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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“If you don’t have a seat at the table, you’re probably on the menu.”

“Most everyone is undoubtedly familiar with the term “having a seat at the table.”

Often reserved for those who are considered to have both the influence and power to make decisions and effect change, the table has become a symbol of power, negotiation and credibility through which one can forward their career, generate a sale or plot a course for enterprise success.

In other words, when one is provided with a seat at the table, it represents an opportunity to be heard and to make a difference.” (A)

When I was appointed President and CEO of Jersey City Medical Center (JCMC) in 1989, we had a Certificate of Need (CN) for a total replacement hospital on a new site but the project had stalled. I was advised to quickly develop political support for the project. The goal: to become a “player” in Trenton to have “a seat at the table”.

The strategy was to join every local board, committee and task force as a pathway for doing the same in Trenton.

So I helped form the new Hudson County Perinatal Consortium and became Chairman, and served on the Boards of the Hudson County Chamber of Commerce, the Hudson County AIDS consortium and the United Way of Hudson County. I then organized and became the first Chairman of the new Local Health Planning Board which gave me an ex-officio seat on the State Health Planning Board (Trenton!).

Early on at the SHPB a Trenton hospital applied for a CN to start open heart surgery, a proposal strongly opposed by Department of Health Staff. Since we aspired to have OHS at JCMC, this was an opportunity to set the stage for our application down the road, so under-the-radar I rounded up the votes to get the Trenton hospital CN approved. (years later we too got OHS!)

In the ways of Trenton this led to my becoming a member of Governor-elect Whitman’s health care transition team. I then served on the Governor’s Advisory Commission on Hospitals, the Task Force on Affordability and Accessibility of Health Care in New Jersey, the Governor’s Advisory Council on AIDS, and the Department of Human Services HMO-Hospital Workgroup.

When I started at JCMC, The University of Medicine and Dentistry of New Jersey (UMDNJ) had a medical education monopoly in New Jersey with three public medical schools under its umbrella. They were the only medical schools in New Jersey.

In our quest for a medical school affiliation our first stop was UMDNJ’s medical school in northern NJ, in Newark. The Dean was in favor but the relationship was vetoed by the President who was focused on developing a community hospital network which was to include all our Hudson County competitors (it never happened).

Our next stop was UMDNJ’s medical school in central NJ, in New Brunswick. The Dean was in favor, but the relationship was vetoed by the President who, we found out, had established each medical school’s “territory” and we were not in the central NJ region.

So we wound up becoming a major teaching hospital affiliate of Mount Sinai in New York City, having to overcome the UMDNJ President’s political (Trenton) efforts to stop this out-of-state relationship as a threat to his monopoly.

While working on Jersey City planning and zoning approvals for our new hospital, we ran into obstacles in one key department. Meeting after meeting the issues were not resolved. So I asked Lynn Schundler, a leader on our board, who was also the Mayor’s wife, if she would come to the next meeting for a cup of coffee. When asked what she should do at the meeting I said “enjoy the cup of coffee.” The meeting took five minutes and everything was approved.

The Board of the New Jersey Hospital Association was comprised of member hospital CEOs, and controlled by suburban hospital CEOs who wanted the state’s Charity Care funding changed from supporting safety-net hospitals like JCMC to every hospital getting its share based on charity care spending. JCMC was 75% Medicaid and Charity Care while their hospitals were 10% or less.  

Becoming Chairman of the NJHA Board was a four year project starting with Secretary, then Treasurer, then Chairman-elect, then Chairman. No safety-net hospital CEO had every made it to Chairman (and no woman CEO either). For years I did everything necessary but was never nominated to be Secretary. So some of us resigned our hospitals from NJHA and started a “renegade” safety-net hospital group. That got their attention and I negotiated our way back into NJHA with the understanding I would get the initial officer nomination. I was the first two year Secretary before becoming Treasurer, and there was a failed effort to throw me under the bus when it was my turn to be Chairman. My year as Chairman was torture but was worth the effort since it enhanced my visibility and “seat at the table” in Trenton for the rest of my career.

Since JCMC was (and still is) a safety-net hospital, we needed FHA financing (bond guarantee) to get started. Then Congressman (now Senator) Menendez was the project’s “champion.” But a glitch developed when we didn’t get FHA approval in the final days of the Clinton administration. Congressman Menendez got the approval early days in the Bush 43 administration, putting the NHP before having discussions on Cuba policy. The Menendez connection was via a senior Board member who served three governors in various capacities, and sat at many tables!

When Jim McGreevey was elected Governor (Jersey City guy, born at JCMC), I was appointed to his health care transition team at the requests of the Assembly Speaker and Senate Majority Leader, both members of our new parent board, LibertyHealth. By then we also had a member of the Assembly on each of our three hospital Boards (JCMC, Greenville Hospital, Meadowlands Hospital).  When we finally had the groundbreaking we honored Governor McGreevey, making him the honorary first newborn at the new hospital.

The New Hospital project finally got started but near the finish line we ran out of money – $5,000,000 short. Governor McGreevey provided the funding to establish the Port Authority of New York and New Jersey Trauma Center (JCMC is right near the Holland Tunnel and a stone’s throw from the Lincoln Tunnel). The key connection was again the same senior Board member.

Developing relationships with legislators is an ongoing CEO responsibility. One told me he was annoyed when a hospital CEO walked in for the first with a problem, having never previously dropped by to say hello. Fortunately I had done that! And when I once came in with three problems he said “Jon, in back of you are ten other constituents with Trenton problems. So which one of yours is most important, and if and when we resolve that, come by with the next request.”

I once asked the Senate Majority leader why his name was on a bill inimical to us. He said “Jon, sometimes I have discretion and other times I have orders from the Senate President. It’s knowing which is which that enables me to help you when appropriate”

For any request always leave a “one-pager” summarizing the topic

(One of the biggest skills a hospital CEO has is helping legislators with the health care, particularly when they or a family member need quaternary care not available nearby. But they need to consider you a friend before they will ask. My relationship with Mount Sinai in NYC paid dividends.)

I once drove an hour and a half to an 8AM Healthcare Facilities Financing Board meeting (table) in Trenton to show “respect” since it was considering an item for our new hospital project. It was the first item and took 3 minutes; we were not introduced or asked to speak. Many CEOs delegate this kind of stuff to subordinates. I never did, ever.

And it’s really important to be at legislative committee hearings and mark-up sessions (another table) when a bill that affect your hospital is on the agenda. Once it was one in the morning when some bill language was unresolved so they asked me and my CFO what to do. We were the only two people in the gallery.

“If they don’t give you a seat at the table, bring a folding chair.”  Shirley Chisholm

An area Assemblyman became Assembly Speaker in 2001. Soon after I was leading a group of hospital governmental affairs VPs from across the state and when we got to the Speaker’s office his assistant announced that the Speaker wanted to see me alone. Turned out it was about a small Hudson County matter that took one minute to discuss but we then chatted for fifteen more, and if I recall correctly mostly about baseball. I said nothing when I came out with a look of gravitas but my reputation as an “insider” was burnished.

My political credibility was further enhanced when a picture of me with President Clinton appeared on the front page of the front page of the New York Times (August 2, 1994), at a reelection rally in Liberty State Park.  Another stroke of luck where I just happened to be sitting in the first row and President Clinton sat down next to me! (Actually I was sitting in the last row of the stage when then Senator Torricelli came in with Bianca Jagger, who sat down next to me while the Senator worked the VIPs. He kept waving Bianca down a few rows at a time, and I followed. We were sitting in the front row when President Clinton came in and sat down next to me, to the dismay of area hospital CEOs who were standing in the crowd.)

In 2004, with all this political assistance we opened the new Hospital and in December of 2004 the open heart surgery/ interventional cardiology program was started only a few months before the CN expired which would have precluded another opportunity for many years, if ever.

 “If you’ve been playing poker for half an hour and you still don’t know who the patsy is, you’re the patsy.” ― Warren Buffett

When Senator Jon Corzine decide to run for Governor in 2005 after Governor McGreevey resigned, I looked for ways to become part of his “team”. First I showed up at an economic summit he held and offered one comment (long forgotten) which he used in his press briefing (long remembered). At that meeting I met his key campaign staff and started an ongoing discussion on health care policy. Soon after I was asked if they could film a health care related campaign ad at our new hospital on a Sunday afternoon. Coincidentally I happened to be there “making rounds” when Senator Corzine arrived for the shoot.

When Corzine ran into some bad news stories about his personal life, I was one of six people asked to participate in a Trenton press conference on his six position papers. One newspaper article called us “surrogates” for Corzine, another said “Attacks Dogs” for Corzine. After the polls closed I waited for Corzine’s last campaign event at the Elks Club in Hoboken for 4 hours to be there when Corzine arrived.

Sticking my neck out led to my appointment as one of four co-chairmen of Governor-elect Corzine’s health care transition team. I was often asked if I was close to Governor Corzine, since he lived in Hoboken where I live. I always said “Yup, see him all the time in Starbucks.” Rumors started that I was on the short list to be Commissioner of Health. The sitting Commissioner who wanted to stay on called me to ask about it.

On March 19th, 2004 the Newark Star Ledger had an article “Now in aisle 6: the governor, living city life -Corzine strolls streets of Hoboken.” “At Starbucks, Jonathan Metsch, wearing a baseball cap and a Hoboken sweatshirt, struck up a conversation about the Nets game the night before. Then he segued into state funding for hospitals; in addition to being Corzine’s neighbor, Metsch is CEO of LibertyHealth, which operates Jersey City Medical Center. Shamelessly lobbying, like everybody else,” Corzine joked.”

When Jon Corzine became Governor he instructed all NJ legislators on various hospital boards across the State to resign. They did.

While serving as President and CEO of LibertyHealth/ Jersey City Medical Center from 1989-2006, Jersey City Medical Center: was State designated as a Regional Perinatal Center, Level II Trauma Center, Teaching Hospital Cancer Program, a Children’s Hospital, and a Medical Coordination Center (for statewide disaster preparedness); started cardiac surgery/ interventional cardiology; and became a major teaching affiliate of Mount Sinai School of Medicine. Many tables involved!

When I left Jersey City Medical Center all my chairs immediately disappeared.

“Don’t just get involved.  Fight for your seat at the table.  Better yet, fight for a seat at the head of the table.”  President Obama, 2012, Barnard College

Revised: December 24, 2018 000000

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PUBLIC HEALTH administrators can transform monumental unique challenges to “rapid response” opportunities. Think: Hurricanes Florence and Michael, the California wildfires, the mysterious polio-like illness, the opioid epidemic, mass shootings, and immigrant family separation.

You are the head of the Department of Public Health Sciences, The University of Texas at El Paso and have been “volunteered” to develop a Rapid Response “shadow” licensing program for the Tornillo, Texas detention camp housing 2300 teens.

Statement from the American Public Health Association and Trust for America’s Health
“As public health professionals we know that children living without their parents face immediate and long-term health consequences. Risks include the acute mental trauma of separation, the loss of critical health information that only parents would know about their children’s health status, and in the case of breastfeeding children, the significant loss of maternal child bonding essential for normal development. Parents’ health would also be affected by this unjust separation.
“More alarming is the interruption of these children’s chance at achieving a stable childhood. Decades of public health research have shown that family structure, stability and environment are key social determinants of a child’s and a community’s health.
“Furthermore, this practice places children at heightened risk of experiencing adverse childhood events and trauma, which research has definitively linked to poorer long-term health. Negative outcomes associated with adverse childhood events include some of society’s most intractable health issues: alcoholism, substance misuse, depression, suicide, poor physical health and obesity.” (A)

“Our field recognizes the importance of avoiding Adverse Childhood Experiences for the healthy growth and development of children. Trauma early in life contributes to a broad range of serious health outcomes, including social impairment, disease and disability, and early death. The harsh treatment of children at the border will affect their health and their lives for many years to come. The trauma to their parents is also devastating, and the lasting consequences to thousands of families will be profound.” (B)

“We also know that as each hour of separation goes by, children’s bodies continue to be flooded with stress hormones, thus creating long-term, disastrous injury and trauma for both the children and families who are separated.
Decades of research tells us that traumatic and forced parent-child separation immediately and permanently affects children’s brain development, educational attainment, mental health functioning, and long-term health outcomes – detailed in this Washington Post story. We also know that families seeking asylum are already traumatized from the circumstances that led to the migration and are exhausted by the journey to reach our borders…” (C)

“There is a significant body of evidence-based research detailing the vast public health implications of adverse childhood experiences. According to the Centers for Disease Control and Prevention, children exposed to adverse childhood experiences suffer from disrupted neurodevelopment; social, emotional, and cognitive impairment; are more likely to adopt health-risk behaviors; are at greater risk of developing chronic diseases, disabilities and social problems; and are susceptible to early death. Family stability is a key social determinant of health, and it’s imperative that we not disrupt these children’s chance at a healthy life.” (D)

“After the United States Department of Justice announced the “Zero Tolerance Policy for Criminal Illegal Entry,” Immigration and Custom Enforcement (ICE — an arm of the Department of Homeland Security) separated approximately 2,000 children from their parents in April and May 2018 as they approached the U.S. border. Children and parents were placed in separate facilities as they were being processed and were not told when or how they would be reunited. This policy and its consequences have raised significant concerns among researchers, child welfare advocates, policy makers, and the public, given the overwhelming scientific evidence that separation between children and parents, except in cases where there is evidence of maltreatment, is harmful to the development of children, families, and communities. Family separations occurring in the presence of other stressors, such as detention or natural disaster, only adds to their negative effects.” (E)

“The policy may have changed, but there’s still a concern over detention. Under the most recent policy change, the administration can still hold children in a confined space with their parents, and there’s a sense that they’re planning large-scale detention. We’ve ended for the moment, family separation, but now we have large-scale detention” (F)

“Reports from the National Academies of Sciences, Engineering, and Medicine contain an extensive body of evidence on the factors that affect the welfare of children – evidence that points to the danger of current immigration enforcement actions that separate children from their parents. Research indicates that these family separations jeopardize the short- and long-term health and well-being of the children involved.” (G)

“Detention, for even brief periods, has short- and long-term negative effects on the health of parents and children. Studies show high levels of psychiatric distress, including depression and post-traumatic stress, among detained asylum seekers, even after short detention periods, and that symptoms worsen over time. Global studies also show significant effects for children held in detention, including depression, post-traumatic stress, suicidal thoughts and behaviors, developmental delays, and behavioral issues. In a policy statement, the AAP notes that research documents negative physical and emotional symptoms among detained children and adults and also shows negative impacts on the parent-child relationship.
In the short term, toxic stress can increase the risk and frequency of infections in children as high levels of stress hormones suppress the body’s immune system. It can also result in developmental issues due to reduced neural connections to important areas of the brain. Toxic stress is associated with damage to areas of the brain responsible for learning and memory.
Over the long term, toxic stress may manifest as poor coping skills and stress management, unhealthy lifestyles, adoption of risky health behaviors, and mental health issues, such as depression. Toxic stress is also associated with increased rates of physical conditions into adulthood, including chronic obstructive pulmonary disease, obesity, ischemic heart disease, diabetes, asthma, cancer, and post-traumatic stress disorder.” (H)

“A top Health and Human Services official told Congress on Tuesday that he and others repeatedly warned the Trump administration that its policy of separating immigrant families apprehended at the U.S.-Mexico border would not be in “the best interest of the child.”
“During the deliberative process over the previous year, we raised a number of concerns in the (Office of Refugee Resettlement) program about any policy which would result in family separation due to concerns we had about the best interest of the child as well as about whether that would be operationally supportable with the bed capacity that we have,” Jonathan White, with the Public Health Service Commissioned Corps, told lawmakers at a Senate Judiciary Committee hearing”.… (I)

“The Department of Homeland Security was not ready to carry out the Trump administration’s family separation policy, and some of the government’s practices made the problem worse, according to a report issued Tuesday by the department’s inspector general…
“DHS was not fully prepared to implement the administration’s zero-tolerance policy or to deal with some of its after-effects,” said John Kelly, the acting inspector general.
Tuesday’s report said Customs and Border Protection held children for long periods in facilities intended to be used for only short terms, lacked the ability to reliably track children separated from their parents, and in some cases failed to adequately inform parents about the separation policy…
Computer systems used by CBP and Immigration and Customs Enforcement lacked the ability to share data about parents whose children were separated from them. And those systems were not integrated with the resettlement agency…
In a separate DHS inspector general report dated September 27, the Adelanto ICE Processing Center, a detention center housing up to 1,940 ICE detainees in California, was cited for serious violations including nooses found hanging in detainee cells, “improper and overly restrictive segregation,” and “untimely and inadequate medical care.” “ (J)

“In shelters from Kansas to New York, hundreds of migrant children have been roused in the middle of the night in recent weeks and loaded onto buses with backpacks and snacks for a cross-country journey to their new home: a barren tent city on a sprawling patch of desert in West Texas.
Until now, most undocumented children being held by federal immigration authorities had been housed in private foster homes or shelters, sleeping two or three to a room. They received formal schooling and regular visits with legal representatives assigned to their immigration cases…
But in the rows of sand-colored tents in Tornillo, Tex., children in groups of 20, separated by gender, sleep lined up in bunks. There is no school: The children are given workbooks that they have no obligation to complete. Access to legal services is limited…
The camp in Tornillo operates like a small, pop-up city, about 35 miles southeast of El Paso on the Mexico border, complete with portable toilets. Air-conditioned tents that vary in size are used for housing, recreation and medical care. Originally opened in June for 30 days with a capacity of 400, it expanded in September to be able to house 3,800, and is now expected to remain open at least through the end of the year.” …
The roughly 100 shelters that have, until now, been the main location for housing detained migrant children are licensed and monitored by state child welfare authorities, who impose requirements on safety and education as well as staff hiring and training.
The tent city in Tornillo, on the other hand, is unregulated, except for guidelines created by the Department of Health and Human Services. For example, schooling is not required there, as it is in regular migrant children shelters…” (K)

“Thousands of foster children may be getting powerful psychiatric drugs prescribed to them without basic safeguards, says a federal watchdog agency that found a failure to care for youngsters whose lives have already been disrupted.
A report released Monday by the Health and Human Services inspector general’s office found that about 1 in 3 foster kids from a sample of states were prescribed psychiatric drugs without treatment plans or follow-up, standard steps in sound medical care.
Kids getting mood-altering drugs they don’t need is only part of the problem. Investigators also said children who need medication to help them function at school or get along in social settings may be going untreated.
The drugs include medications for attention deficit disorder, anxiety, PTSD, depression, bipolar disorder and schizophrenia. Foster kids are much more likely to get psychiatric drugs than children overall.
“We are worried about the gap in compliance because it has an immediate, real-world impact on children’s lives,” said Ann Maxwell, an assistant inspector general.” (L)

“Traditionally, most sponsors have been undocumented themselves, and therefore are wary of risking deportation by stepping forward to claim sponsorship of a child. Even those who are willing to become sponsors have had to wait months to be fingerprinted and otherwise reviewed.
Federal officials say their vetting procedures are designed to safeguard the children in their care.
“Children who enter the country illegally are at high risk for exploitation by traffickers and smugglers,” Ms. Stauffer said in her statement.
But the longer children are detained, the more anxious and depressed they are likely to become, according to Mr. Greenberg, who oversaw the program under Mr. Obama. When that happens, children may try to harm themselves or escape, and can become violent with the staff and with one another, he said.
Stories of such behavior have emerged through reporting in recent months as the shelter system has faced intense criticism by members of Congress and the public…
The separated children injected a new degree of chaos into the facilities, according to several shelter operators, who spoke anonymously because they are barred by the government from speaking to the news media. The children were younger and more traumatized than those the shelters were used to dealing with, and they arrived without a plan for when they could be released or to whom.” (M)

“Deep within the fine print of a newly proposed federal rule change is an admission of its disastrous health consequences. The Department of Homeland Security’s plan would deny legal immigrants permanent residency status if they accept government assistance to which they are entitled, allegedly an effort to “promote immigrant self-sufficiency” and ensure “they are not likely to become burdens on American taxpayers” or “public charges.”
But the certain collateral damage of this misguided policy, which greatly expands an existing principle to make its application downright punitive, reveals it’s not about promoting self-sufficiency at all.
In describing the impact of this effort, the Department of Homeland Security states, “Disenrollment or foregoing enrollment…by aliens otherwise eligible for these programs could lead to:
“Worse health outcomes, including prevalence of obesity and malnutrition, especially for pregnant or breastfeeding women, infants or children…
“Increased use of emergency rooms and emergency care as a method of primary health care due to delayed treatment
“Increased prevalence of communicable diseases, including among members of the U.S. citizen population who are not vaccinated.”..
The rule change, if implemented, will cause legal immigrants, their spouses and children, including U.S. citizens, to withdraw from government assistance programs out of fear that it would endanger the chances for a family member to obtain a green card and become a legal permanent resident. Washington will, in effect, force individuals to choose between their welfare and a family member’s legal residency status…
Some children will not receive necessary vaccines, making them susceptible to preventable diseases, such as measles, mumps, Hepatitis A and B, and polio. Illnesses will not be addressed when they are easily treatable. Without proper prenatal and perinatal care, there will be an increase in birth complications.” (N)

“Complicating matters, the administration has decreed that reunifications must take place in the family’s country of origin. Which means that, once contacted, parents face an excruciating choice: give up their children’s asylum claims and have them returned home, or leave the children in the United States to try to navigate the asylum process on their own.” (O)

“The Trump administration wants to change how the government defines who is or is likely to become a “public charge.” The Department of Homeland Security released a draft regulation on Sept. 22, in which it proposed that any immigrant who is likely to use or who has already used Medicaid, public housing or a rent voucher, cash assistance or food stamps could be barred from the country or kept from getting permanent resident status.
“….The administration would remake the idea of self-sufficiency, admitting only those who never need to turn to the public safety net, but instead rely solely on “their own capabilities” or the resources of their families and private charity. It even asserts that people who use public programs “in a relatively small amount or for a relatively short duration” are still considered dependent on the welfare state.
This redefinition of self-sufficiency ignores the way that most people use these programs. Even people with jobs often cycle on and off assistance as work comes and goes, or to plug the gaps when it just doesn’t pay enough. These programs allow people to remain healthy and solvent — supporting their independence. This rule therefore hurts everyone, not just immigrants, by stigmatizing the safety net funded by all of us to help people survive when they fall on hard times.” (P)

The Trump administration has put the safety of thousands of teens at a migrant detention camp at risk by waiving FBI fingerprint checks for their caregivers and short-staffing mental health workers, according to an Associated Press investigation and a new federal watchdog report.
None of the 2,100 staffers at a tent city holding more than 2,300 teens in the remote Texas desert are going through rigorous FBI fingerprint background checks, according to a Health and Human Services inspector general memo published Tuesday.
“Instead, Tornillo is using checks conducted by a private contractor that has access to less comprehensive data, thereby heightening the risk that an individual with a criminal history could have direct access to children,” the memo says.
In addition, the federal government is allowing the nonprofit running the facility — BCFS Health and Human Services — to sidestep mental health care requirements. Under federal policy, migrant youth shelters generally must have one mental health clinician for every 12 kids, but the federal agency’s contract with BCFS allows it to staff Tornillo with just one clinician for every 100 children. That’s not enough to provide adequate mental health care, the inspector general office said in the memo…
Because the detention camp is on federal property — part of a large U.S. Customs and Border facility — it is not subject to state licensing requirements…
Federal officials have said repeatedly that only children without special needs were being sent to Tornillo. But facility administrators recently acknowledged that the Tornillo detainees included children with serious mental health issues who needed to be transferred out to facilities in El Paso, according to a person with knowledge of the discussion…(Q)

“The deportation and forced separation of immigrants has negative effects that extend beyond individuals and families to entire communities in the United States, according to a division of the American Psychological Association, which has issued a policy statement calling for changes to U.S. policy.
Based on a review of the effects of three decades of U.S. immigration policy, the policy statement details the psychosocial and economic impacts of deportation on children and families, as well as broader community consequences that unfold as immigrants fearful of being targeted withdraw from civic engagement…
Studies reveal that children who lose a parent to sudden, forced deportation experience anxiety, anger, aggression, withdrawal, a heightened sense of fear, eating and sleeping disturbances, isolation, trauma, and depression.
Children also experience housing instability, academic withdrawal, and family dissolution; older children often need to take on jobs to help support the family.
Ten percent of U.S. families with children have at least one family member who lacks citizenship.
5.9 million children have at least one caregiver who lacks authorization to live in the country.” (R)

“Children tend to respond to separation from their caregiver in three fluid phases. First, children enter an acute phase of protest characterized by fear, distress, crying and urgent seeking of their caregiver that may last from a few hours to days. As the length of separation continues, children enter a phase of despair during which crying weakens, movement lessens and children reject the approach of alternative adults. With prolonged parental absence, children may become passively compliant with care staff, giving the appearance of having ‘settled in’ to their new environment. Disturbingly, this can signify that the child has detached from the parents and is now living in a perceived state of ‘fear without resolution’. Children reunited while they are in the early separation protest phase usually fare well. Children in despair may respond to the reappearance of their parent with hostility or ambivalence, taking many weeks to rebuild their bond. Children who have detached from their parents may reject their approaches or treat them as strangers. Additionally, when children interpret themselves as ‘abandoned’ by parents, they may develop a profound sense that they have done something wrong to cause their caregiver to leave, igniting shame and complex emotions that can damage the lifelong relationships with themselves and others.”(S)

“When children are reunited with parents, the reintegration process is sometimes difficult. Widespread videos of families being reunified have shown emotionless children, some even avoiding their parent’s embrace. A number of children do not even recognize their parents upon return, which speaks to the intense trauma that these children have experienced. “We think that we’ve made the family whole again by simply bringing them back together and letting them go on with their lives, when the reality is that there’s a lot of work that still needs to be done,” said Vivek Sankaran, a clinical professor of law at the University of Michigan Law School. After becoming reunited, the families affected by separation need continuing support in order to reestablish their relationships and routines.” (T)

“It is clear, then, that the families affected by the current administration’s separation policy need services to help them cope with the trauma that has occurred. It is possible for the individuals and the family units to find some healing, given the opportunity, resources, and tools to do so.
Griffith says that a key to working through such a trauma is bringing the families back together as quickly as possible. “If the core family unit can stay intact, that accomplishes a lot. [There’s a feeling of] ‘As long as we’re together, we can be okay, regardless of how harsh the circumstances,'” he says. However, the reunification process thus far has been plodding and uncoordinated. It appears that far too many families will remain separated long term.
In addition to reunification and in the face of indefinite separation, family members should have access to psychosocial services to help them cope. Unfortunately, it is unclear what services are currently available to the children still separated from their parents. “We don’t have access to those facilities,” Lusk says.” (U)

“The Trump administration did not tell key government agencies about its “zero tolerance” immigration policy before publicly announcing it in April, leaving the officials responsible for carrying it out unprepared to handle the resulting separations of thousands of children from their families, according to a government report released on Wednesday.
The Department of Homeland Security, which apprehends border crossers, and the Department of Health and Human Services, which cares for separated migrant children, were both caught off guard when Attorney General Jeff Sessions announced plans to criminally prosecute anyone who crossed the border illegally, the report said…
Because they did not know about the “zero tolerance” policy in advance, officials at the Department of Homeland Security said, they did not take steps to prepare for the resulting family separations. Staff members at the Department of Health and Human Services said their leaders told them not to prepare for an increase in children separated from their families because homeland security officials claimed that they did not have an official policy of separating parents and children, according to the report, which was prepared by the Government Accountability Office, Congress’s nonpartisan investigative arm.” (V)

In just six months, the Trump administration has built a detention camp for migrant kids in the Texas desert that is larger than 203 of the 204 U.S. federal prisons.
Driving the news: The Tornillo camp now holds 2,324 boys and girls, most from Central America, between the ages of 13-17, the AP reports.
Why it matters: “Confining and caring for so many children is a challenge. By day, minders walk the teen detainees to their meals, showers and recreation on the arid plot of land guarded by multiple levels of security. At night the area around the camp, that’s grown from a few dozen to more than 150 tents, is secured and lit up by flood lights.”
Between the lines: Among the list of issues at Tornillo discovered by an AP investigation:
1. Security: The 2,100 staffers haven’t done FBI fingerprint background checks.
2. Costs: “What began as an emergency, 30-day shelter has transformed into a vast tent city that could cost taxpayers more than $430 million.”
3. Rules: “Under federal policy, migrant youth shelters generally must have one mental health clinician for every 12 kids, but shelter officials have indicated that Tornillo can staff just one clinician for every 100 children…”..
The bottom line: There are more than 14,000 migrant children in U.S. detention, most from central America. Figuring out what to do with these kids is a challenge that doesn’t seem to be going away.” (W)

“”Aid workers and humanitarian organizations [are sounding the alarm on] unsanitary conditions at the sports complex in Tijuana where more than 6,000 Central American migrants are packed into a space adequate for half that many people,” AP reports.
Lice infestations and respiratory infections are rampant, and Mexico’s National Human Rights Commission reports four cases of chicken pox.” (X)

“The founder of Southwest Key made millions from housing migrant children..
Southwest Key has collected $1.7 billion in federal grants in the past decade, including $626 million in the past year alone. But as it has grown, tripling its revenue in three years, the organization has left a record of sloppy management and possible financial improprieties, according to dozens of interviews and an examination of documents. It has stockpiled tens of millions of taxpayer dollars with little government oversight and possibly engaged in self-dealing with top executives…
Shortly after, the federal government temporarily shuttered a third Arizona shelter, in Youngtown, after Southwest Key staff members were accused of physically abusing three children. In a recent agreement with Arizona officials, Southwest Key was fined $73,000 and agreed to close that facility and another troubled shelter in Phoenix. Mr. Weber, the government spokesman, said there were “numerous red flags and licensure problems” with the two shelters.” (Y)

(A) BUSSW Dean Statement on Migrant Family Separation Crisis, , Jorge Delva,
(B) Sign-on letter: Public health implications of family separation at the border,
(C) The Science is Clear: Separating Families has Long-term Damaging Psychological and Health Consequences for Children, Families, and Communities,
(D) Jacqueline Bhabha speaks to the human rights of children detained at the U.S.-Mexico border., Professor of the Practice of Health and Human Rights at the Harvard T.H. Chan School of Public Health
(E) Statement on Harmful Consequences of Separating Families at the U.S. Border,
(F) Separating parents and children at US border is inhumane and sets the stage for a public health crisis,
(G) Key Health Implications of Separation of Families at the Border (as of June 27, 2018),
(H) Top HHS official warned Trump administration against separating immigrant families, by Eliza Collins, Alan Gomez,
(I) DHS not prepared for family separations under Trump zero tolerance policy, watchdog finds, by Pete Williams and Jacob Soboroff,
(J) Migrant Children Moved Under Cover of Darkness to a Texas Tent City, by Caitlin Dickerson,
(K) Thousands of foster children may be getting psychiatric drugs without safeguards, watchdog agency says, by Ricardo Alonso-Zaldivar,
(L) Detention of Migrant Children Has Skyrocketed to Highest Levels Ever, by Mike Blake,
(M) One sick immigration rule: The ‘public charge’ regulation will make America less healthy, by KENNETH L. DAVIS,
(N) The Continuing Tragedy of the Separated Children,
(O) Trump Wants to Turn the Safety Net Into a Trap, by By Bryce Covert,
(P) Separating Families at U.S. Borders is a Public Health Issue, Ellen J. MacKenzie,
(Q) US waived FBI checks on staff at growing teen migrant camp, by GARANCE BURKE AND MARTHA MENDOZA,
(R) Deportation and family separation impact entire communities, researchers say, by Jennifer McNulty,
(S) Impact of punitive immigration policies, parent-child separation and child detention on the mental health and development of children, by Laura C N Wood,
(T) The Impact of Parent-Child Separation at the Border, by Hurley Riley,
(U) Children and Families Forum: The Impact of Immigrant Family Separation, by Sue Coyle,
(V) ‘Zero Tolerance’ Immigration Policy Surprised Agencies, Report Finds, by Ron Nixon,
(W) Axios PM: Trump’s detention camp for migrant teens; November 27, 2018
(X) Axios AM, November 30, 2018
(Y) He’s Built an Empire, With Detained Migrant Children as the Bricks, Tamir Kalifa for The New York Times, by Kim Barker, Nicholas Kulish and Rebecca R. Ruiz,

..The HHS needs to review thousands of case files by hand for clues to which children were taken from their parents…

“Most immigrants facing deportation wouldn’t climb onto a table during their court hearings. But then again, most 3-year-olds don’t go to court without parents or lawyers.

“President Trump has moved on from caring about the migrant children in cages

“Only a dead heart is unstirred by the intentional infliction of suffering on children and babies as a weapon of deterrence.”

“In 6 Days, Trump Admin Reunited Only 6 Immigrant Children With Their Families”,

“…the only way parents can quickly be reunited with their children is to drop their claims for asylum… and agree to be deported.”

White House Press Secretary Sarah Huckabee Sanders said the government was starting to
“run out of space” to house people apprehended crossing the border

Trump’s policy “could be creating thousands of immigrant orphans in the U.S.”,

Tender-Age Immigrant Children. “They need bilingual workers. Some kids speak indigenous languages, so that’s an issue as well.

“The idea of pulling a child out of a parent’s arms, or identifying a parent but still keeping them separate—it isn’t right.”

“The business of housing, transporting and watching over migrant children detained along the southwest border is not a multimillion-dollar business. It’s a billion-dollar one…

“If it could happen to them…why can’t it happen to us?”…separating children from their parents,

“…Trump’s (family separation) policy amounts to “government-sanctioned child abuse.””,

“The Trump administration’s policy of separating parents and children at the U.S.-Mexico border will have a dire impact on their health, both now and into the future.” (C)

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“…really targeting the depth of the opioid epidemic would require an infusion of federal dollars on par with the more than $20 billion a year spent on HIV/AIDs.”

“Subdued and on-script, President Donald Trump struck a bipartisan tone as he signed sweeping legislation Wednesday to combat the opioid epidemic, an issue that has animated his effort to support Republican midterm candidates.
Discussing a crisis affecting urban centers as well as rural communities that supported his election, Trump touted the measure as a bipartisan response to a problem rarely cited as a top issue for voters that nevertheless touches millions of them personally.
“We are going to end it or we are going to at least make an extremely big dent in this terrible, terrible problem.” Trump said during an East Room event that drew members of both parties. “We have mobilized the entire federal government to address this crisis.”..
Speaking at a rally in Nevada this past weekend, Trump touted the “bold action” and “historic effort” he said his administration embarked on to address the problem. His administration’s response has fallen into two categories, he has said: Stepped up enforcement and more funding for states to expand treatment.
“We obtained $6 billion to fight the opioid epidemic,” Trump said during his most recent stop in Houston this week, referencing a funding bill approved by Congress in March.
The new legislation that Congress approved Oct. 3, makes it easier to intercept drugs being shipped into the country, authorizes new funding for more comprehensive treatment, speeds up research on non-addictive painkillers and clears Medicare and Medicaid regulations that advocates have said can stand in the way of treatment. “ (A)

“Addiction treatment advocates say two provisions — one that would allow Medicaid, the federal-state health insurance plan for the poor, to pay for residential treatment in large facilities and another that would allow Medicare, the federal health plan for people 65 and older, to pay for methadone treatment — will substantially improve access to treatment.
The legislation, approved last month by the House and Wednesday by the Senate, also would pay for research into opioid alternatives, support greater use of non-opioid pain management and invest in new law enforcement efforts to curb illicit drugs.
Some critics say the legislation, which calls for roughly $8 billion in federal investment over five years, doesn’t go far enough given the magnitude of the drug overdose crisis.
In an epidemic that killed more than 72,000 people in 2017, the federal government should commit to spending far more money on treatment, prevention and access to the life-saving drug naloxone, advocacy groups have argued. The groups, including the Harm Reduction Coalition, recommended $100 billion more in federal spending, similar to the Ryan White HIV/AIDS Program.
Still, treatment advocates say that Medicaid coverage of residential treatment and Medicare coverage of methadone would go a long way to boosting treatment quality and capacity, as well as people’s ability to pay.
The residential treatment provision would lift a 53-year-old ban in the federal Medicaid statute that prohibits coverage of mental health and addiction treatment services in facilities with more than 16 beds. Called the “institutions for mental disease” or IMD exclusion, the rule was intended to prevent states from using federal dollars to warehouse people with addiction and mental disorders.” (B)

“While very broad in scope, the final legislation contains a number of provisions related to Medicaid’s role in helping states provide coverage and services to people who need substance use disorder (SUD) treatment, particularly those needing opioid use disorder (OUD) treatment.
Services. The most controversial measure in the bill amends the long-standing prohibition against the use of federal Medicaid funds for services in “institutions for mental disease” (IMDs) for nonelderly adults by creating a state option from 10/1/19 to 9/30/23 to cover those services up to 30 days in a year for individuals with a substance use disorder. To be eligible to receive federal matching funds, states must meet maintenance of effort and other requirements..
The SUPPORT Act also requires state Medicaid programs to cover medication-assisted treatment (MAT), including all FDA-approved drugs, counseling services, and behavioral therapy, from October 2020 through September 2025, unless a state certifies to the Secretary’s satisfaction that statewide implementation is infeasible due to provider shortages…
Demonstrations. Prescription Drug Oversight. The SUPPORT Act requires states to have drug utilization review safety edits in place for opioid refills, monitor concurrent prescribing of opioids and other drugs, and monitor antipsychotic prescribing for children” (C)

“Together,” the president told grieving mothers and fathers, cabinet members, lawmakers, and representatives of local law enforcement, “we will end the scourge of drug addiction in America. We’re going to end it or at least make an extremely big dent in this terrible, terrible problem.”
Almost no one who’s studied the legislation and understands the magnitude of an epidemic in which an estimated 72,000 people died from drug overdoses in 2017 thinks it will do any such thing. The bill’s provisions to expand addiction treatment, speed up research on alternative drugs, and provide Medicaid funding to treatment centers with more than 16 inpatient beds will certainly help, as will $6 billion in funding to fight opioids, “the most money ever received in history,” Trump said. But many public-health experts, and some of Trump’s Democratic opponents in Congress, say something closer to $100 billion is needed over 10 years to end or “make an extremely big dent” in opioid addiction. Senator Elizabeth Warren cites “broken promises” by an administration that still does not have a confirmed director of its Office of National Drug Control Policy (ONDCP) after nearly two years in office.
Formed in 1988 through the Anti-Drug Abuse Act, the ONDCP is supposed to coordinate drug-control policy and funding between 16 federal departments and agencies. The director of the office is intended to be the U.S. president’s “principal advisor” on drug-control issues. The Senate has to confirm whomever the president appoints…
The office has yet to release the annual National Drug Control Strategy, which spells out how the administration will tackle drugs and how it will develop a drug-control budget. Three months after taking office, Trump chose an unorthodox approach to drug policy, establishing the President’s Commission on Combating Drug Addiction and the Opioid Crisis, appointing Governor Chris Christie, a Trump political ally, as chair. The commission, staffed and funded by ONDCP, released a report that recommended nearly 60 ways to address the crisis. The recommendations cover prevention, treatment, recovery, and more. “ (D)

“The legislation takes wide aim at the problem, including increasing scrutiny of arriving international mail that may include illegal drugs. It makes it easier for the National Institutes of Health to approve research on non-addictive painkillers and for pharmaceutical companies to conduct that research.
The Food and Drug Administration would be allowed to require drugmakers to package smaller quantities of drugs such as opioids. And there would be new federal grants for treatment centers, training emergency workers and research on prevention methods.
Karen Yost, CEO of Prestera Center, said in a statement the 70 pieces of this bill is a good start, though there is no “magic bullet” to solving the opioid crisis.
“How this legislation is implemented will be key as even good legislation implemented poorly will not be helpful,” Yost said.
“This bill is a start in the right direction, even though it does not address significant underlying issues in this epidemic, including adverse childhood experiences, extreme poverty, gainful employment, safe affordable housing, related chronic health problems and co-occurring mental health problems.”
That’s a long list, and it helps explain how this problem became so big and is so difficult to overcome.” (E)

“Yet many public health advocates and experts say it doesn’t offer the one thing truly needed: The massive amount of funding needed to fully combat a crisis that deeply affects rural and urban communities across America.
Sarah Wakeman,the medical director for Mass General Hospital’s Substance Use Disorders Initiative, said really targeting the depth of the opioid epidemic would require an infusion of federal dollars on par with the more than $20 billion a year spent on HIV/AIDs.
“We have historically not thought of addiction as a medical issue and so our health care and public health system are woefully unprepared to respond in a robust way,” she said.”..
“I hope Congress doesn’t think they can put this behind them because they passed these bills,” said Patrick Kennedy, a former Democratic congressman of Rhode Island and a mental health advocate . “It takes an urgency like we had during HIV-AIDS. That will call to mind what it takes to address a crisis, it takes political will.” (F)

“”Without real money, it’s just lip service,” said John Rosenthal, co-founder and chairman of the Police Assisted Addiction and Recovery Initiative, to CNHI’s Christian M. Wade. “This disease has been raging for more than a decade without any serious federal response. Now they’re playing catch-up.”
Sarah Wakeman, the medical director for Mass General Hospital’s Substance Use Disorders Initiative, told the Washington Post that really targeting the depth of the opioid epidemic would require an infusion of federal dollars on par with the more than $20 billion a year spent on HIV/AIDs.
Rosenthal agreed and said there are “good things” in the bill, but it needs “billions” of dollars in money — similar to the federal response to cancer and HIV/AIDS prevention and treatment.” (G)

“Governments around the globe and their citizens routinely respond to ecological disasters. Think Exxon Valdez or Love Canal in the U.S.; Chernobyl in the Soviet Union; Bhopal in India; and far too many others. The responses, though not always immediate or thorough, at least tend to be multifaceted. We are currently in the midst of a human-made ecological disaster, the opioid crisis, that isn’t recognized as such, but that can benefit from the same sorts of responses made to ecological disasters…
Treating the opioid epidemic as an ecological disaster could set important precedents for cleanup and prevention that can be particularly useful in areas where effective responses have been lagging. Such efforts are relatively easy to visualize when the disaster is a pollutant like mercury. But what does a cleanup look like when the offending substance is, for some people, a medically essential resource?..
The opioid disaster is occurring simultaneously on so many levels and affecting so many lives in ways that other disasters may not. It can be viewed through many different lenses. I see the opioid disaster as an individual living with chronic pain who depends on opioid medications to manage each day. But I also acknowledge and suffer with members of my community who are experiencing substance abuse themselves, or are in recovery from it, or who have lost family members or friends to opioid overdoses.
Even now, nearly 30 years after the Exxon Valdez struck a reef and spilled nearly 11 million gallons of crude oil into Prince William Sound, some of that oil persists in Alaskan soil and water, breaking down minutely year by year. The opioid disaster will continue to saturate our environment for the near future, but it should not need to take three decades for us to break it down.” (H)

(A) President Trump tries to project image of bipartisan action with opioid bill signing, by David Jackson and John Fritze,
(B) Opioid Bill Expands Treatment Options, by Christine Vestal,
(C) Federal Legislation to Address the Opioid Crisis: Medicaid Provisions in the SUPPORT Act, by MaryBeth Musumeci,
(D) Trump’s ‘Big Dent’ in the Opioid Crisis, by Lola Fadulu,
(E) Federal opioid law moves in right direction,
(F) Senate easily passes sweeping opioids legislation, sending to President Trump, by Colby Itkowitz,
(G) Where’s the money? Federal opioid bill gets flack for lack of funds, by Jonathan Greene,
(H) Viewing the opioid crisis as an ecological disaster could help with ‘cleanup’, by MAIA DOLPHIN-KRUTE,

“The U.S. is about 5% of the world’s population yet consumes about 80% of the world’s oxycodone supply.”

US health official reveals fentanyl almost killed his son,

“For at least six months, staffers in the Office of National Drug Control Policy — often political appointees in their 20s — (have) sat through weekly meetings of an “opioids cabinet” chaired by Kellyanne Conway.,

“The House on Friday passed bipartisan legislation aimed at fighting the nationwide epidemic of opioid abuse, culminating months of work on the crisis…,

Why is there a nationwide hospital shortage of injectable opioids? – follow the money. ,

“In 2016, more than 40 percent of opioid overdose deaths in the U.S. involved a prescription opioid.”,

CASE STUDY ON THE OPIOID CRISIS. “We still have lacked the insight that this is a crisis, a cataclysmic crisis”,

Opioid commission member: Our work is a ‘sham’,

“White House counselor Kellyanne Conway will be the point person for the Trump administration’s opioid crisis efforts…,

Facebook users can easily find these drugs – Oxycodone, Hydrocodone, and Percocets,

“…the president.. reversed course to instead declare opioids a public health emergency, a move that releases no new funding to contend with a drug crisis….”,

“At a time when the United States is in the grip of an opioid epidemic, many insurers are limiting access to pain medications that carry a lower risk of addiction or dependence…..”,

Congress blocked DEA action against drug companies suspected of flooding the country with prescription narcotics,

The rise of ‘grandfamilies’: Opioid crisis requires more Hoosier grandparents to raise children..,

Opioid Crisis. ““We got here in part because there was a paper done in the 1980s by a well-meaning physician that said opioids are not addictive….,

“To manage and (eventually) reverse the opioid epidemic, state Medicaid programs should now take a deeper look at the role prescribing plays…”,

As Washington dawdles, the States step in on the opioid crisis, with initiatives and lawyers,

“We would never tolerate a situation where only one in 10 people with cancer or diabetes gets treatment, and yet we do that with substance-abuse disorders,” (A),

“For most of my surgical career, I gave out opioids like candy….” “With approximately 142 Americans dying every day”….” We need to take away the matches, not put out the fires.”,

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