SEPTEMBER 11, 2001. PART 1. Military helicopters and jets were overhead, as President Bush was getting ready to leave NYC. PART 2. LESSONS LEARNED memorandum by hospital CEO Jonathan Metsch goes “viral”…

PART 1. *written by Jonathan M. Metsch on September 14, 2001; published in the Jersey Journal on September 18, 2001

Military helicopters and jets were overhead, as President Bush was getting ready to leave. The plumes of smoke from the World Trade Center were still billowing skyward.

Suddenly a huge white military hospital ship with four Red Crosses steamed by and docked right across river. I thought how this hospital ship brought the war even closer to home but mostly about how the hospitals in Hudson County had responded and performed so magnificently.

Liberty HealthCare System is comprised of Jersey City Medical Center, Greenville Hospital, and Meadowlands Hospital Medical Center. The Medical Center, the County’s Trauma Center, treated 175 patients. Greenville treated 11 patients and processed over 500 volunteers who wanted to give blood; Greenville had originally been asked by the Red Cross to be a blood center but this was changed early on so donor information was passed (every volunteer was “typed and matched”) to the blood collection centers. Meadowlands treated 7 patients and was preparing to be a command center given its heliport; late Tuesday night Governor DiFrancesco used the heliport to depart from his visit to the triage center at Liberty State Park.

Every hospital in the County provided emergency services to victims. According to the Jersey Journal: Palisades Medical Center treated 12 patients; St. Francis Hospital treated 67 patients; Christ Hospital treated 54 patients; St. Mary Hospital treated 74 patients. Bayonne Hospital treated 58 patients.

At the Medical Center staff watched from windows the attack on the World Trade Center, then immediately went on Disaster Alert. Over 150 physicians covering all medical and surgical specialties were in the building as they are every day, and over 1000 other staff joined predetermined teams – trauma and surgery in the emergency room, and “walking wounded” in the auditorium. The library was organized for aftercare and rooms were set up for family members arriving from all over the metropolitan area. The injured started arriving around 10AM and suddenly, and sadly, everything stopped about 6PM. We hope and waited for more patients, and still wait “on alert”, our hope fading.

Since the New York City Command Center was in the World Trade Center complex and destroyed, good information was not available. We were told to expect somewhere between 2000 and 5000 injured.

Many others contributed to our success in handling the medical response to this act of war:

– Over 200 ambulances simply appeared from all over the state to assist. They were restocked from Medical Center inventory and dispatched by Medical Center EMS.

– New Jersey Commissioner of Health and Senior Services George DiFerdinando was in contact with us immediately and made sure we were re-supplied, and developed a plan with whereby trauma centers outside of Hudson County were on high alert so patients could be transported there to prevent Hudson County hospitals from being overwhelmed.

– Every hospital in the New Jersey was on disaster alert with elective admissions and surgery cancelled, and disaster teams ready until late Tuesday evening.

– Providers of food, IV solutions, medications, surgical supplies, and much more sent in truckloads of supplies without being asked.

– Volunteers poured in to help us in any way possible. For example with their help a “Hot Line” was set up at the Medical Center with up-to-date information on all disaster victims seen at New Jersey hospitals. This “Hot Line” was soon designated as “official” until the New York City Command Post was reestablished.

– Hudson Cradle opened its doors, wanting to help, wanting to serve.

– Mayor Cunningham and Jersey City police and fire officials coordinated all local efforts while supporting the recovery in New York City and securing the waterfront where victims were arriving by ferry in great numbers to several sites including Exchange Place and Liberty State Park. I know public officials in Hoboken, Secaucus, Bayonne and Weehauken did the same.

– And untold numbers were praying for the victims and those providing care – we could feel those prayers.

How can you help? Volunteer to give blood; blood will be needed for weeks and months to come. If you can, make a cash donation to help the families of those killed in this tragedy. Certainly go to community vigils and prayer services. Befriend someone who does not look like you and let them know that all Americans share this pain together and that the beauty of America is that we all came from somewhere else, and now live and work harmoniously side-by-side.

On a practical level we and other local hospitals can use your help. If you are a mental health worker and want to help with World Trade Center disaster Crises Counseling in hospitals, schools, and offices please call us. If you are a nurse who works outside the County or doing something else right now – particularly emergency room, critical care and operating room nurses, though all nurses are welcome – and want to be on our roster of volunteers for future emergencies please us. And if you just want to join the cadre of volunteers at our hospitals please call us. Please call 201 915-2048.

Finally I want to thank all the staff at Liberty, who once again, provided services so well. They acted heroically while worried about missing family and friends, and their children at home who had to cope with this tragedy without them nearby. I am honored to work with you.

PART 2. Confidential September 11, 2001 LESSONS LEARNED memorandum by hospital CEO Jonathan Metsch goes “viral” and becomes a New Jersey gubernatorial campaign issue

Since Jersey City Medical Center was the New Jersey anchor in the response, I prepared a confidential Lessons Learned memorandum in preparation for a Debriefing Meeting called by the Democratic Party candidate for Governor.

As a courtesy I provided a copy of the memorandum to Bret Schundler, the former Mayor of Jersey City who was out-of-the country on September 11th and could not get back for almost a week. He was the Republican Party candidate for Governor. I forget that “No good deed goes unpunished” and Schundler widely circulated the document as a campaign issue.

“Rookie” mistake! Read the article below. What would you have done differently?

New York Times. September 22, 2001

Schundler Assails New Jersey’s Response to Terrorist Attack

By DAVID M. HALBFINGER

Making the World Trade Center disaster the focus of his campaign for governor, Bret D. Schundler is criticizing New Jersey’s response to the attack and has released his own plan to improve the state’s defenses against terrorism and its preparedness for future emergencies.

Mr. Schundler, the Republican candidate, has said that both the State Police and the National Guard reacted slowly and mismanaged their resources after the Sept. 11 attack, and that flaws in New Jersey’s emergency-management system made it difficult to coordinate the efforts of hospitals, ambulance crews and other volunteers.

Mr. Schundler, the former mayor of Jersey City, is now calling for bolstering New Jersey’s defenses, including restoring to the nation’s air-defense system an Air National Guard fighter wing that is stationed in Atlantic City and which, until two years ago, had two F-16’s ready to scramble 24 hours a day. He said New Jersey should conduct a thorough inventory of sensitive installations, like power plants, reservoirs and chemical factories, and immediately enhance security at Newark Airport and the the Hudson and Delaware River crossings.

He is also proposing an array of measures to improve the state’s response to emergencies, like maintaining rosters of doctors, nurses, engineers and others who might be needed in the case of another terrorist attack.

Mr. Schundler’s aides described his proposals as an attempt to provide leadership where it was needed and denied that he was trying to jump-start his campaign, which has stalled along with most of the political machinery in New Jersey.

But in critiquing the state agencies, hospitals and other institutions that responded to the attack — while the smoke is still rising from ground zero and many voters are still awaiting the remains of their loved ones — Mr. Schundler is running a huge risk: that he could be seen as trying to make hay out of a national tragedy.

”This is not a political exercise,” said Richard McGrath, a spokesman for James E. McGreevey, the Democratic candidate. ”Jim McGreevey’s been working in a quiet way to assimilate as much information as possible to address emergency needs and prevent future catastrophes,” Mr. McGrath said. ”This terrorist incident has had a profound effect on all Americans, and we don’t intend to parcel it out with any political agendas.”

In a telephone interview he initiated on Thursday, Mr. Schundler described a number of ways in which the state’s response to the attack had apparently broken down. For instance, he said he had been told by a police official in Jersey City that the State Police troopers who set up an operations center in Liberty State Park ”didn’t do much of anything — they just sat there.”

Mr. Schundler added that the troopers’ ”inaction” had forced the city’s police department to coordinate the supply effort for emergency workers, and said that troopers did not even arrive in Jersey City until 4:30 p.m. on the day of the attack.

Officials of the State Police and other agencies today briefed Mr. Schundler and Mr. McGreevey about their efforts. But on Thursday, Col. Carson Dunbar, the superintendent of the force, said there had been numerous tussles over turf in the hours after the attack, which were compounded by the loss of a radio-transmission tower at the World Trade Center, and which could have led to crossed signals about troopers’ assignments. But Colonel Dunbar said that state troopers were on the scene in Jersey City almost immediately after the attack. For instance, he said, one marine unit was among the first to ferry the injured to safety in New Jersey.

On Thursday, Mr. Schundler also released a five-page memorandum about breakdowns in the state’s response system that was prepared by Jonathan M. Metsch, president and chief executive of Jersey City Medical Center, which treated 175 people hurt in the attack.

The memo noted that police from outside Jersey City had prevented staff members from getting to the hospital; that National Guard troops who drove ambulances to the hospital ”had no leadership and provided no help”; that the blood donor system ”did not work”; and that it ”took too long” to prepare a list of the injured being treated at New Jersey hospitals, meaning each hospital was inundated with thousands of calls.

Dr. Metsch, reached today, said he had written the memo for state health officials, that it amounted only to his own impressions, and that he had done so merely to ensure that lessons would be learned, not to assess blame. He said he provided a copy to Mr. McGreevey on Wednesday after a private meeting of hospital executives that Mr. McGreevey had called to inquire about the response to the twin towers attack and ways to improve New Jersey’s readiness.

Dr. Metsch said he then provided a copy to Mr. Schundler, whom he called a friend, as a courtesy. But he said he had not expected the memo to be released to the public. ”These were off-the-record observations,” he said, adding that over all, New Jersey performed admirably.

But Bill Pascoe, Mr. Schundler’s campaign manager, said Dr. Metsch had not asked Mr. Schundler to keep the memo confidential. And he said Mr. Schundler’s use of it transcended politics.

”If the U.S. responds anytime in the next few days or weeks, we may be facing an immediate counterattack from the terrorists,” Mr. Pascoe said.

”We don’t have the luxury of time to let the dust settle. We have to use this event and our response to it right now as a learning exercise. What have we learned about what we did right and did wrong? What can we do better? That’s the point, and that’s the job of a leader.”

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RAPID RESPONSE. Hurricane Dorian – Hospital Preparedness

ASSIGNMENT: You are the CEO of a hospital in the cone of Hurricane Dorian! Tomorrow morning you have an 8AM Board of Trustees Conference Call to brief Board members on your hospital’s Rapid Response plan.

Starting with the sources below prepare your 15 minute presentation!

____________________

We don’t know what we don’t know” The challenge to emergency preparedness…..

Project Management. The hardest part of getting started….is getting started  http://doctordidyouwashyourhands.com/2019/04/project-management-the-hardest-part-of-getting-started-is-getting-started/

“…the only way..to respond to a crisis ..is to ensure every member of the staff feels as though they are part of a team.” (Hurricanes, Mass Disasters, Wild Fires)

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

______________________

Hospital disaster preparedness: best practices learned from Hurricane Irma

https://www.beckershospitalreview.com/supply-chain/hospital-disaster-preparedness-best-practices-learned-from-hurricane-irma.html

Hurricane Season Ready: Preparedness and Response Resources

Agency for Health Care Administration.  Health Care Facility Updates

https://ahca.myflorida.com/MCHQ/Emergency_Activities/DORIAN_2019.shtml

Hurricane Preparedness in New York State

https://www.phe.gov/Preparedness/planning/hpp/sandy/Pages/prepare.aspx

5 lessons all cities can learn from Hurricane Katrina

https://fortune.com/2015/08/27/5-lessons-all-cities-can-learn-from-hurricane-katrina/

Lessons learned from Hurricane Sandy

________________

Hospitals gather supplies, prepare staff as Hurricane Dorian approaches Florida coast

https://www.cnbc.com/2019/08/29/hospitals-prepare-for-hurricane-dorian-on-pace-for-florida.html

How Florida hospitals are getting ready for Hurricane Dorian

https://qz.com/1699375/how-florida-hospitals-are-preparing-for-hurricane-dorian/

Hurricane Dorian: Central Florida hospitals making sure they’re ready, and free-standing ERs, too

https://www.orlandosentinel.com/health/os-ne-hurricane-dorian-hospitals-central-florida-20190829-45xyaawd4ra7nn4stxvsp35e4i-story.html

Southwest Florida hospitals are ready for Hurricane Dorian

Palms West Hospital

https://palmswesthospital.com/health-info/hurricane-preparedness/

Memorial Hospital Jacksonville

https://memorialhospitaljax.com/health-info/hurricane-preparedness/

West Florida Hospital

https://westfloridahospital.com/health-info/hurricane-preparedness/

“Houston’s world-renowned health care infrastructure found itself battered by Hurricane Harvey, struggling to treat storm victims while becoming a victim itself.”

After Hurricane Harvey – Robust Public Health Response

Hurricane Harvey. “There’s no need to test it (flood water),”…“It’s contaminated. There’s millions of contaminants.”…

“Calling 911 (about Hurricane Harvey) didn’t work. Begging for help on Facebook and Instagram failed, too. “I was like, ‘Siri’s smart enough! Let me ask her!’ …

After Hurricane Harvey a man in Texas says he got infected with flesh-eating bacteria

As he looked at the full beds and patients “packed and stacked in the hallways,” he shifted into triage mode, asking himself “Who’s dying first?” and who could he save.

It appears that Hurricane Irma evacuation shelter managers may make people wait outside for hours? If so, just welcome them in and then do the registration process inside.

‘This Is Like in War’ – Lessons Learned about Hospital Hurricane Preparedness

The new Jersey City Medical Center (2004) was constructed above the 100 year flood plain – then came Sandy, Harvey & Irma

You are Chief Preparedness Officer at Chiang Rai Region General Hospital in Thailand waiting for the twelve boys and their coach trapped in a cave

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“When you come to a fork in the road, take it.”

Over the years I have collected some aphorisms, quotations and “classics” perhaps worth sharing.

“I made a lot of mistakes in my time but didn’t waste any time making them.” (attributed to Gustave Levy, Goldman Sachs)

“There are no secrets to success. It is the result of preparation, hard work and learning from failure.” (Colin Powell)

“A person who never made a mistake never tried anything new.” (Albert Einstein)

The three umpires (attributed to many):

At a post-season symposium three umpires were discussing “what’s a ball and what’s a strike?”

The rookie umpire said “There are balls and there are strikes and I call them as they are.”

The mid-career umpire said “There are balls and there are strikes and I call them as I seem them.”

The veteran umpire said “There are balls and there are strikes but they ain’t nothing til I call them.”

“Trust, but verify!” (Ronald Reagan)

“If Columbus had an advisory committee he would probably still be at the dock.” (Arthur Goldberg)

“Meetings without an agenda are like a restaurant without a menu.” (Susan B. Wilson)

Dr. Jerome Groopman in “How Doctors Think” developed a classification system for medical mistakes, observing a tendency to treat a case based on past experience rather than looking at it based solely on the evidence.

Vertical Line Failure – thinking inside the box

Confirmation Bias – confirming what you expect to find by selectively accepting or ignoring information

Anchoring –the failure to consider multiple possibilities but quickly and firmly latching on a single one

Availability –an unusual event that recently occurred which has similarities to the current case causing MD to ignore important differences

Commission Bias – tendency toward action rather than inaction due to “bravado”, desperation, or patient pressure

Relying on “Strict Logic” – answering a clinical question in the absence of empirical data

Over-reliance on Clinical Algorithms – simply filling in the blanks on the template

Haste – complicated problems cannot be solved quickly

Outcome Bias – thinking that the diagnosis that is wished for has occurred• Limited Searching –stop searching for a diagnosis once “

This is not to criticize physicians who get most things right and in a very challenging, fast-moving environment occasionally make mistakes. The point is we all fall into comfortable patterns of thinking – our own default classification systems.

“If you’re stuck in a routine that’s limiting your creativity or you’re faced with a challenging business problem and need a fresh approach, you can think outside the box. Or even better, think like there is no box.”

When you’re not sure flip a coin because while the coin is in the air, you realize which one you’re hoping for.” (source unknown)

“There are known knowns. These are things we know that we know. There are known unknowns. That is to say, there are things that we know we don’t know. But there are also unknown unknowns. These are things we don’t know we don’t know.” (Donald Rumsfeld)

“No battle plan survives contact with the enemy.” (Helmuth von Moltke the Elder. He was the Chief of Staff of the Prussian army before World War 1)

“Insanity: doing the same thing over and over again and expecting different results.” (Einstein)

“Life is What Happens to You While You’re Busy Making Other Plans.” (John Lennon)

“Never, never, never give up.” (Winston Churchill)

“Don’t depend on anyone else to bring the coffee.” (me)

“The best things in life aren’t things?” (Art Buchwald)

…and the most important

“Character is how you act when no one is watching” (attributed to many)

And….

“When you come to a fork in the road, take it.”  Yogi Berra

SO YOU WANT TO BE A CEO

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

“If you don’t have a seat at the table, you’re probably on the menu.”

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

DON’T DEPEND ON ANYONE ELSE TO BRING THE COFFEE! & other Lessons Learned as a junior hospital CEO back in the day….

“Trust but Verify” (Ronald Reagan) – Four Lessons Learned as a junior CEO back in the day..

Confidential September 11, 2001 LESSONS LEARNED memorandum by hospital CEO Jonathan Metsch goes “viral” and becomes a New Jersey gubernatorial campaign issue

If Columbus had an advisory committee he would probably still be at the dock. (A)

We don’t know what we don’t know” (1) The challenge to emergency preparedness…..

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PART 4. San Francisco General, a public hospital with San Francisco’s only trauma center, all commercial insurance WAS “out-of-network.”

See new PART 4 after PARTS 1, 2and 3.

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)

“The largest public hospital in the city, Zuckerberg San Francisco General cares for 20 percent of all San Franciscans, according to the hospital’s website..

But contrary to the hospital’s position, only 1 percent of ambulance rides nationwide drop patients at out-of-network emergency rooms, according to a study by economist Christopher Garmon at the University of Missouri Kansas City. The study also found that approximately 20 percent of emergency department admissions nationwide resulted in a surprise medical bill. Because of its size and top-tier emergency room, Zuckerberg San Francisco General takes in one-third of ambulances in the city, meaning many of its patients, some unconscious on arrival, are unaware of the hospital’s unusual lack of support for their insurance…

“As a Level 1 trauma center, we must meet certain requirements, 24/7/365, as delineated in the California Code of Regulations (CCR) and by state and national credentialing agencies. The requirements are substantial and, because they require such commitment of resources, costly,” a statement from ZSFG released to Newsweek reads. “We realize there are challenges, difficulties and inefficiencies in our national system of healthcare insurance. We realize burdens are often placed on individuals who are least able to afford them. And we are not in the position of defending the inequities of this system, only working within our prevailing system to the best of our abilities.” (E)

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.” (F)

“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.”

The other side: Ashley Thompson, SVP of policy at the American Hospital Association, said in a statement that “patients and their families should be protected from…unexpected medical bills,” but “insurers have the primary responsibility for making sure their networks include adequate providers.”” (G)

“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.” (H)

“Congress is considering bipartisan legislation to limit balance billing. But some legal scholars say that patients should already be protected against some of the highest, surprise charges under long-standing conventions of contract law.

That’s because contract law rests on the centuries-old concept of “mutual assent,” in which both sides agree to a price before services are rendered, said Barak Richman, a law professor at Duke University.

Thus, many states require, and consumers expect, written estimates for a range of services before the work is done – whether by mechanics and plumbers or lawyers and financial planners.

But patients rarely know upfront how much their medical care will cost, and hospitals generally provide little or no information.

While consumers are obligated to pay something, the question is how much? Hospitals generally bill out-of-network care at list prices, their highest charges.

Without an explicit price upfront, contract law would require medical providers to charge only “average or market prices,” Richman said.

In several recent cases, for example in New York and Colorado, courts have stepped in to mediate cases where a patient received a big balance bill from an out-of-network provider. They ordered hospitals to accept amounts far closer to what they agree to from in-network private insurers or Medicare.

“This is the amount they are legally entitled to collect,” said Richman…

That complexity – and the cost of hiring an attorney – have made legal challenges to medical bills on the basis of contract law relatively scarce.

Also, “it’s not a well-settled area of the law,” said Hall. “(I)

“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…

National leaders have been working on the issue too, but so far a bipartisan effort has only resulted in drafted legislation. The bill would require payers to reimburse out-of-network providers at 125% of the average in-network rate while limiting patient liability to in-network costs.” (J)

“For the past 15 months, I’ve asked Vox readers to submit emergency room bills to our database. I’ve read lots of those medical bills – 1,182 of them, to be exact.

My initial goal was to get a sense of how unpredictable and costly ER billing is across the country. There are millions of emergency room visits every year, making it one of the more frequent ways we interact with our health care system – and a good window into the health costs squeezing consumers today…

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.. (K)

“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.” (L)

“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.

“While we as a city should absolutely seek reimbursement from private insurers, we should not be placing the burden of exorbitant bills on patients – who deserve the highest quality care, not the highest possible costs,” said Gordon Mar, the supervisor who chairs the board’s government audit and oversight committee…

Zuckerberg San Francisco General Hospital has not commented on whether it plans to change its policies, and go in-network with private health insurance, although a spokesperson told Vox they are looking into how to make sure other patients don’t end in a situation like Dang’s.

“We are focused on reducing the number of people who could be in this predicament, through a variety of methods, including our own practices, insurance payments, and policy solutions,” spokesperson Rachael Kagan told Vox in an email.” (M)

“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.

Calls for action against so-called surprise medical bills have been growing, spurred by viral stories like one involving a teacher in Texas last year who received a $108,951 bill from the hospital after his heart attack. Even though the teacher had insurance, the hospital was not in his insurance network.

Lawmakers in both parties say they want to take action to protect people from those situations, marking a health care area outside of the partisan standoff over ObamaCare, where Congress could advance bipartisan legislation to help patients.

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.” (N)

“And the Republican chairman of the Senate health committee told reporters recently he expects pushback from the industry – but warned industry to act before Congress does. “The first place to deal with it is for the hospitals and doctors and insurance companies to get together and end the practice,” Sen. Lamar Alexander, R-Tenn., said. “And if they don’t, Congress will do it for them.” The senator hasn’t, however, put forward any specific legislation or scheduled hearings on the topic yet.” (O)

“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.” (P)

“Matt Gleason had skipped getting a flu shot for more than a decade.

But after suffering a nasty bout of the virus last winter, he decided to get vaccinated at his Charlotte, N.C., workplace in October. “It was super easy and free,” said Gleason, 39, a sales operations analyst.

That is, until Gleason fainted five minutes after getting the shot. Though he came to quickly and had a history of fainting, his colleague called 911. And when the paramedics sat him up, he began vomiting. That symptom worried him enough to agree to go to the hospital in an ambulance.

He spent the next eight hours at a nearby hospital – mostly in the emergency room waiting area. He had one consult with a doctor via teleconference as he was getting an electrocardiogram. He was feeling much better by the time he saw an in-person doctor, who ordered blood and urine tests and a chest-X-ray.

All the tests to rule out a heart attack or other serious condition were negative, and he was sent home at 10:30 p.m.

And then the bill came.

Total Bill: $4,692 for all the hospital care, including $2,961 for the ER admission fee, $400 for an EKG, $348 for a chest X-ray, $83 for a urinalysis and nearly $1,000 for various blood tests. Gleason’s insurer, Blue Cross and Blue Shield of North Carolina, negotiated discounts for the in-network hospital and reduced those costs to $3,711. Gleason is responsible for that entire amount because he had a $4,000 annual deductible. (The ambulance company and the ER doctor billed Gleason separately for their services, each about $1,300, but his out-of-pocket charge for each was $250 under his insurance.)..

The biggest part of Gleason’s bill – $2,961 – was the general ER fee. Atrium coded Gleason’s ER visit as a Level 5 – the second-highest and second-most expensive – on a 6-point scale. It is one step below the code for someone who has a gunshot wound or major injuries from a car accident. Gleason was told by the hospital that his admission was a Level 5 because he received at least three medical tests.

Gleason argued he should have paid a lower-level ER fee, considering his relatively mild symptoms and how he spent most of the eight hours in the ER waiting area.

The American Hospital Association, the American College of Emergency Physicians and other health groups devised criteria in 2000 to bring some uniformity to emergency room billing. The different levels reflect the varying amount of resources (equipment and supplies) the hospital uses for the particular ER level. Level 1 represents the lowest level of ER facility fees, while ER Level 6, or critical care, is the highest. Many hospitals have adopted the voluntary guidelines…

Blue Cross and Blue Shield of North Carolina said in a statement that the hospital “appears to have billed Gleason appropriately.” It noted the hospital reduced its costs by about $980 because of the insurer’s negotiated rates. But the insurer said it has no way to reduce the general ER admission fee…

Gleason, in fighting his bill, actually got the hospital to send him its entire “chargemaster” price list for every code – a 250-page, double-sided document on paper. He was charged several hundred dollars more than the listed price for his Level 5 ER visit…

Resolution: After Gleason appealed, Atrium Health reviewed the bill but didn’t make any changes. “I understand you may be frustrated with the cost of your visit; however, based on these findings, we are not able to make any adjustments to your account,” Josh Crawford, nurse manager for the hospital’s emergency department, wrote to Gleason on Nov. 15.” (Q)

Zuckerberg hospital puts balance billing on hold

Mayor London Breed and Supervisor Aaron Peskin Announce Halt to Balance Billing at Zuckerberg San Francisco General Hospital Until Plan to Improve Long-Term Billing Practices is Implemented

Friday, February 01, 2019

“Department of Public Health and ZSFG will develop a comprehensive plan for improvements within 90 days to address the issue of patients being billed the balance of their bills when their private insurers refuse to cover their bills

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.

The San Francisco Department of Public Health (DPH) operates ZSFG as part of the San Francisco Health Network, the City’s public health care system. As San Francisco’s public hospital, the vast majority of ZSFG patients have Medi-Cal, Medicare or are uninsured. About 6 percent of patients have commercial insurance (including HMO or PPO plans) and come to ZSFG through trauma and emergency services. For those patients, their insurance is billed for services, and the insurance company decides what to pay. When an insurance company does not pay in full, PPO patients can be billed for the balance, a practice known as “balance billing.”

“Although ‘balance billing’ affects a very small number of ZSFG patients, the stress and hardship they experience when it happens is very real,” said Mayor Breed. “We need to look hard at our current billing practices, and until we come up with a plan that works for patients, we will not continue the practice of balance billing. In an emergency, people’s focus should be on getting help quickly, not on what hospital they should go to. Private insurance companies also need to be held accountable to actually pay for the healthcare for anyone they cover.”

“The City is taking the right step by stopping the practice of balance billing at SF General, because there’s nothing ‘balanced’ about it,” said Supervisor Peskin. “It’s extra billing for services that patients don’t have a choice about receiving, further delaying their ability to move on and heal. This immediate halt also covers the previous patients who’ve been stuck with crippling bills, including those being sent to collections. Healing delayed is healing denied, so I’m looking forward to working with the Department of Public Health on a new path forward.”

Greg Wagner, Acting Director of Health, and Dr. Susan Ehrlich, CEO of ZSFG, outlined a set of immediate actions and elements of a comprehensive plan for improvement that will be developed within 90 days. This includes making changes to billing practices, financial assistance and patient communications. In addition, DPH and ZSFG are exploring policy solutions in coordination with local and state elected officials.

“The billing practices at Zuckerberg San Francisco General Hospital and Trauma Center for privately insured patients who receive trauma and emergency services are not working for some of our patients,” Wagner said. “Keeping the patients’ experience as the focal point, we will explore ways to protect patients from financial hardship, increase participation in financial assistance programs and where possible, recover costs for services from insurers to avoid lost revenues to the City.”

“While hospital billing in the United States is very complicated, patients should not be caught in the middle of disputes between hospitals and insurance companies,” Ehrlich said. “At ZSFG, our mission is to provide high quality health care and trauma services with compassion and respect to everyone in San Francisco. We are working to ensure that our billing practices better align with that mission. We are sensitive to people’s circumstances and our patients come from all over the economic spectrum. We cannot solve the problems of the entire health care system, but we can do better to serve San Franciscans, who consistently have supported ZSFG and the rest of the City’s excellent public health programs and services.”

DPH and ZSFG have continued to address the problem of insurance payment shortfalls. DPH sued insurers for underpayment and reached settlements, reducing the number of privately insured patients who might be affected by a dispute. DPH’s patient financial services department works with individuals year-round to help them with billing issues, including financial assistance and appeals to insurance plans.

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 (R)

(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)Zuckerberg Hospital ER Doesn’t Take Private Insurance, Sticking San Francisco Patients With Huge Bills, by Andrew Whalen, https://www.newsweek.com/zuckerberg-hospital-er-private-insurance-medicare-medicaid-mark-facebook-san-1282274

(F)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/

(G)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

(H)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/

(I)Why there’s no surprise hospital bill backlash – yet, https://www.axios.com/hospital-medical-bill-backlash-21127cf3-cffc-4751-9ae5-cadda7b5d3c4.html

(J) 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/

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

(L))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

(M) 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

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

(O)Industry braces as more lawmakers seek to ban surprise billing, by Shannon Mushmore, https://www.healthcaredive.com/news/industry-braces-as-more-lawmakers-seek-to-ban-surprise-billing/547015/

(P) Sarah Kliff has spent the past year reporting on high ER fees. Ask her anything, by Lauren Katz, https://www.vox.com/health-care/2019/1/22/18188777/emergency-room-fees-health-care-costs

(Q)After Vox story, Zuckerberg hospital rolls back $20,243 emergency room bill, by Sarah Kliff, http://health.wusf.usf.edu/post/fainting-spell-after-flu-shot-leads-4692-er-visit#stream/0

(R)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.

“These practices are outrageous,” says Chiu, who represents part of San Francisco in the state assembly. “No one who is going through the trauma of emergency room care should be subsequently victimized by outrageous hospital bills.”..

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.

“Patients would no longer receive exorbitant, surprise bills,” says Chiu. “The discussion between insurers and hospitals would become far more predictable.” ” (A)

“”At the heart of what we are trying to do is to ensure that if you or are a loved one are in the ER, the only thing you should be thinking about is how to get better and not about the bill for that care,” said Chiu.

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.”..

Rachael Kagan, a spokesperson for the San Francisco Public Health Department, which manages the hospital, said in a statement on Friday that the department can’t comment on the proposed legislation but that “we absolutely agree that there is a role for policy changes to improve patients’ experience with billing,” including “local state and federal efforts.”

She added that the hospital and department are working in the meantime on making improvements. One proposal so far suggests capping out-of-pocket payments made by insured patients receiving emergency services, as was previously reported by the San Francisco Examiner.” (B)

Joint Surprise Billing Letter to Congress and Committee Leadership (C)

Dear Congressional and Committee Leadership:

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. Patients should have certainty regarding their cost-sharing obligations, which should be based on an in-network amount. Providers should not balance bill, meaning they should not send a patient a bill beyond their cost-sharing obligations.

Ensure patient access to emergency care. Patients should be assured of access to and coverage of emergency care. This requires that health plans adhere to the “prudent layperson standard” and not deny payment for emergency care that, in retrospect, the health plan determined was not an emergency.

Preserve the role of private negotiation. Health plans and providers should retain the ability to negotiate appropriate payment rates. The government should not establish a fixed payment amount or reimbursement methodology for out-of-network services, which could create unintended consequences for patients by disrupting incentives for health plans to create comprehensive networks.

Remove the patient from health plan/provider negotiations. Patients should not be placed in the middle of negotiations between insurers and providers. Health plans must work directly with providers on reimbursement, and the patient should not be responsible for transmitting any payment between the plan and the provider.

Educate patients about their health care coverage. We urge you to include an educational component to help patients understand the scope of their health care coverage and how to access their benefits. All stakeholders – health plans, employers, providers and others – should undertake efforts to improve patients’ health care literacy and support them in navigating the health care system and their coverage.

Ensure patients have access to comprehensive provider networks and accurate network information. Patients should have access to a comprehensive network of providers, including in-network physicians and specialists at in-network facilities. Health plans should provide easily-understandable information about their provider network, including accurate listings for hospital-based physicians, so that patients can make informed health care decisions. Federal and state regulators should ensure both the adequacy of health plan provider networks and the accuracy of provider directories.

Support state laws that work. Any public policy should take into account the interaction between federal and state laws. Many states have undertaken efforts to protect patients from surprise billing. Any federal solution should provide a default to state laws that meet the federal minimum for consumer protections.

We look forward to opportunities to discuss these solutions and work together to achieve them.

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

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

, a move that comes three months after a Vox story drew national attention to the hospital’s abnormal and aggressive billing tactics.

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)

“We may get called the “enemy of the people,” but the press can make a real difference in forcing the powers that be into changing some of their most horrific and unfair practices. Consider Zuckerberg San Francisco General Hospital, which has been hounded by pesky reporters covering their “aggressive billing tactics” with privately insured patients.

In the wake a January Vox report showing a fully insured woman was charged $20,000 for a broken arm and a San Francisco Chronicle exposé detailing a $92,000 appendectomy, the city’s only trauma center (named for a billionaire worth $70 billion, give or take) has announced a significant change to its billing policy. The Chronicle reports that Zuckerberg General is reversing the policy, and establishing “out-of-pocket” maximum that should not exceed $4,800 for patients with copays. Vox got a copy of the announcement which claims the practice was “was halted on February 1, 2019 and will not resume.”

The practice is called “balance billing,” an Orwellian term that indicates some sort of fairness and balance in a system that bills fully insured patients tens of thousands of dollars for routine injury treatments. Zuckerberg General, which primarily serves Medicare, Medi-Cal, and uninsured patients, had employed an unusual system where fully insured patients’ insurance companies could just choose how much they wanted to cover or not cover, effectively ignoring whatever copay amount they had communicated to the patient.” (C)

“A doctor assured DeAnn Allen the trace of blood in her urine after a car crash was just a little bruising, but she wouldn’t have guessed it by the size of her bill.

That urine test and visit with the doctor cost Allen, who was visiting Las Vegas, more than $1,800.

“If you care about your care, and have a choice, we urge you to go somewhere else!” Allen wrote in a review on Facebook for Elite Medical Center, Las Vegas’ newest emergency hospital situated just west of the Strip.

Just like any full-service emergency room, Elite Medical Center treats a range of urgent medical problems, from headaches to heart attacks. But unlike the other ERs in Southern Nevada, you’ll generally pay more for your care.

That’s because the facility doesn’t contract with any insurer. So if you break a bone or your child has an earache and you go there, you’ll be paying for out-of-network care.

Elite is licensed as a hospital by the state, but experts say it is operating similarly to freestanding emergency rooms that have become common recently in other states. It is the only unaccredited hospital in Clark County that provides emergency care but doesn’t contract with insurers…

There’s no license for a freestanding ER in Nevada, though hospitals are allowed to open satellite emergency rooms that provide care at other locations.

Elite Medical Center pursued a different path by getting the state to license it as a hospital. That means the facility has the capacity to keep patients for 48 hours.

State law doesn’t mandate these facilities be accredited by the federal Centers for Medicare or Medicaid Services or accept any insurance, private or public.” (D)

  1. 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
  2. B.Publicity spurs billing revamp at Zuckerberg hospital, by Kelly Gooch, https://www.beckershospitalreview.com/finance/publicity-spurs-billing-revamp-at-zuckerberg-hospital.html
  3. C.Zuckerberg Hospital Revises Insane Billing Practices After Media Exposés, by JOE KUKURA, https://sfist.com/2019/04/17/zuckerberg-hospital-revises-insane-billing-practices-after-media-exposes/
  4. D.Emergency room off Las Vegas Strip makes waves with new business model, by Milbank News Writer, https://milbankmonitor.com/emergency-room-off-las-vegas-strip-makes-waves-with-new-business-model/14/04/2019/

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.

These charges, known as “facility fees,” are the price that patients pay for walking in the door of an emergency room and seeking service. Nationally, these fees are kept secret. Patients only learn their emergency room’s facility fee when they receive a bill after the visit…

We found that privately insured patients seen at Zuckerberg General end up with significantly bigger bills than those seen at other nearby emergency rooms. For example, the hospital charged a $5,369 facility fee for a patient who presents with a “severe” emergency…

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…

The fees at Zuckerberg General have nearly doubled over the past decade. In 2010, the emergency room fees at the hospital ranged from $287 to $6,118, depending on the severity of the visit. Now the prices range from $525 to $11,958.

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.” (A)

“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 state Assembly member David Chiu and state 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.

“These practices are outrageous,” says Chiu, who represents part of San Francisco in the Assembly. “No one who is going through the trauma of emergency room care should be subsequently victimized by outrageous hospital bills.”..

Zuckerberg San Francisco General Hospital has, in light of reporting from both Vox and the San Francisco Chronicle, promised to revise its billing policies to be more patient-friendly. The hospital is reportedly considering a cap on charges for privately insured patients.

But Chiu thinks that even more action is needed: a statewide law that would outlaw this kind of behavior…

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.

“Patients would no longer receive exorbitant, surprise bills,” Chiu said. “The discussion between insurers and hospitals would become far more predictable.”

Chiu said the hospital and insurance industries are aware of the effort but haven’t yet seen the full text of the legislation, which will be introduced on Monday.”  (B)

“Lawmakers in both the U.S. Senate and House have introduced bills to end surprise billing. But passing federal legislation promises to be an uphill battle because two influential lobbying groups — health insurers and health providers — have been unable to agree on a solution.

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.

Skewered by media reports, the hospital announced in April that it would no longer balance-bill privately insured patients.” (C)

“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.

They wrote the bill in response to Chronicle stories about patients who had undergone treatment at San Francisco General Hospital, often for minor injuries, and been billed tens of thousands of dollars even though they had insurance.

 “After a trip to the emergency room, the only thing you should be focused on is getting better,” Chiu said. “Not a bill for tens of thousands of dollars.”

San Francisco General had billed patients for the difference between the cost of their treatment and what their insurance companies were willing to pay. The hospital announced in April that it would end the practice, meaning patients won’t be billed beyond what their insurance requires.

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.” (D)

 “Zuckerberg is notorious for being not necessarily the worst but one of the worst places to go in terms of prices for emergency care,” Anderson continued. “The prices are outrageously high. They are notorious for it. And everybody knows about them.”

The maddening element about hospital billing is that the costs charged to patients are only abstractly related to the costs incurred by the hospital.

“They do not need to justify their charges. They have full discretion,” explains Ge Bai, a Johns Hopkins professor of both accounting and health management and policy. “There are no regulatory forces to limit their ability to set a high charge. The charge is coming purely from the hospital and subject to no external forces.” 

Patients — especially uninsured patients — “become prey of this charging game.”…

The No. 1 reason that hospitals aggressively bill their most vulnerable patients? That, too, is relatively easy to grasp. It’s the same reason people from around the world phone you up and demand your Social Security Number: A very small percentage of folks give them everything they want.

Hospitals “don’t get most of the money — in most cases,” says Anderson. “It’s simply preferable for them to charge $3,300 and get it from some people rather than charge $200 and get it from nearly everybody.”  (E)

“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. (Photo: Shutterstock)

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.” (F)

The attempt by two San Francisco politicians to stop hospitals around California from sticking patients who receive emergency care with outrageous bills is on life support.

“Assemblyman David Chiu on Tuesday said he is holding back his bill that was inspired by news of San Francisco General Hospital’s unfair billing practices after intense lobbying from hospital CEOs around the state urging his colleagues to kill it.

The bill was supposed to be heard in the Senate’s health committee Tuesday, but Chiu said its passage would have required amendments making the bill worthless, and he wasn’t willing to move ahead with them.

Instead, he’s turning the bill into a two-year piece of legislation, meaning it can be taken up again in January. But that means the earliest Gov. Gavin Newsom can sign it is September, 2020. And that means the 7 million Californians who have private insurance and yet are still at risk of big emergency care bills won’t see any relief for more than a year — if at all.

“It’s disappointing this couldn’t get done this year,” Chiu said. “But this doesn’t mean we’re done. It ain’t over.”” (G)

“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.

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.”

Chiu said he and his team would keep working on amendments to the bill that address the concerns of hospitals while maintaining protections for patients.

Hospitals focused their opposition on a provision of the bill that would have limited what they can charge insurers for out-of-network emergency services, criticizing it as an unnecessary form of rate setting.” (H)

“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.

“It is good for the hospital to diversify its revenue with different payors,” notes Department of Public Health spokeswoman Rachael Kagan. “We have been working to accomplish private contracting for some time now.”

Inundating the hospital with better-paying privately insured patients at the expense of publicly insured patients would be cause for concern. But this doesn’t figure to happen at the Family Birthing Center, one of the few departments at ZSFGH that isn’t overloaded beyond capacity.

Kagan says the Department of Public Health hopes 60 privately insured Canopy patients deliver at ZSFGH. Hospital staff have been told to expect up to 80. This would represent a small bump in the total number of deliveries at the hospital, which is about 1,200 a year.

Just how many privately insured mothers opt to deliver at ZSFGH will depend on how effectively the hospital sells itself as the “good and safe place to have a baby” — and how effectively it can dispel the perception that anyone who could afford to go elsewhere would do so.

Hospitals competing for patients — especially expectant mothers — often play up amenities more closely resembling a luxury resort than a medical center: private rooms, steak dinners, sumptuous views.

It remains to be seen if ZSFGH will go this route. What it does have to offer, however, is a 24-hour/seven-day on-call midwife — which no other city hospital does. ZSFGH also claims the lowest C-section rate in all San Francisco.

Kagan declined to reveal whether the city is in negotiation with other private insurers, which could alter ZSFGH’s payer mix even more. The Canopy deal required three years to close. So it would be surprising if others aren’t in the works, if not imminent.

“Our hope is that down the road we can expand access to more of our services to Canopy Health and other commercially insured patients,” wrote Roland Pickens, the director of the city’s Health Network, in the inter-office memo announcing this deal. “ (I)

“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….

Chiu’s legislation had two major pieces. It prohibited hospitals from charging out-of-network ER patients more than they would charge an in-network patient for the same services. It also established a standard for what a hospital could charge a non-network insurer. In other words, the bill limited what patients would pay hospitals out of pocket but set rules on what insurers would pay the hospitals too.

Originally, the bill set 150% of Medicare reimbursement as a payment benchmark. The sponsors eventually amended that to whatever rate is “reasonable and customary,” defined as the average in-network contracted rate in a hospital’s geographic region. Hospitals could appeal for higher reimbursements through the state Department of Health Care Services.

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…

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.”” (J)

“Twelve Connecticut hospitals charge patients a trauma activation fee when they arrive by ambulance with a serious injury.

These fees, ranging in the thousands of dollars, are unregulated. And 11 of the 12 Connecticut trauma centers won’t reveal publicly how much they charge…

(Only designated trauma centers are permitted to charge trauma activation fees, which can add thousands of dollars to hospital bills.)

A trauma fee is charged when a trauma team is called to attend to a patient with significant or life-threatening injuries who is brought to the hospital by emergency medical services. Only designated trauma centers can use the billing code 068x to charge a trauma activation fee.

These fees are set by the hospitals and can range based on the level of response a patient requires. They help hospitals recoup the costs of having highly trained doctors and specialized nurses on call to respond to tragedies at a moment’s notice. Insurance sometimes covers the fees so not all patients may notice them buried in their hospital bill — if they have health insurance…

Connecticut has four hospitals designated as level I trauma centers, 7 that are level II and one level III. These levels refer to the resources available in the trauma center and the amount of patients admitted yearly — but its unclear if they have any correlation with the amount charged for trauma fees.” (K)

  1. 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
  2. B.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
  3. C.Lawmakers Push To Stop Surprise ER Billing, by Ana B. Ibarra, https://californiahealthline.org/news/lawmakers-push-to-stop-surprise-er-billing/
  4. D.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
  5. E.The cost of *one stitch* at Zuckerberg San Francisco General Hospital? $3,300, by Joe Eskenazi, https://missionlocal.org/2019/06/the-cost-of-one-stitch-at-zuckerberg-san-francisco-general-hospital-3300/
  6. F.https://www.benefitspro.com/2019/07/11/hospitals-block-californias-balance-billing-legislation/?slreturn=20190611134503
  7. G.Legislation to stop patients getting massive ER bills is on life support, by Heather Knight, https://www.sfchronicle.com/politics/article/Legislation-to-stop-patients-getting-massive-ER-14085647.php?psid=etd0j
  8. H.Hospitals Block ‘Surprise Billing’ Measure, by Ana B. Ibarra, https://californiahealthline.org/news/hospitals-block-surprise-billing-measure/
  9. I.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/
  10. J.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
  11. K.CT hospital’s ‘trauma fees’ under state scrutiny, by Emilie Munson, https://www.middletownpress.com/news/article/CT-hospital-s-trauma-fees-under-state-14293754.php
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PART 2. Conflict of Interest. MSK continued & top executives at the University of Maryland Medical System have resigned amid investigations into accusations of self-dealing among the hospital network’s board members

ASSIGNMENT: Identify other health care conflicts in the news then identify Best Practices of Boards of Trustees.

New PART 2 after old PART 1.

PART 1. September 28, 2018. HOW ACADEMIC MEDICAL CENTERS ADDRESS CONFLICTS-OF-INTEREST.

ASSIGNMENT: Profile the University of Maryland Medical System COI challenge.

DISCLOSURE. I am a member and Interim Chairman of the IRB* at Stevens Institute of Technology.

“There are many varieties of conflicts of interest, and they appear in different settings and across all disciplines. While conflicts of interest apply to a “wide range of behaviors and circumstances,” they all involve the use of a person’s authority for personal and/or financial gain. Conflicts of interest may involve individuals as well as institutions. Furthermore, individuals, in certain circumstances, may have conflicts occurring on both an individual and an institutional level, as may be seen among members of an Institutional Review Board (IRB).

Conflicts of interest are broadly divided into two categories: intangible, i.e., those involving academic activities and scholarship; and tangible, i.e., those involving financial relationships.” (A)

“In an article in the May 2014 issue of Compliance Today, Bill Sacks, Vice President and co-founder of HCCS, a HealthStream company, describes how new NIH regulations are forcing academic medical centers (AMCs) to examine and update their conflict-of-interest policies. He lists the 15 best practices for management of conflicts of interest that have been proposed by the Pew Charitable Trust and discusses how some of these recommendations are enjoying wide acceptance, as others are being met by serious objections. The Pew “Best Practice” recommendations are summarized below.

1. No gifts or meals should be accepted from industry sales representatives…

2. Faculty must disclose all conflicts of interest. All academic medical centers must have a process in place to manage conflict of interest (COI) disclosures.

3. Industry-funded speaking should not be allowed…

4. Industry-funding of continuing medical education (CME) should be severely limited or prohibited…

5. Faculty, students, and trainees should not attend industry-supported promotional or educational events…

6. Limit or prohibit pharmaceutical sales representative access in academic medical centers…

7. Limit medical device representative presence in academic medical centers to what is necessary…

8. Conflict-of-interest education should be required for all clinical staff and students

9. Conflict-of-interest policies should apply to everyone with a relationship to the academic medical center—paid, volunteering, affiliated, etc…

10. Industry-supported clinical fellowships should be available for scientific training only…

11. Ghostwriting and honorary authorship are strictly prohibited…

12. …Consulting arrangements must require written contracts with clear deliverables, to ensure that inappropriate payments are not involved…

13. Consulting relationships for marketing purposes are prohibited.

14. Pharmaceutical samples can be accepted and used only when they don’t become marketing tools.

15. Members of pharmacy and therapeutics committee cannot vote on formulary or treatment changes involving a company or product in which they have a financial interest… (B)

“Open Payments gives the public more information about the financial relationships between physicians and teaching hospitals and applicable manufacturers and GPOs. Specifically, the program:

Encourages transparency about these financial ties

Provides information on the nature and extent of the relationships

Helps to identify relationships that can both lead to the development of beneficial new technologies and wasteful healthcare spending

Helps to prevent inappropriate influence on research, education and clinical decision making. (C)

“Community Catalyst offers this Policy Guide to Academic Medical Centers and Medical Schools to assist leaders, faculty, staff and medical students in successfully adopting and improving policies to address conflicts of interest and interactions with the pharmaceutical and device industries. Policies such as these and their effective implementation are of critical importance to the integrity of medical education and patient care…

Toolkit on Transparency and Disclosure. Toolkit on Relations with Sales Representatives. Toolkit on Promotional Speaking. Toolkit on Continuing Medical Education. Toolkit on Ghostwriting and Name-Lending. Toolkit on Samples. Toolkit on Pharmaceutical and Therapeutics Committees. Toolkit on COI Policy Implementation. Conflict of Interest Curriculum Toolkit (D)

“Papers in medical journals go through rigorous peer review and meticulous data analysis.

Yet many of these articles are missing a key piece of information: the financial ties of the authors.

Nearly two-thirds of the 100 physicians who rake in the most money from 10 device manufacturers failed to disclose a conflict of interest in their academic writing in 2016, according to a study published Wednesday in JAMA Surgery.

The omission can have real-life impact for patients when their doctors rely on such research to make medical decisions, potentially without knowing the authors’ potential conflicts of interest…

They did this by sampling 10 large surgical and medical device manufacturers. This list includes Medtronic, Stryker Corp., Intuitive Surgical, Covidien, Edwards Lifesciences Corp., Ethicon, Olympus Corp., W.L. Gore & Associates, LifeCell Corp. and Baxter Healthcare.

The researchers also pinpointed the 10 physicians who received the highest compensation from each company. They then searched for articles published by these physicians between Jan. 1 and Dec. 31, 2016, and reviewed the full text of each article for COI disclosure.

According to their findings, those 10 companies paid more than $12 million in 2015 to the 100 doctors included in the study. The median payment to these physicians was $95,993.” (E)

“Memorial Sloan Kettering Cancer Center launched a conflict of interest task force in the wake of the resignation of its chief medical officer, Dr. José Baselga, who failed to disclose connections to medical industry…

The Manhattan-based cancer center said the task force will assess its internal policies and processes for reporting and managing outside activities and industry-supported clinical trials.

The task force was announced by President and Chief Executive Officer Dr. Craig Thompson. It will be chaired by Debra Berns, MSK’s Senior Vice President and Chief Risk Officer.

Among its objectives, the task force will: Review MSK’s policies, procedures, and training on conflicts of interest; Identify best practices in COI, including monetary and commitment limits; Assess new or improved processes to support timely and thorough disclosure; Identify medical societies and journals with whom to partner in improving public disclosure at meetings and in publications. (F)

“One of the world’s top breast cancer doctors failed to disclose millions of dollars in payments from drug and health care companies in recent years, omitting his financial ties from dozens of research articles in prestigious publications like The New England Journal of Medicine and the Lancet.

The researcher, Dr. José Baselga, a towering figure in the cancer world, is the chief medical officer at Memorial Sloan Kettering Cancer Center in New York. He has held board memberships or advisory roles with Roche and Bristol-Myers Squibb, among other corporations; has had a stake in start-ups testing cancer therapies; and played a key role in the development of breakthrough drugs that have revolutionized treatments for breast cancer.

According to an analysis by ProPublica and The New York Times, Baselga did not follow financial disclosure rules set by the American Association for Cancer Research when he was president of the group. He also left out payments he received from companies connected to cancer research in his articles published in the group’s journal, Cancer Discovery. At the same time, he has been one of the journal’s two editors in chief.

At a conference this year and before analysts in 2017, he put a positive spin on the results of two Roche-sponsored clinical trials that many others considered disappointments, without disclosing his relationship to the company. Since 2014, he has received more than $3 million from Roche in consulting fees and for his stake in a company it acquired.” (G)

“Dr. José Baselga, the chief medical officer of Memorial Sloan Kettering Cancer Center, resigned on Thursday amid reports that he had failed to disclose millions of dollars in payments from health care companies in dozens of research articles…

Thompson echoed comments he made to the hospital staff on Sunday, saying that the cancer center had “robust programs” in place to manage employees’ relationships to outside companies, but that “we will remain diligent.” He added, “There will be continued discussion and review of these matters in the coming weeks.” (H)

“An artificial intelligence start-up founded by three insiders at Memorial Sloan Kettering Cancer Center debuted with great fanfare in February, with $25 million in venture capital and the promise that it might one day transform how cancer is diagnosed.

The company, Paige.AI, is one in a burgeoning field of start-ups that are applying artificial intelligence to health care, yet it has an advantage over many competitors: The company has an exclusive deal to use the cancer center’s vast archive of 25 million patient tissue slides, along with decades of work by its world-renowned pathologists.

Memorial Sloan Kettering holds an equity stake in Paige.AI, as does a member of the cancer center’s executive board, the chairman of its pathology department and the head of one of its research laboratories. Three other board members are investors…

Hospital pathologists have strongly objected to the Paige.AI deal, saying it is unfair that the founders received equity stakes in a company that relies on the pathologists’ expertise and work amassed over 60 years. They also questioned the use of patients’ data — even if it is anonymous — without their knowledge in a profit-driven venture.” (I)

“…The AAMC is continuing to work with member institutions, other associations and societies, journals, and the continuing education community to develop tools and resources to help institutions and individuals manage the disclosure of conflicts of interest.

Institutions looking for immediate steps to take could:

Remind faculty of the importance of full disclosure, not only to your institution, but in other writing, speaking and teaching situations, as well as grant applications.

Use relevant current events as an opportunity to recommit to the institution’s obligation to facilitate transparency about the ways in which faculty and industry may be collaborating, and the processes that are in place to review and manage those relationships.

Encourage faculty to review the information posted about them publicly on the Open Payments website, and to ensure its accuracy as well as consistency with complete disclosures in all aspects of their professional responsibilities.” (J)

* “Under FDA regulations, an IRB is an appropriately constituted group that has been formally designated to review and monitor biomedical research involving human subjects. In accordance with FDA regulations, an IRB has the authority to approve, require modifications in (to secure approval), or disapprove research. This group review serves an important role in the protection of the rights and welfare of human research subjects.

The purpose of IRB review is to assure, both in advance and by periodic review, that appropriate steps are taken to protect the rights and welfare of humans participating as subjects in the research. To accomplish this purpose, IRBs use a group process to review research protocols and related materials (e.g., informed consent documents and investigator brochures) to ensure protection of the rights and welfare of human subjects of research.” (K)

“A vice president of Memorial Sloan Kettering Cancer Center has to turn over to the hospital nearly $1.4 million of a windfall stake in a biotech company, in light of a series of for-profit deals and industry conflicts at the cancer center that has forced it to re-examine its corporate relationships…

The move to hand over his stake is one of several steps now underway as the cancer center tries to contain a crisis that has already led to the resignation of its chief medical officer and a review of its conflict-of-interest policies. Several board members and some executives of the nonprofit institution have maintained close ties to the health and drug industries at a time when stunning cancer breakthroughs are generating excitement among investors and spawning a flurry of biotech startups.

At other cancer centers and research institutions, employees are barred from accepting personal compensation when they represent their institution on corporate boards. But Memorial Sloan Kettering had no such prohibition until now.” (L)

PART 2. Conflict of Interest continued. Memorial Sloan Kettering/ University of Maryland Medical System

“In forging partnerships with a New Jersey hospital and a data analytics startup, Memorial Sloan Kettering Cancer Center has created a web of interlocking financial interests and conflicts that, ethics experts told STAT, raise doubts about whether the prominent New York City hospital can always put its patients’ interests first while using information in their medical records to make money.

In late 2016, Memorial Sloan Kettering signed a deal with Hackensack Meridian Health, one of New Jersey’s largest hospital systems, giving the cancer center access to a larger pool of patients and a bulwark against encroaching competition from other national players in cancer care.

Within a year, MSK launched another collaboration with a data analytics startup called Cota, and invested $1.4 million in the company. Its founder: a Hackensack Meridian executive and oncologist named Dr. Andrew Pecora, who was Hackensack’s lead negotiator in striking the blockbuster 2016 partnership and serves on the board overseeing the hospitals’ joint venture…

The cancer center is also collaborating with IBM in the development and sale of Watson for Oncology, a product that combines its clinical expertise with artificial intelligence to deliver cancer treatment recommendations. The cancer center receives royalties on the sale of IBM’s product.

Ethics experts said these deals fall into a regulatory gray area in which hospitals and other private companies are trading on patient data in novel ways that may cross ethical lines and trigger a backlash among patients.”  (A)

“Hundreds of doctors packed an auditorium at Memorial Sloan Kettering Cancer Center on Oct. 1, deeply angered by revelations that the hospital’s top medical officer and other leaders had cultivated lucrative relationships with for-profit companies.

One by one, they stood up to challenge the stewardship of their beloved institution, often to emotional applause. Some speakers accused their leaders of letting the quest to make more money undermine the hospital’s mission. Others bemoaned a rigid, hierarchical management that had left them feeling they had no real voice in the hospital’s direction.

“Slowly, I’ve seen more and more of the higher-up meetings happening with people who are dressed up in suits as opposed to white coats,” said Dr. Viviane Tabar, chairwoman of the neurosurgery department.

“The corporatization of this institution is clear to many of us who have been here a long time,” said Dr. Carol L. Brown, a gynecologic cancer surgeon, according to an audio recording of the meeting.

The meeting ended after several doctors advocated an immediate no-confidence vote in the hospital’s senior leadership. The turmoil followed reports by The New York Times and ProPublica that the hospital’s chief medical officer, Dr. José Baselga, had been paid millions by drug and health care companies and failed to disclose those ties more than 100 times in medical journals, and that hospital insiders had made lucrative side deals that stood to earn them handsome profits, sometimes for work they had done on the job.

The day after the meeting, the hospital’s chief executive, Dr. Craig B. Thompson, promised greater openness with rank-and-file doctors about decision-making. He also committed to doing the “root-cause analysis” requested by the doctors of how “egregious conflicts of interest,” as one physician put it, had been allowed to happen…

The predicament of Memorial Sloan Kettering also reflects a shift in its own culture. Its prior chief executive, Dr. Harold E. Varmus, a Nobel-prize winning scientist, personally kept companies at arm’s length, while Dr. Thompson, also a respected cancer researcher, has more fully embraced such relationships. The new approach has been applauded by some for expanding access to the cancer center’s discoveries, even as others have worried that the hospital may be losing sight of its mission…

Even as Memorial Sloan Kettering leaders have promised greater transparency, they have engaged a public affairs firm, SKDKnickerbocker, to manage their message and have aggressively pushed back against the idea that the hospital’s leaders are too close to industry.” (B)

“Memorial Sloan Kettering Cancer Center, one of the world’s leading research institutions, announced on Friday that it would bar its top executives from serving on corporate boards of drug and health care companies that, in some cases, had paid them hundreds of thousands of dollars a year.

Hospital officials also told the center’s staff that the executive board had made permanent a series of reforms designed to limit the ways in which its top executives and leading researchers could profit from work developed at Memorial Sloan Kettering, a nonprofit with a broad social mission that admits about 23,500 cancer patients each year.” (C)

“While MSK’s situation has drawn the most attention for its ties to industry, leaders of nonprofit health systems commonly lead pharmaceutical companies at the same time, a BioPharma Dive review from November found.

From that analysis, about two-thirds of the industry’s largest drugmakers had at least one board member who was also leading a nonprofit, creating a potential financial conflict of interest between the two roles.

The typical compensation package from the pharma companies to these directors was worth more than $475,000, while the average director also held roughly $1.7 million in stock of the particular drugmaker they helped to lead.

This MSK memo from Debra Berns, the cancer center’s senior vice president and chief risk officer, establishes some new limits the organization will put in place on its leaders.

The five highest-ranking roles will not be permitted to serve on boards of external, for-profit health- or science-related companies, the memo stated. These roles are the chief executive, chief operating officer, chief financial officer, physician-in-chief and director of MSK.

However, these five leaders can be exempt from the ban if they provide a compelling institutional reason for board service and obtain approval from the executive committee of MSK’s board of managers, according to the document.

Another new policy will limit the relationship with for-profit spin-off companies that MSK officers can have. MSK officers cannot serve on boards of spin-off companies, and the Board of Overseers and Managers cannot invest in or serve on these boards.”  (D)

“Top officials at Memorial Sloan Kettering Cancer Center repeatedly violated policies on financial conflicts of interest, fostering a culture in which profits appeared to take precedence over research and patient care, according to details released on Thursday from an outside review.

The findings followed months of turmoil over executives’ ties to drug and health care companies at one of the nation’s leading cancer centers. The review, conducted by the law firm Debevoise & Plimpton, was outlined at a staff meeting on Thursday morning.

It concluded that officials frequently violated or skirted their own policies; that hospital leaders’ ties to companies were likely considered on an ad hoc basis rather than through rigorous vetting; and that researchers were often unaware that some senior executives had financial stakes in the outcomes of their studies.

In acknowledging flaws in its oversight of conflicts of interest, the cancer center announced on Thursday an extensive overhaul of policies governing employees’ relationships with outside companies and financial arrangements — including public disclosure of doctors’ ties to corporations and limits on outside work…

Scott Stuart, chairman of the cancer center’s Boards of Overseers and Managers, said in an emailed statement: “We took a deep and honest look at what went wrong at our own institution, examined what was occurring in the wider cancer research community, and are putting in place best practices that will not only allow us to learn from our mistakes, but will contribute to best practices for the wider research community.”..

The policy changes that Memorial Sloan Kettering announced on Thursday include the creation of a board committee to focus on overseeing conflicts, an existing hospital policy that the law firm learned had not been carried out.

The hospital also said it would disclose financial interests of faculty members and researchers on its website and create a more centralized review of conflicts between employees’ work at the hospital and their outside duties.

Other changes included new limits on how income is distributed from research discoveries that originate at Memorial Sloan Kettering, and regular audits to ensure the hospital is complying with its own rules. The cancer center reinforced its earlier statements that many profits from outside work should flow back to M.S.K. research.” (E)

“Dr. José Baselga, who resigned his position as the top doctor at Memorial Sloan Kettering Cancer Center after failing to disclose millions of dollars in payments from drug companies, is now going to work for one of them.

AstraZeneca, the British-Swedish drug maker, announced on Monday that it had hired Dr. Baselga as its head of research and development in oncology, a newly created unit that reflects the company’s shift toward cancer treatments, one of the hottest areas in the drug industry.

In a statement, AstraZeneca’s chief executive, Pascal Soriot, described Baselga as “an outstanding scientific leader.” “José’s research and clinical achievements have led to the development of several innovative medicines, and he is an international thought leader in cancer care and clinical research,” he said…

In December, the American Association for Cancer Research said that Baselga, at its request, had resigned his post as one of two editors in chief of its medical journal Cancer Discovery because he did “not adhere to the high standards” of conflict-of-interest disclosures that the group expects of its leaders. Some of his omissions involved articles that were published in Cancer Discovery while he was an editor in chief.” (F)

“Two more members of the University of Maryland Medical System’s board of directors have resigned amid intense scrutiny over the system’s contracting practices — and as the hospital network announced a “comprehensive review” of its business deals.

Stephen A. Burch, chairman of the University of Maryland Medical System board of directors, said Tuesday that he has accepted the resignations of board members John W. Dillon and Robert L. Pevenstein.

 “I take very seriously the concerns raised regarding Board members that have business relationships with UMMS,” Burch said in a statement. “Addressing this issue is of the highest priority for me and the organization. There is nothing more important than the trust of those who depend on our leadership.”

Dillon reported in both 2017 and 2018 that his health care consulting firm, Dillon Consulting, generated more than $150,000 a year through a contract with the system for “capital campaign and strategic planning.” He reported the contract was paying his firm $13,000 a month.

Pevenstein, the founder of technology companies, reported that in 2017 his firms pulled in more than $150,000 through system contracts, including more than $108,000 in pay for himself. In 2018, Pevenstein reported his son also made more than $100,000 from the system.

In tax forms, Maryland hospital system labeled book purchase from Baltimore mayor a ‘grant’ to city schools

The resignations follow Baltimore Mayor Catherine Pugh stepping down from the board Monday. Pugh resigned from the system’s board of directors as Baltimore school officials acknowledged that 8,700 copies of children’s books the medical system purchased from her are sitting unread in a warehouse.

The three departures from the board came after The Baltimore Sun reported nine members of the University of Maryland Medical System’s Board of Directors have business deals with the hospital network that are worth hundreds of thousands to millions of dollars each.

Board chair Burch said Tuesday he also has asked board members who currently have relationships with the medical system to immediately take a voluntary leave of absence during a review of the system’s governance practices. Those members are: August J. Chiasera, Francis X. Kelly, James A. Soltesz and Walter A. Tilley Jr…

Medical system CEO Robert Chrencik has said some of the contracts went through a competitive bidding process, while others did not. The medical system has thus far declined to release a list detailing which of the deals went through a bidding process.” (G)

“The president and chief executive of the University of Maryland Medical System will take a leave of absence amid a growing scandal surrounding its board of directors, several of whom have profited from contracts with the hospital network they oversee.

Robert A. Chrencik, who has led the system since 2008, will be on leave beginning Monday, board chairman Stephen A. Burch announced Thursday. Burch said the board asked Chrencik to step aside and unanimously agreed at an emergency meeting Thursday to engage an independent accounting and legal firm to conduct an audit of the board’s contracts.

Several of the board’s 27 members — including Baltimore Mayor Catherine Pugh (D), who resigned this week from the board — have had business deals with the hospital system they oversee, in some cases worth hundreds of thousands of dollars. The deals, first reported last week by the Baltimore Sun, have been sharply criticized by Gov. Larry Hogan (R) and the Democratic leaders of the General Assembly.” (H)

Several of Maryland’s largest hospitals engage in business transactions with members of their governing boards while avoiding — for the most part — the type of political dealings that ensnared the University of Maryland Medical System in management turmoil this week.

The medical system has faced intense scrutiny since The Baltimore Sun revealed last week that a third of its 27-member board of directors have business dealings with the health care network…

The Baltimore Sun’s review of state disclosure records and federal tax forms for MedStar Health, LifeBridge Health, Mercy Medical Center, Greater Baltimore Medical Center and St. Agnes Hospital showed all have some dealings with board members.

GBMC said it always uses competitive bidding when awarding contracts.

LifeBridge Health officials said in a statement that board members with “conflicts may be required to be recused from any discussion where the potential conflict may influence their vote and are recused from any vote where a conflict may exist.” In addition, they said, an “audit and compliance committee also oversees conflicts of interest to ensure that there is no undue influence on any contract or vote.”

MedStar Health, which has seven hospitals in Maryland, reported business transactions with board members at five of its hospitals: Franklin Square Medical Center, Good Samaritan Hospital, Union Memorial Hospital and Harbor Hospital in the Baltimore area and St. Mary’s Hospital in Leonardtown in Southern Maryland.

Dr. P. Justin Tortolani, who serves on Union Memorial Hospital’s board and is director of MedStar’s spine program, reported receiving royalties of nearly $155,000 last year from contracts with two companies he is associated with.

At LifeBridge, relationships ranged from catering services with no reported value provided by Miss Shirley’s owner David Dopkin, a Sinai Hospital of Baltimore board member, to $9.2 million in leasing and construction services from the company of Thomas Obrecht, who serves on the boards of LifeBridge Health and Northwest Hospital Center Inc. In an email, Obrecht said he joined the board to use his experience in business and real estate to help guide “an organization focused on helping people in Baltimore and across Maryland.”.. (I)

“Legislation to overhaul the University of Maryland Medical System board was amended to require all current board members be fired.

The bill has bipartisan support and has significantly changed since it was first introduced. The measure, as amended, is headed to the House floor.

A House committee voted unanimously Friday in favor of legislation to completely overhaul the UMMS board. The board remains under fire following reports nine of its 30 members benefited from business deals with the hospital system, including a children’s book contract with Mayor Catherine Pugh.

Pugh returned $100,000 she made in profits, resigned from the UMMS board and recently made a public apology.

The legislation calls for the termination of all the current board members.

“They will be terminated in two different batches, so that we separate some in June and some in October,” House Health and Government Operations Committee Chairwoman Shane Pendergrass said.

The committee adopted an amendment mandating that no elected officials can serve on the board. Committee members paid close attention to ways to find out how these no-bid contracts happened…

The bill covers much ground, including limiting the number of board members to 25, prohibiting members from using their position for private gain and prohibiting sole source contracts. Financial disclosure statements and notification of any potential conflicts of interest would become a requirement by law.” (J)

“On the last day of Maryland’s General Assembly session, lawmakers gave final approval to sweeping legislation that would reform the University of Maryland Medical System’s board of directors amid revelations of single-source contracts for some board members.

The legislation — which comes after Baltimore Sun reporting sparked an outcry over the board’s practices, including a $500,000 deal to buy Mayor Catherine Pugh’s self-published “Healthy Holly” books — would bar no-bid contracts for board members, force all members to resign and reapply for their positions (if they want to return), and mandate an audit of contracting practices.

By a vote of 46-0, Maryland’s senators approved the legislation sponsored by Baltimore Democratic Sen. Jill P. Carter.

The bill now goes to Republican Gov. Larry Hogan for his consideration; he supports reforms for UMMS. (K)

“After weeks of mounting pressure, Mayor Catherine Pugh of Baltimore resigned on Thursday amid a widening scandal involving hundreds of thousands of dollars worth of children’s books that she wrote and that the University of Maryland Medical System paid for while she was serving on its board of directors.

Her resignation comes days after the Baltimore City Council proposed amending the city charter to make it possible to remove her, and after the F.B.I. raided her two homes and her office at City Hall…” (L)

“Robert A. Chrencik, president and CEO of Baltimore-based University of Maryland Medical System, has resigned, effective April 26, according to the Baltimore Sun.

The health system’s board placed Mr. Chrencik on a leave of absence March 25, as a scandal unfolded involving board members profiting from contracts with hospital networks they oversee.” (M)

“The University of Maryland Medical Center has requested a $75 million rate increase from state regulators, a nearly 5 percent increase.

The request was made before news broke of the University of Maryland Medical System’s inside deals with its board members.

Since then, Catherine Pugh resigned her position on the board and as mayor of Baltimore, and the system’s CEO Robert Chrencik stepped down.

“The rate increase requested by UMMC is necessary to provide funding for ongoing investment in operations and mission-driven goals – vital initiatives that enable the hospital to deliver first-class care to our patients,” a UMMS spokesperson said in a written statement. “Ultimately, this is about UMMC being able to meet the complex needs of our patients while continuing to serve as a safety net provider for the West Baltimore community.”

State Sen. Jill Carter, (D-Baltimore City) said the timing of the request could not be worse.

“Right now, of course, there’s going to be a perception that this rate massive rate increase somehow is a result of the self-dealing,” Sen. Carter said. “Maybe they should hold off until some of the investigations are done or the internal or external audits are done, that the legislation called for that.”” (N)

“The chairman of the embattled University of Maryland Medical System board of directors announced his resignation Tuesday — along with two other board members — as an additional contract with one of the departing board members was revealed.

Board Chairman Stephen Burch, who attended a contentious meeting in March with Republican Gov. Larry Hogan and Democratic state Senate President Thomas V. Mike Miller over the board’s contracting practices, announced his resignation effective July 1.

Burch, who also served as a member of Democrat Catherine Pugh’s transition team when she became mayor of Baltimore, was joined in resigning from the UMMS board by Kevin O’Connor and Dr. Scott Rifkin.

O’Connor’s resignation is effective July 1, while Rifkin’s takes effect immediately.

The system said in a statement that Rifkin and the hospital network had an “active agreement” in which his company “provides software for a pilot program designed to reduce hospital readmissions.”..

Federal, state and local investigations are underway.

System President and CEO Robert Chrencik — who was paid $4.3 million in total compensation in 2017 — resigned last month. Pugh resigned last week from her office as mayor of Baltimore.” (O)

“Former Baltimore mayor Catherine Pugh and her colleagues on the University of Maryland Medical System board were not the only ones who profited from business deals with the hospitals they oversaw.

At least two dozen people who sit on boards of smaller, affiliated institutions in the massive system had contracts with those institutions, in some cases worth hundreds of thousands of dollars annually, according to financial disclosures.

The contracts show the pervasiveness of the kinds of deals that led to Pugh’s resignation as mayor this month and, lawmakers say, point to challenges that remain as they grapple with how to make the system more accountable.

Among those who had deals with hospitals they oversaw were a Harford County veterinarian who has made nearly $3 million since 2013 from rental leases; a vascular surgeon whose Bel Air practice made $2.4 million since 2013; and the former president of an ambulance company whose contracts were worth at least $1.3 million since 2010.

Michael Schwartzberg, a spokesman for UMMS, said those relationships are “all appropriate and consistent with fair market value.” Some of the contracts predated members’ service on the boards, he said; others were signed after members joined their respective boards. He said some deals were competitively bid and did not provide information about others.

There were at least two dozen local board members who had contracts with the hospitals they oversaw, according to the disclosure forms, which in some cases listed the specific amount their contracts were worth but in others required a range, such as “greater than $100,000.” The commission said it was missing forms from UM Rehabilitation & Orthopaedic Institute.” (P)

Gov. Larry Hogan has decried contracts that board members of the University of Maryland Medical System held with the organization they were tasked with overseeing and promised to “clean house.”

But state law long has called for housecleaning along the way, specifying that board members can’t serve more than two consecutive five-year terms. Hogan (R) and his predecessors, who appoint the board members, allowed some to stay well past a decade.

A spokesman for the governor, who took office in 2015, said Thursday that term limits will be enforced from now on.

“These practices were handed down from both Republican and Democratic administrations,” spokesman Michael Ricci said in an email. “Governor Hogan is working to put an end to them so we can help restore public trust in UMMS.”

Members who lingered on the board include former state senator Francis X. Kelly, whose insurance company held some of the largest contracts that are under review as part of a broad investigation of the hospital board.

Kelly, who did not respond to requests for comment, joined the board in 1986 and most recently was reappointed by Hogan in 2016. He took a voluntary leave of absence from the board while auditors probe the contracts.” (Q)

“The University of Maryland Medical System (UMMS) Board of Directors reviewed and voted unanimously to approve a new Conflict of Interest Policy. This is another milestone as the organization continues to improve Board governance and oversight while managing conflicts of interest appropriately. The new Policy is adherent to recently passed Maryland legislation and is effective July 1, 2019.

“This is another major step forward as we improve Board governance, change corporate culture and put UMMS on a strong path forward,” said Interim President and CEO John Ashworth. “We thank the legislators for their work in guiding this policy during the session and helping us focus on providing a sound, long-term foundation for a sustainable, effective Board.”

Of note, the Policy includes:

A prohibition on sole source contracting with any UMMS Board member

Requirements for the recusal of non-independent Board members from certain deliberations and decision-making activities

Provisions that restrict relevant Board leadership positions to independent Board members

Detailed procedures for the disclosure of interests by UMMS Board members, officers and management level employees

The process for identifying and addressing conflicts of interest

The process for handling violations of the Conflict of Interest Policy

A requirement that every Board member attest to compliance with the Conflict of Interest Policy

The new Conflict of Interest Policy was delivered to Governor Hogan and the presiding officers of the Senate and House of Delegates today, as required by Maryland law. The Policy will also be presented to the UMMS affiliate boards for review and approval within 60 days.” (R)

“Four top executives at the University of Maryland Medical System have resigned amid investigations into accusations of self-dealing among the hospital network’s board members, the system announced Thursday.

Those resigning are Megan Arthur, the system’s primary lawyer; Jerry Wollman, the chief administrative officer; Christine Bachrach, the system’s chief compliance officer; and Keith Persinger, the chief performance improvement officer.” (S)

“Maryland Gov. Larry Hogan named Wednesday his initial batch of new appointees to the troubled board of directors at the University of Maryland Medical System, the first step toward reorganizing the board following a scandal over board members having lucrative contracts with the 13-hospital system.

The volunteer board came under fire in March when The Baltimore Sun reported a third of its 30 members or their companies had deals with the hospital system, some of which were not competitively bid. They included then-Mayor Catherine Pugh of Baltimore, a Democrat who made hundreds of thousands of dollars selling children’s books in a sole-source arrangement with UMMS. She later resigned from the board and as mayor amid multiple investigations into the book deals.

In a separate action Wednesday, the hospital board elected new leadership from among its current members and invited four members who voluntarily took leaves of absence to return.

The new appointments to the board are required under a law state legislators passed this year that mandated several reforms at the hospital system. All previously appointed board members must step down by the end of the year, to be replaced or reappointed by the governor.

All new board members are subject to confirmation votes by the state Senate, but can serve until the Senate votes on their appointments. They will take office July 1.

Board members can serve up to two five-year terms. In the past, board members often stayed past the end of their terms if a governor didn’t replace them.

“I pledged that I would appoint new board members who will serve with integrity and accountability, and today, I am delivering on that promise,” Hogan, a Republican, said in a statement. “This is another critical step as UMMS works to restore public trust.”

The medical system board met Wednesday morning and elected James “Chip” DiPaula Jr. as chairman and Alexander Williams Jr. as vice chairman. They’ll serve in those roles for the remainder of the year. Former Chairman Stephen A. Burch was among several board members who resigned amid the scandal.

DiPaula, who Hogan appointed to the board in 2016, is a former state budget secretary and chief of staff to then-Gov. Robert L. Ehrlich Jr., a Republican. DiPaula later founded an e-commerce firm.

Williams is a retired federal judge who has been tapped for other leadership roles, including chairman of the state’s Commission to Restore Trust in Policing and co-chairman of a commission on redistricting that drew up a proposed map for Maryland’s 6th Congressional District. Hogan appointed Williams to the hospital system board in 2015.

In a statement released by UMMS, DiPaula said members of the board “regret the actions and poor decisions which have jeopardized confidence in the system.”

The new board members nominated by Hogan are:

» Eliza Basnight, senior vice president of supply chain for the American Red Cross. Previously, she was chief of staff for the U.S. Mint under the Obama administration and head of the Center for Women Veterans at the U.S. Department of Veterans Affairs.

» Kathleen A. Birrane, an attorney with the firm DLA Piper who previously was the top lawyer for the Maryland Insurance Administration.

» Dr. Joseph Ciotola, health officer for Queen Anne’s County and medical director for that county’s Department of Emergency Services.

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» Matthew Clark, Hogan’s chief of staff. Clark will hold a seat that is reserved for the governor or the governor’s designee.

» Wanda Queen Draper, former director of the Reginald F. Lewis Museum of African-American History and Culture in Baltimore.

» Jason Frankl, senior managing director of FTI Consulting, where his work includes helping companies defend against activist investors and takeover attempts.

» Glenn T. Harrell, retired senior judge of the Maryland Court of Appeals.

» Dr. Joyce M. Johnson, a physician who retired from the U.S. Public Health Service, where she held the rank of rear admiral and was director of health for the U.S. Coast Guard.

» Bonnie Phipps, senior vice president and group operating executive for Ascension Health, a Catholic health system that operates in 21 states and the District of Columbia, including Southwest Baltimore’s St. Agnes Hospital, where she was president from 2005 to 2015.

» Joseph T.N. Suarez, a director at Booz Allen Hamilton, a business consulting firm.

» John T. Williams, chairman and CEO of Jamison Door Company in Hagerstown. He previously served as a newspaper and TV executive.

In addition to mandating a gradual replacement of the current board and requiring term limits, the new law banned no-bid contracts for board members and required a state audit of the hospital system’s contracting practices.” (T)

“Francis Kelly Jr., the former Maryland state senator whose insurance company benefited from contracts with the University of Maryland Medical System while he served on the hospital network’s board of directors , announced Friday that he will give up that seat.

“It has been a tremendous honor for me to have served on the UMMS Board for nearly 35 years, under six different Governors,” Kelly wrote in a resignation letter to board chairman Stephen Burch. “I have decided it is time to move on, and allow someone else the fantastic opportunity of serving.”

Kelly and his sons, John and David, who served on UMMS-affiliated boards, took voluntary leaves of absence in April as probes were opened to review the health system’s contracts with businesses affiliated with board members.

In the resignation letter, Kelly said his sons have also decided not to return to their board positions.

The UMMS board voted Wednesday to ask Kelly and three other members on leave to rejoin the board, after an outside probe of the contracting scandal placed most of the blame with former hospital system chief executive Robert Chrencik, who resigned in April.

Several state lawmakers raised concerns about the board’s decision, however, and said board members who had contracts with the system should not return to the board.

“[W]e feel that the best way to serve the system and its affiliated hospitals at this time is not come back onto these boards,” Kelly wrote in a letter to John Ashworth III, the interim president and chief executive.

Kelly & Associates Insurance Group has had multimillion-dollar transactions with the medical system since at least 2005, the first year for which financial disclosure records are available, handling more than $100 million in premiums.” (U)

“A review of contracts the University of Maryland Medical System had with members of its board of directors and their companies revealed more no-bid and self-dealing practices — including that executives pressured staff to use board members’ products — and blamed former CEO Robert Chrencik and other system leaders.

“Many of these contracts were not competitively bid, were not declared to be necessary by the board or senior leaders, and, if vetted, were without full transparency to the entire board,” concluded the review by Nygren Consulting, which was hired and paid by the 13-hospital network.

The report released Wednesday reviewed business deals with nine board members and found:

» Seven of nine of the deals were entered into without competitive bids;

» In four cases, the board of directors was not properly informed of the business relationships;

» The board member who was in charge of auditing financial dealings himself had a no-bid deal;

» In at least two instances, staff felt pressured to promote the use of software from companies that would have benefited individual board members financially.

The report focused its harshest criticism on deals with four board members that hospital officials described as “personal services” contracts: Former Baltimore Mayor Catherine Pugh, who was paid $500,000 for her self-published children’s books; Robert Pevenstein, a consultant who was paid more than $100,000 a year; John W. Dillon, who was paid $892,000 since 2013 for providing “healthcare consulting services;” and Dr. Scott Rifkin, who runs a health care software company.

The system commissioned the review in response to revelations in The Baltimore Sun, beginning in March, about the contracting practices.

“These arrangements reflect a pattern by management of making decisions without full board approval,” the report found of members’ contracts. “The board was insufficiently informed and, for the most part, had no specific advance knowledge that would have caused the board to consider alternatives that would have forestalled or eliminated perceived and real self-dealing.” “ (V)

“The report on self dealing among UMMS board members comes after the departures of the system’s CEO and board members, including former Baltimore Mayor Catherine Pugh. Controversy arose over board members — including Pugh — who made money in business deals with the system.

Regarding Pugh’s “Healthy Holly” book arrangement, Nygren wrote, “Our review has determined that management did not present the book purchases to the board or any committee for prior approval, as required by then-in-effect Conflict of Interest policies, and the purchase was not subject to any competitive bidding process.”

The report concluded that then-CEO Robert Chrencik “agreed to enter into an agreement with Ms. Pugh without consent of the board.”

Between 2010 and 2018, UMMS agreed to pay a total of $500,000 for the self-published books Pugh authored. She repaid $100,000.

The report also investigated other former board members and found similar violations of board policies.

UMMS said in a statement that the report details “both management and various board members share responsibility for the lack of transparency and strong, modern governance policies that resulted in improper relationships.”

UMMS said the following recommendations have been or will be adopted:

A new, comprehensive Conflict of Interest Policy was authored by Nygren and accepted by the Board of Directors. The policy was delivered to Maryland’s governor, Senate president and Speaker of the House on May 31.

A Governance Committee will be chartered as a permanent Committee of the Board, and tasked with overseeing all board practices, policies and relationships. All appropriate guiding documents will be authored.

A new, research-based “competency” model will be implemented to ensure the makeup of the board is determined based on two levels of competencies: those required of each individual member, and those required by the Board as a whole. This will ensure the board is representative of the communities it serves and has the experience and skills necessary to advance the organization’s strategic direction and mission.

The education process related to disclosures and conflicts will be redesigned and will include an official “Code of Conduct” to ensure all board members and senior management are acutely aware of compliance requirements moving forward.

Board committees will be restructured so chair positions of the Finance Committee and the Audit and Compliance Committee are held by separate individuals, and the chair of the latter maintains no financial or contractual relationship with the organization.

“While Nygren confirmed that outside business interests between a board member and a nonprofit Board of Directors are not uncommon or illegal, great care and caution must be given to ensure there is proper vetting and no real or perceived conflicts of interest. To that end, any proposed professional services agreements with board members will be revealed to the full board, carefully vetted with the Board’s Audit and Compliance Committee and reported to the Compliance Officer. The new Conflict of Interest Policy will be strictly adhered to in all cases. Additionally, the system will no longer allow any board member to engage in a personal services agreement, regardless of circumstance,” the UMMS statement read.”  (V)

“The recent ethical lapses within the University of Maryland Medical System and its board have been appalling, with much of the focus on former Baltimore Mayor Catherine Pugh, state legislation passed to improve board oversight and resignations of certain board members.

Scant attention has been paid, however, to an elephant in the room: Most of the board members were, as required by statute, appointed by Gov. Larry Hogan, with some improperly reappointed beyond the two-term legal limit. And many of them, including several of the 11 newly appointed board members, donated to his campaign as individuals or through affiliated businesses — some in apparent excess of campaign finance limits — for a combined total of over $115,000.

While donors receiving appointments isn’t inherently unlawful, it undermines public confidence, particularly when combined with the fact that some of these donor-appointees, including former state Sen. Frank Kelly Jr., appear to have received generous “insider” contracts from UMMS.

And, despite the governor’s professed outrage over UMMS’ dealings, he recently vetoed an important bill that would improve transparency and strengthen accountability of the Governor’s Appointments Office, whose primary purpose is to vet political appointees to represent Mr. Hogan on boards and commissions and in a small handful of high-level leadership positions in state agencies.

The governor prefers to point the finger at UMMS for its failed internal controls, but he, too, should have known that many of his appointees had business dealings with UMMS. His appointments office requires all appointees to complete a form that probes for conflicts of interest and problematic affiliations.

In examining the governor’s campaign finance records, publicly available from the State Board of Elections, I found at least eight UMMS board members — Stephen Burch, R. Alan Butler, John Coale, James “Chip” DiPaula Jr., Barry Gossett, Mr. Kelly, Robert Pevenstein and Walter Tilley Jr. — who donated to Governor Hogan the $6,000 maximum permitted by law.

Businesses apparently connected to Mr. Tilley, James Soltesz, Mr. DiPaula and Robert Rauch also contributed a combined $16,000 to Governor Hogan’s campaign.

Four board members or related businesses appear to have contributed above the $6,000 legal limit in total over a four-year period:

Kelly Integral Solutions LLC, contributed $11,000 — all while Kelly & Associates received a lucrative UMMS contract reportedly worth $16 million. (Mr. Kelly is among those who recently announced his resignation from the board.)..

In order to boost accountability, and in response to numerous complaints of politicization of the state workforce, I introduced and passed legislation (Senate Bill 751) during this past session that would increase transparency regarding the information gathered by the appointments office by requiring annual aggregated reporting back to the General Assembly. The governor vetoed it.” (X)

“For its report, Nygren reviewed system documents and interviewed about 60 people, including current and former board members, executives and staff. Here are some of the firm’s key findings:

1) Blaming the old boss.

Chrencik was blamed for cutting deals with individual board members without the full board’s approval. In four cases, the board was not properly informed of the deals…

2) Most deals with board members weren’t competitively bid.

Seven of nine of the deals with individual board members were entered into without competitive bids…

3) Who’s doing oversight?

The board member who was in charge of monitoring financial dealings himself had a no-bid deal. Robert Pevenstein, who was chairman of both the audit and finance committees, had several arrangements with the system, including for-profit relationships for the firms Profit Recovery Partners and Optime, as well as a consulting deal. He was paid more than $100,000 a year…

4) Staff felt uncomfortable.

In at least two instances, UMMS employees felt pressured to promote the use of software from companies that benefited individual board members financially…”  (Y)

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A public health approach will enable the United States to address culture, firearm safety, and reasonable regulation

ASSIGNMENT:

– Dig deeper in defining mass firearms killings as a public health issue.

– Profile hospital Rapid Response preparedness for receiving injured from a mass shooting.

– How can hospitals prepare for an “active shooter” situation in the hospital?

“Shortly after the November 2018 publication of the American College of Physicians’ policy position paper on reducing firearm injury and death (1), the National Rifle Association tweeted: Someone should tell self-important anti-gun doctors to stay in their lane. Half of the articles in Annals of Internal Medicine are pushing for gun control. Most upsetting, however, the medical community seems to have consulted NO ONE but themselves…

In 2015, several of our organizations joined the American Bar Association in a call to action to address firearm injury as a public health threat. This effort was subsequently endorsed by 52 organizations representing clinicians, consumers, families of firearm injury victims, researchers, public health professionals, and other health advocates (2). Four years later, firearm-related injury remains a problem of epidemic proportions in the United States, demanding immediate and sustained intervention. Since the 2015 call to action, there have been 18 firearm-related mass murders with 4 or more deaths in the United States, claiming a total of 288 lives and injuring 703 more (3).

With nearly 40 000 firearm-related deaths in 2017, the United States has reached a 20-year high according to the Centers for Disease Control and Prevention (CDC) (4). We, the leadership of 6 of the nation’s largest physician professional societies, whose memberships include 731 000 U.S. physicians, reiterate our commitment to finding solutions and call for policies to reduce firearm injuries and deaths. The authors represent the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American College of Surgeons, American Medical Association, and American Psychiatric Association. The American Public Health Association, which is committed to improving the health of the population, joins these 6 physician organizations to articulate the principles and recommendations summarized herein. These recommendations stem largely from the individual positions previously approved by our organizations and ongoing collaborative discussion among our leaders (1, 5–10)…

Our organizations support a multifaceted public health approach to prevention of firearm injury and death similar to approaches that have successfully reduced the ill effects of tobacco use, motor vehicle accidents, and unintentional poisoning. While we recognize the significant political and philosophical differences about firearm ownership and regulation in the United States, we are committed to reaching out to bridge these differences to improve the health and safety of our patients, their families, and communities, while respecting the U.S. Constitution.

A public health approach will enable the United States to address culture, firearm safety, and reasonable regulation consistent with the U.S. Constitution. Efforts to reduce firearm-related injury and death should focus on identifying individuals at heightened risk for violent acts against themselves or others (20). All health professionals should be trained to assess and respond to those individuals who may be at heightened risk of harming themselves or others.

Screening, diagnosis, and access to treatment for individuals with mental health and substance use disorders is critical, along with efforts to reduce the stigma of seeking this mental health care. While most individuals with mental health disorders do not pose a risk for harm to themselves or others (21), improved identification and access to care for persons with mental health disorders may reduce the risk for suicide and violence involving firearms for persons with tendencies toward those behaviors.

In February 2019, 44 major medical and injury prevention organizations and the American Bar Association participated in a Medical Summit on Firearm Injury Prevention. This meeting focused on building consensus on the public health approach to this issue, highlighting the need for research, and developing injury prevention initiatives that the medical community could implement (22). Here we highlight specific policy recommendations that our 7 organizations believe can reduce firearm-related injury and death in the United States.

Background Checks for Firearm Purchases; Need for Research on Firearm Injury and Death; Intimate Partner Violence; Safe Storage of Firearms; Mental Health; Extreme Risk Protection Orders; Physician Counseling of Patients and “Gag Laws”; Firearms With Features Designed to Increase Their Rapid and Extended Killing Capacity” (A)

“There were three high-profile shootings across the country in one week: The shooting in Gilroy, Calif., on July 28, and then the back-to-back shootings in El Paso, Texas, and Dayton, Ohio, this past weekend.

That’s no surprise, say scientists who study mass shootings. Research shows that these incidents usually occur in clusters and tend to be contagious. Intensive media coverage seems to drive the contagion, the researchers say.

Back in 2014 and 2015, researchers at Arizona State University analyzed data on cases of mass violence. They included USA Today’s data on mass killings (defined as four or more people killed using any means, including guns) from 2006 to 2013, data on school shootings between 1998 and 2013, and mass shootings (defined as incidents in which three people were shot, not necessarily killed) between 2005 and 2013 collected by the Brady Campaign to Prevent Gun Violence.

The lead researcher, Sherry Towers, a faculty research associate at Arizona State University, had spent most of her career modeling the spread of infectious diseases — like Ebola, influenza and sexually transmitted diseases. She wanted to know whether cases of mass violence spread contagiously, like in a disease outbreak.

“What we found was that for the mass killings — so these are high-profile mass killings where there’s at least four people killed — there was significant evidence of contagion,” says Towers. “We also found significant evidence of contagion in the school shootings.”

In other words, school shootings and other shootings with four or more deaths spread like a contagion — each shooting tends to spark more shootings…

Peterson and other researchers who study mass shootings think the media should avoid showing the shooters’ images and dwelling on their life histories and motives. “The fact that we give them that notoriety is problematic,” says Peterson.” (B)

“The country is splitting into the gun law-haves, and the gun law have-nots, and deadly statistics are now revealing the impact those policy decisions have on people’s lives.

It happened again. This time, gunmen in El Paso, Texas, and Dayton, Ohio, murdered 31 people and injured at least 50 more in separate mass shooting attacks within 13 hours of each other Saturday night and Sunday morning. It was, in many ways, just another weekend in America, the only nation in the developed world where horrific gun massacres regularly occur. Though nothing new, the frequency of such public mass shootings appears to have accelerated over the past five years, along with larger and more tragic death tolls. According to one recent analysis by The Washington Post, a mass shooting event has claimed the lives of four or more people every 47 days since June 2015. In the mid-’90s, such attacks happened just twice a year, on average.

But this surge in public executions has not swept across all corners of the country equally. Hawaii, for instance, hasn’t seen a mass shooting since 1999. Florida, on the other hand, has had six such incidents, defined by the US government as four or more people killed by a single individual, in the past three years alone, according to data from the nonprofit Gun Violence Archive. And like other forms of gun violence—including homicide, suicide, and unintended accidents—researchers are finding that mass shooting events happen more often in states with looser gun laws.

Because while Congress may not have passed any national gun laws in the aftermath of past mass shootings, individual state legislatures have. And as the disparity between states with weak gun laws and those with tough ones has widened, so too has the gap in mass shootings. Which means that terrorist acts like those committed in El Paso and Dayton over the weekend are more likely to keep happening to people who live in places where it’s easy to buy, sell, and carry guns. The country is splitting into the gun law haves and the gun law have-nots, and deadly statistics are now revealing the impact those policy decisions have on people’s lives.

Studying mass shootings, which make up only a tiny fraction of all gun deaths, has long been tricky, because of their historical rarity and a general dearth of data on guns or gun deaths. (That’s because of research-stifling federal legislation that was only recently overturned.) But one ironic effect of there being more mass shootings lately is scientists now have enough data to start to see trends emerging…

What the researchers found was that over time states have dug themselves into a bimodal distribution. That is, they’ve self-clumped into two distinct groups—a smaller one made up of eight states scoring between 5 and 25, and another, much larger, one clustered around scores from 70 to 100. “One of the most interesting things about this data is that we aren’t seeing a full spectrum, because there just aren’t that many states directly in the middle,” says Paul Reeping, the study’s lead author.” (C)

“…Two policies exist today that if properly designed, widely enacted, and adequately implemented would likely have saved these lives and could potentially save many more in the future. Their benefits would extend far beyond reducing the incidence of mass shootings (see map and the interactive graphic, available at NEJM.org).

The better known of these policies is the requirement that firearm sales involve background checks on purchasers. Background-check policies work at the population level to prevent firearm purchases by felons, people convicted of certain violent misdemeanors, and others who are at increased risk for violent behavior (specifics vary from state to state). Using background checks to prevent such persons from acquiring firearms is associated with a reduction of at least 25% in their incidence of arrest for a firearm-related or other violent crime.1

The second policy that could prevent firearm-related deaths is to allow courts to have firearms removed temporarily from people who pose an imminent hazard to others or themselves but are not members of a prohibited class. Again, provisions vary; in California, family members and law-enforcement officials can follow procedures based on those established for domestic violence to petition for a firearm to be removed. Physicians can play an important role in these cases by notifying eligible petitioners when intervention is warranted; disclosure of otherwise-confidential information is expressly permitted by Health Insurance Portability and Accountability Act regulations when an imminent hazard exists.” (D)

“Here are 10 of the most talked-about strategies that have been floated to stop mass shootings, and how likely they are to work.

Assault weapons ban. High-capacity magazine ban. Funding CDC research into gun violence. Universal background checks. Gun violence restraining orders or red flag laws. Arming teachers. Active shooter drills. Having students, faculty, and staff report potential threats. Banning violent video games. ‘Hardening schools’” (E)

“In our work at the School of Public Health we are making gun owners part of the solution. My colleague Cathy Barber is working with gun owners, gun advocates, gun trainers, and gun shop owners. Together they are finding common ground and developing solutions. The first area where they have found much common ground is around suicide. The evidence is overwhelming that a gun in the home increases the risk of suicide. More people die from gun suicide than gun homicide, and the people dying are gun owners and their families. Cathy has helped get gun shops in 20 states to play a role in reducing suicide. One grass-roots education effort includes guidelines on how to avoid selling or renting a firearm to a suicidal customer. To activate gunners, you need the right message and the right messenger. And the right messenger isn’t Harvard or public health professionals, it is responsible gun owners themselves. She is hoping to expand her focus to work on preventing guns from moving from the licit to the illicit market. Gun advocates have great ideas; they know about guns; and they are big into safety, so there are large potential benefits to get them to work together with public health professionals. That’s the goal.” (F)

“Following two mass shootings last weekend that ended the lives of 31 people, seven leading medical organizations have said “enough” and called for action to prevent gun-related injuries and deaths.

In the aftermath of the back-to-back mass shootings in Ohio and Texas that shook the country, the leaders of the physician and public health organizations called for immediate action to prevent gun violence in a special article published Wednesday in the Annals of Internal Medicine, the publication of the American College of Physicians (ACP).

“We are living in a world where gun violence is becoming increasingly common, and as physicians, we have a responsibility to address this public health crisis and to keep our patients safe and healthy,” said ACP President Robert McLean, M.D., in a statement.

In addition to the ACP, the article was authored by the physicians who lead the American Academy of Family Physicians, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Psychiatric Association, and the American Public Health Association…

“We, the leadership of 6 of the nation’s largest physician professional societies, whose memberships include 731,000 U.S. physicians, reiterate our commitment to finding solutions and call for policies to reduce firearm injuries and deaths,” the doctors wrote. The leaders of the physician organizations were joined by the American Public Health Association.

In the article, they suggest numerous steps to ending gun violence including addressing high-capacity magazines and firearms. “The magnitude and frequency of mass attacks are unacceptable to our organizations. A common-sense approach to reducing casualties in mass shooting situations must effectively address high-capacity magazines and firearms with features designed to increase their rapid and extended killing capacity,” the physician leaders wrote.” (G)

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

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?

New PART 3 after PARTs 1 and 2.

PART 1. February 26, 2019. Johns Hopkins All Children’s Hospital (St Petersburg, Florida) – problems in the hospital’s heart surgery unit

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

PART 1. February 26, 2019. Johns Hopkins All Children’s Hospital (St Petersburg, Florida) – problems in the hospital’s heart surgery unit

“The Patient Safety and Healthcare Quality Masters program is a fully online, interdisciplinary degree offered by Johns Hopkins University. It is a first-of-its-kind collaboration between the Johns Hopkins Bloomberg School of Public Health, Johns Hopkins School of Medicine, Johns Hopkins School of Nursing and the Armstrong Institute for Patient Safety and Quality. It combines coursework from JHU’s top ranked schools and the Armstrong Institute’s pioneering advances in patient safety-educating students in the transformative mechanisms and evidence-based protocols that reduce preventable patient harm and improve clinical outcomes.

Renowned, industry-shaping experts lead this exciting new program designed for working adults. The program focuses on: Measurement of safety and quality; Designing safer systems; Organizational and cultural change. ” (A)

“Patient Safety and Quality at Johns Hopkins Medicine.

Each day in a hospital, staff members undertake complicated tasks caring for patients. Johns Hopkins Medicine’s patient safety efforts aim to ensure that all of these steps work together to deliver high-quality, compassionate care to all patients across our health system.

Johns Hopkins Health System hospitals and services consistently receive awards and honors for patient safety and quality, including Top Performer on Key Quality Measures by the Joint Commission, Magnet designation for nursing, HomeCare Elite and Delmarva Foundation Excellence Awards. The Johns Hopkins Hospital has been ranked No. 1 in the nation by U.S. News & World Report for 22 years of the survey’s 25-year history, most recently in 2013.

Patient Safety and Quality Measures

This website shares data for the Johns Hopkins Health System. Here, you will find information about key safety issues and the patient’s experience of care, including:

Patient Experience – Based on survey results from previous patients, you can see how others rated their experience of care from a Johns Hopkins Medicine hospital or home health care provider.

Infection Prevention – These measures include the rate of CLABSIs, a bloodstream infection caused by a central line (large IV) that are considered preventable and hand hygiene, the percentage of medical staff members observed washing their hands or using hand sanitizer before and after caring for a patient.

Core Measures – These measures are national standards of care and treatment processes for common conditions. Core measure compliance shows how often a hospital follows each of these steps.

Surgical Volumes – Studies have shown a strong relationship exists between the number of times a hospital performs a specific surgical procedure and the outcomes for those patients. In 2016, we started sharing our hospitals’ surgical volumes for many common and high-risk procedures.

Quality of Care Ratings – The quality of patient care star rating is a summary of how well the Johns Hopkins Home Care Group and Potomac Home Health Care perform on nine quality measures such as ambulation.

Pediatrics – These measures include national standards of treatment for common conditions, infection prevention, pain management and emergency department wait times for Johns Hopkins’ pediatric divisions.

Hospital Readmissions – Patients are most vulnerable for readmission to a hospital immediately following discharge. This measure tracks how many Medicare patients with specific conditions were readmitted to the hospital within 30 days for any reason.

Our Commitment to Transparency

Patients and their loved ones deserve to be informed about the quality of their heath care. At Johns Hopkins Medicine, we are dedicated to sharing our performance and how we work to provide the best care with past, present and future patients. The Johns Hopkins Armstrong Institute for Patient Safety and Quality coordinates safety and quality improvement efforts and training across our health system.

We hope you will find this website a valuable resource and encourage you to ask your health care team if you have any questions or concerns. (B)

“Patient Trust, Confidence Built on Interprofessional Innovation

Medical errors and preventable patient infections and injuries together make up the third-leading cause of death in the United States, a startling statistic.

The Johns Hopkins School of Nursing understands that an increasing focus on patient safety and quality of care depends upon a healthcare workforce that knows the risks and the proper responses from patients’ arrival to their safe discharge.

The Helene Fuld Leadership Program for the Advancement of Patient Safety and Quality (The Fuld Fellows Program) emphasizes interprofessional education and training, simulation, and service-learning experiences involving nurses, medical students, pharmacists, and other health professionals whose collaboration is critical for reducing preventable harm to patients.

Nurses, as the primary contact with patients, play a key role in their safety. Hopkins Nursing, as part of an interprofessional team that includes the Armstrong Institute for Patient Safety & Quality and the Johns Hopkins Health Systems, works to prepare nurses ready to communicate, cooperate, innovate, and lead on issues of patient safety and quality of care.” (C)

“Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality

A roadmap for patient safety and quality improvement

This month the Agency for Healthcare Research and Quality (AHRQ) published a new report that identifies the most promising practices for improving patient safety in U.S. hospitals.

An update to the 2001 publication Making Health Care Safer: A Critical Analysis of Patient Safety Practices, the new report reflects just how much the science of safety has advanced.

A decade ago the science was immature; researchers posited quick fixes without fully appreciating the difficulty of challenging and changing accepted behaviors and beliefs.

Today, based on years of work by patient safety researchers-including many at Johns Hopkins-hospitals are able to implement evidence-based solutions to address the most pernicious causes of preventable patient harm. According to the report, here is a list of the top 10 patient safety interventions that hospitals should adopt now.

Top 10 Recommended Patient Safety Strategies

1. Preoperative checklists and anesthesia checklists to prevent operative and postoperative events.

2. Bundles that include checklists to prevent central line-associated bloodstream infections

3. Interventions to reduce urinary catheter use, including catheter reminders, stop orders, or nurse-initiated removal protocols

4. Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic-suctioning endotracheal tubes to prevent ventilator-associated pneumonia

5. Hand hygiene

6. The do-not-use list for hazardous abbreviations

7. Multicomponent interventions to reduce pressure ulcers

8. Barrier precautions to prevent healthcare-associated infections

9. Use of real-time ultrasonography for central line placement

10. Interventions to improve prophylaxis for venous thromboembolisms…

Even with a list of sound strategies, creating a plan to implement all or even half of them may sound like a daunting task. The Armstrong Institute for Patient Safety and Quality has created a checklist to help you get started.

1. Identify priorities and assess readiness for change.

2. Establish engagement and accountability at all levels of the organization.

3. Communicate constantly (the good and the bad).

4. Measure, measure, measure… and then measure some more. (D)

“Johns Hopkins All Children’s Hospital provides expert pediatric care for infants, children and teens with some of the most challenging medical problems in our community and around the world.

Named a top 50 children’s hospital by U.S. News & World Report, we provide access to innovative treatments and therapies. Taking part in pediatric medical education and clinical research helps us to provide care in more than 50 specialties.

With more than half of our 259 beds devoted to intensive care level services, we are the regional pediatric referral center for Florida’s West Coast. Physicians and community hospitals count on us to care for critically ill patients and perform complex surgical procedures.

Parents count on us, too. Our philosophy of family-centered care means family members are an important part of our health care team. We include parents in making decisions and plans for their child’s care. We also include patients who are old enough to take part in these discussions.

To help us design our hospital that we opened in January 2010, we asked patients, parents and our staff to share ideas. The result was a spacious and bright hospital with individual rooms where parents can comfortably spend the night. With the latest technology and our commitment to family-centered care, our hospital provides an ideal environment for healing.” (E)

“Quality, Outcomes and Patient Safety at Johns Hopkins All Children’s

We are committed to treating you and your child with compassion and respect. We believe that you deserve honesty in our communication about the plan for your child’s care and we will demonstrate uncompromising integrity to earn your trust. We will be responsible for including each family as a part of our care team that is committed to safe and innovative care practices. Our goal is to inspire hope for you and your child through our focus on inquiry, collaboration, and team work.

Johns Hopkins All Children’s Hospital believes in Creating healthy tomorrows… for one child, for All Children. Our focus on Quality assures that we are continually improving our processes in an effort to achieve this vision. Using a team approach we tap into the know-how of our expert medical staff and employees to improve the quality and safety of the care we provide.

Our Quality Model provides the basis for understanding patient needs, measuring and using data, and achieving real improvement. Improving continuously is our goal. To do this we encourage each member of our team to find ways to do their work better and to make patient safety a priority. Together we are focused on pursuing perfection for All Children.

Quality Measures

There are many ways to look at and measure quality. Our data uses information from key areas to help families, healthcare providers, and others learn about our progress in pursuing perfection for All Children.” (F)

“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 hospital six years earlier and vowed to transform its 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.

“Losing a child is something no family should have to endure, and we are committed to learning everything we can about what happened at the Heart Institute, including a top-to-bottom evaluation of its leadership and key processes,” a statement from Johns Hopkins read. “The events described in recent news reports are unacceptable.”

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.

George Jallo, M.D., who is medical director of the Institute for Brain Protection Sciences and chief of pediatric neurosurgery, will serve as interim vice dean and physician-in-chief, and Paul Danielson, M.D., who is chief of the Division of Pediatric Surgery at Johns Hopkins All Children’s Hospital, will serve as interim chair of the surgery department.

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.

“While Dr. Ziemer is not responsible for the current state of the program, we agreed that a fresh start was needed to ensure success for the program,” Johns Hopkins Health System President Kevin Sowers said in a letter to the hospital’s staff.” ..

In his letter to the staff, Sowers said that several hospital executives had been tasked with leading “critically important work around advancing our culture of safety.”

“As we work to rebuild the trust of our community, we must also work to fully embrace and support a culture where we are each empowered and encouraged to speak up and speak out if we see or hear something that concerns us,” he wrote. “This commitment applies to clinical concerns as well as inappropriate workplace behavior.”

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)

“The external review was prompted by multiple reports by the Tampa Bay Times about problems at the center which could have contributed to its mortality rate tripling between 2015 and 2017…

Health News Florida’s Stephanie Colombini talked about what could come next with Kathleen McGrory, one of the lead reporters.

One of the big problems you uncovered in your reporting was the lack of available data about mortality rates at a lot of these heart surgery programs…

Officials have either refused to release it or they only release four-year averages, which could mislead families about the current state of the program they’re choosing.

How is the state looking at making these programs more transparent?

There were some problems at another pediatric heart surgery program in 2015 in Palm Beach County (St. Mary’s Medical Center), and after those problems surfaced, the legislature put together a panel (Pediatric Cardiology Technical Advisory Panel) tasked with looking at transparency and ways we could, as a state, make these programs better and more accountable.

That panel is in the middle of doing its work right now and in fact has come close to finalizing some recommendations.

The panel would like all of these heart surgery programs to be reporting their one-year data (on mortality rates) rather than their four-year data because that four-year data can sometimes hide serious problems…

So the state is looking into making heart surgery programs more accountable, but is anyone calling for change when it comes to the government’s role in this?

You reported that multiple times state and federal regulators were alerted to problems at All Children’s and yet little, to no action was taken.

We saw U.S. Reps. Kathy Castor and Charlie Crist put some really tough questions to federal regulators asking what they had investigated and when. We haven’t heard back yet on that front but we know it’s something they’ll be looking into.

The state told us that they did the best they could do with the information that they had, same thing with the federal government.

But ACHA has a new chief (Mary Mayhew). We haven’t gotten a chance to connect with her yet and see what her thoughts are on this, but we certainly will do that in the new year. (K)

“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.

A Florida Agency for Health Care Administration spokeswoman said her agency had been at the facility.

A spokeswoman for the hospital confirmed federal inspectors had been there, too.

“We appreciate the oversight role that our regulators play and we will, as always, be fully cooperative and collaborative as they conduct any reviews necessary,” a statement from the hospital said.

A spokeswoman for the federal Centers for Medicare and Medicaid Services declined to comment beyond saying the matter remained “an ongoing review.”

In November, the Times reported that the mortality rate for heart surgery patients at All Children’s tripled from 2015 to 2017 to become the highest rate in Florida. The increase occurred after staff members warned the hospital’s leaders about problems with two heart surgeons, the Times found.

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)

Two Omaha surgeons filed a lawsuit Friday against Children’s Hospital & Medical Center, alleging that they were wrongfully suspended and forced to resign privileges there after they raised patient safety concerns.

In the suit, Dr. Jason Miller and Dr. Mark Puccioni say that the hospital suspended their privileges to practice at the Omaha facility after they raised concerns about the death of a 7-month-old during an operation. That operation was performed this fall by another surgeon, Dr. Adam Conley, the suit says.

In their communications, according to the suit filed in Douglas County District Court, the two also questioned Conley’s “skill and ability.”

In addition to the hospital, the lawsuit names as defendants Conley, as well as Dr. Richard Azizkhan, who took over as Children’s president and CEO in October 2015.

Children’s officials said in a statement that the hospital does not comment on pending litigation “other than to say we strongly disagree with these allegations…

Children’s has faced other issues in recent months.

In late November, a former pharmacy director at the hospital was accused of funneling more than $4.4 million from the organization into her personal account over six years. She was terminated in June and faces a hearing regarding possible disciplinary action later this month.

About three weeks ago, the Nebraska Medical Association sent a letter to the board of Children’s Hospital expressing concerns about “patient care, safety and quality” at the Omaha hospital, in addition to the loss of longtime physicians.

In the Dec. 11 letter, the president of the group, Dr. Britt Thedinger, wrote, “We as physicians are concerned about the summary suspensions, terminations and resignations of long-time outstanding physician colleagues.” The letter also expressed concern that children were being transferred to outside institutions because of “complications” and inadequate staffing at the Omaha hospital.

Thedinger said the organization did not intend for the letter to become public. The intent, he said, was to bring issues that had been raised by members to the hospital board and administration.” (M)

“The New Jersey Department of Health is investigating four Acinetobacter baumannii cases in the neonatal intensive care unit (NICU) of University Hospital in Newark, authorities announced Thursday evening.

DOH officials stated:

“The department first became aware of this bacterial infection on Oct. 1 and two department teams have been closely monitoring the situation. Those department teams, which have been at the facility last week and this week, have been ensuring that infection control protocols are followed and are tracking cases of the infection. The department’s inspection revealed major infection control deficiencies.”

According to the DOH, a premature baby with the bacteria who had been cared for at University Hospital was transferred to another facility and passed away toward the end of September, prior to the department’s notification of problems in the NICU.

“Due to the other compounding medical conditions, the exact cause of death is still being investigated,” DOH officials said.

The department has ordered a Directed Plan of Correction that requires University Hospital to employ a full-time Certified Infection Control Practitioner consultant, who will report to the DOH on immediate actions taken in the coming days.

DOH officials said they are also exploring further actions the agency may need to take in the coming days to “ensure patient safety.” (N)

“Four New Jersey pediatric care facilities and one hospital are now under the state’s microscope after nine children died and 26 people were sickened by a deadly virus over the past month.

A Department of Health team of infection control experts and epidemiologists will visit University Hospital in Newark and four pediatric long-term care facilities in November to conduct training and assessments of infection control procedures, Commissioner Dr. Shereef Elnahal has announced.

The team of experts will visit University Hospital, the Wanaque Center for Nursing & Rehabilitation in Haskell, Voorhees Pediatric Facility in Voorhees and Children’s Specialized Hospital in Toms River and Mountainside. The department reached out to the facilities last week to schedule visits in November.

The decision comes after nine children at a Wanaque facility have died since an outbreak of the adenovirus was declared there. Victims became sick between Sept. 26 and Oct. 22. Authorities confirmed that the virus killed eight of the nine kids.

Twenty-six kids and a staff member, who has since recovered, have become ill as part of the outbreak, state health officials said. Laboratory tests confirmed the 26th case. (O)

“Two decades ago, the Institute of Medicine shook the medical profession with its “To Err is Human” report which said nearly 100,000 people a year lost their lives to preventable medical errors…

During the 7th Annual World Patient Safety, Science & Technology Summit over the weekend, the Patient Safety Movement Foundation released a new tool on its website to help with the training.

The patient safety curriculum is one of 17 Actionable Patient Safety Solutions (APSS) made available to organizations for free to help train health professionals in systems science so they can help find ways to reduce preventable patient deaths, officials said.

“The goal is to get every health professional to think in a system way,” said Steven Scheinman, M.D., the president and dean of Geisinger Commonwealth School of Medicine. He led a Patient Safety Movement working group which included experts from Geisinger, San Diego State, University of Pittsburgh Medical Center, Johns Hopkins Health, and MedStar Georgetown to develop the curriculum over an 18-month period.

The Patient Safety Movement was founded in 2013 to help reduce preventable deaths in healthcare and in 2015 set a goal of zero preventable deaths by 2020. More than 90,000 patients who might have died as a result of medical errors were saved in 2018 due to efforts made by more than 4,700 hospitals that committed to patient safety efforts, according to figures released by the foundation. In all, a total of 273,077 lives have been saved since the first summit, officials said.

The newly released safety curriculum can be adapted to any healthcare profession including medicine, nursing, pharmacy, and behavioral health and can be used for student training, as well as training for experienced professionals.

“We want to train every health professional to take ownership of the patient’s safety and experience so they understand safe communication and know when they are telling another person about the patient or handing them over or referring them over, how to make sure they get all the critical information there,” Scheinman said…

“The airline industry solved safety by creating the right systems,” Scheinman said. “Medical errors are very widespread. But they usually aren’t a doctor making a mistake. They can be. But they’re more often the system failed to pick something up or allowed something bad to happen.”

And with this training, he said, those medical professionals might be that much more likely to help figure out a new solution to make sure something bad doesn’t happen again.” (P)

“.. 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

“Johns Hopkins All Children’s Hospital in St. Petersburg, Fla., has been given another extension from federal regulators to correct its problems. The pediatric hospital came under fire in late 2018 after the Tampa Bay Times uncovered widespread problems at the facility, including a rising death rate in the pediatric heart unit.

The reporting from the Times led to the resignation of several high-profile executives at the hospital and a federal investigation from CMS that led to a series of corrective actions with the government.

Now, the hospital still needs more time to meet the demands of inspectors, the Tampa Bay Times reported. Inspectors found problems with All Children’s infection control unit, which the hospital must fix by “early May.” The agreement with CMS to meet corrective actions underscores how the hospital has been at risk of losing public funding, which covered more than 60% of its patients in 2017, according to the Times.” (A)

“Care in a special heart surgery unit at Johns Hopkins All Children’s Hospital in St. Petersburg, Fla., became so troubled that last year one in 10 patients died and others suffered devastating complications before procedures were halted, a year-long investigation by the Tampa Bay Times found.

The investigation found that staff raised safety concerns as early as 2015 but the hospital, led by administrators sent by Hopkins, disregarded warnings and didn’t stop performing the most complex procedures until early last year. All surgeries were curtailed eventually and a review launched. The status of two surgeons connected to most of the complications is unclear…

In a statement to the Tampa Bay Times, All Children’s said it “is defined by our commitment to patient safety and providing the highest quality care possible to the children and families we serve. An important part of that commitment is a willingness to learn. When we became aware of challenges with our heart institute we took action to address them.”

The hospital said it initially stopped performing complex cases and brought in a surgeon from Baltimore. Then it halted all surgeries after that surgeon left. The hospital said it is currently reviewing the program and recruiting new surgeons with aid from Hopkins and plans to resume surgeries “when all involved are confident that the care being delivered meets the high standards set by this organization.”

A statement from Johns Hopkins Medicine to The Baltimore Sun said, “We are devastated when children suffer, and losing a child is something that no parent should have to endure. We are continuing to take a very close look at the program, and will not resume open heart surgeries until we are confident this program at Johns Hopkins All Children’s Hospital delivers care that meets the highest standards.”” (B)

“Johns Hopkins All Children’s Hospital posted an operating loss in the three months ended March 31, as the St. Petersburg pediatric hospital dealt with the fallout of federal and state probes into its practices.

The hospital had an $11.5 million quarterly operating loss, according to a May 13 financial report from The Johns Hopkins Health System Corp. and affiliates. Operating revenue dropped 7.1 percent to $119.9 million, while operating expenses climbed 10.5 percent to $131.4 million.

The operating loss was attributed to closing the hospital’s Heart Institute. The facility closed after an investigation by the Tampa Bay Times found seven children had died or were permanently injured due to substandard care in the cardiovascular surgery program…

“The decrease in income from operations and operating margin percentage was mainly driven by lower net patient service revenue at [Johns Hopkins All Children’s Hospital] as a result of the closing of the Heart Institute,” the May 13 report said.” (C)

“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…

At a conference last fall, Dr. Backer, the Chicago heart surgeon, urged fellow surgeons to consider “rational regionalization,” or joining forces in an effort to reduce mortalities nationwide for congenital heart defects, potentially saving hundreds of lives.

Reaching adequate case volumes to keep up skills is a challenge because so many hospitals are competing for patients – surgical programs are an important driver of revenue. The Orlando, Fla., and San Antonio metropolitan areas, for example, each have three hospitals doing pediatric heart surgeries. Cleveland has two about a mile apart. A study last year by Dr. Backer and other physicians found that 66 percent of hospitals doing the surgeries were within 25 miles of another one.” (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.

A Tampa Bay Times analysis found that the death rate among pediatric heart surgery patients at All Children’s had tripled from 2015 to 2017…

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.

The newspaper said it is suing the health system for more data.

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.”

North Carolina Children’s Hospital, part of the University of North Carolina medical center, performs about 100 to 150 pediatric heart surgeries a year.

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)

“UNC Health declined a CBS 17 request for an interview. Phil Bridges, UNC Health’s Integrated Communications Executive Director issued a written statement:

We are proud of our pediatric congenital heart surgery program, and our current team is receiving top results that would place us among the best in the nation. We have been engaged in continuous quality improvement efforts for decades and have made significant improvements in the past 10+ years.

As the state’s leading public hospital, the UNC Pediatric Congenital Heart Surgery program often receives the most complex and serious cases. For many of these very sick children, we are often parents’ last hope.

As we shared with the New York Times, there were team culture issues back in 2016. They were handled appropriately. That, combined with decades of continuous quality improvement (CQI) efforts, have led us to today in which we have a very strong program. For our team, and each family, even a single death is too many, and we will continue our CQI work.

To characterize today’s program as anything but strong, would not only be misleading, but not factual. To say we ignored issues would also be false.” (F)

“First and foremost, we are physicians who have dedicated our lives to caring for and caring about patients. We celebrate with families the joys of curing illness; and we are deeply impacted by any death, particularly that of a young child. We lead our respective areas of surgery and pediatrics with the mindset of always doing what is right for children and families. Caring for these children is a privilege. Children and families are always our top priority. Our mission is to provide the best care for all children across North Carolina. We and our colleagues live this mission every day.

Regarding this week’s story from The New York Times (“Doctors Were Alarmed: Would I have my children have surgery here”): We are proud of the medical care provided to all patients at UNC Children’s. They become part of our family, and as providers we wouldn’t hesitate to bring our own loved ones here for treatment. Any negative outcome or death is taken incredibly seriously and we strive to constantly look for ways to improve the care provided.” (G)

“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.

“As a mother and a doctor my heart goes out to any family that loses a child,” Dr. Cohen said in the statement. “Patient safety, particularly for the most vulnerable children, is paramount.”

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.

The article included discussions among doctors that were captured on secret audio recordings provided to The Times, in which the physicians talked openly about their concerns, including that some might not feel comfortable allowing their own children to have surgery at the hospital. The physicians also discussed unexpected complications with lower-risk patients.

While the doctors could not pinpoint what might be going wrong, they considered everything from inadequate resources to misgivings about the chief pediatric cardiac surgeon to whether the hospital was taking on patients it was not equipped to handle.” (H)

The 2018-19 Best Children’s Hospitals Honor Roll (I)

1. Boston Children’s Hospital

2. Cincinnati Children’s Hospital Medical Center

3. Children’s Hospital of Philadelphia

4. Texas Children’s Hospital

5. Children’s National Medical Center

6. Children’s Hospital Los Angeles

7. Nationwide Children’s Hospital

8. Johns Hopkins Children’s Center (BALTIMORE)

9. Children’s Hospital Colorado

10. Ann and Robert H. Lurie Children’s Hospital of Chicago

North Carolina Children’s Hospital at UNC. Pediatric Cardiology & Heart Surgery Scorecard.

https://health.usnews.com/best-hospitals/area/nc/north-carolina-childrens-hospital-at-unc-PA6360260/pediatric-rankings/cardiology-and-heart-surgery

Duke Children’s Hospital and Health Center. Pediatric Cardiology & Heart Surgery Scorecard.

https://health.usnews.com/best-hospitals/area/nc/duke-university-medical-center-6360355/pediatric-rankings/cardiology-and-heart-surgery

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.

“If you have any concern about a patient safety issue, misconduct, a legal or unethical behavior or anything else, please call the Johns Hopkins medicine hotline,” Sowers said.

Problems with the hospital’s heart institute did not come to light until they were reported in the Times. The stories prompted inquiries by federal and state regulators and led to the resignation of six top officials.” (C)

“The changes include new checks and balances on the hospital’s president, more rigorous evaluations for top executives, better tracking of internal complaints, more thorough vetting of doctors and improved monitoring of patient safety and quality metrics.

Top executives will now report to both the hospital president and Johns Hopkins Health System leaders in Baltimore. And officials in Baltimore will be more involved in hiring, firing and discipline in St. Petersburg…

System leaders will analyze whether the same steps are needed at the five other Johns Hopkins hospitals, Sowers said.

Sowers said the firm discovered a culture of “fear of retaliation and retribution” across the hospital but determined that the quality and safety issues were limited to the heart unit…

Other recommendations addressed key findings in the Times report.

One example: The Times reported that procedures started going wrong after All Children’s became part of the Johns Hopkins network and hospital leaders made a series of personnel changes within the Heart Institute.

The firm recommended “more strategic planning” when changing clinical programs and more quality monitoring during transitions, especially for units that handle complex procedures.

It made the point bluntly: “In making personnel decisions, consider the effect on team dynamics.”..

As All Children’s carries out the policy changes, it will also work to address systemic problems flagged by the federal government. Hospital leaders recently agreed to hire an external consultant to oversee improvement for 12 months in order to maintain public funding.

Separately, a team of national experts has been working on a plan to restart the heart surgery program. Sowers said the team had drawn up recommendations and given them to the board. But he said he did not have a timeframe for surgeries beginning and that the program would first need to hire another surgeon.” (D)

“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)

“It’s unclear how long a state health department team will take to investigate questions raised in The New York Times about pediatric heart surgeries performed at the North Carolina Children’s Hospital in Chapel Hill.

State regulators were at the UNC Medical Center on Monday as part of an inquiry launched last week by Mandy Cohen, secretary of the state Department of Health and Human Services…

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)

“The actions are in response to a New York Times investigation last month into the medical institution, where cardiologists, department leaders and even the former head of the children’s hospital expressed concerns about patients faring poorly after heart surgery there. Secret audio recordings provided to The Times captured doctors talking openly, some even saying they might not feel comfortable allowing their own children to have surgery at the hospital.

The Times sued for the program’s mortality data and was still in a yearlong legal battle to obtain it when UNC Health Care released previously undisclosed statistics on Monday. The data shows that the mortality rate for heart surgery patients continued to rise after doctors warned administrators several years ago of possible problems.

The data, for four years through December 2018, showed that the hospital’s mortality rate for pediatric heart surgery was higher than those of most of the 82 hospitals in the United States that publicly report such data. The death rate at the North Carolina hospital was especially high among children with the most complex heart conditions — nearly 50 percent, the data shows. Those are the types of cases that some doctors had urged the hospital to temporarily stop handling in 2016 and 2017.

UNC administrators previously denied that there were any problems affecting patient care in the heart surgery program, saying only that there had been difficult team dynamics at the time of the doctors’ warnings, and that they had since been resolved by staffing and leadership changes.

Concerns about the quality of pediatric heart surgery programs have been noted at hospitals across the country. At least five programs were suspended or shut down in the last decade after questions were raised about their performance. 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.

After the Times article was published, the North Carolina secretary of health opened an investigation into the children’s hospital. In addition to an on-site investigation that finished on Friday after more than two weeks, state regulators have reached out to former UNC medical staff, asking to meet and interview them about concerns they had while employed there.

A spokeswoman for the state health department said it would submit a report to federal regulators from The Centers for Medicare & Medicaid Services within 10 business days.

In the statistics released on Monday, UNC Health Care included for the first time the hospital’s risk-adjusted data. Risk-adjustment helps account for prematurity, some genetic abnormalities and other factors that could make a child less likely to survive, and to more fairly assess hospitals that take on the most compromised patients. The statistical method also helps evaluate if hospitals are losing patients who wouldn’t be expected to die.

The health system first told The Times it was “critically important” to use risk-adjusted data, but then later released only raw, unadjusted numbers. The hospital subsequently said that no current risk adjustment adequately accounted for the breadth and severity of its patients’ medical issues.

The hospital’s overall mortality rate for pediatric heart surgery in the four years ending in 2018 was 5.4 percent, compared with a national average of 2.8 percent. The hospital’s risk-adjusted mortality rate was 5.6 percent…” (I)

“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)

“Two Triangle hospitals showed up on the list of Best Children’s Hospitals from U.S. News & World Report released on June 18.

The report broke out 10 different pediatric specialties and ranked the top 50 hospitals in each. Duke Children’s Hospital & Health Center and the North Carolina Children’s Hospital at UNC were the lone Triangle representatives that ranked in the top 50 in any of the categories…

The only pediatric category where a Triangle hospital did not appear in the top 50 was cardiology & heart surgery.” (K)

U.S. News & World Report ranked Johns Hopkins All Children’s Hospital No. 44 out of 50 on the 2019-20 Best Children’s Hospitals list for the two programs.

“Our cancer and pulmonology specialists care for some of the region’s most medically complex children, and we are grateful for this recognition of their hard work,” interim hospital president Tom Kmetz said in the hospital’s blog.

The hospital received an overall score of 73.3 out of 100.” (L)

Johns Hopkins Children’s Center ranked ninth overall and No. 1 in Maryland in U.S. News & World Report’s annual list of the top-ranked children’s hospitals in the United States, which was released earlier today.

The Children’s Center also earned a spot on the U.S. News Best Children’s Hospitals Honor Roll, a list of the 10 pediatric hospitals with the highest point totals in the survey. This marks the Children’s Center’s eighth appearance since the Honor Roll was established 11 years ago…

Founded in 1912 as the Children’s Hospital at Johns Hopkins, the Children’s Center offers one of the nation’s most comprehensive pediatric medical programs, with almost 110,000 patient visits and nearly 9,000 admissions each year. With 295 beds, it is Maryland’s largest children’s hospital and is the only state-designated trauma service and burn unit for pediatric patients. Since 2012, the Charlotte R. Bloomberg Children’s Center Building has been its home.” (M)

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)

“One in four hospitals that participate in The Leapfrog Group’s annual patient safety grades survey do not meet the national healthcare quality group’s standard for handling serious reportable events that should never happen to a patient.

Leapfrog’s 2019 Never Events Report is based on findings from its 2018 Leapfrog Hospital Survey with data voluntarily submitted by more than 2,000 U.S. hospitals. It is aimed at highlighting official hospital policies for responding to the 29 serious reportable events as identified by the National Quality Forum as never events.

Those events include errors and accidents that hospitals should always prevent, such as surgery on the wrong body part, foreign objects left in the body after surgery or death from a medication error…

The Leapfrog standard for hospital policies includes steps such as offering an apology to the patient, not charging for the event, conducting a comprehensive root cause analysis, reporting the event to appropriate officials and implementing a protocol to care for the caregivers involved.

“Patients and payors alike expect that 100% of hospitals will adhere to these basic principles, but unfortunately, we are not seeing that yet, with only 75% of reporting hospitals meeting Leapfrog’s standard,” Leah Binder, president and CEO of The Leapfrog Group, said in a statement.”..

In the report, released with the Johns Hopkins Armstrong Institute for Patient Safety and Quality, officials estimated that 160,000 people died from avoidable medical errors in 2018.” (O)

“Affiliation with a top-ranked cancer hospital appeared to offer no robust advantage for complex cancer surgery, a new study found…

“A favorable mix of hospital characteristics associated with safety at affiliate hospitals appeared to contribute to this mortality advantage,” they wrote in JAMA Oncology. “Thus, affiliate status appears to be a marker, but not a robust, independent predictor of favorable outcomes.”

For their study, the group examined cancer surgery outcomes at 338 hospitals affiliated with a top-50 cancer hospital and 2,729 hospitals that were not.

“This study helps to further our understanding of patient safety after major cancer surgery at hospitals affiliated with top-ranked cancer centers,” Lesly Dossett, MD, MPH, of the division of surgical oncology at the University of Michigan in Ann Arbor, told MedPage Today.

Dossett, who was not involved in the study, pointed to the important fact that the researchers compared outcomes at non-affiliated hospitals with the affiliates of top hospitals, rather than the flagship hospitals themselves.

“While the study does show that outcomes at affiliated centers are better than at non-affiliated centers, these differences are explained by other hospital characteristics known to be associated with patient safety,” Dossett said. “In the end, the study suggests that top-ranked hospitals selectively affiliate with safer hospitals, rather than having an independent effect on their outcomes.” (P)

“Rochester, Minn.-based Mayo Clinic has added Saudi German Hospital Cairo in Egypt to the Mayo Clinic Care Network, a select group of independent health systems that have access to Mayo Clinic’s knowledge and medical expertise.” (Q)

“The announcement Thursday that Jewish Hospital would suspend its heart transplant program was a blow to an institution that once led the nation as an esteemed leader in heart care and innovative medical procedures.

The decision directly affects 32 people on the hospital’s waiting list for new hearts. Once the program is halted next month, officials at Jewish Hospital are expected to help them transition to other transplant programs — and there’s only one other program for adults in the state at the University of Kentucky.

Jewish’s president Dr. Ronald Waldridge told staff on Thursday morning that patients who’ve already had transplants at the downtown Louisville hospital would continue to receive care, and that those who are awaiting the procedure would get help transitioning to another program.

“Though our heart transplant program will not be able to perform transplants or take new physician referrals, we will continue to provide physician coverage to manage care of our current heart transplant program patients,” Waldridge wrote, adding that as volumes of available hearts dropped, Jewish also lost heart transplant cardiologists…

KentuckyOne officials said Thursday that Jewish was in danger of falling out of compliance with federal regulations after its transplant numbers fell far short of required minimums — with just one procedure so far this year.

They blamed the drop on new rules that revised how donated organs are allocated nationwide and, as a result, delivered fewer hearts to Jewish starting last October.” (R)

From the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality:

“If there was a wonder drug to save the lives of infants with serious heart abnormalities, doctors would be sure to prescribe it. Parents would insist that their children get it. The company that invented it would get rich.

But there already is something that can have as dramatic an impact on these young lives as a blockbuster pill: having complex heart surgery performed in a high-volume hospital.

Surgical volume — the number of certain procedures that a hospital performs each year — has far greater impact on whether these patients, most of whom are infants or children, survive than infection rates, readmissions or other publicly reported measures. As U.S. News’ Steve Sternberg reported, the risk of dying was 26 percent lower if a complex congenital heart operation was performed at a high-volume hospital rather than at low- and medium-volume hospitals. Yet, few parents know to ask about volumes, let alone know how to find and evaluate the data.” (S)

“The American Nurses Credentialing Center (ANCC) named Johns Hopkins All Children’s Hospital as a Magnet® designated hospital today. The recognition is considered the highest nursing honor a hospital can receive. There are only 498 Magnet hospitals across the world and fewer than eight percent of U.S. hospitals have received the designation.” (T)

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