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

Assignment: How are you preparing for the treatment and rehabilitation of the boys and their coach

Prequel. August 24, 2017

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

“Twelve boys and their soccer coach trapped in a cave in northern Thailand are in good health, authorities said Tuesday, but it is unclear when they will be able to leave the flooded cavern.

The boys, all members of a youth soccer team aged 11 to 16, and their assistant coach, aged 25, were found late Monday by rescue divers after a dramatic search lasting more than a week in the mountainous province of Chiang Rai.

Provincial Governor Narongsak Osottanakorn told reporters early Tuesday that all 13 of them had undergone health assessments and were found to be in good condition on a scale of “red, yellow and green.” Most were found to be in the green category…

Once extracted, the boys and their coach will be transferred to Chiang Rai Region General Hospital, where the entire 8th floor is being held for their arrival. Thirteen ambulances are on standby to transport them.

The boys are believed to have entered the Tham Luang cave after soccer practice with their assistant coach, Ekkapol Chantawong, on what was meant to be a half-day trek. But monsoon rains flooded several chambers and blocked their exit.

The saga of the trapped team has gripped the nation as search efforts snowballed from a small local team to a multinational emergency response. U.S. and Australian military personnel came to support Thai authorities, as well as technical experts from the U.K., China, Japan and elsewhere.” (A)

“Their skinny faces illuminated by a flashlight, the Thai soccer teammates stranded for nearly two weeks in a partly flooded cave said in a video released Wednesday that they were healthy, as heavy rains forecast for later this week threatened to complicate plans to safely extract the boys.

The 12 boys and their coach are seen in the video sitting with Thai navy SEALs in the dark cave. The boys, many wrapped in foil warming blankets, take turns introducing themselves, pressing their hands together in a traditional Thai greeting and saying their names and that they are healthy…

Authorities said the boys, who had also been shown Tuesday in a video shot by the British diver who discovered them, were being looked after by seven members of the Thai navy SEALs, including medics, who were staying with them inside the cave. They were mostly in stable condition and have received high-protein drinks.

In all of the videos, the boys appeared in good spirits. In the most recent video, a navy SEAL is shown treating minor cuts on the feet and legs of the boys with antibiotic ointment. Several of the boys are seen smiling as they interact with the navy SEAL, who cracks jokes.”

“On Tuesday, Thai officials told reporters that rescuers were providing health checks and treatment, and keeping the boys entertained, adding that none of those trapped were in a serious condition.

“They have been fed with easy-to-digest, high-energy food with vitamins and minerals, under the supervision of a doctor,” Rear Admiral Apagorn Youkonggaew, head of the Thai navy’s special forces, told reporters.” (C)


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You are a new member of the Board of University Medical Center and have been appointed chairperson of the Board’s Compliance Committee.

You were recruited due to concerns about two controversial challenges that apply to your organization.

How do you turn these “challenges into “opportunities?”

Find two other Compliance situations that need to be addressed.

Opportunity 1

“Not-for-profit health systems—no strangers to paying top dollar for talented executives—are using sophisticated methods to avoid the penalties on high employee compensation.

Effective tax year 2018, the Tax Cuts and Jobs Act imposes a 21% excise tax on not-for-profit compensation that exceeds $1 million, a threshold that encompasses just about all major not-for-profit health systems.

Total CEO pay, including bonuses, retirement and other benefits, across the top 25 largest not-for-profit health systems averaged about $5.1 million in 2016, the most recent year for which data are available. That’s up from $4.5 million in 2015.

The tax is significant. This year, a $5.1 million salary, for example, would hit a health system with a roughly $860,000 tax. Bernard Tyson, CEO of Oakland, Calif.-based Kaiser Permanente, made about $10 million in total compensation in 2016. A 21% tax on all of his pay over $1 million would be $1.9 million—perhaps not a huge hit to a $73 billion organization.

St. Louis-based SSM Health’s former CEO Bill Thompson made nearly $2 million in 2016, which would yield a roughly $200,000 tax this year. Again, likely not significant for a $6.5 billion operation…

The law also includes a calculation whereby health systems can be taxed for providing excessive parachute payments to high-paid employees upon their departures. Patrick Fry, who retired as Sutter Health’s CEO in January 2016, received $10.6 million in deferred retirement pay that year, bringing his total compensation to nearly $13.5 million…

Luckily for them, health systems have savvy tax experts recommending maneuvers that will reduce their exposure to the new tax. Even then, systems must tread carefully to ensure they’re staying within the law.”

to read the full article highlight and click on

Not-for-profit health systems working to get around tax on high exec pay, by Tara Bannow,

Opportunity 2

“Doctors and teaching hospitals raked in $8.4 billion in payments from drug companies last year, according to data recently released by the Centers for Medicare and Medicaid Services…

The physicians who received research-related payments number in the hundreds of thousands — about 628,000, by CMS’s count. More generally, they received $2.1 billion overall during the year…

Meanwhile, drug company payments went to about 1,100 teaching hospitals, including $1 billion in research payments and $751 million in non-research payments…

The payments come despite the fact that many physicians, as well as consumers, consider drug companies and medical device manufacturers for rising healthcare costs. A study last fall by the Texas Medical Center Health Policy Institute in Houston found that 19 percent of physicians blame drug and device manufacturers for rising costs, while 47 percent blamed insurance companies.”

to read the full article highlight and click on

Doctors and hospitals got $8.4 billion in payments from drug companies in 2017, says CMS Of those payments, about $4.7 billion were related to research while $2.8 billion were non-research payments, by Jeff Lagasse,

“A drugmaker’s scheme to bolster sales of a potent painkiller with kickbacks to doctors has caused legal problems for the company but has left largely unscathed the physicians who pushed the drug on their patients.

Insys Therapeutics has been sued by state and local governments, private insurance companies and patients. Several former company executives have been indicted or convicted for their roles in bribing doctors to prescribe the fentanyl spray, Subsys.

At least a dozen civil lawsuits accuse individual doctors of accepting kickbacks from Insys to prescribe the drug which is 100 times more potent that morphine.

Those doctors prescribed the drug – intended only for those with cancer pain – to patients with other ailments, leading to harmful addiction and, in some cases, death.

Yet many of the doctors who benefited the most from the Arizona-based drug company’s payouts still practice medicine without consequences, a national Raycom Media investigation found. Insys did not respond to requests for comment…

“When a pain management guy is getting $100,000 to go to these dinners and they’re prescribing this for elbow pain or that hip pain, that’s criminal,” said Randy Hood, a South Carolina lawyer who represents several patients suing doctors who prescribed Subsys.

Speaker fees and other payments to doctors are legal unless they are connected to the volume of drugs physicians prescribe, according to the federal anti-kickback law…

Between 2013 and 2016, Insys paid 126 doctors at least $50,000 each in speakers’ fees and for travel, entertainment or consulting, Raycom Media’s analysis of federal physicians’ payments found.

Raycom mailed each of the doctors a letter with their payment and prescription histories and asked them to comment.

The payments to these doctors may not be nefarious. One oncologist, who never prescribed Subsys, said he was paid nearly $114,000 for food, travel and clinical development services.

Collectively, Insys paid the doctors more than $14 million…

Of the highest paid doctors, only 18 were oncologists.

Nearly 60 percent were pain specialists. Eight were general practice doctors such as family physicians or internal medicine specialists. Two were sports medicine doctors…”

to read the full article highlight and click on

Doctors escape punishment for profiting off prescribing opioids to those who don’t need them, by Jill Riepenhoff and Megan Luther,

“A new report finds a large percentage of panel members that review drug applications for the Food and Drug Administration accept payments and other rewards from companies after their drugs are approved. The report led by investigative correspondent Charles Piller appears in today’s issue of the journal Science.

Piller and colleagues looked into the practice of drug developers providing financial benefits to members of FDA advisory committees after the panels review drug applications and vote to recommend approval. Advisory committees, often comprised of physicians and academic scientists, are recruited by FDA to independently evaluate drug applications in addition to the agency’s professional staff. While FDA does not always follow the assessments of these committees, an endorsement from these panels is often a predictor of FDA approval.

The Science team looked into advisory panels that recommended approval of 28 cardiovascular/renal or psychopharmacologic drugs as well as treatments for arthritis from 2008 to 2014, and were later approved by FDA. The reporters matched up participants on these panels to payments listed in the Open Payments database, collected by Centers for Medicare and Medicaid Services in the U.S. Department of Health and Human Services, from 2013 to 2016. The team also scanned conflict-of-interest disclosures in scientific and medical journals, at least those not behind paywalls. (Editor’s note: Much of Science magazine’s content is behind a paywall.) In their inquiries, the reporters looked for payments from the companies whose products were reviewed, as well as competitors of those companies making similar drugs.

The team found 107 advisers taking part in the committees and recommending the 28 drugs for FDA approval. Of the 107 participants, 40 — or 37 percent — received payments of $10,000 or more in compensation or research support after they voted to approve the drugs, either from the developers of the drugs or from competitors. In addition, 26 of the committee participants earned at least $100,000 from these companies, and 7 gained $1 million or more. The reporters also found the 17 top earning advisers, those making $300,000 or more, took in a total of $26 million over this period, of which nearly all, 94 percent, came from the companies making the products they reviewed or competitors.

An FDA spokesperson told Science in a statement that advisory committee members must disclose prospective employers, but not anticipated payments…”

To read the full article highlight and click on

DA Reviewers Found Accepting Industry Payments After Drug Approvals,

Open Payments is a national disclosure program that promotes a more transparent and accountable health care system by making the financial relationships between applicable manufacturers and group purchasing organizations (GPOs) and health care providers (physicians and teaching hospitals) available to the public. oc:e},”next”===

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Johns Hopkins All Children’s Hospital (St Petersburg, Florida) – problems in the hospital’s heart surgery unit

Assignment: How could this problem have been avoided if Johns Hopkins quality assurance and patient safety protocols had been followed?

“The Patient Safety and Healthcare Quality Masters program is a fully online, interdisciplinary degree offered by Johns Hopkins University. It is a first-of-its-kind collaboration between the Johns Hopkins Bloomberg School of Public Health, Johns Hopkins School of Medicine, Johns Hopkins School of Nursing and the Armstrong Institute for Patient Safety and Quality. It combines coursework from JHU’s top ranked schools and the Armstrong Institute’s pioneering advances in patient safety-educating students in the transformative mechanisms and evidence-based protocols that reduce preventable patient harm and improve clinical outcomes.
Renowned, industry-shaping experts lead this exciting new program designed for working adults. The program focuses on: Measurement of safety and quality; Designing safer systems; Organizational and cultural change. ” (A)

“Patient Safety and Quality at Johns Hopkins Medicine.
Each day in a hospital, staff members undertake complicated tasks caring for patients. Johns Hopkins Medicine’s patient safety efforts aim to ensure that all of these steps work together to deliver high-quality, compassionate care to all patients across our health system.
Johns Hopkins Health System hospitals and services consistently receive awards and honors for patient safety and quality, including Top Performer on Key Quality Measures by the Joint Commission, Magnet designation for nursing, HomeCare Elite and Delmarva Foundation Excellence Awards. The Johns Hopkins Hospital has been ranked No. 1 in the nation by U.S. News & World Report for 22 years of the survey’s 25-year history, most recently in 2013.
Patient Safety and Quality Measures
This website shares data for the Johns Hopkins Health System. Here, you will find information about key safety issues and the patient’s experience of care, including:
Patient Experience – Based on survey results from previous patients, you can see how others rated their experience of care from a Johns Hopkins Medicine hospital or home health care provider.
Infection Prevention – These measures include the rate of CLABSIs, a bloodstream infection caused by a central line (large IV) that are considered preventable and hand hygiene, the percentage of medical staff members observed washing their hands or using hand sanitizer before and after caring for a patient.
Core Measures – These measures are national standards of care and treatment processes for common conditions. Core measure compliance shows how often a hospital follows each of these steps.
Surgical Volumes – Studies have shown a strong relationship exists between the number of times a hospital performs a specific surgical procedure and the outcomes for those patients. In 2016, we started sharing our hospitals’ surgical volumes for many common and high-risk procedures.
Quality of Care Ratings – The quality of patient care star rating is a summary of how well the Johns Hopkins Home Care Group and Potomac Home Health Care perform on nine quality measures such as ambulation.
Pediatrics – These measures include national standards of treatment for common conditions, infection prevention, pain management and emergency department wait times for Johns Hopkins’ pediatric divisions.
Hospital Readmissions – Patients are most vulnerable for readmission to a hospital immediately following discharge. This measure tracks how many Medicare patients with specific conditions were readmitted to the hospital within 30 days for any reason.
Our Commitment to Transparency
Patients and their loved ones deserve to be informed about the quality of their heath care. At Johns Hopkins Medicine, we are dedicated to sharing our performance and how we work to provide the best care with past, present and future patients. The Johns Hopkins Armstrong Institute for Patient Safety and Quality coordinates safety and quality improvement efforts and training across our health system.
We hope you will find this website a valuable resource and encourage you to ask your health care team if you have any questions or concerns. (B)

“Patient Trust, Confidence Built on Interprofessional Innovation
Medical errors and preventable patient infections and injuries together make up the third-leading cause of death in the United States, a startling statistic.
The Johns Hopkins School of Nursing understands that an increasing focus on patient safety and quality of care depends upon a healthcare workforce that knows the risks and the proper responses from patients’ arrival to their safe discharge.
The Helene Fuld Leadership Program for the Advancement of Patient Safety and Quality (The Fuld Fellows Program) emphasizes interprofessional education and training, simulation, and service-learning experiences involving nurses, medical students, pharmacists, and other health professionals whose collaboration is critical for reducing preventable harm to patients.
Nurses, as the primary contact with patients, play a key role in their safety. Hopkins Nursing, as part of an interprofessional team that includes the Armstrong Institute for Patient Safety & Quality and the Johns Hopkins Health Systems, works to prepare nurses ready to communicate, cooperate, innovate, and lead on issues of patient safety and quality of care.” (C)

“Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality
A roadmap for patient safety and quality improvement
This month the Agency for Healthcare Research and Quality (AHRQ) published a new report that identifies the most promising practices for improving patient safety in U.S. hospitals.
An update to the 2001 publication Making Health Care Safer: A Critical Analysis of Patient Safety Practices, the new report reflects just how much the science of safety has advanced.
A decade ago the science was immature; researchers posited quick fixes without fully appreciating the difficulty of challenging and changing accepted behaviors and beliefs.
Today, based on years of work by patient safety researchers-including many at Johns Hopkins-hospitals are able to implement evidence-based solutions to address the most pernicious causes of preventable patient harm. According to the report, here is a list of the top 10 patient safety interventions that hospitals should adopt now.

Top 10 Recommended Patient Safety Strategies
1. Preoperative checklists and anesthesia checklists to prevent operative and postoperative events.
2. Bundles that include checklists to prevent central line-associated bloodstream infections
3. Interventions to reduce urinary catheter use, including catheter reminders, stop orders, or nurse-initiated removal protocols
4. Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic-suctioning endotracheal tubes to prevent ventilator-associated pneumonia
5. Hand hygiene
6. The do-not-use list for hazardous abbreviations
7. Multicomponent interventions to reduce pressure ulcers
8. Barrier precautions to prevent healthcare-associated infections
9. Use of real-time ultrasonography for central line placement
10. Interventions to improve prophylaxis for venous thromboembolisms…
Even with a list of sound strategies, creating a plan to implement all or even half of them may sound like a daunting task. The Armstrong Institute for Patient Safety and Quality has created a checklist to help you get started.
1. Identify priorities and assess readiness for change.
2. Establish engagement and accountability at all levels of the organization.
3. Communicate constantly (the good and the bad).
4. Measure, measure, measure… and then measure some more. (D)

“Johns Hopkins All Children’s Hospital provides expert pediatric care for infants, children and teens with some of the most challenging medical problems in our community and around the world.
Named a top 50 children’s hospital by U.S. News & World Report, we provide access to innovative treatments and therapies. Taking part in pediatric medical education and clinical research helps us to provide care in more than 50 specialties.
With more than half of our 259 beds devoted to intensive care level services, we are the regional pediatric referral center for Florida’s West Coast. Physicians and community hospitals count on us to care for critically ill patients and perform complex surgical procedures.
Parents count on us, too. Our philosophy of family-centered care means family members are an important part of our health care team. We include parents in making decisions and plans for their child’s care. We also include patients who are old enough to take part in these discussions.
To help us design our hospital that we opened in January 2010, we asked patients, parents and our staff to share ideas. The result was a spacious and bright hospital with individual rooms where parents can comfortably spend the night. With the latest technology and our commitment to family-centered care, our hospital provides an ideal environment for healing.” (E)

“Quality, Outcomes and Patient Safety at Johns Hopkins All Children’s
We are committed to treating you and your child with compassion and respect. We believe that you deserve honesty in our communication about the plan for your child’s care and we will demonstrate uncompromising integrity to earn your trust. We will be responsible for including each family as a part of our care team that is committed to safe and innovative care practices. Our goal is to inspire hope for you and your child through our focus on inquiry, collaboration, and team work.
Johns Hopkins All Children’s Hospital believes in Creating healthy tomorrows… for one child, for All Children. Our focus on Quality assures that we are continually improving our processes in an effort to achieve this vision. Using a team approach we tap into the know-how of our expert medical staff and employees to improve the quality and safety of the care we provide.
Our Quality Model provides the basis for understanding patient needs, measuring and using data, and achieving real improvement. Improving continuously is our goal. To do this we encourage each member of our team to find ways to do their work better and to make patient safety a priority. Together we are focused on pursuing perfection for All Children.
Quality Measures
There are many ways to look at and measure quality. Our data uses information from key areas to help families, healthcare providers, and others learn about our progress in pursuing perfection for All Children.” (F)

“Sandra Vázquez paced the heart unit at Johns Hopkins All Children’s Hospital.
Her 5-month-old son, Sebastián Vixtha, lay unconscious in his hospital crib, breathing faintly through a tube. Two surgeries to fix his heart had failed, even the one that was supposed to be straightforward.
Vázquez saw another mom in the room next door crying. Her baby was also in bad shape.
Down the hall, 4-month-old Leslie Lugo had developed a serious infection in the surgical incision that snaked down her chest. Her parents argued with the doctors. They didn’t believe the hospital room had been kept sterile.
By the end of the week, all three babies would die…
The internationally renowned Johns Hopkins had taken over the St. Petersburg hospital six years earlier and vowed to transform its heart surgery unit into one of the nation’s best.
Instead, the program got worse and worse until children were dying at a stunning rate, a Tampa Bay Times investigation has found.
Nearly one in 10 patients died last year. The mortality rate, suddenly the highest in Florida, had tripled since 2015…
Times reporters spent a year examining the All Children’s Heart Institute – a small, but important division of the larger hospital devoted to caring for children born with heart defects…
They discovered a program beset with problems that were whispered about in heart surgery circles but hidden from the public.
Among the findings:
All Children’s surgeons made serious mistakes, and their procedures went wrong in unusual ways. They lost needles in at least two infants’ chests. Sutures burst. Infections mounted. Patches designed to cover holes in tiny hearts failed.
Johns Hopkins’ handpicked administrators disregarded safety concerns the program’s staff had raised as early as 2015. It wasn’t until early 2017 that All Children’s stopped performing the most complex procedures. And it wasn’t until late that year that it pulled one of its main surgeons from the operating room.
Even after the hospital stopped the most complex procedures, children continued to suffer. A doctor told Cash Beni-King’s parents his operation would be easy. His mother and father imagined him growing up, playing football. Instead multiple surgeries failed, and he died.
In just a year and a half, at least 11 patients died after operations by the hospital’s two principal heart surgeons. The 2017 death rate was the highest any Florida pediatric heart program had seen in the last decade.
Parents were kept in the dark about the institute’s troubles, including some that affected their children’s care. Leslie Lugo’s family didn’t know she caught pneumonia in the hospital until they read her autopsy report. The parents of another child didn’t learn a surgical needle was left inside their baby until after she was sent home.
The Times presented its findings to hospital leaders in a series of memos early this month. They declined interview requests and did not make the institute’s doctors available to comment.
In a statement, All Children’s did not dispute the Times’ reporting. The hospital said it halted all pediatric heart surgeries in October and is conducting a review of the program.
“Johns Hopkins All Children’s Hospital is defined by our commitment to patient safety and providing the highest quality care possible to the children and families we serve,” the hospital wrote. “An important part of that commitment is a willingness to learn.” (G)

The top three leaders of Johns Hopkins All Children’s Hospital in Florida resigned Tuesday following a Tampa Bay Times investigation that revealed increasing mortality rates among heart surgery patients.
The resignations from the 259-bed teaching hospital in St. Petersburg included CEO Jonathan Ellen, M.D., and Vice President Jackie Crain, as well as Jeffrey Jacobs, M.D., who is the heart institute’s deputy director, the Tampa Bay Times reported. Paul Colombani, M.D., stepped down as chairman of the department of surgery but will continue working in a clinical capacity, a statement from the health system said.
“Losing a child is something no family should have to endure, and we are committed to learning everything we can about what happened at the Heart Institute, including a top-to-bottom evaluation of its leadership and key processes,” a statement from Johns Hopkins read. “The events described in recent news reports are unacceptable.”
Johns Hopkins, which owns and operates the hospital, said it would install Kevin Sowers, who is president of the Johns Hopkins Health System and executive vice president of Johns Hopkins Medicine, to lead the hospital in a temporary capacity while a plan for interim leadership is put into place.
George Jallo, M.D., who is medical director of the Institute for Brain Protection Sciences and chief of pediatric neurosurgery, will serve as interim vice dean and physician-in-chief, and Paul Danielson, M.D., who is chief of the Division of Pediatric Surgery at Johns Hopkins All Children’s Hospital, will serve as interim chair of the surgery department.
Johns Hopkins’ board also said it commissioned an external review to examine the heart surgery program and said it would share its lessons from the review to help hospitals around the country avoid the same mistakes.
The moves come following the Tampa Bay Times investigation that highlighted a growing number of heart surgery deaths at the hospital amid warnings about safety from staffers that went unheeded. (H)

“Three additional senior administrators have left Johns Hopkins All Children’s Hospital in the wake of a Tampa Bay Times investigation into high mortality rates at the hospital’s Heart Institute, the hospital announced Wednesday.
A total of six senior officials have left since the Times report, including the hospital’s CEO, three vice presidents and two surgeons who held leadership roles at the Heart Institute. A seventh official stepped down as chairman of the surgery department but remained employed at the hospital as a doctor.
The resignations announced Wednesday included vice presidents Dr. Brigitta Mueller, the hospital’s chief patient safety officer, and Sylvia Ameen, who oversaw culture and employee engagement and served as the hospital’s chief spokeswoman.
The hospital also said Dr. Gerhard Ziemer, who started as the Heart Institute’s new director and chief of cardiovascular surgery in October, would leave the hospital. The hospital never publicly announced Ziemer had been hired, and he had not yet obtained his Florida medical license when the Times investigation was published at the end of November. At that point, the hospital said the Heart Institute had already stopped performing surgeries.
“While Dr. Ziemer is not responsible for the current state of the program, we agreed that a fresh start was needed to ensure success for the program,” Johns Hopkins Health System President Kevin Sowers said in a letter to the hospital’s staff.” ..
In his letter to the staff, Sowers said that several hospital executives had been tasked with leading “critically important work around advancing our culture of safety.”
“As we work to rebuild the trust of our community, we must also work to fully embrace and support a culture where we are each empowered and encouraged to speak up and speak out if we see or hear something that concerns us,” he wrote. “This commitment applies to clinical concerns as well as inappropriate workplace behavior.”
Sowers also announced that Johns Hopkins had hired external experts to develop a plan to restart heart surgeries at All Children’s.
That is a separate effort from an external review of the problems in the Heart Institute, which Johns Hopkins announced its board had commissioned last month, spokeswoman Kim Hoppe said…
Johns Hopkins is one of the most prestigious brands in medicine and is internationally renowned for developing innovative patient safety protocols that are used at hospitals across the world. But last weekend, the Times published a story detailing a series of safety problems at hospitals across its network. In response, the health system pledged to “do better.” (I)

“The Johns Hopkins Medicine Board of Trustees has appointed a former federal prosecutor to lead its investigation into the Johns Hopkins All Children’s Hospital’s heart surgery unit, the health system announced late Tuesday.
F. Joseph Warin, of the global law firm Gibson Dunn, and his team will review the high mortality rates and other problems at the hospital’s Heart Institute and report back to a special committee of the board of trustees by May, the health system said.
Once the review is complete, the health system said it would also name an independent monitor at All Children’s to “make sure that the hospital is being held accountable for taking corrective action where necessary.”
The announcement was accompanied by a video of Johns Hopkins Health System president Kevin Sowers, who acknowledged for the first time that the hospital had been warned about problems by frontline workers.
“I know personally that many of you courageously spoke out when you had concerns but were ignored or turned away,” he said. “That behavior is unacceptable and will not be tolerated going forward.”
Sowers, who is also interim president at All Children’s, said he hoped to meet with the families of patients affected by problems in the Heart Institute in the coming days to share his “profound sadness for the failures of care they experienced.” (J)

“The external review was prompted by multiple reports by the Tampa Bay Times about problems at the center which could have contributed to its mortality rate tripling between 2015 and 2017…
Health News Florida’s Stephanie Colombini talked about what could come next with Kathleen McGrory, one of the lead reporters.
One of the big problems you uncovered in your reporting was the lack of available data about mortality rates at a lot of these heart surgery programs…
Officials have either refused to release it or they only release four-year averages, which could mislead families about the current state of the program they’re choosing.
How is the state looking at making these programs more transparent?
There were some problems at another pediatric heart surgery program in 2015 in Palm Beach County (St. Mary’s Medical Center), and after those problems surfaced, the legislature put together a panel (Pediatric Cardiology Technical Advisory Panel) tasked with looking at transparency and ways we could, as a state, make these programs better and more accountable.
That panel is in the middle of doing its work right now and in fact has come close to finalizing some recommendations.
The panel would like all of these heart surgery programs to be reporting their one-year data (on mortality rates) rather than their four-year data because that four-year data can sometimes hide serious problems…
So the state is looking into making heart surgery programs more accountable, but is anyone calling for change when it comes to the government’s role in this?
You reported that multiple times state and federal regulators were alerted to problems at All Children’s and yet little, to no action was taken.
We saw U.S. Reps. Kathy Castor and Charlie Crist put some really tough questions to federal regulators asking what they had investigated and when. We haven’t heard back yet on that front but we know it’s something they’ll be looking into.
The state told us that they did the best they could do with the information that they had, same thing with the federal government.
But ACHA has a new chief (Mary Mayhew). We haven’t gotten a chance to connect with her yet and see what her thoughts are on this, but we certainly will do that in the new year. (K)

“State and federal inspectors descended on Johns Hopkins All Children’s Hospital this week, following sharp calls for an investigation into problems in the hospital’s heart surgery unit, the Tampa Bay Times has learned.
The scope of the inspection is unclear. But hospital regulators had been criticized in recent weeks for their lax response to early signs of an increase in mortality at the hospital’s Heart Institute.
A Florida Agency for Health Care Administration spokeswoman said her agency had been at the facility.
A spokeswoman for the hospital confirmed federal inspectors had been there, too.
“We appreciate the oversight role that our regulators play and we will, as always, be fully cooperative and collaborative as they conduct any reviews necessary,” a statement from the hospital said.
A spokeswoman for the federal Centers for Medicare and Medicaid Services declined to comment beyond saying the matter remained “an ongoing review.”
In November, the Times reported that the mortality rate for heart surgery patients at All Children’s tripled from 2015 to 2017 to become the highest rate in Florida. The increase occurred after staff members warned the hospital’s leaders about problems with two heart surgeons, the Times found.
State and federal regulators knew the institute was having problems months earlier. In April, the hospital’s CEO told the Times that the institute had “challenges” that led to an uptick in mortality, and acknowledged the hospital had left surgical needles inside two children.
In May, state regulators cited the hospital for not properly reporting two medical mistakes, which is required by state law. Days later, a spokeswoman for the federal agency told the Times that it would perform its own investigation.
But state regulators didn’t fine the hospital, and overlooked several subsequent warnings that its surgical results had been poor.
And federal inspectors later changed course and decided not to undertake a comprehensive review of the heart surgery program, the Times reported last month. One reason was that state inspectors hadn’t found any violations of federal rules, a spokeswoman said. Another was that a nonprofit hospital accreditor was due to perform a scheduled review.” (L)

Two Omaha surgeons filed a lawsuit Friday against Children’s Hospital & Medical Center, alleging that they were wrongfully suspended and forced to resign privileges there after they raised patient safety concerns.
In the suit, Dr. Jason Miller and Dr. Mark Puccioni say that the hospital suspended their privileges to practice at the Omaha facility after they raised concerns about the death of a 7-month-old during an operation. That operation was performed this fall by another surgeon, Dr. Adam Conley, the suit says.
In their communications, according to the suit filed in Douglas County District Court, the two also questioned Conley’s “skill and ability.”
In addition to the hospital, the lawsuit names as defendants Conley, as well as Dr. Richard Azizkhan, who took over as Children’s president and CEO in October 2015.
Children’s officials said in a statement that the hospital does not comment on pending litigation “other than to say we strongly disagree with these allegations…
Children’s has faced other issues in recent months.
In late November, a former pharmacy director at the hospital was accused of funneling more than $4.4 million from the organization into her personal account over six years. She was terminated in June and faces a hearing regarding possible disciplinary action later this month.
About three weeks ago, the Nebraska Medical Association sent a letter to the board of Children’s Hospital expressing concerns about “patient care, safety and quality” at the Omaha hospital, in addition to the loss of longtime physicians.
In the Dec. 11 letter, the president of the group, Dr. Britt Thedinger, wrote, “We as physicians are concerned about the summary suspensions, terminations and resignations of long-time outstanding physician colleagues.” The letter also expressed concern that children were being transferred to outside institutions because of “complications” and inadequate staffing at the Omaha hospital.
Thedinger said the organization did not intend for the letter to become public. The intent, he said, was to bring issues that had been raised by members to the hospital board and administration.” (M)

“The New Jersey Department of Health is investigating four Acinetobacter baumannii cases in the neonatal intensive care unit (NICU) of University Hospital in Newark, authorities announced Thursday evening.
DOH officials stated:
“The department first became aware of this bacterial infection on Oct. 1 and two department teams have been closely monitoring the situation. Those department teams, which have been at the facility last week and this week, have been ensuring that infection control protocols are followed and are tracking cases of the infection. The department’s inspection revealed major infection control deficiencies.”
According to the DOH, a premature baby with the bacteria who had been cared for at University Hospital was transferred to another facility and passed away toward the end of September, prior to the department’s notification of problems in the NICU.
“Due to the other compounding medical conditions, the exact cause of death is still being investigated,” DOH officials said.
The department has ordered a Directed Plan of Correction that requires University Hospital to employ a full-time Certified Infection Control Practitioner consultant, who will report to the DOH on immediate actions taken in the coming days.
DOH officials said they are also exploring further actions the agency may need to take in the coming days to “ensure patient safety.” (N)

“Four New Jersey pediatric care facilities and one hospital are now under the state’s microscope after nine children died and 26 people were sickened by a deadly virus over the past month.
A Department of Health team of infection control experts and epidemiologists will visit University Hospital in Newark and four pediatric long-term care facilities in November to conduct training and assessments of infection control procedures, Commissioner Dr. Shereef Elnahal has announced.
The team of experts will visit University Hospital, the Wanaque Center for Nursing & Rehabilitation in Haskell, Voorhees Pediatric Facility in Voorhees and Children’s Specialized Hospital in Toms River and Mountainside. The department reached out to the facilities last week to schedule visits in November.
The decision comes after nine children at a Wanaque facility have died since an outbreak of the adenovirus was declared there. Victims became sick between Sept. 26 and Oct. 22. Authorities confirmed that the virus killed eight of the nine kids.
Twenty-six kids and a staff member, who has since recovered, have become ill as part of the outbreak, state health officials said. Laboratory tests confirmed the 26th case. (O)

“Two decades ago, the Institute of Medicine shook the medical profession with its “To Err is Human” report which said nearly 100,000 people a year lost their lives to preventable medical errors…
During the 7th Annual World Patient Safety, Science & Technology Summit over the weekend, the Patient Safety Movement Foundation released a new tool on its website to help with the training.
The patient safety curriculum is one of 17 Actionable Patient Safety Solutions (APSS) made available to organizations for free to help train health professionals in systems science so they can help find ways to reduce preventable patient deaths, officials said.
“The goal is to get every health professional to think in a system way,” said Steven Scheinman, M.D., the president and dean of Geisinger Commonwealth School of Medicine. He led a Patient Safety Movement working group which included experts from Geisinger, San Diego State, University of Pittsburgh Medical Center, Johns Hopkins Health, and MedStar Georgetown to develop the curriculum over an 18-month period.
The Patient Safety Movement was founded in 2013 to help reduce preventable deaths in healthcare and in 2015 set a goal of zero preventable deaths by 2020. More than 90,000 patients who might have died as a result of medical errors were saved in 2018 due to efforts made by more than 4,700 hospitals that committed to patient safety efforts, according to figures released by the foundation. In all, a total of 273,077 lives have been saved since the first summit, officials said.
The newly released safety curriculum can be adapted to any healthcare profession including medicine, nursing, pharmacy, and behavioral health and can be used for student training, as well as training for experienced professionals.
“We want to train every health professional to take ownership of the patient’s safety and experience so they understand safe communication and know when they are telling another person about the patient or handing them over or referring them over, how to make sure they get all the critical information there,” Scheinman said…
“The airline industry solved safety by creating the right systems,” Scheinman said. “Medical errors are very widespread. But they usually aren’t a doctor making a mistake. They can be. But they’re more often the system failed to pick something up or allowed something bad to happen.”
And with this training, he said, those medical professionals might be that much more likely to help figure out a new solution to make sure something bad doesn’t happen again.” (P)

“.. experience showcases the promise of a much-touted but little understood collaboration in health care: alliances between community hospitals and some of the nation’s biggest and most respected institutions.
For prospective patients, it can be hard to assess what these relationships actually mean – and whether they matter.
Leah Binder, president and chief executive of the Leapfrog Group, a Washington-based patient safety organization that grades hospitals based on data involving medical errors and best practices, cautions that affiliation with a famous name is not a guarantee of quality.
“Brand names don’t always signify the highest quality of care,” she said. “And hospitals are really complicated places.”..
To expand their reach, flagship hospitals including Mayo, the Cleveland Clinic and Houston’s MD Anderson Cancer Center have signed affiliation agreements with smaller hospitals around the country. These agreements, which can involve different levels of clinical integration, typically grant community hospitals access to experts and specialized services at the larger hospitals while allowing them to remain independently owned and operated. For community hospitals, a primary goal of the brand-name affiliation is stemming the loss of patients to local competitors…
In some cases, large hospital systems opt for a different approach, largely involving acquisition. Johns Hopkins acquired Sibley Memorial and Suburban hospitals in the Washington, D.C., area, along with All Children’s Hospital in St. Petersburg, Fla. The latter was re-christened Johns Hopkins All Children’s Hospital in 2016…
Although affiliation agreements differ, many involve payment of an annual fee by smaller hospitals. Officials at Mayo and MD Anderson declined to reveal the amount, as did executives at several affiliates. Contracts with Mayo must be renewed annually, while some with MD Anderson exceed five years…
“It is not the Mayo Clinic,” said Dr. David Hayes, medical director of the Mayo Clinic Care Network, which was launched in 2011. “It is a Mayo clinic affiliate.”
Of the 250 U.S. hospitals or health systems that have expressed serious interest in joining Mayo’s network, 34 have become members.
For patients considering a hospital that has such an affiliation, Binder advises checking ratings from a variety of sources, among them Leapfrog, Medicare and Consumer Reports, and not just relying on reputation.
“In theory, it can be very helpful,” Binder said of such alliances. “The problem is that theory and reality don’t always come together in health care.”
Case in point: Hopkins’ All Children’s has been besieged by recent reports of catastrophic surgical injuries and errors and a spike in deaths among pediatric heart patients since Hopkins took over. Hopkins’ chief executive has apologized, more than a half-dozen top executives resigned and Hopkins recently hired a former federal prosecutor to conduct a review of what went wrong.
“For me and my family, I always look at the data,” Binder said. “Nothing else matters if you’re not taken care of in a hospital, or you have the best surgeon in the world and die from an infection.” ” (Q)

(G) Johns Hopkins promised to elevate All Children’s Heart Institute, by KATHLEEN McGRORY and NEIL BEDI,
(H) Top officials at Johns Hopkins All Children’s Hospital resign following reports of heart surgery deaths, by Tina Reed,
(I) Three more All Children’s officials resign following Times investigation, by By Kathleen McGrory and Neil Bedi,
(J) Johns Hopkins hires former prosecutor to investigate All Children’s Heart Institute,by Kathleen McGrory and Neil Bedi ,
(K) Problems At All Children’s Hospital Could Lead To More Transparency Rules, by STEPHANIE COLOMBINI,
(L) State and federal inspectors visit All Children’s after reports on heart surgery deaths, by Kathleen McGrory and Neil Bedi,
(M) Doctors sue Children’s, alleging wrongful termination after raising concerns about child’s death, by Julie Anderson,
(N) Bacteria In Newark Hospital NICU; Baby’s Death Being Probed: DOH, by Eric Kiefer,
(O) 5 NJ Facilities Under Microscope After Deadly Virus Outbreak by Tom Davis,
(P) Want health professionals to help reduce medical errors? Patient Safety Movement releases new curriculum, by Tina Reed,
(Q) Community Hospitals Link Arms With Prestigious Facilities To Raise Their Profiles, by Sandra G. Boodman,

Jonathan M. Metsch, Dr.P.H.

Log on to the AUPHA Network:

2. Johns Hopkins All Children’s has 3 weeks to correct safety lapses or lose Medicare funding

The agency placed the hospital in a rare status called “immediate jeopardy,” which federal guidelines describe as “a crisis situation.”..

“The federal government said a recent inspection of Johns Hopkins All Children’s Hospital found serious problems and threatened to cut off the institution’s public funding unless the issues are addressed in a matter of weeks.
The hospital was cited for not meeting federal rules on infection control, quality improvement, how it hires and manages doctors, and its leadership structure, according to a letter the Centers for Medicare and Medicaid Services sent the hospital Thursday.
The inspectors’ full report was not available Friday. But the letter says the findings were severe enough to constitute “an immediate or serious threat to patient health and safety.”..
Federal regulators do not directly control whether hospitals are allowed to operate. But they can cut hospitals off from public funds – a potentially devastating situation that could result in closure. Most hospitals are able to correct deficiencies and escape immediate jeopardy status before losing the money.
All Children’s has until Feb. 10 to provide a written plan to address the inspectors’ findings. If it does not correct the problems by Feb. 23, the government will stop allowing the hospital to bill it for new patients.
All Children’s spokeswoman Kim Hoppe said the hospital took the findings “seriously” and did not plan to appeal…
U.S. Rep. Kathy Castor, one of the lawmakers who called for an investigation, said she hoped to see “greater accountability for a hospital that used to be renowned for high quality care.”
“Johns Hopkins and state regulators allowed the quality of care to deteriorate and children died and were injured unnecessarily,” she said. “Our community deserves and demands so much better.”” (A)

  • Federal officials threaten All Children’s funding, citing problems, by Kathleen McGrory and Neil Bedi,

3. “An internal review by Johns Hopkins All Children’s Hospital has found more than a dozen incidents in which children in the hospital’s heart unit were harmed by the care they received.”

The cases should have been immediately reported to state officials, the hospital’s interim president told employees during private town halls this week. None were reported until recently.

The hospital’s former leaders also didn’t properly notify the board of trustees about safety concerns in the heart surgery department. That led to the federal government’s recent declaration that All Children’s had left patients in danger, the interim president said.

“Leadership knew there were quality and safety issues and did not elevate it in appropriate ways to the board,” said Kevin Sowers, who is president of the Johns Hopkins Health System and has also been the interim president at All Children’s since December.

Later, Sowers said that Johns Hopkins had “let this organization down.”

“Some of the people we put here did not act in the best interest of the children we were caring for or this organization,” he said…

Sowers described a series of lapses by the hospital’s former leaders — “people that we trusted,” he said — that hid the Heart Institute’s problems from the internal and external oversight designed to keep patients safe…

He said the hospital’s prior leadership team was aware of the Heart Institute’s problems. But when it filed a required quality improvement plan with the board, “there was absolutely nothing in the plan about the heart center,” he said…

In addition to discussing the governance issues, Sowers told employees the hospital had been cited by the state for not properly reporting the 13 cases in which patients had been harmed by medical care.

Under Florida law, the hospital should have reported those incidents within 15 days of them occurring.” (A)

“Time is just about up for Johns Hopkins All Children’s Hospital to submit its corrective plan to the feds.

The deadline is Sunday for the hospital to provide a written plan to fix serious problems that posed an “immediate or serious threat to patient health and safety” and were uncovered during a recent government inspection.

Several medical errors were found during the January inspection — including quality and infection control issues, plus staff management — but no fines were imposed.

The federal government threatened to cut funding if the hospital did not act…

A spokesperson said the hospital will meet the deadline.

“We take these findings seriously and are continuing to work in close coordination and consultation with both AHCA and CMS to immediately address their concerns,” Kim Hoppe said. “We will submit our corrective action plan by their deadline in areas including governance, physician credentialing, quality improvement planning and infection control.

“The safety of our patients is our top priority. We are confident in the work we are doing to ensure that our hospital continues to meet the highest standards of care.” (B)

“St. Petersburg, Fla.-based Johns Hopkins All Children’s Hospital submitted a corrective action plan after a Tampa Bay Times investigation found safety lapses in the hospital’s heart surgery program, CBS-affiliate TV station WTSP reports.

The hospital’s plan was turned in Feb. 10, just before the deadline. The corrective action includes governance shake-ups, new physician credentialing measures and changes to quality improvement planning and infection control.

In January, the Johns Hopkins Medicine Board of Trustees appointed a former federal prosecutor to lead its investigation into patient safety issues at the hospital.

Several patient safety issues, including quality and infection control problems, were found during a January visit by state and federal inspectors.”  (C)

“The corrective action includes governance shake-ups, new physician credentialing measures and alterations to quality improvement planning and infection control.

“The safety of our patients is our top priority,” the spokesperson said. “We are confident in the work we are doing to ensure that our hospital continues to meet the highest standards of care.” (D)

“The chairwoman of a powerful Florida Senate committee has filed a bill to dramatically increase oversight of children’s heart surgery programs.

The bill is designed to prevent problems like those at Johns Hopkins All Children’s Hospital. The St. Petersburg hospital experienced a sharp rise in heart surgery deaths that came to the attention of the public and regulators as the result of a Tampa Bay Times investigation published three months ago.

Florida Senate Health Policy Chairwoman Gayle Harrell, R-Stuart, said she filed the proposal in response to the issues at All Children’s and at St. Mary’s Medical Center in West Palm Beach, which stopped performing children’s heart surgeries in 2015 after CNN reported on the program’s high death rate.

She said the bill’s changes could have caught some of the issues sooner.

“These are the most fragile of children,” she said. “We want to make sure that we have standards in place and our cardiac centers are doing all they can to make sure children get the very best care.”

The bill, SB 1126, would let teams of pediatric heart doctors make unannounced visits to struggling programs. They would be able to review death records, inspect facilities and interview support staff and administrators.

After each site visit, the team would submit a report to the state’s Pediatric Cardiology Technical Advisory Panel, which would then recommend corrective action…

“We need to do things a little differently and make sure that there is the review of the standards that are expected to be met,” Harrell said…

Harrell’s proposal would let the panel recommend physician experts to visit existing programs and examine information that is not typically made available, including death records dating back one year.

The panel would also be able to make advisory recommendations on hospitals looking to open new pediatric heart surgery programs…

Separately from the new legislation, the panel is working a series of new rules for Florida heart surgery programs. Proposals under consideration include publishing far more detailed data online about heart surgery programs’ mortality rates. The new standards would need to be approved by the Agency for Health Care Administration.” (E)

“”Today Johns Hopkins All Children’s received word from the CMS that they have accepted our Plan of Correction and through an on-site survey have validated that all deficiencies related to the finding of immediate jeopardy have been addressed,” the hospital said in an emailed statement.

The problems were discovered after a review from the Department of Health & Human Services Centers for Medicare & Medicaid Services. Johns Hopkins All Children’s Hospital was notified that its participation in Medicare would terminate on Feb. 23 unless the hospital could meet substantive corrections to remove the conditions found.

Specifically, the facility did not meet the following conditions of participation, according to a CMS letter:

Governing body

Quality assurance performance improvement

Medical staff

Infection control

The finding from the CMS has now been removed, the hospital said in an emailed statement.

“This is good news but it is by no means the end of this important process. We take the issues raised by our regulators very seriously and will continue to collaborate closely with them as we implement our plan,” the hospital wrote. “We must be vigilant and diligent every day and, most importantly, we cannot forget what happened here and what we have learned.” “ (F)

“Choosing to have surgery at a facility affiliated with a highly rated U.S. hospital doesn’t guarantee the same quality experience, a new study in JAMA Surgery finds.

In an analysis of hospitals affiliated with U.S. News & World Report Honor Roll hospitals, surgical outcomes varied widely both within and across networks.

Moreover, Honor Roll hospitals didn’t always outperform network affiliates. While they had lower failure to rescue rates (13.3% versus 15.1%), their complication rates were actually higher (22.1% vs 18%).

Ben Harder, chief of health analysis at U.S. News, noted on Twitter that the study’s findings were not surprising. “That variation is why we evaluate discrete hospitals, not hospital system brands,” he said.” (G)

“A February follow-up inspection of Johns Hopkins All Children’s Hospital found the hospital was still out of compliance with federal rules, officials said this week.

Federal regulators cited problems with the hospital’s governance, quality assurance and infection control, and gave it a new deadline of mid-April to resolve the issues.

In a letter to Johns Hopkins Health System President Kevin Sowers Thursday, the Centers for Medicare and Medicaid Services said it would withhold public funding if the hospital missed the deadline.

It was the second letter the federal government has sent threatening to withhold funding. On Jan. 31, All Children’s was placed at risk of losing federal money because of problems with its governing board that put patients in “immediate jeopardy” of harm. Those specific problems have been addressed, federal regulators said.” (H)

“It should not take the deaths of young heart patients to spur action and better oversight of Florida’s cardiac programs. But the rising mortality rate at the Johns Hopkins All Children’s Hospital Pediatric Heart Institute revealed major gaps in how the state monitors quality of care and responds to problems. State lawmakers are right to consider legislation that would tighten oversight and better protect these fragile young patients…

Sen. Gayle Harrell, R-Stuart, has filed a bill that would allow teams of pediatric heart doctors to make unannounced visits to struggling programs at the Agency for Health Care Administration’s request to review patient records, inspect facilities and interview frontline and administrative staff. On-site inspections by experts in the field are an important part of ensuring quality care and rectifying problems before they escalate. Lawmakers should consider making such inspections annual to identify potential problems earlier.

Given the recent tragedies at All Children’s, where kids died following common heart surgeries, lawmakers should have increase oversight and transparency at Florida’s pediatric heart programs. No parent of a sick child should find out after the fact that a hospital they trusted made mistakes and failed to report them, and that the state failed to intervene. That’s what happened at All Children’s, and that’s what stronger oversight authority can prevent from happening again.” (I)

“The CMS now requires surveyors to complete a template when documenting instances of immediate jeopardy in an effort to better identify and resolve harm against patients at facilities.

In a blog post on Tuesday, CMS Administrator Seema Verma announced revisions to the guidance surveyors use to spot immediate jeopardy, requiring them to fill out a three-question template that describes the incident. The template is then shared with the facility so they have the information necessary to resolve the issue immediately.

Verma said the changes come from recent media attention surrounding harm at facilities. “Despite stringent safeguards, alarming stories continue to be reported about people, including some of our most vulnerable individuals, who have experienced harm in healthcare settings that is devastating to these patients and their families.”..

In recent months, an employee at a nursing home in Phoenix made national headlines after he was accused of raping a patient in a vegetative state. The facility announced it is closing. And just last month, immediate jeopardy was placed on Johns Hopkins All Children’s Hospital in St. Petersburg, Florida, for deficiencies. Late last year, the Tampa Bay Times reported on the hospital’s above-average death rates for pediatric heart surgeries.” (J)

(A)       All Children’s says 13 heart surgery patients were hurt by care, by Kathleen McGrory and Neil Bedi,

(B)       Deadline is today for All Children’s to provide plan to fix ‘serious’ safety issues, by Andrew Krietz,

(C)       Johns Hopkins All Children’s submits corrective plan to CMS amid safety lapse probe, by Megan Knowles,

(D)       All Children’s Hospital hatches plan to fix its problems, by Sarah Rosario,

(E)       After All Children’s deaths, proposal aims to catch heart surgery problems, by Kathleen McGrory, Neil Bedi and Elizabeth Koh,

(F)       Feds accept Johns Hopkins All Children’s Hospital plan to correct conditions putting patients in jeopardy, by Veronica Brezina-Smith, a.fn.andSelf

(G) Quality varies wildly among affiliates linked with US News top hospitals, JAMA study finds, by Meg Bryant,

(H) Federal inspectors find unresolved problems at All Children’s, by Bedi and Kathleen McGrory,

(I) Editorial: More eyes on pediatric heart programs,

(J) CMS creates tool for surveyors to spot immediate jeopardy, by MARIA CASTELLUCCI,

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PARTS 1-3. San Francisco General, a public hospital with San Francisco’s only trauma center, all commercial insurance is “out-of-network.”

ASSIGNMENT: What is the California state legislature doing to address the Out-of-Network challenge?

PART 1. March 21, 2019

 “If you’re shot, stabbed, hit by a car, fall off a roof or suffer any other major injury in San Francisco, you’ll be whisked to San Francisco General Hospital, the only trauma center in the city. …But you may leave with a very unpleasant side-effect: a shockingly high bill. …That’s because S.F. General — whose patients are overwhelmingly poor and are on Medicare or Medi-Cal, or have no insurance at all — lacks a good way to deal with patients who are actually insured.” (A)

 “Under a new state law, if you visit an in-network facility – such as a hospital, lab or imaging center – you will only be responsible for your in-network share of the cost, even if you’re seen by an out-of-network provider…

The new law covers Californians with private health insurance plans that are regulated by the state Department of Managed Health Care, or DMHC, and the state Department of Insurance, which includes roughly 70 percent of the state’s private insurance market, according to the California Health Care Foundation.

It does not cover some 5.7 million people whose employer-sponsored insurance plans are regulated by the U.S. Department of Labor…

The key point to remember is that you shouldn’t pay more than your in-network copayment, coinsurance or deductible, as long as you visited an in-network facility for non-emergency services.” (B)

“The trauma center has no contracts with private insurance companies. If it did, there would be agreements with those insurers on how much a particular drug or a particular procedure costs.

Instead, the hospital charges the highest rates approved by the Board of Supervisors and the mayor, receives whatever amount the patient’s insurance company decides to pay, and bills the patient for the rest.” (C)

On April 3, Nina Dang, 24, found herself in a position like so many San Francisco bike riders — on the pavement with a broken arm.

A bystander saw her fall and called an ambulance. She was semi-lucid for that ride, awake but unable to answer basic questions about where she lived. Paramedics took her to the emergency room at Zuckerberg San Francisco General Hospital, where doctors X-rayed her arm and took a CT scan of her brain and spine. She left with her arm in a splint, on pain medication, and with a recommendation to follow up with an orthopedist.

A few months later, Dang got a bill for $24,074.50. Premera Blue Cross, her health insurer, would only cover $3,830.79 of that — an amount that it thought was fair for the services provided. That left Dang with $20,243.71 to pay, which the hospital threatened to send to collections in mid-December…

Most big hospital ERs negotiate prices for care with major health insurance providers and are considered “in-network.” Zuckerberg San Francisco General has not done that bargaining with private plans, making them “out-of-network.” That leaves many insured patients footing big bills.

The problem is especially acute for patients like Dang: those who are brought to the hospital by ambulance, still recovering from a trauma and with little ability to research or choose an in-network facility.

A spokesperson for the hospital confirmed that ZSFG does not accept any private health insurance, describing this as a normal billing practice. He said the hospital’s focus is on serving those with public health coverage — even if that means offsetting those costs with high bills for the privately insured.

“It’s a pretty common thing,” said Brent Andrew, the hospital spokesperson. “We’re the trauma center for the whole city. Our mission is to serve people who are underserved because of their financial needs. We have to be attuned to that population.”

But most medical billing experts say it is rare for major emergency rooms to be out-of-network with all private health plans.  (D)

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

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

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

On its web site, ZSFG declares that “everyone is welcome here” regardless of their financial situation or immigration status:

Everyone is welcome here, no matter your ability to pay, lack of insurance, or immigration status. We’re much more than a medical facility; we’re a health care community promoting good health for all San Franciscans.

We’re part of a large group of neighborhood clinics and healthcare providers, the San Francisco Health Network. In partnership, we provide primary care for all ages, specialty care, dentistry, emergency and trauma care, and acute care for the people of San Francisco…

 “Our mission is to serve people who are underserved because of their financial needs,” the spokesperson also stated. “We have to be attuned to that population.” (F)

“More than half of U.S. adults “have been surprised by a medical bill that they thought would have been covered by insurance,” according to a new survey from research group NORC at the University of Chicago…

The big picture: Drug prices have been in the crosshairs of lawmakers, and health insurers have always been a punching bag. But hospitals and doctors aren’t attracting any large-scale movement to rein in pricing and billing tactics.

“There’s a huge amount of trust in the providers people choose to go to,” said Caroline Pearson, senior fellow at NORC. “I think we’ve got a long way to go until we have backlash against those providers. But as insurance gets more complicated and out-of-pocket costs rise, we’re going to see more and more surprise bills.”

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

“U.S. Sen. Bill Cassidy, R-La., said federal lawmakers on both sides of the aisle are moving closer to an agreement on legislation to prevent surprise medical bills, according to a Bloomberg Government report…

Republicans and Democrats have been working to address the issue, and bipartisan legislation is predicted for early 2019, Mr. Cassidy told Bloomberg Government…

There have been legislative efforts related to surprise medical bills. In September, a bipartisan group of senators unveiled the Protecting Patients from Surprise Medical Bills Act. Then on Oct. 11, Democrat Sen. Maggie Hassan of New Hampshire introduced the No More Surprise Medical Bills Act of 2018. The first draft bill focuses on preventing out-of-network providers from charging patients more for emergency care than what they would pay using insurance. The second bars healthcare providers from out-of-network billing for emergency services, according to the report.

Meanwhile, Bloomberg Government notes, insurers and hospitals are pointing the finger at each other  over who is at fault for the problem.

Mr. Cassidy told the publication there are “bad apples with both groups” and anticipates both sides “are going to have to give a little bit” when it comes to changes.” (H)

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

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

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

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

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

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

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

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

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

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

“Payer groups, including America’s Health Insurance Plans, are joining forces with employers, consumers and other stakeholders in support of a plan they say will tackle surprise billing.

The groups signed on to a set of guiding principles aimed at protecting consumers from the practice. The guidelines are: inform patients when care is out of network, support federal policy that protects consumers while restraining costs and ensuring quality networks and pay out-of-network doctors based on a federal standard.

Meanwhile, the American Hospital Association and the Federation of American Hospitals released a joint statement saying hospitals and health systems also support patient protections from surprise billing but place blame on insurers, not providers…

AHIP said surprise billing happens because providers aren’t participating in certain networks. “When doctors, hospitals or care specialists choose not to participate in networks — or if they do not meet the standards for inclusion in a network — they charge whatever rates they like,” the group wrote.

In their statement, the hospital groups also backed consumer protections, but pointed the finger at payers for the issue. “Inadequate health plan provider networks that limit patient access to emergency care is one of the root causes of surprise bills. Patients should be confident that they can seek immediate lifesaving care at any hospital. The hospital community wants to ensure that patients are protected from surprise gaps in coverage that result in surprise bills, and we look forward to working with policymakers to achieve this goal,” they wrote…

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

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

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

I’ve read emergency room bills from all 50 states and the District of Columbia. I’ve looked at bills from big cities and from rural areas, from patients who are babies and patients who are elderly. I’ve even submitted one of my own emergency room bills for an unexpected visit this past summer.

Some of the patients I read about come in for the reasons you’d expect: a car accident, pains that could indicate appendicitis or a heart attack, or because the ER was the only place open that night or weekend….

I’ll stop collecting emergency room bills on December 31. But before I do that, I wanted to share the five key things I’ve learned in my year-long stint as a medical bills collector.

1) The prices are high — even for things you can buy in a drugstore

2) Going to an in-network hospital doesn’t mean you’ll be seen by in-network doctors

3) You can be charged just for sitting in a waiting room

4) It is really hard for patients to advocate for themselves in an emergency room setting

5) Congress wants to do something about the issue.. (K)

“Zuckerberg General’s emergency room fees are also higher, on average, than ERs nationally, in the state of California, and in the city of San Francisco. In the city, they’ve charged up to five times as much. The fees are set by the San Francisco Board of Supervisors, which has voted for steady increases, doubling the charge since 2010.

When asked about the fees, board members admitted that they hadn’t kept a close eye on the prices and said they plan to hold hearings on the issue.

“It turns out we should have been monitoring this much more closely,” says Aaron Peskin, a supervisor who has previously voted in favor of the hospital prices and who is now calling for the hearings…

The city of San Francisco manages Zuckerberg General and sets the prices the hospital charges.

The task falls to the San Francisco Board of Supervisors, an 11-member board that oversees city policies and budgets. Every year or two, they approve a lengthy document that lists hospital prices for everything from an emergency room fee to a day in the obstetrics unit to a primary care exam. The document describes the fees as “proper reasonable amounts.”

The current prices were approved at a board a meeting in July 2017. A video recording of that meeting shows there was no debate or discussion of the prices. Instead, the board of supervisors unanimously approved the ZSFG charges in a voice vote that latest less than a minute…

But there is little record of public discussion or debate over that increase. Meeting records for each vote on the hospital prices since 2010 show that the fees have always been approved unanimously.

“I cannot recall there ever being any discussion of them,” says Peskin, a board member who has served on and off since 2001. “I don’t think there has ever been a split vote, and that’s been true as long as I’ve been on the board of supervisors. But that will probably change now.”..

The San Francisco Board of Supervisors now plans to bring greater scrutiny to the hospital’s billing practices in light of Vox’s reporting.”  (L)

“Zuckerberg San Francisco General Hospital is reducing a bike crash patient’s $20,243 bill down to $200 — only after the case drew national attention to the hospital’s surprising policy of being out-of-network with all private health insurance…

The San Francisco Board of Supervisors, which oversees the hospital, now plans to hold hearings on Zuckerberg General’s billing practices as well.

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

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

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

“Momentum is building for action to prevent patients from receiving massive unexpected medical bills, aided by President Trump, who is vowing to take on the issue.

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

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

Trump gave a boost to efforts on Wednesday.

“[People] go in, they have a procedure and then all of a sudden they can’t afford it, they had no idea it was so bad,” Trump said at a roundtable with patients about the issue.

“We’re going to stop all of it, and it’s very important to me,” he added.

But the effort still faces obstacles from powerful health care industry groups — including hospitals, insurers and doctors. Those groups are jockeying to ensure that they avoid a financial hit from whatever solution lawmakers and the White House back.” (N)

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

“There are 141 million visits to the emergency room each year, and nearly all of them.. have a charge for something called a facility fee. This is the price of walking through the door and seeking service. It does not include any care provided.

Emergency rooms argue that these fees are necessary to keep their doors open, so they can be ready 24/7 to treat anything from a sore back to a gunshot wound. But there is also wide variation in how much hospitals charge for these fees, raising questions about how they are set and how closely they are tethered to overhead costs.

Most hospitals do not make these fees public. Patients typically learn what their emergency room facility fee is when they receive a bill weeks later. The fees can be hundreds or thousands of dollars. That’s why Vox has launched a year-long investigation into emergency room facility fees, to better understand how much they cost and how they affect patients…

We found that the price of these fees rose 89 percent between 2009 and 2015 — rising twice as fast as the price of outpatient health care, and four times as fast as overall health care spending.” (P)

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

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

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

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

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

And then the bill came.

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

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

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

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

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

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

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

PART 2. April 7, 2019

Zuckerberg hospital puts balance billing on hold

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

Friday, February 01, 2019

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

San Francisco, CA —Today Mayor London N. Breed, Supervisor Aaron Peskin, the Department of Public Health and Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG) announced immediate steps to improve billing practices at ZSFG for patients who have gotten stuck in the middle of disputes between the hospital and their insurance provider, including a temporary halt to the practice of balance billing.

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

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

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

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

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

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

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

Immediate Changes

Temporarily halt all balance billing of patients

Effective immediately until a better plan is determined

Make financial assistance easier to get

Proactively begin the process of assessing a patient’s eligibility for assistance, rather than waiting for them to apply

Improve patient communications

Proactively reach out to patients who are receiving large bills to explain the situation, remove the element of surprise, and offer to help

Create a Frequently Asked Questions document to clear up many of the routine questions about billing and financial assistance

Publicize the patient financial services hotline, (415) 206-8448, so that people know where to go for help

Increase communication with patients and provide information about financial assistance opportunities

Additional elements of a comprehensive plan to be developed within 90 days

Make financial assistance easier to get

Adjust charity care and sliding scale policies to expand the number of people who are eligible

Revise ZSFG catastrophic high medical expense program to support more patients who are faced with high, unexpected bills for catastrophic events

Streamline the process of applying for assistance

Protect patients’ financial health

Establish an out-of-pocket maximum for patient payments to ZSFG

Pursue agreements with private insurance companies

Work with state partners to explore additional efforts to improve insurance payments

Ensure ZSFG prices and practices are fair

Undertake a study of hospital charges regionally, comparing trauma centers, academic medical centers, San Francisco and Bay Area hospitals

Research billing and financial assistance practices of California public hospitals to identify opportunities for improvement

Conduct financial analysis of impact on the City of proposed changes (R)

(A)San Francisco General Hospital Lacks A Good Way To Deal With Patients Who Are Actually Insured,

(B)Nasty surprise bills prohibited by new California law when people visit facilities in their insurance network , by Emily Bazar,

(C)SF General’s insured patients suffer further trauma when bill arrives, by Heather Knight,

(D)A $20,243 bike crash: Zuckerberg hospital’s aggressive tactics leave patients with big bills, by Sarah Kliffsarah,

(E)Zuckerberg Hospital ER Doesn’t Take Private Insurance, Sticking San Francisco Patients With Huge Bills, by Andrew Whalen,

(F)Report: Zuckerberg Hospital Gouges Paying Patients to Pay For Illegals, by Kit Daniels,

(G)A Fainting Spell After A Flu Shot Leads To $4,692 ER Visit,

(H)Report: Zuckerberg Hospital Gouges Paying Patients to Pay For Illegals, by Kit Daniels,

(I)Why there’s no surprise hospital bill backlash — yet,

(J) Payer, hospital groups trade blame on surprise billing, by Les Masterson,

(K)Taking Surprise Medical Bills To Court, by Julie Appleby,

(L))Prices at Zuckerberg hospital’s emergency room are higher than anywhere else in San Francisco, by  Sarah Kliff,

(M) After Vox story, Zuckerberg hospital rolls back $20,243 emergency room bill, by Sarah Kiff,

(N)Trump boosts fight against surprise medical bills, by PETER SULLIVAN,

(O)Industry braces as more lawmakers seek to ban surprise billing, by Shannon Mushmore,

(P) Sarah Kliff has spent the past year reporting on high ER fees. Ask her anything, by Lauren Katz,

(Q)After Vox story, Zuckerberg hospital rolls back $20,243 emergency room bill, by Sarah Kliff,

(R)Zuckerberg hospital puts balance billing on hold, General Hospital Until Plan to Improve Long-Term Billing Practices is Implemented,

A new bill would outlaw the big, surprise bills that Zuckerberg San Francisco General Hospital has sent to hundreds of patients.

California lawmakers will introduce legislation Monday to end surprise emergency room bills like those that left one patient with a $20,000 treatment bill after a minor bike crash — a move they say was inspired by Vox’s reporting on the issue.

The new bill, introduced by Assemblyman David Chiu and Sen. Scott Wiener, would bar California hospitals from pursuing charges beyond a patient’s regular co-payment or deductible. The ban would apply even if a hospital was out-of-network with a patient’s health insurance.

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

California actually has some of the country’s strongest protections against surprise medical bills — but the state’s laws never anticipated a hospital with billing practices like Zuckerberg San Francisco General.

In 2016, California passed a law that protected patients from surprise bills from out-of-network doctors they didn’t choose.

This might happen if, for example, a patient went to an in-network hospital and then received a bill from an out-of-network anesthesiologist or radiologist they never even met.

That law covered patients receiving scheduled care like surgery or delivering a baby. Separately, a decade-old California Supreme Court ruling provided similar protections for emergency room patients.

Neither the court ruling nor the 2016 law anticipated a situation like Zuckerberg San Francisco General, where the entire hospital is “out of network” with all private health insurance.”..

“This new legislation would tackle that rarer situation where a hospital is not in network, and then sends the patient a bill for whatever balance their insurer won’t pay.

There are two key parts to the proposal. First, the bill would prohibit hospitals from pursuing any balance that the patient owed beyond their regular co-payment or contributions to the health plan’s deductible.

Second, the bill would regulate the prices that the hospital could charge for its care, limiting the fees to 150 percent of the Medicare price or the average contracted rate in the area, whichever is greater.

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

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

He said that the bill is a response “in regard to what we learned is happening at [ZSFGH] — but also across California — this is the situation of patients who get a surprise bill after visiting an emergency room.”..

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

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

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

Dear Congressional and Committee Leadership:

On behalf of our member hospitals, health systems and other health care organizations, we are fully committed to protecting patients from “surprise bills” that result from unexpected gaps in coverage or medical emergencies. We appreciate your leadership on this issue and look forward to continuing to work with you on a federal legislative solution.

Surprise bills can cause patients stress and financial burden at a time of particular vulnerability: when they are in need of medical care. Patients are at risk of incurring such bills during emergencies, as well as when they schedule care at an in-network facility without knowing the network status of all of the providers who may be involved in their care. We must work together to protect patients from surprise bills.

As you debate a legislative solution, we believe it is critical to:

Define “surprise bills.” Surprise bills may occur when a patient receives care from an out-of-network provider or when their health plan fails to pay for covered services. The three most typical scenarios are when: (1) a patient accesses emergency services outside of their insurance network, including from providers while they are away from home; (2) a patient receives care from an out-of-network physician providing services in an in-network hospital; or (3) a health plan denies coverage for emergency services saying they were unnecessary.

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

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

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

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

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

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

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

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


American Hospital Association

America’s Essential Hospitals

Association of American Medical Colleges

Catholic Health Association of the United States

Children’s Hospital Association

Federation of American Hospitals

(A)          After Vox story, California lawmakers introduce plan to end surprise ER bills, by Sarah Kliff,

(B)          Controversial ZSFGH billing practice that left privately-insured owing thousands could be banned, by Laura Waxmann,

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

PART 3. April 23, 2019

“Zuckerberg San Francisco General Hospital announced Tuesday it has overhauled its billing policies, a move that comes three months after a Vox story drew national attention to the hospital’s abnormal and aggressive billing tactics.

The hospital has for years made the rare decision to be out of network with all private health insurance plans. This created an acute problem for patients like like Nina Dang, 24, who made an unexpected trip to the hospital’s emergency room, the largest in San Francisco. An ambulance took Dang to the trauma center after a bike accident last April. She is insured by a Blue Cross plan, but she didn’t know that the ER does not accept insurance. She received a bill for $20,243.

After the Vox story ran, the hospital reduced Dang’s bill to $200, the copay listed on her insurance card.

Now, Zuckerberg San Francisco General Hospital (ZSFG) is essentially making the same change for all future patients: Its new billing policies will no longer charge those with private coverage “any more than they would have paid out of pocket for the same care at in-network facilities, based on their insurance coverage.”

This will put an end to the hospital’s use of a controversial practice call “balance billing,” when a hospital sends a patient a bill for the balance that an insurer won’t pay.

ZSFG will also create a new out-of-pocket maximum on what patients could end up owing for their treatment. The maximum is tethered to a patient’s income and ranges from zero dollars for the lowest earners to a $4,800 maximum for those with the highest incomes (1,000 percent of the poverty line, or $251,400 for a family of four).” (A)

“The changes are aimed at shielding patients from large bills by removing them from payment disputes between the hospital and the insurance company, said Rachael Kagan, director of communications with the department.

“We don’t have a large number of privately insured patients at Zuckerberg San Francisco General Hospital, but some of those who have been in that situation in the past have had a terrible experience and we want to rectify that,” said Ms. Kagan.

“We don’t want that to happen in the future. We know that it’s very stressful to get a large bill and we consider our responsibility to the patients to care for them in all ways. They will have gotten excellent medical care from us, and we want to protect their financial well-being also,” she added.

The hospital estimated that up to 1,700 of its 104,000 patients a year may have received a balance bill…

Zuckerberg hospital will also set a maximum out-of-pocket cost for patients at all income levels, with any insurance status, and this maximum will be income-based. No one will be charged more than 5 percent of their income…

Additionally, the hospital will make its patient financial assistance programs easier to qualify for so more people will get financial assistance. This involves increasing the threshold to qualify for the hospital’s charity care program. The threshold to qualify will increase from 350 percent of the federal poverty level to 500 percent of the federal poverty level.

The hospital is also adjusting the “sliding scale” financial assistance program for San Francisco residents. Previously, Zuckerberg hospital assessed eligibility for the program based on income and assets but will now only take income into account…

Overall, she said she’s pleased the hospital is taking these steps to better align its billing with its values and mission.” (B)

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

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

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

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

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

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

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

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

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

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

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

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

  1. After Vox stories, Zuckerberg Hospital is overhauling its aggressive billing tactics, by Sarah Kliff,
  2. Publicity spurs billing revamp at Zuckerberg hospital, by Kelly Gooch,
  3. Zuckerberg Hospital Revises Insane Billing Practices After Media Exposés, by JOE KUKURA,
  4. Emergency room off Las Vegas Strip makes waves with new business model, by Milbank News Writer,
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“Two-thirds of beneficiary communication is more complex to read than Moby Dick…” Let’s start with EOBs!

When triaging my snail mail I quickly put all the Explanation of Benefits (EOBs) aside. Soon after I toss them into a garbage bag then throw them out without any review.

I have Medicare with secondary coverage from United, and I get sequential Explanations of Benefits (EOBS) from each.

Here are some of the reasons I can’t figure out whether or not my claims have been processed correctly.

– The Medicare and United EOBs are different and it is difficult to try to synchronize them

– Each has a separate deductible and they are hard to track

– United “outsources” certain categories of service such as rehab/chiropractic generating additional EOBs

– I also get a monthly Medicare Part D report, for the Prescription Drug benefit

– If Medicare doesn’t pay then United won’t either even if United would pay if it was primary. For a given provider the secondary co-pay is different depending on whether or not the provider is in or out of network with United, no matter what Medicare pays, if it pays

– Every provider codes claims differently so similar service at two providers may be coded and billed differently.

– When I got PT in two different places one charged me $20 per visit, the other calculated a co-pay for each visit.

– Some offices ask for co- payment at the visit, others way until after the claims are completed.

– United sends out-of-network payments to me, often with insufficient information to identify the provider.

– And United bundles out-of-network payments from several providers then I have to figure who I owe what and write separate checks to each.

– I am going to a chiropractor who accepts Medicare and is out-of-network for United so I do not know my out-of-pocket costs until I get the United EOBs.

-Sometimes I get a United denial because a provider has failed to file with Medicare first. So I have to ask the provider to send a claim to Medicare, adding months to the processing, and receipt of the two EOBs.

– Medicare and United have different appeal procedures. If I can’t link the EOBs it’s impossible to know where to appeal.

Some providers bill so efficiently that it seems like I get a Medicare EOB before I get home from the office visit!

Added confusion after each January 1st, e.g., now I get EOBs for 2018 where deductibles and copays are done, and for 2019 where they start over separately for Medicare and United (and each of its outsourced programs).

Recently I got a check for $37 from a hospital I use. No date of service.  No EOB. No explanation of what was provided.

Here’s a personal frustrating example:

I received a bill and paid $205 for a lab test done at a reference laboratory. No insurance claims had been processed.

After I followed up, in March I got an email: “I contacted XXX and spoke with ZZZ. Per ZZZ Medicare processed and made payment on one of the charges but denied the other (processed the $82.00 charge denied the $123.00 charge). He is confirming the reason for the denial for the second charge and will work with Medicare regarding processing it for payment. Currently you have a credit of $73.38 however Empire has not processed and paid for the $8.62 coinsurance applied by Medicare. ZZZ will submit that as well.”

It took months to get it resolved!

We are “collateral damage” in a war between hospitals and insurance companies. *

The obvious but unlikely solution is universal coding/ claims/ EOB by all providers, integrated to simplify tracking of a claim through primary and secondary insurers.

“Healthcare payers’ beneficiary communication efforts leave a lot to be desired, as organizations let considerations for low patient health literacy and other best practices fall by the wayside, according to a recent report from Visible Thread.

Currently, 86 percent of insurers are not effectively communicating with the 65 and older population, despite strong incentive to do so. With 15 percent of the country eligible for Medicare coverage, it’d behoove payers to cater to this population, the report authors explained…

But healthcare payers are not creating copy that meets those patient needs, the report continued. Six of the 30 surveyed payers use the recommended word density level. Fifty-six percent use the passive voice too often, and the average sentence is two times longer than recommended. Two-thirds of payers produce patient-facing content that is more complex to read than Moby Dick…

But complex explanations of benefits and other payer documents are making that trust difficult to come by. Payers that do not use adequate language to explain policies around pre-existing conditions, for example, are big stressors for patients. Patients who do not know what will and will not be covered in their plan have difficulty selecting an adequate plan…

Health payers looking to improve their beneficiary communication should work to reduce their sentence length, eliminate passive voice from their writing, choose less complex vocabulary, and adopt technology that can simplify copy, the report authors recommended…

“Instead of forcing people to continue to battle complexity, payers can invest in simplifying the ways consumers interact and engage with healthcare…”

Another study, conducted by NORC at the University of Chicago, revealed that complex benefits documents have led to numerous surprise medical bills…

The NORC at the University of Chicago survey found that 57 percent of patients had received a surprise medical bill as a result of unclear benefits explanations and low health literacy.

“Most Americans have been surprised by medical bills that they expected would be covered by their insurance,” Caroline Pearson, senior fellow at NORC at the University of Chicago, said in a statement. “This suggests that consumers may have difficulty understanding their insurance benefits or knowing which providers are included in their plan’s network.”

As consumerization continues to loom large in healthcare, it will be important for patients to be fully informed of all aspects, including access to clinical care and access to comprehensive payer coverage. To do this, payers must employ simpler language in beneficiary communication and engagement documents and be mindful of current patient health literacy levels.” (A)

to learn more about EOBs you might look at:

Understanding Your Explanation of Benefits (EOB) – How to Decipher Your Explanation of Benefits

Three “must read” articles:

Markups On Care Can Fatten Hospital Budgets — Even If Few Patients Foot The Full Bill, by Chad Terhune. Kaiser Health News.

Those Indecipherable Medical Bills? New York Times. by Elisabeth Rosenthal.

Donald Trump Did Something Right, by Elisabeth Rosenthal,

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Are hospital quality/safety metrics used by payers & accrediting organizations getting ahead of the science of q/s measurement? (I)

Back in the day one of our system’s community hospitals achieved the top rating for obstetrics from one of the for-profit hospital rating companies and then, before it could be stopped, bought an obstetrics marketing package from the company. This was cherry-picking since the hospital did not receive marketable ratings on the company’s other clinical categories.


Look at the web sites of the three hospitals nearest to you and compare how they post hospital safety and quality report card information.

Find additional models of patient safety/ quality not based mostly on available Medicare data.

PREQUEL: Hospital web site archeology.

“It sure seems like there’s been a lot of bad news for and about hospitals — specifically, about their protections for patients’ safety.

Driving the news:

•             A WebMD/Georgia Health News investigation found a third of the country’s hospitals have violated basic federal rules for providing emergency care.

•             Baylor St. Luke’s Medical Center is now drawing scrutiny for poor outcomes with its liver and lung transplants, after ProPublica and the Houston Chronicle highlighted failures with heart transplants.

•             Kids at the Johns Hopkins children’s hospital in Florida are dying “at an alarming rate,” the Tampa Bay Times recently reported.

•             The federal government is threatening to end Medicare and Medicaid funding at Vanderbilt University Medical Center after a patient died from getting the wrong medication.

•             A large Detroit hospital faces the same threat due to dirty surgical equipment.

What they’re saying: “We are unnecessarily killing thousands of people every year because hospital quality is not what it should be,” says Leah Binder, CEO of the Leapfrog Group, an organization that grades hospital care.

•             “There’s lots of ratings that will say, ‘This is the No. 1 hospital, this is the great hospital list.’ But what we also need are ratings on where not to go,” Binder says. “But there’s some risk to exposing and embarrassing any part of that.”” (A)

Physician Licensing

“In Louisiana, Larry Mitchell Isaacs, MD, gave up his medical license in the face of discipline, after he removed an allegedly healthy kidney during what was supposed to be colon surgery.

In California, he mistakenly removed a woman’s fallopian tube. According to medical board records, he thought it was her appendix — which already was gone. More surgeries on the woman followed, including one in which he allegedly left her intestine unconnected.

Facing state sanctions, he surrendered his license there, too.

In New York, where regulators were moving to take action based on his California problems, he also agreed to give up his license.

But in Ohio, he has found a home.

There, his medical license remains unblemished, allowing Isaacs to work at an urgent care clinic in the Cincinnati area.” (B)

“Look up the Wisconsin medical license for John Kidd, MD.

All that is posted is a document that says he gave up his Wisconsin license in 2012 because he had moved to New York and didn’t plan to practice again in the state.

Look up Kidd’s license in New York and there is no indication of any allegations of poor care or wrongdoing against him there — or anywhere else in the country.

But, documents obtained by the Milwaukee Journal Sentinel, USA Today, and MedPage Today offer a different picture.

They show Kidd was terminated in 2010 by his employer, a business that provides anesthesiology services for Theda Clark Regional Medical Center in Neenah, Wis., after a series of alleged incidents earlier that year:

When a patient had trouble breathing, Kidd would not help a nurse and doctor who had rushed to the patient’s aid.

When a patient who was having a limb amputated complained of pain and discomfort, Kidd was on his cellphone and did not respond promptly.

A nurse thought he was once impaired at work and smelled of alcohol…

Kidd, 53, is one of more than 250 doctors who surrendered their medical license since 2012, but who were still able to practice in another state, an investigation by the news organizations found.” (C)

“The Medical Board of California has begun monitoring warning letters sent by the FDA to physicians engaged in potentially harmful practices, following a Milwaukee Journal Sentinel/MedPage Today report earlier this year about the failure of states to act on allegations raised in the letters.

That investigation found that 73 physicians around the country with active medical licenses had been the subject of FDA warning letters alleging serious problems over a five-year period, but only one had been disciplined.

The warnings involved fertility clinics that didn’t test donors of eggs and sperm for communicable diseases; researchers who didn’t follow rules designed to protect patients who volunteer for trials of drugs and devices; physicians who pushed dubious treatments and supplements to unwitting customers; and a mammography clinic faulted for inadequate quality control testing…

“The Board reviews the letters and if they contain information regarding physicians licensed by the Board, the Board looks into the matter,” he said in a recent email. The practice began in June, but only now is being confirmed…” (D)

“When it comes to improving the nation’s broken system of physician discipline, many advocates say the starting point should be fixing something that was created to do the job in the first place.

In 1986, Congress created the National Practitioner Data Bank (NPDB), pledging it would improve healthcare and reduce fraud and abuse. The data bank records all sorts of things: malpractice payments, disciplinary action, restrictions of hospital privileges, and other transgressions.

There are just three problems:

The system can be gamed, so not all problem physicians appear on the list.

State medical boards don’t always check the data bank.

And, the information is off limits to those who are most at risk: patients….

Here is a look at five other ways to improve the system:

1. The Problem: Uneven discipline. A physician who holds licenses in multiple states can lose a license in one, but get lesser or no discipline in another…

2. The Problem: Dead letters. When the FDA performs investigations and sends warning letters to physicians — a rare step that indicates serious matters — the letters typically go only to the physician. Copies are rarely sent to medical boards in the states where the physicians are licensed…

3. The Problem: Cryptic surrenders. In some cases, a physician facing discipline agrees to surrender his or her license prior to a hearing or formal charge. That can keep potential problems out of the public eye…

4. The Problem: Inconsistent data. State medical boards vary dramatically when it comes to the information they include on their websites about a physician’s background…

5. The Problem: Medicare payments. Physicians who lose their licenses in one state, or who are banned from a state Medicaid program due to problems such as fraud or putting patients in harm’s way, can still collect money from the taxpayer-financed Medicare program.” (E)

The Joint Commission

“Facts about the National Patient Safety Goals

In 2002, The Joint Commission established its National Patient Safety Goals (NPSGs) program

The first set of NPSGs was effective January 1, 2003

The NPSGs were established to help accredited organizations address specific areas of concern in regard to patient safety

Development of the Goals

Following a solicitation of input from practitioners, provider organizations, purchasers, consumer groups and other stakeholders, The Joint Commission determines the highest priority patient safety issues and how best to address them, including as a NPSG. The Joint Commission also determines whether a goal is applicable to a specific accreditation program and, if so, tailors the goal to be program-specific.” (F)

“The Joint Commission (TJC) requires compliance with standards that will result in continuous improvement in support of safe, high quality care. Accreditation surveys, mid-cycle performance reviews, self-assessments, and plans for corrective action all drive your organization to achieving continuously higher levels of quality of care and patient safety.

QPS consultants can guide your organizations through the intricacies of TJC accreditation process as well as the CMS survey. We are subject matter experts in the accreditation process for organizations that provide behavioral health care and substance abuse treatment.  We have substantial professional experience with accreditation and regulatory surveys for organizations that provide behavioral health care and an in-depth knowledge of the standards being reviewed. QPS consultants can partner with your organization to achieve or maintain your honored status of accreditation.” (G)

“The Trump administration is weighing whether to continue approving hospital and health-accreditation groups that also have consulting arms, following potential conflicts of interest raised in an article in The Wall Street Journal.

The disclosure came in an announcement by the Centers for Medicare and Medicaid Services that it is seeking input on possible conflicts of interest.” (H)

Quality Measures Linked to Physician Reimbursement

“Physician reimbursement increasingly depends upon measures of healthcare quality. Physicians who fall short on quality measures now face financial penalties. But it might be quality measures, themselves, that are falling short, according to a study conducted by the American College of Physicians.

The study involved a panel of people with expertise in evidence-based medicine. Panelists were asked to evaluate the validity of quality measures being used by either Medicare, the National Committee for Quality Assurance, or the National Quality Forum. It is typically measures from these three groups that are used to determine physician quality report cards, and Medicare plans to use its measures to influence reimbursement for individual clinicians…

How do quality measures from these three groups stack up? The experts reviewed each measure and determined whether it was valid, uncertain, or invalid. They looked at 86 quality measures that Medicare will use as part of its MIPS program (an acronym for Merit-based Incentive Payment System). Barely more than a third of these measures were valid. The measures from NCQA and NQF came out better, with 60% and half being judged valid, respectively. But that still leaves a huge number of quality measures that are either uncertain or out and out invalid…

Their results strongly suggest that the use of quality measures, by payers and accrediting organizations, has gotten ahead of the science of quality measurement.” (I)

Electronic Medical Record Algorithms

“Several patients seen in our practice recently were significantly and dramatically transformed by the electronic health record (EHR). And not in a good way.

Take, for instance, the patient whose outside chart was reviewed when she showed up in our office for a follow-up appointment after an emergency department visit.

The notes from the emergency department providers, including a scribe and the attending physician, described her in the following way:

“This 67-year-old woman with morphine sulfate presented after a fall with injury to her head.”

Throughout the documentation, they kept referring to her as a patient with morphine sulfate.

For a while, as I read through it, my eyes skimmed over this, and it didn’t really register as something I needed to pay attention to.

Perhaps they were taking note of the fact that she had morphine sulfate with her when she arrived, had taken morphine sulfate before the fall, or was requesting morphine sulfate to ease her pain.

Only after diving deeper into her past medical history in our own chart did I realize that someone must’ve typed “MS”, and the computer auto-corrected and somehow turned that into morphine sulfate, instead of multiple sclerosis.

I’m not sure how their system works, but most of the functionality of EHRs that has been created to prevent medical confusion from abbreviations offers you a choice of what it thinks you’re looking for, the most obvious or most common diagnoses usually typed by physicians.

So maybe the system saw “MS” and offered up morphine sulfate, multiple sclerosis, mitral stenosis, myasthenic syndrome, magnesium sulfate. Pick one.

Or maybe their system just turned “MS” into morphine sulfate without giving them any choice.” (J)

“Patients often struggle to have errors in their medical records corrected, according to a recent CNBC report.

About 70 percent of patient records have wrong information, sociologist Ross Koppel, PhD, told CNBC.

For one patient — 20-year-old Morgan Gleason — the errors in her medical record claimed she had twice given birth and was diabetic. But she’s never been pregnant, nor been diagnosed with diabetes, she told CNBC.

When Ms. Gleason tried to have her records corrected, the hospital insisted she was wrong, she said. In fact, the hospital told Ms. Gleason that if she hadn’t given her physician the information, it wouldn’t have been in her chart in the first place. It wasn’t until Ms. Gleason made a written request for a correction of her record that changes were made.” (K)

“When Liz Tidyman’s elderly parents moved across the country to be closer to their children and grandchildren years ago, they carried their medical records with them in a couple of brown cardboard folders tied with string.

Two days after their arrival, Tidyman’s father fell, which hadn’t happened before, and went to a hospital for an evaluation.

In the waiting room, Tidyman opened the folder. “Very soon I saw that there were pages and pages of notes that referred to a different person with the same name — a person whose medical conditions were much more complicated and numerous than my father’s,” she said.

Tidyman pulled out sheets with mistaken information and made a mental note to always check records in the future. “That was a wake-up call,” she said…

In the worst-case scenario, an incorrect diagnosis, scan or lab result may have been inserted into a record, raising the possibility of inappropriate medical evaluation or treatment. This, too, is something that Tidyman’s father encountered soon after moving from Massachusetts to Washington. (Her parents have since passed away.)

When both his new primary care physician and cardiologist asked about kidney cancer — a condition he didn’t have — Tidyman reviewed materials from her father’s emergency room visit. There, she saw that “renal cell carcinoma” (kidney cancer) was listed instead of “basal cell carcinoma” (skin cancer) — an illness her father had mentioned while describing his medical history.

“It was a transcription error; something we clearly had to fix,” Tidyman said.”  (L)

“Health systems use numerous methods to exchange patient medical records, but providers continue to rely heavily on the old-fashioned approach of mail or fax, according to new federal data on interoperability.

Nearly three-quarters of non-federal acute care hospitals routinely use fax or mail to receive summary of care records from providers outside their system, according to new data released by the Office of the National Coordinator for Health IT. Two-thirds of health systems use fax or mail to send records…

But hospitals also employ a wide variety of methods to exchange records. Nearly 80% of hospitals used more than one electronic method to send records in 2017. However, a quarter of hospitals are not receiving records electronically at all…

The number of methods used is a detriment to health systems, ONC concluded, adding that its Trusted Exchange Framework could help streamline those options.

“The number of exchange methods hospitals need to ensure that they have information electronically available and subsequently used, contributes to the complexity and costs of exchange,” the agency wrote. “These complexities and increased costs are often cited as barriers to interoperability. Efforts, such as the Trusted Exchange Framework, might help to simplify the exchange of health information through the use of health information networks.”” (M)

Hospital Report Cards

“Consumers are getting “mixed messages” from the CMS Hospital Compare website and penalties levied by the Hospital Readmissions Reduction Program, undermining their ability to shop for quality care, according to a study in The American Journal of Managed Care.

The researchers compared hospital grades posted on Hospital Compare for heart failure and acute myocardial infarction readmissions with the HF and AMI scores for excess readmissions used to set penalties under HRRP. They also looked at how often hospitals were penalized for just one or two of the five HRRP conditions, since the penalty program affects a hospital’s sum Medicare payments.

Of 2,956 hospitals, 92% were deemed “no different” than the national HF readmissions rate on Hospital Compare, yet nearly half (49%) scored high for HF readmissions under HRRP and 87% received an overall readmissions penalty.” (N)

Emergency Medicine Physicians/ Sleep Deprivation

 “Sleep deprivation and fatigue have plagued emergency room physicians for decades but apparent widespread use of sleeping aid medications entails risks.

A recent study found more than half of ER physicians reported actively using a sleeping aid medication. Sleeping aid medications pose risks to physician wellbeing such as rebound insomnia. Negative cognitive effects of sleeping aid medications can last hours after awakening. Use of sleeping aid medication among emergency department physicians is likely far more common than previously reported, recent research shows. Fatigue has been linked to cognitive impairment among ER physicians but sleeping aid medication is a problematic solution. Sleeping aid medication fails to induce normal sleep stages and their progression to natural sleep, and health concerns have implications for physician wellbeing such as rebound insomnia after discontinuance of medications…. The most commonly used medication was a nonbenzodiazepine hypnotic such as Ambien…

ER physicians need the same kind of duty-hour restrictions that were established for medicine residents by the accrediting agency for graduate education,.. (O)

Stethoscopes Carry Bacteria

“DNA from an abundance of bacteria linked to healthcare-associated infections, including Staphylococcus, was found on stethoscopes carried by healthcare professionals in the ICU, and cleaning only led to a modest reduction, researchers found.

On a set of 40 stethoscopes in use in an ICU, all 40 had a high abundance of Staphylococcus DNA, with “definitive” S. aureus DNA present on 24 of 40 stethoscopes tested, reported Ronald G. Collman, MD, of the University of Pennsylvania (UPenn) Perelman School of Medicine in Philadelphia, and colleagues.

Moreover, while cleaning the stethoscopes reduced the amount of bacterial DNA, it did not completely bring all stethoscopes in use in the ICU to the level of “clean,” the authors wrote in Infection Control & Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America…

The CDC, in its guidelines for disinfection, state that “medical equipment surfaces” such as stethoscopes should be disinfected with an EPA-registered low- or intermediate-level disinfectant, with these guidelines adding that “use of a disinfectant will provide antimicrobial activity that is likely to be achieved with minimal additional cost or work.”  (P)


“In 2009, Steve Burrows’ mom, Judie, went in for hip replacement surgery. She came out with brain damage and mobility issues after a weeks-long coma that would change her and her family’s life…

What happened to Judie is complicated, but it essentially began with massive blood loss.

“In the end, that’s really how this whole thing started,” Burrows says in an interview with NPR’s Lulu Garcia-Navarro. “She lost over half the blood in her body.”

After her surgery, she was put into recovery and left alone with what’s called an electronic intensive care unit, or eICU.

With a series of monitoring tools that usually include microphones, video cameras and alarms, eICUs are meant to provide the 24-hour monitoring that many patients require after a major medical emergency.

“This [eICU] didn’t notice my mom was in a coma for at least a day and a half and I wanted to talk to the ICU doctor who was there that night,” Burrows says. “We were told there was no doctor there. I said ‘Well that’s insane, what do you mean?’ ”

He says there were doctors monitoring the cameras out by the airport in Milwaukee and they were supposed to be the safety net for his mother.

Burrows says that when he asked whether the camera was on, the head of the ICU told him it wasn’t because of patient privacy issues…. (Q)

Assuming blame for a medical error may help patients and families heal.

Dr Tigard admits that not all medical errors are preventable. He uses the example of a nurse in an oncology unit responsible for the care of 5 patients because of understaffing at the hospital. In this scenario, 2 patients suddenly need life-saving interventions at the same time. The nurse is able to save only one patient, while the other dies. Although she may be tempted to blame the system, Dr Tigard contends that the nurse should apologize to the family, as it offers the best chance of healing…

“That means medical errors are now the third-leading cause of death in the country — yes, the third-leading cause of death of all people. The number of lives that are lost each day to a medical error, a preventable error, is equivalent to a 747 going down daily,”

Arnold’s work is focused on reducing those errors, particularly in medical emergency situations involving children. The simulation center, which moved into a new, $95-million, 225,000-sq.-ft. Johns Hopkins All Children’s Research and Education Building this fall, features 15 simulation rooms, a dozen hightech mannequins and education space for medical personnel to test their skills in simulated emergencies and learn from the experiences.

 “The technology here, all the computers to run the mannequins, that’s just the tool,” Arnold says. “What it all provides is an opportunity for our providers to become really experts, to hone their skills, not only their clinical skills and their procedural skills, but most importantly their behavioral and communication skills.””  (R)

Let Hospital Patients Sleep!

 “If part of a hospital stay is to recover from a procedure or illness, why is it so hard to get any rest?

There is more noise and light than is conducive for sleep. And nurses and others visit frequently to give medications, take vitals, draw blood or perform tests and checkups — in many cases waking patients to do so…

Peter Ubel understands the problem as both a physician and patient. When he spent a night in the hospital recovering from surgery in 2013, he was interrupted multiple times by blood draws, vital sign checks, other lab tests, as well as by the beeping of machines. “Not an hour went by without some kind of disruption,” said Dr. Ubel, a physician with Duke University. “It’s a terrible way to start recovery.”

It’s more than annoying — such disruptions can harm patients. Short sleep durations are associated with reduced immune function, delirium, hypertension and mood disorders. Hospital conditions, including sleep disruptions, may contribute to “posthospital syndrome” — the period of vulnerability to a host of health problems after hospitalization that are not related to the reason for that hospitalization…

Solutions aren’t hard to fathom. Dr. Ubel listed some in 2013. Hospital workers could coordinate so that one disruption serves multiple needs: a blood draw and a vitals check at the same time instead of two hours apart. Or they could allow patients’ needs to guide schedules. If a patient is at low risk and can go six or eight hours without a vitals check, for example, perhaps don’t do that check once every four hours…”  (S)

Are physicians aware of how much they don’t know?

His epiphany on the subject came in 1984, when he was a resident at Washington University’s Barnes Hospital in St. Louis, Mo. “We had a difficult case, and it was clear doctors had little understanding of [a particular] test result” dealing with prothrombin time, said Laposata, who now chairs the pathology department at the University of Texas Medical Branch at Galveston. As a result, they ended up needlessly giving blood to an 8-year-old boy who was getting a tonsillectomy; the blood turned out to be contaminated with HIV — a disease that was still a mystery at the time. The boy developed HIV and later died.

Upon finishing his residency, Laposata went to work at the University of Pennsylvania, where he became director of the coagulation lab there. “I said, ‘We’re not going to just send [test] results; we’re going to put an interpretative paragraph underneath the numbers,'” he explained. “We did it for 3 months and then I got a surprise visit from the chief of hematology, [who] comes to me and says, ‘Stop doing that.’ I said, ‘Why?’ and he said, ‘Hematology fellows are not seeing cases because you’re giving the diagnosis too soon.'”

When Laposata suggested that a quicker diagnosis was a good thing, the hematology chief replied, “Not for me, because without fellows, we don’t have research projects.” “I said, ‘I thought the patient comes first,’ but he said ‘No,'” said Laposata. “That was a shocker.”

He then went to work at Massachusetts General Hospital, where he became director of a lab. “I thought, ‘I’m going to go for it,'” Laposata said. “We have to change the paradigm for making diagnoses. We should have only experts providing opinions about different areas.”

So he started a diagnosis management team (DMT) for coagulation disorders, in which physicians who treated patients worked with lab experts to figure out the right tests to administer and to properly interpret the test results…”  (T)


“There are plenty of places in the diagnostic process where things can go wrong. But radiology is a frequent source of medical error that is ripe for reform, according to a new report.

Coverys, a Boston-based medical liability insurer, reviewed more than 10,600 malpractice claims from between 2013 and 2017 and found that nearly 600 named a radiologist explicitly. These cases often related to significant patient harm and delayed diagnosis of serious conditions, according to the group’s report…

 “Radiology has done a lot over the last several years to try and see if they can become a safer discipline,” Hanscom said. “They need to continue to press on a number of fronts—they are still finding themselves very much connected to these poor outcomes.”

The report identifies several ways that radiology teams can address the risk of medical errors, including:

•             Using clinical decision support • Having a clear protocol for bringing in a second opinion on a reading •                Building templates for reports and using clear language in them •             Ensuring that incidental findings worthy of follow-up are highlighted so they aren’t missed

Peer review is a key strategy, Hanscom said, especially since the interpretation stage is the riskiest. Getting a second opinion can ensure that nothing on a test result is missed and can prevent communication gaps, such as getting crucial information to the physician that can best use it.”  (U)

National Licensure

“National licensure of nurses, physicians and other healthcare professionals is an idea whose time has come. But it’s coming pretty slowly through painstaking state-by-state approval of interstate compacts.

The underlying issue is basic: Whether you’re in Maine or Arizona, Florida or Oregon, all patients deserve the same high quality of healthcare. That means quality standards for professionals who deliver patient care should be consistent no matter where you live.

There’s no evidence that healthcare professionals in one state are better or worse than in other states. Yet, in most parts of the country, healthcare professionals who can commute to several states in an hour or two must have separate licenses to work in each state.

There’s an important reason for national licensure: flexibility. Clinical workforce shortages don’t follow any geographic rules. Some rural areas have severe physician or nurse shortages, but others don’t. Some cities have an adequate supply of highly skilled nurses, while others face a near crisis. Specialties like OB-GYNs, telemetry nurses, pediatric physical therapists or family nurse practitioners can be sufficient or sparse in different parts of the same region. Healthcare professionals need to be able to go where they are needed quickly and efficiently.

Another reason for national licensure is telemedicine. The immense value of telemedicine in improving patient care is widely acknowledged. Yet, invisible barriers to telemedicine arise at state lines. We need to knock down those barriers.

One argument against national licensure has come from state proponents who say they need to protect patients from problem clinicians who might move from state to state to escape their records of misconduct. But, a national system, where each healthcare professional has only one record, would, in fact, make it easier to catch offenders and protect the patient…”  (V)

Competency Of Aging Physicians

“A set of guiding principles from an American Medical Association council on assessing the competency of senior/late career physicians failed to gain adoption at the AMA’s interim meeting here.

In a floor vote of 281-222 on Tuesday, delegates sent the report back to the Council on Medical Education, which issued the guiding principles. Some hospitals and health systems already require competency testing by older physicians, but there are currently no standards for these tests.

There are currently more than 120,000 practicing physicians 65 and older in the U.S., according to the council. Chairperson Carol Berkowitz, MD, stressed that the report does not mandate age-based competency testing. Instead, it sets out guidelines for any organization or hospital that decides to put in place a testing process to ensure it is “fair, evidence-based, and equitable.”.. (W)

Monitoring EMRs For Patient Safety

Scientists at a patient safety organization developed a way of monitoring EHRs to detect safety risks to hospitalized patients in real time, a method they described in Health Affairs on Monday.

The paper, published in a journal issue dedicated to patient safety, was based on a three-year pilot of a safety management system developed by the organization, Pascal Metrics.

Pascal says it is the first organization to apply machine learning to a dataset of EHR-based adverse event outcomes. The system, which Pascal tested at two community hospitals, can detect patient harm from real-time data and fires triggers that result in patient safety monitoring.

“This appears to be a genuine pivot away from retrospective reviews of patient safety incidents to real-time analysis,” said Jeff Smith, vice president for public policy at the American Medical Informatics Association.

While the study demonstrates the potential for use of real-time data, there were many false positives triggered by the system, noted Dean Sittig, a professor of bioinformatics at the University of Texas Health Sciences Center in Houston.

Until EHR systems become capable of limiting these false alarms, “systems like these will be untenable for all but the highest-staffed facilities,” Sittig said.

Hardeep Singh, a health IT expert at the Baylor College of Medicine, said that while the prototype in the article was good, the portfolio of triggers it used would be limited in detecting the various types of harm seen in hospitals. In addition, few hospitals have the bandwidth to work with sophisticated algorithms to detect or prevent patient harm, he said.” (X)

Preventing Patient Harm – The Conversational Nurse Model

“Imagine an 82-year-old patient – we’ll call him Mr. A — with severe congestive heart failure, bouncing in and out of the hospital with increased frailty. During one hospital admission, Mr. A’s cardiologist consults the palliative care team for symptom management and clarification of goals of care. Mr. A tells the palliative care team that what matters most to him is to return home to be with his wife. He does not want to be placed on a ventilator, nor does he want aggressive measures taken. He agrees to go to a skilled nursing facility (SNF) for strengthening but says that if his heart failure worsens, he wants to return home.

The palliative care consult notes are filed in the medical record, along with a form stating that Mr. A does not want aggressive measures taken. However, this form and the consult notes are lost during transfer to the SNF. Mr. A tells the SNF team that his goal is to get stronger, which is interpreted as wanting all measures taken. Two weeks later, Mr. A develops shortness of breath and confusion and is transferred to the hospital. Records from the SNF indicated that he wants all measures taken. He is put on a ventilator in the emergency department and dies a week later in the intensive care unit…

To address this in our own health system, Care New England in Rhode Island developed the Conversation Nurse model: a program for training nurses in conversational skills to conduct discussions with patients about serious illness and their goals for their care. Our Conversation Nurses meet with patients across the entire health care continuum and talk with them about their understanding of their illnesses and their goals for care as their diseases worsen. We have used this model to increase the workforce trained in serious illness care and have demonstrated the following outcomes: 1) Increased volume of palliative care consults in inpatient settings, 2) Increased documentation of advance directives in the home care agency population, 3) Decreased readmissions and increased hospice consults in skilled nursing facilities, and 4) Broad training of Accountable Care Organization (ACO) interprofessional teams. The model, which started in the inpatient setting and expanded into the community, has proven useful both in increasing the workforce trained in having conversations about serious illness and in optimizing use of finite physician resources.” (Y)

Preventing Patient Harm – The PST Model

That effort takes form in the PST model—primary, secondary and tertiary responses to adverse events that encompass both a proactive and a reactive approach, leaders at the system said at a session at the Institute for Healthcare Improvement’s National Forum on Quality Improvement in Healthcare.

A safety mindset allowed the system to develop a series of interventions to prevent harms and to effectively address them should a safety lapse occur. Steps at the earliest level include adjusting hiring to bring in the best team members and offering training to enhance their skills in safety as needed.

Other proactive steps MedStar took include making safety central to the culture of its hospitals, tracking patient satisfaction to identify risks and offering standardized work processes.

To plan for “secondary” prevention, MedStar expanded its definition of harm from “serious safety event” to “serious unanticipated outcome.” Doing so allowed the system to monitor harms that may not be caused directly by providers, said Seth Krevat, M.D., assistant vice president for safety at MedStar.

That definition switch led the number of reports to increase significantly, providing a greater database for new initiatives, Krevat said. For example, in 2018 so far, 239 unanticipated outcomes have been reported, compared to 41 scenarios that would be considered “serious safety events.”

Further secondary steps taken by the hospital include diving deeper into claims data and patient surveys to flag issues and identify near misses. (Z)

Preventing Patient Harm – the Piedmont Healthcare model

“For one hospital in particular, a poor Leapfrog Hospital Safety Grade rating in 2014 became a launching pad for improved quality and safety.”When we got a ‘D’ from Leapfrog, that was our wake-up call. We had done good patient safety work before, but it wasn’t the fanatic level that we have now,” says Leigh Hamby, MD, MHA, executive vice president and chief medical officer at Piedmont Healthcare, an integrated healthcare system with 11 hospitals and almost 100 physician and specialist offices throughout Atlanta and North Georgia

Since launching systematic initiatives to improve quality and safety in 2014, the health system has posted gains.In November 2018, six of Piedmont’s 11 hospitals received “A” grades in The Leapfrog Group’s Fall 2018 Hospital Safety Grade ratings

 From July 2016 to June 2018, Piedmont reduced hospital-acquired infections 40%

One Piedmont hospital has not reported a hospital-acquired infection for more than a yearHamby says there are four ways Piedmont implemented better quality and safety at the healthcare organization and boosted its rankings.” (AA)

Postscript on Hospital Ratings

“Many organizations have started publishing hospital performance measures and report cards in recent years, growing out of the movement for improved quality and patient satisfaction, lower costs, and greater accountability and transparency. Among the organizations publishing these ratings and measures are government agencies, news organizations, healthcare accreditation and quality groups, and companies and not-for-profits focused on transparency. The emergence of these reviews has put pressure on hospital leaders to do what’s necessary to improve their scores.

But the various reports use significantly different methodologies and have different areas of focus, often producing sharply different ratings for the same hospitals during the same time period. Some hospital leaders say this makes it more difficult to know which areas to prioritize to improve their quality of care and rankings….

Reasonable people disagree on what measures are most important to include, which makes for significant differences in the various ratings, Jha said. One problem with that, though, is that hospitals can cherry-pick favorable ratings for marketing purposes, whether or not those ratings have much validity. “Anyone who wants to dodge accountability can hang their hat on some obscure rating that was good,” he said…

Some groups use a star rating system, some use a 1 to 100 percentage scale, and others use an academic-style A to F grading range. The groups also vary on how frequently they publish ratings, with some issuing reports annually and others offering more frequent updates.

The raters rely on data sets from the government, such as the Medicare Provider Analysis and Review and the Hospital Consumer Assessment of Healthcare Providers and Systems. Some create their own surveys and solicit voluntary responses from the hospitals. Others use diagnostic and procedure coding for specific diseases, conditions and services. But not all groups disclose how they weight the various quality measures in producing their final scores. “They have to create a distinct product,” Daugherty said.” (BB)

Did This Health Care Policy Do Harm?

“No patient leaves the hospital hoping to return soon. But a decade ago, one in five Medicare patients who were hospitalized for common conditions ended up back in the hospital within 30 days. Because roughly half of those cases were thought to be preventable, reducing hospital readmissions was seen by policymakers as a rare opportunity to improve the quality of care while reducing costs.

In 2010, the federal agency that oversees Medicare, the Centers for Medicare and Medicaid Services, established the Hospital Readmissions Reduction Program under the Affordable Care Act. Two years later, the program began imposing financial penalties on hospitals with high rates of readmission within 30 days of a hospitalization for pneumonia, heart attack or heart failure, a chronic condition in which the heart has difficulty pumping blood to the body.

At first, the reduction program seemed like the win-win that policymakers had hoped for. Readmission rates declined nationwide for target conditions. Medicare saved an estimated $10 billion because of the reduction in hospital admissions. Based on those results, many policymakers have called for expanding the program.

But a deeper look at the Hospital Readmissions Reduction Program reveals a few troubling trends. First, since the policy has been in place, patients returning to a hospital are more likely to be cared for in emergency rooms and observation units. This has raised concern that some hospitals may be avoiding readmissions, even for patients who would benefit most from inpatient care.

Second, safety-net hospitals with limited resources have been disproportionately punished by the program because they tend to care for more low-income patients who are at much higher risk of readmission. Financially penalizing these resource-poor hospitals may impede their ability to deliver good care.

Finally, and most concerning, there is growing evidence that while readmission rates are falling, death rates may be rising.” (CC)

Physician Burnout

“Studies have shown that medical errors are common in the United States healthcare system, representing a major source of inpatient deaths. Evidence indicates that physician burnout, characterized by exhaustion and cynicism, is associated with medical errors. Safety grades provide a summary reflection of the patient safety practices within a patient care setting (or “work unit”) intended to reduce these errors. However, the interactions among these patient safety practices, physician burnout, and medical errors have remained unknown.” (DD)

Physician Stress

“Surgeons under stress are far more likely to make mistakes on patients in the operating room, even if the stress is caused by a trivial source and lasts briefly, a Columbia University study finds.

The research shows that all it takes is a negative thought or a loud noise in the room to trigger moments of short-term stress for doctors, according to lead author Peter Dupont Grantcharov, a master’s student at the Data Science Institute at Columbia.

For the study, Grantcharov had Dr. Homero Rivas, Associate Professor of Surgery at Stanford Medical Center, wear a high-tech “smart shirt” under his scrubs during 25 surgical procedures, most of which were gastric bypasses… (EE)

NIH: antibiotic-resistant bacteria living in the plumbing

“Patients were infected with antibiotic-resistant bacteria living in the plumbing of the National Institutes of Health’s hospital in Bethesda, Md., contributing to at least three deaths in 2016.

A study published Wednesday in the New England Journal of Medicine found that, from 2006 to 2016, at least 12 patients at the NIH Clinical Center, which provides experimental therapies and hosts research trials, were infected with Sphingomonas koreensis, an uncommon bacteria. The paper, written by NIH researchers, suggests that the infections came from contaminated water pipes, where the bacteria may have been living since as early as 2004, soon after construction of a new clinical center building.” (FF)

“There could be a whole post dedicated to medical inaccuracies on Grey’s Anatomy or political impossibilities on Scandal, but we’re about to explore so much more than just technical knowledge (although, there will be some of that too). Even some of the most eagle-eyed fans missed these mistakes in Shondaland’s most beloved shows, from huge mistake in birthdates to tiny mistakes in continuity. Because we’ll be talking about many seasons of many shows, beware of spoilers, especially if you’re not caught up on Grey’s Anatomy and How To Get Away With Murder.

Here are the 20 Mistakes Fans Completely Missed In Shondaland Shows.” (GG)

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

“Big Silicon Valley companies have often competed for talent with specialized skills, like expertise in artificial intelligence or trendy new programming languages.

Now they’re competing for heart doctors.

Apple hired Dr. Alexis Beatty, a cardiologist, to its growing health team in July, according to a LinkedIn search. Amazon hired Dr. Maulik Majmudar, also a cardiologist, the following month. Alphabet’s life sciences company Verily named Dr. Jessica Mega as its chief medical officer almost three years ago. Mega, of course, is a cardiologist…

Apple’s smartwatch now includes an electrocardiogram, which can detect heart rhythm irregularities. Verily’s study watch, which is designed for clinical trial research, also tracks heart rate and heart rhythm, and it’s doing a lot of work in chronic disease management. Another Alphabet team, Google Fit, worked closely with the American Heart Association for its design revamp. Amazon’s plans in cardiology are less clear, but the company does have a secretive research and development team that is working on a variety of health projects under the leadership of an electrical engineer — former Google X employee Babak Parviz.

So the more likely explanation is that tech companies are interested in health care, and they have all come to the conclusion that cardiology should be an early (if not initial) target.

Here’s why….” (A)

“…. The question now is how far will Amazon, the master disrupter, take this?”

The answer: very far, it’s safe to assume. Anyone who continues to think of Amazon as just a very big digital retailer needs to think again. The company has repeatedly shown that it has the capabilities, the patience and the deep pockets to disrupt industry after industry. Healthcare is no exception. There are at least three reasons to believe Amazon is has a good shot. First, as one of the largest private employers in the United States, Amazon would reap huge financial benefits from lowering the high cost of healthcare in this country. Second, the numerous inefficiencies of the healthcare system present enticing avenues for Amazon to explore, and as CEO Jeff Bezos has famously stated, “Your margin is my opportunity.” Finally, healthcare is just the kind of big, complex problem that Bezos likes to sink his teeth into. An unabashed “Star Trek” fan with a utopian view of the future, Bezos has always aspired “to boldly go where no one has gone before.” Bezos strongly believes that Amazon has a role to play in making things better.

As Amazon turns its focus to healthcare, we believe there are four potential points of entry, with increasing levels of complexity from simple product distribution. Durable medical equipment and medical supplies. Mail-order and retail pharmacy. Pharmacy benefit manager. AI powered telemedicine, diagnostics or in-home healthcare.  (B)

“To get to their next trillion dollars, Apple and Amazon are realizing that they can’t ignore opportunities in the health sector. But to get that right, they need to focus on the things they’re good at.

Amazon is focusing on its area of expertise: the supply chain. The company bought PillPack, an internet pharmacy, and it has a grocery delivery business through Whole Foods. It is also working with two other employers, J.P. Morgan and Berkshire Hathaway, on an initiative to reduce health care costs…

But these are just the things that we know about. Undoubtedly, Apple and Amazon, which both have a strong focus on research and development, are thinking about new health-focused hardware and software products for the next decade. And where better to try them out than by talking to their doctors and garnering feedback from real patients (incidentally, their own workers)? It makes a lot of sense, health experts say, especially for tech companies that are notoriously obsessed with secrecy.

“If Amazon and Apple had considered these clinics for internal use only, they would have likely outsourced to any of the number of clinics that offer on-site clinic services,” said Nikhil Krishnan, a health-focused analyst with CB Insights, a market research firm. “The fact that Apple and Amazon are testing it in-house means they want to test the model with employees, iterate, and eventually release this product to their respective customers.”

Weinberg from the Bay Area Council Economic Institute has seen tech companies try and fail to get into health care, if they assume there’s a simple tech solution.

Health care is “devilishly complicated,” he says. In his experience, those that do succeed will be richly rewarded, while having an opportunity to make a difference. And one of the best ways to get there, says Weinberg, is to get into the business of both patient care and population health management, which includes tools to keep a population of patients as healthy as possible.” (C)

“The healthcare initiative formed by Inc. (AMZN – Get Report) , Berkshire Hathaway Inc. (BRK.A – Get Report) and JPMorgan Chase & Co. (JPM – Get Report) made a “bold statement” with its appointment of Comcast Corp. (CMCSA – Get Report) alum Jack Stoddard as chief operating officer, according to Leerink Partners LLC analyst Ana Gupte.

The venture is “reaffirming its commitment to upending the way consumers access healthcare in an increasing digital ecosystem,” Gupte wrote in a Wednesday, Sept. 5, note. “We believe the Stoddard hire clearly shows that [the venture] is looking to own the digital front door to healthcare.”

Stoddard, who was most recently general manager of digital health at Comcast, started his new role this month, according to his LinkedIn profile. CNBC first reported on Stoddard’s appointment on Tuesday.

The news follows the hiring of Atul Gawande, a surgeon, public health researcher and a staff writer for The New Yorker, as CEO of the healthcare initiative effective July 9. Amazon, Berkshire and JPMorgan unveiled their partnership in January, saying they’ve banded together to address healthcare for their U.S. workers…

Comcast could offer a blueprint for what Stoddard might aim to do at the Amazon-Berkshire-JPMorgan venture, Gupte wrote.

“As noted in a recent New York Times article, Comcast has been at the forefront of health insurance innovation,” she wrote. “Instead of pushing the financial burden to employees via high-deductible health plans (as nearly 50% of large employers have), Comcast has focused on lowering costs by partnering with innovative tech-enabled companies to improve employee engagement (Accolade), care management (Grand Rounds which provides second opinions) and telehealth (Dr. On Demand).””  (D)

“Amazon’s increased presence in healthcare has caught the attention of many hospital and health system leaders who are vested in a healthcare model that is at risk of being disrupted. So far the company has considered a number of patient-centered initiatives, but what would it look like if Amazon CEO Jeff Bezos took the helm of a major integrated delivery system?..

Healthcare leaders stand to learn a lot by examining Mr. Bezos’ approach toward processes. A good process serves the provider so they can serve the customer, but one of the most dangerous epidemics gripping our industry is that we have stopped focusing on the outcomes of our processes. Mr. Bezos refers to this fallacy as “managing by proxy.” If patients complain about an undesirable outcome, the first thing many clinical leaders do is defend the process that drove the outcome, so long as they followed protocol. Instead of swearing by adherence to protocol, we should examine the process itself to see if it can be improved. Do we own the process or does it own us? If Mr. Bezos ran my health system, he would be constantly reevaluating our processes not by cost optimization or operational efficiency, but by the true value that they bring directly to our patients and members…

Anyone familiar with the number of individuals and organizations that orchestrate the payment and delivery of care knows that misalignment is a troubling reality within our industry. Healthcare is extremely siloed, but Mr. Bezos has made his fortune by streamlining efficiency among numerous players to deliver the best product as quickly as possible. I believe Mr. Bezos would take innovative steps to challenge healthcare’s misalignment and integrate the model to create efficiency and savings for our patients and members.  His long-term view of success would drive Sentara’s development into a system fully aligned to maximize the value to our consumers.  Under his watch, Sentara would rapidly become the first, most convenient choice for our patients and members for all their healthcare needs.”  (E)

“Out of all the technology giants with ambitions in healthcare, hospital executives have overwhelmingly put their faith in Amazon, according to a new survey.

A full 59% of executives say Amazon will have the biggest impact, according to the survey by Reaction Data. Respondents cited resources available to the retail and technology behemoth…

 “Amazon has a huge market they can use to distribute materials. They are already a household name and the users are not specific to Apple or Android,” one CEO said.

About 80% of survey respondents were from the C-suite, including chief nursing officers, chief financial officers and chief information officers.

While Amazon alone may be generating significant excitement in boardrooms, a previous survey by HealthEdge shows consumers are largely skeptical about Amazon’s partnership with JPMorgan and Berkshire Hathaway.

Amazon’s push into healthcare “has been a shot across the bow for the entire industry,” Rita Numerof, Ph.D., president of Numerof & Associates told FierceHealthcare. The company’s consistent and deliberate investments indicate they are serious about making substantial changes within the industry.

“Amazon is known for its relentless focus on the consumer and its ability to use data systematically to identify and meet unmet needs in an accessible manner,” she said. “Unfortunately, access, consumer engagement, and segmentation haven’t been the hallmark of healthcare delivery.” (F)

“Amazon, JPMorgan and Berkshire Hathaway’s buzzy partnership over their employee healthcare announced in January caught plenty of other large employers’ attention.

Sure, it could just end up being just another purchasing coalition.

But if it actually takes advantage of the breadth of Amazon’s connection with consumers? That could stand to truly—pardon the overused term—”disrupt” healthcare for employers, said National Business Group on Health President and CEO Brian Marcotte.

“If they begin to leverage Amazon’s footprint within the home, their relationship with the consumer, their customer obsession … the customer loyalty they have, and begin to leverage their ability,” Marcotte said, it could change everything.

“One of the challenges in healthcare is employees don’t touch the system with enough frequency in order for it to be routine, in order for them to be sophisticated consumers,” added Marcotte. Amazon and other online shopping platforms are routine, he said.

“When I look at this coming together, the opportunity is how do you leverage their platform to reach people in a more natural way, in a more frequent way then we reach them today,” he said.”  (G)

“Former Cleveland Clinic CEO Toby Cosgrove said healthcare’s potential innovators need to have one key trait—persistence.

The industry is resistant to change, he said, so new ideas aren’t likely to be met with a warm reception. Instead, expect colleagues to push back.

“Don’t expect everyone to love [your ideas]—they’ll hate it,” he said. “Don’t get discouraged when your ideas aren’t immediately embraced.” ..

While the innovative examples provided by Cosgrove himself are on the clinical side, he said what keeps him up at night, and where there’s the greatest room for future growth, is cost and new tech.

“We are under tremendous pressure in the United States…about the cost of healthcare,” he said.

In innovation, cost and technology are likely to go hand-in-hand, he said. Cleveland Clinic, for example, has 2,000 employees involved in revenue cycle management, he said. Artificial intelligence could streamline that process significantly, cutting costs and improving efficiency.

Another area ripe for future innovation is leadership development. Healthcare needs administrators and often has to train people internally for top roles. Cosgrove said he didn’t really have a grasp on what a CEO does at the time he took over the Cleveland Clinic.

But strong leadership, once it’s built, can serve as a catalyst for further innovation in the ranks and sets the tone that trying new things is valued, he said.

“It’s amazing how leadership…just cascades down through the rest of the organization,” Cosgrove said. (H)

Jeff Bezos gave a master class on life and business onstage in Washington last night, with this keeper advice: “All of my best decisions in business and in life have been made with heart, intuition, guts, … not analysis.”

“If you can make a decision with analysis, you should do so. But it turns out in life that your most important decisions are always made with instinct and intuition.”

“Everything I have ever done has started small,” Bezos added, drawing laughter at the 32nd anniversary dinner of the Economic Club of Washington, D.C.:

“Amazon [now with 500,000 employees] … started with five people.”

“It’s hard to remember for you guys, but for me it’s like yesterday I was driving the packages to the post office myself, and hoping one day we could afford a forklift.”..

Turning to business best practices, Bezos said he sets his first meeting at 10 a.m.:

“I go to bed early and I get up early. I like to putter in the morning. So I like to read the newspaper. I like to have coffee. I like have breakfast with my kids before they go to school.”

“I do my high-IQ meetings before lunch. Like anything that’s going to be really mentally challenging, that’s a 10 o’clock meeting. And by 5 p.m., I’m like, ‘I can’t think about that today. Let’s try this again tomorrow at 10 a.m.'”

Bezos said he gets eight hours of sleep:

“I prioritize it. … I think better. I have more energy. My mood is better.”

“As a senior executive, you get paid to make a small number of high-quality decisions. Your job is not to make thousands of decisions every day.”

“Is that really worth it if the quality of those decisions might be lower because you’re tired or grouchy?”

“All of our senior executives operate the same way I do. They work in the future, they live in the future.”

“Right now, I’m working on a quarter that’s going to reveal itself in 2021 sometime.”

“If I make, like, three good decisions a day, that’s enough.”

“Warren Buffett says he’s good if he makes three good decisions a year.” [Laughter]. (I)

“Online retail giant Amazon is set to sell medical devices straight to consumers in a partnership with Arcadia Group, a consultancy with a history of partnering with big brand retailers such as Walmart Pharmacy to sell exclusive medical devices.” (J)

“CVS Health CEO Larry Merlo doesn’t want to leave any room for Amazon to disrupt the pharmacy benefits industry, according to CNBC.

Mr. Merlo, whose company won Justice Department approval to move forward with its $69 billion acquisition of Aetna Oct. 10, said he is more concerned with meeting customer needs than fearful off disruptors.

“So that’s what we focus on as an organization, with the goal being: Don’t leave any white space for Amazon to disrupt,” Mr. Merlo said.” (K)

“But Amazon has yet to provide any indication it’s entering the business of providing face-to-face healthcare to patients, which is increasingly the strategy being pursued by traditional drugstore chains.

Walgreens, which operates 9,800 drugstores in all 50 U.S. states, is testing myriad healthcare partnerships and this summer launched a digital marketplace that links its customers to medical care providers and their prices beyond services inside the drugstores. And CVS Health is touting its relationships with medical care providers and the potential to add more healthcare services once its acquisition of the health insurance giant Aetna is completed in coming weeks.

The strategies unfolding at CVS, Walgreens and Walmart are designed to stress the patient connection beyond the ability to order something online and have it delivered overnight or within hours. Though they don’t mention Amazon when they discuss their strategies, it’s clear they want to fill their emptying retail space with healthcare services and don’t see Amazon as a threat.” (L)

“Netflix co-founder and California resident Marc Randolph says Dallas is his favorite place in the world.

Randolph’s emotional connection to the city stems from a meeting he had with Blockbuster executives in its downtown Renaissance Tower when they were Goliaths of the video industry, and Netflix a lowly David.

With Netflix struggling to stay financially viable, Randolph and co-founder Reed Hastings tried to set up a meeting with Blockbuster executives to see whether there was any interest in buying their company.

But Netflix, at a little more than 2 years old, had less than 100 employees while Blockbuster had 60,000, so getting a meeting at all had been like pulling teeth, Randolph recalls.

“We sent emails, we tried calling, and not a peep — nothing,” he said.

Finally, Randolph and Hastings were invited to Blockbuster headquarters at Renaissance Tower. Underdressed because of the short notice, and seemingly without much leverage, the men offered to sell Netflix for $50 million.

“The meeting went downhill very quickly after that,” Randolph said.

The men returned to California without a deal — and as determined as ever to best Blockbuster.

A “miraculous” combination of no late fees, personalized rental queues automatically ordering the next DVD for customers, and a new subscription revenue model ultimately turned the company around, Randolph said, and Netflix never looked back, even as its success began to depend more and more on video streaming. It now has 130 million paying customers.

Meanwhile, Blockbuster has one remaining store in the United States, in Bend, Oregon.” (M)

“Here are seven ways Google is tackling healthcare today: HIPAA compliance; Online search; Clinical documentation; AI; Genomics research; Application Programming Interfaces; Consumer health.” (N)

“Google, Amazon, insurers and credit card companies have long been able to tell whether you vote, own a dog, spent time in prison or drive a rusty 1997 Chevrolet. Now, that type of information is starting to pop up in front of doctors when you walk into their examination rooms.

A small but fast-growing number of technology companies, including data brokers LexisNexis and Acxiom, sell health care providers detailed analyses of their patients, incorporating criminal records, online purchasing histories, retail loyalty programs and voter registration data…

The medical profession increasingly recognizes that it needs to be aware of how socioeconomic context — the buzz phrase is “social determinants of health” — is vital to a patient’s whole health. The flip side of benevolent concern, however, could be pigeonholing or invasions of privacy.

There are few safeguards on how such outside information can be used within the health system. The algorithms that companies use to classify some patients as “high risk” are rarely made public, so patients may not know their purchasing history or lifestyle could catapult them into a higher-risk strata. For every health plan that uses algorithms to predict substance abuse and help patients get treatment, there could be one that turns patients away when it learns they have.” (O)

“Geisinger President and CEO David Feinberg will reportedly lead health strategy at Google. The move comes after he turned down a high-profile job earlier this year leading the Amazon-Berkshire Hathaway-J.P. Morgan healthcare venture.

Feinberg will be tasked with pulling together and coordinating health initiatives across Google’s properties such as Google Brain, Nest home automation and Google Fit, according to CNBC. He’ll report to Google’s artificial intelligence head Jeff Dean but will work closely with CEO Sundar Pichai…

Feinberg will have a lot to work with. Google, through parent company Alphabet and life sciences arm Verily, has been relatively secretive about explicit healthcare ambitions, but there’s clear interest in the space. The tech giant has invested in methods to help stop the spread of infectious diseases, voice technology to help doctors as well as patients and numerous AI projects. Google-owned connected home device company Nest has also shown health sector ambitions.” (P)

“Sean Parker, the tech billionaire and cancer research philanthropist, may be a product of a Silicon Valley tech giant — but he’s skeptical about the impact those companies will have as they increasingly make a play in medicine.

“I just don’t think the innovations that are going to drive this revolution in health care and discovery are going to come out of Amazon or Google,”…

While coders face their own formidable challenges, Parker said, “tech people coming from tech to biology so dramatically underestimate the complexity of the human body. It’s not designed by us. It doesn’t work in ways that make sense.”” (Q)

“HERE COMES AMAZON: The tech giants keep on trampling into medicine. Seattle tech giant Amazon announced Wednesday it’s got a new machine learning service — called Amazon Comprehend Medical — intended to help the health care sector understand free text contained in medical records.

Amazon says the information will be useful for clinical decision support, revenue cycle management, clinical trials, and population health, and will potentially save lots of clerical work stemming from the need to tag or structure prose.

“We’re able to completely, automatically look inside medical language and identify patient details,” including diagnoses, treatments, dosage and strengths, “with incredibly high accuracy,” Amazon exec Matt Wood told the Wall Street Journal.” (R)

“Amazon Web Services, the company’s cloud business, announced last week that three of its most popular services — Amazon Translate, Amazon Comprehend and Amazon Transcribe — are now HIPAA-eligible. That brings to six the number of HIPAA-eligible AWS machine learning services in its catalog of offerings. The other three are Amazon Polly, Amazon SageMaker and Amazon Rekognition.” (S)

“Technology is rapidly changing the healthcare industry: surgeries are microscopic, patients have virtual appointments, doctors offer 3D visualizations on medical scans and more. But while these advancements in patient care are happening on the front lines, there seems to be a gridlock in the healthcare supply chain industry behind the scenes. Hours are wasted each day on ordering supplies and inventory is not always in stock, which leads to delayed procedures, higher costs, and ultimately, a negative impact on patients…

Imagine the scenario: on one side of the hospital, doctors perform surgeries with robots, while on the other side — either the loading dock or a supply room — procurement teams manually check spreadsheets to ensure their inventory is in stock. As budgets get smaller and executives face more pressure to bring costs down, the need to reduce both the time and money spent on outdated inventory management processes is more pressing than ever.

And while change can be complicated, there is no denying that there are a number of ways healthcare leaders — whether at a hospital or doctor’s office — can spend less time on procurement and more time on care.” (T)

“Amazon’s potential foray into healthcare has already caused players in the space to scramble and reevaluate their core competencies.” (U))

“…Dr. David Feinberg, the Geisinger CEO turned Google healthcare leader..

Because Geisinger also insures the patients it serves, there’s a built-in financial incentive to keep people healthy and out of the hospital. Dr. Feinberg took that notion one step further in his opening remarks: “I run a health system and we have about 13 or so hospitals, and I think my job is to close every one of them.”

The alternative? As he told it, bring healthcare to the people instead of bringing people to care providers.

“I think a lot of patients could be managed better at home,” he said. “We look at our highest utilizers, our sickest patients (and) we show up at their house in two cars, because we can’t all fit in one car. We got a nurse, a palliative care nurse, a community health worker, a pharmacist, a doc. We say, hi sir or ma’am, we’re here to take care of you, and our goal is that you never go in the hospital again and we know you’ve been hospitalized 12 times in the last year. Let’s clean out the medicine cabinet. Let’s make sure the house is safe. Oh, you have a bunch of appointments that are hard for you to get to? We’ll do them through telemedicine right now at the kitchen table. We just completely eliminate the need for those folks to ever go in the hospital again.”” (V)

“Amazon made headlines this year — especially as it leaped further into the healthcare arena. While there has been speculation about Amazon’s entry into the industry for years, announcements by the e-commerce giant in 2018 make it clear that it’s planning to make a big splash in healthcare. 

Here’s a breakdown of Amazon’s healthcare ventures, acquisitions, hiring trends and product developments reported by Becker’s Hospital Review.” (W)


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