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.
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
In an emergency, your life may depend on getting to the nearest hospital. When you can, plan ahead, you and your doctor should discuss which hospital will best meet your health care needs.” (A)
“Identifying a better hospital on your own may be conceptually simple, but in practice it’s not so easy. (Obviously, this is something you’d want to consider in advance of an emergency like a heart attack.)” (B)
Sometimes the best way to start is by determining where not to go and then focusing on a group of possible appropriate hospitals.
Stories like this one, as a first step, can help you decide which hospitals to avoid.
“A few years ago a friend punctured her hand with a BBQ skewer. So she went to the nearest ER.
She was triaged and escorted to a treatment room. Then sat there for 45 minutes because the desk never told the doctor she was waiting, even though the ER had a computerized patient tracking system. A COMMUNICATIONS FAILURE.
While standing at the treatment room door, trying to remind the staff he was there, she overheard doctors talking about other patients’ clinical information. A HIPPA (CONFIDENTIALITY) VIOLATION.
A tetanus shot was ordered by the doctor, but it took another 45 minutes for the nurse to show up. A SYSTEMS PROBLEM.
When asked if she had washed her hand, the nurse said she always washed her hands after each patient. A PATIENT SAFETY ISSUE.
An email sent to the CEO got a “form letter” response addressed to the wrong last name. A PUBLIC RELATIONS PROBLEM.
Two weeks later when she touched the punctured area a splinter popped out. When this information was emailed to the ER Director the email response was “A splinter?! After reading the note and talking to the physician, I was under the impression that the wound was from a “barbeque skewer”. I guess it was not really clarified in the note whether it was metal or wood. I suppose I was just thinking that it was metal.” A CHARTING OMMISSION & A MEDICAL ERROR. AND AN OUTRAGEOUS STATEMENT TO PUT IN WRITING!”
“It’s still a good idea to check the quality ratings and consult with your doctor about where you’ll get the best care — and not be put off if it means driving a bit farther. It could save your life.” (B)
Here’s a link to “Steps to Choosing a Hospital Checklist”. https://www.medicare.gov/Pubs/pdf/10181.pdf (pages 7-10).
Most pregnant women with Zika will eventually wind up at academic medical centers for prenatal care and delivery by a perinatologist, with newborn care provided by a comprehensive team of pediatrician sub-specialists including neonatologists and pediatric neurologists. The earlier during the pregnancy the better!
Highlights from August’s Emergency Preparedness Coordinating Council
Kevin Chason, DO, of the Mount Sinai Health System, shared how his system uses the emergency management structure to coordinate preparedness and response to Zika virus. A multidisciplinary team co-led by representatives from the emergency management and infection control departments has been meeting regularly since May. Key focus areas are patient communication, provider guidance, tracking and monitoring of specimens, and staff safety.
Zika continues to infiltrate US, 20 babies born with Zika-related birth defects
Twenty babies in the U.S. have been born with Zika-related birth defects and 749 pregnant women have lab evidence of possible Zika infection as of Sept. 15, according to the CDC’s most recent update.
There are 3,358 people in the U.S. with the mosquito-born and sexually transmitted virus in the U.S. as of Sept. 21. Of those, 28 people were infected via sexual contact.
Additionally, the CDC reported 43 of the total cases were acquired from mosquitoes in Florida. However, the Florida Department of Health lists its number of locally acquired Zika cases at 92 as of Sept. 22.
Doctors Brace for Zika Babies
This month, the first group of babies in Puerto Rico known to have been exposed to the Zika virus in their first trimester are being born. Pediatricians do not know what to expect.
“This is not like any other outbreak or epidemic,” said Dr. Fernando Ysern, a pediatrician in Caguas, Puerto Rico, who is the president of the Puerto Rico chapter of the American Academy of Pediatrics.
In the pediatric field, Zika looms as a kind of developmental doomsday virus, attacking the vulnerability of early brain development, striking at the neurological basis of human potential. While Puerto Rico, a United States territory, will experience the first wave of children affected by Zika, the rest of the United States is bracing for the spread of the virus.
I recall a surgeon telling me many, many years ago he did open hernia repairs, turns out he hadn’t been trained yet to do them laparoscopically.
There is an old phrase in teaching hospitals about learning a new technique: “See one, do one, teach one.” And then some physicians continue to do that forever even as new evidence suggests otherwise. It is the patient’s responsibility to make sure that a procedure is necessary, that it is “state of the art “and that potential gain outweighs possible harm.
For example, It seems everyone I know has had meniscus surgery or been told they need it (like I have!). Have you already had it done? A new study raises questions about the efficacy of meniscus surgery.
“Injury to the menisci, the cartilaginous discs within the knee joint, can be painful when running, and can cause the knee to give way or ‘lock’. Such injuries are troublesome and sometimes painful, and can prevent you from exercising or attending work.
A new study shows that exercise therapy is just as effective for treating meniscus injuries as surgery… lots for treatment with either exercise or surgery. … “Two years later, both groups of patients had fewer symptoms and improved functioning. There was no difference between the two groups.“ (A)
However, those who had exercised had developed greater muscular strength. This is consistent with previous research, which showed that surgery yielded no additional benefits for patients who had had exercise therapy.”
“A 2012 report by the Institute of Medicine estimated that $750 billion—about 30 percent of all health spending in 2009—was wasted on unnecessary services and other issues, such as excessive administrative costs and fraud.” (B)
In 2013, USA Today reported six “common surgeries are often done unnecessarily”: Cardiac angioplasty; Cardiac pacemakers; Back surgery, spinal fusion; Hysterectomy (surgical removal of the uterus); Knee and hip replacement; and Cesarean section. (C)
And more recently the Wall Street Journal reported that” “In the medical community, however, experts are divided on whether there is a benefit to getting an annual exam. Some research has shown regular physicals don’t reduce rates of illness or mortality and are a waste of health-care resources. They also could be harmful, for example, when false positives result in additional, unnecessary testing. 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.” (D)
WHAT IS ONE TO DO?
CHOOSING WISELY aims to promote conversations between clinicians and patients by helping patients choose care that is: Supported by evidence; Not duplicative of other tests or procedures already received; Free from harm; Truly necessary. (E)
“The goal of the campaign is to reduce waste in the health care system and avoid risks associated with unnecessary treatment. It calls upon leading medical specialty societies and other organizations to identify tests or procedures commonly used in their field whose necessity should be questioned and discussed with patients. The effort has garnered the participation of over 70 medical specialty societies who have published more than 400 recommendations of overused tests and treatments that clinicians and patients should discuss. (F)
Examples of topics include: Treatments and Tests Your Baby May Not Need in the Hospital; Back Pain Tests and Treatments; When It’s Hard to Get Pregnant; Antibiotics for People with Catheters; Clogged Neck Arteries; Neck and Back Pain; Making Smart Decisions About Genetic Testing; Do I Need This Cancer Test or Treatment? ; Colds, Flu, and Other Respiratory Illnesses in Adults; Blood Tests When You’re In The Hospital. And there is a Search Engine to help you find specific areas of interest. (G)
Are you ready to ask your physician to go over CHOOSING WISELY with you when you are deciding whether or not to have a procedure?
EXPECT MEDICARE AND INSURANCE COMPANIES TO START USING CHOOSING WISELY AS A REIMBURSEMENT THRESHOLD!
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.
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.
Everyone knows, including our physicians, that proper hand washing is the most effective patient safety measure right?
Your physician and other clinicians (e.g. nurses, PTs, lab techs drawing blood) should wash their hands before and after each patient, and when beforehand wash in front of the patient.
Do you ask “Doctor, Did You Wash your Hands?” If not, why not?
First some history.
“Ignaz Semmelweis, a young Hungarian doctor working in the obstetrical ward of Vienna General Hospital in the late 1840s, was dismayed at the high death rate among his patients.
He had noticed that nearly 20% of the women under his and his colleagues’ care in “Division I” (physicians and male medical students) of the ward died shortly after childbirth. This phenomenon had come to be known as “childbed fever.” Alarmingly, Semmelweis noted that this death rate was four to five times greater than that in “Division II” (female midwifery students) of the ward.
One day, Semmelweis and some of his colleagues were in the autopsy room performing autopsies as they often did between deliveries. They were discussing their concerns about death rates from childbed fever.
One of Semmelweis’ friends was distracted by the conversation, and he punctured his finger with the scalpel. Days later, Semmelweis’ friend became quite sick, showing symptoms not unlike those of childbed fever. His friend’s ultimate death strengthened Semmelweis’ resolve to understand and prevent childbed fever.
In an effort to curtail the deaths in his ward due to childbed fever, Semmelweis instituted a strict hand washing policy amongst his colleagues in “Division I” of the ward. Everyone was required to wash their hands with chlorinated lime water prior to attending patients. Mortality rates immediately dropped from 18.3% to 1.3% in 1848 in Semmelweis’ division. (A)”
(1861) “…. Louis Pasteur was showing the world that microorganisms did indeed exist, that they acted on our world in myriad ways and that the ancient wisdom about “bad vapors” and spontaneous generation were wrong. Dead wrong. Prior to Pasteur and what would become known as “germ theory,” the prevailing theories held that organisms, like maggots and fleas, were spontaneously originated from other matter, like raw meat or diseased flesh…..
Pasteur is credited with opening the world’s eyes to the new science of microbiology and ushering in a brand new form of preventive medicine: immunization. …Building on what Pasteur was discovering, British surgeon Lister began to use this new germ theory to demonstrate the lifesaving value of disinfectant. Despite his skill at surgery, Lister knew that half his amputee patients would die of infection after the procedure…..
He began to treat his surgery equipment, before and after use, with carbolic acid. He also treated his patients’ wounds with it…..within two years, operative mortality decreased from nearly 50 percent to just 15 percent.” “Much of the greatness of Pasteur and Lister lies in their dogged persistence to spend 20 years convincing the rest of the medical world of the truth of their investigations,” ….. (B)
“What Dr. Towsend did next was something that Joseph Lister, despite years spent traveling the world, proving the source of infection and pleading with physicians to sterilize their hands and instruments, had been unable to prevent. As the president (Garfield) lay on the train station floor, one of the most germ-infested environments imaginable, Towsend inserted an unsterilized finger into the wound in his back, causing a small hemorrhage, and almost certainly introducing an infection that was far more lethal than Guiteau’s bullet.” (C) (1881)
FAST FORWARD 150 YEARS. 50% COMPLIANCE.
“Why Hospitals Want Patients to Ask Doctors, ‘Have You Washed Your Hands?’
It’s a simple enough request, but for patients and families who feel vulnerable, scared or uncomfortable in a hospital room, the subject can be too intimidating to even bring up with a doctor or nurse: Have you washed your hands?
Hospitals are encouraging patients to be more assertive, amid growing concern about infections that are resistant to antibiotics.
Strict hand hygiene measures are the gold standard for reducing infections associated with health care. Acquired primarily in hospitals but also in nursing homes, outpatient surgery centers and even doctor’s offices, they affect more than one million patients and are linked to nearly 100,000 deaths a year, according to the Centers for Disease Control and Prevention.
The CDC aims to engage both patients and caregivers in preventing dangerous hospital infections. Centers for Disease Control.
Yet despite years of efforts to educate both clinicians and patients, studies show hospital staff on average comply with hand-washing protocols, including cleansing with soap and water or alcohol-based gels, only about 50% of the time. (D)
In can be done! “How a team of doctors at one hospital boosted hand washing, cut infections and created a culture of safety.” (E)
BUT! THE MOST EFFECTIVE SOLUTION IS FOR YOU AS A PATIENT TO ASK “Doctor, Did You Wash your Hands?” Every time!
(C) DESTINY OF THE REPUBLIC, 2011
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