All pregnant women with Zika diagnosed at community hospitals must be referred to academic medical centers for prenatal care!

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!

Here’s why….. 

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.

http://gnyha.org/PressRoom/Publication/1e9f564d-eec3-4371-af75-31f0896b89e1/

 

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.

http://www.beckershospitalreview.com/quality/zika-continues-to-infiltrate-us-20-babies-born-with-zika-related-birth-defects.html

 

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.

http://www.nytimes.com/2016/09/26/well/family/doctors-brace-for-zika-babies.html

 

 

 

 

 

 

 

 

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Most surgical meniscus repairs are unnecessary. How do you learn about other possibly unnecessary procedures? What is CHOOSING WISELY?

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.

 

(A) https://www.sciencedaily.com/releases/2016/07/160722093239.htm#.V7mt31UCZ7g.email

(B) http://www.scientificamerican.com/article/medical-procedures-prove-unnecessary/

(C) http://www.usatoday.com/story/news/health/2013/06/19/surgeries-unnecessary-patients-medical/2439075/

(D) http://www.wsj.com/articles/is-an-annual-physical-necessary-1453140799

(E) http://www.choosingwisely.org/about-us/

(F) http://abimfoundation.org/what-we-do/choosing-wisely

(G) http://www.choosingwisely.org/patient-resources/

 

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.

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Should physicians be afforded Mulligans for non-reimbursable Medicare readmissions?

Let’s start off by making it clear that most adverse clinical outcome are not medical errors. OK?

Now….

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?

(A) http://kff.org/medicare/issue-brief/aiming-for-fewer-hospital-u-turns-the-medicare-hospital-readmission-reduction-program/

(B) http://www.prnewswire.com/news-releases/geisingers-renowned-provencare-program-launches-three-new-orthopaedic-offerings-total-hip-total-knee-and-hip-fracture-274334131.html

(C) http://www.modernhealthcare.com/article/20140905/NEWS/309059944

(D) http://www.latimes.com/business/ Considering surgery? Some healthcare providers offer warranties

(E) http://www.fuqua.duke.edu/news_events/news-releases/health-care-warranties/#.V5j_eo-cFYc

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Hospitals are developing their own Zika preparedness models. Compare the Central Florida and Johns Hopkins approaches! Which template makes more sense?

 

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.

http://www.orlandosentinel.com/health/zika-virus/os-local-hospitals-zika-preparation-20160902-story.html

 

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.

ttp://www.hopkinsmedicine.org/news/media/releases/johns_hopkins_opens_unique_comprehensive_care_center_for_zika_virus_led_by_the_wilmer_eye_institute

 

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….the evidence today does not support the idea of the annual physical exam

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.

 

(A) http://www.cbsnews.com/news/do-you-really-need-a-yearly-physical-exam/

(B) http://www.health.harvard.edu/blog/a-checkup-for-the-checkup-do-you-really-need-a-yearly-physical-201510238473

(C) http://content.time.com/time/health/article/0,8599,1735156,00.html

(D) http://www.emedicinehealth.com/checkup/article_em.htm

(E) http://www.foxnews.com/health/2016/01/19/is-annual-physical-necessary.html

(F) http://www.usnews.com/news/articles/2015/12/10/confusion-surrounds-free-obamacare-wellness-visits

 

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.

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Concierge medicine is the all the rage but rather should we be enraged about it?

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.

Some background.

“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)

(A) http://www.thehealthjournals.com/concierge-medicine/

(B) http://www.hhs.gov/about/strategic-plan/strategic-goal-1/index.html

(C) https://www.thehappymd.com/blog/bid/285923/Concierge-Medicine-will-get-Massive-Boost-from-Obamacare

(D) http://www.aarp.org/health/healthy-living/info-01-2013/boutique-doctors.html(E) http://aapp.org/about-us-2/

(F) https://sites.sju.edu/icb/question-is-concierge-medicine-ethical/

(G) https://conciergemedicinetoday.org/2013/10/21/legal-concierge-medicine-raises-legal-issues/

(H) http://journalofethics.ama-assn.org/2013/07/ecas3-1307.html

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With little gudiance about caring for Zika patients, hospitals are planning on their own

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/

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