“About a year ago, I began to have stomach discomfort and thought I had overdone it at Starbucks. The pain got worse overnight. Antacids didn’t help. Then came the nausea, 102-degree fever and pain that had moved to my lower right side, making it difficult to lift my leg. By dawn, I knew it was appendicitis and told my husband we had to go to the hospital… Then we met the surgeon as I was being prepared to be taken into the operating room. He explained that if he didn’t operate right away, I might get sepsis and die. He also said he didn’t take my insurance but assured us I was in capable hands, as he was very experienced. After asking about our occupations, he announced his fee for my laparoscopic appendectomy would be $15,000. We were stunned by the timing and the amount. Was this supposed to be a negotiation?” Eventually, the surgeon’s bill arrived: $17,000 including charges for an ER consult neither my husband nor I recall. I called the insurance company (for which we’re paying more than $25,000 in annual premiums). Sorry, he’s not one of ours. No contract with us.” (U)

The House Energy and Commerce Committee and the Senate Health, Education, Labor and Pensions Committee reached a deal last year that uses a benchmark rate and an arbitration backstop for any charges above $750. But the House Ways and Means Committee announced shortly thereafter they are working on their own legislation that may be more provider-friendly…

House Majority Leader Steny Hoyer told reporters last week that he is turning to the committee chairmen to settle any dispute, according to a report in The Hill newspaper. Energy and Commerce Committee Chairman Rep. Frank Pallone, D-New Jersey, calls tackling “devastating” surprise medical bills one of his top priorities, a committee spokesperson said.” (V)

Prequel

PARTS 1-4. SURPRISE MEDICAL BILLS. “I was never in a position to preselect who (would) perform my heart transplant,” (and if the physicians and surgeons were in network)….because I did not know when a new heart would become available.

ASSIGNMENT: after doing a comprehensive analysis of current state Surprise Billing legislation, prepare a model state bill.

“A woman from New York City received an eye-widening check after visiting a doctor for her strep throat. She had to pay more than $28,000 after taking simple tests that involved only a swab, taking blood samples and antibiotics…

Kasdan told “Bill of the Month,” a joint project between NPR and Kaiser Health News, that she received the bill worth $28,395.50 in October. Her health insurance company gave her a check for $25,865.24…

Her strep throat checkup grew to the eye-popping amount because both the clinic and laboratory that conducted the tests were out of network. The lab also appeared with the same phone number and address as the doctor’s office Kasdan visited.

A $25,000 bill should be surprising for a strep throat test. An in-network throat swab and tests commonly cost only nearly $600, while an average co-pay for a specialist ranges from $30 to $50, MarketWatch reported Wednesday.” (A)

“People who are in the middle of a health crisis often are at an especially high risk for surprise medical bills, according to previously unreleased data from the Kaiser Family Foundation.

The big picture: The new data underscore the importance of a legislative solution to help patients who are powerless to protect themselves.

Details: People having surgery or receiving mental health and substance abuse treatment at an in-network hospital are the most likely to experience a surprise bill from an out-of-network provider.

Among people with employer-based insurance, out-of-network charges were 50% higher among heart-attack victims than for other diagnoses…

Half of the American people say they would have to borrow money or go into debt to pay a $500 medical bill, or wouldn’t be able to pay it at all.

Unexpected medical bills are the public’s top health cost concern, ahead of deductibles, premiums, drug costs, and even paying the rent or the mortgage.

People with major medical conditions and chronic illnesses are most likely to experience problems paying their medical bills.

The bottom line: Congress is torn between two competing ideas solving this issue and settling payment disputes between insurers and providers. Each plan has its own implications for premiums and industry negotiations, but for patients, just getting a fix is the most important thing.” (B)

“Emergency medicine specialists were most likely to generate “surprise bills,” or out-of-network bills for services provided at in-network facilities, compared to six other specialties, according to an analysis by the Health Care Cost Institute, an independent, nonprofit research organization.

The analysis is based on national claims data for patients with employer-sponsored insurance in 2017. Claims for anesthesia, behavioral health, cardiovascular, emergency, pathology, radiology and surgery services were included. HCCI grouped claims into “visits” by compiling claims by individual patient, type of service and day, and then examined how many of those visits involved out-of-network claims.

How the seven specialties compare:

Emergency medicine specialists — 16.5 percent of emergency visits resulted in a surprise bill from an emergency medicine specialist

Pathologists — 12.9 percent

Anesthesiologists — 8.3 percent

Behavioral health provider — 6.7 percent

Radiologist — 4.2 percent

Surgeon — 2.1 percent

Cardiovascular specialists — 2 percent (C)

“Heart attack patients may be more at risk of surprise medical bills

We examined the incidence of out-of-network charges among people covered by large employer health plans who received emergency services or inpatient stays at in-network facilities for a heart attack. The incidence of out-of-network charges was 50% higher for heart attacks compared to the incidence rate of all diagnoses for both emergency services (27% vs. 18%) and for inpatient admission at in-network facilities (23% vs. 16%), respectively…

While potential surprise bills are relatively common, in general, patients with serious or complex conditions may be even more likely to face such charges, depending on the types of services they need and providers they encounter. As this analysis shows, admissions at in-network hospitals for maternity and newborn led to an out-of-network bill about 10% of the time, compared to almost a quarter of admissions involving a heart attack. The higher likelihood of surprise out-of-network medical bills, in turn, increases a patient’s financial exposure. While a person giving birth usually has more time to prepare and presumably plan for in-network provider use than a person having a heart attack would, one in ten maternity-related admissions at in-network hospitals still led to an out-of-network charge. The nature of surprise medical bills is that they cannot be reasonably prevented through planning.” (D)

“Texas will soon enact a law to prevent patients from getting hit with surprise medical bills.

It appears Texas will get one of the strongest laws in the nation against surprise medical bills after all.

Earlier this year, lawmakers passed legislation to protect people in state-regulated health plans from getting outrageous bills for out-of-network care.

The law, which takes effect Jan. 1, wavered last month when the Texas Medical Board drafted the rules for its implementation. The board, made up of health care providers, tried to get a blanket exception to the law for virtually all nonemergency cases.

Instead, after an outcry from advocates and media coverage by KUT, NPR and Kaiser Health News, the board decided to relinquish its rule-making authority.

The Texas Department of Insurance instead took over writing the rules that health care providers will have to follow. On Wednesday, the agency released a set of rules that advocates say are good for patients…

At issue is a piece of the law meant to allow patients to freely choose a doctor out of their insurance networks when they wish. In those cases, patients can sign a form saying they realize they may have to pay more for out-of-network care. The medical board tried to interpret that part of the law broadly, so that every patient would sign such a form before any nonemergency procedure…

Senate Bill 1264 creates an arbitration process for insurers and providers to negotiate fair prices for that out-of-network care without involving patients. Currently, patients can get a “surprise bill” when both sides can’t agree on a fair price…

Jamie Dudensing, the CEO of the Texas Association of Health Plans, said the state insurance agency’s new rules “correctly implement the consumer protections in Senate Bill 1264 and ensure Texas patients no longer have to worry about surprise billing.” “(E)

“After months of hearings and negotiations, millions of dollars in attack ads, full-court-press lobbying efforts and countless rounds of negotiations, Congress appears to be moving toward a solution to the nation’s surprise medical bill problem. Sort of…

Two committees, the Senate Health, Education, Labor and Pensions Committee and the House Energy and Commerce Committee, have been working on plans and announced a compromise Dec. 8. Later that week, the House Ways and Means Committee followed suit by announcing its solution, though details are few…

Despite the rushed way some committee members announced the agreement Dec. 8 — issuing a press release on a Sunday before any official bill text was released — it’s now looking unlikely that Congress will consider the package before it wraps up work for the year…

Over the past few months, the biggest debate around remedies for surprise bills has centered on how to determine payment for out-of-network doctors and hospitals. One group wanted an arbitration process while the other sought a benchmark system. It seems neither side will get exactly what it was seeking.

Under benchmarking, the government would set a compensation rate for providers when they see out-of-network patients. The most popular proposition was one that paid a “median in-network” rate, where doctors are paid in the middle of the range of what others in the area are paid by insurance companies for the same service.

The other idea was independent dispute resolution, or arbitration. The provider and insurer bring their best offer to a third party, who chooses between the two…

Generally, employers and consumer advocates favor benchmarking. Hospitals and doctors’ groups — especially those backed by private equity firms — pushed for arbitration.

Political muscle could also factor into the measure’s momentum.

Money from private equity has been flowing into the debate, from millions of dollars spent on commercials and online ads to campaign donations… “(F)

“The House Ways and Means Committee released its own proposal Wednesday for ending surprise medical bills, potentially complicating an effort by some lawmakers to include a rival proposal in a year-end spending bill…

The Ways and Means Committee plan appears to resolve payment disputes by allowing health care providers and insurers to enter into arbitration, a method favored by hospitals and most doctors’ groups. The committee’s leaders called on lawmakers to slow down the process, while the leaders of the House Energy and Commerce Committee have been pushing for action within the next two weeks.

“There are multiple good-faith proposals from other Committees, but given our jurisdiction, it is crucial that we get this right,” Ways and Means Chairman Richard E. Neal, D-Mass., and ranking member Rep. Kevin Brady, R-Texas, said in a joint statement. “The House, Senate, and Administration all need to stay at the table and debate these ideas as we decide the best, most patient-focused path forward. We look forward to working together with our Committee Members and having this be one of the first things we consider in the new year.”…

So far, no top party leader in either chamber has endorsed the House-Senate committee deal, which several lawmakers have said is holding up movement on the agreement. Senate Minority Leader Charles E. Schumer, D-N.Y., said in response to a CQ Roll Call question Tuesday that there were “many disagreements” on the policy, although he also said, “We have to do something about surprise billing.” (G)

“Doctors and the private equity firms behind them can reap huge extra profits by charging patients essentially whatever they decide the price should be. The practice raises insurance costs for everyone….

Opinions vary on what happened. Some think it may have just been jurisdictional jostling, whereas Republicans suspect Neal was working with Democratic leadership to deliberately tank a solution. Of particular frustration is that Neal’s counterproposal wasn’t even a piece of legislation but only a vague one-page outline.

When asked by BuzzFeed News, Neal conceded his proposal does not answer the key question of how much to pay for out-of-network emergency room procedures after surprise billing is banned. “We have not fleshed that out, no,” he said. Neal previously proposed a bill that did not contain a solution at all. Instead, it would have kicked the matter to the Trump White House to solve.

But Neal insists he is committed to ending surprise medical billing. He said the House–Senate compromise was rushed and there was not enough time to scrutinize it between impeachment, the USMCA trade deal, and other pressing issues.

“We didn’t have time to review it. There was no time to review it because of the way that it was mustered,” said Neal. He said that any solution needs to hold up under the scrutiny of a magnifying glass and that’s what he intends to work on next year.” (H)

“This is what makes surprise billing so uniquely Kafkaesque, even among the many horrors of the American medical system: The bills victimize people who do everything right. You can pay for insurance, pick a doctor carefully, make sure the hospital where you have scheduled your procedure takes your coverage, and still end up on the hook for more than $100,000 because an assistant surgeon who didn’t accept your insurance swooped in to the operating room while you were unconscious. True story.

The sheer unfairness of it all, and bipartisan voter support for fixing it (78 percent of Americans have said they would like to see a federal bill) is why both Democrats and Republicans basically agree that something needs to be done. Moreover, it’s an issue that only Washington can fix. States have taken steps to protect some of their residents from surprise bills but can’t fully address the issue because of a federal law that prevents them from regulating most large employer-based health plans. If Congress doesn’t act, nobody can…

But beyond the tough optics of taking on the doctor lobby, this also seems like a story about the power of donors over some influential Democrats—particularly Neal, the Ways and Means chairman. Health care providers have long been some of his largest donors, which is unsurprising, since his committee has jurisdiction over Medicare. This year, however, he received a $29,000 donation from the Blackstone Group, the private equity giant that owns TeamHealth, one of the country’s largest physician staffing firms, which stood to lose out from Congress’ compromise bill. As Kaiser Health News reporter Rachel Bluth notes, this was the first year Blackstone showed up in Neal’s top five donors.” (I)

“Here are some other reasons you might receive a shock bill:

Out-of-pocket costs. How surprised you are by the size of a medical bill may be a function of how well you understand the cost-sharing terms of your insurance policy, such as the deductible, copays and coinsurance. Experts estimate that one-fourth of Americans who carry health insurance are actually underinsured because of coverage gaps and out-of-pocket expenses, according to a 2019 Commonwealth Fund report…

Billing errors. Every medical procedure has a five-digit Current Procedural Terminology (CPT) code, which providers list on bills and insurance claims. (Medicare has a similar system called the Healthcare Common Procedure Coding System, or HCPCS.) With thousands of codes, and paperwork that goes through multiple hands, “human error happens, both in inputting those codes and in accepting them as accurate,” says Caroline Pearson, a health policy expert at NORC, a research institution at the University of Chicago.

The more complex the bill, the more likely it is to include mistakes. A surgery or hospitalization can involve dozens of services, medications and consultations. That’s dozens of opportunities for typos, clerical errors and confusion between what a doctor ordered and what was actually done, says Victoria Caras, the owner of Aspen Medical Billing Advocates, a Colorado firm that works with patients to review and reduce health care bills…

Billing fraud. Most medical billing errors are just that — errors. But outright phony charging does occur. According to the National Health Care Anti-Fraud Association and billing experts, common types of billing fraud include:

Billing for procedures or services that were not performed, or that were performed but were not medically necessary.

Double billing for a procedure that was done once.

Billing for a more expensive service than was performed, a practice known as “upcoding.” For example, tests done by technicians could be coded as being done by physicians.

“Unbundling” — boosting charges by billing individually for related services that are commonly billed with a single code, such as cleaning, stitching and dressing a wound.

Billing a patient for more than the copay amount…”  (J)

“Given the market failures and consumer expectations at the heart of surprise billing, it is no surprise that there is pressure for the government to intervene. Currently there’s no federal law to protect consumers from receiving a surprise bill. There are some state laws, tracked by Kevin Lucia and Jack Hoadley of Georgetown University’s Health Policy Institute for the Commonwealth Fund. But even the states that have acted are preempted by federal law from protecting consumers who get their insurance from employers with self-funded plans.

Solutions at the state level fall into two categories. States may set a reimbursement rate for out-of-network services received at an in-network facility — for example, tying them to Medicare rates so the consumer doesn’t receive an astronomically high bill. The other is establishing an arbitration procedure that determines how a dispute between insurers, providers, and consumers should be resolved.

To avoid accusations of price-setting, policymakers have shied away from the first approach and leaned toward the second. Although arbitration is a form of regulation, it doesn’t cause opponents as much aggravation: the government is determining the process of rate-setting rather than the rate itself. But even establishing a process is a step away from free markets…

As policymakers search for a solution, they should consider that regulation that either prevents providers from balance billing or holds the consumer harmless — that is, protects them from paying the surprise bill by leaving it to the insurers and providers to fight it out — would help address the public sense of injustice around these bills. Many state laws do this. But without price regulation to take market power away from local providers, the surprise billing problem won’t go away.” (K)

“The fall issue of Regulation includes two articles on surprise billing that propose different solutions. One endorses mandatory arbitration of surprise charges as the most neutral market-oriented solution. Unlike the dropped provision, this solution would not impose a rate for physicians’ services. Instead, in cases in which in-network reimbursement rates differed from out-of-network provider charges, patients would be responsible only for the usual in-network charge and the decision over whether the provider payment request or the insurer network reimbursement would prevail would be made by an independent arbitrator.

A second recommends a contract-based alternative in which in-network hospitals become responsible for resolving surprise billing by providers who work at the hospitals. This solution would require all providers at a hospital to contract with the same insurers as the hospital or to secure payment for their services from the hospital, which would bundle these payments in the in-network facility fees they charge insurers. This would incentivize hospitals to directly address the problem of surprise billing because if they did not the costs would fall on them. This is consistent with economic theory that recommends placing burdens on those that face the lowest transaction costs to resolve disputes.

The primary difference between these two proposals is their understanding of the root cause of surprise billing. Are surprise bills the natural outcome of failed negotiations between insurers and providers? Then an independent dispute resolution process replaces patients as the final backstop in negotiations. Or are surprise bills a symptom of a flawed system in which bad-faith actors set artificially high prices? The second solution requires hospitals to resolve the problem contractually or be responsible for the surprise bills.” (L)

“One short-sighted “solution” known as benchmarking could actually make things much worse. It would put the government in control of setting payments to physicians by using insurance companies’ in-network averages as the “benchmark” for out-of-network services.

However, since these rates have been deeply discounted during the contract negotiation process, benchmarking would cause local hospitals and emergency rooms to incur significant losses that could translate to diminished access, fewer choices and higher costs for patients.

None of these outcomes are acceptable.

Congress should instead focus on passing a balanced solution that is fair to both providers and insurers while holding patients responsible for only their standard, in-network cost-sharing amounts.

Just such a solution can be found in another proposal called Independent Dispute Resolution, or IDR.

An integral part of our Washington state law is an IDR system that establishes appropriate reimbursement for out-of-network care when physicians and insurance carriers cannot agree on what constitutes “commercially reasonable rates.”

It passed the Legislature overwhelmingly because it was a compromise among physicians, hospitals and insurance carriers.

For our state law to be truly effective, it requires broad participation among health plans, specifically self-insured health plans that have the option to opt in to compliance with the law.

If federal legislation is adopted that does not include an arbitration/IDR component, the likelihood that self-insured plans would opt to comply with the state law is slim to none because the plans would be subjecting themselves to arbitration.

So even though the state law would not technically be superseded, its efficacy would be compromised if federal legislation without an arbitration/IDR provision is adopted.

Conversely, if federal law is adopted with such a provision, it would establish a level playing field for all parties – something that can’t be done at the state level due to federal preemption of self-insured plans.

Additionally, initial payments made at the onset of the IDR process would help keep rural healthcare facilities financially strong and secure, ensuring no one’s access to quality, affordable care is at risk.

Unlike benchmarking, the IDR approach also provides extra incentives for insurance companies to grow their provider networks, helping prevent the kinds of gaps in insurance that lead to surprise medical billing in the first place.”… (M)

“It is the duty of physician companies — not Congress — to end surprise billing, Ashish Jha, MD, a health policy professor at the Harvard T.H. Chan School of Public Health in Boston, wrote in an op-ed for The Boston Globe.

Estimates say more than half of American adults have received a surprise bill from a medical provider they thought was in network, Dr. Jha said. He argues surprise bills aren’t really an accident, but “an intentional exploitation of weaknesses in our healthcare system” by physician groups who refuse to contract with insurers.

“These physician groups will argue that insurers aren’t negotiating in good faith, and while sometimes that’s true, the primary culprit of this deception has been physician companies whose business model is to exploit patients when they are most vulnerable — in an emergency or under anesthesia,” he wrote.

While mandatory arbitration has been floated as a possible solution, Dr. Jha thinks capping how much providers can charge for out-of-network services is a better solution that will encourage physician companies to negotiate with insurers.

“We all took an oath to ‘do no harm.’ To financially ruin our patients when they are sick shows a moral rot in our community,” Dr. Jha said. “If we don’t voluntarily stop this practice, Congress will eventually stop us. And shame on us for making Congress do what we should do on our own.” (N)

“In a new paper, coauthor Brian Blase and I propose a market-based solution to such surprise medical bills. This proposal, if implemented, will equip consumers with the information they need to so they can make more informed health care decisions.

Our proposal requires insurers and providers to supply accurate and timely information about networks and prices. It segments the surprise billing problem into four distinct categories, depending on the network status of the facility and whether the medical services are emergency or nonemergency.

Here are the three major elements of our recommendations:

1. Price disclosure. Unlike virtually every other service in the economy, consumers don’t know the prices of scheduled, nonemergency care until long after receiving it. The government does not need to mandate price disclosure in other areas of the economy that function efficiently. But efficiency is not a key feature of health care markets, which are beset by excessive third-party payment and price opacity.

Congress should correct this problem by requiring providers to supply a good faith estimate of the cost of scheduled medical care before it occurs, unless the patient affirmatively declines an estimate. Providers that refuse to supply an estimate before providing care could not “balance bill” (i.e., charge a patient an amount above what the insurer pays the provider) afterward.

2. Penalties on insurers and providers for supplying false and misleading information about a facility’s network status. Consumers typically seek network physicians and hospitals to avoid high out-of-network bills. They rely on representations about network status from their insurance company and from the hospital itself.

What their insurer and hospital often don’t tell patients is that other doctors who might participate in their care are not part of their insurer’s network. Patients learn that only weeks or months later, when the bill from the non-network physician arrives.

Congress should protect consumers against false and misleading information. It should establish penalties for insurers that represent a facility as being in-network, and a facility that presents itself as being in-network, if doctors balance-bill for services they provide at that facility.

To be considered a network facility, the insurer, the facility, and the doctors who practice there would have to negotiate arrangements that protect patients against surprise bills. Hospitals that permit surprise bills could not be represented as network hospitals without penalty.

3. Ban balance billing at non-network emergency departments. Accurate information about a hospital’s network status and price transparency don’t help the patient who is suffering severe chest pains or being transported in an ambulance. Such patients generally will go or be taken to the nearest emergency room. Broad consensus exists in Congress and among the public that patients in those circumstances should not face large bills for out-of-network care.

Consistent with that consensus, we propose that Congress ban surprise billing in these limited circumstances and require insurers to pay, and providers to accept, reimbursement rates spelled out in existing federal regulations.

Those regulations, which already govern insurance company payments to non-network providers of emergency care, require insurers to pay providers the greatest of: a) the Medicare rate; b) the median network rate; or c) the amount an insurer generally pays non-network providers.

The alternatives—such as doing nothing and arbitration—are worse, and accurate information about network status and prices are of no value in this unique circumstance.

These recommendations should, to the extent possible, be implemented in a way that preserves the ability of states to adopt policies that best serve their residents.

This proposal offers a better path for Congress, which currently seems headed in a very different and counterproductive direction. Although they differ in some respects, the House and Senate proposals rely on sweeping and unnecessary federal price regulation, rather than market-based alternatives, to eliminate balance billing. Both would force doctors and insurers who have not contracted with each other to accept rates set in contracts they haven’t signed.”  (O)

“Comprehensive state laws hold consumers harmless against surprise medical bills. The hold-harmless protection generally involves two types of requirements – one for state-regulated health insurers, and one for providers. Insurers are required to cover out-of-network claims and apply in-network level of cost sharing for surprise medical bills. In addition, laws prohibit providers from balance billing patients covered by state-regulated plans; instead, the out-of-network provider is limited to collect no more than the applicable in-network cost-sharing amount from patients in cases of surprise medical bills.

State laws may also require notice to consumers about their rights and protections. New York, for example, requires state-regulated insurers to include prominent, standardized notice on the explanation-of-benefits (EOB) statement summarizing consumer rights regarding surprise medical bills. Notices also give consumers information about where they can file complaints or receive help. In California and New Mexico, out-of-network providers also are required to include prominent notice in billing invoices and other written communications pertaining to surprise medical bills that the consumer is not liable to pay more than the in-network cost sharing amount.

Resolve payment for surprise bills

After indemnifying the patients, comprehensive state laws then provide for resolution of the payment amount for surprise medical bills. Approaches vary, with some states adopting a payment standard for all applicable surprise medical bills, while other states establish a dispute resolution process that insurers and providers can use to arrive at a payment amount for each surprise medical bill. States sometimes use a combination of both approaches.”  (P)

“Instead of waiting idly for Congress to act — and action is by no means certain — consumer advocates and payers ought to exploit the significant legal vulnerabilities to physician staffing firms’ out-of-network business model. Opening a second front with targeted legal challenges might shift momentum in the legislative fight against surprise medical bills…

Although different states have different rules about a hospital’s qualification for a not-for-profit exemption from taxation, in general hospitals must adhere to a charitable mission and not become vehicles for a profit-making enterprise. In 1998, the Pennsylvania Superior Court upheld revoking the tax exemption for a hospital that had transferred funds to an affiliated medical practice. The court held that because the medical practice did not provide charity care and used noncompete covenants, the hospital was supporting a for-profit entity.

Not-for-profit hospitals are granting franchises to staff their emergency departments to for-profit companies that aggressively bill the captive clientele attracted by the hospitals’ network participation while declining to join those networks themselves. An affected community loses twice: paying higher tax rates to offset the hospital’s exemption while also paying exorbitant prices for services that hospitals claim as a “community benefit.”

A strong argument can be made to taxing authorities that this is inconsistent with a nonprofit mission.

It’s time to pilot legal challenges to surprise medical bills

Litigation has played an important role in improving health and health care. Lawsuits against tobacco companies led to changes that drastically curbed smoking; similar litigation is changing the face of opioid production, distribution, and prescription. Malpractice lawsuits over deaths from anesthesia resulted in huge improvements in patient safety.

Applying legal pressure on the staffing firms and their host hospitals could bring a relatively quick and inexpensive change of the “facts on the ground” and break impasses in both legislative and network contracting negotiations. It would be helpful to have such activities running in the background during Congress’s 2020 session.” (Q)

“House Majority Leader Steny Hoyer (D-Md.) said Wednesday that two Democratic committee chairmen are trying to work out their differences over a measure that would protect patients from surprise medical bills.

A bipartisan group of lawmakers has been pushing for months to pass legislation protecting patients from getting massive bills when they go to the emergency room and one of their doctors happens to be outside their insurance network. That effort was derailed last month when House Ways and Means Committee Chairman Richard Neal (D-Mass.) and ranking member Rep. Kevin Brady (R-Texas) proposed an approach that differs from the bill put forward by House Energy and Commerce Committee Chairman Frank Pallone Jr. (D-N.J.) and Rep. Greg Walden (Ore.), the top Republican on the panel.

“Mr. Neal and Mr. Pallone are talking and the committee members are talking about the differences,” Hoyer told reporters when asked if he or Speaker Nancy Pelosi (D-Calif.) would step in to try to resolve the dispute. “It’s like infrastructure — there’s universal agreement that we need to deal with surprise billing. There obviously are differences with respect to how you deal with that, and they’re discussing that now.”

Hoyer added that hopefully they can “resolve those differences and move ahead in a way that will protect patients.”..

Pelosi has said she hopes surprise billing legislation will be included in a health care package ahead of a May 22 deadline for renewing certain expiring health programs.” (R)

Experts warn that some providers — such as hospital staffing companies backed by private equity funds — avoid joining networks to cash in on the lucrative world of surprise billing. That lets them charge more than the rates negotiated by insurance companies.

A Stanford University analysis of millions of insurance claims found more than 80% of ambulance rides fell outside patients’ insurance networks. New research from Yale University, meanwhile, estimates that reining in out-of-network billing by anesthetists and others could cut health care spending by tens of billions of dollars annually.” (S)

“America’s sky-high health-care costs are so far above what people pay in other countries that they are the equivalent of a hefty tax, Princeton University economists Anne Case and Angus Deaton say. They are surprised Americans aren’t revolting against these taxes.

“A few people are getting very rich at the expense of the rest of us,” Case said at conference in San Diego on Saturday. The U.S. health-care system is “like a tribute to a foreign power, but we’re doing it to ourselves.”

The economists say they understand it will be difficult to alter the health-care system, with so many powerful interests lobbying to keep it intact. They pointed to the practice of “surprise billing,” where someone is taken to a hospital — even an “in network” hospital covered by their insurance — but they end up getting a large bill because a doctor or specialist who sees them at the hospital might be considered out of network.

Surprise billing has been widely criticized by people across the political spectrum, yet a bipartisan push in Congress to curb it was killed at the end of last year after lobbying pressure.

“We believe in capitalism, and we think it needs to be put back on the rails,” Case said.” (T)

“About a year ago, I began to have stomach discomfort and thought I had overdone it at Starbucks….continued

“But there was no time for discussion. I was wheeled off for a straightforward surgery that took about 35 minutes — not much longer than a colonoscopy. The procedure went well.

Eventually, the surgeon’s bill arrived: $17,000 including charges for an ER consult neither my husband nor I recall. I called the insurance company (for which we’re paying more than $25,000 in annual premiums). Sorry, he’s not one of ours. No contract with us.

Fortunately, my insurance covered all other related hospital costs — the ER doctors and tests, the operating room, medications, the anesthesiologist’s fee — but that still left us with the $17,000 charge from the surgeon. That’s more than seven times the out-of-network, uninsured rate for the hospital’s locale, according to FAIRHealth Consumer.

I appealed to the Maryland Insurance Administration, which regulates the state’s insurance industry. MIA was sympathetic, but there was nothing to be done because the surgeon didn’t have a contract with the insurance company.” (U)

“Lawmakers concede escalating tensions with Iran and impeachment could cripple progress on deals for surprise billing as a stalemate over how to pay providers lingers…

Lawmakers didn’t include legislation on surprise billing in an end-of-year spending package. But in that package, Congress only reauthorized funding for key health programs until May.

The thinking was to create a new deadline for Congress to get something done on surprise billing and other healthcare legislation. However, the Senate is waiting on the House to sort out a way forward.

How to pay providers has remained a key sticking point, as providers endorse arbitration to settle disputes on out-of-network charges and payers a benchmark rate for out of network. Provider groups, some of which are backed by private equity firms, and insurers have launched massive ad campaigns over the issue.

The House Energy and Commerce Committee and the Senate Health, Education, Labor and Pensions Committee reached a deal last year that uses a benchmark rate and an arbitration backstop for any charges above $750. But the House Ways and Means Committee announced shortly thereafter they are working on their own legislation that may be more provider-friendly.

The stalemate has continued into the new year.

House Majority Leader Steny Hoyer told reporters last week that he is turning to the committee chairmen to settle any dispute, according to a report in The Hill newspaper. Energy and Commerce Committee Chairman Rep. Frank Pallone, D-New Jersey, calls tackling “devastating” surprise medical bills one of his top priorities, a committee spokesperson said.” (V)

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ASK FOR CLEAN HANDS

Germs that can cause serious infections are in every healthcare facility. They can be on your healthcare provider’s hands and also your own.

It’s OK to ask for clean hands. It could save your life. Make sure everyone around you has clean hands to protect against infection.

SPEAK UP FOR CLEAN HANDS.

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Hand hygiene plays a critical role in preventing the spread of pathogens that can lead to healthcare-associated infections (HAI), yet many U.S. health systems are falling short on their hand hygiene compliance rates. The Centers for Disease Control & Prevention (CDC) estimates that healthcare providers clean their hands about half the times they should. Missing these hand hygiene opportunities puts patients at risk for HAIs.” (K)

ASSIGNMENT: Develop an evidence-based hand-washing plan for your community hospital.

“Hand hygiene is described by many health care workers as the single most important tool in preventing the spread of health care-associated infections between patients…

Organisms found on HCW hands after such patient contact range from Klebsiella spp., Staphylococcus aureus, Clostridium difficile, MRSA and gram-negative bacteria. However, direct patient contact is not the only way HCW hands can be contaminated. HCWs can acquire bacteria on their hands by touching contaminated surfaces in the patient environment and simply by touching a contaminated chart at the nurses’ station, according to the literature.

Washing hands before and after patient contact seems like a simple solution to prevent the spread of bacteria between patients. Most hospitals have hand hygiene policies in place that guide their employees to do just that. But it is not as simple as it seems.

“When we look at all of the things that we can do to prevent infections in the hospital, one of the most important things about hand hygiene is that it works for so many different types of organisms, and you get a lot of bang for the buck,” …“The issue is that you have to practice it at a high level of compliance for it to work. There are so many opportunities for hand hygiene, and it is difficult to get to a level of compliance where we’re able to make changes to infection rates.”” (A)

“What’s The Problem? Most germs that cause serious infections in healthcare are spread by people’s actions. Hand hygiene is a great way to prevent infections. However, studies show that on average, healthcare providers clean their hands less than half of the times they should. This contributes to the spread of healthcare-associated infections that affect 1 in 25 hospital patients on any given day. Every patient is at risk of getting an infection while they are being treated for something else. Even healthcare providers are at risk of getting an infection while they are treating patients. Preventing the spread of germs is especially important in hospitals and other facilities such as dialysis centers and nursing homes.” (B)

“How much hand hygiene is enough? Guidelines vary, but according to Dr. Clifford McDonald, associate director for science at the CDC, nurses or doctors in the intensive care unit may have to clean their hands over 100 times in an eight-hour shift.

SCVMC and many other hospitals are working on ways to increase compliance. One strategy involves publicizing compliance data — apparently, some hospital departments enjoy some healthy competition.

Another study being presented at APIC from the Henry Ford Health System in Detroit found that hand-washing rates improved after hospital staff members were shown images of millions of bacteria found on common surfaces. Appealing to human emotions — like disgust — seems to have had a meaningful impact.

On May 5, the CDC launched a “Clean Hands Count Campaign” to promote hand hygiene adherence in hospitals. Part of their mission is to empower patients to hold healthcare workers accountable for cleaning their hands.

McDonald encourages patients to remind doctors and nurses to sanitize their hands — even though it might feel like an uncomfortable shift in the traditional power dynamic.

“If we can get the patients more involved in that — and get them to be able to speak up, that is really the main thing,” he said. “A lot of patients are nervous about that kind of thing — that’s another culture we’re trying to change.”” (C)

“My colleagues and I have been studying how to prevent hospital infections for years. Our research – which has included site visits to over 50 U.S. hospitals as well as a large-scale collaborative effort involving over 1,000 U.S. hospitals and several hospitals in Japan and Italy – found that opposition to hospitals’ infection prevention initiatives comes from a type of health care worker that we classified as active resisters.

Active resisters are people who like doing things a certain way for the simple reason that things have always been done that way. During one site visit, an infectious diseases doctor involved in preventing infections told us:

Getting the surgeons to adopt things in general is problematic …they’re like baseball players, they’ve got superstitions…in their minds if it’s working, why should we change it.

But at least you know who these people are since they speak up at meetings and actively resist changing behavior.

Active resister or organizational constipator?

The second type are what we termed organizational constipators. These individuals often have nothing against an initiative per se but simply enjoy exercising their power by refusing to change, albeit below the radar. The challenging aspect about organizational constipators is that the people above them think they are doing a good job, while those below them cannot believe they still have a job.

Yet another barrier we found in our research is that many hospitals have a culture of mediocrity rather than a culture of excellence. These hospitals are content to be just good enough. Leadership is generally ineffective. Overperformers are rewarded with more work…

If guidelines, personal bottles of hand sanitizer and constant feedback aren’t enough, perhaps health care workers should heed the words of Dr. Avedis Donabedian, an internationally known expert in health care quality.

In an interview about health care and how to improve it. Dr. Donabedian was clear:

Health care is a sacred mission…Doctors and nurses are stewards of something precious…Ultimately, the secret of quality is love. You have to love your patient, you have to love your profession…If you have love, you can then work backward to monitor and improve the system.

If we have love, we will wash our hands before touching our patients.” (D)

“What is the correct hand washing technique for good hand hygiene?

It’s important that we know when to wash our hands before we consider the best technique for doing so. Hand Hygiene Australia have identified ‘5 moments for hand hygiene’ which include:

before touching a patient

before a procedure

after a procedure or body fluid exposure

after touching a patient

after touching a patient’s surroundings.

The commonly held thought is that it’s only before or after direct patient contact that it becomes necessary to wash our hands but clearly there are so many more instances where we can pick up infection carrying organisms.

One of the key risks is that the organisms are invisible and we cannot know they are there, it’s crucial that good hand hygiene becomes more than a habit but second nature.

Despite the clear need for good hand hygiene, there are many obstacles that appear to be preventing it becoming routine amongst healthcare professionals. Some of these are down to poor perception – such as patient need taking priority over hand washing, that gloves are an effective barrier or a lack of understanding of cross contamination. Whereas institutional problems can also be a barrier, such as not enough hand washing stations, staff shortages, lack of policy, or simple forgetfulness.

The battle against hospital acquired infection continues, and with antibiotic resistance ever increasing, there shows little sign of it stopping soon. Effective hand hygiene is one of the simple steps every nurse, midwife and medical professional can take to help combat infection and protect their patients from harm.” (E)

“Walk into most manufacturing plants that are performing well, perhaps winning the Malcolm Baldrige Award,1  and you will find robust leadership and management systems focused on customer needs. Good leaders establish a bedrock of values, a clear moral compass, and a compelling vision and inspire others to embrace that vision. Good managers declare goals and measures and ensure that both of these cascade through each level of the organization, with designated processes and persons accountable for them. Workers know the behaviors needed to achieve the goals, and management is visible in their work area and posts performance on key behaviors.

Health care has not yet widely embraced these management practices. Despite considerable clinical research to identify essential behaviors and practices, health care processes are unreliable, for which there are several reasons. First, we are still heavily practicing the “art” of medicine, reflecting a failure to determine when art is needed and when more disciplined science should be practiced.

Second, at most organizations, clinicians are not trained in the tools and methods of Lean, Six Sigma, and change management—which Chassin and colleagues, in their two articles in this issue of The Joint Commission Journal on Quality and Patient Safety, 2,3 refer to collectively as Robust Process Improvement® (RPI®).

Third, our accountability systems are grossly underdeveloped, and low compliance with evidence-based practices is too often tolerated.” (F)

“Five key categories of hand hygiene intervention (HHI) emerged: (1) improving awareness with education (knowledge transfer, evaluation, mentoring and feedback), (2) facility design and planning, (3) unit-level protocols and procedures, (4) institution-wide programs, and (5) multimodal interventions.

•Although some evidence-based HHI has been developed, sustaining hand hygiene compliance remains challenging.

•Components like environmental psychology, behavioral economics, and financial rewards should be used to better understand and catalyze improved behavioral change in various contexts and environments to improve hand hygiene.” (G)

“Recent trials have demonstrated that Surfaceskins, self-disinfecting door push-pads and pull-handles designed to kill deposited germs in seconds, promote hand hygiene awareness and significantly improve hand hygiene compliance.

Surfaceskins Ltd, a company part owned by University of Leeds spin off, NIRI (Nonwovens Innovation and Research Institute Ltd) believes the latest trial, conducted in hospital theaters over six months with results published in the Journal of Hospital Infection, is a watershed moment for the company, as it shows that, in addition to the potential to eliminate doors as a source of hand contamination, Surfaceskins can also have an additional infection control benefit by improving hand hygiene awareness and compliance.” (H)

“Ultraviolet sanitizing devices could be stationed around hospitals to help prevent the spread of bacteria on workers’ devices like smartphones, a small Canadian study suggests.

Researchers in British Columbia recruited staff at three hospitals to disinfect their smart devices twice daily and found a drastic reduction in the amount of bacteria growing on the devices afterward, according to the report…

Smartphones and wearable devices are becoming the medium of choice for doctors to communicate with staff and patients, Stephanie Huffman of Island Health and the University of British Columbia in Vancouver and her colleagues write in the American Journal of Infection Control.

Infections can spread by contact with unclean hands and equipment like respiratory machines, but most hospitals have hand-hygiene rules and systems in place to regularly disinfect medical instruments.

Routine and proper cleaning of smartphones and wearables such as the popular Vocera Badge has not been well explored, the study team writes. Using alcohol wipes is generally not recommended by smartphone makers.” (I)

“Two hospitals in Singapore believe they have developed a more effective hand hygiene program by focusing on handwashing compliance throughout entire wards instead of just from staff member to staff member.

Ng Teng Fong General Hospital and Jurong Community Hospital launched new hand hygiene programs a few years ago using World Health Organization (WHO) guidelines, and the results are encouraging, reports Infection Control Today.

As part of the program, staff trained in WHO methods audited administrative staff that were not members of the ward staff, as well as infection control liaison nurses and infection control nurses. Wards that didn’t reach targeted compliance rates within the first month were asked to increase their hand hygiene education. If the heightened education didn’t yield results after the second month of monitoring, then the infection committee chairperson was asked to take over the education. In the event of a third month of failure, a special task force comprised of a doctor or nurse was created to implement a compliance improvement strategy.

No ward exceeded four months of being below its compliance target.” (J)

PREQUELS

PART 4. CANDIDA AURIS. “.. nursing facilities, and long-term hospitals, are…continuously cycling infected patients, or those who carry the germ, into hospitals and back again.”, http://doctordidyouwashyourhands.com/2019/09/part-4-candida-auris-nursing-facilities-and-long-term-hospitals-arecontinuously-cycling-infected-patients-or-those-who-carry-the-germ-into-hospitals-and-back-again/

Renaissance Master Caravaggio Didn’t Die of Syphilis, but of Sepsis, http://doctordidyouwashyourhands.com/2019/03/renaissance-master-caravaggio-didnt-die-of-syphilis-but-of-sepsis/

“President Garfield didn’t die from an assassin’s bullet, but rather from a doctor’s dirty hands.”, http://doctordidyouwashyourhands.com/2019/03/president-garfield-didnt-die-from-an-assassins-bullet-but-rather-from-a-doctors-dirty-hands-2/

It’s okay and important to ask your doctor “DID YOU WASH YOUR HANDS?”, http://doctordidyouwashyourhands.com/2017/08/its-okay-to-ask-your-doctor-did-you-wash-your-hands/

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“Raw” Curated Contemporaneous Case Study Methodology by Jonathan M. Metsch, DR.P.H.

I taught full time in the Baruch MBA in Health Care Administration program from 1972 to 1975, then was a health care administrator for over thirty years, finishing for seventeen years as President & CEO of LibertyHealth/ Jersey City Medical Center, where we built a replacement safety-net hospital (it took 15 years), played a key role on September 11th, 2001, and once again became a medical school affiliated teaching hospital (having been free-standing for decades).
After retiring from LibertyHealth, I returned to the Baruch program for four years as Adjunct Professor and started writing case studies. I developed case studies based on my CEO experiences. Interestingly case studies on failures provided better Lessons Learned than cases on successes. I also used Harvard Case Studies, and invited “Visiting” Professors to present cases typically related to the new realities of Obamacare, mostly C-Level executives I was still in touch with from my first stint at Baruch. I was very proud of what they had accomplished and shared.
In retirement I have watched health care disruption become so complex that there are few, if any, up-to-date case studies. So I developed a method of “raw” contemporaneous cases studies each developed by curating news articles into a coherent thread, after a topic has called out to me. Topics come from navigating the system (think out-of-network physicians, for example), news feeds, and friends and family.
Now, my Career Capstone Project is to bring “raw” cases to AUPHA that can be used in real-time, meaning they can start a discussion for immediate use in class.

For example if I was teaching now I would be doing contemporaneous cases on Medicare for ALL v. “TrumpCare”, surprise medical bills/ out of network, Candida auris, Ebola, WalmartCare, conflict of interest, migrant children holding facilities..

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Here’s my way of developing a case:

A. Spend some time looking at the case format at http://doctordidyouwashyourhands.com/

B. To identify CCCS topics sign-up for daily automatic health care news feeds. For example:
1. STAT https://www.statnews.com/
2. MedPageToday https://www.medpagetoday.com/
3. Becker’s Hospital Review https://www.beckershospitalreview.com/
4. Healthcare Dive https://www.healthcaredive.com/
5. FierceHealthcare https://www.fiercehealthcare.com/
6. New York Times
7. Hospital Association Daily News Clips

C. Set up Google Alerts https://www.google.com/alerts https://support.google.com/websearch/answer/4815696?hl=en (for example: Amazon. health care; medical/ recreational marijuana; cost of prescription/ generic drugs; Ebola; Emerging viruses; flu; health care disruption; health care innovation; health insurance; hospital innovation;.; ObamaCare; opioid crisis; Trump Care; Zika)

D. Select topics to follow and make a folder for each (for example: Amazon+, precision medicine, Zika, marijuana, antibiotics; insurance; flu, hospitals; Obamacare/ TrumpCare; opioid crisis; prescription and generic drugs, right-to-try)

E. Then every day from News Feeds select articles on your topics and move them to the appropriate folder.

F. When you are inspired to write a “case” start a Word document, then go to the case folder and select key points from the articles, and cut and paste them to the Word document. As well capture article title, author and hyperlink.

G. Move the key points around until you have created a story.

H. Then label each point A,B.C…and move article title, author and hyperlink to footnotes at the end of the case.

I. Then write an introduction to the case.

J. Questions to jonathanmetsch@gmail.com

Jonathan M. Metsch, Dr.P.H.
http://www.mountsinai.org/profiles/jonathan-m-metsch

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PART 5. What are the Lessons Learned (or not!) from the Johns Hopkins All Children’s Hospital and North Carolina Children’s Hospital pediatric cardiac surgery program failures?

“Repairing a heart is a risky business, especially when the organ fails to develop properly in the womb. Any number of abnormalities can arise, from major arteries that grow in the wrong place to pumping chambers that fail to form.

Now, a 2017 U.S. News analysis underscores a crucial factor that can tip the balance between life and death: where the surgery is performed.

The analysis of four years of data from hospitals across the country indicates that 26 percent of deaths – more than 1 out of every 4 – that occur following surgery for the most severe heart defects could be prevented by having the operation performed at hospitals where surgical teams do the greatest numbers of procedures.” (A)

Little has changed, however, since the first research linked volume to outcomes in the 1970s. Smaller surgical programs continue to perform procedures best left to surgeons at more experienced institutions, even when there’s a high-volume hospital nearby.

The reasons for the health care industry’s reluctance to act include the same forces that shape so much else in medicine: prestige and money. Hospitals mindful of their reputation and bottom line encourage doctors to keep patients in-house, rather than referring them to rivals with the experience and resources to care for them. Surgeons also oppose efforts to limit the scope of their practice.

Community leaders, too, may rebel at the notion of closing low-volume services, because lost revenue could threaten a local hospital’s survival. Plus, some smaller hospitals provide high-quality care and get excellent results.

In 2015, U.S. News demonstrated that thousands of lives could be saved each year if patients with certain conditions, including those needing joint-replacement operations, were treated in high-volume settings. Overall, knee-replacement patients who had their surgery in the lowest-volume centers were nearly 70 percent more likely to die than patients treated at the busiest centers. For hip-replacement patients, the risk was nearly 50 percent higher…

Children who need complex congenital heart procedures face a 1 in 5 chance of dying before going home, while the risk for those needing simple repairs is less than 1 percent, says Dr. Jeffrey Jacobs, chief of cardiovascular surgery at Johns Hopkins All Children’s Hospital in St. Petersburg, Florida. Jacobs also leads The Society of Thoracic Surgeons Workforce on National Databases.” (A)

ASSIGNMENT: What are the Lessons Learned from the Johns Hopkins All Children’s Hospital and North Carolina Children’s Hospital pediatric open cardiac surgery program failures? What are the regulatory implications?

First scan Parts 1-4 by clicking on:

 “The U.S. has more than double the number of congenital heart surgery centers that it needs, researchers said here.

Currently, the nation boasts more than 150 such centers: 116 participating in the Society of Thoracic Surgeons (STS) National Database as of 2018, and probably another 30-40 not reporting to it, said Carl Backer, MD, of Ann & Robert H. Lurie Children’s Hospital of Chicago, and former president of the Congenital Heart Surgeons’ Society (CHSS).

Among them are “problem institutions,” outliers with unexpectedly high mortality rates, Backer told a standing-room-only crowd at the American Heart Association (AHA) annual meeting…

The idea is that higher case volume is tied to lower patient mortality in pediatric cardiac surgery, 300 cases per year being the inflection point in one study cited by Backer.

This 300-case threshold held up in a separate analysis by his group, which mined STS data and found that mortality rates adjusted for case complexity came out to 1.7% for centers doing at least 300 cases annually and 5.4% for others with 100 each year (P<0.01).

Regionalizing congenital heart surgery therefore should have the goal of keeping case volumes above 300 per hospital while minimizing travel distance. In addition, policies should allow for at least one program per state that has over 2 million inhabitants, according to Backer.

His magic number: 71 sites scattered across the country.

Currently, Florida and Texas each already have 10 pediatric heart surgery centers — and California 11. In Backer’s plan, this would be reduced to six programs in Texas, four in Florida, and nine in California.” (B)

“A decision on the future of the Sydney Children’s Hospital Network has been delayed four months after an independent review called for urgent action amid protracted conflict over the state’s paediatric heart surgeries.

In July, Health Minister Brad Hazzard held a roundtable of doctors and other healthcare workers from across the state after reviewers said governance issues and tensions between the Randwick and Westmead hospitals needed to be settled “as a matter of urgency”…

A NSW Health spokesman said Professor Henry’s review will make recommendations on the governance and planning of healthcare services for children for the next five years.

“These recommendations will obviously relate to considerations of the governance of the Children’s Hospitals Network and the configuration of paediatric cardiac surgery at the Sydney Children’s Hospital, Randwick and Children’s Hospital at Westmead,” the spokesman said…

Westmead cardiologists believe patients will have better outcomes if cardiac services are focused at one hospital, while doctors from Randwick believe losing cardiac surgery would compromise other services.

“Our message has always been very clear, we believe that cardiac surgery is a vital component of any children’s tertiary referral hospital,” Chair of the Sydney Children’s Hospital Randwick medical staff council Dr Susan Russell said after July’s roundtable.

Most clinicians at that roundtable – including paediatric healthcare workers from rural and regional NSW – agreed the state would be best served with one major children’s hospital providing cardiac surgery services. But medical staff from the Randwick hospital disagreed.” (C)

“Johns Hopkins All Children’s Hospital has hired a familiar face to help it restart its troubled heart surgery unit.

Dr. James Quintessenza will return as the department’s chief surgeon and co-director, hospital leaders announced Tuesday.

Quintessenza, 62, oversaw the pediatric heart surgery department at All Children’s for almost two decades. But he was pushed out after the hospital became part of the Johns Hopkins system…

 “We will spend the next year recruiting additional doctors and staff, including for cardiac intensive care, interventional and fetal cardiology,” Kmetz wrote. “We will take whatever time is necessary to do this right.”..

The announcement comes after a tumultuous 11 months for the hospital and its heart surgery unit.

The Times investigation, published last November, found that the department’s 2017 death rate was higher than any other children’s heart surgery program in Florida had seen in the past decade. Complication rates also spiked, the Times found.

The problems began after Johns Hopkins took over All Children’s in 2011 and started making changes to the heart department. Quintessenza had performed the most difficult surgeries. But the hospital’s new leaders wanted the cases evenly divided among its three heart surgeons.

Frontline workers noticed problems with surgeries performed by the other two surgeons as early as 2015 and raised concerns to their supervisors, the Times reported. But procedures continued as the hospital’s leaders pushed to grow the Heart Institute.

Hospital leaders also made changes to the cardiologists and critical care doctors who worked in the department.

Quintessenza disagreed with the hospital’s leaders, the Times reported. The spike in deaths and complications happened after he left.

After the Times’ investigation, six top administrators resigned, including the hospital’s CEO and the chief heart surgeon who had replaced Quintessenza. Federal and state inspectors identified widespread safety problems throughout the hospital and mandated sweeping changes…

 “We made a mistake, and we need to make sure we help support these families and make it right,” Johns Hopkins Health System president Kevin Sowers told the Times in June.

Quintessenza, who graduated from the University of Florida School of Medicine, was instrumental in growing the All Children’s heart surgery program.

He performed the first pediatric heart transplant there in 1995. Two years later he became the chief of pediatric heart surgery. The heart transplant program was ranked one of the nation’s best in a 1999 federal government review.

After Quintessenza left in 2016, he was quickly hired by Kentucky Children’s Hospital to help restart its pediatric heart surgery program. The hospital had halted surgeries after its death rate increased in 2012.” (D)

“In just three years, Johns Hopkins All Children’s Hospital has tripled the number of babies it treats born with congenital diaphragmatic hernia – a hole in their diaphragm, a life-threatening birth defect.

The St. Petersburg pediatric hospital treated 50 children with congenital diaphragmatic hernia in the third year of its CDH program, up from 16 to 18 patients treated in the first year, said Dr. David Kays, medical director of the program.

About half the patients are from families in Florida, and about half travel from around the United States to St. Petersburg for treatment.

Now, the hospital has a dedicated Center for Congenital Diaphragmatic Hernia, a 15-bed unit that is believed to be the nation’s first inpatient unit dedicated to the treatment of infants and children with condition, said Thomas Kmetz, president of Johns Hopkins All Children’s Hospital.

The center is staffed by an interdisciplinary team and led by Kays, who was recruited to All Children’s in early 2016 from University of Florida. At UF, he treated 321 children over 23 years – about 15 children a year, Kays said at a dedication ceremony Thursday for the new center at All Children’s.

“I came here to build what I thought would be the world’s best program in congenital diaphragmatic hernia,” Kays said. “There was a trajectory to this children’s hospital that was perfect for this program. I couldn’t take this program to Boston Children’s or Children’s Hospital in Philadelphia. There were too many egos to accept me to come in and change the paradigm. But this place was just right. It had the same vision to be a great children’s hospital the way I wanted to build a great program.”..

Kays has a reputation in the pediatric surgical world as a bit of a renegade, “a hard-driving guy with outcomes so great that some people don’t even believe it,” said Dr. Paul Danielson, interim chair of the hospital’s department of surgery.

Danielson describes Kays as a revolutionary, and the CDH unit as truly interdisciplinary.

“It’s not multi-disciplinary, where different specialties come and work together. It’s where different disciplines come together and create their own new discipline,” Danielson said. (E)

“Johns Hopkins All Children’s Hospital in St. Petersburg and Golisano Children’s Hospital of Southwest Florida have entered into an agreement to expand care for kids across Florida’s west coast. The agreement gives providers at both locations access to medical privileges to admit and treat patients. Golisano Children’s Hospital will also be able to take part in pediatric research studies and protocols through Johns Hopkins All Children’s Hospital.

This relationship provides a process for collaboration between the two hospitals, with a focus on increasing access to specialized pediatric care. Through this agreement, Johns Hopkins All Children’s Hospital and Golisano Children’s Hospital will work together to deliver the highest quality care, leverage resources and create better value for families.” (F)

“Three cardiologists from outside the state have reviewed the North Carolina Children’s Hospital pediatric heart surgery program and concluded the program can resume complex pediatric heart surgeries there.

The six-page advisory report released this week by UNC Health Care officials acknowledged that new leadership and investment in the program has helped resolve some of the thornier issues exposed several months ago in a New York Times investigative piece.

The external review panel also highlighted the program’s precarious perch as a smaller-volume pediatric cardiology program aspiring to grow in the shadow of a larger program only miles away at Duke University.

“The current pediatric cardiac surgical volume presents challenges in a number of areas,” according to the report compiled by Catherine Krawczeski, division chief of pediatric cardiology at Nationwide Children’s Hospital Heart Center, Victor Morell, surgeon-in-chief and division chief of the UPMC Children’s Hospital of Pittsburgh’s pediatric cardiothoracic surgery, and Edward Bove, chairman of the University of Michigan medical school’s cardiac surgery department.

The external panel suggests having two pediatric cardiac surgeons at a minimum, able to provide coverage 24 hours a day throughout the year.

UNC averaged slightly fewer than 120 “index pediatric surgeries” in the last year, putting it in a “medium” category in terms of volume. The panel found this “borderline for optimally supporting and maintaining” two full-time pediatric cardiac surgeons…

Meanwhile, the panel noted UNC “must balance” its role as a state hospital and being an important resource for patients with complex needs while also considering whether a referral to another institution might produce a better outcome.

“Complex patients with additional comorbidities that place the patient at higher risk of poor outcome (either surgically or postoperatively) should continue to be carefully evaluated by the medical and surgical teams with referral to another center if deemed appropriate,” the panel stated…

The panel suggested also considering programs that might differentiate UNC from regional competitors, suggesting perhaps a comprehensive multi-disciplinary single care unit that includes cardiac, liver, kidney and neurodevelopment specialists, or an adult congenital heart program, a pulmonary hypertension program or cardio genetics program.” (G)

“Wesley Burks, chief executive of UNC Health Care, reportedly said Tuesday that North Carolina Children’s would be making “further enhancements” to its program, “because we recognize the importance of caring for very sick children with incredibly complex medical problems.”

The health system hasn’t announced a date for resuming surgeries.” (H)

“The federal agency that oversees transplant programs said it would investigate Newark Beth Israel Medical Center after ProPublica reported that the hospital was keeping a vegetative patient on life support for the sake of boosting its survival rate…

The team appeared to tailor medical decisions for at least four patients because of these concerns. In the case of Darryl Young, a heart transplant recipient, members of the medical staff didn’t offer options like hospice care to his family because they wanted to make sure Young lived at least a year after his surgery, according to current and former employees familiar with his care. In an audio recording obtained by ProPublica, Dr. Mark Zucker, the director of the heart and lung transplant programs, told the team at an April meeting, “I’m not sure that this is ethical, moral or right,” but it’s “for the global good of the future transplant recipients.”

In response to the concerns raised by the article, Newark Beth Israel said that it would conduct an “evaluation and review of the program, its processes and its leadership.” It later added that it had hired an outside consultant to perform the review…

Dr. Herb Conaway, a New Jersey assemblyman and chair of the Legislature’s Health and Senior Services Committee, called for the transplant team’s actions to be reviewed. “The implicated doctors must face consequences if the allegations are indeed accurate,” he said in a statement on Friday. “Their actions are a stain on the entire medical community, and they must be held accountable for what they have done to both this patient and his family.”

The editorial board of The Star-Ledger in Newark, which co-published the ProPublica investigation, urged prompt scrutiny of the hospital. “This is astoundingly unethical, and if true, should prompt firings of those involved and a federal and state review,” the board wrote. “The Attorney General’s Office should look into it, too, in case there’s something criminal here.” (I)

“The heart transplant program at Oregon Health & Science University Hospital will resume operations after a yearlong suspension, the hospital announced Aug. 26.

Portland, Ore.-based OHSU voluntarily suspended its transplant program last August after all four of the program’s cardiologists resigned for unspecified reasons.

Since then, OHSU has hired three advanced heart failure cardiologists to join the program. On Aug. 26, the United Network for Organ Sharing approved the program’s new primary physician for heart transplantation, which will allow the transplant program to resume operations.” (J)

“There was a life-threatening mistake at one of the largest hospitals in the Delaware Valley, involving two patients waiting for a kidney transplant. Last week, CBS3 received a tip that a patient at the Lourdes Hospital Transplant Center received a kidney transplant meant for another patient on the waiting list.

The hospital system confirmed that the surgery mix-up did, in fact, take place last week. The two patients have the same name and are around the same age.

After several follow-up conversations with Virtua Health, which took over Lourdes Health System earlier this year, the hospital system admits they gave the wrong person a kidney transplant last Monday.

Officials tell us the organ recipient was in need of a kidney and the surgery was successful. But, they say, the next day a staff member discovered the kidney recipient was out of priority order based on the matching organ donor list.” (K)

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MEDICARE FOR ALL. “Midway through July’s interminable Democratic debate, Senator Elizabeth Warren asked a simple question. “I don’t understand why anybody goes to all the trouble of running for president of the United States just to talk about what we really can’t do and shouldn’t fight for,”..“I don’t get it.” (A)

ASSIGNMENT: After scanning From REPEAL & REPLACE to WRECK & REJOICE (from Obamacare to Trumpcare) http://doctordidyouwashyourhands.com/2018/04/from-repeal-replace-to-wreck-rejoice-from-obamacare-to-trumpcare/ , start tracking Medicare for All.

“On March 24th, 2017. “Speaker Paul Ryan (R-Wis.) on Friday said his party “came up short” in a news conference minutes after pulling the GOP healthcare bill off the House floor, acknowledging that ObamaCare will stay in place “for the foreseeable future.””

Yet on December 20th, 2017 the INDIVIDUAL MANDARE was repealed. ““When the individual mandate is being repealed that means ObamaCare is being repealed,” Trump said…“We have essentially repealed ObamaCare, and we will come up with something much better…””

At the end of this post there are links to a series of over 60 posts tracking the activity between March 24th and December 20th. Laws are like sausages,” goes the famous quote often attributed to the Prussian Chancellor Otto von Bismarck, “it is better not to see them being made.”

_______________________

“Senator Elizabeth Warren on Friday revealed her plan to pay for an expansive transformation of the nation’s health care system, proposing huge tax increases on businesses and wealthy Americans to help cover $20.5 trillion in new federal spending…

Under Ms. Warren’s plan, private health insurance — which now covers most of the population — would be eliminated and replaced by free government health coverage for all Americans. That is a fundamental shift from a market-driven system that has defined health care in the United States for decades but produced vast inequities in quality, service and cost…

Like Mr. Sanders, Ms. Warren would essentially eliminate medical costs for individuals, including premiums, deductibles and other out-of-pocket expenses. But it is not clear if her plan would cover the costs of free health care for everyone. It relies on ambitious assumptions about how much it can lower payments to hospitals, doctors and pharmaceutical companies, and how cheaply such a large system could be run.” (B)

“Warren’s plan estimates that total health costs could be held to $52 trillion and that $20.5 trillion in new federal spending would be necessary…

Where the $20.5 trillion comes from:

Employers are one of the main sources of revenue in this proposal. Warren says she would raise nearly $9 trillion here, a figure that comes from the roughly $9 trillion private employers are projected to spend over the next decade on health insurance. The idea here is that instead of contributing to employees’ health insurance, employers would pay virtually all of that money to the government.

In addition, she will boost her proposed 3% wealth tax on people with over a billion dollars to 6% and also boost taxes on large corporations. Altogether, she believes, taxes on the rich and on corporations would raise an estimated $6 trillion. An additional $2.3 trillion would come from improving tax enforcement.

But there are lingering questions about how much revenue some of these taxes would bring in or how easy it would be to impose a wealth tax in particular.

“Something like half of the wealth of the wealthiest people in America are held in privately held corporations, privately held businesses,” said Howard Gleckman, senior fellow at the Urban-Brookings Tax Policy Center. “And it’s really hard to value those assets for tax purposes.”

Warren also includes comprehensive immigration reform as part of her plan. Giving more people a path to citizenship would mean more taxpayers, which would mean more tax revenue.

While Medicare for All is Sanders’ plan, his bill does not include set methods to pay for the plan. Rather, Sanders has included “options” to pay for his health care plan. In a recent interview with CNBC, he said “we’ll have that debate” over how exactly to finance the plan.” (C)

“Here’s a summary of what Ms. Warren has proposed on either side of the ledger.

To reduce the plan’s costs:

Change the way Medicare pays for certain types of hospital stays, such as paying a package rate rather than different fees for surgical services, and paying doctors in hospital-owned practices the lower prices paid to those in private practices. ($2.3 trillion)

Assume that the Medicare for all program itself can operate very leanly. The Urban Institute estimated that Medicare would devote about 6 percent of its health budget on administrators to decide what and how Medicare would pay for things, and to prevent fraud. In Ms. Warren’s plan, that rate is 2.3 percent. ($1.8 trillion)

Assume very aggressive drug discounts. Ms. Warren believes a government system will be able to reduce spending on drugs substantially, including lowering the prices of branded prescription drugs by 70 percent. ($1.7 trillion)

Assume slower growth in health spending over time. The federal government now thinks health spending will increase by 5.5 percent a year; the Warren campaign assumes 3.9 percent growth under Medicare for all, closer to the rate of growth in gross domestic product. ($1.1 trillion)

Assume lower payments to hospitals. The campaign believes hospitals can be paid around 110 percent of what they are currently paid by Medicare, a number that would cause some hospitals to operate at a loss. Currently, private health insurers often pay a lot more to hospitals than Medicare for similar procedures. ($600 billion)

What Warren Proposes

“Medicare for all” would shift a huge amount of health care money to the federal budget, increasing federal spending by $34 trillion over a decade, according to the Urban Institute. Here’s how Elizabeth Warren would make the math work.

To pay for the plan:

Employers would be required to pay fees to the federal government, equivalent to 98 percent of what they now spend on their employees’ health care. Some companies would be exempt, and companies with unionized work forces would be able to lower this payment if they increased workers’ wages. Currently, companies vary greatly in the cost and generosity of their health benefits, so this fee would vary substantially by firm. ($8.8 trillion)

States and local governments would be required to make payments to the federal government, similar to what they currently spend on government employee benefits and their share of Medicaid expenses. ($6.1 trillion)

Corporate taxation would be increased. ($2.9 trillion)

Tax collections would increase through improvements to I.R.S. enforcement, which Ms. Warren believes could raise a lot of money. ($2.3 trillion)

The top 1 percent of individual earners would pay new taxes on their capital gains; they would pay taxes on increases in investment value annually, instead of waiting until assets are sold. ($2 trillion)

Income tax collections would increase, since workers would no longer pay part of their salaries for insurance premiums, which are not taxed now. ($1.4 trillion)

Billionaires would pay a higher wealth tax than the rate Ms. Warren has previously proposed: 6 percent, up from 3 percent. ($1 trillion)

A new financial transactions tax would be imposed on stock trades. ($800 billion)

Pentagon spending from an overseas contingency fund, often criticized as a slush fund, would be eliminated. ($800 billion)

Income earned by immigrants, following the passage of her immigration overhaul plan, would provide new tax revenues. ($400 billion)

A risk fee on the liabilities of banks with more than $50 billion in assets would be introduced. ($100 billion)” (D)

“Displaying a new assertiveness toward her Democratic opponents, Elizabeth Warren laced into her chief political rivals, warning on Friday night that the country was in a “time of crisis” and arguing that Democrats would lose in 2020 if they nominated “anyone who comes on this stage and tells you they can make change without a fight.”

Speaking to thunderous applause during the party’s biggest Iowa political event of the year, Ms. Warren denounced candidates in the presidential race who opposed bold ideas in favor of more moderate solutions, in veiled attacks on Joseph R. Biden Jr. and Pete Buttigieg.

“Fear and complacency does not win elections,” she said at the Iowa Democratic Party’s fund-raising dinner. “Hope and courage wins elections. I’m not running some consultant-driven campaign with some vague ideas that are designed not to offend anyone.”..

 “We need big ideas, and here’s the critical part: We need to be willing to fight for them,” Ms. Warren said. “It’s easy to give up on a big idea, but when we give up on big ideas, we give up on the people whose lives would be touched by those ideas.”” (E)

“How does the Warren plan expand Medicare to cover everyone without raising taxes on the middle class? There are four main components.

First, the Warren team argues that a single-payer system would provide significant savings in overall medical costs — more than other studies are assuming. Some of these would come from bargaining down prices, especially on drugs. Others would come from a reduction in administrative costs.

Are these savings plausible? Well, America does pay incredibly high prices for drugs compared with other countries, and the complexity of our system imposes a huge administrative burden — not just the overhead of insurance companies, but the sheer number of people doctors and hospitals have to employ to deal with multiple insurers. I’ve been puzzled at the reluctance of other studies to credit Medicare for all with big savings on these fronts.

And we should note that even with these assumed cost savings, U.S. health spending per capita would remain far above that of other advanced countries. So there’s a case — not an open-and-shut case, but a reasonable one — for optimism here.

Second — and the cleverest item in the plan — the Warren team would basically require employers who are now offering health insurance to their employees to pay the cost of that insurance to the government instead. Bear in mind that large employers are already required by law (specifically, the Affordable Care Act) to provide insurance. So this would just redirect those funds.

Third, state and local governments currently spend a lot on health care, mainly but not only through their share of Medicaid spending. The Warren plan would require “maintenance of effort,” basically requiring that states continue to spend that money, but on supporting a national plan.

Finally, even with all this there’s a significant budget hole. Warren’s team argues that this can be closed in two ways: some further taxes on corporations and large fortunes, and — an important point — strengthening the I.R.S., which we know fails to collect large amounts of legally owed taxes, principally from people with high incomes, because Republicans have starved the agency of resources.” (F)

“Whatever their many flaws, Medicare for All advocates used to have a decent answer to the question of how they’d pay for it. Taxes would go up, they’d admit, but these taxes would be de facto premiums, because they’d replace the money Americans already spend on premiums and other health costs. On top of that, the taxes would be progressive, increasing with income, unlike normal premiums — and aggressive price controls would reduce costs overall.

I mean, good luck with that, both politically and practically. But you can’t deny that there’s a logic to it.

For whatever reason, though, Elizabeth Warren today opted for a different approach: one where premiums go away, middle-class taxes don’t go up (not even a penny!), and taxes on the rich make up the difference. In other words, it’s a system where everyone else gets their health care at the expense of the wealthy. Even if that sounds appealing, her plan for doing this shows how silly it is.

First, the plan doesn’t keep its promise. Nearly half the funds come from redirecting the money that employers spend on health benefits to the government. Sorry, but your health benefits are part of your compensation. Sending that money to the state instead is a tax on you, not your employer.

And second, in trying to force rich people to pay for (much of the other half of) everyone’s health care, the plan basically blows every dollar the government could hope to collect from the wealthy in the coming years. The corporate tax goes back up to the uncompetitive 35 percent rate it was before the tax reform, and would be collected far more aggressively too. (Part of the burden of the corporate tax is borne by workers, by the way.) Warren’s wealth tax for “ultra-millionaires” gets a new 6 percent annual rate for those with more than $1 billion.

We already have a ton of debt and frightening obligations to provide old-age entitlements to hordes of retiring Baby Boomers, and yet this plan would eat up trillions in new revenue sticking the rich with the health-care bills of middle-class Americans who say they like their current insurance…

The easy solution is just to go back to the old argument, where taxes do go up but they’re more progressive than premiums and lower on average. But maybe middle-class Americans won’t want to give up their health insurance unless you bribe them with buckets of rich-people money.” (G)

“Senator Elizabeth Warren vowed on Friday to pass major health care legislation in her first 100 days as president, unveiling a new, detailed plan to significantly expand public health insurance coverage as a first step, and promising to pass a “Medicare for all” system by the end of her third year in office that would cover all Americans.

The initial bill she would seek to pass if elected would be a step short of the broader Medicare for all plan she has championed. But it would substantially expand the reach and generosity of public health insurance, creating a government plan that would offer free coverage to all American children and people earning less than double the federal poverty rate, or about $50,000 for a family of four, and that could be purchased by other Americans who want it…

But under the plan she presented on Friday, she would not seek passage of a single-payer system early in her presidency. The proposal would instead move people into that system gradually — in a way she hopes would build public support for full-fledged Medicare for all — while temporarily preserving the employer-based insurance system that covers most working-age adults today.

“I believe the next president must do everything she can within one presidential term to complete the transition to Medicare for all,” Ms. Warren, of Massachusetts, wrote in her plan. “My plan will reduce the financial and political power of the insurance companies — as well as their ability to frighten the American people — by implementing reforms immediately and demonstrating at each phase that true Medicare for all coverage is better than their private options. I believe this approach gives us our best chance to succeed.”..

With her interim plan, Ms. Warren is attempting to offer something attractive to both sides of the Democratic health care debate: preserving her commitment to the single-payer vision that energizes voters on the left, while offering a less disruptive set of proposals in the short term to those who may be reluctant to give up their existing coverage…

Ms. Warren’s agenda would cost more than $30 trillion. She plans to offset much of that cost through new taxes on the richest Americans and on businesses.

But she would still rely on Democrats winning control of the Senate, where Republicans currently hold a slim majority. And she is laying out ambitious details for getting to a single-payer system even as voter support for the idea is narrowing; polls suggest substantially more Americans prefer the “public option” type of plans that Mr. Biden and Mr. Buttigieg have proposed…”  (H)

“Allowing more time underscores Warren’s — or any candidate’s — difficulty in delivering on government-run universal health coverage. Winning congressional approval would be a heavy lift, no matter which party holds majorities in the House and Senate.

 “Every serious proposal for Medicare for All contemplates a significant transition period,” Warren wrote in an online post. “My plan will be completed in my first term. It includes dramatic actions to lower drug prices, a Medicare for All option available to everyone that is more generous than any plan proposed by any other presidential candidate, critical health system reforms to save money and save lives, and a full transition to Medicare for All.”

Even as she continued to praise Medicare for All, though, Friday’s announcement represented a move toward the political middle on an issue that has been one of the most important to voters in the Democratic primary — which begins Feb. 3 in Iowa…

Taking years to get to Medicare for All would give Warren time to convince people happy with their current, private insurance to accept a fully government-funded system. But Friday’s announcement seems sure to raise more tough questions about health care for a candidate who has been struggling with it lately — following her riding improved polling throughout the summer to become one of the front runners in the crowded Democratic primary field…

She is also recognizing that incremental measures that progressives often dismiss as not going far enough could have a real impact on people’s lives. That view was reinforced by a recent study by the Urban Institute and Commonwealth Fund policy centers, which concluded that Democrats have more than one way to get to coverage for all.

“Warren’s proposals to shore up the Affordable Care Act, lower drug prices, and create a public option would still provide substantial health care cost relief for people,” said the Kaiser Foundation’s Levitt.” (I)

Back in 2010, as Obamacare was about to squeak through Congress, Nancy Pelosi famously declared, “We have to pass the bill so that you can find out what is in it.” This line was willfully misrepresented by Republicans (and some reporters who should have known better) as an admission that there was something underhanded about the way the legislation was enacted. What she meant, however, was that voters wouldn’t fully appreciate the A.C.A. until they experienced its benefits in real life.

It took years to get there, but in the end Pelosi was proved right, as health care became a winning issue for Democrats. In the 2018 midterms and in subsequent state elections, voters punished politicians whom they suspected of wanting to undermine key achievements like protection for pre-existing conditions and, yes, Medicaid expansion…

The lesson I take from the politics of Obamacare, however, is that successful health reform, even if incomplete, creates the preconditions for further reform. What looks impossible now might look very different once tens of millions of additional people have actual experience with expanded Medicare, and can compare it with private insurance.

Although I’ve long argued against making Medicare for All a purity test, there is a good case for eventually going single-payer. But the only way that’s going to happen is via something like Warren’s approach: initial reforms that deliver concrete benefits, and maybe provide a steppingstone to something even bigger.” (J)

“Last week, President Donald Trump signed an executive order titled “Protecting and Improving Medicare for Our Nation’s Seniors.” The order is the latest example of how Trump says one thing while doing another. Rather than strengthening Medicare, Trump envisions turning large swaths of the 54-year-old program for the elderly over to the private sector while directing the federal government to dismantle safeguards on seniors’ health care access, shift costs onto beneficiaries, and limit seniors’ choice of providers.

Among other things, the executive order lays out a path to:

Shift the Medicare program toward private plans

Expand private contracting between beneficiaries and providers, putting seniors at risk for higher costs and surprise medical bills

Further restrict seniors’ choice of providers in Medicare Advantage

Expand Medicare Medical Savings Accounts as a tax shelter for the wealthy.. (K)

  1. A.Why Run For President If You Don’t Want to Fight?, by Sarah Jones, https://www.thecut.com/2019/07/elizabeth-warren-best-question-democratic-debate.html
  2. B.Elizabeth Warren Proposes $20.5 Trillion Health Care Plan, by Thomas Kaplan, Abby Goodnough and Margot Sanger-Katz, https://www.nytimes.com/2019/11/01/us/politics/elizabeth-warren-medicare-for-all.html?smid=nytcore-ios-share
  3. C.Here’s How Warren Finds $20.5 Trillion To Pay For ‘Medicare For All’, by Danielle Kurtzleben, https://www.npr.org/2019/11/01/775339519/heres-how-warren-finds-20-5-trillion-to-pay-for-medicare-for-all
  4. D.Elizabeth Warren’s ‘Medicare for All’ Math, by Margot Sanger-Katz and Sarah Kliff, https://www.nytimes.com/2019/11/01/upshot/elizabeth-warrens-medicare-for-all-math.html?smid=nytcore-ios-share
  5. E.Warren Laces Into Rivals as Iowa Campaign Grows Combative, by Sydney Ember and Reid J. Epstein, https://www.nytimes.com/2019/11/01/us/politics/iowa-democrats.html?smid=nytcore-ios-share
  6. F.Did Warren Pass the Medicare Test? I Think So, by Paul Krugman, https://www.nytimes.com/2019/11/01/opinion/did-warren-pass-the-medicare-test-i-think-so.html?smid=nytcore-ios-share
  7. G.Just Admit There Will Be Premiums in Medicare for All and Get It Over With, by ROBERT VERBRUGGEN, https://www.nationalreview.com/corner/elizabeth-warren-medicare-for-all-plan-there-will-be-premiums/
  8. H.Elizabeth Warren Vows to Expand Health Coverage in First 100 Days, by Abby Goodnough, Thomas Kaplan and Margot Sanger-Katz, https://www.nytimes.com/2019/11/15/us/politics/elizabeth-warren-medicare-for-all-100-days.html?smid=nytcore-ios-share
  9. I.Elizabeth Warren Says ‘Medicare for All’ Rollout Process Will Take 3 Years, by WILL WEISSERT, https://time.com/5730682/elizabeth-warren-medicare-for-all/
  10. J.Doing the Health Care Two-Step, by Paul Krugman, https://www.nytimes.com/2019/11/18/opinion/medicare-for-all.html?smid=nytcore-ios-share
  11. K.Trump’s Plan To Privatize Medicare, by By Emily Gee, Maura Calsyn, and Nicole Rapfogel, https://www.americanprogress.org/issues/healthcare/news/2019/10/11/475646/trumps-plan-privatize-medicare/

SUPPLEMENTARY MATERIAL

S.1129 – Medicare for All Act of 2019

Sponsor: Sen. Sanders, Bernard [I-VT] (Introduced 04/10/2019)

https://www.congress.gov/bill/116th-congress/senate-bill/1129/text

Compare Medicare-for-all and Public Plan Proposals

Where 2020 Democrats stand on Medicare-for-all https://www.washingtonpost.com/graphics/politics/policy-2020/medicare-for-all/

Where the top Democratic U.S. presidential candidates stand on ‘Medicare for All’

https://www.reuters.com/article/us-usa-election-healthcare-factbox/where-the-top-democratic-us-presidential-candidates-stand-on-medicare-for-all-idUSKCN1VV13A

MEDICARE FOR ALL. Use this calculator to find out what Elizabeth’s plan for Medicare for All will mean for you. https://elizabethwarren.com/calculator/medicare-for-all

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“The soldier, above all other people, prays for peace, for he must suffer and bear the deepest wounds and scars of war.” Douglas MacArthur

From 1967 to 1970, during the Vietnam War, my first assignment as a junior Air Force 2nd Lieutenant, was as Administrative Officer of the 4th Casualty Staging Flight attached to Wilford Hall USAF Medical Center, Lackland AFB in San Antonio, Texas. We received combat casualties still in battlefield bandages, often within 24 hours of injury, and either admitted them to Wilford Hall or further transported them to hospitals near home.

Recently it occurred to me to look back at how battlefield casualties were handled going back to the Revolutionary War and forward to Iraq/ Afghanistan. BATTLEFIELD MEDICINE is now a medical discipline! (But battlefield surgeon readiness may be at risk.)

BATTLEFIELD MEDICINE. “A war benefits medicine more than it benefits anybody else. It’s terrible, of course, but it does.” *

Introduction

SURGEONS IN EVERY branch of service in military hospitals worldwide perform complex, high-risk operations on active-duty personnel, their family members and some retirees in such small numbers that they may put patients at risk, a U.S. News & World Report investigation has found.

Three decades of research has shown doctors and hospitals with the highest volumes of certain complex surgical procedures achieve the best results. But military surgeons serve a population that’s relatively young and healthy. They lack the steady stream of older patients requiring surgery that would allow the doctors to sharpen their skills and sustain their readiness to help troops on the battlefield.

“You want to do more. In some cases, you’re begging to do more,” says Dr. Scott Steele, chair of colorectal surgery at the Cleveland Clinic, a West Point Graduate, former Army surgeon and Bronze Star recipient with more than two decades of service, including deployments in Iraq and Afghanistan…

The U.S. News analysis suggests that the surgical case shortage, coupled with the remoteness of some base hospitals from larger military or civilian medical centers, prompts some surgeons to tackle cases that may exceed their surgical skills…”  (A)

THE REVOLUTIONARY WAR

“When the Revolutionary War began its actual skirmishes in 1776, early attempts to prepare for the medical needs related to War were made in the City of New York. During the spring and summer of 1776, Samuel Loudon was publishing his newspaper the New York Packet, in which he included numerous articles and announcements regarding the Continental Army. On July 29, for example, came the following announcement written by Thomas Carnes, Stewart and Quartermaster to the General Hospital of King’s College, New York. Anticipating an increase demand for medically trained staff, he filed the following request for volunteers:

“GENERAL HOSPITAL New-York, July 29, 1776 Wanted immediately in the General Hospital, a number of women who can be recommended for their honesty, to act in the capacity of nurses: and a number of faithful men for the same purpose…King’s College, New York” (A)

“One of the most famous surgeons, and the first, was Cornelius Osborn. He was recruited in the Spring of 1776 and had little training even as a physician. The Continental Congress was even concerned about the well-being of the troops and the militia. They passed several ordinances and helped establish the order for the several field Hospitals during the War. The hospitals served about 20,000 men in the fight. Each hospital was required for each surgery to have at least one physician or surgeon, and one assistant, which was usually and apprentice of some sort. Each hospital’s staff numbers varied on how many wounded it served and the severity of the wounds….

Most of the deaths in the Revolutionary War were from infection and illness rather than actual combat. The common practice if a limb was badly infected of fractured was to amputate it, where most amputees died of gangrene a result of not properly cleaning instruments after surgeries. Only 35% of amputees actually survived surgery. There were no pain killers quite developed back then. So at most the patient were given alcohol and a stick to bite down on while the surgeon worked. Two assistants would hold him down, a good surgeon could perform the entire process in a mere 45 seconds, after which the patient usually went into shock and fainted. This allowed the surgeon to stich up the wound and prepare for the next amputation. Another way they decided to clean wounds, disease, or infection was by applying mercury directly to the cut of injured space, and letting it run through the blood stream which usually resulted in death.” (B)

“To seek treatment for any serious ailment, a soldier would have had to go to a hospital of sorts. Military regiments had a surgeon on staff to care for the men, so the soldier’s first stop would be with the surgeon. During battles, the surgeon could be found in a makeshift or “flying” hospital that consisted of a tent, an operating table, and some medical equipment. If the surgeon could not treat the soldier, he might be sent to a hospital. Many regimental hospitals were in nearby houses, while general hospitals for more in-depth treatment were sometimes set up in barns, churches, or other public buildings. The conditions were often cramped, which resulted in the rapid spread of contagious illnesses and infections….

Woe to the soldier who required surgery after being wounded on the battlefield! The conditions in “flying” hospitals were deplorable. Not only was the operating room simply a table in a tent, but there was little thought given to keeping the table and tools clean. In fact, wounds were sometimes cleaned using plain water from a bucket, and the used water would be saved to clean out the next soldier’s wounds as well.” (C)

“Hospitalization was a serious problem during the American Revolutionary War. Plans were made quite early to care for the wounded and sick, but at the best they were meager and inadequate. However on April 11, 1777 Dr. William Shippen Jr., of Philadelphia was chosen Director General of all the military hospitals for the army. Consequently the reorganization of hospital conditions took place…

After the battle of Brandywine, September 11, 1777, hospitals were established at Bethlehem, Allentown, Easton and Ephrata. After the battle of Germantown, October 4, 1777, emergency hospitals were organized at Evansburg, Trappe, Falkner Swamp and Skippack. Hospitals at Litiz and Reading were also continued. By December 1777, new hospitals were opened at Rheimstown, Warwick and Shaeferstown. Yellow Springs (now Chester Springs) an important hospital was organized under the direction of Dr. Samuel Kennedy. At Lionville, Uwchlan Quaker Meeting House was also made a hospital for a time. Apothecary General Craigie’s shop, Carlisle, was the source of hospital drugs….” (D)

WAR of 1812

“The big advances in military medicine were decades away.  William Morton would develop ether anesthesia for surgery, but not before 1846.  Florence Nightingale would create the professional nurse and reform the British hospital, but not until 1857.  Robert Koch would put forth his germ theory in 1890.  Although the War of 1812 took place well before these advances, there were many skilled military surgeons, most of them aware of the salutary effects of cleanliness.

At one Army hospital in Burlington, Vermont for example, the ward master had a long list of rules: chamber pots were to be cleaned at least three times a day and lined with water or charcoal.  Beds and bedclothes were to be aired daily and exposed to sunlight when possible. Once a month the straw in each bed sack was to be changed. If a patient died, the straw was to be burned…

Skilled as some practitioners were, the war took place in a period when some medical attention could kill you.  Army doctors used emetics to cause vomiting and cathartics to cause diarrhea, both as stomach cleansers.  Patients were sometime bled intentionally.  These cures often left the patients weak, dehydrated and unlikely to survive.

Battle injuries, of course, just compounded the misery.  A bullet in the head, chest or abdomen meant almost certain death.  A bullet in the limbs meant a twenty percent chance of death if the wound was cleaned and in most cases the limb amputated…

Stoicism seemed to be the watchword of the day.  There are accounts of soldiers singing, joking, and even smoking during an amputation.  People at this time were familiar with pain, and soldiers were expected to rise to the occasion. Recovery took place in the hospital, where, in some units, a soldier received half-rations and half-pay as an incentive to get well quickly.” (A)

“Military surgeons often resorted to so-called “heroic” treatments. Those treatments often seem crude and sometime barbaric to modern eyes. Bleeding, the deliberate opening of vein to remove blood from a patient, was thought to reduce blood volume and reduce fever and infection. Blistering, the practice of creating a skin infection on the patient, was thought to lead to pus that would carry away infection. Other physicians deliberately induced vomiting in an attempt to combat disease. Such practices were seldom helpful and often made the patient’s condition worse.

Among the items found in a surgeon’s medicine chest were opium and alcohol, useful for pain management, and quinine, found to be effective in treating malaria. But many drugs were either unhelpful or, in the case of the mercury used to treat syphilis, quite toxic.

Army medicine also suffered from some basic organizational shortcomings. The War Department was ill prepared when the conflict broke out in 1812. Officials had no standardized system of accounting for or replenishing its medical supplies, or for evaluating the competency and training of its medical staff.

But as the conflict wore on, army medicine improved noticeably. Congress created the post of surgeon general and outlined professional qualifications for selecting surgeons. In addition, the Congress attempted to improve cleanliness among soldiers through better camp sanitation, and tried to alleviate hospital overcrowding. Over time, the contents of the surgeon’s medicine chest became standardized, and a better system of hospitals emerged. Permanent hospitals were located well to the rear, away from the fighting, and linked to more mobile, “flying hospitals” closer to the front lines.

But in many ways, the most intractable problem remained the scientific unknowns. Solutions to the fundamental puzzles—the nature of disease, how it was transmitted, and how to prevent infection—remained several decades away. More often than not, army doctors found themselves groping in the dark for answers.” (B)

MEXICAN WAR

“Disease posed far greater threat than the battlefield. In addition to ubiquitous camp diseases like dysentery that had hounded Taylor’s army before it ever crossed the Rio Grande, the rainy season and its mosquito-borne malaria came directly on the heels of the city’s occupation and further compounded public health woes for all of Matamoros’ residents.[6] Smallpox, too, carried off its share of victims. Although all American soldiers were supposed to have been vaccinated against the disease upon entering the army, volunteers sometimes fell through the cracks in the rush to deploy troops, and one army surgeon complained his supply of the vaccine had been ruined by the Mexican heat.[7] Most to be feared was the deadly yellow fever, and with the help of correspondents on other battlefronts in Mexico and from coastal U.S. cities like New Orleans and Mobile, the bluntly titled English language newspaper The American Flag carefully tracked the fever’s progress throughout the Gulf of Mexico.[8]” (A)

To care for the many sick in General Taylor’s command, surgeons set up eight regimental hospitals, each sheltered in two or three large hospital tents, and a general hospital, housed in a large frame building in Corpus Christi. In the latter facility, those whose illness was likely to be prolonged joined the overflow of patients from the regimental hospitals. The medical staff manning these hospitals included the medical director for Taylor’s force, Presley H. Craig, Jarvis as director of the general hospital, a purveyor, and thirteen more department physicians. Three civilian doctors were hired until more Regular Army surgeons could be assigned to Taylor’s command..” (B)

“From the founding of the nation and throughout the first half of the 19th century, drugs were not regulated by the federal government. Problems with drug impurity were episodic, and when occurring, they were usually contained within a state or a region. The usual reaction to a case involving impure or bogus medicine was a call for reform at state houses with individual states instituting laws governing aspects of drug manufacture and trade, but these regulations were spotty at best. The situation changed during the MexicanAmerican War, which began in 1846 and ended in 1848…

Although the high death rate had many contributing factors from compromised food provision and poor living conditions to infectious diseases, public outrage focused on the medical care given to soldiers. It was concluded that adulterated drugs supplied to the Army had caused the large numbers of deaths among soldiers.

This enraged the public, and the outcry led Congress to pass the Drug Importation Act of 1848, the first federal drug law. It was very limited in scope and addressed only the purity of drugs imported into the United States. Congress charged Customs with enforcing the law. Special examiners were appointed at six major ports of entry—New York, Boston, Philadelphia, Baltimore, Charleston, and New Orleans. They checked the “quality, purity, and fitness for medical purposes” of imported drugs using the major  pharmacopoeias (publications describing drugs) and dispensatories for standards.” (C)

THE CIVIL WAR

 “Many of America’s modern medical accomplishments have their roots in the legacy of America’s defining war.”

“During the 1860s, doctors had yet to develop bacteriology and were generally ignorant of the causes of disease. Generally, Civil War doctors underwent two years of medical school, though some pursued more education. Medicine in the United States was woefully behind Europe. Harvard Medical School did not even own a single stethoscope or microscope until after the war. Most Civil War surgeons had never treated a gunshot wound and many had never performed surgery. Medical boards admitted many “quacks,” with little to no qualification. Yet, for the most part, the Civil War doctor (as understaffed, underqualified, and under-supplied as he was) did the best he could, muddling through the so-called “medical middle ages.” Some 10,000 surgeons served in the Union army and about 4,000 served in the Confederate. Medicine made significant gains during the course of the war. However, it was the tragedy of the era that medical knowledge of the 1860s had not yet encompassed the use of sterile dressings, antiseptic surgery, and the recognition of the importance of sanitation and hygiene. As a result, thousands died from diseases such as typhoid or dysentery…

Battlefield surgery…was also at best archaic. Doctors often took over houses, churches, schools, even barns for hospitals. The field hospital was located near the front lines — sometimes only a mile behind the lines — and was marked with (in the Federal Army from 1862 on) with a yellow flag with a green “H”. Anesthesia’s first recorded use was in 1846 and was commonly in use during the Civil War. In fact, there are 800,000 recorded cases of its use. Chloroform was the most common anesthetic, used in 75% of operations. ..A capable surgeon could amputate a limb in 10 minutes. Surgeons worked all night, with piles of limbs reaching four or five feet. Lack of water and time meant they did not wash off hands or instruments

Bloody fingers often were used as probes. Bloody knives were used as scalpels. Doctors operated in pus stained coats. Everything about Civil War surgery was septic. The antiseptic era and Lister’s pioneering works in medicine were in the future. Blood poisoning, sepsis or Pyemia (Pyemia meaning literally pus in the blood) was common and often very deadly…” (A)

“Early on, stretcher bearers were members of the regimental band, and many fled when the battle started. Soldiers acting as stretcher bearers rarely returned to the front lines. As the war evolved, stretcher bearers became part of the medical corps. At the battle of Antietam, there were 71 Union field hospitals. As the war went on, these were consolidated. There were ambulances here that were used to bring the wounded to temporary battlefield hospitals, which were larger, often under tents, and out of artillery range. Later in the war, patients were transported to large general hospitals by train or ship in urban centers. These did not exist when the war began. There was no military ambulance corps in the Union Army until August of 1862. Until that time, civilians drove the ambulances. Initially the ambulance corps was under the Quartermaster corps, which meant that ambulances were often commandeered to deliver supplies and ammunition to the front…

Large general hospitals were established by September of 1862 (11). These were in large cities, and soldiers were transported there by train or ship. At the end of the war, there were about 400 hospitals with about 400,000 beds. There were 2 million admissions to these hospitals with an overall mortality of 8%. In the South, the largest general hospital, Chimborazo, was in Richmond, Virginia. It was built out of tobacco crates on 40 acres. It contained five separate hospitals, each made up of 30 buildings. There were 150 wards with 40 to 60 patients per ward. The census was as high as 4000. They treated about 76,000 patients with a 9% mortality (12)…”  (B)

Most of the major medical advances of the Civil War were in organization and technique, rather than medical breakthroughs. In August of 1862, Jonathan Letterman, the Medical Director of the Army of the Potomac, created a highly-organized system of ambulances and trained stretcher bearers designed to evacuate the wounded as quickly as possible…

A system of triage was established that is still used today. The sheer number of wounded at some of the battles made triage necessary. In general, the wounded soldiers were divided into three groups: the slightly wounded, those “beyond hope”, and surgical cases. The surgical cases were dealt with first since they would be the most likely to benefit from immediate care. These included many of the men wounded in the extremities and some with head wounds that were considered treatable. The slightly wounded would be tended to next, their wounds were not considered life-threatening so they could wait until the first group was treated. Those beyond hope included most wounds to the trunk of the body and serious head wounds. The men would have been given morphine for pain and made as comfortable as possible…

Due to the sheer number of wounded patients the surgeons had to care for, surgical techniques and the management of traumatic wounds improved dramatically. Specialization became more commonplace during the war, and great strides were made in orthopedic medicine, plastic surgery, neurosurgery and prosthetics. Specialized hospitals were established, the most famous of which was set up in Atlanta, Georgia, by Dr. James Baxter Bean for treating maxillofacial injuries. General anesthesia was widely used in the war, helping it become acceptable to the public. Embalming the dead also became commonplace.

Medical technology and scientific knowledge have changed dramatically since the Civil War, but the basic principles of military health care remain the same. Location of medical personnel near the action, rapid evacuation of the wounded, and providing adequate supplies of medicines and equipment continue to be crucial in the goal of saving soldiers’ lives.” (C)

“Many misconceptions exist regarding medicine during the Civil War era, and this period is commonly referred to as the Middle Ages of American medicine. Medical care was heavily criticized in the press throughout the war. It was stated that surgery was often done without anesthesia, many unnecessary amputations were done, and that care was not state of the art for the times. None of these assertions is true. Actually, during the Civil War, there were many medical advances and discoveries..

Medical Use of quinine for the prevention of malaria

Use of quarantine, which virtually eliminated yellow fever

Successful treatment of hospital gangrene with bromine and isolation

Development of an ambulance system for evacuation of the wounded

Use of trains and boats to transport patients

Establishment of large general hospitals

Creation of specialty hospitals

Surgical Safe use of anesthetics

Performance of rudimentary neurosurgery

Development of techniques for arterial ligation

Performance of the first plastic surgery..”  (D)

SPANISH-AMERICAN WAR

“In the three decades between the Civil War and the Spanish-American War, virtually all practical experience of trauma medicine evaporated. Yet in those years, medicine advanced. The 1893 appointment of George Sternberg to Surgeon General allowed the rise of bacteriology and many other vogue advancements to be incorporated into trauma medicine. Additionally, the opening of 200 nursing schools across the United States kept attendant medical practitioners well-versed on germ theory and sterilization…

The Spanish-American War of 1898 was brief, with relatively few battle casualties, but epidemic disease, especially typhoid fever, devastated the volunteer troops. Post-war investigations and commissions generated better understanding of the problem of asymptomatic carriers and a series of recommendations that greatly improved military medicine. The new practices, including the development of a typhoid vaccine, saved thousands of lives during World War I. Studies that established the role of the mosquito in yellow fever spawned preventive measures that ended the huge epidemics of that disease in the Western Hemisphere; this in turn made possible successful construction of the Panama Canal…

New forms of surgical dressings especially designed for field use, composed of sterilized, sublimated, and iodoform gauze; sterilized gauze bandages, absorbent cotton, catgut, and silk, sterilized and packed in convenient envelopes; tow, compressed cotton sponges, and plaster of paris bandages were also prepared under the immediate supervision of this office…”  (A)

“Despite the lessons learned in the Civil War, the government had taken no concerted steps toward establishing a skilled nursing service to care for the sick and wounded during wartime…

The war with Spain was quickly demonstrating the important need for trained nurses as hastily constructed army camps for more than twenty-eight thousand members of the regular army were devastated by diarrhea, dysentery, typhoid fever, and malaria— all of which took a much greater toll than did enemy gunfire.

As a result of their work in the Civil War, religious sisters were recognized for providing skilled nursing services. In view of the urgent need for medical assistance in the summer of 1898, it was no surprise when the government called for every nursing sister who could be spared. Official government records indicated that the various orders furnished around 250 sister nurses, with the Daughters of Charity (originally referred to in the United States as Sisters of Charity), providing the majority of nurses.8 Although members of other orders were represented, their numbers were considerably less” (B)

World War I

Medicine, in World War I, made major advances in several directions. The war is better known as the first mass killing of the 20th century—with an estimated 10 million military deaths alone—but for the injured, doctors learned enough to vastly improve a soldier’s chances of survival. They went from amputation as the only solution, to being able to transport soldiers to hospital, to disinfect their wounds and to operate on them to repair the damage wrought by artillery. Ambulances, antiseptic, and anesthesia, three elements of medicine taken entirely for granted today, emerged from the depths of suffering in the First World War…

Antiseptics and anesthesia saved lives once they arrived at the hospital, but without motor ambulances and hospital trains to get them there, wounded soldiers stood little chance. From the impromptu rescue of soldiers from Meaux in September 1914, the American Ambulance Field Service grew to number more than 100 ambulances by the end of the first year of the war. Philanthropists such as Anne Harriman Vanderbilt bought cars, as did civic groups from cities around the United States. The Ford Motor Company donated 10 Model-T chassis to be converted into ambulances…

What inspired these major advances in medicine? There was a deep need, and people stepped up to find solutions. The new technology of war—heavy artillery, long-range cannons, barrage shelling, and machine guns—rained devastation at unprecedented levels. Medicine had to try to keep up. One good example of this evolution is in facial reconstruction surgery. Soldiers survived having jaws and noses shattered by artillery fragments, so surgeons at the American Hospital and Val-de-Grace Hospital pioneered maxillofacial techniques, and at the same time, brought dentistry into the medical sciences in France.”  (A)

“On the battlefields, physicians employed recently invented medical technology in addressing their patients’ injuries. The X-ray machine, which had been invented a couple decades before the war, was invaluable for doctors searching for bullets and shrapnel in their patients’ bodies. Marie Curie installed X-ray machines in cars and trucks, creating mobile imaging in the field. And a French radiologist named E.J. Hirtz, who worked with Curie, invented a compass that could be used in conjunction with X-ray photographs to pinpoint the location of foreign objects in the body. The advent of specialization within the medical profession in this era, and the advancement of technology helped to define those specialized roles.” (B)

WORLD WAR II

“Battlefield medicine evolved considerably between World War I and World War II. In the former, approximately 4 out of every 100 wounded men could expect to survive; in the latter, the rate improved to 50 out of 100…

A number of new drugs and medical techniques developed in the years between the world wars dramatically improved the survival rate among the sick and injured. For example, combat medics (and even men in the field) carried packets of sulfanilamide and sulfathiazole to coat wounds as a first line of defense against infection. Antibiotics such as streptomycin and penicillin also helped save the lives of countless soldiers…

American servicemen were also inoculated for a wide variety of diseases before being shipped overseas. The most common vaccinations were for smallpox, typhoid, and tetanus, though soldiers assigned totropical or extremely rural areas were also vaccinated for cholera, typhus, yellow fever, and, in somecases, bubonic plague.” (A)

“World War Two was a time where medicine began catching up with evolving technology.  In World War One infection took the lives of many soldiers along with disease.  The number of deaths from injury complications motivated scientists and doctors to determine cures for infection…  

One development was the creation of Penicillin.  It was created pre-war but was not used in large quantities till World War Two.  The first batches in 1939 were weak, but through determination a new version, 20 times more strong, came out in 1945 ().  On D-Day penicillin was used en masse, saving thousands of lives and strengthening America’s cause.  It saved many lives, but still left many to die because the time lapse between injury and treatment still remained very broad.  However, the number of people being infected was vastly decreased and survival chances were greatly increased…

The mediocre blood transfusion process was also greatly improved upon in World War Two.  Primitive techniques became more advanced, and the system of storing and distributing blood became more efficient.  With a better system of storing blood, blood was usually available when a soldier needed it.  The blood was also most likely fresher and less contaminated since the containers were better constructed.  However, blood was often in short supply.”  (B) 

“A major contribution of the 20th century was the widespread recognition and treatment of what we now call post-traumatic stress disorder, or PTSD. It has probably existed back into history. There are case reports from the Civil War, for example. During World War I, it was sometimes called “shell shock,” which probably included cases of actual brain damage. More often soldiers suffering from PTSD were diagnosed as “cowardice.” Soldiers were shot for it in the British, French, German, Austrian, and Russian armies. As the war dragged on, it became better recognized, but its treatment varied widely. The Russians tried to treat near the front lines, sending the soldiers back to their units as early as feasible. We adopted that practice, and in fact, armies today still treat psychiatric casualties this way. What may seem heartless, actually proved to be the most effective way to treat PTSD and to prevent long term sequelae. The recognition of PTSD as a psychiatric disease of war was not firmly established until World War II. They called it “combat fatigue.” But whatever they called it, they recognized it and treated it.” (C)

KOREAN WAR

“Though the Korean War came to be regarded as a failure by many because of its unsettled conclusion, in one area it was an unreserved success: the care and treatment of wounded soldiers. In World War II, the fatality rate for seriously wounded soldiers was 4.5 percent. In the Korean War, that number was cut almost in half, to 2.5 percent. That success is attributed to the combination of the Mobile Army Surgical Hospital, or MASH unit, and the aeromedical evacuation system – the casualty evacuation (casevac) and medical evacuation (medevac) helicopter. Both had been developed and used to a limited extent prior to 1950, but it was in the Korean War that both – particularly the helicopter – came into their own, and as Army Maj. William G. Howard wrote, “fundamentally changed the Army’s medical-evacuation doctrine.” Helicopter medevacs transported more than 20,000 casualties during the war. One pilot, 1st Lt. Joseph L. Bowler, set a record of 824 medical evacuations over a 10-month period. Another example tellingly highlights the impact of the helicopter. The Eighth Army surgeon estimated that of the 750 critically wounded soldiers evacuated on Feb. 20, 1951, half would have died if only ground transportation had been used…

The Korean War also provided an opportunity to study and test new equipment and procedures, many of which would go on to become standards of care in both the military and civilian medical communities. These included vascular reconstruction, the use of artificial kidneys, development of lightweight body armor, and research on the effects of extreme cold on the body, which led to development of better cold weather clothing and improved cold weather medical advice and treatment. The newest antibiotics were used widely, and other drugs that advanced medical care included the anticoagulant heparin, the sedative Nembutal, and the use of serum albumin and whole blood to treat shock cases. In addition, computerized data collection (in the form of computer punch cards) of the type of battle and non-battle casualties was used for the first time. The extensive detail and accessibility of this data allowed for the most thorough and comprehensive analysis of military medical information yet…” (A)

Medical professionals made significant changes to the way they treated injured troops during the Korean War, which led to fewer casualties as well as medical advancements for civilians. The war set the stage for how medical professionals treat trauma patients today.” (B)

VIETNAM

Both the Korean and Vietnam wars proved to be severe challenges to the medical system, the former for cold weather operations, and the latter for tropical and jungle warfare. The medical services gradually adapted to these challenges. By the time of the Vietnam war, for example, operations could be done in contained, air-conditioned operating theaters that were containerized so as to be moved close to the battlefield. (See Figure 6.) Helicopter evacuation supplemented ground ambulances, and air transport replaced hospital trains. The system of progressive levels of casualty care has turned into doctrine, and remains the guiding principle for casualty care. Operation during the 40 years since Vietnam have produced far fewer casualties, yet have challenged the military medical services in different ways. Small unit operations at greater and greater distances have increased reliance on medical corpsmen, who are now trained to at least the level of civilian Emergency Medical Technicians, and often higher. Casualty care and evacuation in a hostile civilian environment, always a problem in warfare, has been made more complex by opponents who refuse to respect the non-combatant status of medical facilities and personnel.” (A)

IRAQ and AFGHANISTAN

“In the Vietnam War, with its close quarters and heavy use of helicopters, the time between hurt and help averaged two hours but could be as little as 30 minutes. With the improved speed came a reduction in deaths among the wounded, from 8.5 percent in World War I to 1.7 percent in Vietnam.

In the Persian Gulf, “many of the wounded may have to be carried first by litter from the field, then by truck back to a station where helicopters may evacuate them to a surgical hospital,” General Blanck said. “It could take hours in some situations.” The Platoon Lifesaver

Because of potential delays, the military now gives all soldiers training in a few emergency medical techniques like clearing respiratory blockage. “A wounded soldier’s survival may depend on his buddy’s ability to initiate lifesaving care on the battlefield,” wrote Lieut. Col. James A. Martin, commander of the Army Medical Research Unit. “Each soldier should possess the skill to clear an airway, control bleeding and start an intravenous fluid line to control shock.”

Foot soldiers do not have that full training, but in many platoons, General Blanck said, one soldier has been trained and designated the lifesaver.

“We did not have this in Vietnam,” he said, “and it may really be needed in the kind of warfare we may have in the gulf.”

Other changes since the Vietnam War include new vaccines and treatments, including one for Hepatitis A and one to prevent septic shock from a sudden invasion of certain types of bacteria in people who are most seriously wounded. There are vaccines against local diseases, and one against anthrax to protect troops who may be targets of biological warfare.

Once they reach a hospital, soldiers will benefit from improved techniques to repair torn blood vessels and treat burns. CAT scanners will be available in the larger hospitals of each corps, General Blanck said. Heat Is a Serious Factor”  (A)

“Injured veterans of the Iraq and Afghanistan Wars can give credit to the medical personnel of earlier wars, including the Vietnam War, for their care and recovery.

Surgeons, anesthesiologists, nurses, and other staff advanced medical practices for soldiers receiving care in the areas of trauma care and blood supply, repair of blood vessels to save limbs, and studying the effects of a range of weapons.

The contributions of medical personnel improved the outcomes of those wounded not only in Vietnam, but also subsequent wars.

A technique in trauma care in the use of topical antimicrobial chemotherapy for the care of burns and other wounds was available for the first time in the theater of operations.

Another practice that evolved during the Vietnam War was the use of universal donor, or Type O, blood banks in various stations throughout Vietnam.

Techniques that were developed during World War II and the Korean War greatly reduced the need for amputations in the field by tying the major artery to the affected limb.

The improvements in emergency responses and trauma care techniques that were developed during the Vietnam War are still relevant now.” (B)

“DRONES”

 “The Navy corpsman was overwhelmed. Dozens of Marines lay injured at the casualty collection point following a devastating artillery bombardment—and the corpsman didn’t have nearly enough to blood at hand to treat them all.

A soldier’s odds of survival increase nearly threefold if they receive a blood transfusion within an hour of being injured. Unfortunately, the Medical Battalion’s field hospital and its copious blood supplies was over a dozen miles away. With the combat zone interdicted by enemy fire, the odds that medical supplies or evacuation would arrive anytime soon looked grim.

Hastily, the corpsman transmits a map coordinate and a brief request.

Fifteen minutes later, a swarm of drones comes swooping down at over a miles per minute. Hatches in their bellies flip open, releasing not bombs but small boxes which come floating down near the collection point using paper parachutes.

Inside each box is some bubble wrap—and three units of blood ready for transfusion.

Overhead, the drones bank around and soar back to the medical battalion and glide towards a large trapeze-like contraption on the ground. Precise maneuvers allow a hook on the drone’s tail to snag onto the trapeze, bringing the unmmaned aircraft to a halt.

As the drones are recovered, staff swap out their spent lithium-ion batteries for recharging, replacing them with fresh batteries—and new cargo boxes in their bellies.

In a few minutes, the drones are ready to deliver even more life-preserving blood products.

The above battle may never have happened—but it was simulated in a series of exercise in Australia involving a U.S. Marine Corps Air-Ground Taskforce, the Australian Defense Force…and a gaggle of forward-deployed commercial drones.” (A)

(A).Will Blood-Bearing Delivery Drones Transform Disaster Relief and Battlefield Medicine?, by Sebastien Roblin,  https://www.forbes.com/sites/sebastienroblin/2019/10/22/will-blood-bearing-delivery-drones–transform-disaster-relief-and-battlefield-medicine/#4e4ddb506252

ROBOTIC SURGERY“U.S. Army physicians, located far from a field hospital, could soon be performing delicate, highly specialized surgery on wounded soldiers using robotics and other forms of telemedicine.

Army Surgeon General Lt. Gen. Nadja West said recently that the demands of future battlefields will force the military medical community to prepare for operational environments that are vastly different.

“We might not have the life-saving ‘golden hour’ evacuation system we have been accustomed to for the past 17 years,” West told an audience recently at an Association of the United States Army function.

“Our soldiers may be isolated for 72 hours or more, requiring prolonged field care if injured in an austere environment,” she said.

Enemy air superiority may not allow the U.S. military to fly critically wounded soldiers to well-equipped hospitals in far-off countries, so field hospitals may have to rely on new, robotic technology to save patients, West added.

Robotic surgery, which is currently used in non-invasive procedures, could be adapted to meet the Army’s battlefield needs, she said.

“There is robotic surgery that’s going on right now,” West said, adding that the challenge will be “how quickly we can scale it all throughout our enterprise.” (A)

** https://www.brainyquote.com/quotes/douglas_macarthur_125212

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PART 2. “Massachusetts Surgeons will have to document each time they enter and leave the operating room, and who took over in their absence… amid controversies over doctors who perform more than one surgery at a time…

Over twenty years ago a general surgeon at one of our community hospitals left the OR to operate at a competing hospital and told a nurse to close the incision. He claimed OR nurses could train and be certified as “closers”. Problem was the nurse hadn’t been certified and we did not have hospital privileges for this competency. The nurse was fired and the surgeon fought disciplinary action although up to the Board of Trustees. Recollection is that he had been suspended from the medical staff, by me for over six months and that became his penalty as well as a long period of probation.

There are many areas in the hospital where it may be hard for a patient to discern who is actually providing care: an attending or a resident? An anesthesiologist or a nurse anesthetist? an orthopedic (foot) surgeon or a podiatrist for ankle surgery?; a primary care physician or a nurse practitioner?

PART 1 before new Part 2.

ASSIGNMENT: You are the CMO of your local teaching and the CEO wants to know if you should prohibit double-booking? And you are instructed to make sure patients know who is treating them, so what do you do?

PART 1. December 5, 2017. Should surgeons be allowed to operate in more than one OR at a time?

“Dr. Kirkham Wood arrived in the operating room at Massachusetts General Hospital before 7 one August morning with a schedule for the day that would give many surgeons pause.

Wood, chief of MGH’s orthopedic spine service at the time and a nationally renowned practitioner in his specialty, is a confident, veteran surgeon. He would need all of his talent and confidence this day, and then some, as he planned to tackle two complicated spinal surgeries over the next many hours — two patients, two operating rooms, moving back and forth from one to the other, focusing on the challenging tasks that demanded his special skills, leaving the other work to a general surgeon, who assisted briefly, and two surgeons in training.

In medicine it is called concurrent surgery, and the practice is hardly unique to Wood or MGH. It is allowed in some form at many prestigious hospitals, limited or banned at many others. Hospitals that permit double-booking consider it an efficient way to deploy the talents of their most in-demand specialists while reducing wasted operating room time.” (A)

‘Known as “running two rooms” – or double-booked, simultaneous or concurrent surgery – the practice occurs in teaching hospitals where senior attending surgeons delegate trainees – usually residents or fellows – to perform parts of one surgery while the attending surgeon works on a second patient in another operating room. Sometimes senior surgeons aren’t even in the OR, but are seeing patients elsewhere.

The decision about whether to allow the practice is left to hospitals, which are primarily responsible for policing it. Medicare billing rules permit it as long as the attending surgeon is present during the critical portion of each operation – and that portion is defined by the surgeon. And while it occurs in many specialties, double-booking is believed to be most common in orthopedics, cardiac surgery and neurosurgery.”  (B)

American College of Surgeons – Overlapping Operations- Statements on Principles (C)

“Overlap of two distinct operations by the primary attending surgeon occurs in two general circumstances.

The first and most common scenario is when the key or critical elements of the first operation have been completed, and there is no reasonable expectation that the primary attending surgeon will need to return to that operation. In this circumstance, a second operation is started in another operating room while a qualified practitioner performs noncritical components of the first operation—for example, wound closure—allowing the primary surgeon to initiate the second operation. In this situation, a qualified practitioner must be physically present in the operating room of the first operation.

The second and less common scenario is when the key or critical elements of the first operation have been completed and the primary attending surgeon is performing key or critical portions of a second operation in another room. In this scenario, the primary attending surgeon must assign immediate availability in the first operating room to another attending surgeon.

The patient needs to be informed in either of these circumstances. The performance of overlapping procedures should not negatively affect the seamless and timely flow of either procedure.””

“The Centers for Medicare and Medicaid Services does allow surgeons to bill for concurrent surgeries under certain circumstances but requires that the attending physician is “present during all critical and key portions of both operations.”

Surgeon Matthew Indeck, president of the American College of Surgeons’ central Pennsylvania chapter, said he “certainly would not support

[concurrent]

cases being done in distant hospitals” or keeping a patient under anesthesia longer than necessary.

But he acknowledged that a line delineating what’s appropriate and what isn’t “is very fuzzy.”” (D)

“……transparency and patient consent. Wrong is the only way to describe the fact that secretaries, nurses, anesthesiologists, residents, and fellows knew but the patient did not. If you defend double-booking, tell the patient. Sometimes I wonder why doctors don’t see themselves as patients. To us, the experienced professional, medical, and surgical practice is rote. It’s hardly so to the person being wheeled onto a narrow table on which they will be cut open. Would any surgeon-patient consent to this practice?” (E)

“Swedish Health has decided to largely prohibit its doctors from conducting overlapping surgeries, responding to the concerns of patients who were troubled by the practice…

Under the new policy, implemented Monday, surgeons must be present for the “substantial majority” of each surgical procedure. They are not required to be present for the very end of the case — closing the surgical incision once the planned procedure is completed — as that can be delegated to a qualified fellow assisting on the case.

Some smaller aspects at the beginning of a surgery, such as the harvesting of healthy blood vessels that would later be used in a coronary-artery bypass surgery, can also be delegated while the attending surgeon is out of the room, according to the policy. There is also flexibility for unexpected emergencies.

Staff will document the times surgeons enter and exit the operating room — something that didn’t previously appear in the records of many surgical patients.” (F)

“Patients whose hip surgeries were performed by surgeons overseeing two operations at once were nearly twice as likely to suffer serious complications as those whose doctors focused on one patient at a time, according to a large Canadian study, the first research to show that overlapping surgery can pose health risks.

The study of more than 90,000 hip operations at some 75 hospitals in Ontario also found that the longer the duration of overlap between surgeries, the more likely patients were to suffer a serious complication within a year, including infections and a need for follow-up surgery.

“If your surgeon is in multiple places, there’s an increased risk of having a complication,” Dr. Bheeshma Ravi, a hip surgeon at Sunnybrook Health Sciences Centre in Toronto and lead author of the study to be published Monday in JAMA Internal Medicine, told the Globe. “I think that just makes sense.”” (G)

PART 2. July 29, 2019

“Surgeons will have to document each time they enter and leave the operating room, and who took over in their absence, under a rule approved Wednesday by the (Massachusettes) state medical board amid controversies over doctors who perform more than one surgery at a time…

Massachusetts is the first state to approve such requirements, according to board members. A spokesman for the Federation of State Medical Boards, which represents the nation’s 70 state medical and osteopathic regulatory boards, said it was unaware of any other states with similar regulations… (A)

“Beginning next month, all surgeons in Massachusetts will be required to document every time they enter or leave the operating room, and for how long, for any reason. That’s according to a new rule passed Wednesday by the Massachusetts Board of Registration in Medicine. Along with documenting their entry or exit, surgeons will also be required to identify the names of any participating “physician extenders” including residents, fellows, and physicians assistants…

Candace Lapidus Sloane, chairwoman of the medical board, told The Globe, “As a doctor and as a patient, I know that when you undergo a serious surgery, or your loved one undergoes a serious surgery, you find the best doctor you can. You’re going there for that surgeon’s skill. And if it’s not going to be that surgeon [who actually does the operation], the patient has a right to know.” Basically, it comes down to getting what you’re paying for, right?

The only opposition to the rule, as stated by The Globe, was from the Massachusetts Medical Society which deemed it too hard to identify all “physician extenders” because, especially at teaching hospitals, things can switch in an instant. But at that point, the patient should be informed and it should be their prerogative to move forward with the procedure or not.” (B)

“The issue was catapulted into public consciousness in October 2015 by an exhaustive investigation of concurrent surgery at Harvard’s famed Massachusetts General Hospital by The Boston Globe. The validity of the story has been vehemently disputed by hospital officials who defend their care as safe and appropriate…

Patients who signed standard consent forms said they were not told their surgeries were double-booked; some said they would never have agreed had they known…

Critics of the practice, who include some surgeons and patient-safety advocates, say that double-booking adds unnecessary risk, erodes trust and primarily enriches specialists. Surgery, they say, is not piecework and cannot be scheduled like trains: Unexpected complications are not uncommon.

All patients “deserve the sole and undivided attention of the surgeon, and that trumps all other considerations,” said Michael Mulholland, chair of surgery at the University of Michigan Health System, which halted ­double-booking a decade ago. Surgeons might leave the room when a patient’s incision is being closed, Mulholland said. A computerized system records the doctor’s entry and exit…

Some surgeons say they are troubled by the resemblance of double-booking to a practice known as “ghost surgery,” in which patients learn, usually after something goes wrong, that someone other than the surgeon they hired performed their operation…

Rickert and others advise patients who want to avoid overlap to ask detailed questions well in advance and to put their request in writing and on the consent form.

“If you say, ‘I want only you to do the surgery,’ doctors will typically do it,’” Rickert said. “They want the business.”

He also recommends asking, “Are you going to be in the room the entire time during my surgery?” and then repeating that statement in front of the OR nurses the day of surgery. “If the doctor’s not willing to say yes, vote with your feet.”

If a surgeon says he or she will be “present” or “immediately available,” a patient should ask what that means. It may mean that the surgeon is somewhere on a sprawling hospital campus but not in — or even near — your operating room. (C)

“I certainly knew that for many procedures, residents might be involved,” said Arthur Caplan, a professor of bioethics at NYU School of Medicine. (NYU Langone Medical Center does not permit concurrent surgery.) “But I was a little taken aback that the attending surgeon was not in the room.” (D)

“A recent trial resulting in a $2 million malpractice verdict pulled back the curtain on a Syracuse orthopedic surgeon’s routine of doing 14 operations in a single day.

A state Supreme Court jury in Syracuse unanimously found Dr. Brett Greenky and his practice, Syracuse Orthopedic Specialists, negligent July 2 for his handling of a hip replacement surgery performed six years ago. The lawsuit says the operation permanently injured Dorothy G. Murphy, 63, who is still limping, using a cane and in pain. She is a former Camillus resident who now lives in Florida.

The trial shined a light on a controversial hospital practice in which a doctor leaves the operating room after completing the most critical part of an operation to start surgery on another patient in a second room.

Murphy was the sixth of Greenky’s 14 patients on Sept. 9, 2013 at St. Joseph’s Hospital Health Center…

During the trial Robert Lahm, Murphy’s attorney, likened Greenky’s surgical approach to an “assembly line.” A copy of Greenky’s schedule for that day shows most of the operations were total knee and hip replacements.

Patients were staggered across two operating rooms. Greenky would cut open a patient, put in an implant, close up part of the incision, then leave before the operation was over to start surgery on another anesthetized patient in a second room. Meanwhile, a resident physician in training or physician assistant closed the previous patient’s wound and applied a dressing.

Sometimes Greenky does overlapping surgery in three operating rooms. In a deposition, he said he performs about 600 knee and hip replacements annually and each operation takes, on average, 45 minutes…

Murphy said she cannot understand why surgeons performing complex operations are allowed to work more than 14 hours a day when bus drivers are prohibited by federal regulations from driving more than 10 hours.” (E)

“A judge has ordered Massachusetts General Hospital to release a secret 2011 report written by a lawyer whom the hospital hired to investigate its practice of letting some surgeons oversee more than one operation at a time.

Suffolk Superior Court Judge Rosemary Connolly said that — pending a possible appeal — the hospital must share an unredacted copy of the report with an orthopedic surgeon fired by Mass. General in 2015 after he complained about concurrent surgeries…

Burke, who now practices at Beth Israel Deaconess Hospital in Milton, worked for Mass. General for 35 years until he was dismissed in August 2015. The hospital said he was fired for improperly releasing patient records, with names redacted, to the Globe. Burke contends he was sacked because he blew the whistle on what he considered a serious patient-safety issue.

In 2011, the hospital hired a former US attorney, Donald Stern, to investigate Burke’s complaints to Mass. General officials about concurrent surgeries, also known as double-booking. The hospital never made the report public, but Dr. Peter Slavin, the hospital’s president, told the Globe in 2015 that Stern “found no basis to support Dr. Burke’s concerns.”

Burke’s attorneys have repeatedly requested the report. But Mass. General’s lawyers have insisted it contains legal advice from Stern to the hospital and is protected by attorney-client privilege.

The judge rejected that argument. She said Mass. General hired Stern to conduct an internal review, not to provide legal advice. She also noted that the hospital shared the report with a public relations firm, Rasky Baerlein Strategic Communications, which it hired to respond to the Globe’s inquiries.

And, the judge wrote, the hospital allowed the report to be stored on a computer server at Simmons College, which employed a dean who headed Mass. General’s Board of Trustees.

“MGH has used the report as both sword and shield,” Connolly wrote.

“The mounting evidence all leads to the conclusion that even if sections of the Stern report were once privileged, they no longer are,” she continued.

In addition to ordering the hospital to turn over the report, the judge directed it to provide all drafts of the document and backup materials.

Ellen J. Zucker, Burke’s lead counsel, was pleased. “In the end, based on MGH’s own words and conduct, this is not a close call,” Zucker said.

A hospital spokeswoman declined to comment.” (F)

Prequels

Every clinician with a doctoral degree has earned the respect to be called doctor.

Do you want to be treated by a stranger when you are admitted to the hospital? Every practicing physician should have hospital privileges.

Have you met your interventional pathologist or interventional neurologist or interventional oncologist?

It’s like the Wild, Wild West, the (physician specialty) turf wars….

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