Let’s start off by making it clear that most adverse clinical outcome are not medical errors. OK?
Back about twenty years ago during my tenure as President and CEO of Jersey City Medical Center, insurers when reviewing a claim for hospital reimbursement, would “deny” days. More specifically the hospital got a per diem payment for “approved” days only. But even if the insurer reduced the number of approved hospital days say from six to four, they still reimbursed the physician for six days. With no disincentive for physicians to be concerned about length-of-stay, denied days were costly to the hospital.
Fast Forward. Medicare is penalizing hospitals for certain readmissions.
“Generally speaking, a hospital readmission occurs when a patient is admitted to a hospital within a specified time period after being discharged from an earlier (initial) hospitalization. For Medicare, this time period is defined as 30 days, and includes hospital readmissions to any hospital, not just the hospital at which the patient was originally hospitalized.
Medicare uses an “all-cause” definition of readmission, meaning that hospital stays within 30 days of a discharge from an initial hospitalization are considered readmissions, regardless of the reason for the readmission.” (A)
Some systems are working to align hospital and physician performance, avoid reimbursement penalties, and increase patient satisfaction.
“In 2006, Geisinger Health System transformed the health care industry by testing and rewarding how elective cardiac surgery was performed and by offering a “warranty” on coronary artery bypass surgeries. That innovative effort marked the birth of the Pennsylvania-based health system’s eminent ProvenCare program, which applies evidence-based protocols aimed at reducing mortality rates, improving outcomes and reducing costly readmissions”…..”By eliminating unwarranted variation and applying scientific best practices to coronary artery bypass graft (CABG) patients, Geisinger has been able to reduce readmissions, complications and length of stay while raising its profit margin by 17 percent.” (B)
”Patients who undergo routine hip or knee replacements at Seattle’s Virginia Mason Medical Center, and their employers, now can worry less about paying twice if surgical complications occur. That’s because the hospital has decided to offer a warranty to privately insured patients on avoidable complications stemming from total joint replacements, making it one of the first hospitals in the nation to do so.” (C)
“Surgical warranties vary somewhat in terms of what they cover. Generally, though, it’s a guarantee to fix any avoidable complications related to surgery — at no extra charge to the patient. Warranties are offered as part of a group of bundled services that come as one-price package deals.” (D)
“Hospital readmissions occur for a number of reasons: infections and other complications; premature discharge; failure to coordinate and reconcile medicines; inadequate communication among hospital personnel, patients, caregivers and clinicians; and poor planning for care transitions.” (E)
Warranties sound innovative but can only work to improve outcomes and reduce expense if physicians share the rewards and risks with the hospital. This sounds easy with employed physicians but will it work with unpaid voluntary physicians in private practice or will they simply move their practices to hospitals without warranties?
(D) http://www.latimes.com/business/ Considering surgery? Some healthcare providers offer warranties
To fight Zika, Central Florida hospitals and doctors ramp up patient education, surveillance
In the fight against the spread of Zika, local doctors and hospitals are ramping up education and surveillance in Central Florida to contain the spread of the virus.
There is a heavy emphasis on patient education, while providers are on high alert for travel histories and on the lookout for potential cases that should be tested for Zika.
“There’s a limit in what we can do to reverse the effects of Zika,” said Dr. Vincent Hsu, hospital epidemiologist at Florida Hospital. “So what we do is a combination of supportive care and making sure that babies are referred to the right specialists. It’s really ensuring that there’s coordination of care among specialties.”
“We haven’t had pathogens in the past that have done all of these,” said Dr. Asim Jani, hospital epidemiologist for Orlando Health.
Jani and Hsu are former CDC disease detectives. The two have been collaborating since earlier this year to align their health systems’ Zika preparation efforts, most of which involve updating and educating their staff on the evolving Zika screening and testing guidelines.
The two systems, which have well-established labor and delivery units and maternal-fetal specialists, have also taken on the responsibility of caring for pregnant women who test positive for the Zika virus.
Johns Hopkins Opens Unique Comprehensive Care Center for Zika Virus Led by the Wilmer Eye Institute
As the number of patients with Zika virus grows worldwide, Johns Hopkins Medicine announces the opening of the new Johns Hopkins Zika Center, dedicated to caring for pregnant women and newborn babies, but also men and women of all ages with the mosquito-borne and sexually transmitted virus. The center will focus not only on diagnosis and treatment of infected individuals but also on the assessment of long-term effects, as well as new approaches to prevention and treatment of Zika virus infection. It is composed of providers and staff members from adult and pediatric departments and divisions within Johns Hopkins Medicine and the Johns Hopkins Bloomberg School of Public Health, including cellular engineering, epidemiology, infectious diseases, maternal-fetal medicine, neonatology, neurology and neurosciences, ophthalmology, orthopaedics, pediatrics, physiotherapy, psychiatry, psychology and social work. Medical experts from Brazil, a country greatly affected by Zika virus, are also members of the center.
I don’t get an annual physical since I see my PCP a few times a year, but I do ask him periodically whether it is time for a “full” blood profile since I am treated with prescriptions for various “senior” conditions such as high cholesterol.
“Worthless is a very strong word and it provokes a very emotional reaction from not just patients but doctors. But the reality is we like to practice evidence-based medicine, and the evidence today does not support the idea of the annual physical exam,” …. (A)
“But what are the true benefits of this practice? Careful reviews of several large studies have shown that these annual visits don’t make any difference in health outcomes. In other words, being seen by your doctor once a year won’t necessarily keep you from getting sick, or even help you live longer. And some of the components of an annual visit may actually cause harm. For example, lab tests and exams that are ordered for healthy patients (as opposed to people with symptoms or known illnesses) are statistically more likely to be “false positives” — that is, when test results suggest a problem that doesn’t exist.” (B)
“Sometimes there is confusion about preventive health exams versus preventive care in general. Things like mammograms, pap smears, PSA testing, those are considered preventive care procedures — and there’s a clear evidence base that these are very important for patients to receive. What we’re talking about [in our] study is the special visit for [general] preventive care.” (C)
“…. the American Medical Association and other similar groups have moved away from the yearly exam. They now suggest that medical checkups be referred to as Periodic Health Assessments or Examinations and that they be performed every five years (for adults over 18) until age 40 and every one to three years thereafter. The requirements are for more frequent evaluations for those taking prescription medications. (D))
“Other experts say a yearly checkup is an important part of building a physician-patient relationship and can lead to unexpected diagnoses such as of melanoma and depression. I think there are probably subsets of people who can go longer than a year between visits but I think it’s quite important for people to know their doctor before they get sick,”………………(E)
BEWARE! “Under the law, most health insurance plans must cover a set of preventive services without any cost to patients. Services include vaccines, colonoscopies, mammograms, pap smears, diabetes screenings and tobacco use screenings – all aimed at helping doctors and patients catch problems early, so they don’t become costly and more difficult to manage later.
Patients are soon discovering, however, that anything else discussed during a visit with their health care providers could cost them.
“There are times when a person might be charged cost-sharing for a service that is unrelated to the screening or preventive service, while they are not charged cost-sharing for the screening or preventive service itself,”…….(F)
So………discuss with your PCP the plusses and minuses of a physical examination for you specifically in place of the seemingly now outdated generic annual physical for everyone.
Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.
Is Concierge Medicine simply an under-the-radar way of letting CM members “jump to the front of the line” silently creating a dual system of care based on ability to pay a “private” surcharge? (A)
A stated goal of the Affordable Care Act is to “Make coverage more secure for those who have insurance, and extend affordable coverage to the uninsured.” (B)
Obamacare was enacted to give millions of people access to health care. That is, to change the system where those who had insurance walked in the front doors of the health care system, while those without insurance were relegated to the Emergency Room (and then chastised for ER “abuse”) or just didn’t get care.
“The Association of American Medical Colleges estimates that there will be a shortage of 91,500 doctors by 2020 as the Obamacare insurance coverage provisions are implemented and 30 million Americans become eligible for health insurance coverage.” (C)
So let’s talk about Concierge Medicine.
“In this type of medical practice (also called boutique medicine, retainer-based medicine or direct care), doctors — mainly in primary care — see fewer patients so they can spend more time with ones they do see.
For their part, patients pay an out-of-pocket fee that typically ranges from several hundred dollars to $15,000 annually. In addition to longer visits, patients receive a comprehensive annual physical examination, a commitment to shorter waits and, in many cases, the doctor’s cellphone number and email address so they can get in touch quickly.
Concierge medicine is not a substitute for health insurance. The retainer, no matter how steep, does not cover out-of-office visits to specialists, emergency room care, hospitalization, major surgery or high-tech diagnostic tests, such as CT scans and MRIs. The fee is not reimbursed by either private health insurance or Medicare, although patients’ health savings accounts may cover some of the cost. (D)
Some concerns about CM.
Although Concierge Medicine is a “business model” it markets itself as a clinical model. “The American Academy of Private Physicians (AAPP) is a nonprofit organization founded in 2003 for the purpose of supporting and fueling the growth of medical practices that provide “concierge” and other forms of personalized, value-based medical care. AAPP members are united by their common efforts and dedication to making medical care more accessible and convenient to patients by redefining and re-pricing medical services in ways that are not possible for medical practices that rely solely on insurance payers for their revenue.” (E)
“Concern for quality of care the patient receives should be the physician’s first consideration. However, it is important that a retainer contract not be promoted as a promise for more or better diagnostic and therapeutic services. Physicians must always ensure that medical care is provided only on the basis of scientific evidence, sound medical judgment, relevant professional guidelines, and concern for economic prudence.” (F)
“Typically, the concierge medical practice is on safer legal ground when it includes only medical services that are typically non-covered by insurance. The insurance legal problem is most thorny where Medicare is involved. If the concierge practice charges patients an access fee for services that are covered under Medicare, federal enforcement authorities could see this as violating Medicare rules. In such case, the safest legal strategy may be to simply opt out of Medicare.” (G)
And food for thought:
“Simply running away from the problems and inefficiencies of our current health care system and into the comforts of “retainer medicine” does little to advance health and well-being for the vast number of patients or address some of medicine’s biggest challenges (e.g., cost and access). These are difficult times for physicians and patients alike. We must be careful not to compromise on our commitments and renew our efforts to find sustainable solutions that support physicians in the advancement of the health and well-being of all patients.” (H)
(D) http://www.aarp.org/health/healthy-living/info-01-2013/boutique-doctors.html(E) http://aapp.org/about-us-2/
As many of you know I have been advocating (unsuccessfully) for the designation of Zika Regional Referral Centers (ZRRFs).
Perhaps this article from STAT will convince policy makers that it is time to stage Zika hospital preparedness.
With little known about Zika virus, hospitals scramble to stay ahead
By Andrew Joseph https://www.statnews.com/2016/08/17/hospitals-zika-virus-disease-birth-defects/
“The threat of Zika virus is reshaping operations at hospitals across the country, as medical teams rush to figure out how best to provide care for pregnant women with the disease and monitor and treat babies with related brain damage.
With scientists still trying to better understand the virus — and without any treatments available — hospitals have been forced to adapt to a changing Zika outbreak, particularly in states such as Florida, Texas, and New York that are at risk for local transmission or have seen large numbers of travel-related cases.
Hospitals say they have built up their diagnostic tools, started performing more regular ultrasounds for patients, and are keeping closer-than-usual watch on amniotic fluid levels and fetal heart rates. Social workers and physical, speech, and occupational therapists are preparing to work with babies born with Zika-associated defects, should they require their care.”
“To bridge the gap, hospital officials say they have assigned doctors to keep up with the growing body of literature and confer with public health agencies. They are also bringing together obstetricians trained in high-risk pregnancies, pediatrician specialists, and virologists and other biomedical researchers.
Doctors say they don’t have good answers yet to the most pressing questions they get from pregnant patients, including if their fetuses are at risk throughout the pregnancy or only certain stages, and how likely their children are to have some sort of developmental problem.
Doctors also worry about what might happen to children who appear to be fine at birth. In the case of other congenital infections like cytomegalovirus, hearing and vision problems can emerge in apparently healthy children years down the road.”
To read the full STAT article click on https://www.statnews.com/2016/08/17/hospitals-zika-virus-disease-birth-defects/
CDC’s revised Zika Interim Response Plan (July) states: ”Neither vaccines nor proven clinical treatments are expected to be available to treat or prevent virus infections before local transmission begins within CONUS or Hawaii.”; “Scientific understanding of Zika virus continues to evolve, and new characteristics of the virus and how it is spread may arise.” (A)
“CDC director Tom Frieden has said that the mosquitoes carrying Zika in Miami could be developing resistance. Researchers can project what Zika infection rates will look like in multiple scenarios, but not what will happen if Zika is evolving at the DNA level or if its vectors multiply beyond sex and mosquitoes, both of which are real possibilities.” (B)
The New Jersey and New York Departments of Health Zika pages focus on community awareness, default to CDC, then stop at the door to the hospital ER. (C)
So we are not dealing with Zika “evidenced based medicine” but “best practices” aggregated and amended from Swine Flu, Ebola, Dengue, and other mosquito transmitted viruses.
Examples of some recent news reports make it clear that Zika parameters are changing so quickly, that only medical school affiliated teaching hospitals should be caring for Zika patients.
- “Zika virus infection during pregnancy may be related to a severe birth defect called arthrogryposis, whereby the joints – particularly those in the arms or legs – are deformed. This is the finding of a new study published in The BMJ.” “Researchers focused on seven babies whose mothers were infected with Zika while pregnant. Six of the seven developed microcephaly— the most widely publicized birth defect from Zika— but six also had trouble swallowing, six had clubfoot, five had eye abnormalities, and two needed breathing and feeding tubes.” (D)
- “NEW ORLEANS — Officials at the front lines of fighting the Zika virus are warning residents that mosquitos that carry the disease are already here.” (E)
- “Texas reported its first Zika-related death Tuesday after a baby girl whose mother traveled to El Salvador while pregnant died shortly after birth in a suburban Houston hospital. The girl, who died a few weeks ago, had microcephaly linked to the Zika virus….” (F)
- “In an effort to detect any local transmission of the Zika virus, the New York City Department of Health and Mental Hygiene said on Tuesday that it had expanded the guidelines on who should be tested for the disease to include anyone with its most-common symptoms.” (G)
- “Amid news of a Zika outbreak in the Miami area, the U.S. Food and Drug Administration’s Center for Veterinary Medicine (FDA-CVM) has cleared the experimental release of genetically modified (GMO) mosquitoes in the Florida Keys to help combat the virus. “ (H)
- “Suncoast Blood Bank announces they are testing all donated blood for the Zika virus. Effective immediately the blood bank will test all donors for the virus.” They say this is a proactive measure to protect the community blood supply.” (I)
- “I got Zika. The US health care system had no idea what to do with me. How do you spell Zika?”I stood at the front desk of a major Washington, DC, hospital last month. I had a head-to-toe rash that developed after I’d returned from the Dominican Republic, where Zika is much more common than it is stateside. The friend I’d traveled with was showing symptoms of the virus. I’d come to the emergency room to find out if I had it too.This was not a question I wanted to hear from the man who was checking me in.But ignorance of what Zika is, and uncertainty about how to deal with it, was common in my quest to get diagnosed — even from parts of the medical community that I expected would know what to do.” (J)
- “On Thursday, scientists described two cases in which the semen of men who contracted Zika in Haiti early this year continued to test positive for the virus, even though it has been six months since they were infected.The semen of one tested positive 188 days after he first experienced symptoms of the illness. Testing on day 181 came back positive for the other man. Both men are still being followed. Previously, the longest period in which evidence of virus was seen in the semen of a Zika-infected man was 93 days.” (K)
- “Until this week, there had been no reported cases of birth defects related to Zika in Canada.Public health officials are releasing no other information about the fetus, including whether or not he or she is alive. It represents the second confirmed case of maternal-to-fetal transmission of the Zika virus in Canada.” (L)
- “U.S. Sen. Bob Menendez can add a personal motivation to his efforts to get Congress to approve federal funding to combat the spread of the Zika virus. Menendez said this week his daughter is five months’ pregnant in Miami with his first grandchild.”(M)
- “Beyond Zika: How Congress Is Flirting With Medical Disaster. The dysfunctional response to the Zika virus lays bare a system that is increasingly ill-equipped to respond to outbreaks.” (N)
- “While the Zika virus has its moment, few people are discussing the problems underlying the worldwide increase in emerging infectious diseases.” (O)
- “Zika fits into the category of unforeseen emerging threats that migrate into new environments where they suddenly pose major hazards to unprepared populations — think severe acute respiratory syndrome (SARS) or Ebola, for instance. These required “urgent mobilization to protect and manage the introduction of these alien, and dangerous, pathogens,”….(P)
Soooooo……if you are concerned that you may have been exposed to Zika, until there are national protocols in place, bypass your community hospital ER, and go to the nearest medical school affiliated teaching hospital.
EMERGENCY ROOMS are not all created equal! (Q)
Stop the name games! University hospitals and regional medical centers should live up to their billing. (R)
(C) http://www.nj.gov/health/cd/zika/ https://www.health.ny.gov/diseases/zika_virus/
Many of you might be familiar with my advocacy for designating Zika Regional Referral Centers. If not see links below.
We don’t know what we don’t know” – The challenge to emergency preparedness….. http://doctordidyouwashyourhands.com/2016/04/we-dont-know-what-we-dont-know-about-zika-1-the-challenge-to-emergency-preparedness/
Former hospital prez says: Designate local Zika centers now. “Medical experts do not know if, or where, or how much, or on what trajectory the Zika virus may spread across the United States.” http://doctordidyouwashyourhands.com/2016/06/former-hospital-prez-says-designate-local-zika-centers-now-medical-experts-do-not-know-if-or-where-or-how-much-or-on-what-trajectory-the-zika-virus-may-spread-across-the-united-states/
Suspending a chicken over your bed could protect against Zika virus and malaria (A) http://doctordidyouwashyourhands.com/2016/07/suspending-a-chicken-over-your-bed-could-protect-against-zika-virus-and-malaria-a/
Zika “panic” – IS YOUR HOME TOWN READY FOR ZIKA?
Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.
I used to. I stopped. Here’s why.
Like many people I know I also stockpiled antibiotics thinking I knew when to call my physician and get his approval or would infrequently simply start myself on an antibiotic regimen. ZPack for an upper respiratory infection. Augmentin for a sinus infection. Cipro for a prostate discomfort. Doxycycline for Lyme disease.
Here’s the chain of antibiotic abuse and its consequences.
“You’re sick. You’re not sure what it is, but you know you would really love for this achy feeling, stuffed-up head or painful cough to go away. So you go to the doctor and demand drugs.If recent research is any indication, your physician will probably prescribe you an antibiotic, even if he or she knows it won’t make you better any faster.” (A)
“Antibiotic agents don’t work for viral infections and should not be prescribed. However, it is often easier to write a prescription than to explain to a patient why you won’t. I have had patients leave my office very angry and immediately go to another doctor to get the antibiotics that I have declined to give.” (B)
“Antibiotic use promotes development of antibiotic-resistant bacteria. Every time a person takes antibiotics, sensitive bacteria are killed, but resistant germs may be left to grow and multiply. Repeated and improper uses of antibiotics are primary causes of the increase in drug-resistant bacteria. While antibiotics should be used to treat bacterial infections, they are not effective against viral infections like the common cold, most sore throats, and the flu. Widespread use of antibiotics promotes the spread of antibiotic resistance. Smart use of antibiotics is the key to controlling the spread of resistance.” (C)
“Antibiotic resistance is highly problematic because it severely hinders our ability to treat infectious diseases. In addition, surgery is dependent on the administration of antibiotics before and after the operation. Cancer patients and patients who have received organ transplants rely on antibiotics to protect them from bacteria, as the former have compromised immune systems while the latter needs to suppress their immune systems from attacking the transplanted organs.Without effective antibiotics, basic medical procedures and surgical operations could become very high risk because there’s a much higher risk the patient could be infected with an antibiotic microbe and be without appropriate treatment while recovering from the operation.”In addition to causing deaths and preventing basic infectious conditions to be treated, antibiotic and antimicrobial resistance will lead to steeper healthcare costs. Patients will need to spend more time in hospital in order to receive more expensive types of treatment.” (D)
“As drug resistance increases, we will see a number of dangerous and far-reaching consequences. First, common infections like STDs, pneumonia, and “staph” infections will become increasingly difficult to treat, and in extreme cases these infections may require hospitalization or treatment with expensive and toxic second-line therapies…. Health care providers are increasingly encountering highly resistant infections not only in hospitals – where such infections can easily spread between vulnerable patients – but also in outpatient care settings.” (E)
“Any species of bacteria can turn into a superbug. Misusing antibiotics (such as taking them when you don’t need them or not finishing all of your medicine) is the “single leading factor” contributing to this problem, the CDC says. The concern is that eventually doctors will run out of antibiotics to treat them. “What the public should know is that the more antibiotics you’ve taken, the higher your superbug risk …… The more encounters you have with the hospital setting, the higher your superbug risk.” (F)
“For the first time, researchers have found a person in the United States carrying bacteria resistant to antibiotics of last resort, an alarming development that the top U.S. public health official says could mean “the end of the road” for antibiotics.The antibiotic-resistant strain was found last month in the urine of a 49-year-old Pennsylvania woman. Defense Department researchers determined that she carried a strain of E. coli resistant to the antibiotic colistin, according to a study published Thursday in Antimicrobial Agents and Chemotherapy, a publication of the American Society for Microbiology. The authors wrote that the discovery “heralds the emergence of a truly pan-drug resistant bacteria.” (G)
“Taking antibiotics you do not need will not help you feel better, cure your illness, or keep others from catching your infection. But taking them may cause side effects such as: • Nausea. • Diarrhea. • Stomach pain. •An allergic reaction. In rare cases, this reaction can require emergency care.
Antibiotics also can cause Clostridium difficilecolitis (also called C. difficilecolitis), a swelling and irritation of the large intestine, or colon camera.gif. This happens because the antibiotics kill the normal bacteria in your intestine and allow the C. difficile bacteria to grow. This problem can cause diarrhea, fever, and belly cramps. In rare cases, it can cause death. Women may get vaginal yeast infections from taking antibiotics.” (H)
“When an antibiotic is prescribed, it is wise to ask what the drug is and whether it is necessary, what side effects to be alert for, whether there are effective alternatives, when to expect the diagnosed condition to resolve, and when to call if something unexpected happens or recovery seems delayed.” (I)
NOTE: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.