35 buyouts of hospitals or chains of facilities in the last two and a half years by private equity firms

Among the secrets to HCA’s success: It figured out how to get more revenue from private insurance companies, patients and Medicare by billing much more aggressively for its services than ever before; it found ways to reduce emergency room overcrowding and expenses; and it experimented with new ways to reduce the cost of its medical staff

HCA decided not to treat patients who came in with nonurgent conditions, like a cold or the flu or even a sprained wrist, unless those patients paid in advance.

In one measure of adequate staffing — the prevalence of bedsores in patients bedridden for long periods of time — HCA clearly struggled. Some of its hospitals fended off lawsuits over the problem in recent years, and were admonished by regulators over staffing issues more than once.

inadequate staffing in important areas like critical care

Many doctors interviewed at various HCA facilities said they had felt increased pressure to focus on profits under the private equity ownership. “Their profits are going through the roof, but, unfortunately, it’s occurring at the expense of patients,” said Dr. Abraham Awwad, a kidney specialist in St. Petersburg, Fla., whose complaints over the safety of the dialysis programs at two HCA-owned hospitals prompted state investigations.

One facility was fined $8,000 in 2008 and $14,000 last year for delaying the start of dialysis in patients, not administering physician-prescribed drugs and not documenting whether ordered tests had been performed.

Claiming he provided poor care, the other hospital did not renew Dr. Awwad’s privileges. Dr. Awwad is suing to have them reinstated.

“If you were a for-profit hospital with investors and shareholders,” said Paul Levy, a former nonprofit hospital executive in Boston unaffiliated with HCA, “there would be a natural tendency to be more aggressive and to seek more revenues.” Executives at profit-making hospitals are “judged in greater measure by profitability” than the administrators of nonprofit hospitals, he said.

some of HCA’s tactics are now under scrutiny by the Justice Department. Last week, HCA disclosed that the United States attorney’s office in Miami has requested information about cardiac procedures at 10 of its hospitals in Florida and elsewhere.

HCA’s cardiac business is extremely lucrative, and the Justice Department has requested reviews that HCA conducted that indicate some of the heart procedures at some of its hospitals might not have been necessary and resulted in unjustified reimbursements from Medicare and other insurers.

Small and nonprofit hospitals are closing or being gobbled up by medical conglomerates, many of which operate for a profit and therefore try to increase revenue and reduce costs even as they improve patient care. The trend toward consolidation is likely to accelerate under the Obama administration’s health care law as hospitals grapple with what are expected to be lower reimbursements from the federal and state governments and private insurers.

Columbia/HCA became the target of a widespread fraud investigation in the late 1990s, which led to one of the largest Medicare settlements ever.

HCA wanted to attract more patients to its emergency rooms, and it did. Annual visits climbed 20 percent from 2007 to 2011. But while emergency departments are often a critical source of patient admissions, they are frequently money-losers because many patients do not have insurance. HCA found a solution: it figured out how to be paid more for the patients it was seeing.

Nearly overnight, HCA’s patients appeared to be much, much sicker.

No one has accused HCA of up-coding, or billing for more expensive services that were not needed — one of the complaints made against it a decade ago.

The acting head of Medicare is Marilyn B. Tavenner, a former HCA executive who left there in 2005 to become the secretary of Health and Human Resources in Virginia.

Several former emergency department doctors at Lawnwood Regional Medical Center in Fort Pierce, Fla., said they frequently had felt compelled to override the screening system in order to treat patients.

When the doctors failed to meet the hospital’s goals for how many patients should be considered emergencies, “they really started putting pressure on.”

Regulators in several states have taken HCA hospitals to task over screening out patients too aggressively, including situations where the screening missed serious conditions.

“Staffing is critical,” said Courtney H. Lyder, the dean at the UCLA School of Nursing and an expert on wound care. “When you see high levels of wounds, you usually see a high level of dysfunctional staff,” he said.

HCA owned eight of the 15 worst hospitals for bedsores among 545 profit-making hospitals nationwide, each with more than 1,000 patient discharges, tracked by the Sunlight Foundation using Medicare data from October 2008 to June 2010.

an examination of lawsuits shows bedsore problems have been persistent at several HCA facilities

The hospital was cited twice by Florida regulators, in 2008 and 2010, for having inadequate numbers of nurses on its staff to oversee wound care for patients.

In England, the government requires hospitals to report all C. diff cases, underpinning a regulatory campaign that has slashed infections more than 50% since 2008. A new C. diff reporting rule for U.S. hospitals isn't scheduled to take effect until 2013.

England and other European countries also require health care institutions to have antibiotic control programs and meet targets for reducing C. diff. There are no such rules for U.S. facilities: The federal government doesn't track antibiotic use in hospitals, nursing homes and other care settings, and there is no penalty under Medicare and Medicaid for facilities that have high C. diff rates.

Thirty-four states now require hospitals to publicly report their rates of infections, but fewer than a quarter of those include C. diff

Reporting requirements for nursing homes are even less common.

Hospitals have cut housekeeping budgets up to 25% in recent years, according to the Association for the Healthcare Environment, an arm of the American Hospital Association. And the group's surveys show that many hospitals spend as little as 18 minutes cleaning a patient's room. That's well below the 25-30 minutes the group's studies have identified as optimal.

Other health care infections have been stemmed

Strategies to combat C. diff are more complicated and costly. Successful initiatives often require interdisciplinary teams.

Though infection control programs are shown to save facilities money in the long run, Jarvis, the former CDC infection control chief, says administrators often balk at the upfront investments because they worry about operating margins."Saving money is not the same as making money," he adds.

In a 2009 survey of 2,000 infection prevention specialists from U.S. hospitals, 41% said their facility had cut spending on infection control.

The U.S. Centers for Medicare and Medicaid Services has begun reducing reimbursement to hospitals for care tied to certain health care infections it deems preventable, such as those related to catheter use. But C. diff is not on that list.

It's difficult to hold facilities accountable for C. diff because it can be impossible to know where a patient was infected

That hasn't been a roadblock in England, where hospitals must meet strict targets for reducing infection rates or face sanctions. In fiscal 2011-12 through March, the country had just 18,000 C. diff cases — 17% below the prior year.

The transition reduced supply, which shifted bargaining power to nursing unions and led to bidding wars among the provinces.

Is nursing care better? We have no clue. There is some (largely American) research that attributes hospital care outcomes to RN staffing levels, but the studies have deliberately avoided comparing diploma vs. baccalaureate degree nurses.

Has the class structure of nursing education changed now that the profession is degree-only? Are fewer working class kids inclined to choose a career in nursing because it is much more expensive and time-consuming to acquire the credential? What about Aboriginal peoples, recent immigrants and other minorities?

One of the reasons professions raise ETPC is to increase their status and credibility in the academy. They do this in part by developing complex theory and creating specialized identities. Merging these identities into unified interprofessional teams is a challenge under any circumstances; even stronger and more fragmented identities forged in longer education programs will hardly make this easier. Furthermore, graduates with higher credentials will expect to work at a higher level and many will be disappointed and bored by the everyday but important work of patient care.

Canadians should expect to get equal health care no matter where they live or travel in the country. Instead, she said, "It's a different set of rules everywhere you go in the country."

She said the federal government needs to take a larger role in setting standards and conditions for how money given to the provinces and territories is spent."We're a country here, we're all Canadians and this is federal money going out to the provinces," said Reid.

no pharmaceutical strategy, no long-term care strategy

"How are we going to provide pharmaceuticals? Is it going to be a social insurance scheme? Is it going to be a private insurance plus public partnership?

Canada could find itself in the same position if it does not flex its collective muscle.

Instead of developing a real national strategy, most provinces (except Quebec and Newfoundland and Labrador) decided to concentrate only on standalone agreements for very expensive brand-name prescription drugs, through what are called product listing agreements (PLAs).

By choosing to stand alone in the way that they have purchased prescription drugs in the past, provinces collected some crumbs in terms of savings, but they consolidated a system that remains inefficient and inequitable for Canadian workers and patients. It also puts the smaller provinces at a disadvantage because, alone, they will never be able to obtain the same savings from PLAs as their larger cousins.

Every new drug in Canada should be purchased through a national bulk-purchasing agency to maximize savings for the benefit of all Canadians.In fact, the smartest path would be to establish a national drug plan with no deductible or co-insurance payment, which will ensure equity of funding and access to essential medicines for all Canadians.

The fastest growing aspect of private health care insurance is for drugs, with premium inflation set at 12.1% this year.   That is down from 14% last year due reportedly to the implementation of government led generic drug pricing reform and the expiry of  patents for several major drugs.  Apparently, however, this will be offset in the future by the rise in expensive 'biologic' and specialty drugs.

The seniors' advocate office will take longer to establish, however, and is not expected to be in place until next year, the ministry said.

The COF Secretariat, which is funded by all the provinces and territories, is contributing around $250,000 to pay for the annual meetings.

Sponsors are contributing $225,000 in cash this year to cover social events

with the host province absorbing approximately the remaining one-third of conference costs

Insurance Brokers Association of Canada

Amgen Canada, Borealis Infrastructure, Canada’s Research-Based Pharmaceutical Companies, the Canadian Pharmacists Association

Johnson & Johnson

Lobbyists and other corporate players will get ample opportunity to chat with the premiers and raise issues important to their companies and organizations.

owned by Revera, which operates retirement homes and nursing homes throughout Canada and the United States

Daniels’ relationship with the home soured about a month ago, when she found out her mother was going to be hit with new fees for services such as continence toileting or being escorted to the dining room.

Those services have been costing $478 a month on top of the $2,774 she pays for accommodation and food. The same care services will rise to $2,271 in September for a total monthly charge of $5,045.

Revera says it is introducing an “à la carte” service for all residents in its Ontario retirement homes to cover its costs.

Daniels says her mother is receiving all those services now for about one-fifth of the price. “It just boggles the mind,” she says.

The new fees don’t apply to Revera’s Ontario nursing homes because monthly rates for such facilities are determined by the provincial health ministry. But the ministry does not regulate fees for retirement homes or their long-term care components, so Provost and others living on Westwood’s two long-term floors are sitting ducks.

Bernard Bouchard, executive director of the Council on Aging of Ottawa, says he believes Revera is trying to make up some of its extra costs from new licensing regulations brought in by the Ontario government in April 2011. As well, he says, operators are trying to find new revenues as retirement homes are operating at about 80-per-cent capacity.

Daniels says her mother will have to move to a nursing home. And there lies another problem. She will have to go on a waiting list because nursing homes are full.

having a staff member escort her mother, who uses a walker, to the dining area and back to her room three times a day will cost $606 a month. Helping feed her when she needs assistance is another $252. Checking her room twice nightly, to see if she has fallen out of bed or needs to go to the washroom is $168. Continence toileting is $673.70. She will also be charged an additional $505 monthly for general staff assistance.

they said: ‘We can look after her, we have palliative care. She can stay here until she dies.’ ”

In its poll, Ipsos Reid asked Canadians which system of funding they primarily support when given the option between a for-profit model, a not-for-profit model and a mixed model of both profit and non-profit.It found that 53 per cent preferred the mixed model.

When asked to what extent they'd support or oppose the idea of Canadians being allowed to buy private health insurance for all forms of medically-necessary treatment that could then be obtained outside of the current system, including cancer care and heart surgery, 76 per cent supported the idea.

But, when only given a choice between a not-for-profit and a for-profit model, four out of five (80 per cent) Canadians said they preferred a not-for-profit model of health care - up nine percentage points since 2006.

At the end of the day, Canadians are hesitant to give up the values inherent in medicare, said Dr. Michael Rachlis

in the United States, people are prepared to let other people die because they don't want to pay for their medical care and in Canada, we're different," Rachlis said. "We care more about each other."

Public sector innovations are being developed across the country every day, Rachlis said, but they tend not to get attention, or don't catch on

In the poll, Canadians were split on whether or not doctors should be allowed to work in a private system, with 46 per cent saying they support doctors being permitted to work in a private system, and 54 per cent opposing it.

study published in the journal PLoS One

Substituting the least expensive version of each drug could have saved $1.6 million, or 47 per cent, for PPIs

hospitals and governments should look at ways to break down the silos around prescription drug purchasing and dispensing

health care expenditures in Canada are on a steep upward climb

Medications represent an increasing share of those costs, currently around 16 per cent.

Ontario has the fewest hospital beds per capita of any jurisdiction almost in the world

According to the Organization for Economic Development and Co-operation, Ontario has two hospital beds for every 1,000 residents. Only Mexico has fewer. Canada-wide, there are three hospital beds per 1,000 residents, an amount also considered relatively low.