LESSONS LEARNED: TrumpRyanCare Obits

Ryan: ObamaCare will be law for ‘foreseeable future’
“GOP leadership and the White House had spent weeks attempting to bring skeptical Republicans on board. Conservatives argued the bill didn’t go far enough to repeal ObamaCare, while moderate lawmakers worried about backlash in their districts from those who came to rely on ObamaCare.”
http://thehill.com/policy/healthcare/325700-ryan-we-came-close-but-came-up-short-on-healthcare-bill
THE HILL. Ben Kamisar

Why Trumpcare Failed
“After making repeal of that law their top legislative priority for the past seven years, Republicans now join the much longer list of failures because, during all that time, they never reached a consensus. Rather than come up with a plan the party could unite behind, and with the ACA filling the space where bipartisan consensus could be had, they splintered and entrenched. You can’t bridge that divide. (For their own political sakes, they’re lucky they didn’t.)”
“Freedom Caucus members have a cold vision of health care reform, but a coherent one. They believe that the government being involved in health care, either through regulation or subsidies, is the factor driving up prices, and undoing all of that architecture is what’s necessary to allow market forces to drive down prices. Being coherent in this way on health care policy means accepting the trade-offs that your vision entails, and Freedom Caucus members accept that this approach would leave a lot of vulnerable people in the lurch, left to the care of charities and communities. They have an odd belief that a vast majority of the American public shares this vision despite representing only a small percentage of the House of Representatives.”
Slate. Jim Newell http://www.slate.com/articles/news_and_politics/politics/2017/03/all_of_the_reasons_why_trumpcare_failed.html

In Major Defeat for Trump, Push to Repeal Health Law Fails
“The Republican bill would have repealed tax penalties for people without health insurance, rolled back federal insurance standards, reduced subsidies for the purchase of private insurance and set new limits on spending for Medicaid, the federal-state program that covers more than 70 million low-income people. The bill would have repealed hundreds of billions of dollars in taxes imposed by the Affordable Care Act and would also have cut off federal funds to Planned Parenthood for one year.
Mr. Ryan had said the bill included “huge conservative wins.” But it never won over conservatives who wanted a more thorough eradication of the Affordable Care Act. Nor did it have the backing of more moderate Republicans who were anxiously aware of the Congressional Budget Office’s assessment that the bill would leave 24 million more Americans without insurance in 2024, compared with the number who would be uninsured under the current law.
The budget office also warned that in the short run, the Republicans’ legislation would drive insurance premiums higher. For older Americans approaching retirement, the cost of insurance could have risen sharply.”
New York Times. ROBERT PEAR, THOMAS KAPLAN and MAGGIE HABERMAN

Why Republicans failed to repeal Obamacare
“Let me briefly try to answer this question: How did Republicans fail to repeal and replace the Affordable Care Act? In no order, and off the top of my addled mind at the end of a crushing week:
— They hated Obamacare but they never understood the Affordable Care Act. This is the uber-explanation for much of what follows. Hating Obamacare became just what you did on the right. It didn’t mean you understood it, beyond maybe getting that it was a government program and thus paid for by taxes. It certainly (and this turned out to be very important) didn’t mean you had any ideas about what it did, how it worked or how many people were benefiting from it … or how to replace it.”
The Washington Post. Jared Bernstein
https://www.washingtonpost.com/posteverything/wp/2017/03/24/what-just-happened-explaining-the-republicans-big-health-care-fail/?utm_term=.15fbea5ab191

The Trumpcare Con Implodes
“Passing the bill would have also made a joke of Republican promises that, given the chance, they would replace Obamacare with something that would result in cheaper, better insurance for more people. Trump himself went much further, guaranteeing “insurance for everybody” at government expense. The American Health Care Act was diametrically opposed to those supposed goals.
And that’s what really matters, after all: The practical effects of huge changes to the health care system for those who actually need to use it, alongside the faith Americans can have that their elected officials are making promises they will at least attempt to keep.
Instead, the GOP, from Trump on down, spent years claiming they had a magic plan to make everyone’s health care better, and then tried to bang through a bill in just a few weeks that would have covered fewer people, who would have had to pay much more for whatever care they got, without even reducing the deficit conservatives pretend to care about by all that much. They didn’t even bother waiting for the Congressional Budget Office to assess the final product, so little did they care for the real-world effects it might have.”
U.S.News. Pat Garofalo
https://www.usnews.com/opinion/thomas-jefferson-street/articles/2017-03-24/trumpcare-con-ends-in-deserved-gop-failure

Three Real Reasons “TrumpCare” Failed
“Why was the bill so unpopular? First and foremost it’s because most people hate the underlying Republican philosophy pertaining to health care. And they hate it for good reason: it doesn’t work.
We tried the GOP philosophy of allowing the “competitive” market to provide the “most wonderful health care plan in the world” and it produced a system that resulted in per person health care costs twice as high as the rest of the industrial world and outcomes that were worse. That was the world of pre-ACA health care.
The “unfettered market” allowed insurance companies to discriminate against people with pre-existing conditions – and to define one of those “pre-existing conditions” as simply being a woman. It allowed them to enforce lifetime caps on coverage – so if you got really sick you were simply out of luck.”
The Huffington Post. Robert Creamer
http://www.huffingtonpost.com/entry/three-real-reasons-trumpcare-failed-gop-divisions_us_58d78074e4b0c0980ac0e701

The cruel double standard that may have saved Obamacare
“But others cite another factor: The face of Obamacare is now white.
More Americans now realize Obamacare helps millions of working class whites and that it’s not — as once portrayed by conservatives — a form of welfare pushed by the first black president to help people of color, historians and scholars say. The media landscape is filled with images of the furrowed brows of anxious white residents at congressional town halls who fear they will suffer if they lose Obamacare, says Judy Lubin, a sociologist and adjunct professor at Howard University in Washington.
“When you see white working-class Americans saying that I’m benefiting and my family is getting help from the Affordable Care Act, you start to hear ‘repair’ not ‘repeal,'” Lubin says. “Whites standing up in support of a policy changes the dynamics of the conversation.”
CNN. John Blake
http://www.cnn.com/2017/03/24/politics/obamacare-double-standard/

Trump’s Trainwreck
“For seven years — seven years — Republicans thundered about the evils of Obamacare, yearned for the day when they could bury it and vowed to do precisely that once the ball was in their hands.
Last week proved that this had all been an emotional and theatrical exercise, not a substantive one. The ball was in their hands, and they had no coherent playbook. No real play. They scurried around the Capitol with their chests deflated and their tails between their legs.
For the entirety of his campaign, Donald Trump crowed about his peerless ability to make deals, one of which, he assured us, was going to be a replacement for Obamacare that would cut costs without leaving any Americans in the lurch.
Last week proved that there was no such swap, that he hadn’t done an iota of work to devise one and that he was spectacularly unprepared to shepherd such legislation through Congress. As his promise lay in tatters at his feet, he gave a delusional interview to Time magazine about what an infallible soothsayer he is, then tried to shift the blame to Democrats, who, he said, would soon be the ones hankering for an Obamacare replacement.”
New York Times. Frank Bruni

Trump: I never said repeal and replace would come in 64 days
“Yet asked if he would talk to Democrats now that Republicans are moving on, Trump said no.
“I think we have to let Obamacare go its way for a little while, and we’ll see how things go. I’d love to see it do well, but it can’t. I mean, it can’t,” Trump said. “It’s not a question of, ‘Gee, I hope it does well.’ I would love it to do well. I want great health care for the people of this nation, but it can’t do well. It’s imploding and soon will explode, and it’s not gonna be pretty. So the Democrats don’t wanna see that so they’re gonna reach out when they’re ready. And whenever they’re ready, we’re ready.” “
POLITICO. Nolan D. McCaskill
http://www.politico.com/story/2017/03/trump-obamacare-statement-repeal-replace-236482

With GOP Plan Dead, Trump Weighs Other Ways to Reshape Health Care
Republicans have ability to make changes to Affordable Care Act but do so at their own risk
“With the collapse of Republicans’ health plan in the House on Friday, the Trump administration is set to ramp up its efforts to alter the Affordable Care Act in one of the few ways it has left—by making changes to the law through waivers and rule changes.”
Wall Street Journal. Stephanie Armour
https://www.wsj.com/articles/with-gop-plan-dead-trump-eyes-other-ways-to-reshape-health-care-1490434201

Jonathan M. Metsch, Dr.P.H.
Clinical Professor, Preventive Medicine, Icahn School of Medicine at Mount Sinai
Adjunct Professor, Ziklin School of Business, Baruch College, C.U.N.Y.
Adjunct Professor, Rutgers School of Public Health & School of Public Affairs and Administration

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The Mayo Clinic is discriminating against Medicare Patients. Unbelievable! Outrageous!

As a former hospital CEO, with many colleagues at nearby hospitals, I had quick access to the best medical care.

Now, as a Medicare enrollee, I am finding it more and more difficult and time-consuming to find doctors who will take Medicare. And, of course, I don’t want to sacrifice quality for price.

When a physician opts out of Medicare, ”The physician must sign and file an affidavit agreeing to forgo receiving any payment from Medicare for items or services provided to any Medicare beneficiary for the following 2-year period…”

Most significantly, if getting care from an opted-out physician the beneficiary (me or any other Medicare enrollee): “gives up all Medicare payment for services furnished by the “opt out” physician; agrees not to bill Medicare or ask the physician to bill Medicare; is liable for all of the physician’s charges, without any Medicare balance billing limits; acknowledges that Medigap or any other supplemental insurance will not pay toward the services; and acknowledges that he or she has the right to receive services from physicians for whom Medicare coverage and payment would be available. http://www.aafp.org/practice-management/regulatory/medicare.html

I have paid into Medicare for 45 years and, like many of you, now or later, don’t want to pay full out-of-pocket charges where doctors have opted out of Medicare. Why pay life-time premiums for Medicare than get care from non-Medicare providers.

One can inadvertently wind up with a big bill even when vigilant. For example:
– Go to an Emergency Room where the hospital takes Medicare but the ER group does not. http://www.cbs5az.com/story/23063821/emergency-room-doctors-may-not-take-insurance-even-if-hospital-does
– Your primary care physician takes Medicare but refers you to specialists who don’t.
– When you are admitted to the hospital for surgery and the surgeons takes Medicare and the anesthesiologist which you had no say in selecting (and perhaps radiologist and pathologist) does not.
– And when the surgeon is assisted by another surgeon, which you were not told about, who does not take Medicare.
– https://www.verywell.com/out-of-insurance-network-claims-and-bills-2615282
– You assume your MediGap insurance will cover an expense because like I was, you aren’t aware that MediGap insurance only clicks in for Medicare approved care.

Now blaming it on Obamacare and perhaps in anticipation of Trump/ Ryan Care, the Minneapolis Star Tribune, in an article by Jeremy Olson reported that:
“Mayo Clinic’s chief executive made a startling announcement in a recent speech to employees: The Rochester-based health system will give preference to patients with private insurance over those with lower-paying Medicaid or Medicare coverage, if they seek care at the same time and have comparable conditions.
“Mayo will always take patients, regardless of payer source, when it has medical expertise that they can’t find elsewhere, said Dr. John Noseworthy, Mayo’s CEO. But when two patients are referred with equivalent conditions, he said the health system should “prioritize” those with private insurance.”
http://www.beckershospitalreview.com/finance/mayo-clinic-to-give-preference-to-privately-insured-over-medicaid-medicare-patients.html

Incomprehensible! Unethical?
Let’s make sure that access to Medicare is not further compromised by health care providers.
________________
POSTSCRIPT
“DHS questions whether Mayo policy violates law”
Recent reports say that Mayo Clinic will give preference to privately insured patients under a new policy, which is under scrutiny by the DHS.
The Minnesota Department of Human Services is probing the Mayo Clinic for possible violations of civil- and human-rights laws by putting a higher priority on patients with commercial insurance.
https://www.mprnews.org/story/2017/03/16/mayo-under-scrutiny-for-possible-civil-human-rights-law-violations

____________________
Jonathan M. Metsch, Dr.P.H.
Clinical Professor, Preventive Medicine, Icahn School of Medicine at Mount Sinai
Adjunct Professor, Management, Zicklin School of Business, Baruch College, C.U.N.Y.
Adjunct Professor, Rutgers School of Public Affairs and Administration & Rutgers School of Public Health

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Doctor is going on sabbatical to think about the pending nullification of Obamacare…here’s why

Doctor, Did You Wash Your Hands?™  was created to explore healthcare transformation with the advent of the ACA.

Now that it will be likely be nullified we need to figure out what that might mean and what will happen.

Foundations of the ACA for providers included: Population Health management and Investment in ambulatory care centers; preparation for Pay for Value replacing fee-for-service reimbursement; Medicaid expansion; and a steep and fast trajectory in employing physicians particularly primary care physicians and hospitalists. And much more!

This triggered consolidation of hospitals into becoming regional hospital systems quickly transitioning into integrated health care delivery systems, then to mega systems focusing on geographic reach, then to super-size systems which have started or taken over medical schools, now functioning  like insurance companies and investment banks.

Billions of dollars were invested nationally to build and support this newly created infrastructure, often paid for by issuing bonds, using lines of credit and perhaps even dipping into endowment funds.

Months ago I suggested “stress tests” for super-sized hospital systems. Now we will find out if there are contingency plans or a “bubble.” Will we have an orderly unwinding or “toxic derivatives”? What will be the impact if 20 million people lose insurance and providers lose the payments associated with them?

So I am starting over by studying Nullification 101 and may be back if I have any insights.

DOCTOR appreciates our valued readers. It’s a challenge being an “orphan” blog so we will take a break and look for a host organization or web site. Please send any comments or suggestions to jonathanmetsch@gmail.com

Thanx! for being my treasured readers.

Jonathan

 

Jonathan M. Metsch, Dr.P.H.

Clinical Professor, Preventive Medicine, Icahn School of Medicine at Mount Sinai

Adjunct Professor, Management, Zicklin School of Business, Baruch College, C.U.N.Y.

Adjunct Professor, Rutgers School of Public Affairs and Administration & Rutgers School of Public Health

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“There’s a growing movement in the United States to install video cameras in operating rooms…”

Video surveillance has become increasingly pervasive. It is being used to prevent shoplifting, for homeland security at public events, police officers wearing cameras, in airplane cockpits and train locomotives, and for “instant replay” in college and professional sports.

Which led to me research a bit about the use of video surveillance cameras in hospitals.

There was an article this year about “Operating room staff are heard on the recording making rude comments about Ms. Easter while she is sedated. A surgeon calls Ms. Easter “a handful” and is heard laughing about how upset Ms. Easter was when she was told how long she would have to wait to schedule her surgery. The surgeon also comments that he feels sorry for Ms. Easter’s husband. OR staff also made derogatory comments about Ms. Easter’s body. Laughter is recorded in the OR after a female voice, which Ms. Easter claims is that of an OR nurse, is heard saying, “Did you see her belly button?” (A)

And I remember the 2002 episode where” “Massachusetts… indefinitely suspended a surgeon’s medical license because he left a patient anesthetized on an operating table with an open incision in his back while he went to a bank several blocks away.” (B)

A classic situation is Munchausen syndrome by proxy. “…a mental illness and a form of child abuse. The caretaker of a child, most often a mother, either makes up fake symptoms or causes real symptoms to make it look like the child is sick.” (C) “Beatrice Crofts Yorker, RN, JD,… writes that she has personally observed a videotape (of a hospitalized child) that showed a mother rinsing a thermometer under running water and then calling in the nurse to read an elevated temperature (covert video surveillance). Indeed, some hospitals have employed covert videotaping to observe the alleged perpetrator’s (mother’s) behavior with the child.” (D)

Some of the articulated benefits that video surveillance provides include: “Keeps patients’ records and identities safe; Ensures staff are meeting health and safety standards; Allows for remote monitoring from a smartphone or tablet; Prevents intruders from gaining access to restricted areas; Deters vandalism and other criminal acts; Increases safety for patients and staff.” (E)

And much has been written about using video surveillance to monitor hand washing and improve compliance. “For example, Summerville Medical Center, a 94-bed acute-care hospital in South Carolina, is having employees wear sensor tags to determine who is washing their hands before and after coming into contact with patients. The technology was first rolled out in the medical center’s intensive care unit in the spring of 2012 and then expanded to its surgery units and the emergency room. Each hospital caregiver wears a badge-like sensor tag that counts room entries and exits as well as the use of soap or sanitizer dispensers. The data collected from the system is used to model and characterize clinician-patient interactions, providing detailed data to help monitor and modify behavior. (F)

“At North Shore University Hospital on Long Island, motion sensors, like those used for burglar alarms, go off every time someone enters an intensive care room. The sensor triggers a video camera, which transmits its images halfway around the world to India, where workers are checking to see if doctors and nurses are performing a critical procedure: washing their hands.” (G)

But there are skeptics. “Another potential issue with the video observation is a false accusation of failure to wash. Patient rooms and patients themselves are not being watched. Let’s say a nurse went into a patient’s room to tell him something and didn’t touch anything. A person in India watching a video from a camera focused on a door or sink would not be able to tell that. If the nurse doesn’t wash her hands when she leaves the room, is she going to be cross-examined? (H)

“Operating rooms have long been equipped with cameras for security and training purposes. But video technology has rarely been used to improve patient care. ……… staff check in with the videos once every two minutes, and follow a checklist to look out for errors that could creep into surgery when staff skip steps in safety protocols. The data they collect on the performance of each team is then streamed real-time to the frontlines of the operating room; the medical teams and staff in charge can view the information on their smartphones.” (I)

“An eICU support center can provide care to patients in multiple hospitals. The goal of an eICU initiative is to optimize clinical expertise and facilitate 24-hour-a-day care by ICU caregivers, whether the caregivers are down the hall from the patient that’s being monitored or in another city. Two-way cameras, video monitors, microphones and smart alarms connected by high speed data lines provide eICU caregivers, who are called intensivists, with real-time patient data around the clock. Intensivists can also communicate with on-site caregivers through dedicated telephone lines. “ (J)

Some examples are useful “Chris Nowakowski’s wife died in Wisconsin during what should have been a routine procedure on her pacemaker. Danny Long’s wife in North Carolina suffered catastrophic neurological injury during a surgery to relieve numbness in her extremities. A doctor perforated the colon and esophagus of Deirdre Gilbert’s daughter in Texas, then operated on her after she was dead. In each case, the families still don’t know the full story of what happened to their loved ones because of a lack of documentation and an inability to pursue a costly lawsuit. They are relatives of an estimated 400,000 a year people who die in the United States of preventable medical errors, the third-leading cause of death after heart disease and cancer. But the families say they could have known much more if cameras had been installed in the operating rooms, recording the actions and movements of the doctors and staffers involved.” (K)

“There’s a growing movement in the United States to install video cameras in operating rooms (ORs)….. The idea is to document possible adverse events and thereby prevent similar ones from occurring in the future, but critics worry that recording devices in the OR would not only compromise patient and doctor privacy but lead to a wave of new malpractice lawsuits.

The camera-in-the-OR movement has taken off because of a number of high-profile medical mistakes. A woman named Julie Ayer Rubenzer died after breast-enhancement surgery done in Florida, after she was given excessive amounts of propofol, the same anesthetic that led to the 2009 death of pop star Michael Jackson.” (L)

“However the benefits of having video evidence in the operating rooms could be enormous. Think of the abusive surgeon who terrorizes the entire OR staff. Finally there will be evidence for disciplinary action, instead of just another he said/she said in front of some hospital committee. Wrong site surgery can be analyzed so that others can see what went wrong instead of reading through vague medical records which pretty much parrot the hospital’s time out protocol and doesn’t give any insight into how the mistake was made. Lap sponges left in the patient? The unblinking eye of the camera can show why the sponge was not counted properly at the end of the case. Were the nurses distracted by a shift change? Was the music too loud causing people not to be able to hear each other clearly? Was the count wrong at the beginning of the case and nobody noticed? All these could be answered by a simple video.” (M)

But not everyone agrees. “What scares me is the intent of such a policy. What exactly would a videotaped be used for? So the patient can watch it? Surely the patient will have no clue what he or she is watching. If the videotape is going to be used for malpractice, then I think patients will be the ones who suffer. Everybody in medicine knows that although surgical technique is standard, it varies widely. You will always find someone who is willing to say that your technique is not the standard of care. How they operate in Boston is not necessarily how they operate in San Francisco. Thus I don’t really think their (sic) is much utility because the nature of medicine and surgery is constant criticism to improve practice. This however is different from critique in the form of malpractice.” (N)

Which raises a number of medical ethics challenges, e.g. “Should a patient be able to refuse video surveillance? If so, shouldn’t the hospital be allowed to refuse medical care to patients that do not consent? Kind of like walking into an airport and refusing to be video recorded. If you don’t want to be videotaped, find another means of travel. For now, smile … if you enter a hospital, you’re going to be on camera. Ethics committee approval notwithstanding.” (O)

“Healthcare can benefit from the power of cameras to improve accountability,” Makary, Pawlik and Xu conclude. “In an era where 86% of nurses report having recently witnessed disruptive behavior at work, hand washing compliance remains highly variable, and many physicians do not use evidence based medicine, recorded video can be an invaluable quality improvement tool. If concerns about consent, privacy, and data security are dealt with carefully, video data can tell a story that simply cannot be matched by written documentation.” (P))

The use of technology in medical care is a reality “to improve clinical care and slash error rates, and to reduce patient stress, encouraging healing.” (Q)

Advanced patient safety technology should be embraced!

 

(A) http://www.beckershospitalreview.com/news-analysis/texas-hospital-or-staff-recorded-mocking-sedated-patient.html

(B) http://www.nytimes.com/2002/08/09/us/surgeon-who-left-an-operation-to-run-an-errand-is-suspended.html?_r=0

(C) https://medlineplus.gov/ency/article/001555.htm

(D) http://www.camorrison.com/articles/fourth_amendment.htm

(E) https://www.videosurveillance.com/healthcare.asp

(F) http://www.computerworld.com/article/2497225/healthcare-it/hospitals-use-cameras–sensor-tags-to-track-hand-washing.html

(G) http://www.nytimes.com/2013/05/29/nyregion/hospitals-struggle-to-get-workers-to-wash-their-hands.html?_r=0

(H) http://www.physiciansweekly.com/hand-washing-hospital-monitoring/

(I) http://www.newsweek.com/video-auditing-hospital-surgery-safety-medical-errors-479107

(J) http://searchhealthit.techtarget.com/definition/Electronic-Intensive-Care-Unit-eICU

(K) https://www.washingtonpost.com/local/could-cameras-in-operating-rooms-reduce-preventable-medical-deaths/2015/08/25/fc2696c4-3ae2-11e5-b3ac-8a79bc44e5e2_story.html

(L) http://www.medscape.com/viewarticle/851426

(M) http://www.blog.greatzs.com/2014/04/cameras-in-operating-room-is-it-time.html

(N) http://brainblogger.com/2007/05/09/do-you-want-your-surgery-to-be-videotaped/

(O) http://drwhitecoat.com/hospital-video-surveillance/

(P) https://www.minnpost.com/second-opinion/2015/10/its-time-start-videotaping-surgical-procedures-doctors-argue

(Q) http://health.usnews.com/health-news/best-hospitals/articles/2009/07/15/the-high-tech-hospital-of-the-future

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A Medicare Conundrum: Observation status – Readmission penalties – Hospitalist handoff to primary care physician.

You may have wondered how Obamacare pays for medical care for the 20 million+ newly insured. If you don’t understand the incentives and disincentives to hospitals and physicians and get caught in the regulatory quagmire, then you will be the payor!

Using Medicare, here’s an example of how three related concepts determine whether or not Medicare will pay for a hospital admission.

Observation Status.

“When you’re put in the hospital, you’re assigned either inpatient status or observation status. You’re assigned inpatient status if you have severe problems that require highly technical, skilled care.

You’re assigned observation status if you’re not sick enough to require inpatient admission, but are too sick to get your care at your doctor’s office. Or, you might be assigned to observation status when the doctors aren’t sure exactly how sick you are. They can observe you in the hospital and make you an inpatient if you become sicker, or let you go home if you get better.

Since observation patients are a type of outpatient, some hospitals have a special observation area or wing of the hospital for their observation patients. But, many hospitals put their observation patients in the same rooms as their inpatients.

If you’re an inpatient, but Medicare or your health insurance company determines that you should have been assigned observation status, it can refuse to pay for the entire inpatient hospital stay. You probably won’t discover this until the hospital has submitted the claim and had it denied by the insurance company weeks or even months after your hospitalization.” (A)

Medicare Readmission Penalties.

“The ACA requires that inpatient prospective payment system hospitals with higher-than-expected readmissions rates will experience decreased Medicare payments for all Medicare discharges.

In fiscal year (FY) 2013, payment penalties were based on hospital readmissions rates within 30 days for heart attack, heart failure and pneumonia. In 2015, CMS will add readmissions for patients undergoing hip or knee replacement, and in 2016, readmissions for patients with chronic obstructive pulmonary disease. CMS is likely to add other measures in the future. (B)

Hospitalists.

“Practically speaking, increasing the number of physicians involved in a patient’s care creates opportunities for miscommunication and discoordination, particularly at admission and discharge. Gaps between community physicians and hospitalists may result in failures to follow up on test results and treatment recommendations. Moreover, the acute care focus of hospital medicine may not match the need of many patients for effective disease prevention and health promotion. Studies are under way to see whether these pitfalls can be mitigated, but I suspect the inherent tensions will remain fundamentally irresolvable.

From the patient’s point of view, it can be highly disconcerting to discover that the physician who knows you best will not even see you at your moment of greatest need — when you are in the hospital, facing serious illness or injury. Who is better equipped to abide by an incapacitated patient’s preferences or offer counseling on end-of-life care: a physician with whom the patient is well acquainted or one the patient has only just met? The patient–physician relationship is built largely on trust, and levels of trust are usually lower among strangers.” (C)

And….

So it’s just not narrow provider networks, out-of-network penalties, restricted drug formularies…

It’s also steps towards inventing health care reimbursement “derivatives” such as:

REFERENCE PRICING. Reference pricing serves as a reverse deductible. Rather than the patient paying up to a defined limit and then the insurer covering the remainder, the insurer pays up to a defined limit and the patient pays the remainder.

VALUE BASED INSURANCE. “The additional cost when patients choose procedures that research shows are unlikely to help their condition is a key element of ….value-based insurance, the premise of which is that a mix of financial carrots and sticks can steer patients toward medical services that will help them and away from ineffective or unnecessary ones.”

Hospitals and their employed physicians, including hospitalists, look to minimize the risk of reimbursement penalties and maximize reimbursement. PATIENT BEWARE!

(A) https://www.verywell.com/an-explanation-of-inpatient-v-observation-status-1738455

(B) http://www.aha.org/content/13/fs-readmissions.pdf

(C) August 10, 2016, at NEJM.org. (Richard Gunderman, M.D., Ph.D.)

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“I am still a family medicine physician and still see my own patients each day. My nurse and I review all messages for the day and all phone calls are returned before we leave.” (A)

Sounds great! But with the transformation of health care more and more physicians are “employed” and not in “private practice.”

The Medical Group Management Association reports that more than 50 percent of physicians are now employed by organizations affiliated with health systems. In some specialties, like cardiology, that is closer to 75 percent.

Discussion of employment tend to focus on the pros and cons for the physician.

Briefly they are:

Pros: The check will clear — The security of knowing that you are not at risk for making payroll may be significant. Both staff and physicians are virtually assured of their incomes. • Administrative headaches disappear — The hospital will worry about issues such as human resources, billing and collecting, rent and overhead, and daily operations. • Incomes are often higher — Many physicians do substantially better in an employment arrangement than they did in private practice.

Cons: You aren’t in charge — Regardless of the assurance that “nothing will change,” it does. Policies are set by the employer. Staff knows who writes their checks. You may end up seeing patients that would not have normally be part of your practice. • Compensation can be changed — Nearly all hospitals pay physicians on some form of production-based compensation formula but that does not mean that can’t change. • You may be judged by new metrics — Hospitals are aggressively adopting quality and patient satisfaction measures that are part of the overall compensation plan. • There may be new technology — Even though you have an EHR it might not be their EHR. You may need to go through another conversion. (B)

But how about the patient?

“One potential downside of the employed model is an increase in physician turnover, which can erode continuity of care. Employed physicians may not have the same financial and emotional stake in their practices as do independent physicians, making it relatively easy for them to move on as practice conditions or other opportunities dictate….

..An additional, more subjective concern is the effect of physician employment on the nature of the medical profession. Will physicians be less likely to take ownership of their patients’ health and be fully engaged patient advocates if they are financially beholden to large, corporate organizations? Will medicine cease being a calling and become in effect a trade?” (C)

“…. hospital-physician partnerships can deteriorate when expectations and accountability on both sides are not well defined up front. A physician may enter into one of these relationships expecting secure compensation and a better lifestyle with more sensible hours while the hospital aims to maintain their volume and/or build their market share with proper control. ….. paying close attention to the metrics of success for both parties, and appropriate consideration of the legal aspects of the contract, including exit clauses for both parties, is essential for long-term success.

Another potential advantage of hospital-physician partnerships is delivering a more integrated care experience for patients. “Many patients do not realize that doctors and hospitals are often separate business entities,” he said. “They assume that everyone is working together to provide them a seamless care experience. Being more closely aligned with the hospital can allow a physician to do that.”

Access to better technology and the ability to streamline care are both major advantages to a partnership,….. but “the overall goal has to be to improve quality and reduce costs of care through a more seamless integrated care experience.” (D)

If you are younger your only experience may be with employed physicians. If you are older perhaps you have already have seen changes in the physician-patient relationship from “back in the day.” So it here are some benchmarks to use:

The core elements comprising patient satisfaction include:

◾Expectations: Providing an opportunity for the patient to tell their story.

◾Communication: patient satisfaction increased when members of the healthcare team took the problem seriously, explained information clearly, and tried to understand the patient’s experience, and provided viable options.

◾Control: Patient satisfaction is improved when patients are encouraged to express their ideas, concerns and expectations.

◾Decision-making: Patient satisfaction increased when the importance of their social and mental functioning as much as their physical functioning was acknowledged.

◾Time spent: Patient satisfaction rates improved as the length of the healthcare visit increases.

◾Clinical team: Although it is clear that the patient first concern is their clinician, they also value the team for which the clinician works.

◾Referrals: Patient satisfaction increases when their healthcare team initiates referrals relieving the patient of this responsibility.

◾Continuity of care: Patient satisfaction increases when they receive continuing care from the same healthcare provider(s).

◾Dignity: As expected, patients who are treated with respect and who are invited to partner in their healthcare decisions report greater satisfaction. (E)

(A) http://www.physicianspractice.com/blog/pros-and-cons-private-practice

(B) http://www.physicianspractice.com/blog/hospital-employment-vs-private-practice-pros-and-cons

(C) http://www.aafp.org/fpm/2015/0700/p11.html

(D) http://www.healio.com/orthopedics/business-of-orthopedics/news/print/orthopedics-today/%7B18032629-f0ad-4b49-94ea-f8f69d614846%7D/private-practice-vs-salaried-employment-a-complicated-decision

(E) http://healthcarecomm.org/about-us/impact-of-communication-in-healthcare/

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ZIKA: The imperative to integrate basic science, epidemiology and case finding, clinical protocols, big data, and more by designating ZIKA/ Emerging Viruses Regional Referral Centers!

what is the federal government waiting for?

 

Congenital Zika Syndrome. Zika causes a unique syndrome of devastating birth defects

Doctors confirmed the link between the Zika virus and microcephaly in April. While the most visible sign of microcephaly is the small size of the head, its actually inside the brain where the most damage occurs. (Whitney Leaming, Julio Negron/The Washington Post)

The birth defects caused by Zika have been described in heartbreaking detail as the virus has spread to more than 45 countries, infecting hundreds of thousands of people, including tens of thousands of pregnant women. Now researchers have concluded that a Zika infection during pregnancy is linked to a distinct pattern of birth defects that they are officially calling congenital Zika syndrome.

In a report released Thursday in JAMA Pediatrics, researchers from the Centers for Disease Control and Prevention describe five types of birth defects that are either unique to Zika or occur rarely with other infections during pregnancy: Severe microcephaly (abnormally small head size) with partly collapsed skull. Decreased brain tissue with a specific pattern of calcium deposits indicating brain damage. Damage to the back of the eye with a specific pattern of scarring and increased pigment. Joints with limited range of motion, such as clubfoot. Too much muscle tone, restricting movement soon after birth.

https://www.washingtonpost.com/news/to-your-health/wp/2016/11/03/congenital-zika-syndrome-is-the-new-name-for-a-group-of-devastating-birth-defects/?postshare=221478184729260&tid=ss_tw

 

 

First Baby in Puerto Rico With Zika-Related Microcephaly Born

The first child in Puerto Rico with Zika-related microcephaly has been born, the territory’s secretary of health announced Friday.

The fetus’s abnormally small head was not detected until the mother was nearly eight months pregnant, according to The Associated Press, even though the mother was probably infected in her second month.

http://www.nytimes.com/2016/10/29/health/zika-microcephaly-puerto-rico.html?_r=0

 

 

Nearly 600 Zika Investigations Force Harris County Public Health to Improvise

Denver, Oct. 31, 2016 — The Harris County Public Health Department — which this past summer confirmed the state of Texas’ first Zika-associated death — has investigated nearly 600 suspected cases this year, 55 percent of which were pregnancy-related, according to new research released today at the American Public Health Association’s 2016 Annual Meeting in Denver.

“And, we believe those case numbers will continue to rise,” said Umair A. Shah, MD, MPH, executive director of Harris County Public Health. “Every day we learn more about Zika. The more we learn, the more we realize that there is not a one-prong approach to combat the spread of the virus, it requires the efforts from all sectors within our health department.”

http://www.newswise.com/articles/nearly-600-zika-investigations-force-harris-county-public-health-to-improvise

 

 

Congenital Zika Virus Syndrome: Beyond Microcephaly

This study shows that congenital Zika virus syndrome is complex and involves many areas of the nervous system. It also indicates that screening for microcephaly alone would be inadequate in newborns with suspected Zika virus syndrome. The details of the clinical and pathological findings of these 11 infants reported in this study can help clinicians assess the offspring of mothers exposed to Zika virus during pregnancy.

http://www.jwatch.org/na42671/2016/10/31/congenital-zika-virus-syndrome-beyond-microcephaly

 

 

Neurologic Complications of Zika Include More Than Microcephaly 

Consequences of neurologic dysfunction in other diseases include problems in hearing, vision, and swallowing, as well as epilepsy. Only longer term follow-up in survivors will establish if this is also true in congenital Zika syndrome. Ocular abnormalities that have been observed in affected infants include anterior and posterior eye anomalies.

http://www.contagionlive.com/news/neurologic-complications-of-zika-include-more-than-microcephaly

 

 

Zika’s million-dollar question: Where are the birth defects?

We created three graphics for a better look at the latest numbers. They offer a glimpse at why researchers are so perplexed by Zika’s uneven impact across the Americas — what University of Texas Zika expert Nikos Vasilakis calls Zika’s “million-dollar question.”

http://www.pri.org/stories/2016-11-01/zika-s-million-dollar-question-where-are-birth-defects

 

 

Here’s What We Could Be Doing to Stop Pandemics Like Zika and Ebola

But while the global health industry and national governments and regulators have made a lot of progress, there’s still much more that these groups can do together to better plan, fund, and organize the battle against emerging pandemics, said a group of experts at Fortune’s Brainstorm Health conference in San Diego, Calif……

http://fortune.com/2016/11/01/zika-ebola-virus-vaccines-pandemics/

 

 

Harmonisation of Zika virus research protocols to address key public health concerns

While the evidence linking Zika virus infection and GBS in adults and separately between microcephaly and other neurological conditions in the fetuses of pregnant women is strong and growing, many key research and public health questions need to be addressed through comprehensive epidemiological studies to better understand the extent of Zika virus infection and the diseases Zika virus causes in humans and their offspring.

http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(16)30255-8/fulltext?rss=yes

 

 

Progress on Zika. Yale researchers are active on several fronts.

As the Zika virus epidemic spreads, and Zika’s known risks and dangers multiply—including underdevelopment of fetal brains and transmission of the virus through sexual contact—scientists are racing to catch up. The good news: they’re making progress. At Yale alone, researchers are active on several fronts.

At the School of Medicine, scientists have shown that the Zika virus targets the neural stem cells, which give rise to the developing nervous system in a fetus. ….Researchers at the School of Public Health were part of a team that developed a novel online tool (zika.cidma.us) for evaluating anti-Zika interventions (how cost-effective are mosquito nets?

Another team has shown that Zika travels directly from the vaginal tracts of pregnant mice into the brains of their fetuses.

https://yalealumnimagazine.com/articles/4376-progress-on-zika

 

 

11 things we learned about Zika from a top disease expert

Even a bottle cap full of water can be a mosquito breeding ground.

Our mosquito control found hot spots in surprising places.

An Aedes Aegypti mosquito is really good at biting people.

But it doesn’t go very far.

We did really well fighting Zika in Wynwood. But even doing everything right isn’t enough.

Insecticides, while controversial, are really effective.

But we simply don’t have the technology to totally stop Zika.

It will be several more years before we have a vaccine.

The CDC would be stoked if they could wipe out Aedes Aegypti.

Zika takes a long time to show its worst effects, which makes it hard to get money to fight it.

This is the new normal.

https://thenewtropic.com/11-things-learned-zika-top-disease-expert/

 

 

 

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