“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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“A SEVERE FLU PANDEMIC… could kill more than 33 million people worldwide in just 250 days.” – “Boy, do we not have our act together.” — Bill Gates”. (J)

“It’s never an easy business to predict which flu viruses will make people sick the following winter. And there’s reason to believe two of the four choices made last winter for this upcoming season’s vaccine could be off the mark.”

“Flu circulation “remains difficult to predict and flu viruses are constantly breaking rules that we try to establish for them,”..”

 “No battle plan survives contact with the enemy” * 

Worth reading:

The Next Plague Is Coming. Is America Ready?, by Ed Yong

https://www.theatlantic.com/magazine/archive/2018/07/when-the-next-plague-hits/561734/

ASSIGNMENT: Does your community have a seasonal flu EMERGENCY RESPONSE PLAN? Do your community’s hospitals have SURGE CAPACITY  and RAPID RESPONSE TEAMS? If not, develop a plan!

HOBOKEN CASE STUDY

In July of 2009 the Mayor of Hoboken asked me to organize a H1N1 “Swine Flu” Task Force. We started with a set of questions based on reports from communities that had already experienced a Swine Flu surge:

Health Officer: Where vaccination sites should be established? Is there a special plan to monitor restaurants and food shops where flu-related safety guidelines need to be strictly enforced? Who will start preparing a Community Education plan?

Hospital: What is the back-up plan if hospital becomes “contaminated” and is closed to admissions, or if nursing staff is depleted by flu-related absenteeism, etc.? ICU triage? Availability of respirators?

OEM:  off-site screening centers if hospital ER is on overload

Hoboken Volunteer Ambulance Corps:  “mutual assist” plan

Hoboken Police Department & Hoboken Fire Department: back-up plan if the ranks get depleted by the flu

BOE: criteria in deciding whether or not to close schools

Stevens Institute of Technology: surveillance and plan for (college) students

“Field Manual” for the Mayor outlining all variabilities and options

Why was there no swine flu surge in NJ/ NYC metro area? maybe “herd” immunity” from prior year’s flu?

“Australia had an unusually early and fairly severe flu season this year. Since that may foretell a serious outbreak on its way in the United States, public health experts now are urging Americans to get their flu shots as soon as possible.

“It’s too early to tell for sure, because sometimes Australia is predictive and sometimes it’s not,” said Dr. Daniel B. Jernigan, director of the influenza division of the Centers for Disease Control and Prevention. “But the best move is to get the vaccine right now.”..

In 2017, Australia suffered its worst outbreak in the 20 years since modern surveillance techniques were adopted. The 2017-2018 flu season in the United States, which followed six months later as winter came to the Northern Hemisphere, was one of the worst in modern American memory, with an estimated 79,000 dead.” (A)

“Maryland health officials on Tuesday confirmed the first 11 influenza cases of the flu season. Officials urge Marylanders to get vaccinated.

“We don’t know yet whether flu activity this early indicates a particularly bad season on the horizon,” Maryland Department of Health Secretary Robert R. Neall said in a statement. “Still, we can’t emphasize strongly enough – get your flu shot now. Don’t put it off. The vaccine is widely available at grocery stores, pharmacies and local health clinics, in addition to your doctor’s office.”

Most of the 11 cases recorded since Sept. 1 have been subtyped as influenza A, with a few classified as influenza B. Though most influenza cases are mild, the virus can pose a serious risk for young children, seniors, pregnant women and people with compromised immune systems.

During last year’s flu season, 3,274 people were hospitalized and 82 died as a result of the flu in Maryland, according to state health officials.” (B)

“The first pediatric influenza-associated death of the 2019-20 flu season has been reported in California. According to a statement issued by Riverside University Health System a 4-year-old child who tested positive for the flu and had underlying health issues passed away from his illness.

According to the US Centers for Disease Control and Prevention (CDC) a total of 130 influenza-associated pediatric deaths were reported during the 2018-19 flu season. This number was a decrease from the 187 pediatric deaths reported during the 2017-18 season.

CDC investigators hypothesize that the real-world impact of the flu is being underreported. “Using mathematical modeling to account for under-detection, CDC estimates that the actual number of flu-related deaths in children during [the 2017-18] season was closer to 600—nearly 3 times what was reported through existing mechanisms,” the authors of a recent report wrote in a flu spotlight.

Cameron Kaiser, MD, public health officer of Riverside County, says that this early season death could be predictive of a severe flu season.” (C)

“The overall effectiveness of last flu season’s vaccine was only 29% because it didn’t protect against a flu virus that appeared later in the season, according to the U.S. Centers for Disease Control and Prevention.

It said the vaccine was 47% effective into February, but that dropped to just 9% after the late strain showed up, the Associated Press reported.

Flu vaccines are created each year to protect against flu strains predicted to be circulating in the upcoming season.

The effectiveness of last season’s vaccine was the second lowest since 2011. The vaccine for the 2014-15 flu season was only 19% effective, the AP reported.” (D)

It’s never an easy business to predict which flu viruses will make people sick the following winter. And there’s reason to believe two of the four choices made last winter for this upcoming season’s vaccine could be off the mark.

Twice a year influenza experts meet at the World Health Organization to pore over surveillance data provided by countries around the world to try to predict which strains are becoming the most dominant. The Northern Hemisphere strain selection meeting is held in late February; the Southern Hemisphere meeting occurs in late September.

The selections that officials made…for the next Southern Hemisphere vaccine suggest that two of four viruses in the Northern Hemisphere vaccine that doctors and pharmacies are now pressing people to get may not be optimally protective this winter. Those two are influenza A/H3N2 and the influenza B/Victoria virus…

Flu vaccine is a four-in-one or a three-in-one shot that protects against both influenza A viruses — H3N2 and H1N1 — and either both or one of the influenza B viruses, B/Victoria and B/Yamagata. Most flu vaccine is made with killed viruses, and most vaccine used in the United States is quadrivalent — four-in-one…

Flu circulation “remains difficult to predict and flu viruses are constantly breaking rules that we try to establish for them,” Hensley said, adding that flu vaccines “often protect against severe disease even when … mismatched.” (E)

“A shortage of high dose flu shots is concerning some older adults.

The Vanderburgh County Health Department says people older than 65 are recommended to take a high dose flu shot.

Director of Clinical Outreach, Lynn Herr, says there is an option rather than not getting the shot at all.

“Then we need to have a conversation with our primary caregiver saying go ahead and get the regular or go ahead and wait for the higher dose flu shot.”

According to the CDC, the high dose vaccine helps people 65 years or older have a better fight against the flu.

This shot contains four times the antigen than a regular flu shot.” (F)

“DEFINITION OF EMERGENCY RESPONSE

 What Are “Emergencies”? Emergencies are incidents that threaten public safety, health and welfare.  If severe or prolonged, they can exceed the capacity of first responders, local fire fighters or law enforcement officials.  Such incidents range widely in size, location, cause, and effect, but nearly all have an environmental component.” (G) 

Medical surge capacity refers to the ability to evaluate and care for a markedly increased volume of patients—one that challenges or exceeds normal operating capacity. The surge requirements may extend beyond direct patient care to include such tasks as extensive laboratory studies or epidemiological investigations.

Because of its relation to patient volume, most current initiatives to address surge capacity focus on identifying adequate numbers of hospital beds, personnel, pharmaceuticals, supplies, and equipment. The problem with this approach is that the necessary standby quantity of each critical asset depends on the systems and processes that:

Identify the medical need

Identify the resources to address the need in a timely manner

Move the resources expeditiously to locations of patient need (as applicable)

Manage and support the resources to their absolute maximum capacity.

In other words, fewer standby resources are necessary if systems are in place to maximize the abilities of existing operational resources. Moreover, the integration of additional resources (whether standby, mutual aid, State or Federal aid) is difficult without adequate management systems. Thus, medical surge capacity is primarily about the systems and processes that influence specific asset quantity.

Basic example: If a hospital wishes to have the capacity to medically manage 10 additional patients on respirators, it could buy, store, and maintain 10 respirators. This would provide an important component of that capacity (other critical care equipment and staff would also be needed), but it would also be very expensive for the facility. If the hospital establishes a mutual aid and/or cooperative agreement with regional hospitals, it might be able to rely on neighboring hospitals to loan respirators and credentialed staff and, therefore, might need to invest in only a few standby items (e.g., extra critical care beds), minimizing purchase and maintenance of expensive equipment that generate no income except during rare emergency situations.”  (H)

Today, Rapid Response Teams (RRTs) are a crucial component of many hospitals.  Implementing a RRT was one of the six strategies that defined the Institute for Healthcare Improvement (IHI) 100,000 Lives campaign.  Most RRTs consist of critical care nurses, but they can also include respiratory therapists, pharmacists, and physicians.

Research consistently shows that patients exhibit signs and symptoms of deterioration for several hours prior to a code.  These symptoms include changes in vital signs, mental status, and lab markers. The goal of a RRT is to intervene upstream from a potential code.  They reach the patient before deterioration turns into crisis.  This is different than a code blue team that typically responds to a patient that has already decompensated to cardiac arrest.

Historically, most hospitals relied on busy bedside nurses to identify crashing patients and call for rapid response.  With 49 states having no limits on the number of patients assigned per nurse, many medical-surgical ward nurses are caring for 6 or more patients per shift.  Placing this additional responsibility on their already over-flowing plate is challenging at best.  Providing a RRT empowers bedside nurses to trigger an escalation of care earlier and faster. (I)

“… even the U.S. is disturbingly vulnerable—and in some respects is becoming quickly more so. It depends on a just-in-time medical economy, in which stockpiles are limited and even key items are made to order. Most of the intravenous bags used in the country are manufactured in Puerto Rico, so when Hurricane Maria devastated the island last September, the bags fell in short supply. Some hospitals were forced to inject saline with syringes—and so syringe supplies started running low too. The most common lifesaving drugs all depend on long supply chains that include India and China—chains that would likely break in a severe pandemic. “Each year, the system gets leaner and leaner,” says Michael Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “It doesn’t take much of a hiccup anymore to challenge it.”” (J)

“One hundred years ago, in 1918, a strain of H1N1 flu swept the world. It might have originated in Haskell County, Kansas, or in France or China—but soon it was everywhere. In two years, it killed as many as 100 million people—5 percent of the world’s population, and far more than the number who died in World War I. It killed not just the very young, old, and sick, but also the strong and fit, bringing them down through their own violent immune responses. It killed so quickly that hospitals ran out of beds, cities ran out of coffins, and coroners could not meet the demand for death certificates. It lowered Americans’ life expectancy by more than a decade. “The flu resculpted human populations more radically than anything since the Black Death,” Laura Spinney wrote in Pale Rider, her 2017 book about the pandemic. It was one of the deadliest natural disasters in history—a potent reminder of the threat posed by disease.” (K)

To receive email updates about Seasonal Flu, enter your email address at:

https://www.cdc.gov/flu/weekly/fluactivitysurv.htm

fluupdate@WHO.INT.

https://www.who.int/influenza/surveillance_monitoring/updates/latest_update_GIP_surveillance/en/

Flu Near You https://flunearyou.org/#!/

Everyday Health Flu Map https://www.everydayhealth.com/flu/map/

PREQUELS

PANDEMIC PREPAREDNESS. “It’s like a chain—one weak link and the whole thing falls apart. You need no weak links.”

Tomorrow morning’s Emergency Preparedness meeting (just scheduled for 8AM)

“We are arguably as vulnerable—or more vulnerable—to another (flu) pandemic as we were in 1918.”

“..in a severe (flu) pandemic, the U.S. healthcare system could be overwhelmed in just weeks.

“Think hospitals are under a strain now, from a slightly bad flu season? Wait until a really bad one hits.”

In the ICU at Massachusetts General Hospital, nurses use Gatorade to combat flu-related dehydration (due to shortages of intravenous fluids)

The CDC postponed its briefing on preparation for nuclear war and will focus on responding to severe influenza

______________________

* Helmuth von Moltke the Elder.

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PART 4. New Jersey. “..heart transplant center, inflated survival rates to keep its funding — keeping a brain-dead patient on life support until he hit a one-year survival benchmark..”

When I started as President & CEO of Jersey City Medical Center in 1989, New Jersey had a comprehensive Certificate of Need process. When the state awarded a “CN” funding followed through the all payor reimbursement system then in place.

Over time JCMC was designated as: a Regional Perinatal Center; Level II Trauma Center; Teaching Hospital Cancer Program; a Children’s Hospital; and approved to start cardiac surgery/ interventional cardiology. With these programs JCMC became a major teaching affiliate of Mount Sinai School of Medicine and a total replacement hospital was opened on a new site in 2004.

The pediatric cardiac surgery problems at Johns Hopkins All Children’s Hospital and North Carolina Children’s Hospital are due, in part, to the disappearance of most state CON regulations resulting in hospitals opening “trophy” services that lead to low volume programs. Funding becomes a challenge.

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?

After New PART 4 are excerpts from Parts 1-3, as well as an unabridged chronology.

PART 4. Johns Hopkins All Children’s Hospital and North Carolina Children’s Hospital pediatric cardiac surgery programs at “crossroads.”

“The hospital that calls itself New Jersey’s premier heart transplant center, Newark Beth Israel, inflated survival rates to keep its funding — in at least one instance by keeping a brain-dead patient on life support until he hit a one-year survival benchmark, startling new reporting revealed.

Family members were never told that Navy veteran Darryl Young was in an irreversible vegetative state after his heart transplant last year, and staff never offered hospice, other palliative care services or a Do Not Resuscitate directive, ProPublica revealed.

Meanwhile, behind the scenes, doctors were secretly recorded discussing how Young needed to be aggressively cared for despite their belief that he would never wake up or recover function, the ProPublica report said.” (H)

 “The North Carolina Children’s Hospital got a bit of good news last week from a state agency that sent a team of investigators on-site for 11 days of questioning and review of the pediatric heart surgery program.

The state Department of Health and Human Services says the program currently is in compliance with U.S. Centers for Medicare and Medicaid Services requirements…

An external review board was tapped to evaluate the program and new Quality and Safety reporting procedures were put in place.

The external review board has had one telephone conference meeting, according to Alan Wolf, a spokesman for the health care system, and has plans to meet in person soon.

Despite the state health department’s findings, the UNC Health Care system has no plans to schedule those types of surgeries before the external review is complete, according to Wolf.” (A)

“The families of two children who were paralyzed after heart surgeries at Johns Hopkins All Children’s Hospital will receive $26 million and $12.75 million in settlements with the hospital, state records show.

Although the identities of the children are not public, the records describing their cases match two of the patients featured in a Tampa Bay Times investigation into the hospital’s troubled heart unit. Both families were struggling with the costs of caring for a permanently disabled child with no relief in sight.

A third family that lost a child after heart surgery will receive $750,000…

In June, Johns Hopkins Health System CEO Kevin Sowers told the Times that he and hospital leaders had reached out to the families of children who died or were injured in the hospital’s heart surgery unit.

“We made a mistake, and we need to make sure we help support these families and make it right,” he said…  (B)

“UNC Hospitals in Chapel Hill is on probation after the system received preliminary denial of its accreditation.

Preliminary Denial of Accreditation is recommended when there’s an immediate threat to health and safety, a submission of falsified documents or misrepresented information, a lack of a required license, or significant noncompliance with Joint Commission standards, according to the Joint Commission..

“To be clear: There was no finding of any immediate threats to patient health and safety,” UNC Health Care spokesman Alan Wolf said in an email.

The Joint Commission recently conducted the triennial accreditation survey, when surveyors examined the main hospital in Chapel Hill.

UNC Health Care credited the slide in accreditation to new standards by the Joint Commission. The hospital will remain on preliminary denial of accreditation status until the hospital undergoes a new survey and satisfies the requirements.

The hospital network says it has already put plans in place to fix each problematic area…

UNC Health Care said the Joint Commission accepted its plans of correction, and expects the validation survey to take place next week.” (C)

UNC Hospitals is one step closer to regaining its clean reputation, but concerns remain.

After completing follow-up inspections, the Joint Commission lifted its preliminary denial of UNC Hospitals’ accreditation and upgraded the hospital to “accreditation with a follow-up survey.”

UNC Hospitals was originally placed on probation because it failed to meet the suicide prevention standards of the Joint Commission…

Most of the serious problems revolved around the treatment of mental health patients, particularly those at risk for suicide attempts or for being abused and exploited. The Joint Commission demanded better management of ligature risks — places where a patient could hang or choke themselves — and better identification of potential victims of abuse.

The Joint Commission only recommends Preliminary Denial of Accreditation when there’s an immediate threat to health and safety, a submission of falsified documents or misrepresented information, a lack of a required license, or significant noncompliance with Joint Commission standards…

The clean bill of accreditation means the Joint Commission is satisfied with UNC Hospitals’ response to its performance issues. But the hospitals will probably face added scrutiny.”  (D)

A North Carolina children’s hospital that stopped performing complex heart surgeries in recent months after high death rates were disclosed may now resume the procedures, according to an advisory board that was examining the hospital’s practices.

The board noted “significant investment and progress” had been made at North Carolina Children’s Hospital while suggesting areas for improvement, including increasing the number of surgeries performed, a factor associated with better outcomes.

The external board made its recommendations in a six-page report released on Tuesday by UNC Health Care, which runs the hospital and is affiliated with the University of North Carolina…..

The advisory board did not seem to address conditions at the hospital when doctors voiced concerns several years ago, but noted that “team dynamics and interactions appear to be strong.” Recommendations it made to the hospital’s board of directors included continuing to publicly report mortality data; hiring a second full-time pediatric heart surgeon; and considering a joint venture with another hospital to increase the volume of surgeries.

Concerns about the quality of pediatric heart surgery programs have been disclosed at hospitals across the country, especially at institutions with a smaller number of surgeries. Several programs have been suspended or shut down; other hospitals have merged their programs with larger ones to achieve more consistent results.

The advisory board was composed of three doctors from outside institutions: Nationwide Children’s Hospital in Columbus, Ohio; the University of Michigan School of Medicine; and Children’s Hospital of Pittsburgh.

Two doctors leading UNC’s pediatric heart program previously worked at two of those institutions: Dr. Timothy Hoffman, chief of pediatric cardiology, came to UNC from Nationwide Children’s Hospital. Dr. Mahesh Sharma, chief pediatric cardiac surgeon, joined UNC from Children’s Hospital of Pittsburgh.” (E)

“The News & Observer reports the outside review board’s report was announced Tuesday. It noted ongoing improvements in the unit, though it advised the hospital to consider if patients with complex heart problems along with additional illnesses should be referred to other hospitals.” (F)

“Rumors floated around a children’s heart surgery unit in a major hospital of a major city. Babies operated on for complex heart problems were dying, and dying at rates far higher than those of comparable hospitals. Doctors and cardiologists feared, even avoided, referring young babies for surgery at the unit — a culture of silence surrounding it all…

But this is not UNC. And this is not 2019. This was thirty years ago at Bristol Royal Infirmary, the flagship hospital of Bristol, a city of about 500,000, in the United Kingdom.

“It would be reassuring to believe that it could not happen again,” wrote Sir Ian Kennedy, chair of the public inquiry into the tragedy that claimed the lives of dozens of babies at Bristol. But he didn’t sound particularly reassured, and sadly his doubt has been borne out. It has happened again.

The parallels between the two scandals are uncanny. At both hospitals, the cardiac surgery for very young babies was malfunctioning, and babies were dying at appalling rates. At both hospitals a culture of silence surrounded a growing sense among staff that something was going catastrophically wrong.

And at both hospitals it took outsiders to blow the whistle: at UNC someone leaked recordings of the conversations held by a group of concerned cardiologists (doctors who refer patients to cardiac surgery) in June 2016 to the New York Times. Dr Kevin Kelly, leader of the children’s hospital at UNC, had convened the meeting to discuss the “crisis.” “When you walk out of here,” he says in the recordings, “stop talking about it outside of this room.”

At Bristol thirty years ago, a young new anesthetist named Stephen Bolsin grew concerned about eight-hour operations instead taking twelve. He began to collect data on the outcomes of babies at the unit. When he sensed the numbers didn’t look good, he took his concerns to the head of the unit, surgeon James Wisheart, who shut him down.

When Bolsin went over his head to the hospital manager, Wisheart got wind of this breach in the strict medical hierarchy and said this amazing – and terrifyingly similar – thing: “If you wish to remain in Bristol you should not disclose the results of pediatric cardiac surgery to people outside the unit ever again.”” (G)

PART 1. Brand names don’t always signify the highest quality of care

 “Sandra Vázquez paced the heart unit at Johns Hopkins All Children’s Hospital.

Her 5-month-old son, Sebastián Vixtha, lay unconscious in his hospital crib, breathing faintly through a tube. Two surgeries to fix his heart had failed, even the one that was supposed to be straightforward.

Vázquez saw another mom in the room next door crying. Her baby was also in bad shape.

Down the hall, 4-month-old Leslie Lugo had developed a serious infection in the surgical incision that snaked down her chest. Her parents argued with the doctors. They didn’t believe the hospital room had been kept sterile.

By the end of the week, all three babies would die…

The internationally renowned Johns Hopkins had taken over the St. Petersburg All Children’s Hospital six years earlier and vowed to transform its pediatric heart surgery unit into one of the nation’s best.

Instead, the program got worse and worse until children were dying at a stunning rate, a Tampa Bay Times investigation has found.

Nearly one in 10 patients died last year. The mortality rate, suddenly the highest in Florida, had tripled since 2015…

Times reporters spent a year examining the All Children’s Heart Institute – a small, but important division of the larger hospital devoted to caring for children born with heart defects…

They discovered a program beset with problems that were whispered about in heart surgery circles but hidden from the public.

Among the findings:

All Children’s surgeons made serious mistakes, and their procedures went wrong in unusual ways. They lost needles in at least two infants’ chests. Sutures burst. Infections mounted. Patches designed to cover holes in tiny hearts failed.

Johns Hopkins’ handpicked administrators disregarded safety concerns the program’s staff had raised as early as 2015. It wasn’t until early 2017 that All Children’s stopped performing the most complex procedures. And it wasn’t until late that year that it pulled one of its main surgeons from the operating room.

Even after the hospital stopped the most complex procedures, children continued to suffer. A doctor told Cash Beni-King’s parents his operation would be easy. His mother and father imagined him growing up, playing football. Instead multiple surgeries failed, and he died.

In just a year and a half, at least 11 patients died after operations by the hospital’s two principal heart surgeons. The 2017 death rate was the highest any Florida pediatric heart program had seen in the last decade.

Parents were kept in the dark about the institute’s troubles, including some that affected their children’s care. Leslie Lugo’s family didn’t know she caught pneumonia in the hospital until they read her autopsy report. The parents of another child didn’t learn a surgical needle was left inside their baby until after she was sent home.

The Times presented its findings to hospital leaders in a series of memos early this month. They declined interview requests and did not make the institute’s doctors available to comment.

In a statement, All Children’s did not dispute the Times’ reporting. The hospital said it halted all pediatric heart surgeries in October and is conducting a review of the program.

“Johns Hopkins All Children’s Hospital is defined by our commitment to patient safety and providing the highest quality care possible to the children and families we serve,” the hospital wrote. “An important part of that commitment is a willingness to learn.” (G)

The top three leaders of Johns Hopkins All Children’s Hospital in Florida resigned Tuesday following a Tampa Bay Times investigation that revealed increasing mortality rates among heart surgery patients.

The resignations from the 259-bed teaching hospital in St. Petersburg included CEO Jonathan Ellen, M.D., and Vice President Jackie Crain, as well as Jeffrey Jacobs, M.D., who is the heart institute’s deputy director, the Tampa Bay Times reported. Paul Colombani, M.D., stepped down as chairman of the department of surgery but will continue working in a clinical capacity, a statement from the health system said…

Johns Hopkins, which owns and operates the hospital, said it would install Kevin Sowers, who is president of the Johns Hopkins Health System and executive vice president of Johns Hopkins Medicine, to lead the hospital in a temporary capacity while a plan for interim leadership is put into place.

Johns Hopkins’ board also said it commissioned an external review to examine the heart surgery program and said it would share its lessons from the review to help hospitals around the country avoid the same mistakes.

The moves come following the Tampa Bay Times investigation that highlighted a growing number of heart surgery deaths at the hospital amid warnings about safety from staffers that went unheeded. (H)

“Three additional senior administrators have left Johns Hopkins All Children’s Hospital in the wake of a Tampa Bay Times investigation into high mortality rates at the hospital’s Heart Institute, the hospital announced Wednesday.

A total of six senior officials have left since the Times report, including the hospital’s CEO, three vice presidents and two surgeons who held leadership roles at the Heart Institute. A seventh official stepped down as chairman of the surgery department but remained employed at the hospital as a doctor.

The resignations announced Wednesday included vice presidents Dr. Brigitta Mueller, the hospital’s chief patient safety officer, and Sylvia Ameen, who oversaw culture and employee engagement and served as the hospital’s chief spokeswoman.

The hospital also said Dr. Gerhard Ziemer, who started as the Heart Institute’s new director and chief of cardiovascular surgery in October, would leave the hospital. The hospital never publicly announced Ziemer had been hired, and he had not yet obtained his Florida medical license when the Times investigation was published at the end of November. At that point, the hospital said the Heart Institute   had already stopped performing surgeries.

Sowers also announced that Johns Hopkins had hired external experts to develop a plan to restart heart surgeries at All Children’s.

That is a separate effort from an external review of the problems in the Heart Institute, which Johns Hopkins announced its board had commissioned last month, spokeswoman Kim Hoppe said…

Johns Hopkins is one of the most prestigious brands in medicine and is internationally renowned for developing innovative patient safety protocols that are used at hospitals across the world. But last weekend, the Times published a story detailing a series of safety problems at hospitals across its network. In response, the health system pledged to “do better.” (I)

“The Johns Hopkins Medicine Board of Trustees has appointed a former federal prosecutor to lead its investigation into the Johns Hopkins All Children’s Hospital’s heart surgery unit, the health system announced late Tuesday.

F. Joseph Warin, of the global law firm Gibson Dunn, and his team will review the high mortality rates and other problems at the hospital’s Heart Institute and report back to a special committee of the board of trustees by May, the health system said.

Once the review is complete, the health system said it would also name an independent monitor at All Children’s to “make sure that the hospital is being held accountable for taking corrective action where necessary.”

The announcement was accompanied by a video of Johns Hopkins Health System president Kevin Sowers, who acknowledged for the first time that the hospital had been warned about problems by frontline workers.

“I know personally that many of you courageously spoke out when you had concerns but were ignored or turned away,” he said. “That behavior is unacceptable and will not be tolerated going forward.”

Sowers, who is also interim president at All Children’s, said he hoped to meet with the families of patients affected by problems in the Heart Institute in the coming days to share his “profound sadness for the failures of care they experienced.” (J)

 “State and federal inspectors descended on Johns Hopkins All Children’s Hospital this week, following sharp calls for an investigation into problems in the hospital’s heart surgery unit, the Tampa Bay Times has learned.

The scope of the inspection is unclear. But hospital regulators had been criticized in recent weeks for their lax response to early signs of an increase in mortality at the hospital’s Heart Institute…

State and federal regulators knew the institute was having problems months earlier. In April, the hospital’s CEO told the Times that the institute had “challenges” that led to an uptick in mortality, and acknowledged the hospital had left surgical needles inside two children.

In May, state regulators cited the hospital for not properly reporting two medical mistakes, which is required by state law. Days later, a spokeswoman for the federal agency told the Times that it would perform its own investigation.

But state regulators didn’t fine the hospital, and overlooked several subsequent warnings that its surgical results had been poor.

And federal inspectors later changed course and decided not to undertake a comprehensive review of the heart surgery program, the Times reported last month. One reason was that state inspectors hadn’t found any violations of federal rules, a spokeswoman said. Another was that a nonprofit hospital accreditor was due to perform a scheduled review.” (L)

 “.. experience showcases the promise of a much-touted but little understood collaboration in health care: alliances between community hospitals and some of the nation’s biggest and most respected institutions.

For prospective patients, it can be hard to assess what these relationships actually mean – and whether they matter.

Leah Binder, president and chief executive of the Leapfrog Group, a Washington-based patient safety organization that grades hospitals based on data involving medical errors and best practices, cautions that affiliation with a famous name is not a guarantee of quality.

Brand names don’t always signify the highest quality of care,” she said. “And hospitals are really complicated places.”..

To expand their reach, flagship hospitals including Mayo, the Cleveland Clinic and Houston’s MD Anderson Cancer Center have signed affiliation agreements with smaller hospitals around the country. These agreements, which can involve different levels of clinical integration, typically grant community hospitals access to experts and specialized services at the larger hospitals while allowing them to remain independently owned and operated. For community hospitals, a primary goal of the brand-name affiliation is stemming the loss of patients to local competitors…

In some cases, large hospital systems opt for a different approach, largely involving acquisition. Johns Hopkins acquired Sibley Memorial and Suburban hospitals in the Washington, D.C., area, along with All Children’s Hospital in St. Petersburg, Fla. The latter was re-christened Johns Hopkins All Children’s Hospital in 2016…

Although affiliation agreements differ, many involve payment of an annual fee by smaller hospitals. Officials at Mayo and MD Anderson declined to reveal the amount, as did executives at several affiliates. Contracts with Mayo must be renewed annually, while some with MD Anderson exceed five years…

“It is not the Mayo Clinic,” said Dr. David Hayes, medical director of the Mayo Clinic Care Network, which was launched in 2011. “It is a Mayo clinic affiliate.”

Of the 250 U.S. hospitals or health systems that have expressed serious interest in joining Mayo’s network, 34 have become members.

For patients considering a hospital that has such an affiliation, Binder advises checking ratings from a variety of sources, among them Leapfrog, Medicare and Consumer Reports, and not just relying on reputation.

“In theory, it can be very helpful,” Binder said of such alliances. “The problem is that theory and reality don’t always come together in health care.”

Case in point: Hopkins’ All Children’s has been besieged by recent reports of catastrophic surgical injuries and errors and a spike in deaths among pediatric heart patients since Hopkins took over. Hopkins’ chief executive has apologized, more than a half-dozen top executives resigned and Hopkins recently hired a former federal prosecutor to conduct a review of what went wrong.

“For me and my family, I always look at the data,” Binder said. “Nothing else matters if you’re not taken care of in a hospital, or you have the best surgeon in the world and die from an infection.” ” (Q)

PART 2. June 1, 2019. “The situation that the New York Times described in North Carolina parallels that at Johns Hopkins All Children’s Hospital in St. Petersburg, which stopped performing heart surgeries after the Tampa Bay Times reported on problems in the unit

 “Tasha and Thomas Jones sat beside their 2-year-old daughter as she lay in intensive care at North Carolina Children’s Hospital. Skylar had just come out of heart surgery and should recover well, her parents were told. But that night, she flatlined. Doctors and nurses swarmed around her, performing chest compressions for nearly an hour before putting the little girl on life support.

Five days later, in June 2016, the hospital’s pediatric cardiologists gathered one floor below for what became a wrenching discussion. Patients with complex conditions had been dying at higher-than-expected rates in past years, some of the doctors suspected. Now, even children like Skylar, undergoing less risky surgeries, seemed to fare poorly.

The cardiologists pressed their division chief about what was happening at the hospital, part of the respected University of North Carolina medical center in Chapel Hill, while struggling to decide if they should continue to send patients to UNC for heart surgery…

That March, a newborn had died after muscles supporting a valve in his heart appeared to have been damaged during surgery. At least two patients undergoing low-risk surgeries had recently experienced complications. In May, a baby girl with a complex heart condition died two weeks after her operation. Two days later, Skylar went in for surgery.

In the doctors’ meeting, the chief of pediatric cardiology, Dr. Timothy Hoffman, was blunt. “It’s a nightmare right now,” he said. “We are in crisis, and everyone is aware of that.”

That comment and others – captured in secret audio recordings provided to The New York Times – offer a rare, unfiltered look inside a medical institution as physicians weighed their ethical obligations to patients while their bosses also worried about harming the surgical program.

In meetings in 2016 and 2017, all nine cardiologists expressed concerns about the program’s performance. The head of the hospital and other leaders there were alarmed as well, according to the recordings. The cardiologists – who diagnose and treat heart conditions but don’t perform surgeries – could not pinpoint what might be going wrong in an intertwined system involving surgeons, anesthesiologists, intensive care doctors and support staff. But they discussed everything from inadequate resources to misgivings about the chief pediatric cardiac surgeon to whether the hospital was taking on patients it wasn’t equipped to handle. Several doctors began referring more children elsewhere for surgery.

The heart specialists had been asking to review the institution’s mortality statistics for cardiac surgery – information that most other hospitals make public – but said they had not been able to get it for several years. Last month, after repeated requests from The Times, UNC released limited data showing that for four years through June 2017, it had a higher death rate than nearly all of the 82 institutions nationwide that do publicly report…

The best option, Dr. Kelly said, was to combine UNC’s surgery program with Duke’s. For years, physicians at both children’s hospitals talked informally about joining forces, but nothing came of it. They were “basically destroying each other’s capacity to be great,” Dr. Kelly said, by running competing programs less than 15 miles apart. But even combining the programs wasn’t an instant fix: It would take at least a year and a half, he said… (D)

“The situation that the New York Times described in North Carolina parallels that at Johns Hopkins All Children’s Hospital in St. Petersburg, which stopped performing heart surgeries after the Tampa Bay Times reported on problems in the unit…

UNC Health Care only made some of its death rate data public to the New York Times after numerous requests from the newsroom. The statistics showed that UNC’s children’s heart surgery program had one of the highest four-year death rates in the country…

UNC Health Care told the New York Times that the physicians’ concerns had been handled appropriately.

After the New York Times started reporting, the hospital ramped up efforts to find a temporary pediatric heart surgeon and reached out to families whose children had died or had unusual complications to discuss their cases…

The turmoil at UNC underscores concerns about the quality and consistency of care provided by dozens of pediatric heart surgery programs across the country. Each year in the United States about 40,000 babies are born with heart defects; about 10,000 are likely to need surgery or other procedures before their first birthday.

The best outcomes for patients with complex heart problems correlate with hospitals that perform a high volume of surgeries – several hundred a year – studies show. But a proliferation of the surgery programs has made it difficult for many institutions, including UNC, to reach those numbers: The North Carolina hospital does about 100 to 150 a year. Lower numbers can leave surgeons and staff at some hospitals with insufficient experience and resources to achieve better results, researchers have found.

“We can do better. And it’s not that hard to do better,” said Dr. Carl Backer, former president of the Congenital Heart Surgeons’ Society, who practices at Lurie Children’s Hospital of Chicago. “We don’t have to build new hospitals. We don’t have to build new ICUs. We just need to move patients to more appropriate centers.”

Studies show that the best outcomes for patients with complex heart problems correlate with hospitals that do a higher volume of surgeries – several hundred a year.

At least five pediatric heart surgery programs across the country were suspended or shut down in the last decade after questions were raised about their performance; a Florida institution run by the prestigious Johns Hopkins medical system stopped operations after reporting by The Tampa Bay Times in 2018. At least a half-dozen hospitals have merged their programs with larger ones to achieve more consistent results. And more institutions are considering such partnerships.” (E)

“North Carolina’s secretary of health on Friday called for an investigation into a hospital where doctors had suspected children with complex heart conditions had been dying at higher than expected rates after undergoing heart surgery.

Dr. Mandy Cohen, the secretary, said in a statement that a team from the state’s division of health service regulation would work with federal regulators to conduct a “thorough investigation” into events that occurred in 2016 and 2017 at North Carolina Children’s Hospital, part of the University of North Carolina medical center in Chapel Hill…

The investigation is in response to an article published by The New York Times on Thursday, which gave a detailed look inside the medical institution as cardiologists grappled with whether to keep sending their young patients there for surgery.” (H)

PART 3. Hopkins All Children’s Hospital/ North Carolina Children’s – pediatric cardiac surgery debacles.

“Johns Hopkins All Children’s Hospital has begun implementing some of the dozens of recommendations from a law firm hired to identify deficiencies at the hospital and its parent organization, Johns Hopkins Medicine, in the wake of high death rates in the St. Petersburg hospital’s pediatric cardiology program…

The recommendations focus on four key areas, said Dr. Kevin Sowers, president of Johns Hopkins Health System and executive vice president of Johns Hopkins Medicine.

He outlined those four areas in a video posted online. They are: strengthen the management and culture at Johns Hopkins All Children’s Hospital; improve processes for evaluating patient clinical quality and safety; clarify and streamline the reporting structure between the six Johns Hopkins Hospitals and the Johns Hopkins Health System; and review the ways in which the boards of Johns Hopkins All Children’s Hospital and Johns Hopkins Medicine should advance their governance responsibilities…

…In the coming weeks, the board of Johns Hopkins Medicine will appoint a monitor to track and report regularly back to them on the hospital’s progress.” (A)

“The recommendations for improvement include:

Prioritize a culture of absolute commitment to patient safety and of raising and addressing problems and concerns, including throughout the process of hiring and evaluating senior executives

Give physician leaders a stronger voice, create a more robust check-and-balance on the president

Better educate staff and faculty about JHM’s commitment to transparency and a culture of “see something, say something” and to improve channels to submit complaints and provide for independent review

Separate the medical staff office responsibilities from the patient safety and quality department responsibilities, which previously were overseen by a single vice president of medical affairs…

In the coming weeks, the board of Johns Hopkins medicine will appoint an external monitor to track and report back regularly to them on the hospital’s progress,” he said.

The initial focus will be on the St. Petersburg hospital, a team will go to the other five hospitals in the network to ensure the changes are taking place.” (B)

“The review recommended a commitment to patient safety and said the “see something, say something” culture is a vital part of that.

The hospital published the report on its website along with a video of Sowers talking about the results.

“Above all, we must work each and every day to support a culture in which each of us is supported and empowered to speak up and speak out,” Sowers said in the video.

He provided a toll free number where employees can anonymously report any issues: 1-844-SPEAK2US.” (C)

 “Children’s heart surgery departments across Florida will soon be subject to more oversight.

Gov. Ron DeSantis signed a bill late Tuesday that will let physician experts visit struggling programs and make recommendations for improvement…

The bill signed into law Tuesday makes significant changes.

It lets a committee called the Pediatric Cardiac Technical Advisory Panel appoint physician experts to visit Florida’s 10 children’s heart surgery programs. They will be able to examine surgical results, review death reports, inspect the facilities and interview employees.

Dr. David Nykanen, the chairman of the advisory panel and a pediatric cardiologist at Arnold Palmer Hospital for Children in Orlando, called site visits “crucially important,” especially when departments are having problems.

He said visits could start within the next six months…

The hospital has not yet resumed heart surgeries. The results of a review commissioned by the Johns Hopkins Medicine board are expected soon.” (E)

“A state regulatory process that limited the number of hospitals and some specialty services like transplant programs are going away on July 1.

Despite attempts by two hospitals, Central Florida doesn’t have a pediatric heart transplant program. But that could change in the coming years because a state regulatory process that limited the number of hospitals and some specialty services like transplants is going away on July 1.

For nearly five decades, the program known as certificate of need has required hospitals to get authorization from the state before building new facilities or offering new or expanded services — a complicated process that’s costly, includes reams of paperwork and potential challenges from competitors, and can take months or years…

Starting July 1, general hospitals are no longer required to obtain a certificate of need to build a facility or to start services such as pediatric and adult open heart surgery, organ transplant programs, neonatal intensive care units and rehab programs…

The second part of the bill goes into effect on July 1, 2021, when the certificate of need requirement will be eliminated for certain specialty hospitals such as children’s and women’s hospitals, rehab hospitals, psychiatric and substance abuse hospitals and hospitals that offer intensive residential treatment services for children.” (F)

“Cohen announced late last week that she had assembled a team from the state Division of Health Service Regulation, which licenses and oversees health care facilities, to “conduct a thorough investigation into these events.” They are coordinating with the U.S. Centers for Medicare & Medicaid Services, a federal oversight agency…

Kelly Haight Connor, a spokeswoman for the state health department, said Monday it’s difficult to know how long an investigation will take. In other DHHS investigations, a team often interviews a range of people, from caregivers, staff and those in their care.

Wesley Burks, CEO of UNC Health Care since December 2018 and dean of the UNC School of Medicine, sent a five-paragraph email to staff on May 30 at 10:16 a.m. and attached the Times’ article he described as “critical of UNC Medical Center’s pediatric congenital heart surgery program.”

 “While this program faced culture challenges in the 2016-2017 timeframe, we believe the Times’ criticism is overstated and does not consider the quality improvements we’ve made within this program over many years,” Burks wrote in the email. “As the State’s leading public hospital, UNC Medical Center often gets the most complex and serious cases in its pediatric congenital heart program. For many of these very sick children, we are often parents’ last hope…

On Monday, UNC Health Care spokesman Phil Bridges released a “timeline of Continuous Quality Improvement within the program over the past 10 years.”

The timeline mentions a four-month period from June to September in 2016 in which “concerns and allegations against specific individuals in the Congenital Heart Program” were “independently investigated and reviewed” by the dean’s office and the chief medical officer.

“Allegations of misconduct and concerns determined to be unfounded,” the document states, adding “allegations against specific individuals and results of the investigations constitute personnel records, which may not be disclosed,” citing public records law.

An ongoing initiative, according to the document, calls for a Department of Pediatrics review after every death in the Pediatric Intensive Care Unit, including pediatric cardiac patients, to assess the care provided and evaluate any opportunities for improvement.” (G)

“UNC Health Care officials announced Monday they are halting the most complex pediatric heart surgeries following a report that raised serious safety concerns over a number of child deaths at UNC Children’s Hospital…

Officials from UNC HealthCare said in a statement they plan to create an advisory board of external medical experts and “pause the most complex heart surgeries” until that board and regulatory agencies review the program.

The external advisory board, which is expected to have members from the University of Southern California, the University of Michigan, University of Pittsburgh Medical Center and Nationwide Children’s Hospital, will examine the efficacy of the UNC Children’s Hospital pediatric heart surgery program and make recommendations for improvement. The group will report to the UNC Health Care Board of Directors.

UNC Healthcare officials said they are also developing a new structure to support internal hospital reporting and plan to publicly release Society for Thoracic Surgeons’ (STS) patient outcome data, make a $10 million investment in new technology and bring in new specialists as part of their efforts to “restore confidence” in its pediatric heart program.

“Our pediatric heart program cares for very sick children with incredibly complex medical problems, and our clinical team works tirelessly to help those patients return to normal, healthy and productive lives,” Wesley Burks, M.D., CEO of UNC Health Care said in a statement. “We grieve with families anytime there is a negative outcome and we constantly push to learn from those tragic instances.

UNC Health Care’s board also endorsed the creation of a pediatric heart surgery family advisory council to provide a voice for patients, family members and staff directly to hospital leadership…

Most recently, Johns Hopkins’ All Children’s Hospital came under fire for increasing mortality rates among heart surgery patients at the 259-bed hospital following a Tampa Bay Times investigation. Top leaders of that hospital ultimately resigned and Johns Hopkins’ board also said it commissioned an external review to examine the heart surgery program.

In 2015, St. Mary’s Medical Center in Florida closed it’s pediatric heart surgery program after a CNN investigation revealed it had a mortality rate of more than three times the national average. In 2009, Massachusetts General Hospital suspended its pediatric surgery program in the wake of surgical errors.” (H)

 “UNC Children’s Hospital should merge its pediatric heart surgery program with the same work being done at Duke Health’s Children’s Hospital, just 10 miles away. A common program would greatly enhance the treatment of children and babies in need of complex heart surgery.

As it is, UNC Children’s does 100 to 150 pediatric heart surgeries a year, a rate considered low volume. That makes it harder to recruit and retain surgeons and limits surgeons ability to hone their skills. It also makes it harder to maintain the other parts of the program, cardiologists, anesthesiologists and staff for a pediatric heart intensive care unit.

East Carolina University’s hospital faced similar challenges as it provided pediatric heart surgery at a low-volume level of 50 to 75 surgeries a year. Eighteen months ago, ECU started sending all its pediatric heart surgery patients to Duke. The change helped boost Duke’s volume to where it has done more than 800 surgeries in 18 months. During the same period, Duke has posted a 1 percent mortality rate, despite a caseload in which a third of the operations are high risk.

Unfortunately, UNC Children’s Hospital appears uninterested in combining resources despite overtures from Duke. In a statement Thursday, the hospital said, “While there have been discussions with Duke Health over the years about ways to collaborate across various pediatric specialties, there are no plans to combine our programs. Patients in this region benefit from having two world-class medical institutions located so close together. Our clinicians frequently collaborate with colleagues at Duke. We sometimes transfer patients to them and vice versa.

UNC Children’s would prefer to run its own pediatric heart surgery program as a matter of institutional pride and money — the most complex operations can cost a half-million dollars. But pride and money aren’t — or shouldn’t be — the primary concerns. What matters most is how to get the best care for children in this highly specialized and high-stakes area of medicine. To do that, North Carolina’s best hospitals should combine their resources and expertise.” (J)

Typically, with complex medical procedures, outcomes are strongly correlated with volume. That means that if a program does more procedures, it has more expertise, the healthcare team has more experience working together — and as a result, patients have better results. Larger programs often have better equipment and more personnel. Sadly, the pediatric surgery program at North Carolina Children’s Hospital was a low-volume center…

Powerful forces stand in opposition to the closure of low-volume centers. Low-volume centers are attractive because they are geographically convenient; patients do not have to travel long distances for their care. Some insurance coverage is regionally-restricted, and families without resources are unable to access high-volume centers. Low-volume centers are often staffed by entrepreneurial physicians who don’t want restrictions on their right to practice medicine. And their goals are often closely aligned with those of local political officials, who would like to imagine that low-volume programs can replicate the results at large medical centers. Perhaps most importantly, hospital administrators at low-volume centers do not wish to see their revenues slashed — and their leadership positions eliminated.

So the problem of decentralized medicine and low-volume centers is getting worse, not better. To an increasing degree, a larger and larger proportion of specialized procedures in the United States are being done at low-volume centers…” (N)

For an unabridged chronology, click on

PART 3. Hopkins All Children’s Hospital/ North Carolina Children’s – pediatric cardiac surgery http://doctordidyouwashyourhands.com/2019/08/part-3-hopkins-all-childrens-hospital-north-carolina-childrens-pediatric-cardiac-surgery-debacles/

NOTES

PART 1

G.Johns Hopkins promised to elevate All Children’s Heart Institute, by KATHLEEN McGRORY and NEIL BEDI, http://www.tampabay.com/projects/2018/investigations/heartbroken/all-childrens-heart-institute/

H.Top officials at Johns Hopkins All Children’s Hospital resign following reports of heart surgery deaths, by Tina Reed, https://www.fiercehealthcare.com/hospitals-health-systems/top-officials-at-johns-hopkins-all-children-s-hospital-resign

I.Three more All Children’s officials resign following Times investigation, by By Kathleen McGrory and Neil Bedi, https://www.tampabay.com/investigations/2019/01/02/three-more-all-childrens-officials-resign-following-times-investigation/

J.Johns Hopkins hires former prosecutor to investigate All Children’s Heart Institute,by Kathleen McGrory and Neil Bedi , https://www.tampabay.com/investigations/2019/01/09/johns-hopkins-hires-former-prosecutor-to-investigate-all-childrens-heart-institute/

Q.Community Hospitals Link Arms With Prestigious Facilities To Raise Their Profiles, by Sandra G. Boodman, https://khn.org/news/community-hospitals-link-arms-with-prestigious-facilities-to-raise-their-profiles/

PART 2

D.” Horrible complications are happening that you can’t explain.” ” We have to be honest with the patients.” ” It’s a nightmare right now.” Secret recordings captured physicians’ concerns that more children seemed to fare poorly after heart surgery. Their hospital kept doing the operations, by BY ELLEN GABLER, https://www.nytimes.com/interactive/2019/05/30/us/children-heart-surgery-cardiac.html?smid=nytcore-ios-share

E.In North Carolina, the New York Times reveals another heart surgery program in trouble, by Kathleen McGrory and Neil Bedi, https://www.tampabay.com/investigations/2019/05/30/in-north-carolina-the-new-york-times-reveals-another-heart-surgery-program-in-trouble/

H. Secretary Cohen calls for investigation into NC Children’s hospital, https://www.ncspin.com/secretary-cohen-calls-for-investigation-into-nc-childrens-hospital

PART 3

A.Johns Hopkins All Children’s releases ‘lessons learned’ from review, by Margie Manning, https://stpetecatalyst.com/johns-hopkins-all-childrens-releases-lessons-learned-from-review/

B.Law firm recommends Johns Hopkins hospital to make administrative, patient safety changes, by  Veronica Brezina-Smith, https://www.bizjournals.com/tampabay/news/2019/07/01/law-firm-recommends-johns-hopkins-hospital-to.html

C.Johns Hopkins All Children’s Hospital Faces More Changes, by Julio Ochoa, https://wusfnews.wusf.usf.edu/post/johns-hopkins-all-childrens-hospital-faces-more-changes

E.Extra oversight for children’s heart surgery signed into law, by By Kathleen McGrory and Neil Bedi, http://www.tampabay.com/investigations/2019/06/26/extra-oversight-for-childrens-heart-surgery-signed-into-law/

F.Hospitals, transplant programs could multiply in Central Florida with law change, by Naseem S. Miller, https://www.orlandosentinel.com/health/os-ne-health-florida-certificate-of-need-repeal-20190701-tujobp6zofe7dorx7jxhfwc37q-story.html

G.No timeline for state investigation into NC Children’s Hospital, by Anne Blythe, http://www.tampabay.com/investigations/2019/06/26/extra-oversight-for-childrens-heart-surgery-signed-into-law/

H.UNC Children’s suspends complex heart surgeries after report raising safety concerns, by Tina Reed, | https://www.fiercehealthcare.com/hospitals-health-systems/unc-children-s-suspend-complex-heart-surgeries-after-report-raising-safety

J.UNC and Duke should unite on pediatric heart surgery, https://www.newsobserver.com/opinion/article231271418.html

N.Does Medicine Have a Wall of Silence?, by Milton Packer, https://www.medpagetoday.com/blogs/revolutionandrevelation/80256

PART 4

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EBOLA. PART 13. Ebola Treatment Centers are having difficulty maintaining their ability to respond to Ebola cases that may come again to the U.S.

In 2016 The World Health Organization identified the top 8 emerging diseases that were likely to cause severe outbreaks in the near future: Crimean-Congo haemorrhagic fever; Ebola; Marburg; Lassa Fever; MERS; SARS;  Nipah; and Rift Valley fever. (Q)

The Ebola epidemic in the Democratic Republic of Congo is breaching its contiguous borders with South Sudan, Uganda, and Tanzinia; it also borders four other countries.

 “…If the purse strings tighten, however, and the WHO cannot continue its work, the outbreak will almost certainly pick up speed. It’s only a matter of time until the virus crosses borders…

There are a few possible explanations for this (funding) shortcoming. The first is unspoken, but (is) true of the world’s largest outbreak of the disease in West Africa — Ebola has not yet spread to rich countries…”

Are we ready?

ASSIGNMENT: As Ebola spreads from Congo to contiguous countries In Africa, is the United States prepared for Ebola and other known and unknown emerging viruses?

“It sounds like an improbable fiction: a virulent flu pandemic, source unknown, spreads across the world in 36 hours, killing up to 80 million people, sparking panic, destabilising national security and slicing chunks off the world’s economy.

But a group of prominent international experts has issued a stark warning: such a scenario is entirely plausible and efforts by governments to prepare for it are “grossly insufficient”.

The first annual report by the Global Preparedness Monitoring Board, an independent group of 15 experts convened by the World Bank and WHO after the first Ebola crisis, describes the threat of a pandemic spreading around the world, potentially killing tens of millions of people, as “a real one”.

There are “increasingly dire risks” of epidemics, yet the world remained unprepared, the report said. It warned epidemic-prone diseases such as Ebola, influenza and Sars are increasingly difficult to manage in the face of increasing conflict, fragile states and rising migration…

 “Ebola, cholera, measles – the most severe disease outbreaks usually occur in the places with the weakest health systems,”.. “As leaders of nations, communities and international agencies, we must take responsibility for emergency preparedness, and heed the lessons these outbreaks are teaching us. We have to ‘fix the roof before the rain comes.’” (A)

“On Wednesday (July 17), the World Health Organization declared the Ebola outbreak in Democratic Republic of Congo a global health emergency…

A WHO committee that decided the outbreak would be a PHEIC lays out specific recommendations in a statement, including keeping borders open and not placing restrictions on trade and travel. The members call for a “coordinated international response” and for neighboring countries to work with partners to prepare for detecting and managing imported cases.

The emergency committee writes that, nearly a year into the outbreak, “there are worrying signs of possible extension of the epidemic.” Robert Steffen, who chaired the group, tells STAT that WHO is now declaring a PHEIC in part because disease transmission in the DRC city of Beni has increased, there is a risk to response workers’ safety, and that the disease is still actively transmitted in large geographical areas of the country.” (B)

“South Sudan has stepped up surveillance along its porous southern border after an Ebola case was detected just inside DR Congo, an health official in Juba told AFP Wednesday…

It is the closest Ebola is known to have come to South Sudan since a major outbreak began in Congo last August.

Dr Pinyi Nyimol, the director general of South Sudan’s Disease Control and Emergency Response Centre, said a team of reinforcements had been sent to the region to bolster surveillance after the case was confirmed.

“We are very worried because it is coming nearer, and people are on the move so contact (with Ebola) could cross to South Sudan,” he told AFP.”  (C)

“Uganda’s ministry of health announced late on Thursday a second Ebola outbreak in the western district of Kasese, about 472 km from the capital Kampala, following an imported case from the neighboring Democratic Republic of the Congo (DRC).

Joyce Moriku Kaducu, minister of state for primary health care, said in a statement that a 9 year-old female Congolese who entered the country with her mother on Wednesday through the Mpondwe border to seek medical care at Bwera Hospital has tested positive of the deadly virus.

The minister said the child was identified by the point of entry screening team with symptoms of high fever, body weakness, rash, and unexplained mouth bleeding…

“Since the child was identified in Uganda at the point of entry, there are no contacts in Uganda,” she said…

In June, Uganda confirmed three index cases of the highly contagious disease who visited the neighboring DRC. The outbreak was declared finished after 42 days of close monitoring.” (D)

“A  nine-year-old Congolese girl who tested positive for Ebola in neighbouring Uganda has died of the disease, as the World Health Organisation (WHO) warned that the current outbreak was approaching the grim milestone of 3,000 cases and 2,000 deaths.

Her death makes her the fourth case to cross into Uganda amid the continuing struggle to contain the deadly outbreak.” (E)

The World Health Organization issued an extraordinary statement Saturday raising concerns about possible unreported Ebola cases in Tanzania and urging the country to provide patient samples for testing at an outside laboratory.

The statement relates to a Tanzanian doctor who died Sept. 8 after returning to her country from Uganda; she reportedly had Ebola-like symptoms. Several contacts of the woman became sick, though Tanzanian authorities have insisted they tested negative for Ebola.

But the country has not shared the tests so they can be validated at an outside laboratory, as suggested under the International Health Regulations, a treaty designed to protect the world from spread of infectious diseases.

It is highly unusual for the WHO, which normally operates through more diplomatic means, to publicly reveal that a member country is stymying an important disease investigation.

 “The presumption is that if all the tests really have been negative, then there is no reason for Tanzania not to submit those samples for secondary testing and verification,” Dr. Ashish Jha, director of the Harvard Global Health Institute, told STAT…” (F)

“The statement comes hard on the heels of similar remarks by the US health secretary, Alex Azar, last week amid mounting concern that Tanzania may be in breach of its international commitments to share critical data relating to global health security.

Although Tanzania has insisted that its own tests showed negative for the Ebola virus, international health organisations have raised the alarm about not being given access to samples.

According to unconfirmed reports, the woman, in her mid-30s, had been conducting health research and had visited several health facilities in central Uganda before her death, after showing symptoms of a serious febrile illness.

The patient, who died on 8 September, had not been to the Democratic Republic of the Congo or had contact with Ebola cases, leading international health monitoring organisations to initially rule out the Ebola virus.

However, as several more reported cases emerged, including the initial patient’s sister, Tanzania’s response to the issue has prompted alarm about the country’s willingness to share either its test results or allow secondary testing of samples.

Azar voiced his own criticism during a visit to Uganda, telling reporters that he and others are “very concerned” as he urged Tanzania’s government to share laboratory results regarding the case.” (G)

A team of specialists at Emory University will never forget Aug. 2, 2014. That’s the day Kent Brantley, an American missionary based in Liberia, became the first of four patients with the Ebola virus to arrive at its Atlanta facility.

The eyes of the world watched as the Serious Communicable Diseases Unit ⁠— in hazmat suits, successfully treated Brantley and three other patients with the highly infectious disease.

The team at Emory is innovating on what they learned five years ago to help treat the disease now. “ (H)

“This fall, the University of Nebraska Medical Center is scheduled to open a cutting-edge center for training, simulation and quarantine to prepare federal workers to address highly infectious diseases. Creation of the National Center for Health Security and Biopreparedness is timely and important, given the troubling new Ebola outbreak in Africa.

As a result, the infectious disease initiative at UNMC and clinical partner Nebraska Medicine is taking on particular importance. UNMC received a $19.8 million federal grant for creation of the new biopreparedness center. A team of infectious disease experts from UNMC and Nebraska Medicine was in Uganda last year to train local health care workers in infection response and control…

During 2014-15, the med center treated three Ebola patients and monitored several others who were exposed but did not develop the disease. On Dec. 29 last year, an American doctor who had been treating patients in the Democratic Republic of Congo arrived in Omaha, where he completed the last 14 days of a 21-day monitoring period in UNMC’s biocontainment unit.” (I)

“During the outbreak five years ago, 56 hospitals across the U.S. were designated Ebola treatment centers, or ETCs. The idea was to increase national capacity to care for patients who contracted this highly infectious disease. These hospitals are mostly clustered around major airports where travelers from West Africa are likely to arrive, including Chicago’s O’Hare International Airport. They were initially equipped with dedicated clinical care resources, specialized infrastructure and trained staff to safely manage and treat patients suspected or confirmed to have Ebola. Since its inception in 2014, fewer resources have been allocated to this hospital network. As a result, the ETCs are having difficulty maintaining their ability to respond to Ebola cases that may come again to the U.S., and other infectious diseases that may follow.

Outbreaks are costly. Public health responses to Ebola, Zika, MERS, SARS and other diseases cost tens of billions of dollars, much of which can be avoided by taking preventive action. Congress can wait until Ebola or some equally deadly infectious disease arrives in our country, overwhelms state, local, tribal and territorial health care and public health capacity, and threatens lives and then provide billions in emergency supplemental funding. Or Congress can now recognize that these significant disease events will continue to occur and proactively take steps to ensure we can respond by creating a standing response fund.” (J)

“… In the past two years, the Trump administration has dissolved the federal government’s biosecurity directorate, scaled back its infectious disease prevention efforts, restricted development aid for countries like Congo, made several attempts to rescind foreign aid, including for global health, and pulled C.D.C. workers from Congo’s outbreak zones without a clear plan to send them back.

The administration has also announced policies meant to scare legal immigrants off public assistance programs, including for health care, to which they are legally entitled. Such policies imperil everyone: The more people who don’t have access to vaccines or antibiotics, the greater the risk that an infectious disease will spread. That applies to diseases like Ebola that might arrive on American shores from other countries, but it also applies to diseases that are already here, like flu and measles. The only reliable way for a country to protect itself from these threats is for it to help other countries do the same.

The new medications for Ebola and tuberculosis are the product of years of investment and careful work. That investment could continue to pay off, but only if the United States and its partners around the world increase their global health efforts, instead of shrinking away from them.” (K)

“As the Ebola epidemic in the DRC has become a global health emergency, we must not relent in our efforts to fight back. There are Ebola vaccines available today (pending licensing) thanks to the research and development and vaccine trials conducted during the West Africa Ebola epidemic. But the public health community needs a greater supply of those vaccines, and we need coordinated action on behalf of the public, philanthropic and private sectors to arrest the outbreak in the DRC. Stopping outbreaks at the source protects America. Infectious, deadly diseases such as Ebola do not recognize or respect borders.” (L)

“I’m not a social scientist. I have zero data on which to lean here. Someone who actually does this sort of research may conclude that donor fatigue, or the financial straits some countries and most media outlets currently face, or the turning inward that has accompanied the rise of populism can explain why this Ebola outbreak isn’t as front burner an issue as it would have been a decade ago, why organizations struggling to stop it are finding fewer donors writing smaller checks.

But in the meantime I am left wondering if we have learned to fear this virus less. And in the process, if we have let Ebola drift toward the column of bad diseases — things like cholera and yellow fever, Guinea worm and malaria — that we’re not so concerned about. Sure, they sicken and kill lots of people. But they don’t do it here.” (M)

“…If the purse strings tighten, however, and the WHO cannot continue its work, the outbreak will almost certainly pick up speed. It’s only a matter of time until the virus crosses borders…

There are a few possible explanations for this shortcoming. The first is unspoken, but was true of the world’s largest outbreak of the disease in West Africa — Ebola has not yet spread to rich countries…

At last month’s G20 summit in Japan, high-income countries, including the United States, declared their full support for the Ebola response. They must now make good on that promise to the WHO. If countries procrastinate, the world risks a repeat of the 2014–16 Ebola outbreak, in which a slow response contributed to the loss of more than 11,300 lives in Africa and a cost to taxpayers of more than $3 billion. The WHO needs just a fraction of this to prevent a horrific repeat of history.” (N)

“A dispute between two major players in the epidemic response — Doctors Without Borders and the W.H.O. — erupted on Monday, just as the W.H.O. announced that a new vaccine, the second to be deployed, would be introduced into the region.

On Monday, Doctors Without Borders accused the World Health Organization of “rationing Ebola vaccines and hampering efforts to make them quickly available to all who are at risk of infection.”

The W.H.O. quickly fired back, saying it was “not limiting access to vaccine but rather implementing a strategy recommended by an independent advisory body of experts and as agreed with the government of the D.R.C. and partners.”..

The approach so far has relied on a traditional strategy called ring vaccination that has been used successfully against other diseases. It involves vaccinating everyone who has had contact with an infected person, and all the contacts of those people, as well.

Officials from Doctors Without Borders say the strategy has not worked in Congo, in part because it has not been possible to track down every person who has come into contact with someone infected with Ebola, and because some contacts have refused to cooperate. The group has urged more widespread vaccination in regions where the disease is spreading, whether people are known contacts or not.

But it says that instead the W.H.O. has doled out limited amounts of vaccine. About 225,000 people have been vaccinated, but Doctors Without Borders says 450,000 to 600,000 should have received the vaccine by now.” (O)

“The United States has warned its citizens to take extra care when visiting Tanzania amid concerns over Ebola, adding to calls for the East African country to share information about suspected cases of the deadly disease there…

U.S. travelers should “exercise increased caution”, the State Department said on Friday in an updated travel advisory that cited reports of “a probable Ebola-related death in Dar es Salaam”.” (P)

“The medical response to an Ebola infection is markedly more challenging than many other diseases. It is one of the most deadly viruses with a 60% – 90% mortality rate compared to 2% for measles.

The Ebola virus is extremely infectious and highly communicable. Treating the disease is resource intensive. Patients must be kept in isolation in specialised, well-designed treatment centres. Health care workers are at high risk of exposure and must take extreme precautions to examine patients. Breakdown in personal protection and infrastructure can be fatal. In fact, approximately 6% of the victims have been involved in looking after patients.” (R)

“Today (June 12, 2019) the U.S. Centers for Disease Control and Prevention (CDC) is announcing activation of its Emergency Operations Center (EOC) on Thursday, June 13, 2019, to support the inter-agency response to the current Ebola outbreak in eastern Democratic Republic of the Congo (DRC). The DRC outbreak is the second largest outbreak of Ebola ever recorded and the largest outbreak in DRC’s history. The confirmation this week of three travel-associated cases in Uganda further emphasizes the ongoing threat of this outbreak. As part of the Administration’s whole-of-government effort, CDC subject matter experts are working with the USAID Disaster Assistance Response Team (DART) on the ground in the DRC and the American Embassy in Kinshasa to support the Congolese and international response. The CDC’s EOC staff will further enhance this effort.

CDC’s activation of the EOC at Level 3, the lowest level of activation, allows the agency to provide increased operational support for the response to meet the outbreak’s evolving challenges. CDC subject matter experts will continue to lead the CDC response with enhanced support from other CDC and EOC staff.” (S)

“…if we want to prevent Ebola cases evolving into wider outbreaks, then we’ll need to move beyond reactionary responses and address the factors that pave the way for epidemics.”..

To prevent future outbreaks, and to support the health of local communities in the poorest parts of the world, we need to invest in strengthening primary care and medical education. Otherwise, we will be here again in another five years, once again having failed to learn from our mistakes.” (T)

________________

May 15, 2017

Lesson Learned from recent EBOLA and ZIKA episodes. We need to designate REGIONAL EMERGING VIRUSES REFERRAL CENTERS (REVRCs).

1. There should not be an automatic default to just designating Ebola Centers as REVRCs although there is likely to be significant overlap.

2. REVRCs should be academic medical centers with respected, comprehensive infectious disease diagnostic/ treatment and research capabilities, and rigorous infection control programs. They should also offer robust, comprehensive perinatology, neonatology, and pediatric neurology services, with the most sophisticated imaging capabilities (and emerging viruses “reading” expertise).

3. National leadership in clinical trials.

4. A track record of successful, large scale clinical Rapid Response.

5. Organizational wherewithal to address intensive resource absorption.

  • Faculty might want to scan the following unabridged Ebola chronology

PART 1. May 15, 2017. EBOLA is back in Africa. Is ZIKA next? Are we prepared?

PART 2. May 9, 2018. New Ebola outbreak declared in Democratic Republic of the Congo

PART 3. May 18, 2018 . As ZIKA and EBOLA reemerge, Trump administration cuts funding to halt international epidemics

PART 4. June 11, 2018 . “With an outbreak like this, it’s a race against time, as one Ebola patient with symptoms can infect several people every day.”

PART 5. June 16, 2018. EBOLA, ZIKA. EMERGING VIRUSES. ” All too often with infectious diseases, it is only when people start to die that necessary action is taken.”

PART 6. June 17, 2018. ANDEMIC PREPAREDNESS. “It’s like a chain-one weak link and the whole thing falls apart. You need no weak links.”

PART 7. June 21, 2018. Democratic Republic of Congo’s Ebola outbreak has been “largely contained”…

PART 8. June 24, 2018. “Slightly over a month into the response, further spread of [Ebola Virus Disease] has largely been contained,” WHO announced on June 20.

PART 9. August 10, 2018. After Ebola scare, Denver Health wishes it notified public of potential deadly virus sooner

PART 10. August 20, 2018. At least 10 health-care workers have been infected with the deadly Ebola virus as they battle an outbreak in an eastern province of Congo

PART 11. August 30, 2018. “…(WHO) reports the next seven to 10 days are critical in controlling the spread of the Ebola virus in eastern Democratic Republic of Congo.” http://doctordidyouwashyourhands.com/2018/08/who-reports-the-next-seven-to-10-days-are-critical-in-controlling-the-spread-of-the-ebola-virus-in-eastern-democratic-republic-of-congo/

PART 12. June17, 2019. “Three cases of EBOLA have emerged in Uganda, a neighboring country to the Democratic Republic of the Congo.” http://doctordidyouwashyourhands.com/2019/06/part-12-june17-2019-three-cases-of-ebola-have-emerged-in-uganda-a-neighboring-country-to-the-democratic-republic-of-the-congo/

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“Walmart’s (health care) strategy is based on price competition. Patients know what services will cost before they walk into the physician’s office. Prices are rock-bottom.”

Health care “disruption” is well underway with most attention focused on paradigm-challenging players like: Amazon, Berkshire Hathaway and JPMorgan Chase forming an independent health care company for their employees; and the CVS Health Aetna Acquisition.

In the meantime, under-the-radar, Walmart’s strategy has been “based on the hospital inefficiency in innovation and the business theory of bundling and unbundling services.”

Now Walmart is leveraging its 1.5 million employees and 4,769 stores throughout the United States (90% of Americans live within 10 miles of a Walmart store) to launch its major health care initiatives.

“Walmart, the world’s biggest retailer, is moving deeper into the primary care and mental health market, opening a new clinic called Walmart Health in Georgia.

The company recently updated its website with a link to Walmart Health, describing its “newest location in Dallas, GA.” It also went online with the site “Walmarthealth.com,” where patients can set up appointments. Walmart is testing the concept with the initial clinic and could open more in the future, according to people familiar with the matter who asked not to be named because the plans are confidential.

The website indicates that first appointments are available on Sept. 13, and the company will offer primary care, dental, counseling, labs, X-rays and audiology, among other services…

The new clinic will have on-site health providers, including nurses, to offer consultations, immunizations and lab tests, people familiar with the matter said. Added services include hearing tests, 60-minute counseling sessions and vision tests.” (A)

“Walmart’s new Georgia location opening comes as rivals CVS Health and Walgreens Boots Alliance push further into outpatient healthcare services through various models. The retailers see 10,000 baby boomers aging into Medicare coverage each day and are also looking to fill emptying space in their brick and mortar stores in the face of changing consumer shopping habits driven by online retail giant Amazon, which is also exploring new ways to get into the healthcare business but has yet to offer face-to-face personalized healthcare services for customers.

This year, CVS has said its new health hub concept store will reach four U.S. metropolitan areas and 50 locations by the end of this year as part of a major expansion. CVS said the HealthHub rollout will grow to 1,500 locations by the end of 2021, or about 500 HealthHubs a year…

Walgreens has a joint venture with the big health insurer Humana, opening senior clinics in certain markets and the drugstore chain has a partnership with UnitedHealth Group’s MedExpress urgent care subsidiary that has opened centers that include X-rays and are staffed by physicians with a door connecting to an adjacent Walgreens store.

But Walmart says the new Walmart Health centers aren’t designed to increase foot traffic and customer volume into their stores… Walmart has a different approach.

“We are trying to solve problems for our customers,”… “We already have the volume. We have the locations and the right people.” (B)

“Here we see two rival strategies to marketing healthcare services. Walmart’s strategy is based on price competition. Patients know what services will cost before they walk into the physician’s office. Prices are rock-bottom. This directly benefits patients, who will come again. Word will get out. In contrast, the hospital’s strategy is based on billing insurance companies for services whose prices are not revealed to patients in advance. Patients have no economic incentive to seek lower-cost services elsewhere.

These two strategies reflect different organizational legal structures. Walmart is a profit-seeking corporation. Profit-seeking enterprises whose business plans seek a growing market, as Walmart’s business plan always has, are forced by price-sensitive consumers to compete by cutting costs and then lowering prices. In contrast, the hospital is a non-profit enterprise. By law, non-profit enterprises have no owners. Employees may not profit directly from innovations that lead to higher profits. In non-profits, everyone is salaried. There is therefore far less incentive to cut costs and reduce prices.” (C)

“As Walmart moves deeper into primary care, the retail giant wants to ensure there is a skilled healthcare workforce to fill critical roles in its 20 care clinics…

Walmart announced Tuesday its 1.5 million associates will be able to apply for one of seven bachelor’s degrees and two career diplomas in health-related fields for $1 a day through Live Better U, Walmart’s education benefit program…

The new degrees and certificate programs will provide Walmart employees with a path to higher-paying careers in the growing healthcare field, Walmart executives said..

The health and wellness courses include career diploma programs for pharmacy technicians and opticians through Penn Foster and seven bachelor’s degrees in health science, health and wellness and healthcare management/administration offered through Purdue University Global, Southern New Hampshire University, Bellevue University and Wilmington University.

The education program will arm employees with training to fill critical healthcare roles across Walmart and Sam’s Club, which includes more than 5,000 retail pharmacies, 3,000 vision centers and 400 hearing centers, the retailer said in a release. The upskilled workforce will help the retailer make quality healthcare more affordable and accessible to customers in the communities it serves.” (D) 

“What is health care’s allure for Walmart? Medical services typically have higher margins than store products. Since they are often provided in person, there is more opportunity for consumers to pick up other items while visiting the store. And usage is growing, especially as the United States’ population ages.

In particular, Walmart is eyeing both the Medicare and Medicaid markets since many of its customers are senior citizens and lower-income Americans. Its prices are generally lower than at pharmacy chains, such as CVS.

As Walmart expands its health care menu, it builds even more ties with its shoppers. Its deal with Anthem, for instance, lets the insurer’s Medicare Advantage customers use their plan benefits to purchase over-the-counter medicine, first aid supplies, support braces and pain relievers from a store.

And Walmart can market its healthy grocery items to certain Medicare Advantage enrollees since the federal government recently allowed insurers to cover such products as a supplemental benefit. This has given the company another advantage over pharmacy chains, which have much more limited food selections.

Also, the retailer’s locations blanket the nation. Many are in rural areas where there are few other health care options. Walmart often operates as a community center, with customers dropping in a few times a week. And it serves as a one-stop shop, where people could access medical services and pick up whatever other items they need.”  (E)

“On the heels of Walmart offering health clinics in certain locations, the big-box retailer is adding on a digital healthcare site—WalmartHealth.com—so consumers can make doctor, dentist, and behaviorial health medical appointments, in addition to scheduling hearing tests and immunizations…

There are some true loyalty-generating opportunities in extending your ambulatory offerings with select regional retail clinics, utilizing technology to improve your digital front door and provide real-time patient obligations.” (F)

Walmart’s Centers of Excellence program gives associates access to world-class specialists for:

Certain heart surgeries, like cardiac bypass and valve replacements. Certain spine surgeries, like spinal fusions and removal of spinal discs (discectomy). Hip and knee joint replacements. Breast, lung, colorectal, prostate, and blood cancers (including myeloma, lymphoma, and leukemia). Certain weight loss surgeries, like gastric bypass and gastric sleeve procedures. Organ and tissue transplants (except kidney, cornea, and intestinal), ventricular assist devices (VADs) and total artificial hearts, and CAR-T cell therapy. Outpatient radiology, which will be reviewed automatically through the pre-authorization program

Walmart has partnered with several world-class health systems across the country to serve the Centers of Excellence program, and a few of these include: Cleveland Clinic, in Cleveland, Ohio, for cardiac surgery. Johns Hopkins Hospital, in Baltimore, Maryland, for joint replacement surgery. Mayo Clinic in Minnesota, Florida and Arizona, for transplants and cancer care. Geisinger Medical Center, in Danville, Pennsylvania, for weight loss surgery. Mercy Springfield, in Springfield, Missouri, for spine surgery..

In addition to the full cost of treatment for many conditions, the benefit includes travel and lodging expenses for both the patient and a companion caregiver. Travel and lodging are not included for the weight-loss-surgery benefit.” (G)

“Geisinger has earned designation as a Radiology Center of Excellence by Covera Health, a New York City-based company that uses advanced clinical analytics to objectively measure quality in radiology.

With its new distinction, Geisinger joins a national program that integrates with self-funded insurers’ existing health networks to steer community members toward local radiology providers based on their diagnostic accuracy — not price — to curb misdiagnoses. Danville, Pa.-based Geisinger is also a member of Covera Health’s Quality Care Collaborative, in which participants receive practical, actionable feedback to improve their clinical practice.”  (H)

“Walmart’s retail strategy in health care is based on the hospital inefficiency in innovation and the business theory of bundling and unbundling services. The vast majority of hospital revenue is rooted in the fee-for-service business model: rather than make money for improving health (a reimbursement model that is much harder to design than it sounds), providers are paid more for the number of services provided — hampering incentives for innovation. Providers are thus incentivized to provide a high-volume, high-cost standard of care, squeezing money from insurance companies. In turn, those costs are passed down to consumers in the form of higher premiums. However, as hospital operational costs ballooned, health systems began to treat their departments like a public investment portfolio. They unbundled (divested from) low-end services that required all the same operating expenses but didn’t turn a profit.

Outpatient primary care is a prime unit to be unbundled from traditional health care delivery systems, i.e. hospitals, for two reasons:

Most patients that visit primary care physicians don’t need the resources of an expensive medical center on-hand for each visit, and would be better served by an experience that emphasized price, convenience, and attention.

Reimbursement rates for most primary care services, e.g. a blood pressure checkup or physical exam, are much lower than specialty care (imaging, biopsies, intensive procedures, etc) and thus provide a lower short-term return on invested capital…

This brings us to the biggest loser of Walmart’s foray into health care: traditional health systems. Walmart’s strategy notably doesn’t utilize any ownership of inpatient hospitals; all incentives are aligned to provide the highest value care at the lowest possible cost in outpatient settings, ultimately decreasing utilization of expensive health care services like inpatient hospitalizations. (I)

“After more than a decade of transforming health care for its roughly 1 million workers and huge and loyal customer base, Walmart plans to play an even larger role. Marcus Osborne, vice president of transformation and wellness for the retail giant, made that point clear in a recent talk with the Health Care Council of Chicago.

Osborne said Walmart will continue to expand its health care services for customers and employees until or unless the company “hits a third rail” by entering a space in which it can’t compete effectively. To date, he emphasized that every significant initiative the company has undertaken to address its customers’ top three health care concerns — cost, convenience and access — has delivered value for employees and customers and a return for the company.

He also reported that all projects that Wal-Mart Stores Inc. undertook over the last two years, including a pilot with its Boston-based partner Beacon Health to bring affordable, behavioral health care to customers, performed better than expected. He said Walmart’s most successful venture recently has been its partnership with Quest Diagnostics to provide in-store testing services to customers, providing a level of convenience that has increased patient compliance with their physicians’ directives by 50 percent or more.

Other topics Osborne addressed include: Access to care; Variation in clinical practice; Solving obesity; Scaling success. (J)

Sam’s Club, a retail warehouse club operated by Walmart, is teaming up with healthcare companies to offer four bundled healthcare service offerings for its members, ranging from $50 to $240 per year.

The pilot, called Care Accelerator, is in tandem with payer Humana and on-demand primary care app 98point6. Bundles vary in included services, but each offers free prescriptions on some generic medications, low-cost dental and vision services, prepaid health debit cards for use within the network and unlimited telehealth for $1 a visit.

The company stressed that Care Accelerator is not a health insurance plan. Participating Sam’s Club members will still have to pay their healthcare provider at the point of service, though it will be at a discounted rate.

The family bundle, for example, costs $240 a year and covers up to six family members. It includes access to preventive lab screenings for early detection of heart disease and diabetes, a 10% discount on hearing aids and up to a 30% discount on chiropractic, massage and acupuncture services.

By comparison, the “Starter A” bundle only includes free select generic medications, $1 telehealth visits, $60 eye exams and a $5 prepaid health debit card. Medications must be filled at Sam’s Club pharmacies and eye exams must be done at Sam’s Club, guaranteeing business for the retailer and its 566 pharmacy locations.” (K)

CODA

“Back in 2005, a memo from Walmart’s then-Vice President of Benefits, Susan Chambers, outlined a strategy for how the company could remove sick workers from the payrolls and avoid paying healthcare benefits. More recently, premiums on Walmart’s health plans have soared, and the company has cut eligibility considerably.

Starting in 2015, Walmart cut coverage for anyone working less than 30 hours per week.

In the last five years, the cost of Walmart’s cheapest healthcare plan has more than doubled.

Hundreds of thousands of Walmart workers and their family members qualify for publicly funded health insurance.

Walmart’s health care plans fail to cover hundreds of thousands of associates. In 2009, Walmart claimed that 52% of associates were covered under its healthcare plan. The company has refused to disclose coverage rates for its 1.5 million U.S. employees since then.

In recent years, Walmart has made it even more difficult for associates to get quality health care for themselves and their families. The company stopped offering health insurance to part-time employees working less than 24 hours per week in 2012, and starting in 2015, it cut coverage for anyone working less than 30 hours per week, including those who had previously been grandfathered in. In the last five years, the cost of Walmart’s cheapest healthcare plan has more than doubled. The cost of many of the company’s family plans has more than quadrupled over that time period.

For employees earning Walmart’s starting rate of $9.00/hour working an average of 34 hours per week, the deductible alone on Walmart’s cheapest plan for workers with children is over a third of the employee’s annual gross income.”  (L)

ASSIGNMENTS TO CONSIDER.

#1

You are the CEO of a suburban community hospital, the only one in town, two block away from a big Walmart store that just opened a Walmart Health clinic.

Last year the hospital purchased a second MRI and started an interventional cardiology program. University Medical School, 50 miles away, has just opened a local cancer program satellite.

The Board is in a panic as Walmart is hiring your biggest physician admitters and senior technical staff. Admissions are falling.

There is a Board meeting next week.

Where do you start?

#2

Compare WalmartCare with CVSCare, AppleCare, GoogleCare, MicrosoftCare, AmazonCare, and other nontraditional models.

Analysis: Impact of CVS, Walgreens, Walmart Retail Healthcare Expansion Strategies by Ethan Chernofsky  https://hitconsultant.net/2019/09/27/cvs-walgreens-walmart-retail-healthcare-expansion/#.XY-HDEZKhlA

If you want to discuss other ways of organizing this case for class discussion please contact me at jonathanmetsch@gmail.com

Some Resources For Faculty Preparation

Project Management. The hardest part of getting started….is getting started

“…what would it look like if Amazon CEO Jeff Bezos took the helm of a major integrated (health care) delivery system?”

Apple, Amazon, Google and Microsoft trajectories for healthcare http://doctordidyouwashyourhands.com/2018/07/apple-amazon-google-and-microsoft-trajectories-for-healthcare/

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PART 3. 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.

THIS CASE HAS BEEN ABRIDGED TO FACILITATE DISCUSSION. Parts 1-4 have been condensed 40%.

Going forward all new cases will be shorter and for ongoing cases new and previous posts will be thoughtfully edited.

On continuing cases do you prefer that new posts be shown first or last?

Reminder. You can edit these cases for classroom use with attribution to Doctor, Did You Wash Your Hands? ®      http://doctordidyouwashyourhands.com/

Why not “test drive” a case in the classroom?

Please post your comments, feedback and suggestions and/ or email me at jonathanmetsch@gmail.com

thanx! for your interest

Jon

Jonathan Metsch, Dr.P.H.

https://www.mountsinai.org/profiles/jonathan-m-metsch

PART 1: January 31, 2019. “If you’re shot, stabbed, hit by a car, fall off a roof or suffer any other major injury in San Francisco, you’ll be whisked to San Francisco General Hospital, the only trauma center in the city “

PART 2: February 20, 2019. A new bill would outlaw the big, surprise bills that Zuckerberg San Francisco General Hospital has sent to hundreds of patients.

PART 3: April 18, 2019. “Zuckerberg San Francisco General Hospital announced Tuesday it has overhauled its billing policies…

PART 4: August 20, 2019. Hospitals kept ER fees secret

ASSIGNMENT: How do other states address financial sustainability for their “safety-net” hospitals?

PART 1: January 31, 2019. “If you’re shot, stabbed, hit by a car, fall off …

“If you’re shot, stabbed, hit by a car, fall off a roof or suffer any other major injury in San Francisco, you’ll be whisked to San Francisco General Hospital, the only trauma center in the city. …But you may leave with a very unpleasant side-effect: a shockingly high bill. …That’s because S.F. General – whose patients are overwhelmingly poor and are on Medicare or Medi-Cal, or have no insurance at all – lacks a good way to deal with patients who are actually insured.” (A)

“Under a new state law, if you visit an in-network facility – such as a hospital, lab or imaging center – you will only be responsible for your in-network share of the cost, even if you’re seen by an out-of-network provider…

The new law covers Californians with private health insurance plans that are regulated by the state Department of Managed Health Care, or DMHC, and the state Department of Insurance, which includes roughly 70 percent of the state’s private insurance market, according to the California Health Care Foundation.

It does not cover some 5.7 million people whose employer-sponsored insurance plans are regulated by the U.S. Department of Labor…

The key point to remember is that you shouldn’t pay more than your in-network copayment, coinsurance or deductible, as long as you visited an in-network facility for non-emergency services.” (B)

“The trauma center has no contracts with private insurance companies. If it did, there would be agreements with those insurers on how much a particular drug or a particular procedure costs.

Instead, the hospital charges the highest rates approved by the Board of Supervisors and the mayor, receives whatever amount the patient’s insurance company decides to pay, and bills the patient for the rest.” (C)

On April 3, Nina Dang, 24, found herself in a position like so many San Francisco bike riders – on the pavement with a broken arm.

A bystander saw her fall and called an ambulance. She was semi-lucid for that ride, awake but unable to answer basic questions about where she lived. Paramedics took her to the emergency room at Zuckerberg San Francisco General Hospital, where doctors X-rayed her arm and took a CT scan of her brain and spine. She left with her arm in a splint, on pain medication, and with a recommendation to follow up with an orthopedist.

A few months later, Dang got a bill for $24,074.50. Premera Blue Cross, her health insurer, would only cover $3,830.79 of that – an amount that it thought was fair for the services provided. That left Dang with $20,243.71 to pay, which the hospital threatened to send to collections in mid-December…

Most big hospital ERs negotiate prices for care with major health insurance providers and are considered “in-network.” Zuckerberg San Francisco General has not done that bargaining with private plans, making them “out-of-network.” That leaves many insured patients footing big bills.

The problem is especially acute for patients like Dang: those who are brought to the hospital by ambulance, still recovering from a trauma and with little ability to research or choose an in-network facility.

A spokesperson for the hospital confirmed that ZSFG does not accept any private health insurance, describing this as a normal billing practice. He said the hospital’s focus is on serving those with public health coverage – even if that means offsetting those costs with high bills for the privately insured.

“It’s a pretty common thing,” said Brent Andrew, the hospital spokesperson. “We’re the trauma center for the whole city. Our mission is to serve people who are underserved because of their financial needs. We have to be attuned to that population.”

But most medical billing experts say it is rare for major emergency rooms to be out-of-network with all private health plans. (D)

On its web site, ZSFG declares that “everyone is welcome here” regardless of their financial situation or immigration status:

Everyone is welcome here, no matter your ability to pay, lack of insurance, or immigration status. We’re much more than a medical facility; we’re a health care community promoting good health for all San Franciscans.

We’re part of a large group of neighborhood clinics and healthcare providers, the San Francisco Health Network. In partnership, we provide primary care for all ages, specialty care, dentistry, emergency and trauma care, and acute care for the people of San Francisco…

“Our mission is to serve people who are underserved because of their financial needs,” the spokesperson also stated. “We have to be attuned to that population.” (E)

“More than half of U.S. adults “have been surprised by a medical bill that they thought would have been covered by insurance,” according to a new survey from research group NORC at the University of Chicago…

The big picture: Drug prices have been in the crosshairs of lawmakers, and health insurers have always been a punching bag. But hospitals and doctors aren’t attracting any large-scale movement to rein in pricing and billing tactics.

“There’s a huge amount of trust in the providers people choose to go to,” said Caroline Pearson, senior fellow at NORC. “I think we’ve got a long way to go until we have backlash against those providers. But as insurance gets more complicated and out-of-pocket costs rise, we’re going to see more and more surprise bills.”  (F))

“U.S. Sen. Bill Cassidy, R-La., said federal lawmakers on both sides of the aisle are moving closer to an agreement on legislation to prevent surprise medical bills, according to a Bloomberg Government report…

Republicans and Democrats have been working to address the issue, and bipartisan legislation is predicted for early 2019, Mr. Cassidy told Bloomberg Government…

There have been legislative efforts related to surprise medical bills. In September, a bipartisan group of senators unveiled the Protecting Patients from Surprise Medical Bills Act. Then on Oct. 11, Democrat Sen. Maggie Hassan of New Hampshire introduced the No More Surprise Medical Bills Act of 2018. The first draft bill focuses on preventing out-of-network providers from charging patients more for emergency care than what they would pay using insurance. The second bars healthcare providers from out-of-network billing for emergency services, according to the report.

Meanwhile, Bloomberg Government notes, insurers and hospitals are pointing the finger at each other over who is at fault for the problem.

Mr. Cassidy told the publication there are “bad apples with both groups” and anticipates both sides “are going to have to give a little bit” when it comes to changes.” (G)

“Payer groups, including America’s Health Insurance Plans, are joining forces with employers, consumers and other stakeholders in support of a plan they say will tackle surprise billing.

The groups signed on to a set of guiding principles aimed at protecting consumers from the practice. The guidelines are: inform patients when care is out of network, support federal policy that protects consumers while restraining costs and ensuring quality networks and pay out-of-network doctors based on a federal standard.

Meanwhile, the American Hospital Association and the Federation of American Hospitals released a joint statement saying hospitals and health systems also support patient protections from surprise billing but place blame on insurers, not providers…

AHIP said surprise billing happens because providers aren’t participating in certain networks. “When doctors, hospitals or care specialists choose not to participate in networks – or if they do not meet the standards for inclusion in a network – they charge whatever rates they like,” the group wrote.

In their statement, the hospital groups also backed consumer protections, but pointed the finger at payers for the issue. “Inadequate health plan provider networks that limit patient access to emergency care is one of the root causes of surprise bills. Patients should be confident that they can seek immediate lifesaving care at any hospital. The hospital community wants to ensure that patients are protected from surprise gaps in coverage that result in surprise bills, and we look forward to working with policymakers to achieve this goal,” they wrote…”  (H)

“I’ve read emergency room bills from all 50 states and the District of Columbia. I’ve looked at bills from big cities and from rural areas, from patients who are babies and patients who are elderly. I’ve even submitted one of my own emergency room bills for an unexpected visit this past summer.

Some of the patients I read about come in for the reasons you’d expect: a car accident, pains that could indicate appendicitis or a heart attack, or because the ER was the only place open that night or weekend….

I’ll stop collecting emergency room bills on December 31. But before I do that, I wanted to share the five key things I’ve learned in my year-long stint as a medical bills collector.

1) The prices are high – even for things you can buy in a drugstore

2) Going to an in-network hospital doesn’t mean you’ll be seen by in-network doctors

3) You can be charged just for sitting in a waiting room

4) It is really hard for patients to advocate for themselves in an emergency room setting

5) Congress wants to do something about the issue.. (I)

“Zuckerberg General’s emergency room fees are also higher, on average, than ERs nationally, in the state of California, and in the city of San Francisco. In the city, they’ve charged up to five times as much. The fees are set by the San Francisco Board of Supervisors, which has voted for steady increases, doubling the charge since 2010.

When asked about the fees, board members admitted that they hadn’t kept a close eye on the prices and said they plan to hold hearings on the issue.

“It turns out we should have been monitoring this much more closely,” says Aaron Peskin, a supervisor who has previously voted in favor of the hospital prices and who is now calling for the hearings…

The city of San Francisco manages Zuckerberg General and sets the prices the hospital charges.

The task falls to the San Francisco Board of Supervisors, an 11-member board that oversees city policies and budgets. Every year or two, they approve a lengthy document that lists hospital prices for everything from an emergency room fee to a day in the obstetrics unit to a primary care exam. The document describes the fees as “proper reasonable amounts.”

The current prices were approved at a board a meeting in July 2017. A video recording of that meeting shows there was no debate or discussion of the prices. Instead, the board of supervisors unanimously approved the ZSFG charges in a voice vote that latest less than a minute…

But there is little record of public discussion or debate over that increase. Meeting records for each vote on the hospital prices since 2010 show that the fees have always been approved unanimously.

“I cannot recall there ever being any discussion of them,” says Peskin, a board member who has served on and off since 2001. “I don’t think there has ever been a split vote, and that’s been true as long as I’ve been on the board of supervisors. But that will probably change now.”..

The San Francisco Board of Supervisors now plans to bring greater scrutiny to the hospital’s billing practices in light of Vox’s reporting.” (J)

“Zuckerberg San Francisco General Hospital is reducing a bike crash patient’s $20,243 bill down to $200 – only after the case drew national attention to the hospital’s surprising policy of being out-of-network with all private health insurance…

The San Francisco Board of Supervisors, which oversees the hospital, now plans to hold hearings on Zuckerberg General’s billing practices as well.”  (K)

“Momentum is building for action to prevent patients from receiving massive unexpected medical bills, aided by President Trump, who is vowing to take on the issue…

Trump gave a boost to efforts on Wednesday.

“[People] go in, they have a procedure and then all of a sudden they can’t afford it, they had no idea it was so bad,” Trump said at a roundtable with patients about the issue.

“We’re going to stop all of it, and it’s very important to me,” he added.

But the effort still faces obstacles from powerful health care industry groups – including hospitals, insurers and doctors. Those groups are jockeying to ensure that they avoid a financial hit from whatever solution lawmakers and the White House back.” (L)

 “There are 141 million visits to the emergency room each year, and nearly all of them.. have a charge for something called a facility fee. This is the price of walking through the door and seeking service. It does not include any care provided.

Emergency rooms argue that these fees are necessary to keep their doors open, so they can be ready 24/7 to treat anything from a sore back to a gunshot wound. But there is also wide variation in how much hospitals charge for these fees, raising questions about how they are set and how closely they are tethered to overhead costs.

Most hospitals do not make these fees public. Patients typically learn what their emergency room facility fee is when they receive a bill weeks later. The fees can be hundreds or thousands of dollars. That’s why Vox has launched a year-long investigation into emergency room facility fees, to better understand how much they cost and how they affect patients…

We found that the price of these fees rose 89 percent between 2009 and 2015 – rising twice as fast as the price of outpatient health care, and four times as fast as overall health care spending.” (M)

 “San Francisco, CA -Today Mayor London N. Breed, Supervisor Aaron Peskin, the Department of Public Health and Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG) announced immediate steps to improve billing practices at ZSFG for patients who have gotten stuck in the middle of disputes between the hospital and their insurance provider, including a temporary halt to the practice of balance billing…

Immediate Changes.

Temporarily halt all balance billing of patients

Effective immediately until a better plan is determined

Make financial assistance easier to get

Proactively begin the process of assessing a patient’s eligibility for assistance, rather than waiting for them to apply

Improve patient communications

Proactively reach out to patients who are receiving large bills to explain the situation, remove the element of surprise, and offer to help

Create a Frequently Asked Questions document to clear up many of the routine questions about billing and financial assistance

Publicize the patient financial services hotline, (415) 206-8448, so that people know where to go for help

Increase communication with patients and provide information about financial assistance opportunities

Additional elements of a comprehensive plan to be developed within 90 days

Make financial assistance easier to get

Adjust charity care and sliding scale policies to expand the number of people who are eligible

Revise ZSFG catastrophic high medical expense program to support more patients who are faced with high, unexpected bills for catastrophic events

Streamline the process of applying for assistance

Protect patients’ financial health

Establish an out-of-pocket maximum for patient payments to ZSFG

Pursue agreements with private insurance companies

Work with state partners to explore additional efforts to improve insurance payments

Ensure ZSFG prices and practices are fair

Undertake a study of hospital charges regionally, comparing trauma centers, academic medical centers, San Francisco and Bay Area hospitals

Research billing and financial assistance practices of California public hospitals to identify opportunities for improvement

Conduct financial analysis of impact on the City of proposed changes (N)

(A)San Francisco General Hospital Lacks A Good Way To Deal With Patients Who Are Actually Insured, https://californiahealthline.org/morning-breakout/san-francisco-general-hospital-lacks-a-good-way-to-deal-with-patients-who-are-actually-insured/

(B)Nasty surprise bills prohibited by new California law when people visit facilities in their insurance network , by Emily Bazar, https://www.sacbee.com/news/local/health-and-medicine/article157970259.html

(C)SF General’s insured patients suffer further trauma when bill arrives, by Heather Knight, https://www.sfchronicle.com/bayarea/heatherknight/article/SF-General-s-insured-patients-suffer-further-13543542.php

(D)A $20,243 bike crash: Zuckerberg hospital’s aggressive tactics leave patients with big bills, by Sarah Kliffsarah, https://www.vox.com/policy-and-politics/2019/1/7/18137967/er-bills-zuckerberg-san-francisco-general-hospital

(E)Report: Zuckerberg Hospital Gouges Paying Patients to Pay For Illegals, by Kit Daniels, https://www.infowars.com/zuckerberg-hospital-offsets-healthcare-costs-of-illegals-by-gouging-privately-insured/

(F)A Fainting Spell After A Flu Shot Leads To $4,692 ER Visit, http://health.wusf.usf.edu/post/fainting-spell-after-flu-shot-leads-4692-er-visit#stream/0

(G)Report: Zuckerberg Hospital Gouges Paying Patients to Pay For Illegals, by Kit Daniels, https://www.infowars.com/zuckerberg-hospital-offsets-healthcare-costs-of-illegals-by-gouging-privately-insured/

(H) Payer, hospital groups trade blame on surprise billing, by Les Masterson, https://www.healthcaredive.com/news/payer-hospital-groups-trade-blame-on-surprise-billing/544064/

(I)Taking Surprise Medical Bills To Court, by Julie Appleby, https://khn.org/news/taking-surprise-medical-bills-to-court/

(J)Prices at Zuckerberg hospital’s emergency room are higher than anywhere else in San Francisco, by Sarah Kliff, https://www.vox.com/2019/1/22/18183534/zuckerberg-san-francisco-general-hospital-er-prices

(K)After Vox story, Zuckerberg hospital rolls back $20,243 emergency room bill, by Sarah Kiff, https://www.vox.com/health-care/2019/1/24/18195686/vox-zuckerberg-hospital-emergency-room-bill

(L)Trump boosts fight against surprise medical bills, by PETER SULLIVAN, https://thehill.com/policy/healthcare/427066-trump-boosts-fight-against-surprise-medical-bills

(M)Emergency rooms are monopolies. Patients pay the price, by Sarah Kliff, https://www.vox.com/health-care/2017/12/4/16679686/emergency-room-facility-fee-monopolies

(N)Zuckerberg hospital puts balance billing on hold, General Hospital Until Plan to Improve Long-Term Billing Practices is Implemented, https://sfmayor.org/article/mayor-london-breed-and-supervisor-aaron-peskin-announce-halt-balance-billing-zuckerberg-san

PART 2:  February 20, 2019. A new bill would outlaw the big, surprise bills that Zuckerberg San Francisco General Hospital has sent to hundreds of patients.

“California lawmakers will introduce legislation Monday to end surprise emergency room bills like those that left one patient with a $20,000 treatment bill after a minor bike crash – a move they say was inspired by Vox’s reporting on the issue.

The new bill, introduced by Assemblyman David Chiu and Sen. Scott Wiener, would bar California hospitals from pursuing charges beyond a patient’s regular co-payment or deductible. The ban would apply even if a hospital was out-of-network with a patient’s health insurance…

California actually has some of the country’s strongest protections against surprise medical bills – but the state’s laws never anticipated a hospital with billing practices like Zuckerberg San Francisco General.

In 2016, California passed a law that protected patients from surprise bills from out-of-network doctors they didn’t choose.

This might happen if, for example, a patient went to an in-network hospital and then received a bill from an out-of-network anesthesiologist or radiologist they never even met.

That law covered patients receiving scheduled care like surgery or delivering a baby. Separately, a decade-old California Supreme Court ruling provided similar protections for emergency room patients.

Neither the court ruling nor the 2016 law anticipated a situation like Zuckerberg San Francisco General, where the entire hospital is “out of network” with all private health insurance.”..

This new legislation would tackle that rarer situation where a hospital is not in network, and then sends the patient a bill for whatever balance their insurer won’t pay.

There are two key parts to the proposal. First, the bill would prohibit hospitals from pursuing any balance that the patient owed beyond their regular co-payment or contributions to the health plan’s deductible.

Second, the bill would regulate the prices that the hospital could charge for its care, limiting the fees to 150 percent of the Medicare price or the average contracted rate in the area, whichever is greater.”  (A)

“Publicity over “balance billing,” a practice that at Zuckerberg San Francisco General Hospital has left some patients with insurance on the hook for thousands of dollars in bills, has prompted San Francisco lawmakers to call for a ban.

SF General made headlines recently for being out of network with all private insurance companies and charging its insured patients high bills — in one case $20,000 for a broken arm — without informing them first of the practice.

Assembly Bill 1161, introduced by Assemblymember David Chiu and state Sen. Scott Wiener, would mandate that insured patients across the state owe the same copayment or deductible they would normally pay for their in-network emergency care.

The ban would apply regardless of whether or not the emergency room is in-network or out-of-network with a patient’s insurer.

Patients receiving non-emergency care already benefit from protections of a similar state law. However, the law does not apply to Preferred Provider Organization (PPO) patients.

Some 6 million people across the state have federally regulated self-insured plans, and some 1 million have plans regulated by the California Department of Insurance who don’t benefit from this protection, per the bill…

He said that the bill is a response “in regard to what we learned is happening at [ZSFGH] — but also across California — this is the situation of patients who get a surprise bill after visiting an emergency room.” (B)

Dear Congressional and Committee Leadership: (C)

On behalf of our member hospitals, health systems and other health care organizations, we are fully committed to protecting patients from “surprise bills” that result from unexpected gaps in coverage or medical emergencies. We appreciate your leadership on this issue and look forward to continuing to work with you on a federal legislative solution.

Surprise bills can cause patients stress and financial burden at a time of particular vulnerability: when they are in need of medical care. Patients are at risk of incurring such bills during emergencies, as well as when they schedule care at an in-network facility without knowing the network status of all of the providers who may be involved in their care. We must work together to protect patients from surprise bills.

As you debate a legislative solution, we believe it is critical to:

Define “surprise bills.” Surprise bills may occur when a patient receives care from an out-of-network provider or when their health plan fails to pay for covered services. The three most typical scenarios are when: (1) a patient accesses emergency services outside of their insurance network, including from providers while they are away from home; (2) a patient receives care from an out-of-network physician providing services in an in-network hospital; or (3) a health plan denies coverage for emergency services saying they were unnecessary.

Protect the patient financially…

Ensure patient access to emergency care…

Preserve the role of private negotiation…

Remove the patient from health plan/provider negotiations…

Educate patients about their health care coverage…

Ensure patients have access to comprehensive provider networks and accurate network information…

Support state laws that work…

Sincerely,

American Hospital Association, America’s Essential Hospitals, Association of American Medical Colleges, Catholic Health Association of the United States, Children’s Hospital Association, Federation of American Hospitals

A.After Vox story, California lawmakers introduce plan to end surprise ER bills, by Sarah Kliff, https://www.vox.com/2019/2/24/18236482/zuckerberg-hospital-surprise-bills-california

B.Controversial ZSFGH billing practice that left privately-insured owing thousands could be banned, by Laura Waxmann, http://www.sfexaminer.com/controversial-zsfgh-billing-practice-left-privately-insured-owing-thousands-banned/

(C) Joint Surprise Billing Letter to Congress and Committee Leadership, https://www.aha.org/letter/2019-02-20-joint-surprise-billing-letter-congress-and-committee-leadership

PART 3. April 18, 2019. “Zuckerberg San Francisco General Hospital announced Tuesday it has overhauled its billing policies…

The hospital has for years made the rare decision to be out of network with all private health insurance plans. This created an acute problem for patients like like Nina Dang, 24, who made an unexpected trip to the hospital’s emergency room, the largest in San Francisco. An ambulance took Dang to the trauma center after a bike accident last April. She is insured by a Blue Cross plan, but she didn’t know that the ER does not accept insurance. She received a bill for $20,243.

After the Vox story ran, the hospital reduced Dang’s bill to $200, the copay listed on her insurance card.

Now, Zuckerberg San Francisco General Hospital (ZSFG) is essentially making the same change for all future patients: Its new billing policies will no longer charge those with private coverage “any more than they would have paid out of pocket for the same care at in-network facilities, based on their insurance coverage.”

This will put an end to the hospital’s use of a controversial practice call “balance billing,” when a hospital sends a patient a bill for the balance that an insurer won’t pay.

ZSFG will also create a new out-of-pocket maximum on what patients could end up owing for their treatment. The maximum is tethered to a patient’s income and ranges from zero dollars for the lowest earners to a $4,800 maximum for those with the highest incomes (1,000 percent of the poverty line, or $251,400 for a family of four).” (A)

“The changes are aimed at shielding patients from large bills by removing them from payment disputes between the hospital and the insurance company, said Rachael Kagan, director of communications with the department.

“We don’t have a large number of privately insured patients at Zuckerberg San Francisco General Hospital, but some of those who have been in that situation in the past have had a terrible experience and we want to rectify that,” said Ms. Kagan.

“We don’t want that to happen in the future. We know that it’s very stressful to get a large bill and we consider our responsibility to the patients to care for them in all ways. They will have gotten excellent medical care from us, and we want to protect their financial well-being also,” she added.

The hospital estimated that up to 1,700 of its 104,000 patients a year may have received a balance bill…

Zuckerberg hospital will also set a maximum out-of-pocket cost for patients at all income levels, with any insurance status, and this maximum will be income-based. No one will be charged more than 5 percent of their income…

Additionally, the hospital will make its patient financial assistance programs easier to qualify for so more people will get financial assistance. This involves increasing the threshold to qualify for the hospital’s charity care program. The threshold to qualify will increase from 350 percent of the federal poverty level to 500 percent of the federal poverty level.

The hospital is also adjusting the “sliding scale” financial assistance program for San Francisco residents. Previously, Zuckerberg hospital assessed eligibility for the program based on income and assets but will now only take income into account…

Overall, she said she’s pleased the hospital is taking these steps to better align its billing with its values and mission.” (B)

A.After Vox stories, Zuckerberg Hospital is overhauling its aggressive billing tactics, by Sarah Kliff, https://www.vox.com/2019/4/16/18410905/zuckerberg-san-francisco-hospital-bills

B.Publicity spurs billing revamp at Zuckerberg hospital, by Kelly Gooch, https://www.beckershospitalreview.com/finance/publicity-spurs-billing-revamp-at-zuckerberg-hospital.html

PART 4: August 18, 20129. Hospitals kept ER fees secret.

Zuckerberg San Francisco General and the University of California San Francisco are two of the city’s busiest hospitals, about 4 miles apart. But if you have private insurance and visit Zuckerberg General, you could end up paying a lot more for the same treatment.

For an especially serious visit, Zuckerberg General charges a facility fee of $11,176, 46 percent more than UCSF, which charges an average of $7,635.

The hospital is also out-of-network with all private insurance, leaving patients responsible for the fee and the cost of treatment. UC San Francisco, meanwhile, accepts insurance from most big providers. Insurers generally negotiate lower prices for patients, and many plans cover ER visits in part or in full…

When asked about the fees, board members admitted that they hadn’t kept a close eye on the prices and said they plan to hold hearings on the issue.

“It turns out we should have been monitoring this much more closely,” says Aaron Peskin, a supervisor who has previously voted in favor of the hospital prices and who is now calling for the hearings…

 “I cannot recall there ever being any discussion of them,” says Peskin, a board member who has served on and off since 2001. “I don’t think there has ever been a split vote, and that’s been true as long as I’ve been on the board of supervisors. But that will probably change now.” (A)

“Frustrated by waiting for federal lawmakers to act, states have been trying to solve this issue. As of December 2018, 25 states offered some protection against surprise billing, and the protections in nine of those states were considered “comprehensive,” according to the Commonwealth Fund. California, New York, Florida, Illinois and Connecticut are among the nine.

New state laws also have been adopted since, including in Nevada, which will limit how much out-of-network providers, including hospitals, can charge patients for emergency care, starting next year.

In California, a 2009 state Supreme Court ruling protects some patients against surprise billing for emergency care, and a state law that took effect in 2017 protects some who receive non-emergency care.

But millions remain vulnerable, largely because California’s protections don’t cover all insurance plans. The California Supreme Court ruling applies to people with plans regulated by the state Department of Managed Health Care. That leaves out the roughly 1 million Californians with plans regulated by the state Department of Insurance and the nearly 6 million people with federally regulated plans, most of whom have employer-sponsored insurance.

The state law governing non-emergency care also doesn’t apply to the millions of residents with health plans regulated by the federal government…

The California Hospital Association opposes the measure, which would limit the amount hospitals could charge insurance plans to a certain rate for each service, varying by region…

 “We fully support the provision of the bill that protects patients. It is the rate-setting piece that is our concern,” she said.”  (B)

“Legislation to prohibit California hospitals from sticking patients with huge emergency room bills that their insurers won’t cover has cleared a crucial hurdle in the state Capitol.

Lawmakers in the Assembly voted 48-9 on Thursday to approve AB1611, which would prohibit hospitals from “balance billing” patients if their insurance won’t cover the full cost for care.

Assemblyman David Chiu and state Sen. Scott Wiener, both Democrats from San Francisco, co-wrote the legislation. The bill now moves to the Senate…

AB1611 would prohibit hospitals from billing patients for any cost beyond their insurance deductible and co-payment. It also spells out rules for how hospitals and insurers resolve cost disputes.” (C)

 “Hospitals focused their opposition on a provision of the bill that would have limited charges for out-of-network emergency services.

The proposal would have required hospitals to work directly with health plans on billing, leaving the patients responsible only for their in-network copayments, coinsurance and deductibles.

Citing fierce pushback from hospitals, California lawmakers sidelined a bill Wednesday that would have protected some patients from surprise medical bills by limiting how much hospitals could charge them for emergency care.” (D)

The legislation, which contributed to the intense national conversation about surprise medical billing, was scheduled to be debated Wednesday in the state Senate Health Committee.

Instead, the bill’s author pulled it from consideration, vowing to bring it back next year.

“We are going after a practice that has generated billions of dollars for hospitals, so this is high-level,” said Assemblyman David Chiu (D-San Francisco). “This certainly does not mean we’re done.” (E)

 “California hospitals want you to know that they’re fully on board with the idea that emergency room patients shouldn’t be hit with thousands of dollars in surprise billings because the ER isn’t in their insurance plan’s network.

You should also know, however, that the hospitals just killed a measure in Sacramento that would have accomplished that goal, and that the reason they did so was to protect their own revenues….

The state’s hospitals went to the mattresses over the payment provision, cursing it as “government rate setting” that they would never accept.

Hospital executives inundated legislators with warnings that rate-setting would force their institutions to shut down.

We have 450 hospitals in California,” says Anthony Wright, executive director of Health Access, “and every hospital CEO has the cellphone number of his state senator and assemblyman. A hospital saying it would close would give pause to any lawmaker.”

The proponents were aware that they were poking a stick into a tiger’s cage. “We’re going after a practice that has generated billions of dollars in profits for hospitals, Chiu told me, “and hospital CEOs around the state waged very aggressive lobbying to protect those profits.”” (F)

“San Francisco’s health network has finalized its first contract with a private health insurer, Canopy Health Canopy — meaning Zuckerberg San Francisco General Hospital, long perceived as the hospital of last resort, is now in the business of wooing expectant mothers to choose to deliver at its Family Birth Center…

Department of Public Health staff said the signing of this contract was not a reaction to billing controversies at ZSFGH that erupted earlier this year, when it was revealed that even insured patients were being hit with crippling debts through the practice of “balance billing.” Because the hospital was out-of-network for private insurance companies, there was often a great divergence between what ZSFGH billed the insurance and what the insurance company would deign to pay — leaving individuals responsible for the “balance.”

This situation, however, did highlight the hospital’s unhealthy and precarious “payer mix.” With few privately insured patients, ZSFGH ministers mostly to Medi-Cal recipients or the marginally insured. Deals like the one initiated July 15 with Canopy would begin to change that mix, however.”  (G)

A.Prices at Zuckerberg hospital’s emergency room are higher than anywhere else in San Francisco, by Sarah Kliff, https://www.vox.com/2019/1/22/18183534/zuckerberg-san-francisco-general-hospital-er-prices

B.Lawmakers Push To Stop Surprise ER Billing, by Ana B. Ibarra, Lawmakers Push To Stop Surprise ER Billing, by Ana B. Ibarra, https://www.google.com/search?q=lawmakers+push+to+stop+surprise+er+billingby+ana+b.+ibarra&ie=&oe=

C.Legislation prompted by huge SF General bills passes California Assembly, by Dustin Gardiner, https://www.sfchronicle.com/politics/article/Legislation-prompted-by-huge-SF-General-bills-13908291.php

D.Hospitals block California’s balance-billing legislation, By Ana B. Ibarra, https://www.benefitspro.com/2019/07/11/hospitals-block-californias-balance-billing-legislation/

E.Lawmakers Push To Stop Surprise ER Billing, by Ana B. Ibarra, https://californiahealthline.org/news/lawmakers-push-to-stop-surprise-er-billing/

F.Column: How the hospital lobby derailed legislation to protect you from surprise hospital bills, by MICHAEL HILTZIK, https://www.latimes.com/business/story/2019-08-01/hospital-lobby-surprise-billing-legislation

G.San Francisco inks first contract with private health insurer, by Joe Eskenazi, https://missionlocal.org/2019/07/san-francisco-inks-first-contract-with-private-health-insurer/

Prequel ((still unabridged))

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