G-Man To Mediation Man

Quality Healthcare: More Than Hype?

New Nursing School? Not Quite

Tales of Toxicity: Nothing’s Simple

For Aging Parents, Medicaid’s Vagaries

House Calls? Maybe

Unlisted Numbers?

Corrections or additions?

These articles by Peter J. Mladineo and Barbara Fox were published in U.S. 1 Newspaper on Wednesday, June 3, 1998. All rights reserved.

Survival Guide

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G-Man To Mediation Man

For nearly 15 years, William H. Webster presided over two of the most powerful organizations in the world -- as director of the FBI from 1978 to 1987 and as head of the CIA from 1987 to 1991. Now he has become a mouthpiece for mediation. Almost immediately after entering private practice in 1991 as a partner in the Washington law firm Millbank, Tweed, Hadley & McCloy though, Webster began employing his skills in neutrality, obtained as a federal judge prior to the FBI and CIA stints.

"I have in many ways become a professional neutral," says Webster, in a phone interview from his Washington office. "Mediation is a settlement discussion with the help of neutral third person. In a big business situation that's what the mediator does between the parties. It can be substantially less expensive, it can be a lot quicker, and it can preserve relationships that could be permanently impaired."

Webster is the keynoter at the New Jersey Association of Professional Mediators' conference on Friday, June 5, at 8:30 a.m. at the East Brunswick Hilton. The opening address is by William K. Slate II, president and CEO of the American Arbitrators Association. There will also be a session on "The Business of Dispute Resolution -- Beyond the Year 2000" with Nancy Hardin Rogers, a law professor at Ohio State University. A workshop on court-referred divorce mediation is scheduled with Hanan M. Isaacs, the Ewing Street attorney, as moderator, Valerie Armstrong, Atlantic County judge, and state senator Robert Martin. The cost is $185. Call 973-539-5242.

Webster graduated from Amherst College and got his JD from Washington University School of Law. Prior to heading the FBI, he had judgeships with the U.S. Court of Appeals and with the District Court in Missouri. He was also chairman of the corporation, banking and business law section of the American Bar Association. Most recently he was appointed by the IRS to head a review of its criminal investigation process.

Mediation is a starting point in the realm of alternative resolution, and is attractive to many parties because it is non-binding, unlike certain forms of arbitration. Webster's niche is in business mediation, and usually involves disputes over money. "In most cases it's a money solution," he says. "It is using imagination to find ways to make a settlement possible."

"It's increasing the pay, decreasing the pain," he adds. "That's a very crude cliche, but that's often what a mediator can do to make a settlement possible."

While parties in litigation are usually only interested in winning the case, parties in mediation often are thinking beyond the outcome. "Do I want to keep doing business with this fellow when this is over? It's private," says Webster. "Even the settlement can be confidential, so your dirty laundry hasn't been aired in the media. And often, as the parties try to come up with solutions, they think about interest rather than legal rights."

To reduce caseloads, many courts are now insisting that certain cases go through a mediation process before they are litigated. "Many lawyers don't want to be wimpy so they don't want to suggest mediation," says Webster.

But if a judge orders a mediation process, he adds, the lawyers no longer have to save face, and often happily concur. "You can continue mediating right through litigation," he explains. "They like to keep that parallel track going and if they're lucky they can get the case settled before it is tried."

-- Peter J. Mladineo

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Quality Healthcare: More Than Hype?

In the age of managed care, a new buzzword is rolling off the tongues of healthcare professionals: quality. Maybe it's because of the cacophony of patients unhappy with their HMOs. Maybe it's the increasing competition of healthcare companies.

Lorraine Quatrone thinks the quality revolution can be attributed to both camps. "The organizations that can provide quality care while at the same time being cost-effective will be the healthcare organizations that thrive," says Quatrone, director of performance improvement at Carrier Foundation and the chair of the healthcare focus group for Quality New Jersey.

She has helped to organize a seminar on healthcare at Quality New Jersey on Wednesday, June 10, at 9:30 a.m. at the Carrier Foundation. The other speakers are Cindy McManus, director or operations support for corporate and major accounts with Blue Cross-Blue Shield of New Jersey, Toni Fiore, vice president of patient care and chief nursing officer at Hackensack University Medical Center, Sonya Lambdon, director of quality and resource management, Caryl Distel, director of patient representatives at JFK Medical Center, Ruth Jane Peterson, performance improvement manager with V.A. New Jersey Health Systems, and Bruce Waltuck, a compliance specialist with the U.S. Department of Labor's wage and hour division. For information call 908-281-1308.

Quality may mean different things to different sectors of the healthcare industry, but all agree that the need to focus on it during the age of cost-cutting and consolidation -- and as America ages and becomes more reliant on its healthcare system -- is paramount.

For Hackensack University Medical Center, quality means more nurses. That could be why it recently won the Magnet Award for Nursing Services, considered the highest award a healthcare institution can win for nursing. "We have a high number of professional nurses," says Toni Fiore. "We have not replaced them with non-nurse or unlicensed assistant personnel. There is a definite difference. We're finding that if we have nurses who are competent we avoid costly infection rates, we avoid costly bad outcomes, and we also keep a shorter length of stay."

To keep this standard an institute must reject the "bottom line-first" attitude. "Quite frankly I think that the key of good care of quality is standards," says Fiore. "Standards of care are the prerequisite of doing the right thing at the right time. We benchmark ourselves against similar hospitals of our size and scope in the nation, and we're not wasteful."

And for some organizations the concept of Total Quality Management still has something to offer. TQM may now seem a little dated and even a little Dilbert-esque, but Cindy McManus of Blue Cross/Blue Shield feels that most of TQM's scoffers are those who haven't yet mastered it.

"Out of all the companies that begin down the road to TQM, approximately 80 percent of them stop for various reasons," says McManus. "They run out of steam. They discover that it's more hard work than they have to give. It is a long and painful road, but I think that some of this sentiment now that it's dated may well be coming from that 80 percent that stopped. You have to keep going with it. I don't think it's ever dated to listen to your customers and to try to give them what they want. That just doesn't ever go out of style. In a service economy we have to listen to our customers and figure out ways to give them the service that they expect."

For Blue Cross/Blue Shield, implementing new quality measures is a path that will forever wend its way into the future. "We've improved our membership process so that we can get people enrolled more quickly. We've made it easier for people to get to their service representative. We have improved some of our claims processes so that we're paying claims more quickly and efficiently," she says.

"We live by a million rules, probably more than a lot of companies. It's not like we just pay claims in a vacuum. Everyone wants to know if we paid the claims correctly."

One of those people is Uncle Sam, who fervently wants in on the healthcare quality revolution. Take it from Bruce Waltuck, with the U.S. Department of Labor wage/hour division: It's a lot better for a healthcare organization implementing quality programs to let the government know about them beforehand. "For an employer who's going to be redesigning or improving the process of their work we feel that it's fundamental for them to consider the regulatory environment of any quality effort," he says.

Quality, he explains, is part of a food chain that begins with regulatory compliance. For instance, direct healthcare providers, like nurses, receive the most regulatory violations from their employers. "Regulatory compliance increases employee satisfaction," he says. "Employee satisfaction increases the quality of service provided. Improved service quality results in increased customer satisfaction, and that equates to a better bottom line for the business. There is hard data to support this claim."

But Waltuck, a 22-year veteran with the department and co-author of an in-print book, "Unions, Management, and Quality," reports that the government is striving for user-friendliness. "The best way we can influence employer behavior is through awareness and knowledge," he says. "My goal is to change the perception of government regulation as an adversary to government regulator as resource and partner."

Is this all talk? Maybe not.

The Robert Wood Johnson Health Network, the subject of a new contractual affiliation with Presbyterian Homes of New Jersey (see story in Life in the Fast Lane), is instituting a mindblowing new "15-30" emergency room policy, explains Andrew Greene, the CEO. Patients coming to a RWJHN hospital emergency room are guaranteed to see a nurse within 15 minutes and a physician within 30 minutes or the emergency room charges are dropped. Sounds like a quality pledge at a restaurant or a gas station, but it's true.

"You've got to be able to deliver a quality product and quality can't be sitting three hours in an emergency room," says Greene. "And if you think about it, that's some people's first and only experience in a hospital. Most people don't have bypass surgery but most people do wind up in an emergency room as someone needing assistance or taking someone else there."

Peter J. Mladineo

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New Nursing School? Not Quite

As a result of the merger of Helene Fuld and Mercer medical centers, there will be one less nursing school with an expanded student body. By 2000, the Mercer Medical Center School of Nursing will be phased out and the Helene Fuld School of Nursing will continue operating under the new name Capital Health School of Nursing.

This school will absorb the students and faculty from the Mercer Medical Center. Students who enroll at either school for classes this fall will be applying to and graduating from the Capital Health school, based at the Fuld campus. The school will continue to be hospital-based, with a cooperative arrangement with Mercer County College. Last year, the Mercer school graduated 1,981 students; Fuld graduated 1,818 students.

School officials chose this route so that the Fuld school would keep receiving support from a trust fund that pays for students' nursing courses (the funds are lost if the Fuld school folds). Also the school received the more recent accreditation from the National League for Nursing Accrediting Commission, and the school has a newer curriculum that is approved by the National League for Nursing and the New Jersey Board of Nursing. Call 609-394-4050 or 609-394-3174 for information.

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Tales of Toxicity: Nothing's Simple

Learn how chemicals affect one's well being at the 55PLUS meeting on Thursday, June 4, at 10 a.m., at the Jewish Center of Princeton, 435 Nassau Street. Myra Weiner, manager of toxicology at FMC on Route 1 North, will describe some principles of the science of toxicology and discuss how chemicals may cause cancer and how government agencies make decisions on potential risks. Both men and women may attend, though the group is geared for men who have retired or who have flexible schedules. Call 609-924-6328.

Author of more than 30 scientific publications, Weiner makes safety assessments of existing and new products, designs and directs toxicology studies, and interfaces with trade associations and government agencies on a global basis. She will present case studies of three chemicals -- including saccharine and unleaded gasoline -- to illustrate some of the issues with the "state of science" of toxicology and risk assessment.

Weiner does not believe that either substance is a human carcinogen. "These aren't simple decisions. Some of the animal models do not serve as good surrogates of human responses," she says. An alumna of Yeshiva University's Stern College for Women, Class of 1966, she has a Ph.D. in pharmacology from State University of New York.

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For Aging Parents, Medicaid's Vagaries

If you are elderly and forgetful, the government won't help. But if you are elderly, forgetful, and sick, Medicare will pay for skilled nursing or rehabilitation care.

That's just one of the twists in the healthcare system that discriminates against those with dementia or Alzheimer's Disease. It will be addressed in a panel on "Caring for Aging Parents," with Marcella Gaughn and Ellen DuPont of Genesis Eldercare in Westfield and Kelly Higgins of Senior Quarters at Jamesburg, and moderated by Michele Morris of Morris Enterprises on Monday, June 8, at 6:15 p.m. at Coach & Four restaurant. For $16.50 reservations call the Hightstown-East Windwsor BPW at 609-426-4490.

"Those who pass the Medicaid income guidelines of less than $25,000 in assets can stay as our resident for their entire life," says Gaughn. But first they have to be sick -- and come from the hospital after at least a three-day stay, or come from their home within a month after the hospital stay.

"One of our goals is to keep patients at home as long as possible in order for them to have a full life," says Gaughn, an internal case manager for Genesis, a publicly held firm that trades as GHV.

If the elderly persons are being discharged from a hospital or nursing home, they may be able to qualify for skilled nursing services five times a week, and a home health aide or physical therapist three times a week. These services can continue for 100 days per spell of illness.

But if patients merely need "standby supervision" or custodial care on a live-in or hourly basis, they must pay for it themselves. If they go into an "assisted living" environment, they must also pay.

Vaughn wishes the healthcare system would adopt a wellness model instead of a disease model, so that home nurse visits would be covered before people got sick. Or that assisted living costs could be eligible for Medicaid reimbursement.

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House Calls? Maybe

Don't assume that your doctor will not make house calls, says the Medical Society of New Jersey. Partly because the "frail elderly" population is growing, and partly because patients are discharged from hospitals "quicker and sicker," some physicians are indeed seeing patients in their homes.

"When I make a house call, I'm seeing shut-ins -- mostly older individuals with bad arthritis or acute illness who aren't able to leave their homes," says William Ryan, a rheumatologist at Hopewell Valley Medical Associates on Pennington-Washington Crossing Road.

Says Barbara Bristow of Senior Care Management on Route 31 in Pennington, "More and more doctors seem to be willing to do it."

"If doctors could make house calls, it would enable the elderly to stay in the home longer," says Marcella Gaughn of Genesis Eldercare in Westfield, who speaks on a panel on Monday, June 8 (see story above). "When the elderly get sick, they call 911 because they have no other way of getting to see a doctor. Medicare does not cover transportation to the doctor's office."

For a shut-in to go to doctor's office is an all-day production and an expense that can involve round-trip taxis, says Stephen Hirschberg, a podiatrist (973-227-1200). He is assembling a statewide network of podiatrists to make house calls to patients cared for at home.

Half of the primary care physicians who participated in a recent American Medical Association poll claimed that they make housecalls. In a different survey by a trade magazine, Medical Economics, more than half of family or general practice physicians reported that they make at least one house call per month, with 11 percent of family physicians (five percent of the general practice physicians) saying they make 10 or more house calls per month.

Physicians often lose money on house calls because of low Medicare reimbursement levels -- yet patients choose the hospital affiliated with residents who treat them at home in what the society calls "overwhelming" numbers. Therefore, says the medical society, large teaching hospitals often consider house call programs as loss leaders.

Nevertheless, a quick phone poll of four Princeton area rheumatologists yielded none who regularly make home visits. Ryan is definitely in the minority.

HMOs don't look kindly on house calls now, but that may change. "If house calls prove to be cost effective," says Paul Langevin Jr., president of the New Jersey HMO Association, "there is no reason why managed care organizations won't view them as another service to offer. For the very sick, homebound patient, house calls by a physician, nurse practitioner, or other health care provider certainly are a cost-effective alternative to hospice care or a move to a long-term facility."

"These people are delighted to have someone come to them," says podiatrist Hirschberg. "You have no idea how many offers of milk and cookies I get. The need is large and is not, at this point, being filled."

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Unlisted Numbers?

Where would you call and what would you do if a colleague was threatening suicide? The death of J. Timothy Hogan in Taunton, Massachusetts, has raised a considerable controversy about managed care organizations' policies on providing listings for mental health providers.

Hogan, formerly the controller at the Trentonian newspaper in Trenton, killed himself after taking a job in Taunton, and the Associated Press reported that his suicide note stated that he had repeatedly tried to obtain a therapist's name from an HMO referral but was unable to get one.

His HMO book directed clients to call customer service for a mental health referral -- yet some experts say that those who are severely depressed may not be able run the gauntlet of question-asking.

In his note, Hogan reportedly said that he offered to pay cash to see a therapist, but that his payment was refused because it was too expensive.

In New Jersey, emergency mental health and referral services are available 24 hours a day. Police stations in each county know where to call. The contract for services in Mercer County, for instance, is held by the Capital Health System on Brunswick Avenue in Trenton. Jon Nelson, the director, says that a psychiatrist is on duty at all times for on or off-site evaluation, and a multi-disciplinary team of psychiatrists, registered nurses, and certified screeners is available for assessment, counseling, and referrals.

The number to call is 609-394-HELP.

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