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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Advanced patient safety technology should be embraced!


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Observation Status.

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

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

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

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

Medicare Readmission Penalties.

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

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


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

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


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

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

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

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

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

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

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

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

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

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

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

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

Briefly they are:

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

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

But how about the patient?

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

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

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

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

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

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

The core elements comprising patient satisfaction include:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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I went on my morning walk committed to losing the weight I gained over the summer

After turning on my GPS app to monitor my walking time, pace, distance, and calories burned, I started thinking about how technology can change physician/ patient communication for the better, if used thoughtfully.

For example, an article discussing the stethoscope as a historical artifact, raises the question are our physicians’ early or deferred adopters of advanced diagnostic technology.

“The stethoscope, the iconic device representing medical technology for the past two centuries, may be fading from the scene as physicians start to embrace mobile technology in the form of handheld ultrasound devices and smartphone apps. Newer digital stethoscopes enable doctors to not only listen to heart sounds and record them, but handheld devices provide high-resolution ultrasound that can actually “see” what’s wrong with the heart.“ Why do you want to still focus on these heart sounds that provide very indirect information and secondary acoustic events?” (A)

A related question: Do your physicians take full advantage of the scope of uses of their Electronic Medical Record? • Access to patient information, such as diagnoses, allergies, lab results, and medications. •Access to new and past test results among providers in multiple care settings. •Computerized provider order entry. •Computerized decision-support systems to prevent drug interactions and improve compliance with best practices. •Secure electronic communication among providers and patients. •Patient access to health records, disease management tools, and health information resources. •Computerized administration processes, such as scheduling systems. •Standards-based electronic data storage and reporting for patient safety and disease surveillance efforts.” (B)

And next on the horizon: Smart Phones, if used thoughtfully, can facilitate doctor/ patient communication.

“Smartphones already can be used to take blood-pressure readings or even do an electrocardiogram. ECG apps have been approved by the U.S. Food and Drug Administration for consumers and validated in many clinical studies. The apps’ data are immediately analyzed, graphed, displayed on-screen updated with new measurements, stored and (at an individual’s discretion) shared. I thought I’d seen it all in my decades long practice as a cardiologist, but recently, for the first time, I had an ECG emailed to me by a patient, with the subject line, “I’m in atrial fib, now what do I do?” I immediately knew that the world had changed. The patient’s phone hadn’t just recorded the data; it had interpreted it.” (C)

Getting back to weight loss, just-for-fun, here’s an interesting “futuristic” app. (D)

“Our team has created the world’s first handled device able to scan food at a molecular level: the …. Food Sensor. Our technology includes a three-part system: a pocket-sized spectrometer, a cloud-based patented analysis engine, and a mobile app that work together to scan foods, identify calories, macronutrients, allergens, and also provide relevant information such as food fraud, food adulteration and food quality.”

So besides reading these blog posts you can gauge how innovative your physicians in some of the following ways: every Tuesday the New York Times Science section includes health care technology updates; subscribe (usually free) to email newsletters from nationally prominent academic medical centers. “Google” (carefully) about your medical concerns and conditions, and what new diagnostic technology is being used.

My app says I burned 150 calories writing this post!


(A) http://www.healthdatamanagement.com/news/handheld-ultrasound-devices-making-stethoscopes-obsolete

(B) https://healthit.ahrq.gov/key-topics/electronic-medical-record-systems

(C) http://www.wsj.com/articles/the-future-of-medicine-is-in-your-smartphone-1420828632

(D) http://tellspec.com/en/

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“Insanity: doing the same thing over and over again and expecting different results.” (attributed to Einstein). Perhaps increasing access to primary care needs a new approach – rewarding evidenced based care, rather than outpatient visits.

Some highly acclaimed initiatives to improve access to quality primary health care and reduce cost have proved challenging. Over the past several weeks we have seen several glaring examples –  hospitals leaving ACOs, no change in ED use, the uphill strategy to train more primary care physicians, and “whatever happened” to medical homes. 

Dartmouth was the national leader in establishing an Accountable Care Organization. “Why Accountable Care? The current health care system, which pays for discrete medical services instead of outcomes, has resulted in fragmented care and fueled enormous growth in health care costs. To create a more sustainable system, we need a new model that holds health systems and providers accountable for the quality of care delivered to patients. By promoting strategic integration and rewards based on quality care, the Accountable Care Organization (ACO) model offers a potential win-win for providers, payers and patients alike.” (A)

The Dartmouth Atlas quickly became the ACO “bible.” “Under the program, primary care physicians are encouraged to join together with other providers to take responsibility for the full continuum of their primary care patients’ care. They must commit to reporting comprehensive measures of the quality and — eventually — outcomes of care. If they are able to improve quality and thereby reduce costs, they will receive a share of the savings achieved. The term “accountable” is intended to mean just that; ACOs should only receive additional payments to the extent that they are demonstrably improving care for their patients.” (B)

Now: “Dartmouth-Hitchcock Medical Center will abandon the Pioneer Accountable Care Organization program, the system confirmed Tuesday, after losing more than $3 million over the past two years in the Centers for Medicare and Medicaid model.” (C)

“Will Medicaid expansion save the country money as people stop using expensive emergency rooms for primary care? Not yet, suggest the latest findings from a landmark study published online Wednesday in the New England Journal of Medicine. The study of Medicaid patients in Oregon who got Medicaid in 2008 found their ER use stayed high two years after they gained the health insurance coverage — even as they also increased their visits to doctors’ offices.” (D) “People covered by Medicaid were more likely to both see a physician at a regular office visit and also go to the emergency room, casting doubt on the idea that people were using health coverage to shift their health care to a primary care doctor.” (E)

“One “hidden” benefit of the Affordable Care Act is its potential to make primary care more accessible. The U.S. has long lagged behind other industrialized countries on primary care—at great cost to our health and our economy. Throughout the legislation are provisions that, if considered together and implemented effectively, will strengthen primary care for all Americans. With stronger primary care, people will be more likely to receive recommended preventive care and timely care for medical problems before they become serious and more costly to treat.” (F)

Well over twenty new medical schools have opened in the last ten years with more in the pipeline. “Many of the schools under development are making a bigger push to educate future primary care physicians, which will be in greater need to improve the quality of medical care and lower costs by keeping patients out of the more expensive hospital setting.” (G)

But in 2013 AARP reported: “Today, the United States is short about 16,000 primary care doctors — the very doctors (family practitioners, internists and pediatricians) who offer the treatments and preventive screenings that save lives and head off expensive emergency room visits and hospitalizations. Why the shortage? It starts with huge medical school debts and ends with a doctor who is often overworked and underpaid. While students may enter medical school wanting to practice primary care medicine, they graduate saddled with heavy debt — $250,000 is not unusual — which prompts them to switch to a more lucrative specialty. The starting salary for a primary care physician is $150,000 to $170,000; a radiologist or gastroenterologist can make two to three times that. Only one in five graduating internal medicine residents plans to go into primary care medicine……” (H)

“The number of primary care physicians is projected to increase from 205,000 FTEs in 2010 to 220,800 FTEs in 2020, an 8-percent increase. The total demand for primary care physicians is projected to grow by 28,700, from 212,500 FTEs in 2010 to 241,200 FTEs in 2020, a 14-percent increase. Without changes to how primary care is delivered, the growth in primary care physician supply will not be adequate to meet demand in 2020, with a projected shortage of 20,400physicians. While this deficit is not as large as has been found in prior studies, the projected shortage of primary care physicians is still significant.” (I)

The “medical home” was the moon shot to improve access to primary care. “The medical home is best described as a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. It has become a widely accepted model for how primary care should be organized and delivered throughout the health care system, and is a philosophy of health care delivery that encourages providers and care teams to meet patients where they are, from the most simple to the most complex conditions. It is a place where patients are treated with respect, dignity, and compassion, and enable strong and trusting relationships with providers and staff. Above all, the medical home is not a final destination instead, it is a model for achieving primary care excellence so that care is received in the right place, at the right time, and in the manner that best suits a patient’s needs.” (J) “Medical home” has fallen off the innovation radar.

Some extreme, perhaps patient “unfriendly,” options to think about:

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

REFERENCE PRICING.  “Reference pricing serves as a reverse deductible. Rather than the patient paying up to a defined limit and then the insurer covering the remainder, the insurer pays up to a defined limit and the patient pays the remainder. This has the remarkable feature of exposing the patient to the variation in prices for treatments that are above deductible thresholds. And the patient’s contribution isn’t limited by an annual out-of-pocket maximum. “(L)

Perhaps we can do better! by rewarding evidenced based care, rather than outpatient visits.




(A)      http://tdi.dartmouth.edu/research/evaluating/health-system-focus/accountable-care-organizations

(B)      http://www.dartmouthatlas.org/keyissues/issue.aspx?con=2943

(C)      http://www.healthcarefinancenews.com/news/dartmouth-hitchcock-exit-pioneer-aco-program-over-losses-calls-model-%E2%80%98unsustainable%E2%80%99

(D)      http://www.npr.org/sections/health-shots/2016/10/19/498526110/emergency-room-use-stays-high-in-oregon-medicaid-study

(E)       https://www.washingtonpost.com/news/wonk/wp/2016/10/19/more-evidence-expanding-medicaid-increases-emergency-room-visits/

(F)       http://www.commonwealthfund.org/publications/blog/2011/jan/affordable-care-act-bolsters-primary-care

(G)      http://www.forbes.com/sites/brucejapsen/2012/07/17/as-obamacare-looms-new-medical-schools-open-to-address-doctor-shortage/#ee36f65767ca

(H)      http://www.aarp.org/health/medicare-insurance/info-03-2013/how-to-beat-doctor-shortage.html

(I)        http://bhpr.hrsa.gov/healthworkforce/supplydemand/usworkforce/primarycare/

(J)       https://www.pcpcc.org/about/medical-home

(K)      http://www.reuters.com/article/us-usa-healthcare-insurance-idUSBRE9BI04X20131219

(L)       http://www.wsj.com/news/articles/SB10001424052702303448104579152111004814066

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Is “community hospital cancer center” an oxymoron? Do “cancer hospitals” have better outcomes?

Back in the 1990s while I was President & CEO of LibertyHealth/ Jersey City Medical Center (a teaching hospital affiliated with Mount Sinai School of Medicine), a neighboring community purchased a linear accelerator and declared itself a Cancer Center, including signs on the New Jersey Turnpike saying “exit here” for cancer care.

And I remember when a friend with possible breast cancer was about to pick a breast surgeon who was in-network (though we didn’t use that terminology then) rather than one based on credentials, hospital affiliations, and experience.

With increasing frequency community hospitals market their cancer centers.

The information below can help you evaluate and weigh cancer care options!

The “gold standard”! National Cancer Institute Designated Cancer Centers.

“The NCI Cancer Centers Program is one of the anchors of the nation’s cancer research effort. There are currently 69 NCI-Designated Cancer Centers, located in 35 states and the District of Columbia, that form the backbone of NCI’s programs for studying and controlling cancer. At any given time, hundreds of research studies are under way at the cancer centers, ranging from basic laboratory research to clinical assessments of new treatments. Many of these studies are collaborative and may involve several cancer centers, as well as other partners in industry and the community.” (A)

To find an NCI Designated Cancer Center click on http://www.cancer.gov/research/nci-role/cancer-centers/find

“Accreditation by the Commission on Cancer (CoC), a quality program of the American College of Surgeons, demonstrates a cancer program’s commitment to providing high-quality, multidisciplinary, patient-centered cancer care.

CoC accreditation is nationally recognized by organizations, including the National Cancer Institute, Centers for Medicare & Medicaid Services, National Quality Forum, American Cancer Society, and The Joint Commission, as having established data-driven performance measures for the provision of quality cancer care.” (B)

There are 9 CoC designations. Comprehensive Community Cancer Program (CCCP).Community Cancer Program (CCP) .Academic Comprehensive Cancer Program (ACAD). Integrated Network Cancer Program (INCP). Veterans Affairs Cancer Program (VACP). NCI-Designated Comprehensive Cancer Center Program (NCIP). Pediatric Cancer Program (PCP). Hospital Associate Cancer Program (HACP). Free Standing Cancer Center Program (FCCP). (C)

Comprehensive Community Cancer Program (CCCP). Accessions more than 500 or more newly diagnosed cancer cases each year. Full range of diagnostic and treatment services provided either on-site or by referral. Participates in cancer-related clinical research either by enrolling patients in cancer-related clinical trials or by referring patients for enrollment at another facility or through a physician’s office. Training resident physicians is optional.

Community Cancer Program (CCP). Accessions more than 100 but fewer than 500 newly diagnosed cancer cases each year. Full range of diagnostic and treatment services provided, but referral for a portion of diagnosis or treatment may occur. Participates in cancer-related clinical research either by enrolling patients in cancer-related clinical trials or by referring patients for enrollment at another facility or through a physician’s office. Training resident physicians is optional.

Academic Comprehensive Cancer Program (ACAD).Provides postgraduate medical education in at least four program areas, including internal medicine and general surgery. Accessions more than 500 newly diagnosed cancer cases each year. Full range of diagnostic and treatment services either on-site or by referral. Participates in cancer-related clinical research either by enrolling patients in cancer-related clinical trials or by referring patients for enrollment at another facility or through a physician’s office.

Hospital Associate Cancer Program (HACP). Accessions 100 or fewer newly diagnosed cancer cases each year. Limited range of diagnostic and treatment services available on-site. Other services are available by referral. Clinical research is not required. Training resident physicians is optional.

Free Standing Cancer Center Program (FCCP). Facility is a non–hospital-based program and offers at least one cancer-related treatment modality. Full range of diagnostic and treatment services is available by referral. Referral to CoC-accredited cancer program(s) is preferred. Participation in cancer-related clinical research is encouraged but not required. Patients may be enrolled in cancer-related clinical trials either at the facility or by referring patients for enrollment at another facility or through a physician’s office. Training resident physicians is optional. No minimum caseload requirement for this category.

To find a CoC accredited cancer program click on https://www.facs.org/search/cancer-programs

Finally, there is an ongoing debate whether or not Cancer Hospitals have better outcomes than   hospitals that have cancer programs as part of a broader array of clinical activity.

Perhaps not unsurprisingly studies done by Cancer Hospitals suggest better outcomes in cancer specialty hospitals. (D) (E) For example, one states: “In our analysis, we also show large and persistent risk-adjusted differences in cancer treatment outcomes associated with the type of treating hospital. The findings suggest that compared with community hospitals, survival appears to be superior for patients treated at PPS-exempt cancer hospitals, at NCI-designated cancer centers, and at academic teaching hospitals—all findings consistent with prior reports……..”(F)

Yet a 2014 article notes: “…..in cancer there are lots of metrics, but no settled-on methodology for measuring treatment performance and comparing treatment outcomes between institutions, care settings, or providers. (G)

Some resources to consider:

– National Cancer Institute. How To Find a Doctor or Treatment Facility If You Have Cancer. Click on http://www.cancer.gov/about-cancer/managing-care/services/doctor-facility-fact-sheet

– The American Cancer Society How to Choose a Hospital: Worksheet. Click on http://www.cancer.org/acs/groups/cid/documents/webcontent/003292-pdf.pdf

– Choosing Your Cancer Treatment Hospital. How can you tell a good cancer treatment hospital from a mediocre one? Click on http://www.webmd.com/cancer/features/choosing-your-cancer-treatment-hospital

(A) http://www.cancer.gov/research/nci-role/cancer-centers

(B) https://www.facs.org/quality-programs/cancer/coc/apply/benefitscoc

(C) https://www.facs.org/quality-programs/cancer/coc/apply/categories

(D) https://www.mskcc.org/blog/msk-study-examines-care-outcomes-among-u-s-hospitals

(E) https://www.fredhutch.org/en/news/center-news/2015/11/cancer-center-patients-live-longer.html

(F) http://oncology.jamanetwork.com/article.aspx?articleid=2451426

(G) http://jop.ascopubs.org/content/10/3/215.full


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

“Effective meetings don’t happen by accident, the happen by design.” (author unknown)

In 1975 I was appointed Administrator of Mount Sinai Services at City Hospital at Elmhurst, a public hospital where Mount Sinai School of Medicine contractually provided professional services. We had a quarterly Dean’s Committee meeting with the Dean of the Medical School. After our first Dean’s Committee meeting I was proud of my contributions only to be chastised by our Clinical Director of Medicine who said: “Dr. Metsch, this is our meeting with the Dean not yours, you can meet with the Dean (your boss) whenever necessary, we only get to talk to him four times a year. It’s our agenda, not yours!”

A painful but important Lesson Learned which led me to constantly monitor committee work for the rest of my career. Here are some more Committee Lessons Learned.

When I was an SVP (Office of the President) at Mount Sinai I had to remember that my role was different at every meeting. Meeting with the same people on different topics my role might range from full participant to minute taker.

Parenthetically I once had a staff member who always thought he was as important as the most important person in the room and spoke up accordingly. If he was in a meeting with the President of our organization, he acted presidential too.

I remember a meeting with a Board member who was a senior state legislator. I introduced several important issues and asked his assistance on them. He said: “Jonathan, there are ten people outside waiting to see me after our meeting. They all have important issues. So which one issue do you want me to help you with, and after we finish that please come back and raise the next most important one then.”

Parenthetically I once asked another Board member, also a senior state legislator why he had signed on to a bill that was not good for our hospital. He said: “Jonathan, I am part of the Leadership. Sometimes I can vote how I want but there are other times the Senate President directs the caucus on an issue. At the end of the day you should want me to be in the leadership group more than you are upset about one bill.”

Lesson Learned: when you are asking an influential to step in on an issue, make sure you understand the “demands” on that person and request support accordingly. Otherwise you may wind up with no gain.

If you raise ten great ideas at a meeting, no one will remember any of them. Be prepared by doing your homework and raise one sensational idea at a meeting, and everyone will remember.

I have served on numerous industry and community Boards. It is always easy to go to a few Committee meetings and quickly identify some “best practices” that would make a committee more effective. Share those ideas privately with the chairperson; never embarrass the chairperson publicly.

Parenthetically, when I was the CEO I once made a colossal mistake at a SVP/ VP staff meeting. One SVP caught it but he walked out of the meeting with the others at the end of the meeting, then circled back, explained my mistake which I quickly corrected.

Every project management committee meeting should end with scheduling the next meeting and clarifying individual assignments. Meeting notes should be produced quickly. And anyone with an assignment for the next meeting should send out reading material at least two days before the next meeting.

Parenthetically, always volunteer to write to write the Meeting Notes if the opportunity is there. This gives you a strategic role and earns you appreciation from the chairperson (particularly if the chairperson is higher up in the organization).

Never hijack someone else’s meeting because you would do things differently.

When someone makes a point that adds value never say “I was going to say that” when you didn’t speak up first.

When you chair a committee your job is to facilitate not dominate.

And at any meeting you learn more by listening than by talking. So pick your spots strategically.

“When in doubt, don’t call a meeting.” (source unknown)

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


(A) Arthur Goldberg

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