency medical
mothers at Hopkins.
technician.
Many adolescent mothers who deliver a baby at
the Hospital are referred to TAC, the teen-age
Vick's clients at the clinic are,not ill. Often,
clinic. "We see them when the baby is about 2
however, it is a social worker's task to deal with
weeks old," says Vick, who is the social worker in
very sick individuals and their families, doing
what's known formally as the Hospital's Adoles-
everything from coordinating home care to help-
Duty calls Home Care nurse Karen Pechulis, who heads out on 0
cent Parenting Program. Its mission - and hers
ing them find the best possible resources to assist
- is to provide comprehensive health care and
recovery.
social services for between 900 and 1,000 teen-age
That task becomes more challenging with to-
mothers and their babies.
day's emphasis on shorter hospital stays, says de-
Her door is always open. Vick interviews about
partment director Jerry Reardon. An estimated
KAREN PECHULIS,
four new mothers a week to find out what they
15 percent of patients discharged from the Hospi-
HOME CARE NURSE
and their babies need, then follows mothers and
tal need follow-up care at home - and the help
babies for four years. "We're there to support the
of social workers like Carrie Vick.
Most days Karen Pechulis starts out early, around
7 a.m., hoping to be back in the office by noon or
1 o'clock. That's when she and her Home Care
nurse colleagues do the paperwork and make
calls to doctors, social workers, and referral agen-
cies. "But things never go as planned. You may
get a call from a patient and have to go out at 4
p.m. You learn to roll with it," Pechulis says.
"I love home care nursing because I spend all
my time with patients, not answering an inter-
com. That means I can teach patients - our pri-
ority - without interruption. We teach them to
change their own dressings, to eat properly, to
look out for certain symptoms, to know when to
call the doctor.
sometimes call in a nutritionist to help a dia-
betic with a diet or a social worker to counsel a
dying patient's family," says Pechulis, who sees
from five to seven patients a day. "Recently I
helped a patient, an alcoliolic, get admitted to a
rehab program. You can't change everything in a
person's life but, if we make one little dent, we
feel great."
In addition to working with Home Care,
Pechulis works part-time on Nelson 8. In fact, she
says, "I've had patients in the Hospital that I later
took care of through Home Care. This takes pri-
mary care nursing as far as it can go."
Teen-age mothers can lurn to senior clinical social worker Carrie Vick (right) for counseling on health care, parent-
ing, and relationships.
4
Photo Copy Preservation
IT HAPPENS ALL THE TIME.
RECENTLY HELPED A PATIENT,
"A GIRL COMES IN, SAYS THERE'S NO.
"BECAUSE OF THE NEW TECHNOLOGY,
AN ALCOHOLIC, GET ADMITTED
WE CAN NOW CARE FOR SOME PATIENTS
MILK, OR SHE HAS NO PLACE TO GO, OR
TO A REHAB PROGRAM.
AT HOME AS WELL AS WE COULD IN THE
SHE'S HAD A FIGHT WITH HER MOM,"
YOU CAN'T CHANGE EVERYTHING IN A
HOSPITAL, AND THEY THRIVE
SAYS CARRIE VICK, SENIOR CLINICAL
PERSON'S LIFE BUT, IF WE MAKE ONE
SOCIAL WORKER, WHO WORKS WITH
THAT'S THE SATISFACTION IN MY JOB,"
LITTLE DENT, WE FEEL GREAT," SAYS
SAYS REID ZIMMER,
TEEN-AGE MOTHERS AT HOPKINS.
KAREN PECHULIS, HOME CARE NURSE.
MED-CARE PHARMACY DIRECTOR.
REID ZIMMER, MED-CARE
PHARMACY DIRECTOR
HOME
Reid Zimmer is smiling. "It was like inheriting a
In addition to IV therapies; Med-Care pro-
million dollars," he says, describing his feeling
vides respiratory and medical equipment such as
upon hearing that a little girl with an immune
wheelchairs, apnea monitors, ventilators, and hos-
deficiency had been successfully treated at home
pital beds. Med-Care also keeps other smaller
using medicines and equipment provided by
items on hand, including oxygen, tubing, and
Med-Care:
dressing supplies.
CARE
Patient contact is a bonus for Zimmer, Med-
Also on their shelves are IV pumps small
Care's director of pharmacy. His job is to make
enough to hang from a belt, allowing patients to
sure that patients receive the best medication as
move around freely. Zimmer remembers one pa-
well as the most comfortable and efficient means
tient who took his IV pump on a European vaca-
of taking it.
tion. "Because of the new technology, we can now
Typically a clinical pharmacist on Zimmer's
care for some patients at home as well as we could
staff visits a new patient at home to "see the
in the hospital, and they thrive. That's the satis-
atmosphere. Is there refrigeration? Do they know
faction in my job," Zimmer says.
how to take the medicine properly? You have to
treat each patient as an individual."
921
Sharon Bondroff
Pharmacy makes up intravenous medications,
chemotherapy, and nutrition for home use.
Through a glass wall in.his office, Zimmer has a
clear view of the aseptic clean room where his
staff prepares the prescriptions. Before entering,
yone must scrub and wear a cap, gown, and
gloves.
Every morning Zimmer meets with other Med-
Care staff members to discuss the patients they re
of her many patient visits.
going to have for the day. The delivery person
finds out what needs to be sent and when. The
client service person calls patients to make sure
they have what they need.
Currently, Home Care makes 3,500 visits a
month - a figure that's expected to double in
one year. There are 30 nurses on staff, plus
speech, physical, and occupational therapists,
2016
nutritionist, home health aides, and clinical social
workers. Some nurses specialize in IV therapy
and work out of the Med-Care office, where IV
prescriptions are formulated and the delivery of
equipment and supplies are coordinated.
Med-Care pharmacy director Reid Zimmer's job is to make sure Med-Care's patients receive the best medication and
most comfortable and efficient means of taking it.
Photo Copy Preservation
5
HOME CARE:
NOW IT'S SYSTEMWIDE
As president and CEO of
effort to provide a network
Dome Management Serv-
of home care services to
Ices, an Important part of
Y
our patients," Bloom says.
Irwin Bloom's Job is to coor-
"These programs will be
I
dinate Med-Care and two
Hopkins quality with direc-
Health System home health
tion from Hopkins health
agencies, Hopkins Home
professionals."
Care and Hopkins Home
Care Alternatives, a now
service which is a "major
HOME HEALTH CARE:
WHAT WE DO AND HOW WE DO IT
"WE HELP PATIENTS AND FAMILIES
"THE POINT OF HOME CARE IS TO
COPE WITH ILLNESS
"WE PROVIDE HIGH-TECH PRODUCTS AND
PROMOTE CONTINUITY OF CARE, HELP
AND PLAN FOR THE FUTURE
SERVICES FOR HOME CARE, BUT OUR FOCUS
PATIENTS ADAPT AND REMAIN
ONCE THE PATIENT LEAVES
IS ALWAYS ON THE PATIENT."
INDEPENDENT.
THE HOSPITAL.
JS9U
JERRY REARDON, PH.D., DIRECTOR,
SHARON BROWN, R.N., M.S., PRESIDENT
SOCIAL WORK
DEBBIE ZIENTS, M.B.A., PRESIDENT,
HOPKINS HOME CARE
MED-CARE
(onth
DEPARTMENT OF SOCIAL WORK
HOME CARE
MED-CARE
The Department of Social Work was established
Johns Hopkins Home Care has been part of the
at the Hospital in 1907 by a group of volunteers
Med-Care, a subsidiary of the Dome Corp., pro-
Hospital since 1984 and is one of the fastest grow-
concerned with home hygiene, nutrition, and
vides IV pharmaceuticals, respiratory therapy,
ing segments of Hopkins health care. In July,
other problems that would affect the patient's
and high-tech medical equipment to patients re-
when it becomes a Health System-wide service,
condition after hospital treatment. Today, the de-
ceiving home care. Twenty-seven full-time em-
Home Care will expand to offer private duty
partment has 57 social workers on staff, continu-
ployees include client service representatives, res-
nursing and homemaker services, and will be
ing the tradition of helping patients and families
piratory therapists; pharmacists, and drivers, as
available to all Hopkins affiliates. TT 5-6788
make successful transitions from hospital to
well as administrative personnel. " 385-4100
home, as well as helping them cope with the im-
SERVICES OFFERED BY HOME CARE
pact of illness and hospitalization. = 5-5885
SERVICES OFFERED BY MED-CARE
Home care planning before a patient leaves the
Intravenous nutrition, chemotherapy and anti-
hospital
SERVICES OFFERED BY THE DEPARTMENT
biotic drug therapy
Home visits by nurses, therapists, social work
Help with admission and discharge for patient
ers, home health aides, nutritionists
Pharmacy services, including pain manage-
and family
ment, hydration therapy, and other IV therapies
Health education for patient and family
Evaluation of patients with pyschological and
Transfusions of platelets or red blood cells
Intravenous therapy
social problems, working with Hospital staff to
Central venous catheter care
Hospice services
lessen the effects of those problems on the pa-
Care for the terminally ill
tient's health
Referrals to other community services
Enteral nutrition therapy for patients who can-
24-hour on-call and visits
Patient counseling
not swallow (provided directly to the stomach
Delivery of supplies to the home
Help for patients in obtaining Hospital and
through a catheter)
Private duty nursing (begins soon)
community services
Respiratory therapy to help patients breathe,
Homemaker services (begins soon)
Health education for patient and family
using oxygen, ventilators, nebulizers, and apnea
Community program development
monitoring
Medical equipment, such as wheelchairs, hospi-
halvtal beds and walking aids
Home visits by pharmacists
Nursing through Johns Hopkins Home Care
Training for patient and family in proper use
of equipment
Delivery of supplies to the home
- Sharon Bondroff
6
Photo Copy Preservation
SHE OUGHT TO KNOW
ThenNow
"He's a perfectionist," says
Lyn Dwelley, Ross's socre-
tary for 15 years, "and ad-
mire him. He's precise, and
his memory Is unbellevable.
It's difficult for people to
realize how busy the dean's
Job is - people in and out
every half hour, $0 many
things to do, and crises In
betwoon. I think his life will
calm down considerably,
but I think ho'll always be
busy because he onjoys H."
A DEAN FOR
whether he really was too sick to testify in the Wa-
tergate trials (a job Ross accepted); as well as an
15 SEASONS
offer of the directorship of the National Heart,
Lung, and Blood Institute (a job he declined). He
has been president of the American Heart Asso-
Richard Starr Ross has left
ciation and an editor of the classic Hopkins
the Dean's Office, but he -
textbook, The Principles and Practice of Medicine. He
and his namesakes - will still
is also a member of the National Academy of Sci-
ences' Institute of Medicine.
be part of the Medical Institutions
In 1975 he became dean, a position he has
The first dean of the School of Medicine, William
filled longer than all but one of his predecessors.
His list of accomplishments is long, but his favor-
Henry Welch, posted this notice announcing of-
ite moments have involved honors to other
fice hours: "The dean will be in from 8 to 4 Tues-
people: watching Drs. Hamilton Smith and Da-
day afternoons."
niel Nathans receive the 1978 Nobel Prize in
"That was all it took," says Richard S. Ross,
M.D., a bit wistfully. "But it's pretty clear now it's
Medicine for their discovery of how to slice genes,
Dean emeritus Richard S. Ross
and presenting President George Bush with an
not only a full-time job but, in addition to:one
curable heart ailments. This was an exciting time
honorary degree as part of the Hopkins Centen-
person's activity, it takes a tremendous staff, and
nial celebration. "I think the most fun has been in
support from a great number of people."
at Hopkins, with a new Department of Medicine
chairman, A. McGehee Harvey, M.D.
getting to know a lot of bright young people who
Many of those people - and many of the
people Ross has supported during his 15-year
"It was the beginning of my love affair with
come through this office and are willing to teach
tenure as dean - got together to recognize him
clinical medicine," Ross says. "Those were won-
me something," Ross says.
Ross credits his wife, Elizabeth "Boo" Ross
at a banquet on June 22 to mark the occasion of
derful days, and priceless emotions. Patients came
his retirement from the position.
from all over the world with tremendous diagnos,
(whom he met at Hopkins), for her support over
tic problems that nobody really knew much about.
the last 40 years, and for doing "far more in rais-
It was scarcely a farewell, though. Dean Ross's
ing our three fine children than I did." He looks
name will be a permanent and prominent part of
And Helen Taussig was putting it all together."
Hopkins. The new medical research building on
Still, Ross calls the 1960s and early 1970s "the
forward to spending more time with his four
Rutland Avenue will be named after him (an
most exciting period of my life at Hopkins." He
grandchildren, playing golf, taking long walks,
and fishing, after July 1.
honor voted by the Board of Trustees), and so
How would he like people to remember his
will the Richard Starr Ross Fund for the Physician
"I THINK THE MOST FUN HAS BEEN
Scientist (his own favorite project, which offers
deanship? "As an exciting, pleasant, stimulating
IN GETTING TO KNOW A LOT OF
internal grants to young researchers). And Ross
time to be part of The Johns Hopkins Medical In-
BRIGHT YOUNG PEOPLE WHO
stitutions," he answers. "I've tried to make it that
will maintain an office at the School to make him-
COME THROUGH THIS OFFICE AND ARE.
way for people."
self available as needed to his successor, Michael
WILLING TO TEACH ME SOMETHING."
E. Johns, M.D.
As for his strategy for achieving excellence in
Instead of a farewell, the banquet was a cele-
medical education, Ross believes in selecting "the
was director of the Wellcome Research Labora-
bration of 43 years spent in the service of
best possible students - bright, well-rounded,
tory and director of cardiology, and he and radi-
Hopkins. Ross came to the School of Medicine in
motivated, imaginative people. Put them together
ology chief Russell Morgan introduced cineangi-
1947, intending to complete a one-year in-
with good faculty who enjoy teaching, and pro-
ography to the Hospital and Medical School. "We
ternship and return to Harvard, where he took
vide good facilities. Then leave it alone. Just let
were taking the first motion pictures of the heart
his undergraduate and medical degrees. But the
the process work. That's worked for 100 years."
at Hopkins," Ross says.
- Anne Childress
blue baby operation developed by Drs. Blalock
In those years, 100, came recognition of many
and Taussig at Hopkins had just opened wide the
kinds: a request from Judge John J. Sirica for
field of research and treatment for previously in-
Material for this story came from interviews with Ross by
Ross to examine ex-President Nixon to determine
Janet F. Worthington and by Richard Johns, M.D.
ROSS: 'ALL THAT YOU HAVE
Encouraging more broadly educated young
HELPED TO ACCOMPLISH'
people to enter medicine. The medical school
dropped the MCAT requirement for admission,
In a recent letter to his colleagues in the School of
Medicine, Dean Richard S. Ross listed "all that
approved a Flex-Med program with greater op-
tions, and expanded the enrollment of minority
you have helped to accomplish" during his tenure
students.
as dean. The list includes:
Developing the $5 million Fund for the Physi-
Defending the right of private medical schools
cian Scientist to support the budding research ca-
to select their own students. In 1977, the federal
reers of young physicians. By December, 71
government tried unsuccessfully to force U.S.
medical schools to admit foreign-trained, under-
young faculty had received grants, and all who re-
qualified American students.
ceived two years of funding went on to win gov-
ernment or foundation support.
Rebuilding the physical plant for patients, stu-
Established 29 new endowed professorships to
dents, and scientists. Major construction projects
support senior faculty.
include the Preclinical Teaching Building, the
Denton A. Cooley Recreation Center, the A.
Increased Hopkins' share of federal biomedical
McGehee Harvey Building, the Hunterian Build-
research funding. Since 1975, Hopkins has
ing, the Richard Starr Ross Medical Research
Richard Starr Ross Medical Research Building
moved from seventh to second place in NIH
Building on Rutland Avenue, and the Asthma
awards to medical schools.
and Allergy Center. The Hospital has replaced
Celebrated the Centennial of Johns Hopkins
every bed.
Medicine in style.
7
Photo Copy Preservation
Photo Copy Preservation
BEA GADDY HONORED
Who What
The second annual Clar-
ence "Du" Burns Award for
Community Service was
recently awarded to Bea
Gaddy for her commitment
to helping Baltimore's
homeless. The award and
its $1,000 prize, created by
the Health System last year,
is awarded to the Individual
who has contributed most
to the quality of life In East
Baltimore during the pre-
ceding year.
cal School Council. Julia Haller, M.D., assistant
professor of ophthalmology, has been elected vice
chairman of the council
Steve Hegedeos,
M.S.Ed., has been appointed administrator of re-
habilitation medicine
Bruno Lima, M.D., as-
sociate professor of psychiatry and mental hy-
giene, is the recipient of the 1989 Award of the
Brazilian Psychiatric Association
Carolyn
Machamer, Ph.D., assistant professor of cell biol-
ogy and anatomy, has been selected for a 1990
Alfred Sommer, M.D.,
Mary Jo Wagandt was
Pew Scholars award
Deborah McGuire, R.N.,
M.H.S., professor of oph-
elected president of the
Ph.D., assistant professor of nursing, was reappo-
thalmology with joint ap-
Hospital's Women's Board
inted for a second term as the American Cancer
pointments In epidemiology
at the organization's annual
Society, Maryland Division, Mary Edna Busch
and International health,
meeting last May. In the
professor of nursing in oncology
Vernon B.
and director of the Dana
upcoming year, the Women's
Warren Beatty and Madonna were on hand to greet
Mountcastle, M.D., University professor of neu-
Center for Preventive Oph-
Board will contribute more
thalmology, has been ap-
Hopkins employees and others attending the benefit pre-
roscience, presented the John P. McGovern
than $400,000 to Hospital
pointed dean of the School
Award Lecture in the Behavioral Sciences at the
projects.
miere of "Dick Tracy."
of Public Health, effective
156th annual AAAS National Meeting
Stanley
Sept. 1.
'DICK TRACY' PREMIERE
E. Order, M.D., professor of oncology and direc-
tor of the radiation oncology division of the On-
BENEFITS HEMATOLOGY
cology Center, was named chairman of the board
of directors of the American Society for Thera-
Dozens of Hopkins doctors and staff members at-
peutic Radiology and Oncology. Order also re-
tended the star-studded premiere of the
cently completed Radiation Therapy of Benign Dis-
mer's much talked about movie, "Dick Tracy"
eases
Frank A. Osld, director of theirey
an event that raised more than $120,000 for
Children's Center, received the 1990 Joseph St.
Hopkins' hematology research program. Dick
Geme Award, the only such award presented by
Tracy" stars Warren Beatty (whose family has had
the nation's major pediatric organizations, for
a long association with Hopkins) and Madonna,
outstanding leadership in pediatrics
Albert H.
Edward A. Halle has been
Jane E. Stanck has been
who also attended, as did newscaster Ted Koppel,
Owens Jr., M.D., director of the Oncology Center,
appointed senior vice prest-
named director of govern-
actress Linda Carter, and White House Chief of
dent for adminstration of
was named vice president and president-elect of
mental relations for the
Staff John Sununu. Underwritten by the Walt
the Hospital and Health
the Association of American Cancer Institutes and
Hospital and Health System.
Disney Co., the event was held at D.C.'s Uptown
System. Since 1984, Halle
For the last three years, she
chairman of the National Coalition for Cancer
had been vice president for
Theatre and was followed bysa party at the Na-
served as deputy to Robert
Research
Thomas D. Pollard, M.D., director
adminstration. He's been
R. Heall, who has resigned
tional Building Museum. Moviegoers also en-
and Bayard Halstead professor of cell biology and
with Hopkins since 1970.
to run for public office.
joyed a pre-screening cocktail party with Beatty,
anatomy, was elected to membership in the
underwritten by Xerox Co.
American Academy of Arts and Sciences
Joan
Richtsmeier, Ph.D., assistant professor of cell bi-
ology and anatomy, has won the 1990 Maryland's
DON'T MISS
Outstanding Young Scientist Award
John
The NEH Summer Film Series, "Soul Doctors:
Rock, M.D., director of the division of reproduc-
The Psychopathology of Everyday Life," running
tive endocrinology and professor of gynecology
Wednesdays through Aug. 8, 7:30 p.m., Preclini-
and obstetrics, has been appointed to the board of
cal Teaching Building, main floor auditorium. =
directors of the American Fertility Society
5-3363 for details.
Curtis L. Ruegg, a graduate student in the De-
Mike Plank Is the Hospital's
John E. Hoopes, M.D., who
partment of Pharmacology and Molecular Sci-
new director of housekeep-
directed expansion of the
NEWSMAKERS
ences, received the 1990 Sandoz Award presented
Ing. Formerly an area man-
division of plastic surgery
by Sandoz Pharmaceuticals in recognition of su-
ager for Broadway Services
over the last 20 years, re-
perior academic achievement and contribution to
Inc., with clients Including
tired June 30. Hoopes has
John Bacon has been named the Hospital's EEO/
health care
Norman Sheppard, Ph.D., assis-
FSKMC, Plank helped start
published 160 scientific pa-
AA Officer
Joseph T. Coyle, M.D., director
tant professor of biomedical engineering, was
the company's housekeep-
pers, more than 50 book
and distinguished service professor of child psy-
awarded a Presidential Young Investigator Award
ing division at Hopkins.
chapters, and has been CO-
chiatry, and professor of neuroscience, of phar-
from the National Science Foundation
Medi-
editor of three books.
macology and molecular science, and of pedia-
cal student John Sinard was awarded the 1989-90
trics, and Murray B. Sachs, Ph.D., professor of
Straus Award honoring the Hopkins medical stu-
biomedical engineering, of neuroscience, and of
dent who demonstrates the greatest fascination
otolaryngology, have been elected to the Institute
with anatomical research
Solomon H. Snyder,
of Medicine
DOME
Catherine DeAngelis, M.D., dep-
M.D., director and distinguished service professor
uty director, of the Children's Center, received the
of neuroscience, received an honorary doctorate
Ambulatory Pediatric Association's research award
of science at Ben-Gurion University of Negev,
Published monthly except July, August and January for
employees and friends of The Johns Hopkins Medical
for her contributions to pediatric knowledge
Beer-Sheva, Israel
Paul Talalay, M.D., J.J.
Institutions by the Office of Public Affairs, Elaine
Morton Goldberg, M.D., F.A.C.S., chairman and
Abel distinguished service professor of pharma-
Freeman, director. Deadline is the 10th of the month
professor of ophthalmology, has beenelected
cology and molecular science, has been elected a
for the following month's issue. Send news items to the
president of the Association of University Profes-
member of the American Philosophical Society,
editor, 550 North Broadway, Suite 1100, Baltimore
sors of Ophthalmology Sidney O. Gottlieb,
21205, FAX 955-4452, or call to 301/955-5422.
the nation's oldest learned society
Henry N.
Dot Sparer, editor; John Bartgis, managing editor; Kim
M.D., assistant professor of medicine and director
Wagner Jr., director and professor of nuclear
Goad, publications coordinator; Bernice Edmonds,
of the cardiac catheterization laboratory at
medicine, was awarded an honorary degree from
publications assistant; Ben Allen, layout; Rob Smith,
FSKMC, has been elected chairman of the Medi-
the Free University of Brussels.
photography.
8
A JOINT PROGRAM OF
THE CITY OF BALTI-
MORE, THE BALTIMORE
CITY PUBLIC SCHOOLS,
AND THE PREVENTION
CENTER OF THE DE-
PARTMENT OF MENTAL
HYGIENE, JOHNS
HOPKINS UNIVERSITY,
SCHOOL OF HYGIENE
AND PUBLIC HEALTH.
PROMOTING
SELF-ESTEEM, HIGH
ACHIEVEMENT, AND
FULL POTENTIAL.
PREVENTING DROP
OUT, MENTAL DIS-
ORDERS, DRUG ABUSE
AND VIOLENCE.
1916
CITY OF
1797
THE PREVENTION PROGRAM
R
ince 1984, the Baltimore City Public Schools and the Prevention
Research Center of the Johns Hopkins School of Hygiene and
Public Health have been working together on a program to improve
learning and behavior for 2400 school children. The goal of this
Prevention Program is for all children to reach their full potential
and to feel good about themselves.
The Prevention Program was based on studies of children's experi-
ence in first grade. These studies show that how children behave,
how they feel about themselves, and how they learn are good
indicators of whether they will have problems when they are teenagers.
THE PREVENTION PRO-
For instance, learning difficulties as early as first grade are related to depression in adoles-
GRAM WAS BASED ON
cence. Some ways of behaving in first and second grade, such as not obeying rules, staying
STUDIES OF CHILDREN
away from school or habitually fighting with classmates, predict later problems with alcohol
IN FIRST GRADE. THESE
and drug use, dropping out of school and delinquency.
STUDIES SHOW THAT
Children who are very shy, such as those who sit alone most of the time, have no friends
HOW CHILDREN BE-
and do not participate in class, may have anxiety problems as teenagers. Based on these
HAVE, LEARN, AND FEEL
studies, the researchers in the Prevention Center have developed programs to change or
ABOUT THEMSELVES
improve behaviors and skills at an early stage, and thus affect the way these children will
IN FIRST GRADE ARE
act when they are teenagers.
GOOD INDICATORS OF
As a first step in their Prevention Program, the Baltimore City Public Schools and the
WHETHER THEY WILL
Prevention Center worked with school teachers and principals and with parents to obtain
HAVE PROBLEMS WHEN
information about each child. Parents were requested to give consent for the participation
of their children in 19 elementary schools.
THEY ARE TEENAGERS.
In confidential interviews, classroom teachers were asked about each child's progress in
learning and behavior in class twice each year. School records were examined for test
scores, classroom grades, attendance, and similar information related to learning and
behavior. The children themselves were asked how they felt about themselves. They were
asked how they thought their classmates were doing in school, who made friends easily, and
who stayed away from others. Of course, all this information was obtained on a confidential
basis, in accordance with School District and Medical Institution regulations.
After first learning about the children and their classrooms, the Prevention Program carried
out two separate interventions, one directed at improving learning and the other at
improving shy and aggressive behavior.
The first intervention, Enhanced Mastery Learning, works to increase learning for all the
children in the class. Each child is given enough time to learn, helped with difficulties, and
regularly checked to see how much has been learned. Children do not go on to the next
learning task until most of them have achieved mastery of the previous task.
RESULTS FROM THE
FIRST YEARS OF THE
PREVENTION PROGRAM
SHOW THAT THE IN-
TERVENTIONS WERE
SUCCESSFUL. FIRST
GRADERS IN THE
ENHANCED MASTERY
LEARNING CLASS-
ROOMS HAD GREATER
SUCCESS IN LEARNING
TO READ THAN THEIR
AMA
PEERS. WHERE THE
GOOD BEHAVIOR
IN THE
GAME WAS PLAYED,
CHILDREN BEHAVED
LESS AGGRESSIVELY
AND LESS SHYLY AFTER
A YEAR AND TEACHERS
WERE ABLE TO TEACH
MORE EFFECTIVELY.
he second intervention, called the Good Behavior Game, works to
reduce aggressive and shy behavior in the classroom. Children
form teams and rewards are given the team when members behave
appropriately in class by sitting quietly and participating in
classroom activities rather than breaking rules and fighting. All
teams can win.
Results from the first years of the Prevention Program show that
these interventions had, at least, short term benefits on achieve-
ment and behavior. First graders in the Enhanced Mastery
Learning classrooms had greater success in learning to read according to national test scores
than their peers who were tested in our standard setting classrooms. In first grade classrooms
where the Good Behavior Game was played, children behaved less aggressively and less
shyly after a year and teachers were able to teach more effectively in a more cooperative
environment.
The Prevention Program can help us understand when children start thinking about and
using drugs and weapons during their later years, whether the two early interventions help,
and what else is needed. The Baltimore What's Happening (BWH) project asks children
what they know about tobacco, alcohol, and other drugs and whether they use them. The
interviewers also ask each child privately and confidentially whether they get into fights or
carry weapons.
One of the most common and important problems a child may have in school is impaired
attention. The Attention Project has been developing new methods of evaluating and
helping with these problems by studying how children perform on computer, card sorting
and memory tasks that measure different aspects of attention.
These and similar assessments conducted every year allow us to identify children who may
have problems and to develop ways to help them before these problems occur or at least
before they reach the crisis stage. Professionals in the schools and in the Prevention
Center work with teachers, parents and the child in finding new ways for prevention.
THE
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THE
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LETTER
Weekly Reader Children's Book Club
everal strategies are planned next to ensure that parents are
heavily involved and have ample opportunity to participate in the
Prevention Program during its next stages. The rights of the
children must be protected including confidentiality and strong
respect for the parents' role in the formal consent in each child's
participation. Several strategies are planned to provide these
opportunities:
1) The formation of a Community Advisory Board which will
include parents, community leaders, and legislators. 2) The
formation of a Parent Council which will work closely with the Prevention Center SO that
the parents can inform the Prevention Program staff about their views, and work with staff
AT EACH STAGE, THE
to develop acceptable programs and measures. 3) Creation of a quarterly newsletter.
PREVENTION PROGRAM
In working with large numbers of young children through the Prevention Program, some
PLANS TO INCLUDE
children come to our attention who are in urgent need of help. Emotional, behavioral, and
PARENTS IN ASSESSING
home problems all have been brought to our attention. The Prevention Program is not
HOW THEIR CHILDREN
empowered to provide direct services, but the staff is obliged to help children receive
ARE DOING. INTER-
services, if possible, through the proper designated officials in the schools or in other
VIEWERS WILL ASK
agencies within the city. Efforts will be made by special prevention staff to assess a child's
WHAT CONCERNS
needs and the staff will require the support and consent of parents in doing so.
PARENTS HAVE ABOUT
It is important that we continue following the progress of the children who have partici-
THEIR CHILDREN, WHAT
pated in the Prevention Program well into teenage years. We plan to continually evaluate
DIFFICULTIES FAMILIES
who benefits, who does not, whether the benefits from these programs continue into their
later years, and what else is needed. At each stage, the Prevention Center actively plans to
AND CHILDREN FACE,
include parents in assessing how their children are doing. Interviewers will ask what
AND WHAT PROBLEMS
concerns parents have about their children, what difficulties families and children face, and
THEY THINK THE PRE-
what problems they think the Prevention Program should address in the future. Meetings
VENTION PROGRAM
with groups of parents are planned, and special workshops and seminars will be available.
SHOULD ADDRESS IN
The Prevention Research Center has recently been funded for the next five years to develop
THE FUTURE.
four new interventions for children and families in the areas of behavior, achievement, and
attention.
We plan to combine the Mastery Learning and the Good Behavior Game and to evaluate
whether this strengthens the impact of each on school achievement and on aggressive and
shy behaviors. We will also develop and offer families of entering first graders an opportu-
nity to participate in a family learning environment program to promote each child's
learning in school and we will evaluate its effectiveness. A program in behavior manage-
ment will be developed to help families promote good behavior in their children and to
evaluate its effectiveness. Children who show early signs of attention problems will be
offered new programs that we are preparing to improve this vital part of the child's class-
room behavior. They also will need careful evaluations and development.
To achieve these goals we will be collaborating with legislators, school leaders, community
organizations, individuals and parents.
THE PREVENTION PROGRAM PARTNERSHIP
City of Baltimore
Mayor Kurt L. Schmoke
Board of School Commissioners
Mr. Joseph Lee Smith, President
Mr. Lloyd T. Bowser, Sr.
Mr. Stelios Spiliadis, Vice President
Mrs. Arnita Hicks McArthur
Dr. Phillip H. Farfel
Mr. James E. Cusack
Mr. Meldon S. Hollis, Jr.
Mr. Michael Rosemond, Northwestern H.S.
Mrs. Linda C. Janey
Ms. Tanika Chapman, Dunbar H.S.
Baltimore City Public Schools
Walter G. Amprey, Ed.D., Superintendent of Public Instruction
Patsy Blackshear, Ph.D., Deputy Superintendent
Lillian Gonzalez, Ed.D., Deputy Superintendent
Norman J. Walsh, Ed.D., Associate Superintendent for Curriculum Development, Planning,
Research and Evaluation
Herman Howard, Ed.D., Associate Superintendent, Special and Vocational Education and
Compensatory Education
Robert Clinkscales, Ph.D., Associate Superintendent for Vocational and
Alternative Education
Jerrelle F. Francois, Assistant Superintendent for Secondary Education
Leonard Wheeler, Ed.D., Assistant Superintendent for Elementary Schools
Alice Morgan-Brown, Ph.D., Assistant Superintendent, Curriculum Development
Charlene Cooper-Boston, Ph.D., Assistant Superintendent, Special Projects/Director of
Central District
Marguerite Walker, Director III, Elementary Schools
Charles Burke, Director III, Elementary Schools
Matthew Riley, Director III, Elementary Schools
Nancy Gimbel, Director, Elementary Curriculum Development
Carla Ford, Curriculum Specialist, Early Childhood Education
Prevention Research Center, Department of Mental Hygiene,
The Johns Hopkins University
Sheppard G. Kellam, M.D., Center Director
James Anthony, Ph.D., Substance Abuse
Bruno Anthony, Ph.D., Attention Problems
Lawrence Dolan, Ph.D., School Achievement and Mental Health
Lisa Werthamer-Larsson, Sc.D., Child Services
Nicholas Ialongo, Ph.D., Family and Child Mental Health
George Rebok, Ph.D., Health and Development
Penelope Keyl, Ph.D., Child Injury Prevention
Mary Bruce Webb, M.A., M.S., Chief of Operations
Elva J. Edwards, M.S.W., L.C.S.W., Director, Community Relations
Amir Saharkhiz, M.S., M.B.A., Data Manager
The Prevention Program is funded by grants and contracts from the National Institute of Mental
Health and the National Institute on Drug Abuse.
For more information on the Prevention Program, call Mrs. Elva J. Edwards - 301-955-3945
or write to:
The Prevention Research Center
Department of Mental Hygiene
School of Hygiene and Public Health
624 North Broadway
Baltimore, Maryland 21205
Baltimore
THE CITY THAT READS
DOING WHAT
11141
11111
WE DO BEST...
1
THE
EVEN BETTER
Quality Management at Work
JOHNS
HOPKINS
HEALTH
SYSTEM
1991 ANNUAL REPORT
THE YEAR IN REVIEW
Superb medicine has been the basis of Hopkins' reputation
acute inpatient units in the System-Homewood Hospi-
for 100 years. Today, however, superb medicine is not
tal-required a complete change of direction if it were to
enough. Quality in medicine must be backed by a system
serve the purposes of the public and the Johns Hopkins
that adds efficiency and reduces cost at every turn. In the
Health System. In 1991, we concluded that the contribu-
1990s, health care providers will live or die by how they
tion of Homewood Hospital to the System and the commu-
manage investments in technology and facilities, how they
nity simply did not warrant its continued operation as an
are perceived in terms of quality in medicine and services,
acute hospital. We were supported in the decision to close
and whether they can deliver quality at an affordable price.
it by the Health Resources Planning Commission and the
Consequently, over the past three years, we have focused an
Health Services Cost Review Commission of the State of
intense effort on improving the services we provide
Maryland, and the political structure of the City and State.
patients.
Every effort was made to ease the painful transition to other
As a large health care system with an academic medical
employment for Homewood Hospital employees. We are
center at its core, Hopkins has a responsibility to lead the
grateful to them for their competence and help in a diffi-
search for new and better ways to deliver su-
perb medicine and related services. With an
ultimate goal of centering operations around
the imperatives of patient care, this search is
taking place in every area of our organization,
from tracking the flow of people and paper
among departments to exploring optimal
configurations for the System itself.
While we were focused on long-term qual-
ity improvements, the year that closed June
30, 1991 was one of challenges in other areas
as well. Financial performance in the hospi-
tals of the System was less than budgeted, a
combination of soaring expenses-primarily
in the supply area-and State of Maryland
Medicaid cutbacks which reduced revenues.
Nevertheless, gains were made in general operations, vol-
H. Furlong Baldwin (left)
and Robert M. Heyssel. M.D.
ume remained strong at The Johns Hopkins Hospital and
The Francis Scott Key Medical Center (FSKMC), and
length of stay declined further. Hopkins Hospital reached
national averages for Medicare length of stay in one year
rather than two, as planned. The latter accomplishment is
very important for preservation of the State Medicare
waiver. The efforts of the medical staff made that possible.
At the same time, it became apparent that one of the
1
cult time. Many now are employed at other Johns Hopkins
Three new facilities represent the thrust of our plans for
Health System sites. We currently are negotiating the sale
the future. A state-of-the-art Outpatient Center will open
of Homewood Hospital's assets on North Charles Street,
in May at The Johns Hopkins Hospital. At FSKMC, The
and hope to return the facilities to productive efforts in
Johns Hopkins Geriatrics Center opened in the spring, and
health care.
a new 190-bed acute care patient tower will begin con-
This year we also announced the sale of The Johns Hop-
struction this fall.
kins Health Plan to the Prudential Insurance Company.
Of course, cutting costs, increasing efficiency and focus-
That decision had been under exploration for nine months,
ing more closely on the needs of patients is not just a mat-
during which time we held conversations with several po-
ter of facilities design. These concepts must be made tangi-
tential buyers. We based our action on what we believed to
ble in daily operations and in the worklife of everyone
be changes in the health insurance market. Large employ-
associated with Hopkins.
ers-the clients an HMO must attract to be profitable-
Toward that end, our Quality Management initiative,
are looking for single insurers who offer a spectrum of ser-
begun three years ago with the help of a generous grant
vices from traditional indemnity insurance through
from the Baxter Foundation, is taking hold. More people
managed care. We decided to focus on what we do best-
become involved every day. And even more are feeling the
provide health care-rather than remain in the insurance
positive results of change. Managing for quality is an ongo-
business.
ing force that will enable Hopkins people to put their good
In that vein, the agreement with Prudential resulted in
ideas to work, matching our reputation for superb medicine
our retaining physician groups and 18 sites of care in the
with one for superb service to our patients.
Baltimore region. The sale of the insurance, marketing and
membership services and claims processing to Prudential
included an agreement for Johns Hopkins to continue pro-
H-Bl
viding services to Prudential members. Importantly, as part
of the agreement, we will continue to enroll Medicaid re-
Robert M. Heyssel, M.D.
H. Furlong Baldwin
President and
Chairman
cipients as before in the only HMO in the Baltimore region
Chief Executive Officer
Board of Trustees
to mix public and private members.
This strategic divestiture allows us to concentrate on
building outpatient services at Homewood North and the
sites formerly owned by the Hopkins Health Plan. Dr.
Richard Tompkins joined us in March to lead a combined
physicians' group composed of former Hopkins Health
Plan physicians and those of the Wyman Park Medical As-
sociates. In the coming year, the combined group will have
revenues of $100,000,000 from contracts with the Depart-
ment of Defense and Prudential and fee-for-service income.
During all of these changes, the legal, financial, human
resources and general management staff of the Johns Hop-
kins Health System performed superbly.
2
DOING WHAT
H
ave you ever spent three hours waiting
for a 10-minute lab test? Or been daz-
zled by an array of indecipherable bills after a hospital
WE DO BEST...
stay? Do you ever find senseless hospital routines bog-
ging you down? Or that the simplest procedure trig-
gers an avalanche of forms? Don't you think it's time
EVEN BETTER we did something about it? We are. Read on
3
T
his year, The Johns Hopkins Hospital was recognized as "The Best of the
Best" by U.S. News & World Report. According to the magazine's survey
of physicians nationwide, Hopkins is at or near the top in 13 of the 15
specialties reviewed. This recognition of the high calibre of medicine practiced here is a
tribute to everyone who works at Hopkins. For more than 100 years, offering patients the
highest standards of quality in medicine has been our mission. But there is another side to
the quality story that is proving equally crucial, if a bit less acclaimed, in this age of cost
WHAT IF EVERYONE DID THIS?
"First we defined our 'customers': the families of our patients.
Then we looked for the coffee stains, anything that would upset
or aggravate them," says Ski Lower, nurse manager of the Neuro-
Critical Care Unit. "The goal was to find ways to do 99 things
just 1 percent better. This approach to QM has tapped into the
creativity of our nurses, and the ideas are great.
"We looked for things that would cause stress to families," she
continues. "Like the phone ringing 12 times before it's answered.
Or meeting us and seeing the unit for the first time on admitting
day, when their anxiety is highest. Now the phone is answered
in three rings, and patients come for tours well before surgery.
None of these ideas is earth-shattering, but together they make
a tremendous difference
in the comfort level of
our patients and their
families.
"Each year, we're
going to pick a differ-
ent 'customer' and
look for new '1 per-
centers. The 'cus-
tomer' might be
pharmacy, another
nursing unit, even
ourselves, any rela-
tionship that could
benefit from fresh ideas
and better teamwork. This is really the root of QM. Can you
imagine how it would be if everyone did this? Quality manage-
ment would be part of everyday life. We constantly would be
making the system better for ourselves and for our patients."
4
concerns and shrinking labor pools. For the past three
for paperwork and well-defined pre-employment proce-
years, we have been taking a hard look at the non-clinical
dures for staff and recruits.
aspects of health care delivery within the Johns Hopkins
The QM team's recommendations-including redesign
Health System. We haven't always liked what we've discov-
of the work flow, clearer linkage between departments, and
ered. Surveys of our patients, physicians, nurses and em-
a new employee information packet and map-are already
ployees have revealed a litany of frustrations that often
easing the transition for new employees. Creative solutions
cloud the ideal of giving and receiving excellent care.
are turning a once difficult initiation into a warm welcome
To focus on these issues, we launched a Systemwide
to Hopkins.
Quality Management (QM) process in 1989. With the
THROUGH THE LOOKING glass
wave of total participation now swelling, we know one
thing for certain: We have what it takes to be "The Best of
Of course, arriving at solutions that seem self-evident after
the Best" in service as well as in medicine. Slowly but
the fact is not always easy. As any scientist will acknowl-
surely, we are bringing that knowledge to life throughout
edge, moments of insight usually are powered by long
our organization.
hours of scrutiny rather than flashes of serendipity. The
THE TAIL WAGGING THE DOG
path to new and better ways of doing things is lined with
"We discovered that new nurses were often upset by the
time they began orientation," says Linda Arenth, vice presi-
dent for nursing and patient services at Hopkins
Hospital. Arenth is also chairman of the hospital's
QM Steering Committee. "Who could blame
them. As it turns out, we had a potentially frus-
QM IS like UNRAVELING
trating employment process."
A MYSTERY. IT FORCES YOU
A 16-person, multidisciplinary QM team
called the Employment Task Force set to work,
with the idea that taking care of the caregivers
TO UNTANGLE THE PIECES
supports a more caring environment for patients.
Composed of people from human resources and
OF AN ACTIVITY, THEN SEE
nursing, the team took the entire employment
process apart, piece by piece, using a flow chart
HOW YOU CAN BEST PUT
to map the path of paper and people that new
nurses travel before starting work. With all pos-
THEM BACK TOGETHER.
sible frustration-causers now gathered together
on a single diagram, a few likely culprits began
to emerge.
"For one thing, the flow of paperwork couldn't keep up
with the flow of people," says Peter McGinn, Ph.D., vice
president for human resources. "New nurses had too many
places to go and things to do just to sign on." Other vil-
lains? Fingers pointed to the lack of tracking mechanisms
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days spent collecting data, analyzing systems, testing hy-
as they are fundamental to the smooth functioning of every
potheses and measuring results. It is this step-by-step ap-
department.
proach that eventually peels away layers of complexity to
PUTTING THE HORSE BEFORE THE CART
reveal the essence from which new answers come.
"QM is like unraveling a mystery," says Judy Reitz,
The QM-powered hunt for functional glitches has revealed
Sc.D., vice president for patient care and medical support
some elemental truths. For one, rarely is the solution a
services at The Francis Scott Key Medical Center (FSKMC).
matter of simply working harder. Clearly, Hopkins people
"That's what's SO exciting. The process forces you to untangle
already apply large doses of industry and elbow grease to
all the pieces-to find out how something actually works-
their jobs. And as Ronald Peterson, president of FSKMC,
then see how you can best put it back together again."
points out, "QM doesn't mean throwing money at a prob-
QM teams throughout the Health System now are
lem. It's a common misconception that high quality and
prying into the secrets of interdepartmental, intradepart-
low cost are incompatible. Clarifying procedures and re-
mental and Systemwide functions. The projects cover the
solving issues between people and departments will result
gamut-admissions, discharge, patient transport, medical
in quality improvements."
records, to name a few-and are proving to be as complex
Quality issues in hospital management often are a case of
having put the cart before the horse, of having opera-
tions-rather than the needs of patients-dictate proce-
IN SEARCH OF THE MISSING LINKS
dures. As Reitz points out, trouble spots also arise from
Unlocking the mysteries of cash balances and bill collection rates
outmoded routines. "We're finding that many of the proce-
ordinarily would be relegated to the number crunchers in the
dures we use no longer make sense," she says. "As an orga-
accounting department. But, thanks to QM, a team at FSKMC
representing every major area of the hospital, from nursing and
nization grows and changes, inefficiencies get embedded.
medical staff services to risk management, computer operations
We need to look at all areas-medical records, visitor con-
and admitting, is on the case. Its mission? To make billing more
trol, admissions-to see if they are serving us and our pa-
accurate. Getting it right the first time will mean fewer hassles
for patients, third-party payers and the hospital.
tients well today."
As Ken Grabill puts it, "Timely, accurate billing is tied to the
entire process of information capture from admission on." Grabill
is vice president of finance at FSKMC. "The way diagnoses are
filed, the way procedures
are reported, the speed
with which medical
documents are passed
along all affect billing."
Interdepartmental co-
operation will be the
key to cutting through
hang-ups and delays.
The early phases of
information collection
have given way to a
timetable for accom-
plishing 65 specific action
plans. As part of those plans, the team is creating unified poli-
cies, procedures and performance measurements for every step
of the billing process throughout the patient flow. Coupled with
the QM effort, a powerful new computer system will correlate
data across hospital functions.
8
The catalyst for improving non-clinical aspects of health
IF AT FIRST YOU DON'T SUCCEED
care came three years ago in the form of a $1 million grant
It's a tale replete with mistaken identities and circuitous twists
from the Baxter Foundation. The idea was to look at man-
and turns. The plot: "What's the matter with patient transport?,"
agement processes with an eye toward creating a national
says Gerard Reardon, director of social work and co-chair of the
model for improving the service side of health care. The
X-ray transport QM team at Hopkins Hospital. "There was a leg-
endary story of a patient leaving at 8 a.m. for a routine chest
grant heralded what has become a rallying cry in the indus-
X-ray and not returning until after lunch."
try. Where accrediting organizations such as JCAHO once
Fingers pointed to the escort messenger service, the people re-
sponsible for transporting patients in wheelchairs or on gurneys
looked only at medically oriented quality assurance pro-
to and from the units. But, as the team found out, the first sus-
grams as indicators of excellence, they now are moving
pect isn't always the culprit. "Over the past year, we've discov-
toward mandating quality management programs that han-
ered how complex something as simple as moving a patient to
radiology really is," says Reardon. "We asked our own experts-
dle issues of patient satisfaction as well.
X-ray technicians, escorts, nurses, clerical staff-how things
Robert M. Heyssel, M.D., president of the Hopkins
actually worked in their departments, and found a lack of
coordination at key interchanges."
Health System and Hospital, believes QM to be an essen-
tial force for the future. "We're asking people to think dif-
ferently about how they do things," he observes. "This is a
process for the long-haul, not just a quick fix. Once QM
takes hold, it will represent a change in the culture of our
institution. The process empowers people to do their best
work, and will ultimately ensure even better, more efficient
care for our patients."
MORE THAN A MOUTHFUL OF JARGON
Of course, to be anything more than the slogan of the
The first solution? Block times when nursing units could send
month, QM must become a deeply ingrained mind-set that
patients to radiology, coupled with a goal of returning patients
to the unit within one hour. "After we put the plan in effect, we
emphasizes practical solutions to everyday problems. Train-
started meeting the time goal," Reardon explains. "But strangely
ing and the inspiration of other companies' experiences are
enough, when we evaluated further, we found that most patients
helping jump-start creative attitudes toward worklife at ev-
were not going down during the block times. It was very per-
plexing.
ery level.
"I think what actually happened was a subtle shift in aware-
Understanding how to set up and work on a QM team is
ness. Radiology scheduling had been organized around outpa-
tient needs," he continues. "Now they schedule around inpatient
not an innate talent. Successful QM depends on knowledge
needs, as well." The team's most recent survey of key players
of problem-solving, the use of statistical tools and the dy-
reveals better communication and, in typical QM fashion, new
areas for improvement.
namics of teamwork. Intensive training, which every
Health System employee eventually will undertake, is the
critical first step. Teams train together to build esprit de
corps. More than 500 people have received training so far.
An additional 900 people at Hopkins Hospital alone will
attend the 16-hour program in the coming year.
"It was fascinating," says Steven Lipstein of the training
sessions developed by Dome Learning Systems Inc., a Hop-
kins subsidiary. Lipstein is executive director of the new
9
Outpatient Center. "In one of the exercises, each team
zations like Healthcare Forum, 3M, Abbott Laboratories
member got a series of cards with facts relative to the care
and Federal Express bring us concrete examples of how QM
of a lawn. We had to figure out why the lawn wasn't grow-
can work in different environments. This is having a pro-
ing. Based on their own cards, everyone believed that he
found effect on my managers."
knew what the problem was. When we started putting all
LEARNING TO HEAR, NOT just LISTEN
the cards together, a whole different picture took shape. It
became clear that pooling information and building con-
sensus must happen before you can work on solutions."
As the process gathers momentum through increasing staff
Colene Daniel-Forde, vice president for corporate ser-
participation, important lessons are emerging. One of the
vices, finds the experience of other businesses equally en-
most significant has to do with listening to our custom-
lightening. "We invite corporations here on a monthly
ers, discovering what they actually mean by a criticism or
basis to find out how they have implemented the QM pro-
compliment.
cess," she says. "Managers and supervisors from organi-
Says Barbara Reick, director of Quality Management at
Hopkins Hospital, "In our initial surveys to identify areas
that needed work, patients said that our facilities were not
HOMING IN ON PATIENT SATISFACTION
as clean as they could be. But when we started talking with
people and looking at the problem from the patients' point
Imagine a hospital experience in which every aspect of care moves
like clockwork. For an outpatient that would mean scheduling
of view, we realized that cleanliness wasn't the issue. The
all appointments with one phone call, moving swiftly through
rooms were immaculate. The real problem was that some of
reception to the physician's office, having every step along the
the rooms needed a fresh coat of paint, new curtains or per-
path clearly defined. Or for an inpatient, always receiving care
by familiar faces, having services like X-ray and physical therapy
haps a brighter lightbulb."
right on the unit, receiving a single invoice for all aspects of care.
The QM team working on this project decided to talk to
We call it the ideal patient encounter, a concept which has
guided the planning of two new facilities, the Outpatient Center,
some of our own experts manning the front-lines in facili-
scheduled to open at Hopkins Hospital this spring, and a new
ties and housekeeping, as well as experts in hotel manage-
patient tower at FSKMC slated to begin construction this fall.
Says Steven Lipstein, executive director of the Outpatient Cen-
ment at Marriott Corporation. The team's recommenda-
ter, "The ideal patient encounter has three components: first,
tions, now being tested in a pilot program at the Hopkins
we'll deliver expert medical care; second, we'll treat patients with
Children's Center, include a room refurbishment plan mod-
kindness, attentiveness and caring. Importantly, our third goal is
to have patients spend more time seeing the clinician than they
eled after Marriott's.
do registering, waiting for appointments or walking between of-
fices. To achieve this, we've used computer modeling to deter-
mine the best organization of services for 8,000 outpatients
per week."
The result is a facility designed for
smooth patient flow. Automated
systems and defined procedures,
like advance registration, will
help avoid bottlenecks. Diag-
nostic services, like radiology
and blood testing, will be
grouped together for conve-
nience. Patient service
coordinators will guide patients
through the process. And sys-
tems for continually measuring
our performance will be in
place before our first patient
walks through the door.
10
LOOKING TO OURSELVES FOR ANSWERS
physician's initial referral to the moment the patient enters
the room. We find that simple things, like a physician's
Gathering an arsenal of QM tricks from other industries
secretary holding paperwork to send in batches, can slow
can be misleading, however. The case for change must be
everything down all along the line. Now that we know
built on facts and goals that reflect the multiple missions of
how all the pieces link together, we can determine how
our own institution. According to Peterson, Hopkins' tri-
each connection is best achieved."
fold mission of patient care, medical education and research
"As QM progresses, we're finding that more people look
complicates matters. "This is not like for-profit businesses
to their peers and co-workers to solve problems or increase
where the mission is clearly organized around the bottom
efficiency," adds Daniel-Forde. "Quality teams define their
line," he says. "We have to address business imperatives in
own projects and design new systems themselves. They
the light of our social and educational missions."
begin to understand the importance of their jobs and the
As McGinn puts it, "The challenge in health care is to
value placed on their ideas. Clearly this makes the Health
identify the right things to measure and to gather that data
System run better and improves the patient care envi-
in a way that is non-intrusive. We don't want to build a
ronment."
new bureaucracy. This has to be a built-in process, carried
And that's the whole point. With the QM process help-
out by the people involved in patient care."
ing us bring more mysteries of managing the Health
Industrial quality-management techniques designed to
System to light, everyone at Hopkins will have more op-
root out inefficiencies and streamline procedures are most
portunities to do what we do best even better.
applicable to functions involving information
trails, accuracy and timeliness. "It's interesting
to note that the statistical tools we're using to
gather and analyze data on non-clinical functions
QM DOESN'T MEAN
are not easily applied to issues of medical effi-
cacy," observes Lipstein. "Quality management
THROWING MONEY AT A
serves a different purpose from traditional qual-
ity assurance."
PROBLEM. IT'S A COMMON
Hot on the heels of QM fact-finding and anal-
ysis comes a step-by-step outline and timetable
MISCONCEPTION THAT
for implementing changes, and a strategy for
measuring results. Consistent monitoring of
HIGH QUALITY AND LOW
progress and periodic reassessment of goals will
plant the seeds for continual improvement in all
COST ARE INCOMPATIBLE.
things related to patient comfort and satisfaction.
back TO BASICS
Perhaps the most basic lesson learned so far is that there is
no substitute for good communication. "Consistently we
find that people don't understand how their job affects
someone else's," observes Arenth. "The QM team working
on the admissions process is tracing every step from the
11
FACTS AND FIGURES
HOSPITAL OPERATING STATISTICS
Fiscal Year 1991
JHH
FSK¹
JHMSC³
Total
Discharges
37,263
13,234
5,279
55,776
Deliveries
3,734
1,136
0
4,870
Patient Days
292,856
87,799
38,550
419,205
Average Length of Stay (Days)
7.9
6.7
7.3
7.5
Average Daily Census
802
241
106
1,149
Outpatient Visits/Encounters²
397,135
180,327
394,820
972,282
Emergency Visits
83,887
36,972
8,279
129,138
Operating Room Procedures
— Inpatient
14,362
2,990
1,221
18,573
- Outpatient
9,553
2,051
2,407
14,011
¹Acute Care Hospital - excludes Mason F. Lord
2JHH includes Hospital and University Clinics
JHMSC includes The Johns Hopkins Health Plan and The Homewood Hospital Center Inc.
FINANCIAL STATISTICS
Fiscal Year 1991
JHH
FSK¹
JHMSC²
Total
Gross Revenue
$ 414.3
$ 117.9
$ 80.6
$ 612.8
Net Revenue
367.8
120.1
85.8
573.7
Total Expenses
365.3
118.6
87.6
571.5
Margin Before Debt
2.5
1.5
-1.8
2.2
Margin After Debt
0.0
1.5
-3.9
-2.4
Uncompensated Patient Care
37.0
11.9
6.7
55.6
¹Includes Mason F. Lord and Grant Programs
²Includes Net Operating Revenue. Other Revenue and Net Financial Results of Discontinued Operations for The Johns Hopkins Health Plan and The Homewood
Hospital Center Inc.
GROSS REVENUES
REVENUE PAYER Mix
Fiscal Year 1991
Fiscal Year 1991
Johns Hopkins Hospital $414.3M
Medicare 21.4%
Johns Hopkins Med. Serv. Corp. $80.6M
Medicaid 17.5%
Francis Scott Key Med. Center $117.9M
Commercial Insurance 12.1%
Blue Cross 9.9%
Self Pay/Other 11.9%
Managed Care 27.2%
Total Johns Hopkins Health System $612.8M
12
HOSPITAL PATIENT ORIGIN
Baltimore City and
Baltimore
Remainder of
Other USA &
Calendar Year 1990
Adjacent Communities
Metropolitan Area
Maryland
International
Johns Hopkins Hospital
57%
15%
13%
15%
Francis Scott Key Medical Center
90%
5%
3%
2%
Johns Hopkins Medical Services Corporation
86%
11%
2%
1%
Johns Hopkins Health System
68%
13%
9%
10%
MEDICAL STAFF AND PerSONNEl
Fiscal Year 1991
JHH
FSK¹
JHMSC
Total
Total Employees (FTEs)²
5,617
1,579
1,590
8,786
Medical Staff³
1,527
471
457
2,455
Registered Nurses (FTEs)
1,522
359
190
2,071
House Staff⁴
597
107
0
704
'Acute Care Hospital - excludes Mason F. Lord and Grant Programs
²Excludes Hospital Medical Staff
SActive. Courtesy. and Associate Staff
4Interns and Residents - includes some shared appointments
UNCOMPENSATED CARE
Millions
70
O/P SURGERY PROCEDURES
60
Thousands
16
50
14
40
12
30
10
20
8
10
6
0
87
88
89
90
91
4
Francis Scott Key Medical Center
2
Johns Hopkins Medical Services Corporation
Johns Hopkins Hospital
0
87
88
89
90
91
13
THE JOHNS HOPKINS HOSPITAL
We were pleased this year to be recognized once again by
Peter V. McGinn
William McMillan
Vice President-
John M. Nelson III
U.S. News & World Report, this time as "The Best of the
Human Resources
Russell A. Nelson, M.D.
Paul M. Rosenberg
Oliver H. Reeder
Best." In a national survey of physicians, we ranked at or
Vice President-
William F. Schmick Jr.
near the top in 13 of the 15 specialties reviewed.
General Counsel & Secretary
The Rev. Donald O. Wilson
This has been a most significant year for the discovery of
W. Thomas Barnes
MEDICAL BOARD
Vice President-
new knowledge that will benefit patients. Two findings in
Treasurer & Secretary Emeritus
Edward E. Wallach, M.D.
Ethel E. Landis
Chairman
particular-the gene whose altered forms cause two inher-
Assistant Secretary
Frank A. Oski, M.D.
ited types of colon cancer and a gene responsible for Marfan
Robert J. Tabeling
Vice Chairman
Assistant Treasurer
Chris Ponticas
syndrome -should lead to the rapid development of
Secretary
screening tests and earlier treatment for high-risk individ-
BOARD OF TRUSTEES
Linda M. Arenth, M.S.
uals. The opening of the Richard Starr Ross Research
H. Furlong Baldwin
John K. Boitnott, M.D.
Chairman
William R. Brody, M.D.
Building in June increased School of Medicine research
Andre W. Brewster
John L. Cameron, M.D.
George L. Bunting Jr.
Charles W. Cummings, M.D.
space by more than one third, and will support the contin-
Leslie B. Disharoon
John L. Fox, M.D.
ued flow of such advances from laboratory to bedside.
Edward K. Dunn Jr.
Edward Goldberg, M.D.
Manuel Dupkin II
Morton F. Goldberg, M.D.
Hopkins physician scientists also are looking at the
Nicholas J. Fortuin, M.D.
J. Alex Haller Jr., M.D.
Robert M. Heyssel, M.D.
Robert M. Heyssel, M.D.
impact of various technologies and procedures on patient
President
Richard T. Johnson, M.D.
Alan P. Hoblitzell Jr.
Michael J. Kaminsky, M.D.
recovery. This research, together with ongoing quality
Eli S. Jacobs
Donlin M. Long, M.D.
assurance and quality management programs, will support
Michael E. Johns, M.D.
Paul N. Manson, M.D.
*Elizabeth L. Jones
Paul R. McHugh, M.D.
our efforts to maintain quality while controlling the cost
Francis X. Knott
Francis D. Milligan, M.D.
Robert D. Kunisch
Hamilton Moses III, M.D.
of health care.
Raymond A. Mason
Albert H. Owens Jr., M.D.
Finally, work on the new Outpatient Center is proceed-
William J. McCarthy
Thomas T. Provost, M.D.
Harvey M. Meyerhoff
Bruce A. Reitz, M.D.
ing smoothly. We expect to open our doors for business in
*Morris W. Offit
P. Preston Reynolds, M.D.
Albert H. Owens Jr., M.D.
Robert C. Rock, M.D.
May 1992.
J. Stevenson Peck
Mark C. Rogers, M.D.
Vice Chairman
Arthur A. Siebens, M.D.
Anne M. Pinkard
Keith T. Sivertson, M.D.
*William C. Richardson
Richard N. Stauffer, M.D.
Robert M. Heyssel, M.D.
Francis G. Riggs
John D. Stobo, M.D.
President
Theo C. Rodgers
Patrick C. Walsh, M.D.
Henry A. Rosenberg Jr.
Richard S. Ross, M.D.
WOMEN'S BOARD
*John D. Stobo, M.D.
Mrs. Charles L. Wagandt II
*Mary Jo Wagandt
President
OFFICERS OF THE
Hamilton Moses III, M.D.
*Edward E. Wallach, M.D.
Mrs. D. William Schlott
CORPORATION
Vice President-
Calman J. Zamoiski Jr.
First Vice President
Medical Affairs
H. Furlong Baldwin
*Ex Officio
Mrs. Alan W. Insley
Linda M. Arenth
Chairman of the Board
Second Vice President
Vice President-
EMERITUS TRUSTEES
J. Stevenson Peck
Nursing & Patient Services
Mrs. David L. Guyton
Vice Chairman of the Board
Richard W. Emory Sr.
Recording Secretary
Colene Daniel-Forde
Harrison Garrett
Robert M. Heyssel, M.D.
Vice President-
Mrs. Robert K. Brawley
President
Robert D.H. Harvey
Corporate Services
Assistant Recording Secretary
Jerold C. Hoffberger
Edward A. Halle
Sally W. MacConnell
Henry J. Knott
Mrs. William F. Rienhoff III
Senior Vice President-
Vice President-
John S. Lalley
Corresponding Secretary
Administration
Facilities
W. Wallace Lanahan Jr.
Mrs. Richard L. Cover
Irvin W. Kues
Christopher J. Macmanus
Robert H. Levi
Assistant Corresponding Secretary
Senior Vice President-
Vice President-
Robert E. Mason, M.D.
Mrs. J. Raymond Moore Jr.
Finance & Treasurer
Information Services
William E. McGuirk Jr.
Treasurer
14
Mrs. W. Gill Brooks
BALANCE SHEETS*
June 30,
June 30,
Assistant Treasurer
(in thousands)
1991
1990
Mrs. D. William Schlott
Assets
Chairman, Executive Committee
Current Assets
ACTIVE MEMBERS OF
Cash and temporary investments
$ 24,936
$ 27,163
THE WOMEN'S BOARD
Accounts receivable, net
94,783
83,664
Mrs. Robert K. Brawley
Other current assets
Mrs. W. Gill Brooks
4,649
5,031
Mrs. David H. Carroll
Total current assets
124,368
115,858
Mrs. Edmund J. Cashman
Investments at cost, which approximates market
9,367
8,971
Mrs. Richard L. Cover
Mrs. Richard A. Eliasberg
Property, Plant and Equipment, net of depreciation
236,662
210,051
Mrs. Yener S. Erozan
Capital Improvement Funds
4,701
3,764
Mrs. Ira B. Fader Jr.
Assets Whose Use Is Limited
Mrs. William A. Fisher III
46,243
65,100
Mrs. Nicholas J. Fortuin
Other Assets
9,567
8,895
Mrs. William F. Fritz
Total Assets
$ 430,908
$ 412,639
Mrs. Douglas M. Godine
Mrs. Leonard L. Greif Jr.
Mrs. Henry L. Gutman
Mrs. David L. Guyton
Liabilities and Capital
Mrs. Michael S. Hoffberger
Current Liabilities
Mrs. Alan W. Insley
$ 81,517
$ 67,760
Mrs. Michael E. Johns
Long-Term Debt
181,752
182,172
Mrs. Harris Jones Jr.
Unexpended Restricted Gifts and Grants
9,226
8,760
Mrs. Virginia White Kline
Mrs. James Lawrence III
Other Liabilities
884
884
Mrs. John W. Littlefield
Fund Balance
157,529
153,063
Mrs. J. Jefferson Miller II
Total Liabilities and Fund Balance
Mrs. Mack C. Mitchell Jr.
$ 430,908
$ 412,639
Mrs. Garland P. Moore Jr.
Mrs. J. Raymond Moore Jr.
Mrs. William D. Naughton
STATEMENTS OF REVENUE AND EXPENSE
June 30,
June 30,
Mrs. W. David Novak
(in thousands)
1991
1990
Mrs. George F. Obrecht
Mrs. William H. Oster
Gross revenue from services to patients:
Mrs. Lawrence C. Pakula
Inpatient
$ 333,842
$ 307,566
Mrs. Timothy E. Parker
Mrs. J. Stevenson Peck
Outpatient
80,422
74,271
Mrs. Walker F. Peterson Jr.
414,264
381,837
Mrs. Walter D. Pinkard Jr.
Allowances
54,237
45,490
Mrs. M. Elliott Randolph Jr.
Mrs. James H. Ridgely
Net revenue from services to patients
360,027
336,347
Mrs. William F. Rienhoff III
Other operating revenue
6,219
6,149
Mrs. Richard S. Ross
Mrs. Charles H. Salisbury Jr.
Total operating revenue
366,246
342,496
Mrs. D. William Schlott
Operating expenses
365,278
337,883
Mrs. James G. Schmidt
Excess (deficiency) of operating revenue
Mrs. Stephen T. Scott
Mrs. Jacob W. Slagle
over operating expenses
968
4,613
Mrs. John D. Stobo
Non-operating revenue
1,542
1,884
Mrs. David S. Thaler
Mrs. J. Richard Thomas
Excess (deficiency) of revenue over expenses
$
2,510
$
6,497
Mrs. J. Richard Thomas Jr.
Mrs. Charles L. Wagandt II
Mrs. J. Donald Woodruff
*For full financial statements, write:
Senior Vice President for Finance, the Johns Hopkins Health System,
600 North Wolfe Street, Baltimore, Maryland 21205.
15
THE FRANCIS SCOTT KEY MEDICAL CENTER
Last year's successful $99 million bond issue enabled us to
OFFICERS OF THE
CORPORATION
move briskly ahead with our redevelopment plan for The
Robert D.H. Harvey
Francis Scott Key Medical Center. We celebrated the open-
Chairman
ing of the new Geriatrics Center in June. Phase I, which
Robert M. Heyssel, M.D.
Vice Chairman
included the center and a new central utilities plant, is
William J. McCarthy
officially complete.
Vice Chairman
Ronald R. Peterson
We now are beginning redevelopment Phase II. Plans
President
for the new acute patient tower are nearing completion,
William J. Ward Jr.
Vice President-
and construction is slated to start this fall. We expect the
Operations & Secretary
new facility to open late in 1993, with 190 replacement
L. Kenneth Grabill II
Vice President-
beds and new ancillary and support services. The design
Finance & Treasurer
process has been most exciting. Because we are building
Judy A. Reitz, R.N., Sc.D.
Vice President-
from the ground up, the tower will embody the most pro-
Patient Care & Medical Support
Services
gressive ideas for delivering efficient, patient-focused medi-
Joan H. Williams
cal care and services.
Vice President-
Human Resources
Roman R
Philip D. Zieve, M.D.
Chairman-Medical Board
BOARD OF TRUSTEES
Ronald R. Peterson
President
Edward A. Halle
Robert D.H. Harvey
Robert M. Heyssel, M.D.
Michael E. Johns, M.D.
Francis X. Knott
Irvin W. Kues
W. Wallace Lanahan Jr.
William J. McCarthy
James D.M. McComas
Ronald R. Peterson
Richard S. Ross, M.D.
Philip D. Zieve, M.D.
MEDICAL BOARD
John R. Burton, M.D.
Ronald P. Byank, M.D.
Fabien G. Eyal, M.D.
William R. Furman, M.D.
Archie S. Golden, M.D.
Stanford M. Goldman, M.D.
Gary S. Hill, M.D.
George R. Huggins, M.D.
Peter W. Kaplan, M.D.
Philip O. Katz, M.D.
David E. Kern, M.D.
Frederick A. Lenz, M.D.
Christopher T. Morrow, M.D.
Andrew M. Munster, M.D.
Chester W. Schmidt Jr., M.D.
Gardner W. Smith, M.D.
Philip D. Zieve, M.D.
16
BALANCE SHEETS*
June 30,
June 30,
(in thousands)
1991
1990
Assets
Current Assets
Cash and temporary investments
$ 18,122
$ 14,226
Accounts receivable, net
34,761
29,688
Other current assets
1,446
1,473
Total current assets
54,329
45,387
Property, Plant and Equipment, net of depreciation
64,054
45,052
Assets Whose Use Is Limited
57,202
0
Other Assets
3,859
268
Total Assets
$ 179,444
$ 90,707
Liabilities and Capital
Current Liabilities
$ 29,486
$ 20,585
Long-Term Debt
97,204
19,067
Unexpended Restricted Gifts and Grants
781
593
Other Liabilities
184
184
Fund Balance
51,789
50,278
Total Liabilities and Fund Balance
$ 179,444
$ 90,707
STATEMENTS OF REVENUE AND EXPENSE
June 30,
June 30,
(in thousands)
1991
1990
Gross revenue from services to patients:
Inpatient
$ 92,955
$ 90,334
Outpatient
24,943
21,340
117,898
111,674
Allowances
18,221
16,280
Net revenue from services to patients
99,677
95,394
Other operating revenue
19,419
17,482
Total operating revenue
119,096
112,876
Operating expenses
118,684
110,794
Excess (deficiency) of operating revenue
over operating expenses
412
2,082
Non-operating revenue
1,043
1,179
Excess (deficiency) of revenue over expenses
$
1,455
$ 3,261
*For full financial statements, write:
Senior Vice President for Finance, the Johns Hopkins Health System,
600 North Wolfe Street, Baltimore, Maryland 21205.
17
THE JOHNS HOPKINS MEDICAL SERVICES CORPORATION
We are in the process of pulling together two physician
OFFICERS OF THE
CORPORATION
groups-the Hopkins Health Plan Associates and the
Robert M. Heyssel, M.D.
Wyman Park Medical Associates-into a single organiza-
Chairman of the Board
tion. At the same time, we are reorganizing the manage-
Richard K. Tompkins, M.D.
President
ment of 18 clinical sites under the umbrella of the Medical
Edward A. Halle
Services Corporation.
Secretary & Treasurer
These two entities share a series of common goals:
BOARD OF DIRECTORS
to offer Hopkins-quality managed and fee-for-service care
Anthony J. Ambridge
Michael A. Guye
in the community, to be a referral source for Health System
Edward A. Halle
Robert M. Heyssel, M.D.
hospitals, and to participate in the broader mission of med-
Melvin W. Kenny
ical education by providing on-site clinical experience for
Irvin W. Kues
Patrick H. Mattingly, M.D.
students. Through these physician groups, we also will ful-
Francis G. Riggs
Richard K. Tompkins, M.D.
fill our commitment to care for Prudential Health Plan
members and Uniformed Services dependents and retirees.
We look forward to strengthening the Hopkins presence
in an expanding area of medical services.
Richard K. Tomptons, ms
Richard K. Tompkins, M.D.
President and Chief Executive Officer
18
BALANCE SHEETS*
June 30,
June 30,
(in thousands)
1991
1990
Assets
Current Assets
Cash and temporary investments
$ 5,599
$ 22,956
Accounts receivable, net
10,642
22,524
Current assets of discontinued operations
33,347
0
Other current assets
193
983
Total current assets
49,781
46,463
Investments at cost, which approximates market
0
142
Property, Plant and Equipment, net of depreciation
40,271
60,321
Assets Whose Use Is Limited
73
1,161
Other Assets
3,488
1,791
Total Assets
$ 93,613
$ 109,878
Liabilities and Capital
Current Liabilities
$ 7,279
$ 38,848
Liabilities related to discontinued operations
39,990
0
Long-Term Debt
11,035
21,495
Unexpended Restricted Gifts and Grants
66
21
Other Liabilities
921
1,427
Fund Balance
34,322
48,087
Total Liabilities and Fund Balance
$ 93,613
$ 109,878
STATEMENTS OF REVENUE AND EXPENSE
June 30,
June 30,
(in thousands)
1991
1990
Gross revenue from services to patients:
Inpatient
$ 204
$ 379
Outpatient
2,078
3,965
Capitation
78,366
60,627
80,648
64,971
Allowances
2,866
2,191
Net revenue from services to patients
77,782
62,780
**Other revenue
7,973
5,936
Total revenue
85,755
68,716
Operating expenses
87,520
69,897
Deficiency of revenue over expenses
($ 1,765)
($ 1,181)
**Includes Net Gain from Sale of The Johns Hopkins Health Plan Commercial Insurance Line of Business and Closure of
The Homewood Hospital Center Inc.
*For full financial statements, write:
Senior Vice President for Finance, the Johns Hopkins Health System,
600 North Wolfe Street, Baltimore, Maryland 21205.
19
THE JOHNS HOPKINS HEALTH SYSTEM CORPORATION
OFFICERS OF THE
BOARD OF TRUSTEES
EMERITUS TRUSTEES
CORPORATION
H. Furlong Baldwin
Robert D.H. Harvey
H. Furlong Baldwin
Chairman
Jerold C. Hoffberger
Chairman of the Board
Andre W. Brewster
John S. Lalley
J. Stevenson Peck
George L. Bunting Jr.
W. Wallace Lanahan Jr.
Vice Chairman of the Board
Leslie B. Disharoon
Robert H. Levi
Edward K. Dunn Jr.
Oliver H. Reeder
Robert M. Heyssel M.D.
Manuel Dupkin II
The Rev. Donald O. Wilson
President &
Nicholas J. Fortuin, M.D.
Chief Executive Officer
Robert M. Heyssel, M.D.
Edward A. Halle
President
Senior Vice President-
Alan P. Hoblitzell Jr.
Administration
Eli S. Jacobs
Irvin W. Kues
Michael E. Johns, M.D.
Senior Vice President-
*Elizabeth L. Jones
Finance & Treasurer
Francis X. Knott
Robert D. Kunisch
Hamilton Moses III, M.D.
Vice President-
Raymond A. Mason
Medical Affairs
William J. McCarthy
Harvey M. Meyerhoff
Colene Daniel-Forde
*Morris W. Offit
Vice President-
Albert H. Owens Jr., M.D.
Corporate Services
J. Stevenson Peck
Christopher J. Macmanus
Vice Chairman
Vice President-
Anne M. Pinkard
Information Services
*William C. Richardson
Peter V. McGinn
Francis G. Riggs
Vice President-
Theo C. Rodgers
Human Resources
Henry A. Rosenberg Jr.
Richard S. Ross, M.D.
Paul M. Rosenberg
*John D. Stobo, M.D.
Vice President-
*Mary Jo Wagandt
General Counsel & Secretary
*Edward E. Wallach, M.D.
W. Thomas Barnes
Calman J. Zamoiski Jr.
Vice President-
*Ex Officio
Treasurer & Secretary Emeritus
Ethel E. Landis
Assistant Secretary
Robert J. Tabeling
Assistant Treasurer
20
JOHNS HOPKINS HEALTH SYSTEM
600 North Wolfe Street
Baltimore, Maryland 21205