PART 1: January 31, 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 “
PART 2: February 20, 2019. A new bill would outlaw the big,
surprise bills that Zuckerberg San Francisco General Hospital has sent to
hundreds of patients.
PART 3: April 18, 2019. “Zuckerberg San Francisco General
Hospital announced Tuesday it has overhauled its billing policies…
PART 4: August 20, 2019. Hospitals kept ER fees secret
ASSIGNMENT: How do other states address financial
sustainability for their “safety-net” hospitals?
PART 1: January 31, 2019. “If you’re shot, stabbed, hit by a
car, fall off …
“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)
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.” (E)
“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.” (F))
“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.” (G)
“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…” (H)
“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.. (I)
“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.” (J)
“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.” (K)
“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…
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.” (L)
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.” (M)
“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…
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 (N)
PART 2: February 20,
2019. 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…
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.” (A)
“Publicity over “balance billing,” a practice that at
Zuckerberg San Francisco General Hospital has left some patients with insurance
on the hook for thousands of dollars in bills, has prompted San Francisco
lawmakers to call for a ban.
SF General made headlines recently for being out of network
with all private insurance companies and charging its insured patients high
bills — in one case $20,000 for a broken arm — without informing them first of
the practice.
Assembly Bill 1161, introduced by Assemblymember David Chiu
and state Sen. Scott Wiener, would mandate that insured patients across the
state owe the same copayment or deductible they would normally pay for their
in-network emergency care.
The ban would apply regardless of whether or not the
emergency room is in-network or out-of-network with a patient’s insurer.
Patients receiving non-emergency care already benefit from
protections of a similar state law. However, the law does not apply to
Preferred Provider Organization (PPO) patients.
Some 6 million people across the state have federally
regulated self-insured plans, and some 1 million have plans regulated by the
California Department of Insurance who don’t benefit from this protection, per
the bill…
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.” (B)
Dear Congressional and Committee Leadership: (C)
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…
Ensure patient access to emergency care…
Preserve the role of private negotiation…
Remove the patient from health plan/provider negotiations…
Educate patients about their health care coverage…
Ensure patients have access to comprehensive provider
networks and accurate network information…
Support state laws that work…
Sincerely,
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
PART 3. April 18, 2019. “Zuckerberg San Francisco General
Hospital announced Tuesday it has overhauled its billing policies…
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)
PART 4: August 18, 20129. Hospitals kept ER fees secret.
Zuckerberg San Francisco General and the University of
California San Francisco are two of the city’s busiest hospitals, about 4 miles
apart. But if you have private insurance and visit Zuckerberg General, you
could end up paying a lot more for the same treatment.
For an especially serious visit, Zuckerberg General charges
a facility fee of $11,176, 46 percent more than UCSF, which charges an average
of $7,635.
The hospital is also out-of-network with all private
insurance, leaving patients responsible for the fee and the cost of treatment.
UC San Francisco, meanwhile, accepts insurance from most big providers.
Insurers generally negotiate lower prices for patients, and many plans cover ER
visits in part or in full…
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…
“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.” (A)
“Frustrated by waiting for federal lawmakers to act, states
have been trying to solve this issue. As of December 2018, 25 states offered
some protection against surprise billing, and the protections in nine of those
states were considered “comprehensive,” according to the Commonwealth Fund.
California, New York, Florida, Illinois and Connecticut are among the nine.
New state laws also have been adopted since, including in
Nevada, which will limit how much out-of-network providers, including
hospitals, can charge patients for emergency care, starting next year.
In California, a 2009 state Supreme Court ruling protects
some patients against surprise billing for emergency care, and a state law that
took effect in 2017 protects some who receive non-emergency care.
But millions remain vulnerable, largely because California’s
protections don’t cover all insurance plans. The California Supreme Court
ruling applies to people with plans regulated by the state Department of
Managed Health Care. That leaves out the roughly 1 million Californians with
plans regulated by the state Department of Insurance and the nearly 6 million
people with federally regulated plans, most of whom have employer-sponsored
insurance.
The state law governing non-emergency care also doesn’t
apply to the millions of residents with health plans regulated by the federal
government…
The California Hospital Association opposes the measure,
which would limit the amount hospitals could charge insurance plans to a
certain rate for each service, varying by region…
“We fully support the
provision of the bill that protects patients. It is the rate-setting piece that
is our concern,” she said.” (B)
“Legislation to prohibit California hospitals from sticking
patients with huge emergency room bills that their insurers won’t cover has
cleared a crucial hurdle in the state Capitol.
Lawmakers in the Assembly voted 48-9 on Thursday to approve
AB1611, which would prohibit hospitals from “balance billing” patients if their
insurance won’t cover the full cost for care.
Assemblyman David Chiu and state Sen. Scott Wiener, both
Democrats from San Francisco, co-wrote the legislation. The bill now moves to
the Senate…
AB1611 would prohibit hospitals from billing patients for
any cost beyond their insurance deductible and co-payment. It also spells out
rules for how hospitals and insurers resolve cost disputes.” (C)
“Hospitals focused
their opposition on a provision of the bill that would have limited charges for
out-of-network emergency services.
The proposal would have required hospitals to work directly
with health plans on billing, leaving the patients responsible only for their
in-network copayments, coinsurance and deductibles.
Citing fierce pushback from hospitals, California lawmakers
sidelined a bill Wednesday that would have protected some patients from
surprise medical bills by limiting how much hospitals could charge them for
emergency care.” (D)
The legislation, which contributed to the intense national
conversation about surprise medical billing, was scheduled to be debated
Wednesday in the state Senate Health Committee.
Instead, the bill’s author pulled it from consideration,
vowing to bring it back next year.
“We are going after a practice that has generated billions
of dollars for hospitals, so this is high-level,” said Assemblyman David Chiu
(D-San Francisco). “This certainly does not mean we’re done.” (E)
“California hospitals
want you to know that they’re fully on board with the idea that emergency room
patients shouldn’t be hit with thousands of dollars in surprise billings
because the ER isn’t in their insurance plan’s network.
You should also know, however, that the hospitals just
killed a measure in Sacramento that would have accomplished that goal, and that
the reason they did so was to protect their own revenues….
The state’s hospitals went to the mattresses over the
payment provision, cursing it as “government rate setting” that they would
never accept.
Hospital executives inundated legislators with warnings that
rate-setting would force their institutions to shut down.
We have 450 hospitals in California,” says Anthony Wright,
executive director of Health Access, “and every hospital CEO has the cellphone
number of his state senator and assemblyman. A hospital saying it would close
would give pause to any lawmaker.”
The proponents were aware that they were poking a stick into
a tiger’s cage. “We’re going after a practice that has generated billions of
dollars in profits for hospitals, Chiu told me, “and hospital CEOs around the
state waged very aggressive lobbying to protect those profits.”” (F)
“San Francisco’s health network has finalized its first
contract with a private health insurer, Canopy Health Canopy — meaning
Zuckerberg San Francisco General Hospital, long perceived as the hospital of
last resort, is now in the business of wooing expectant mothers to choose to
deliver at its Family Birth Center…
Department of Public Health staff said the signing of this
contract was not a reaction to billing controversies at ZSFGH that erupted
earlier this year, when it was revealed that even insured patients were being
hit with crippling debts through the practice of “balance billing.” Because the
hospital was out-of-network for private insurance companies, there was often a
great divergence between what ZSFGH billed the insurance and what the insurance
company would deign to pay — leaving individuals responsible for the “balance.”
This situation, however, did highlight the hospital’s
unhealthy and precarious “payer mix.” With few privately insured patients,
ZSFGH ministers mostly to Medi-Cal recipients or the marginally insured. Deals
like the one initiated July 15 with Canopy would begin to change that mix,
however.” (G)
PART 1. April16, 2019. Is it ethical for the public not to
be notified about new “super bugs” in hospitals so they can decide whether or
not to go to affected hospitals?
PART 2. May 13, 2019. CANDIDA AURIS. “In 30 years, I’ve
never faced so tough a reporting challenge – and one so unexpected. Who
wouldn’t want to talk about a fungus?…
PART 3. June 6, 2019. CANDIDA AURIS. “Antibiotic-resistant
superbugs are everywhere. If your hospital claims it doesn’t have them, it
isn’t looking hard enough.”
PART 1. April16, 2019.
Is it ethical for the public not be notified about new “super bugs” in
hospitals so they can decide whether or not to go to affected hospitals?
“Last May, an elderly man was admitted to the Brooklyn
branch of Mount Sinai Hospital for abdominal surgery. A blood test revealed
that he was infected with a newly discovered germ as deadly as it was
mysterious. Doctors swiftly isolated him in the intensive care unit.
The germ, a fungus called Candida auris, preys on people
with weakened immune systems, and it is quietly spreading across the globe.
Over the last five years, it has hit a neonatal unit in Venezuela, swept
through a hospital in Spain, forced a prestigious British medical center to
shut down its intensive care unit, and taken root in India, Pakistan and South
Africa.
Recently C. auris reached New York, New Jersey and Illinois,
leading the federal Centers for Disease Control and Prevention to add it to a
list of germs deemed “urgent threats.”
The man at Mount Sinai died after 90 days in the hospital,
but C. auris did not. Tests showed it was everywhere in his room, so invasive
that the hospital needed special cleaning equipment and had to rip out some of
the ceiling and floor tiles to eradicate it.
“Everything was positive – the walls, the bed, the doors,
the curtains, the phones, the sink, the whiteboard, the poles, the pump,” said
Dr. Scott Lorin, the hospital’s president. “The mattress, the bed rails, the
canister holes, the window shades, the ceiling, everything in the room was
positive.”” (A)
“Back in 2009, a 70-year-old Japanese woman’s ear infection
puzzled doctors. It turned out to be the first in a series of hard-to-contain
infections around the globe, and the beginning of an ongoing scientific and
medical mystery.
The fungus that infected the Japanese woman, Candida auris,
kills more than 1 in 3 people who get an infection that spreads to their blood or
organs. It hits people who have weakened immune systems, and is most often
found in places like care homes and hospitals. Once it shows up, it’s hard to
get rid of: unlike most species of fungi, Candida auris spreads from person to
person and can live outside the body for long periods of time.
Mount Sinai wasn’t the first hospital to face this task: a
London hospital found itself with an outbreak in 2016, and the only way to stop
it was to rip out fixtures…
Scientists still aren’t sure exactly where this happened or
when. That’s one of the things they’re working on now, says Cuomo, because
figuring out how the fungus evolved could help researchers develop treatments
for it…
Although the “superbug” moniker might sound alarmist,
Candida auris qualifies for two reasons, says Cuomo. First, all strains of the
yeast are resistant to antifungals. There are three major kinds of antifungals
used to treat humans, and some strains of Candida auris are resistant to all of
them, while other strains are resistant to one or two. That limits the
treatment options for someone who has been infected-someone who is probably
already in poor health. The other reason is “this really scary property of not
being able to get rid of it,” Cuomo says.” (B)
“Superbugs are a terrifying prospect because of their
resistance to treatment, and one superbug that is sweeping all over the world
is the Candida auris.
C. auris is a fungus that causes serious infections in
various parts of the body, including the bloodstream and the ear.
While its discovery has been relatively recent in 2009, this
fungus has already wreaked havoc in hospitals in more than 20 different
countries, including the United States, United Kingdom, and Spain, among
others.
In the United States, CDC reports a total of 587 clinical
cases of C. auris infections as of February. Most of it occurred in the areas
of New York City, New Jersey, and Chicago.” (C)
“The CDC issued a public alert in January about a
drug-resistant bacteria that a dozen Americans contracted after undergoing
elective surgeries at Grand View Hospital in Tijuana, Mexico. Yet when similar
outbreaks occur at U.S. hospitals, the agency does not issue a public warning.
This is due to an agreement with states that prohibits the CDC from publicly
disclosing hospitals undergoing outbreaks of drug-resistant infections,
according to NYT.
Patient advocates are pushing for more transparency into
hospital-based infection outbreaks, saying the lack of warning could put
patients at risk of harm.
“They might not get up and go to another hospital, but
patients and their families have the right to know when they are at a hospital
where an outbreak is occurring,” Lisa McGiffert, an advocate with the Patient
Safety Action Network, told NYT. “That said, if you’re going to have hip replacement
surgery, you may choose to go elsewhere.”..
The CDC declined NYT’s request for comment. Agency officials
have previously told the publication the confidentiality surrounding outbreaks
is necessary to encourage hospitals to report the drug-resistant infections.”
(D)
“New Jersey is among the states worst affected by an
increasing incidence of the potentially deadly fungus Candida auris, whose
resistance to drugs is causing headaches for hospitals, state and federal
health officials said on Monday.
There were 104 confirmed and 22 probable cases of people
infected by the fungus in New Jersey by the end of February, according to the
federal Centers for Disease Control and Prevention, up sharply from a handful
when the fungus was first identified in the state about two years ago.
The state’s number of cases – now the third-highest after
New York and Illinois – has risen in tandem with an increase, first overseas,
and now in the United States, in a trend that some doctors attribute to the
overuse of drugs to treat infections, prompting the mutation of infection
sources, in this case, a fungus.
The fungus mostly affects people who have existing
illnesses, and may already be hospitalized with compromised immune systems,
health officials said.
Nicole Kirgan, a spokeswoman for the New Jersey Department
of Health, said she didn’t know whether any of the state’s cases have been
fatal, and couldn’t say which hospitals are treating people with the fungus
because they have not, so far, been required to report their cases to state
officials…
But Dr. Ted Louie, an infectious disease specialist at
Robert Wood Johnson University Hospital in New Brunswick, said many hospitals
don’t know how to eradicate the fungus once it has occurred.
Some disinfectants commonly used in hospitals have proved
ineffective in removing the fungus, Dr. Louie said, so hospitals have been
urged to use other disinfecting agents, although it’s not yet clear which of
them work, if any.
“This is a fairly new occurrence and we are still learning
how to deal with it,” he said. “We have to figure out which disinfectant
procedures may be best to try to eradicate the infection, so at this point, I
don’t think we have good enough information to advise.” (E)
“Adding to the difficulty of treating candida auris is
finding it in the first place. The infection is often asymptomatic, showing few
to no immediate symptoms, said Chauhan. The symptoms that do appear, such as
fever, are often confused for bacterial infections, he said.
“Most routine diagnostic tests don’t work very well for
candida auris,” he said. “They’re often misidenfitied as other species.”
The best way to identify candida auris is by looking under a
microscope, which often takes time because it requires doctors to grow the
fungus, Chauhan said.
As with most infectious diseases, the best course of action
is good hygiene and sterilization protocol. Washing your hands and using hand
sanitizer after helps to prevent transmission and infection, Chauhan said.
Doctors and healthcare workers should use protective gear,
and people visiting loved ones in hospitals and long-term care centers should
take proper precautions, he said.
The Center for Disease Control recommends using a special
disinfectant that is used to treat clostridium difficile spores. The
disinfectant has been effective in wiping out clostridium difficile, known as
c. diff, and disinfects surfaces contaminated with candida auris, as well.” (F)
“Hospitals and nursing homes in California and Illinois are
testing a surprisingly simple strategy against the dangerous,
antibiotic-resistant superbugs that kill thousands of people each year: washing
patients with a special soap.
The efforts – funded with roughly $8 million from the
federal government’s Centers for Disease Control and Prevention – are taking
place at 50 facilities in those two states.
This novel approach recognizes that superbugs don’t remain
isolated in one hospital or nursing home but move quickly through a community,
said Dr. John Jernigan, who directs the CDC’s office on health care-acquired
infection research.
“No health care facility is an island,” Jernigan said. “We
all are in this complicated network.”
At least 2 million people in the U.S. become infected with
an antibiotic-resistant bacterium each year, and about 23,000 die from those
infections, according to the CDC…
Containing the dangerous bacteria has been a challenge for
hospitals and nursing homes. As part of the CDC effort, doctors and health care
workers in Chicago and Southern California are using the antimicrobial soap
chlorhexidine, which has been shown to reduce infections when patients bathe
with it. Though chlorhexidine is frequently used for bathing in hospital
intensive care units and as a mouthwash for dental infections, it is used less
commonly for bathing in nursing homes…
The infection-control work was new to many nursing homes,
which don’t have the same resources as hospitals, Lin said.
In fact, three-quarters of nursing homes in the U.S.
received citations for infection-control problems over a four-year period,
according to a Kaiser Health News analysis, and the facilities with repeat
citations almost never were fined. Nursing home residents often are sent back
to hospitals because of infections.” (G)
“The C.D.C. declined to comment, but in the past officials
have said their approach to confidentiality is necessary to encourage the
cooperation of hospitals and nursing homes, which might otherwise seek to
conceal infectious outbreaks.
Those pushing for increased transparency say they are up
against powerful medical institutions eager to protect their reputations, as
well as state health officials who also shield hospitals from public scrutiny…
Hospital administrators and public health officials say the
emphasis on greater transparency is misguided. Dr. Tina Tan, the top
epidemiologist at the New Jersey Department of Health, said that alerting the
public about hospitals where cases of Candida auris have been reported would
not be useful because most people were at low risk for exposure and public
disclosure could scare people away from seeking medical care.
“That could pose greater health risks than that of the
organism itself,” she said.
Nancy Foster, the vice president for quality and patient
safety at the American Hospital Association, agreed, saying that publicly
identifying health care facilities as the source of an infectious outbreak was
an imperfect science.
“That’s a lot of information to throw at people,” she said,
“and many hospitals are big places so if an outbreak occurs in a small unit, a
patient coming to an ambulatory surgical center might not be at risk.”
Still, hospitals and local health officials sometimes hide
outbreaks even when disclosure could save lives. Between 2012 and 2014, more
than three dozen people at a Seattle hospital were infected with a
drug-resistant organism they got from a contaminated medical scope. Eighteen of
them died, but the hospital, Virginia Mason Medical Center, did not disclose
the outbreak, saying at the time that it did not see the need to do so.” (H)
“Many have heard of the rise of drug-resistant infections.
But few know about an issue that’s making this threat even scarier in the
United States: the shortage of specialists capable of diagnosing and treating
those infections. Infectious diseases is one of just two medicine
subspecialties that routinely do not fill all of their training spots every
year in the National Resident Matching Program (the other is nephrology).
Between 2009 and 2017, the number of programs filling all of their
adult-infectious-disease training positions dropped by more than 40 percent…
Everyone who works in health care agrees that we need more
infectious-disease doctors, yet very few actually want the job. What’s going
on?
The problem is that infectious-disease specialists care for
some of the most complicated patients in the health care system, yet they are
among the lowest paid. It is one of the only specialties in medicine that
sometimes pays worse than being a general practitioner. At many medical
centers, a board-certified internist accepts a pay cut of 30 percent to 40
percent to become an infectious-disease specialist.
This has to do with the way our insurance system reimburses
doctors. Medicare assigns relative value units to the thousands of services
that doctors provide, and these units largely determine how much physicians are
paid. The formula prioritizes invasive procedures over intellectual expertise.
The problem is that infectious-disease doctors don’t really
do procedures. It is a cognitive specialty, providing expert consultation, and
insurance doesn’t pay much for that…
Infectious-disease specialists are often the only health
care providers in a hospital – or an entire town – who know when to use all of
the new antibiotics (and when to withhold them). These experts serve as an
indispensable cog in the health care machine, but if trends continue, we won’t
have enough of them to go around. The terrifying part is that most patients
won’t even know about the deficit. Your doctor won’t ask a specialist for help
because in some parts of the country, the service simply won’t be available.
She’ll just have to wing it…
We must hurry. Superbugs are coming for us. We need experts
who know how to treat them.” (I)
People visiting patients at the hospital, and most
hospitalized patients, have little to fear from a novel fungal disease that has
struck more than 150 people in Illinois – all in the Chicago area – a Memorial
Medical Center official said Friday.
“For normal, healthy people, this is not a concern,” Gina
Carnduff, Memorial Health System director of infection prevention, said in
reference to Candida auris infections.
Carnduff, who is based at Memorial Medical Center, said only
the “sickest of the sick” patients are at risk of catching or spreading the C.
auris infection or dying from it.
Those patients, she said, include people who have stayed for
long periods at health care facilities – such as skilled-care nursing homes or
long-term acute-care hospitals – and who are on ventilators or have central
venous catheter lines or feeding tubes…
Officials from both Memorial Medical Center and HSHS St.
John’s Hospital said their institutions already are using the bleach-based
cleaning solutions known to prevent the spread of C. auris and other
infections.
The Illinois Department of Public Health’s website says more
than one in every three people with “invasive C. auris infection” affecting the
blood, heart or brain will die…
The state health department says 154 confirmed cases of C.
auris and four probable cases have been identified, all in the Chicago area.
Ninety-five cases were in Chicago, 56 were in Cook County outside of Chicago,
and seven were spread among the counties of DuPage, Lake and Will.
Eighty-five of the 158 people making up the confirmed and
probable cases have died, but only one death was “directly attributed” to the
infection, Arnold said. It’s not known whether C. auris played a role in the
deaths of the other 84 people, she said. (J)
“There is also the fact that some lab tests will not
identify the superbug as the source of an illness, which means that some
patients will receive the wrong treatment, increasing the duration of the
infection and the chance to transmit the fungus to another person.” (K)
“Hospitals, state health departments and the Centers for
Disease Control and Prevention are putting up a wall of silence to keep the
public from knowing which hospitals harbor Candida auris.
New York health officials publish a yearly report on
infection rates in each hospital. They disclose rates for infections like MRSA
and C. Diff. But for several years, the same officials have been mum about the
far deadlier Candida auris. That’s like posting “Wanted” pictures for
pickpockets but not serial murderers.
Health officials say they’ll disclose the information in
their next yearly report. That could be many months from now. Too late.
Patients need information in real time about where the risks are…
Dr. Eleanor Adams, a state Health Department researcher,
examined all the facilities in New York City affected by Candida auris over a
four-year period. Adams found serious flaws, including “inadequate disinfection
of shared equipment” to take vital signs, hasty cleaning and careless
compliance with rules to keep infected patients isolated…” (L)
“Remedies for curtailing the advance of C. auris are
familiar. Health care facilities must undergo stringent infection controls,
test for new cases and quickly identify any sources passing it along. Visitors
and medical workers must wash their hands after touching patients or surfaces.
The yeast spreads widely throughout patients’ rooms. Some cleanups have
reportedly required removing ceiling and floor tiles.
C. auris isn’t simply an opportunistic infection. Its rise
is additional evidence that becoming too reliant on certain types of drugs may
have unintended consequences. Exhibit A is the overuse of antibiotics in
doctors’ offices and on farms that encourages the development of drug-resistant
bacteria. Researchers suspect a similar situation involving C. auris and
agricultural fungicides used on crops. So far the origins of C. auris are
unclear, with different clusters arising in different areas of the world.
There’s no need to panic. But vigilance is required to track
C. auris and raise awareness in order to combat it. Officials typically are
eager to spread the word about potential health crises, from measles to MRSA.
In this case, the CDC issued alerts about fungus to health care facilities, but
the New York Times encountered an unusual wall of silence while investigating
superbugs such as C. auris. Medical facilities didn’t want to scare off
patients.
Any attempts to hide the spread of a communicable disease
are irresponsible. Knowledge leads to faster prevention and treatment. Patients
and their families have a right to know how hospitals and government agencies
are responding to a new threat. Medical workers also deserve to be informed of
the risks they encounter on the job.
Battling the superbugs requires aggressive responses and,
ultimately, scientific advancements. Downplaying outbreaks won’t stop their
rise.” (M)
“The rise of C. auris, which may have lurked unnoticed for
millennia, owes entirely to human intervention – the massive use of fungicides
in agriculture and on farm animals which winnowed away more vulnerable species,
giving the last bug standing a free run. Sensitised to clinical fungicides, C.
auris has proved to be difficult to extirpate, and culls infected humans who
cannot fight diseases very effectively – infants, the old, diabetics, people
with immune suppression, either because of diseases like HIV or the use of
steroids. The new superfungus has the makings of a future plague, one of
several which may cumulatively surpass cancer as a leading killer in a few
decades.
The origin of C. auris is known because it broke out in the
21st century, but the plagues from antiquity lack origin stories. Even their
spread was understood only retrospectively, in the light of modern science. The
father of all plagues, the Black Death, originated in China in the early 14th
century and ravaged most of the local population before it began its long
journey westwards down the Silk Route, via Samarkand. At the time, the chain of
hosts that carried it would have been incomprehensible – the afflicting
organism Yersinia pestis, the fleas which it infested, the rats which the fleas
in turn infested, which carried it into the homes of humans….” (N)
“WebMD: Most of us know candida from common yeast infections
that you might get on your skin or mucous membranes. What makes this one
different?
Chiller: It’s not acting like your typical candida. We’re
used to seeing those.
Candida – the regular ones – are already a major cause of
bloodstream infection in hospitalized patients. When we get invasive
infections, for example, bloodstream infections, we think that you sort of auto-infect
yourself. You come in with the candida already living in your gut. You’re in
the ICU, you’re on a broad spectrum antibiotic. You’re killing off bad
bacteria, you’re killing off good bacteria, so what are you left with? Yeast,
and it takes over.
What’s new with Candida auris is that it doesn’t act like
the typical candida that comes from our gut. This seems to be more of a skin
organism. It’s very happy on the skin and on surfaces.
It can survive on surfaces for long periods of time, weeks
to months. We know of patients that are colonized [meaning the Candida auris
lives on their skin without making them sick] for over a year now.
It is spreading in health care settings, more like bacteria
would, so it’s yeast that’s acting like bacteria” (O).
PART 2. In 30 years, I’ve never faced so tough a
reporting challenge – and one so unexpected. Who wouldn’t want to talk about a
fungus?…
“C. auris is a drug-resistant fungus that has emerged
mysteriously around the world, and it is understood to be a clear and present
danger. But Connecticut state officials wouldn’t tell us the name of the
hospital where they had had a C. auris patient, let alone connect us with her
family. Neither would officials in Texas, where the woman was transferred and
died. A spokeswoman for the City of Chicago, where C. auris has become rampant
in long-term health care facilities, promised to find a family and then stopped
returning my calls without explanation.” (A)
“Candida auris, also referred to as C. auris, is a
potentially deadly fungal infection that appears to be making its way through
hospitals and long-term care facilities across the country. The New York City
area and New Jersey have reported more than 400 cases over the last few years
alone. Federal health authorities have declared this fungus a “serious global
health threat.”” (B)
“The Council of State and Territorial Epidemiologists (CSTE)
says Candida auris infections have been “associated with up to 40% in-hospital
mortality.”
“Most strains of C. auris are resistant to at least one
antifungal drug, one-third are resistant to two antifungal drug classes, and
some strains are resistant to all three major classes of antifungal drugs. C.
auris can spread readily between patients in healthcare facilities. It has
caused numerous healthcare-associated outbreaks that have been difficult to
control,” the CSTE said.
The CDC added, “Patients who have been hospitalized in a
healthcare facility a long time, have a central venous catheter, or other lines
or tubes entering their body, or have previously received antibiotics or
antifungal medications, appear to be at highest risk of infection with this
yeast.”
The CDC is alerting U.S. healthcare facilities to be on the
lookout for C. auris in their patients.” (C)
“”It’s a very serious health threat,” said Dr. Irwin
Redlener, Columbia University professor and an expert on public health policy.
“It’s a superbug, meaning resistant to all-known antibiotics.”..
“These people would be in danger, so you don’t want somebody
visiting the hospital not knowing that it’s around and somehow contracting the
infection,” Dr. Redlener said. “That would be an utter disaster.”..
Dr. Redlener says the secrecy is a big mistake.
“If they’re rattled by Candida auris to the point where we
have secrecy pacts among hospitals and public health agencies, then you’re just
hiding something that obviously needs more attention and resources to deal
with,” he said.
The state Department of Health says there is no risk to the
general public and notes that the vast majority of patients have had serious
underlying medical conditions.
Jill Montag, a spokesperson for the New York State
Department of Health, issued a statement to Eyewitness News.
“We are working aggressively with impacted hospitals and
nursing homes to implement infection control strategies for Candida auris,” it
read.
Montag says they plan to include the name of the impacted
facilities in their annual infection report, which will be released later this
year.
Dr. Redlener says they have the information now and should
release the names now…
“To keep that a secret is putting people in danger,” he
said. “And I don’t think that’s reasonable or ethical.”” (D)
“We don’t know why it emerged,” said Dr. Maurizio Del Poeta,
a professor of molecular genetics and microbiology at Stony Brook University’s
Renaissance School of Medicine. At the very least, he is recommending hospitals
develop stricter rules on foot traffic in and out of patients’ rooms because
the microbe can be carried on the bottom of shoes.
The pathogen clings to surfaces in hospital rooms,
flourishes on floors, and adheres to patients’ skin, phones and food trays. It
is odorless, invisible – and unlikely to vanish from health care institutions
anytime soon.
“It can survive on a hospital floor for up to four weeks,”
Del Poeta said of C. auris. “It attaches to plastic objects and doorknobs.”..…
“If we don’t want it to become like Staphylococcus aureus,
then we have to act now,” said Del Poeta, referring to the bacteria that became
the poster child of drug resistance when it developed the ability to defeat the
antibiotic methicillin, garnering the name methicillin-resistant Staphylococcus
aureus, or MRSA…
“In order to get Candida auris out of a room, you have to
take away everything – doorknobs, plastic items, everything. It is very
difficult to eradicate it in a hospital,” Del Poeta said. He said his
institution has never had a patient with C. auris…
Scientists such as Del Poeta contend it’s time for new
methods of addressing resistant microbes of all kinds because infectious
pathogens have developed the power to outwit, outpace and outmaneuver
humankind’s most potent agents of chemical warfare, many of them developed in
the 20th century.” (E)
“A case management program piloted by the New York City
health department monitors patients colonized with Candida auris after they are
discharged into the community and notifies health care facilities of their status,
researchers reported at the CDC’s annual Epidemic Intelligence Service
conference….
Patients can remain colonized with C. auris for months in a
health care setting, but it is unclear if they remain colonized after
discharge, noted Genevieve Bergeron, MD, MPH, an Epidemic Intelligence Service
officer with the New York City Department of Health and Mental Hygiene (DOHMH),
and colleagues.
According to Bergeron and colleagues, the state health
department began referring patients colonized with C. auris to the DOHMH on
Oct. 4, 2017. Approximately 12 case managers handled the referrals, conducting
patient interviews and reviewing medical records to obtain relevant clinical
information. They informed the patients’ providers and health care facilities
about their C. auris status and infection control needs.
“We requested that facilities flag the patient in their
electronic medical records to ensure that the patient has the proper
precautions, if the patient were to seek care again at those facilities,”
Bergeron said in a presentation. “Case mangers sent a medical alert card to the
patients for them to use when encountering health care providers unaware of
their infection control needs.”” (F)
“Regions are considering the use of electronic registries to
track patients that carry antibiotic-resistant bacteria including
carbapenem-resistant Enterobacteriaceae (CRE). Implementing such a registry can
be challenging and requires time, effort, and resources; therefore, there is a
need to better understand the potential impact…
When all Illinois facilities participated (n=402), the
registry reduced the number of new carriers by 11.7% and CRE prevalence by 7.6%
over a 3-year period. When 75% of the largest Illinois facilities participated
(n=304), registry use resulted in a 11.6% relative reduction in new carriers
(16.9% and 1.2% in participating and non-participating facilities,
respectively) and 5.0% relative reduction in prevalence. When 50% participated
(n=201), there were 10.7% and 5.6% relative reductions in incident carriers and
prevalence, respectively. When 25% participated (n=101), there was a 9.1%
relative reduction in incident carriers (20.4% and 1.6% in participating and
non-participating facilities, respectively) and 2.8% relative reduction in
prevalence.
Implementing an XDRO registry reduced CRE spread, even when
only 25% of the largest Illinois facilities participated due to patient
sharing. Non-participating facilities garnered benefits, with reductions in new
carriers.” (G)
“Quebec public-health authorities are bracing for the
inevitable arrival of a multi drug-resistant fungus that has been spreading
around the globe and causing infections, some of them fatal…
“We will definitely have cases here and there at one point,”
said Dr. Karl Weiss, chief of infectious diseases at the Jewish General
Hospital. “It’s almost guaranteed. The only thing is when you know what you’re
fighting against, it’s always easier and we will be able to contain it a lot
faster.”
C. auris poses a quadruple threat: it’s tricky to identify;
it can thrive in hospitals for weeks (preying on patients with weakened immune
systems); it’s resistant to two classes of anti-fungal medications; and it can
cause invasive disease, with lingering bloodstream infections that are hard to
treat. The mortality rate can rise as high as 60 per cent.
The pathogen has emerged at a time when hospitals in Quebec
– their budgets stretched more than ever – are already struggling with
antibiotic-resistant superbugs like C. difficile, MRSA and VRE that have caused
outbreaks. The Institut national de santé publique du Québec published a
bulletin last year on steps that hospitals and long-term centres can take to
prevent C. auris outbreaks.
“The problem is if you don’t identify the fungus properly,
then it can slip in between your hands, and you can have an outbreak in your
institution without even knowing it,” Weiss explained.
There was a lot of mis-indentification of this with other
Candida (fungi); and even the automated systems in institutions that identify
bacteria and yeast were mislabelling this Candida for something else. For a
while, people were not aware of this auris. But now we know how to identify it.
“The first thing we did in Quebec – and this was for all the
microbiology labs – is we taught all the microbiologists how to properly
identify Candida auris,” Weiss continued. “All the major labs in Quebec put in
place protocols.”
Weiss, who is president of the Quebec Association of Medical
Microbiologists, noted that under a quality assurance program, samples have
been sent to different labs to test whether the fungus is identified correctly.
The results show that that labs are detecting C. auris to a high degree.
If a patient is discovered to be infected, hospital protocol
dictates that the patient be isolated. During the patient’s hospitalization,
the housekeeping staff must disinfect the room daily with hydrogen peroxide and
other chemicals…” (H)
“Federal officials should declare an emergency over a
deadly, incurable fungus infecting people in New York, New Jersey and across
the country, Sen. Chuck Schumer said Sunday.
Schumer said he’s pushing the federal government to allocate
millions of dollars to fighting Candida auris, which is drug-resistant and
proving very difficult to eradicate…
“When it comes to the superbug, New York could use a little
more help,” said Schumer. “The CDC has the power to declare this an emergency
and automatically give us the resources we need.”..
Schumer said that an emergency declaration by the CDC would
lead to more cases being identified with better testing, and to better tracking
of the disease. It might also reduce the number of unnecessary antibiotic
prescriptions, which Schumer says have helped the disease become
drug-resistant…
Schumer cited other CDC emergency declarations that helped
stop the spread of deadly diseases, including a $25 million award to fight the
Zika virus in 2016 and $165 million given to contain Ebola in 2014.
“Every dollar we can use to better identify, tackle and
treat this deadly fungus is a dollar well spent,” Schumer said.” (I)
“Other medical experts see the overuse of human antifungal
medications in agriculture and floriculture as potential reasons for resistance
in Candida auris, known as C. auris, and possibly other fungi.
Dr. Matt McCarthy, a specialist in infectious diseases at
Weill Cornell Medicine in Manhattan, said tulips, signature flowers of the
Netherlands, are dosed with the same antifungal medications developed to treat
human infections.
“Antifungals are pumped into tulips in Amsterdam to achieve
flawless plants,” he said. “As a fungal expert, I know that we have very few
antifungal medications, and this is a misuse of the drugs.”
Studies conducted at Trinity College in Ireland support
McCarthy’s argument and have demonstrated that tulip and narcissus bulbs from
the Netherlands may be vehicles that spread drug-resistant fungi.
Trinity scientists, who examined resistance in another
potentially deadly fungus, Aspergillus fumigatus, uncovered why the bugs
repelled the drugs known as triazoles. The fungi became resistant because of
the overuse of triazoles in floriculture. As with C. auris, drug-resistant A.
fumigatus can be deadly in people with poor immunity.
When patients need treatment with triazole-class
medications, the drugs don’t work because the fungi have been overexposed in
the environment, McCarthy said.
He added that the use of antifungal medications in
floriculture is similar to the overuse of antibiotics in the poultry and beef
industries, which have helped drive resistance to those drugs.
The floriculture example is just one way that drug-resistant
fungi can spread around the world. Global trade networks, human travel and the
movement of animals and crops are others.” (J)
“It will take further research to determine if the new
strains of C. auris have their origins in agriculture, but Aspergillus has
already illustrated the perils of modern farming. Antibiotics are applied on a
massive scale in food production, pushing the rise of bacterial drug
resistance. A British government study published in 2016 estimated that, within
30 years, drug-resistant infections will be a bigger killer than cancer, with
some 10 million people dying from infections every year.
We don’t have to end up there. Pesticide use on most farms
can be greatly reduced, or even eliminated, without reducing crop yields or
profitability. Methods of organic farming, even as simple as crop rotation,
tend to promote the growth of mutualistic fungi that crowd out pathogenic
strains such as C. auris. Unfortunately, because conventional agriculture is
heavily subsidized and market prices don’t reflect the costs to the environment
or human health, organic food is more expensive and faces an uphill battle for
greater consumption.
Of course, improved technology could help, with drugs of new
kinds or in breeding and engineering resistant strains of plants. There’s also
plenty of opportunity for lightweight agricultural robots, which can weed
mechanically or spray pesticides more accurately, reducing the quantity of
chemicals used. But tech shouldn’t be the sole focus just because it happens to
be the most profitable route for big industries.” (K)
“The recent outbreak of the so-called superbug – and other
drug-resistant germs – has thrown a spotlight on locally based Xenex Disinfection
Systems. The company makes a robot that uses pulsing, ultraviolet rays to
disinfect surgical suites and other environments that are supposed to be
germ-free.
With the spread of C. auris, Xenex officials say they’ve
seen an uptick in queries about their LightStrike Germ-Zapping Robots, which
are in use at more than 400 health-care facilities around the world since
manufacturing started in 2011.
These devices – often called R2Clean2, Mr. Clean and The
Germinator – disinfect rooms in a matter of minutes. A dome on the top of the
robot rises up, exposing a xenon bulb that emits UV light waves that kill germs
on contaminated surfaces.
Bexar County-owned University Hospital has a fleet of six
Xenex robots. One of the robots is assigned to the Cystic Fibrosis Center to
help protect patients from infection by other patients.
“We are taking every measure possible to reduce the risk of
infections, and this is an additional layer of security that bathes the room in
UV-C light,” said Elizabeth Allen, public relations manager at University
Health System…
Another study, recently published by a doctor at the
Minnesota-based Mayo Clinic, showed that when the hospital used the robots in
rooms that had already been cleaned, infection rates of another superbug –
called Clostridium difficile, or C. diff – fell by 47 percent.” (L)
“It wasn’t publicized locally, but within the past few years
teams of health officials at two Oklahoma health facilities took rapid actions
to contain the spread of a fungal “superbug” that federal officials have
declared a serious global health threat.
Only one patient at each facility was infected, and both
patients recovered. But the incidents reflect the growing alarm among health
officials over the deadly, multidrug-resistant Candida auris, or C. auris,
which can kill 30 percent to 60 percent of those infected…
In April 2017, a team of experts from the federal Centers
for Disease Control and Prevention converged on the University of Oklahoma
Medical Center in Oklahoma City after a patient tested positive for the
drug-resistant fungus.
About a year later, a patient at a southeast Oklahoma health
facility tested positive for the germ during a routine test. In both cases,
health officials isolated the patients, locked down their rooms and ordered dozens
of lab tests to see if the multidrug-resistant fungus had spread…
Unlike with outbreaks in Illinois, New York and New Jersey,
the potentially deadly infection was quickly contained.”..
Public knowledge about the OU Medical Center case makes it
an exception. Typically, health care facilities across the nation don’t release
to the public information when C. auris and other drug-resistant pathogens are
found. No law or policy requires them to do so.
Patient-rights advocates maintain that the public has the
right to know when and where outbreaks or even single cases occur. But health
officials have routinely fought back, suggesting that it could violate patient
rights and discourage patients from seeking hospital care.
But the CDC allows states to make that decision.
Burnsed said the Department of Health tries to walk a tight
line between notifying the public and protecting the patient’s privacy.
He said he would be more likely to identify a facility if
it’s anything more than an isolated case or if officials believed the exposure
wasn’t contained.
“What we consider is if there was a risk to a broader group
of individuals and if there was any evidence that there were a breach in lab
controls,” Burnsed said. “We didn’t put out anything at the time (on Oklahoma’s
two cases) because we didn’t think there was a greater risk to the public, but
it’s a good question to consider.”” (M)
“How many people will needlessly die from a deadly bug
sweeping through New York hospitals and nursing homes before local health
officials acknowledge the danger publicly – and act accordingly?..
Yet public-health officials here have been slow to let
patients know in which hospitals the bug is lurking. Folks are left to take
their chances. That’s outrageous.
Why are officials mum? Partly because they fear that if they
disclose the information, some people who need treatment won’t go for it.
That’s a weak excuse: As McCaughey notes, there are plenty
of local hospitals that aren’t plagued by Candida auris, so patients could get
care and avoid the risk, if they know where it’s safe to go.
More likely, no one wants to damage the reputations (or
incomes) of the affected hospitals. Yet the best way to protect those
reputations is to make sure the facilities are Candida auris-free…
Meanwhile, officials say they will reveal which hospitals
have the germ – in their next yearly report. But that could be months away;
patients need to know now.
If neither the hospitals nor their government regulators are
willing to move sooner, perhaps state lawmaker should step in and require them
to do so… (N)
Infectious disease experts tell Axios they agree with a dire
scenario painted in the UN report posted earlier this week saying that, if
nothing changes, antimicrobial resistance (AMR) could be “catastrophic” in its
economic and death toll.
Threat level, per the report: By 2030, up to 24 million
people could be forced into extreme poverty and annual economic damage could
resemble that from the 2008–2009 global financial crisis, if pathogens continue
becoming resistant to medications. By 2050, AMR could kill 10 million people
per year, in its worst-case scenario.
“There is no time to wait. Unless the world acts urgently,
antimicrobial resistance will have disastrous impact within a generation.”..
By the numbers: Currently, at least 700,000 people die each
year due to drug-resistant diseases, including 230,000 people from
multidrug-resistant tuberculosis, per the UN. Common diseases – like
respiratory infections, STDs and urinary tract infections – are increasingly
untreatable as the pathogens develop resistance to current medications.
The Centers for Disease Control and Prevention says AMR
causes more than 23,000 deaths and 2 million illnesses in the U.S. annually…
What needs to be done: Jasarevic says the economic and
health systems of all nations must be considered, and targets made to increase
investment in new medicines, diagnostic tools, vaccines and other
interventions.”
The bottom line: Action must be taken to avoid a
catastrophic future.” (O)
“A recent study of patients at 10 academic hospitals in the
United States found that just over half care about what their doctors wear,
most of them preferring the traditional white coat.
Some doctors prefer the white coat, too, viewing it as a
defining symbol of the profession.
What many might not realize, though, is that health care
workers’ attire – including that seemingly “clean” white coat that many prefer
– can harbor dangerous bacteria and pathogens.
A systematic review of studies found that white coats are
frequently contaminated with strains of harmful and sometimes drug-resistant
bacteria associated with hospital-acquired infections. As many as 16 percent of
white coats tested positive for MRSA, and up to 42 percent for the bacterial
class Gram-negative rods.”
It isn’t just white coats that can be problematic. The
review also found that stethoscopes, phones and tablets can be contaminated
with harmful bacteria. One study of orthopedic surgeons showed a 45 percent
match between the species of bacteria found on their ties and in the wounds of
patients they had treated. Nurses’ uniforms have also been found to be
contaminated.
Among possible remedies, antimicrobial textiles can help
reduce the presence of certain kinds of bacteria, according to a randomized
study. Daily laundering of health care workers’ attire can help somewhat,
though studies show that bacteria can contaminate them within hours…
It’s a powerful symbol. But maybe tradition doesn’t have to
be abandoned, just modified. Combining bare-below-the-elbows white attire, more
frequently washed, and with more conveniently placed hand sanitizers –
including wearable sanitizer dispensers – could help reduce the spread of
harmful bacteria.
Until these ideas or others are fully rolled out, one thing
we can all do right now is ask our doctors about hand sanitizing before they
make physical contact with us (including handshakes). A little reminder could
go a long way.” (P)
PART 3. May 28, 2019. CADIDA AURIS.
“Antibiotic-resistant superbugs are everywhere. If your hospital claims it
doesn’t have them, it isn’t looking hard enough.”
“So far, 12 states from coast to coast have had confirmed
cases of Candida auris, which has spread with particularly speed in New York,
which has had more than half of the nation’s infections.
Some are even calling for the federal government to declare
a national state of emergency and fund better containment of the fungus.
Health officials there are scrambling to contain what the
Centers for Disease Control and Prevention (CDC) have deemed an emerging health
threat, but without stricter guidelines and screening, the fungus will only get
more deadly…
Doctors sometimes struggle to diagnose fungal infections, in
part because their symptoms are little different from those of bacterial
infections…
‘Candida auris has the ability to develop resistance and has
developed mechanisms to survive,’..
‘It’s at least starting to figure that out, and that’s
obviously concerning.’
There are really only three antifungal medications in the
US, so it doesn’t take long for a fungus to become wholly drug resistant.
Dr Chiller says that approximately 90 percent of strains the
CDC has logged are resistant to the first-line drug, another third are
resistant to a second, and between 20 and 30 percent of Candida auris
infections have acquired multi-drug resistance.
‘Some are pan-resistant and those need to be isolated and
stopped and we need to try to prevent them from developing,’ he says.
Neither the CDC, other nation’s health officials or any of
the 12 affected states have been able to work out where the fungus came from,
or how exactly it has spread from state-to-state…
If states don’t require their hospitals to report cases the
fungal infection, the CDC may be severely underestimating the number of cases
across the country.
‘It’s a bit of an uphill battle and it needs to be a really
concerted effort on multiple tiers of the health care system,’ Dr Chiller says…
‘We need to stay on top of it and not let our guard
down.’ (A)
“New York State health officials are considering rigorous
new requirements for hospitals and nursing homes to prevent the spread of a
deadly drug-resistant fungus called Candida auris.
The requirements could include mandatory pre-admission
screening of patients believed to be at-risk and placing in isolation those
patients who are infected, or even those just carrying the fungus on their
skin.
Dr. Howard Zucker, the state health commissioner, and a
fungal expert from the federal Centers for Disease Control and Prevention met
last Friday in Manhattan with nearly 60 hospital officials from across the
state to discuss the proposed guidelines. State health officials said they were
seeking hospital input before issuing the guidelines, which they acknowledged
would likely be a hardship for some institutions.
“One of our guiding objectives is to stop the geographic
spread,” said Brad Hutton, the state’s deputy commissioner of public health. He
said the state’s efforts to contain the spread have required significant
resources — including sending individual infection specialists to investigate
more than 150 cases — and that New York now needs help from individual
institutions.
“We’re at a point where our response strategy needs to
change,” he said. He added that he hoped the guidelines would be finalized by
the end of the year, but said the state is still determining whether to apply
them statewide or just to New York City and surrounding areas. It has yet to be
decided whether the guidelines would be recommendations or regulatory
requirements, he said…
For the moment…. hospitals are pre-screening many patients
who appear to be at risk. But it can take a week to get skin-swab results back
from the state laboratory, posing challenges for housing patients in isolation
during the interim. Further, she said, regular testing is likely to turn up
patients who are carriers but not infected, increasing the number of patients
who require isolation, appropriately or not.”..
For now, much of the burden for surveillance has fallen to
the state. The effort has involved the development of a fast-screening test
that can analyze a skin swab in a matter of hours. But all hospitals, for the
moment, have to send those tests to a state laboratory in Albany and wait
several days before receiving the results, though hospitals say the backlog
means tests can take a week.” (B)
“Unlike cholesterol drugs taken by millions of people for
their entire lives, or $100,000 cancer drugs designed to prolong life,
antibiotics are short-term drugs with limited shelf lives.
“Antibiotics are not valued by society as a high-value
product, so they’re not priced very high,” said Gregory Frank, director of infectious
disease policy at the Biotechnology Innovation Organization, in a phone
interview.
A 2014 paper.. cited a London School of Economics study
showing that while a new arthritis drug’s net present value – a measure of a
drug’s net value over the ensuing decades – would be $1 billion, that of a new
antibiotic would be negative $50 million…
People will buy innovative products in almost any other part
of the economy, but doctors will still keep even the most innovative antibiotic
behind the glass and use it only in the most dire circumstances.
“Antibiotic stewardship is a good thing, but devastating for
the company developing it,” Outterson said…
Jersey City, New Jersey-based Scynexis is one company
developing a treatment for drug-resistant fungal infections, ibrexafungerp,
currently in several clinical trials, including one for C. auris. The company
plans to file its first approval application with the FDA for ibrexafungerp
next year. The drug is expected cost $450-600 per day, in line with the pricing
of other antifungals, said company CEO Marco Taglietti, in a phone interview…
The race against drug-resistant infectious is ultimately a
scientific one. It’s not about finding
better treatments, but newer ones in an endless war that requires always
staying one step ahead of ever-evolving germs, Taglietti said. On the one hand,
it’s important to practice good stewardship in order to delay resistance.
“But that creates a big challenge from an economic point of
view – from the moment you launch your product after spending several hundreds
of millions to develop it, it doesn’t sell,” he said.
The problem appears to be a vicious cycle of science and
economics: Even existing push incentives, however generous, don’t make up for
antibiotics’ lack of the large and chronic patient populations of
cardiovascular disease drugs or the high prices of cancer drugs.” (C)
“Demanding that hospitals release lists of every superbug
they find within their walls, however, as many transparency advocates want, is
not the answer. The irony is that the hospitals that see the most superbugs are
often the best ones we have, for the simple reason that they have the most
sophisticated diagnostic platforms, the most powerful antibiotics and the
experts to administer them.
Compelling a world-class hospital like Massachusetts General
Hospital, where I saw my first superbug as a medical student, to reveal a
microbe list would only freak patients out. It wouldn’t explain where the
microbes came from, whether any patients were infected, and how they were
cured.
In a worst-case scenario, more transparency could lead to
patients avoiding medical care out of a misplaced fear of encountering
drug-resistant bacteria. Hospitals might start refusing patients with certain
infections, especially those coming from nursing facilities where these
microbes are common, out of a concern that the patient’s bacteria could be
added to the list. This would do everyone a disservice: Patients wouldn’t
receive optimal care and superbugs would multiply.
But hospital administrators and government officials do need
to be honest about the microbes in our medical centers and explain what is
really going on. No comment will no longer suffice. People have questions and
this story is not going away. To ensure that patients are well-informed,
hospitals should train spokesmen to address these issues and states should
revisit their reluctance to disclose information. Above all, health care
workers and administrators should speak openly about the measures their
hospitals are already employing to keep people safe.
I’m not particularly interested in the microbes that dwell
inside of a given hospital; what matters is whether its employees follow the
strict protocols that prevent these organisms from going where they shouldn’t…
Silence and evasion gives the perception that this is a
problem spiraling out of control when, in fact, it’s not. An intricate tracking
system exists so that epidemiologists across the country can monitor any
outbreaks to ensure that proper protocols and containment strategies are
implemented. We need to hear more from these superbug hunters.” (D)
“A new study published in the Journal of Occupational and
Environmental Health has established protocols for containing the drug
resistant Candida auris (C. auris ) in an animal facility, and by doing so, has
identified four simple rules that can potentially be adopted by healthcare
facilities to limit exposure to staff and patients. The study found that their
double personal protective equipment (PPE), work ‘buddy’ system, disinfection
and biomonitoring protocols were effective at containing high levels of C.
auris infection within their animal facility, even six months after their
experiments…
Before entering the animal holding and procedure rooms,
staff donned a second layer of booties, gloves and gowns, which were later
removed and placed in biohazard bins before exiting the rooms. Handling of
infected cages and equipment was restricted to biosafety cabinets where a buddy
system was implemented so that one person handed clean cages and supplies to a
second person working inside the contaminated biosafety cabinet. This
system-controlled workflow from clearly defined ‘clean’ to ‘dirty’ areas and
allowed workers to monitor each other to ensure proper procedures were
followed. Surfaces and equipment that came in contact with infected mice or
tissues were treated with a strict disinfection protocol of 10% bleach followed
(after five minutes) by 70% ethanol. The effectiveness of the workflow and
protocols were continually monitored using swab testing on surfaces suspected
to be contaminated, and as a second measure, Sabbaroud dextrose plates were
placed inside the biosafety cabinet and on the floor underneath to determine
whether C. auris was aerosolised within the cabinet or whether any debris
contaminated the floor.
The researchers found that possible contamination came from
direct contact with the infected mice or tissues but not from aerosolisation.”
(E)
“A pernicious disease is eating away at Roy Petteway’s
orange trees. The bacterial infection, transmitted by a tiny winged insect from
China, has evaded all efforts to contain it, decimating Florida’s citrus
industry and forcing scores of growers out of business.
In a last-ditch attempt to slow the infection, Mr. Petteway
revved up his industrial sprayer one recent afternoon and doused the trees with
a novel pesticide: antibiotics used to treat syphilis, tuberculosis, urinary
tract infections and a number of other illnesses in humans…
The use of antibiotics on citrus adds a wrinkle to an
intensifying debate about whether the heavy use of antimicrobials in
agriculture endangers human health by neutering the drugs’ germ-slaying
abilities. Much of that debate has focused on livestock farmers, who use 80
percent of antibiotics sold in the United States.
Although the research on antibiotic use in crops is not as
extensive, scientists say the same dynamic is already playing out with the
fungicides that are liberally sprayed on vegetables and flowers across the
world. Researchers believe the surge in a drug-resistant lung infection called
aspergillosis is associated with agricultural fungicides, and many suspect the
drugs are behind the rise of Candida auris, a deadly fungal infection.” (F)
“A large Candida
auris outbreak at a hospital in England appears to be linked to reusable
patient-monitoring equipment, a team of researchers reports today in the New
England Journal of Medicine.
The outbreak in the neurosciences intensive care unit (ICU)
at Oxford University Hospitals involved 70 patients who were infected or
colonized with C auris, a fungus that has become increasingly resistant to
azoles, echinocandins, and polyenes—the three classes of antifungals used to
treat infections caused by Candida and other fungal species.
An epidemiologic investigation and case-control study by
investigators from the University of Oxford, Public Health England, and
elsewhere found that the most compelling explanation for the prolonged outbreak
was the persistence of the organism on reusable skin-surface axillary probes, a
device placed in a patient’s armpit for continuous temperature monitoring.
“Our results indicate that reusable patient equipment may
serve as a source of healthcare-associated outbreaks of infection with C.
auris,” the authors of the study write.” (G)
B.To Fight Deadly Candida Auris, New York State Proposes New Tactics, by Matt Richtel, https://www.nytimes.com/2019/05/23/health/candida-auris-hospitals-ny.html?smid=nytcore-ios-share
PART 4. CANDIDA AURIS. “.. nursing facilities, and
long-term hospitals, are…continuously cycling infected patients, or those who
carry the germ, into hospitals and back again.”
“Maria Davila lay mute in a nursing home bed, an anguished
expression fixed to her face, as her husband stroked her withered hand. Ms.
Davila, 65, suffers from a long list of ailments — respiratory failure, kidney
disease, high blood pressure, an irregular heartbeat — and is kept alive by a
gently beeping ventilator and a feeding tube.
Doctors recently added another diagnosis to her medical
chart: Candida auris, a highly contagious, drug-resistant fungus that has
infected nearly 800 people since it arrived in the United States four years
ago, with half of patients dying within 90 days.
At least 38 other patients at Ms. Davila’s nursing home,
Palm Gardens Center for Nursing and Rehabilitation in Brooklyn, have been
infected with or carry C. auris, a germ so virulent and hard to eradicate that
some facilities will not accept patients with it…
Much of the blame for the rise of drug-resistant infections
like C. auris, as well as efforts to combat them, has focused on the overuse of
antibiotics in humans and livestock, and on hospital-acquired infections. But
public health experts say that nursing facilities, and long-term hospitals, are
a dangerously weak link in the health care system, often understaffed and
ill-equipped to enforce rigorous infection control, yet continuously cycling
infected patients, or those who carry the germ, into hospitals and back again.”
(A)
“A team of doctors at Lenox Hill Hospital has reported that
a patient at their facility lost an eye due to panophthalmitis, which was
caused by a Candida auris infection. In their report published in the Annals of
Internal Medicine, the group describes the patient, his symptoms and treatment…
In this new finding, a 30-year-old male patient came to the
trauma center at Lenox Hill Hospital complaining of eye pain and loss of vision
in one eye. He was diagnosed with panophthalmitis—a condition, not a disease—in
which the entire eye becomes inflamed. The doctors treating him reported that
the eye was damaged beyond repair. They removed it and cleaned up the socket.
Lab tests showed that the inflammation was due to Candida auris—the first such
infection of its kind seen in the eye. The doctors also noted that the patient
did not have a compromised immune system despite having syphilis and HIV. After
dispensing treatment aimed at eradicating the fungus, the patient was
discharged with instructions to return for a follow-up. But he did not do so,
thus it is not known if the infection was fully cleared, or if the patient
infected anyone else.” (B)
“A relatively new
fungus has scientists scratching their heads in 30 countries, including India.
Called Candida auris (C. auris), it has become a red flag for the medical
community. Why? C. auris is drug-resistant, it can survive almost anywhere –
even on sterilized medical equipment – and it is increasingly causing
infections in patients in the Intensive Care Unit (ICU).
Normally Candida, a species of fungus, causes the most
superficial skin infections and can be treated with over-the-counter drugs. C.
auris, by contrast, does not respond well to antifungal drugs – not only is C.
auris resistant to most medicines, it is actually more likely to affect
patients who are given antifungal drugs to prevent common Candida infections.
First isolated in japan in 2009, C. auris was originally
thought to cause ear infections. Since then, scientists have discovered that it
is more invasive – and deadly. In India, the first cases of C. auris infection
came to light in 2011.
According to the US-based Centres of Disease Control and
Prevention (CDC), there’s a higher chance of C. auris infection in patients in
a hospital set-up, and among those fitted with a central venous catheter and
other devices which go inside the body. CDC data also show that patients who
have received antibacterial or antifungal drugs are at the highest risk of C.
auris infection than those who have not. The CDC says that 30-60% of patients
infected with C. auris infection die, however, most had a prior serious illness
with a compromised immune system…
“What makes C. auris
even more dangerous is that it can grow in all kinds of places – dry areas,
moist places, plastic surfaces, and sterilized areas and equipment,” said Dr
Archana Nirula, medical officer, myUpchar.com…
It’s an understatement to say that C. auris is quirky. Even
as scientists are throwing all their weight behind research to find a cure,
doctors are banking on good old hygiene and echinocandins – an antifungal drug
that seems to work in select cases of C. auris infection. ICMR has even
recommended that doctors schedule any interventional procedures for C.
auris-infected patients at the end of the day – C. auris can survive
sterilization and the infection can spread to other patients through medical
equipment.” (C)
“When this deadly fungus first emerged in America, it was
not disclosed to the public for a lengthy period of time. Then, when details of
deaths in hospitals due to the superbug went public, the national news media
reacted but then went silent. Why?…
“Who’s speaking up for the baby that got the flu from the
hospital worker or for the patient who got MRSA from a bedrail? The idea isn’t
to embarrass or humiliate anyone, but if we don’t draw more attention to
infectious disease outbreaks, nothing is going to change,” Arthur Caplan, PhD…
“The average person
calls Candida infections yeast infections,” William Schaffner, MD, Professor
and Chair, Department of Preventative Medicine at Vanderbilt University Medical
Center, told Prevention. “However, Candida auris infections are much more
serious than your standard yeast infection. They’re a variety of so-called
superbugs [that] can complicate the therapy of very sick people.”
The CDC reports that, as of May 31, 2019, there have been a
total of 685 cases of C. auris reported in the US. The majority of those cases
occurred in Illinois (180), New Jersey (124), and New York (336). Twenty more
cases were reported in Florida, and eight other states—California, Connecticut,
Indiana, Maryland, Massachusetts, Oklahoma, Texas, and Virginia—each had less
than 10 confirmed cases of C. auris.
The CDC states the infection seems to be most prominent
among populations that have had extended stays in hospitals or nursing
facilities. Patients who have had lines or tubes such as breathing tubes,
feeding tubes, or central venous catheters entering their body, and those who
have recently been given antibiotics or antifungal medications, seem to be the
most vulnerable to contracting C. auris…
The fungus typically attacks people who are already sick or
have weakened immune systems, which can make it challenging to diagnose, the
CDC notes. C. auris infections are typically diagnosed with special clinical
laboratory testing of blood specimens or other body fluids. Infections have
been found in patients of all ages, from infants to the elderly…
The CDC states that it and its public health partners are
working hard to discover more about this fungus, and to devise ways to protect
people from contracting it. Average healthy people probably don’t need to worry
about becoming infected with Candida auris. However, individuals who are at
high risk, and healthcare professionals, microbiologists, and pathologists,
should be on the alert for this new superbug strain of fungus.” (D)
“A new report from the US Centers for Disease Control and
Prevention (CDC) warns health care organizations and providers that overseas
hospitalization and carbapenemase-producing organism (CPO) colonization or
infection should be seen as warning signs for the presence of Candida auris.
The warning, published in the CDC’s Morbidity and Mortality
Weekly Report, comes after a case in Maryland last September in which a patient
was admitted to the hospital with multiple CPO colonizations/infections. The
patient had previously spent a month in a Kenyan hospital after suffering a
cerebral hemorrhage while visiting the African country…
The CDC recommends that anyone who has been hospitalized
overnight overseas in the past 12 months be screened for C auris. The agency
also recommends contact precautions and CPO screening for any patient with an
overnight overseas hospital stay in the previous 6 months.
Richard B. Brooks, MD, of the Division of Healthcare Quality
Promotion at the CDC’s National Center for Emerging and Zoonotic Infectious
Diseases, told Contagion® that overseas
travel is an important risk factor for C auris, but he said awareness of the
link between C auris and receiving care overseas varies from hospital to
hospital and provider to provider.
In the case of the Maryland patient, public health officials
were already on alert since the health department had previously found CPOs and
C auris in a patient who had been hospitalized in India.
Unfortunately, Brooks said, many hospitals miss
opportunities for screening because they are unaware that a patient has
traveled overseas…
If a patient is indicated for C auris screening, Brooks
cautioned that most routine hospital testing platforms can easily misidentify C
auris, and he noted that commercial testing is not currently available to
hospitals. However, Brooks said the CDC’s Antibiotic Resistance Laboratory
Network will perform the test free of charge. Health care facilities can
request testing through their state health departments. The test itself is
simple, he said.
“Screening for C auris colonization requires gently rubbing
a cotton swab over a patient’s skin in their axillae (armpits) and groin areas,
and is not particularly difficult, invasive, or time-consuming,” he said.” (E)
“Prevention of invasive Candida infections requires
antibiotic stewardship, improved maintenance practices for central venous
catheters, and targeted antifungal prophylaxis.
Multidrug-resistant Candida auris is an urgent antimicrobial
resistance threat and the key method of C auris prevention is strict adherence
to infection control measures, according to a short opinion paper published in
the Annals of Internal Medicine.
Unlike other Candida spp, C auris is commonly transmitted between
patients in healthcare settings and primarily colonizes the skin and nares.
Currently, there are no known strategies for C auris decolonization…
Although early identification is key to controlling C auris
transmission, “many laboratories lack mycology capacity, and those that have it
may not routinely determine yeast species, even in sterile site isolates”
according to the researchers.
Antibiotic stewardship, improved maintenance practices for
central venous catheters, and targeted antifungal prophylaxis are all required
for preventing invasive Candida infections; however, the key difference for C
auris prevention is strict adherence to infection control measures.
While much more needs to be learned about C auris,
“preventing the spread of this organism is a priority that requires bolstering
laboratory detection capacity, strengthening public health surveillance, and
improving infection control practices, especially in postacute care settings,”
concluded the researchers.” (F)
“In any other year, it seems, this would be big news: A
drug-resistant yeast is spreading around the world, behaving like a cross
between a fungus and a bacterium. It lodges itself so tenaciously in hospital
environments that cleanups can resemble demolitions. It can’t be easily
identified with standard laboratory methods, and it kills 30% to 60% of the
people it infects.
The yeast, Candida auris, “is a creature from the black
lagoon,” according to Dr. Tom Chiller, who heads the Mycotic Diseases
Branch of the U.S. Centers for Disease Control and Prevention. At the 20th
Congress of the International Society for Human and Animal Mycology in
Amsterdam in 2018, he also noted that C. auris is ” more infectious than
Ebola.” Indeed, by the end of May C. auris had been reported in more than
30 countries, according to the CDC.
This sounds like the stuff of nightmares, or material for an
update to the 2011 medical action thriller, “Contagion.”
Surprisingly, Chiller seems unperturbed about the secrecy,
stating that C. auris “is not something I want the general public to go
home and be concerned about.”..
This is why transparency is critical. When Chiller and
others argue that the general public doesn’t need to be concerned about C.
auris, they are drawing a distinction between concerns of public health and
matters of personal health. Obviously these are different, but they are also
linked.
Secrecy in medicine has a long and sordid history, including
the familiar scandals around experimentation, mistakes and malpractice, and
price gouging. Healthcare, pharmaceutical, and agricultural organizations, ever
sensitive to their reputations and the bottom line, respond to public
pressure.” (G)
The considerations by New York State health officials were
reported by the New York Times last week. The newspaper reported that Howard
Zucker, M.D., the state health commissioner, and a fungal expert from the
federal Centers for Disease Control and Prevention met this month with nearly
60 hospitals to discuss possible guidelines.
New York has handled 331 cases of C. auris since it was
first identified in 2009. It spreads easily, is extremely resistant to drug
treatments, is hard to kill on surfaces and may spread in the air. While
scientists are working on ways to short-circuit the fungus itself, New York
wants to stop the costly geographic spread.
“We’re at a point where our response strategy needs to
change,” Brad Hutton, the state’s deputy commissioner of public health, told
the Times. He said it remains undecided whether final guidelines, expected by
year’s end, would apply statewide or only in New York City.
Hospitals and other providers have raised concerns about the
cost and capacity for rapid testing, while isolation for carriers who aren’t
actively infected could take away beds needed by others.” (H)
“”To keep that a secret is putting people in
danger,” said Dr. Irwin Redlener, a Columbia University professor with an
expertise in Public Health policy. “And I don’t think that’s reasonable or
ethical.”
Palm Centers declined comment on repeated questions by
Eyewitness News regarding the presence of Candida auris at the facility.
The New York State Department of Health provided a statement
about its efforts to contain the bug.
“The Department of Health has made controlling the spread
of C. auris a top priority and has conducted extensive training and education
on infection control policies and procedures for Palm Gardens and other nursing
home providers throughout this region. We take complaints regarding quality of
care extremely seriously and ensure all appropriate steps to protect the health
and well-being of nursing home residents,” said Jeffrey Hammond, NY
Department of Health spokesperson.
Hammond added that a list of facilities with C. auris cases
will be released later this year in the 2018 Hospital Acquired Infection
Report.” (I)
PART 1. *written by Jonathan M. Metsch on September 14,
2001; published in the Jersey Journal on September 18, 2001
Military helicopters and jets were overhead, as President
Bush was getting ready to leave. The plumes of smoke from the World Trade
Center were still billowing skyward.
Suddenly a huge white military hospital ship with four Red
Crosses steamed by and docked right across river. I thought how this hospital
ship brought the war even closer to home but mostly about how the hospitals in
Hudson County had responded and performed so magnificently.
Liberty HealthCare System is comprised of Jersey City
Medical Center, Greenville Hospital, and Meadowlands Hospital Medical Center.
The Medical Center, the County’s Trauma Center, treated 175 patients.
Greenville treated 11 patients and processed over 500 volunteers who wanted to
give blood; Greenville had originally been asked by the Red Cross to be a blood
center but this was changed early on so donor information was passed (every
volunteer was “typed and matched”) to the blood collection centers. Meadowlands
treated 7 patients and was preparing to be a command center given its heliport;
late Tuesday night Governor DiFrancesco used the heliport to depart from his
visit to the triage center at Liberty State Park.
Every hospital in the County provided emergency services to
victims. According to the Jersey Journal: Palisades Medical Center treated 12
patients; St. Francis Hospital treated 67 patients; Christ Hospital treated 54
patients; St. Mary Hospital treated 74 patients. Bayonne Hospital treated 58
patients.
At the Medical Center staff watched from windows the attack
on the World Trade Center, then immediately went on Disaster Alert. Over 150
physicians covering all medical and surgical specialties were in the building
as they are every day, and over 1000 other staff joined predetermined teams –
trauma and surgery in the emergency room, and “walking wounded” in the
auditorium. The library was organized for aftercare and rooms were set up for
family members arriving from all over the metropolitan area. The injured
started arriving around 10AM and suddenly, and sadly, everything stopped about
6PM. We hope and waited for more patients, and still wait “on alert”, our hope
fading.
Since the New York City Command Center was in the World
Trade Center complex and destroyed, good information was not available. We were
told to expect somewhere between 2000 and 5000 injured.
Many others contributed to our success in handling the
medical response to this act of war:
– Over 200 ambulances simply appeared from all over the
state to assist. They were restocked from Medical Center inventory and
dispatched by Medical Center EMS.
– New Jersey Commissioner of Health and Senior Services
George DiFerdinando was in contact with us immediately and made sure we were
re-supplied, and developed a plan with whereby trauma centers outside of Hudson
County were on high alert so patients could be transported there to prevent
Hudson County hospitals from being overwhelmed.
– Every hospital in the New Jersey was on disaster alert
with elective admissions and surgery cancelled, and disaster teams ready until
late Tuesday evening.
– Providers of food, IV solutions, medications, surgical
supplies, and much more sent in truckloads of supplies without being asked.
– Volunteers poured in to help us in any way possible. For
example with their help a “Hot Line” was set up at the Medical Center with
up-to-date information on all disaster victims seen at New Jersey hospitals.
This “Hot Line” was soon designated as “official” until the New York City
Command Post was reestablished.
– Hudson Cradle opened its doors, wanting to help, wanting
to serve.
– Mayor Cunningham and Jersey City police and fire officials
coordinated all local efforts while supporting the recovery in New York City
and securing the waterfront where victims were arriving by ferry in great
numbers to several sites including Exchange Place and Liberty State Park. I
know public officials in Hoboken, Secaucus, Bayonne and Weehauken did the same.
– And untold numbers were praying for the victims and those
providing care – we could feel those prayers.
How can you help? Volunteer to give blood; blood will be
needed for weeks and months to come. If you can, make a cash donation to help
the families of those killed in this tragedy. Certainly go to community vigils
and prayer services. Befriend someone who does not look like you and let them
know that all Americans share this pain together and that the beauty of America
is that we all came from somewhere else, and now live and work harmoniously
side-by-side.
On a practical level we and other local hospitals can use
your help. If you are a mental health worker and want to help with World Trade
Center disaster Crises Counseling in hospitals, schools, and offices please
call us. If you are a nurse who works outside the County or doing something
else right now – particularly emergency room, critical care and operating room
nurses, though all nurses are welcome – and want to be on our roster of
volunteers for future emergencies please us. And if you just want to join the
cadre of volunteers at our hospitals please call us. Please call 201 915-2048.
Finally I want to thank all the staff at Liberty, who once
again, provided services so well. They acted heroically while worried about
missing family and friends, and their children at home who had to cope with
this tragedy without them nearby. I am honored to work with you.
Since Jersey City Medical Center was the New Jersey anchor
in the response, I prepared a confidential Lessons Learned memorandum in
preparation for a Debriefing Meeting called by the Democratic Party candidate
for Governor.
As a courtesy I provided a copy of the memorandum to Bret
Schundler, the former Mayor of Jersey City who was out-of-the country on
September 11th and could not get back for almost a week. He was the Republican
Party candidate for Governor. I forget that “No good deed goes unpunished” and
Schundler widely circulated the document as a campaign issue.
“Rookie” mistake! Read the article below. What would you
have done differently?
New York Times. September 22, 2001
Schundler Assails New Jersey’s Response to Terrorist Attack
By DAVID M. HALBFINGER
Making the World Trade Center disaster the focus of his
campaign for governor, Bret D. Schundler is criticizing New Jersey’s response
to the attack and has released his own plan to improve the state’s defenses
against terrorism and its preparedness for future emergencies.
Mr. Schundler, the Republican candidate, has said that both
the State Police and the National Guard reacted slowly and mismanaged their
resources after the Sept. 11 attack, and that flaws in New Jersey’s
emergency-management system made it difficult to coordinate the efforts of
hospitals, ambulance crews and other volunteers.
Mr. Schundler, the former mayor of Jersey City, is now
calling for bolstering New Jersey’s defenses, including restoring to the
nation’s air-defense system an Air National Guard fighter wing that is
stationed in Atlantic City and which, until two years ago, had two F-16’s ready
to scramble 24 hours a day. He said New Jersey should conduct a thorough
inventory of sensitive installations, like power plants, reservoirs and
chemical factories, and immediately enhance security at Newark Airport and the
the Hudson and Delaware River crossings.
He is also proposing an array of measures to improve the
state’s response to emergencies, like maintaining rosters of doctors, nurses,
engineers and others who might be needed in the case of another terrorist
attack.
Mr. Schundler’s aides described his proposals as an attempt
to provide leadership where it was needed and denied that he was trying to
jump-start his campaign, which has stalled along with most of the political
machinery in New Jersey.
But in critiquing the state agencies, hospitals and other
institutions that responded to the attack — while the smoke is still rising
from ground zero and many voters are still awaiting the remains of their loved
ones — Mr. Schundler is running a huge risk: that he could be seen as trying to
make hay out of a national tragedy.
”This is not a political exercise,” said Richard McGrath, a
spokesman for James E. McGreevey, the Democratic candidate. ”Jim McGreevey’s
been working in a quiet way to assimilate as much information as possible to
address emergency needs and prevent future catastrophes,” Mr. McGrath said.
”This terrorist incident has had a profound effect on all Americans, and we
don’t intend to parcel it out with any political agendas.”
In a telephone interview he initiated on Thursday, Mr.
Schundler described a number of ways in which the state’s response to the
attack had apparently broken down. For instance, he said he had been told by a
police official in Jersey City that the State Police troopers who set up an
operations center in Liberty State Park ”didn’t do much of anything — they just
sat there.”
Mr. Schundler added that the troopers’ ”inaction” had forced
the city’s police department to coordinate the supply effort for emergency
workers, and said that troopers did not even arrive in Jersey City until 4:30
p.m. on the day of the attack.
Officials of the State Police and other agencies today
briefed Mr. Schundler and Mr. McGreevey about their efforts. But on Thursday,
Col. Carson Dunbar, the superintendent of the force, said there had been
numerous tussles over turf in the hours after the attack, which were compounded
by the loss of a radio-transmission tower at the World Trade Center, and which
could have led to crossed signals about troopers’ assignments. But Colonel
Dunbar said that state troopers were on the scene in Jersey City almost
immediately after the attack. For instance, he said, one marine unit was among
the first to ferry the injured to safety in New Jersey.
On Thursday, Mr. Schundler also released a five-page
memorandum about breakdowns in the state’s response system that was prepared by
Jonathan M. Metsch, president and chief executive of Jersey City Medical
Center, which treated 175 people hurt in the attack.
The memo noted that police from outside Jersey City had
prevented staff members from getting to the hospital; that National Guard
troops who drove ambulances to the hospital ”had no leadership and provided no
help”; that the blood donor system ”did not work”; and that it ”took too long”
to prepare a list of the injured being treated at New Jersey hospitals, meaning
each hospital was inundated with thousands of calls.
Dr. Metsch, reached today, said he had written the memo for
state health officials, that it amounted only to his own impressions, and that
he had done so merely to ensure that lessons would be learned, not to assess
blame. He said he provided a copy to Mr. McGreevey on Wednesday after a private
meeting of hospital executives that Mr. McGreevey had called to inquire about
the response to the twin towers attack and ways to improve New Jersey’s
readiness.
Dr. Metsch said he then provided a copy to Mr. Schundler,
whom he called a friend, as a courtesy. But he said he had not expected the
memo to be released to the public. ”These were off-the-record observations,” he
said, adding that over all, New Jersey performed admirably.
But Bill Pascoe, Mr. Schundler’s campaign manager, said Dr.
Metsch had not asked Mr. Schundler to keep the memo confidential. And he said
Mr. Schundler’s use of it transcended politics.
”If the U.S. responds anytime in the next few days or weeks,
we may be facing an immediate counterattack from the terrorists,” Mr. Pascoe
said.
”We don’t have the luxury of time to let the dust settle. We
have to use this event and our response to it right now as a learning exercise.
What have we learned about what we did right and did wrong? What can we do
better? That’s the point, and that’s the job of a leader.”
ASSIGNMENT: You are the CEO of a hospital in
the cone of Hurricane Dorian! Tomorrow morning you have an 8AM Board of
Trustees Conference Call to brief Board members on your hospital’s Rapid
Response plan.
Starting with the sources below prepare your 15 minute
presentation!
____________________
We don’t know what we don’t know” The challenge to emergency
preparedness…..
“…the only way..to respond to a crisis ..is to ensure every
member of the staff feels as though they are part of a team.” (Hurricanes, Mass
Disasters, Wild Fires)
“Houston’s world-renowned health care infrastructure found
itself battered by Hurricane Harvey, struggling to treat storm victims while
becoming a victim itself.”
“Calling 911 (about Hurricane Harvey) didn’t work. Begging
for help on Facebook and Instagram failed, too. “I was like, ‘Siri’s smart
enough! Let me ask her!’ …
As he looked at the full beds and patients “packed and
stacked in the hallways,” he shifted into triage mode, asking himself “Who’s
dying first?” and who could he save.
It appears that Hurricane Irma evacuation shelter managers
may make people wait outside for hours? If so, just welcome them in and then do
the registration process inside.
Over the years I have collected some aphorisms, quotations
and “classics” perhaps worth sharing.
“I made a lot of mistakes in my time but didn’t waste any
time making them.” (attributed to Gustave Levy, Goldman Sachs)
“There are no secrets to success. It is the result of
preparation, hard work and learning from failure.” (Colin Powell)
“A person who never made a mistake never tried anything new.” (Albert Einstein)
The three umpires (attributed to many):
At a post-season symposium three umpires were discussing
“what’s a ball and what’s a strike?”
The rookie umpire said “There are balls and there are
strikes and I call them as they are.”
The mid-career umpire said “There are balls and there are
strikes and I call them as I seem them.”
The veteran umpire said “There are balls and there are strikes but they ain’t nothing til I call them.”
“Trust, but verify!” (Ronald Reagan)
“If Columbus had an advisory committee he would probably
still be at the dock.” (Arthur Goldberg)
“Meetings without an agenda are like a restaurant without a menu.” (Susan B. Wilson)
Dr. Jerome Groopman in “How Doctors Think” developed a
classification system for medical mistakes, observing a tendency to treat a
case based on past experience rather than looking at it based solely on the
evidence.
Vertical Line Failure – thinking inside the box
Confirmation Bias – confirming what you expect to find by
selectively accepting or ignoring information
Anchoring –the failure to consider multiple possibilities
but quickly and firmly latching on a single one
Availability –an unusual event that recently occurred which
has similarities to the current case causing MD to ignore important differences
Commission Bias – tendency toward action rather than
inaction due to “bravado”, desperation, or patient pressure
Relying on “Strict Logic” – answering a clinical question in
the absence of empirical data
Over-reliance on Clinical Algorithms – simply filling in the
blanks on the template
Haste – complicated problems cannot be solved quickly
Outcome Bias – thinking that the diagnosis that is wished
for has occurred• Limited Searching –stop searching for a diagnosis once “
This is not to criticize physicians who get most things right and in a very challenging, fast-moving environment occasionally make mistakes. The point is we all fall into comfortable patterns of thinking – our own default classification systems.
“If you’re stuck in a routine that’s limiting your creativity or you’re faced with a challenging business problem and need a fresh approach, you can think outside the box. Or even better, think like there is no box.”
When you’re not sure flip a coin because while the coin is in the air, you realize which one you’re hoping for.” (source unknown)
“There are known knowns. These are things we know that we know.
There are known unknowns. That is to say, there are things that we know we
don’t know. But there are also unknown unknowns. These are things we don’t know
we don’t know.” (Donald Rumsfeld)
“No battle plan survives contact with the enemy.” (Helmuth
von Moltke the Elder. He was the Chief of Staff of the Prussian army before
World War 1)
“Insanity: doing the same thing over and over again and
expecting different results.” (Einstein)
“Life is What Happens to You While You’re Busy Making Other Plans.” (John Lennon)
“Never, never, never give up.” (Winston Churchill)
“Don’t depend on anyone else to bring the coffee.” (me)
“The best things in life aren’t things?” (Art Buchwald)
…and the most important
“Character is how you act when no one is watching” (attributed to many)
Confidential September 11, 2001 LESSONS LEARNED memorandum
by hospital CEO Jonathan Metsch goes “viral” and becomes a New Jersey
gubernatorial campaign issue
PART 1: January 31, 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 “
PART 2: February 20, 2019. A new bill would outlaw the big,
surprise bills that Zuckerberg San Francisco General Hospital has sent to
hundreds of patients.
PART 3: April 18, 2019. “Zuckerberg San Francisco
General Hospital announced Tuesday it has overhauled its billing policies…
PART 4: August 20, 2019. Hospitals kept ER fees secret
ASSIGNMENT:
How do other states address financial sustainability for their “safety-net”
hospitals?
PART 1: January
31, 2019. “If you’re shot, stabbed, hit by a car, fall off …
“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)
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)
PART 2: February
20, 2019. 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.
, 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)
PART 4: August 18,
20129. Hospitals kept ER fees secret.
Zuckerberg San Francisco General and the University of
California San Francisco are two of the city’s busiest hospitals, about 4 miles
apart. But if you have private insurance and visit Zuckerberg General, you
could end up paying a lot more for the same treatment.
For an especially serious visit, Zuckerberg General charges
a facility fee of $11,176, 46 percent more than UCSF, which charges an average
of $7,635.
The hospital is also out-of-network with all private
insurance, leaving patients responsible for the fee and the cost of treatment.
UC San Francisco, meanwhile, accepts insurance from most big providers. Insurers
generally negotiate lower prices for patients, and many plans cover ER visits
in part or in full…
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.
These charges, known as “facility fees,” are the price that
patients pay for walking in the door of an emergency room and seeking service.
Nationally, these fees are kept secret. Patients only learn their emergency
room’s facility fee when they receive a bill after the visit…
We found that privately insured patients seen at Zuckerberg
General end up with significantly bigger bills than those seen at other nearby
emergency rooms. For example, the hospital charged a $5,369 facility fee for a
patient who presents with a “severe” emergency…
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…
The fees at Zuckerberg General have nearly doubled over the
past decade. In 2010, the emergency room fees at the hospital ranged from $287
to $6,118, depending on the severity of the visit. Now the prices range from
$525 to $11,958.
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.” (A)
“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 state Assembly member David Chiu
and state 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 Assembly. “No one who is going through the trauma
of emergency room care should be subsequently victimized by outrageous hospital
bills.”..
Zuckerberg San Francisco General Hospital has, in light of
reporting from both Vox and the San Francisco Chronicle, promised to revise its
billing policies to be more patient-friendly. The hospital is reportedly
considering a cap on charges for privately insured patients.
But Chiu thinks that even more action is needed: a statewide
law that would outlaw this kind of behavior…
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,” Chiu said. “The discussion between insurers and hospitals would become
far more predictable.”
Chiu said the hospital and insurance industries are aware of
the effort but haven’t yet seen the full text of the legislation, which will be
introduced on Monday.” (B)
“Lawmakers in both the U.S. Senate and House have introduced
bills to end surprise billing. But passing federal legislation promises to be
an uphill battle because two influential lobbying groups — health insurers and
health providers — have been unable to agree on a solution.
Frustrated by waiting for federal lawmakers to act, states
have been trying to solve this issue. As of December 2018, 25 states offered
some protection against surprise billing, and the protections in nine of those
states were considered “comprehensive,” according to the Commonwealth Fund.
California, New York, Florida, Illinois and Connecticut are among the nine.
New state laws also have been adopted since, including in
Nevada, which will limit how much out-of-network providers, including
hospitals, can charge patients for emergency care, starting next year.
In California, a 2009 state Supreme Court ruling protects
some patients against surprise billing for emergency care, and a state law that
took effect in 2017 protects some who receive non-emergency care.
But millions remain vulnerable, largely because California’s
protections don’t cover all insurance plans. The California Supreme Court
ruling applies to people with plans regulated by the state Department of
Managed Health Care. That leaves out the roughly 1 million Californians with
plans regulated by the state Department of Insurance and the nearly 6 million
people with federally regulated plans, most of whom have employer-sponsored
insurance.
The state law governing non-emergency care also doesn’t
apply to the millions of residents with health plans regulated by the federal
government…
The California Hospital Association opposes the measure,
which would limit the amount hospitals could charge insurance plans to a
certain rate for each service, varying by region…
“We fully support the
provision of the bill that protects patients. It is the rate-setting piece that
is our concern,” she said.
Skewered by media reports, the hospital announced in April
that it would no longer balance-bill privately insured patients.” (C)
“Legislation to prohibit California hospitals from sticking
patients with huge emergency room bills that their insurers won’t cover has
cleared a crucial hurdle in the state Capitol.
Lawmakers in the Assembly voted 48-9 on Thursday to approve
AB1611, which would prohibit hospitals from “balance billing” patients if their
insurance won’t cover the full cost for care.
Assemblyman David Chiu and state Sen. Scott Wiener, both
Democrats from San Francisco, co-wrote the legislation. The bill now moves to
the Senate.
They wrote the bill in response to Chronicle stories about
patients who had undergone treatment at San Francisco General Hospital, often
for minor injuries, and been billed tens of thousands of dollars even though
they had insurance.
“After a trip to the
emergency room, the only thing you should be focused on is getting better,”
Chiu said. “Not a bill for tens of thousands of dollars.”
San Francisco General had billed patients for the difference
between the cost of their treatment and what their insurance companies were
willing to pay. The hospital announced in April that it would end the practice,
meaning patients won’t be billed beyond what their insurance requires.
AB1611 would prohibit hospitals from billing patients for
any cost beyond their insurance deductible and co-payment. It also spells out
rules for how hospitals and insurers resolve cost disputes.” (D)
“Zuckerberg is
notorious for being not necessarily the worst but one of the worst places to go
in terms of prices for emergency care,” Anderson continued. “The prices are outrageously
high. They are notorious for it. And everybody knows about them.”
The maddening element about hospital billing is that the
costs charged to patients are only abstractly related to the costs incurred by
the hospital.
“They do not need to justify their charges. They have full
discretion,” explains Ge Bai, a Johns Hopkins professor of both accounting and
health management and policy. “There are no regulatory forces to limit their
ability to set a high charge. The charge is coming purely from the hospital and
subject to no external forces.”
Patients — especially uninsured patients — “become prey of
this charging game.”…
The No. 1 reason that hospitals aggressively bill their most
vulnerable patients? That, too, is relatively easy to grasp. It’s the same
reason people from around the world phone you up and demand your Social
Security Number: A very small percentage of folks give them everything they
want.
Hospitals “don’t get most of the money — in most cases,”
says Anderson. “It’s simply preferable for them to charge $3,300 and get it
from some people rather than charge $200 and get it from nearly everybody.” (E)
“Hospitals focused their opposition on a provision of the
bill that would have limited charges for out-of-network emergency services.
The proposal would have required hospitals to work directly
with health plans on billing, leaving the patients responsible only for their
in-network copayments, coinsurance and deductibles. (Photo: Shutterstock)
Citing fierce pushback from hospitals, California lawmakers
sidelined a bill Wednesday that would have protected some patients from
surprise medical bills by limiting how much hospitals could charge them for
emergency care.” (F)
The attempt by two San Francisco politicians to stop
hospitals around California from sticking patients who receive emergency care
with outrageous bills is on life support.
“Assemblyman David Chiu on Tuesday said he is holding back
his bill that was inspired by news of San Francisco General Hospital’s unfair
billing practices after intense lobbying from hospital CEOs around the state
urging his colleagues to kill it.
The bill was supposed to be heard in the Senate’s health
committee Tuesday, but Chiu said its passage would have required amendments
making the bill worthless, and he wasn’t willing to move ahead with them.
Instead, he’s turning the bill into a two-year piece of
legislation, meaning it can be taken up again in January. But that means the
earliest Gov. Gavin Newsom can sign it is September, 2020. And that means the 7
million Californians who have private insurance and yet are still at risk of
big emergency care bills won’t see any relief for more than a year — if at all.
“It’s disappointing this couldn’t get done this year,” Chiu
said. “But this doesn’t mean we’re done. It ain’t over.”” (G)
“Citing fierce pushback from hospitals, California lawmakers
sidelined a bill Wednesday that would have protected some patients from
surprise medical bills by limiting how much hospitals could charge them for
emergency care.
The legislation, which contributed to the intense national
conversation about surprise medical billing, was scheduled to be debated
Wednesday in the state Senate Health Committee.
Instead, the bill’s author pulled it from consideration,
vowing to bring it back next year.
“We are going after a practice that has generated billions
of dollars for hospitals, so this is high-level,” said Assemblyman David Chiu
(D-San Francisco). “This certainly does not mean we’re done.”
Chiu said he and his team would keep working on amendments
to the bill that address the concerns of hospitals while maintaining
protections for patients.
Hospitals focused their opposition on a provision of the
bill that would have limited what they can charge insurers for out-of-network
emergency services, criticizing it as an unnecessary form of rate setting.” (H)
“San Francisco’s health network has
finalized its first contract with a private health insurer, Canopy Health Canopy
— meaning Zuckerberg San Francisco General Hospital, long perceived as the
hospital of last resort, is now in the business of wooing expectant mothers to
choose to deliver at its Family Birth Center…
Department of Public Health staff
said the signing of this contract was not a reaction to billing controversies
at ZSFGH that erupted earlier this year, when it was revealed that even insured
patients were being hit with crippling debts through the practice of “balance
billing.” Because the hospital was out-of-network for private insurance
companies, there was often a great divergence between what ZSFGH billed the
insurance and what the insurance company would deign to pay — leaving
individuals responsible for the “balance.”
This situation, however, did
highlight the hospital’s unhealthy and precarious “payer mix.” With few
privately insured patients, ZSFGH ministers mostly to Medi-Cal recipients or
the marginally insured. Deals like the one initiated July 15 with Canopy would
begin to change that mix, however.
“It is good for the hospital to
diversify its revenue with different payors,” notes Department of Public Health
spokeswoman Rachael Kagan. “We have been working to accomplish private
contracting for some time now.”
Inundating the hospital with
better-paying privately insured patients at the expense of publicly insured
patients would be cause for concern. But this doesn’t figure to happen at the
Family Birthing Center, one of the few departments at ZSFGH that isn’t overloaded
beyond capacity.
Kagan says the Department of Public
Health hopes 60 privately insured Canopy patients deliver at ZSFGH. Hospital
staff have been told to expect up to 80. This would represent a small bump in
the total number of deliveries at the hospital, which is about 1,200 a year.
Just how many privately insured
mothers opt to deliver at ZSFGH will depend on how effectively the hospital
sells itself as the “good and safe place to have a baby” — and how effectively
it can dispel the perception that anyone who could afford to go elsewhere would
do so.
Hospitals competing for patients —
especially expectant mothers — often play up amenities more closely resembling
a luxury resort than a medical center: private rooms, steak dinners, sumptuous
views.
It remains to be seen if ZSFGH will
go this route. What it does have to offer, however, is a 24-hour/seven-day
on-call midwife — which no other city hospital does. ZSFGH also claims the
lowest C-section rate in all San Francisco.
Kagan declined to reveal whether the
city is in negotiation with other private insurers, which could alter ZSFGH’s
payer mix even more. The Canopy deal required three years to close. So it would
be surprising if others aren’t in the works, if not imminent.
“Our hope is that down the road we
can expand access to more of our services to Canopy Health and other
commercially insured patients,” wrote Roland Pickens, the director of the
city’s Health Network, in the inter-office memo announcing this deal. “ (I)
“California hospitals want you to
know that they’re fully on board with the idea that emergency room patients
shouldn’t be hit with thousands of dollars in surprise billings because the ER
isn’t in their insurance plan’s network.
You should also know, however, that
the hospitals just killed a measure in Sacramento that would have accomplished
that goal, and that the reason they did so was to protect their own revenues….
Chiu’s legislation had two major
pieces. It prohibited hospitals from charging out-of-network ER patients more
than they would charge an in-network patient for the same services. It also
established a standard for what a hospital could charge a non-network insurer.
In other words, the bill limited what patients would pay hospitals out of
pocket but set rules on what insurers would pay the hospitals too.
Originally, the bill set 150% of
Medicare reimbursement as a payment benchmark. The sponsors eventually amended
that to whatever rate is “reasonable and customary,” defined as the average
in-network contracted rate in a hospital’s geographic region. Hospitals could
appeal for higher reimbursements through the state Department of Health Care
Services.
The state’s hospitals went to the
mattresses over the payment provision, cursing it as “government rate setting”
that they would never accept. Hospital executives inundated legislators with
warnings that rate-setting would force their institutions to shut down…
The proponents were aware that they
were poking a stick into a tiger’s cage. “We’re going after a practice that has
generated billions of dollars in profits for hospitals, Chiu told me, “and
hospital CEOs around the state waged very aggressive lobbying to protect those
profits.”” (J)
“Twelve Connecticut hospitals charge
patients a trauma activation fee when they arrive by ambulance with a serious
injury.
These fees, ranging in the thousands
of dollars, are unregulated. And 11 of the 12 Connecticut trauma centers won’t
reveal publicly how much they charge…
(Only designated trauma centers are
permitted to charge trauma activation fees, which can add thousands of dollars
to hospital bills.)
A trauma fee is charged when a trauma
team is called to attend to a patient with significant or life-threatening
injuries who is brought to the hospital by emergency medical services. Only
designated trauma centers can use the billing code 068x to charge a trauma
activation fee.
These fees are set by the hospitals
and can range based on the level of response a patient requires. They help
hospitals recoup the costs of having highly trained doctors and specialized
nurses on call to respond to tragedies at a moment’s notice. Insurance
sometimes covers the fees so not all patients may notice them buried in their
hospital bill — if they have health insurance…
Connecticut has four hospitals
designated as level I trauma centers, 7 that are level II and one level III.
These levels refer to the resources available in the trauma center and the
amount of patients admitted yearly — but its unclear if they have any
correlation with the amount charged for trauma fees.” (K)
ASSIGNMENT:
Identify other health care conflicts in the news then identify Best Practices
of Boards of Trustees.
New PART 2 after old PART 1.
PART 1. September 28, 2018. HOW ACADEMIC MEDICAL CENTERS
ADDRESS CONFLICTS-OF-INTEREST.
ASSIGNMENT: Profile the University of Maryland Medical
System COI challenge.
DISCLOSURE. I am a member and Interim Chairman of the IRB*
at Stevens Institute of Technology.
“There are many varieties of conflicts of interest, and they
appear in different settings and across all disciplines. While conflicts of
interest apply to a “wide range of behaviors and circumstances,” they all
involve the use of a person’s authority for personal and/or financial gain.
Conflicts of interest may involve individuals as well as institutions.
Furthermore, individuals, in certain circumstances, may have conflicts
occurring on both an individual and an institutional level, as may be seen
among members of an Institutional Review Board (IRB).
Conflicts of interest are broadly divided into two
categories: intangible, i.e., those involving academic activities and
scholarship; and tangible, i.e., those involving financial relationships.” (A)
“In an article in the May 2014 issue of Compliance Today,
Bill Sacks, Vice President and co-founder of HCCS, a HealthStream company,
describes how new NIH regulations are forcing academic medical centers (AMCs)
to examine and update their conflict-of-interest policies. He lists the 15 best
practices for management of conflicts of interest that have been proposed by
the Pew Charitable Trust and discusses how some of these recommendations are
enjoying wide acceptance, as others are being met by serious objections. The Pew
“Best Practice” recommendations are summarized below.
1. No gifts or meals should be accepted from industry sales
representatives…
2. Faculty must disclose all conflicts of interest. All
academic medical centers must have a process in place to manage conflict of
interest (COI) disclosures.
3. Industry-funded speaking should not be allowed…
4. Industry-funding of continuing medical education (CME)
should be severely limited or prohibited…
5. Faculty, students, and trainees should not attend
industry-supported promotional or educational events…
6. Limit or prohibit pharmaceutical sales representative
access in academic medical centers…
7. Limit medical device representative presence in academic
medical centers to what is necessary…
8. Conflict-of-interest education should be required for all
clinical staff and students
9. Conflict-of-interest policies should apply to everyone
with a relationship to the academic medical center—paid, volunteering,
affiliated, etc…
10. Industry-supported clinical fellowships should be
available for scientific training only…
11. Ghostwriting and honorary authorship are strictly
prohibited…
12. …Consulting arrangements must require written contracts
with clear deliverables, to ensure that inappropriate payments are not
involved…
13. Consulting relationships for marketing purposes are
prohibited.
14. Pharmaceutical samples can be accepted and used only
when they don’t become marketing tools.
15. Members of pharmacy and therapeutics committee cannot
vote on formulary or treatment changes involving a company or product in which
they have a financial interest… (B)
“Open Payments gives the public more information about the
financial relationships between physicians and teaching hospitals and
applicable manufacturers and GPOs. Specifically, the program:
Encourages transparency about these financial ties
Provides information on the nature and extent of the
relationships
Helps to identify relationships that can both lead to the
development of beneficial new technologies and wasteful healthcare spending
Helps to prevent inappropriate influence on research,
education and clinical decision making. (C)
“Community Catalyst offers this Policy Guide to Academic
Medical Centers and Medical Schools to assist leaders, faculty, staff and medical
students in successfully adopting and improving policies to address conflicts
of interest and interactions with the pharmaceutical and device industries.
Policies such as these and their effective implementation are of critical
importance to the integrity of medical education and patient care…
Toolkit on Transparency and Disclosure. Toolkit on Relations
with Sales Representatives. Toolkit on Promotional Speaking. Toolkit on
Continuing Medical Education. Toolkit on Ghostwriting and Name-Lending. Toolkit
on Samples. Toolkit on Pharmaceutical and Therapeutics Committees. Toolkit on
COI Policy Implementation. Conflict of Interest Curriculum Toolkit (D)
“Papers in medical journals go through rigorous peer review
and meticulous data analysis.
Yet many of these articles are missing a key piece of
information: the financial ties of the authors.
Nearly two-thirds of the 100 physicians who rake in the most
money from 10 device manufacturers failed to disclose a conflict of interest in
their academic writing in 2016, according to a study published Wednesday in
JAMA Surgery.
The omission can have real-life impact for patients when
their doctors rely on such research to make medical decisions, potentially
without knowing the authors’ potential conflicts of interest…
They did this by sampling 10 large surgical and medical
device manufacturers. This list includes Medtronic, Stryker Corp., Intuitive
Surgical, Covidien, Edwards Lifesciences Corp., Ethicon, Olympus Corp., W.L.
Gore & Associates, LifeCell Corp. and Baxter Healthcare.
The researchers also pinpointed the 10 physicians who
received the highest compensation from each company. They then searched for
articles published by these physicians between Jan. 1 and Dec. 31, 2016, and
reviewed the full text of each article for COI disclosure.
According to their findings, those 10 companies paid more
than $12 million in 2015 to the 100 doctors included in the study. The median
payment to these physicians was $95,993.” (E)
“Memorial Sloan Kettering Cancer Center launched a conflict
of interest task force in the wake of the resignation of its chief medical
officer, Dr. José Baselga, who failed to disclose connections to medical
industry…
The Manhattan-based cancer center said the task force will
assess its internal policies and processes for reporting and managing outside
activities and industry-supported clinical trials.
The task force was announced by President and Chief
Executive Officer Dr. Craig Thompson. It will be chaired by Debra Berns, MSK’s
Senior Vice President and Chief Risk Officer.
Among its objectives, the task force will: Review MSK’s
policies, procedures, and training on conflicts of interest; Identify best
practices in COI, including monetary and commitment limits; Assess new or
improved processes to support timely and thorough disclosure; Identify medical
societies and journals with whom to partner in improving public disclosure at
meetings and in publications. (F)
“One of the world’s top breast cancer doctors failed to
disclose millions of dollars in payments from drug and health care companies in
recent years, omitting his financial ties from dozens of research articles in
prestigious publications like The New England Journal of Medicine and the
Lancet.
The researcher, Dr. José Baselga, a towering figure in the cancer
world, is the chief medical officer at Memorial Sloan Kettering Cancer Center
in New York. He has held board memberships or advisory roles with Roche and
Bristol-Myers Squibb, among other corporations; has had a stake in start-ups
testing cancer therapies; and played a key role in the development of
breakthrough drugs that have revolutionized treatments for breast cancer.
According to an analysis by ProPublica and The New York
Times, Baselga did not follow financial disclosure rules set by the American
Association for Cancer Research when he was president of the group. He also
left out payments he received from companies connected to cancer research in
his articles published in the group’s journal, Cancer Discovery. At the same
time, he has been one of the journal’s two editors in chief.
At a conference this year and before analysts in 2017, he
put a positive spin on the results of two Roche-sponsored clinical trials that
many others considered disappointments, without disclosing his relationship to
the company. Since 2014, he has received more than $3 million from Roche in
consulting fees and for his stake in a company it acquired.” (G)
“Dr. José Baselga, the chief medical officer of Memorial
Sloan Kettering Cancer Center, resigned on Thursday amid reports that he had
failed to disclose millions of dollars in payments from health care companies
in dozens of research articles…
Thompson echoed comments he made to the hospital staff on
Sunday, saying that the cancer center had “robust programs” in place to manage
employees’ relationships to outside companies, but that “we will remain
diligent.” He added, “There will be continued discussion and review of these
matters in the coming weeks.” (H)
“An artificial intelligence start-up founded by three
insiders at Memorial Sloan Kettering Cancer Center debuted with great fanfare
in February, with $25 million in venture capital and the promise that it might
one day transform how cancer is diagnosed.
The company, Paige.AI, is one in a burgeoning field of
start-ups that are applying artificial intelligence to health care, yet it has
an advantage over many competitors: The company has an exclusive deal to use
the cancer center’s vast archive of 25 million patient tissue slides, along
with decades of work by its world-renowned pathologists.
Memorial Sloan Kettering holds an equity stake in Paige.AI,
as does a member of the cancer center’s executive board, the chairman of its
pathology department and the head of one of its research laboratories. Three
other board members are investors…
Hospital pathologists have strongly objected to the Paige.AI
deal, saying it is unfair that the founders received equity stakes in a company
that relies on the pathologists’ expertise and work amassed over 60 years. They
also questioned the use of patients’ data — even if it is anonymous — without
their knowledge in a profit-driven venture.” (I)
“…The AAMC is continuing to work with member institutions,
other associations and societies, journals, and the continuing education
community to develop tools and resources to help institutions and individuals
manage the disclosure of conflicts of interest.
Institutions looking for immediate steps to take could:
Remind faculty of the importance of full disclosure, not
only to your institution, but in other writing, speaking and teaching
situations, as well as grant applications.
Use relevant current events as an opportunity to recommit to
the institution’s obligation to facilitate transparency about the ways in which
faculty and industry may be collaborating, and the processes that are in place
to review and manage those relationships.
Encourage faculty to review the information posted about
them publicly on the Open Payments website, and to ensure its accuracy as well
as consistency with complete disclosures in all aspects of their professional
responsibilities.” (J)
* “Under FDA regulations, an IRB is an appropriately
constituted group that has been formally designated to review and monitor
biomedical research involving human subjects. In accordance with FDA
regulations, an IRB has the authority to approve, require modifications in (to
secure approval), or disapprove research. This group review serves an important
role in the protection of the rights and welfare of human research subjects.
The purpose of IRB review is to assure, both in advance and
by periodic review, that appropriate steps are taken to protect the rights and
welfare of humans participating as subjects in the research. To accomplish this
purpose, IRBs use a group process to review research protocols and related
materials (e.g., informed consent documents and investigator brochures) to
ensure protection of the rights and welfare of human subjects of research.” (K)
“A vice president of Memorial Sloan Kettering Cancer Center
has to turn over to the hospital nearly $1.4 million of a windfall stake in a
biotech company, in light of a series of for-profit deals and industry
conflicts at the cancer center that has forced it to re-examine its corporate
relationships…
The move to hand over his stake is one of several steps now
underway as the cancer center tries to contain a crisis that has already led to
the resignation of its chief medical officer and a review of its
conflict-of-interest policies. Several board members and some executives of the
nonprofit institution have maintained close ties to the health and drug
industries at a time when stunning cancer breakthroughs are generating
excitement among investors and spawning a flurry of biotech startups.
At other cancer centers and research institutions, employees
are barred from accepting personal compensation when they represent their
institution on corporate boards. But Memorial Sloan Kettering had no such
prohibition until now.” (L)
PART 2. Conflict of Interest continued. Memorial Sloan Kettering/
University of Maryland Medical System
“In forging partnerships with a New Jersey hospital and a
data analytics startup, Memorial Sloan Kettering Cancer Center has created a
web of interlocking financial interests and conflicts that, ethics experts told
STAT, raise doubts about whether the prominent New York City hospital can
always put its patients’ interests first while using information in their
medical records to make money.
In late 2016, Memorial Sloan Kettering signed a deal with
Hackensack Meridian Health, one of New Jersey’s largest hospital systems,
giving the cancer center access to a larger pool of patients and a bulwark
against encroaching competition from other national players in cancer care.
Within a year, MSK launched another collaboration with a
data analytics startup called Cota, and invested $1.4 million in the company.
Its founder: a Hackensack Meridian executive and oncologist named Dr. Andrew
Pecora, who was Hackensack’s lead negotiator in striking the blockbuster 2016
partnership and serves on the board overseeing the hospitals’ joint venture…
The cancer center is also collaborating with IBM in the
development and sale of Watson for Oncology, a product that combines its
clinical expertise with artificial intelligence to deliver cancer treatment
recommendations. The cancer center receives royalties on the sale of IBM’s
product.
Ethics experts said these deals fall into a regulatory gray
area in which hospitals and other private companies are trading on patient data
in novel ways that may cross ethical lines and trigger a backlash among
patients.” (A)
“Hundreds of doctors packed an auditorium at Memorial Sloan
Kettering Cancer Center on Oct. 1, deeply angered by revelations that the
hospital’s top medical officer and other leaders had cultivated lucrative
relationships with for-profit companies.
One by one, they stood up to challenge the stewardship of
their beloved institution, often to emotional applause. Some speakers accused
their leaders of letting the quest to make more money undermine the hospital’s
mission. Others bemoaned a rigid, hierarchical management that had left them
feeling they had no real voice in the hospital’s direction.
“Slowly, I’ve seen more and more of the higher-up meetings
happening with people who are dressed up in suits as opposed to white coats,”
said Dr. Viviane Tabar, chairwoman of the neurosurgery department.
“The corporatization of this institution is clear to many of
us who have been here a long time,” said Dr. Carol L. Brown, a gynecologic
cancer surgeon, according to an audio recording of the meeting.
The meeting ended after several doctors advocated an
immediate no-confidence vote in the hospital’s senior leadership. The turmoil
followed reports by The New York Times and ProPublica that the hospital’s chief
medical officer, Dr. José Baselga, had been paid millions by drug and health
care companies and failed to disclose those ties more than 100 times in medical
journals, and that hospital insiders had made lucrative side deals that stood
to earn them handsome profits, sometimes for work they had done on the job.
The day after the meeting, the hospital’s chief executive,
Dr. Craig B. Thompson, promised greater openness with rank-and-file doctors
about decision-making. He also committed to doing the “root-cause analysis”
requested by the doctors of how “egregious conflicts of interest,” as one
physician put it, had been allowed to happen…
The predicament of Memorial Sloan Kettering also reflects a
shift in its own culture. Its prior chief executive, Dr. Harold E. Varmus, a
Nobel-prize winning scientist, personally kept companies at arm’s length, while
Dr. Thompson, also a respected cancer researcher, has more fully embraced such
relationships. The new approach has been applauded by some for expanding access
to the cancer center’s discoveries, even as others have worried that the
hospital may be losing sight of its mission…
Even as Memorial Sloan Kettering leaders have promised
greater transparency, they have engaged a public affairs firm,
SKDKnickerbocker, to manage their message and have aggressively pushed back
against the idea that the hospital’s leaders are too close to industry.” (B)
“Memorial Sloan Kettering Cancer Center, one of the world’s
leading research institutions, announced on Friday that it would bar its top
executives from serving on corporate boards of drug and health care companies
that, in some cases, had paid them hundreds of thousands of dollars a year.
Hospital officials also told the center’s staff that the
executive board had made permanent a series of reforms designed to limit the
ways in which its top executives and leading researchers could profit from work
developed at Memorial Sloan Kettering, a nonprofit with a broad social mission
that admits about 23,500 cancer patients each year.” (C)
“While MSK’s situation has drawn the most attention for its
ties to industry, leaders of nonprofit health systems commonly lead
pharmaceutical companies at the same time, a BioPharma Dive review from
November found.
From that analysis, about two-thirds of the industry’s
largest drugmakers had at least one board member who was also leading a
nonprofit, creating a potential financial conflict of interest between the two
roles.
The typical compensation package from the pharma companies
to these directors was worth more than $475,000, while the average director
also held roughly $1.7 million in stock of the particular drugmaker they helped
to lead.
This MSK memo from Debra Berns, the cancer center’s senior
vice president and chief risk officer, establishes some new limits the
organization will put in place on its leaders.
The five highest-ranking roles will not be permitted to
serve on boards of external, for-profit health- or science-related companies, the
memo stated. These roles are the chief executive, chief operating officer,
chief financial officer, physician-in-chief and director of MSK.
However, these five leaders can be exempt from the ban if
they provide a compelling institutional reason for board service and obtain
approval from the executive committee of MSK’s board of managers, according to
the document.
Another new policy will limit the relationship with
for-profit spin-off companies that MSK officers can have. MSK officers cannot
serve on boards of spin-off companies, and the Board of Overseers and Managers
cannot invest in or serve on these boards.” (D)
“Top officials at Memorial Sloan Kettering Cancer Center
repeatedly violated policies on financial conflicts of interest, fostering a culture
in which profits appeared to take precedence over research and patient care,
according to details released on Thursday from an outside review.
The findings followed months of turmoil over executives’
ties to drug and health care companies at one of the nation’s leading cancer
centers. The review, conducted by the law firm Debevoise & Plimpton, was
outlined at a staff meeting on Thursday morning.
It concluded that officials frequently violated or skirted
their own policies; that hospital leaders’ ties to companies were likely
considered on an ad hoc basis rather than through rigorous vetting; and that
researchers were often unaware that some senior executives had financial stakes
in the outcomes of their studies.
In acknowledging flaws in its oversight of conflicts of
interest, the cancer center announced on Thursday an extensive overhaul of
policies governing employees’ relationships with outside companies and
financial arrangements — including public disclosure of doctors’ ties to
corporations and limits on outside work…
Scott Stuart, chairman of the cancer center’s Boards of
Overseers and Managers, said in an emailed statement: “We took a deep and
honest look at what went wrong at our own institution, examined what was
occurring in the wider cancer research community, and are putting in place best
practices that will not only allow us to learn from our mistakes, but will
contribute to best practices for the wider research community.”..
The policy changes that Memorial Sloan Kettering announced
on Thursday include the creation of a board committee to focus on overseeing
conflicts, an existing hospital policy that the law firm learned had not been
carried out.
The hospital also said it would disclose financial interests
of faculty members and researchers on its website and create a more centralized
review of conflicts between employees’ work at the hospital and their outside
duties.
Other changes included new limits on how income is
distributed from research discoveries that originate at Memorial Sloan Kettering,
and regular audits to ensure the hospital is complying with its own rules. The
cancer center reinforced its earlier statements that many profits from outside
work should flow back to M.S.K. research.” (E)
“Dr. José Baselga, who resigned his position as the top
doctor at Memorial Sloan Kettering Cancer Center after failing to disclose
millions of dollars in payments from drug companies, is now going to work for
one of them.
AstraZeneca, the British-Swedish drug maker, announced on
Monday that it had hired Dr. Baselga as its head of research and development in
oncology, a newly created unit that reflects the company’s shift toward cancer
treatments, one of the hottest areas in the drug industry.
In a statement, AstraZeneca’s chief executive, Pascal
Soriot, described Baselga as “an outstanding scientific leader.” “José’s
research and clinical achievements have led to the development of several
innovative medicines, and he is an international thought leader in cancer care
and clinical research,” he said…
In December, the American Association for Cancer Research
said that Baselga, at its request, had resigned his post as one of two editors
in chief of its medical journal Cancer Discovery because he did “not adhere to
the high standards” of conflict-of-interest disclosures that the group expects
of its leaders. Some of his omissions involved articles that were published in
Cancer Discovery while he was an editor in chief.” (F)
“Two more members of the University of Maryland Medical
System’s board of directors have resigned amid intense scrutiny over the
system’s contracting practices — and as the hospital network announced a
“comprehensive review” of its business deals.
Stephen A. Burch, chairman of the University of Maryland
Medical System board of directors, said Tuesday that he has accepted the
resignations of board members John W. Dillon and Robert L. Pevenstein.
“I take very
seriously the concerns raised regarding Board members that have business
relationships with UMMS,” Burch said in a statement. “Addressing this issue is
of the highest priority for me and the organization. There is nothing more
important than the trust of those who depend on our leadership.”
Dillon reported in both 2017 and 2018 that his health care
consulting firm, Dillon Consulting, generated more than $150,000 a year through
a contract with the system for “capital campaign and strategic planning.” He
reported the contract was paying his firm $13,000 a month.
Pevenstein, the founder of technology companies, reported
that in 2017 his firms pulled in more than $150,000 through system contracts,
including more than $108,000 in pay for himself. In 2018, Pevenstein reported
his son also made more than $100,000 from the system.
In tax forms, Maryland hospital system labeled book purchase
from Baltimore mayor a ‘grant’ to city schools
The resignations follow Baltimore Mayor Catherine Pugh
stepping down from the board Monday. Pugh resigned from the system’s board of
directors as Baltimore school officials acknowledged that 8,700 copies of
children’s books the medical system purchased from her are sitting unread in a
warehouse.
The three departures from the board came after The Baltimore
Sun reported nine members of the University of Maryland Medical System’s Board
of Directors have business deals with the hospital network that are worth
hundreds of thousands to millions of dollars each.
Board chair Burch said Tuesday he also has asked board
members who currently have relationships with the medical system to immediately
take a voluntary leave of absence during a review of the system’s governance
practices. Those members are: August J. Chiasera, Francis X. Kelly, James A.
Soltesz and Walter A. Tilley Jr…
Medical system CEO Robert Chrencik has said some of the
contracts went through a competitive bidding process, while others did not. The
medical system has thus far declined to release a list detailing which of the
deals went through a bidding process.” (G)
“The president and chief executive of the University of
Maryland Medical System will take a leave of absence amid a growing scandal
surrounding its board of directors, several of whom have profited from
contracts with the hospital network they oversee.
Robert A. Chrencik, who has led the system since 2008, will
be on leave beginning Monday, board chairman Stephen A. Burch announced
Thursday. Burch said the board asked Chrencik to step aside and unanimously
agreed at an emergency meeting Thursday to engage an independent accounting and
legal firm to conduct an audit of the board’s contracts.
Several of the board’s 27 members — including Baltimore
Mayor Catherine Pugh (D), who resigned this week from the board — have had
business deals with the hospital system they oversee, in some cases worth
hundreds of thousands of dollars. The deals, first reported last week by the
Baltimore Sun, have been sharply criticized by Gov. Larry Hogan (R) and the
Democratic leaders of the General Assembly.” (H)
Several of Maryland’s largest hospitals engage in business
transactions with members of their governing boards while avoiding — for the
most part — the type of political dealings that ensnared the University of
Maryland Medical System in management turmoil this week.
The medical system has faced intense scrutiny since The
Baltimore Sun revealed last week that a third of its 27-member board of
directors have business dealings with the health care network…
The Baltimore Sun’s review of state disclosure records and
federal tax forms for MedStar Health, LifeBridge Health, Mercy Medical Center,
Greater Baltimore Medical Center and St. Agnes Hospital showed all have some
dealings with board members.
GBMC said it always uses competitive bidding when awarding
contracts.
LifeBridge Health officials said in a statement that board
members with “conflicts may be required to be recused from any discussion where
the potential conflict may influence their vote and are recused from any vote
where a conflict may exist.” In addition, they said, an “audit and compliance
committee also oversees conflicts of interest to ensure that there is no undue
influence on any contract or vote.”
MedStar Health, which has seven hospitals in Maryland,
reported business transactions with board members at five of its hospitals:
Franklin Square Medical Center, Good Samaritan Hospital, Union Memorial
Hospital and Harbor Hospital in the Baltimore area and St. Mary’s Hospital in
Leonardtown in Southern Maryland.
Dr. P. Justin Tortolani, who serves on Union Memorial
Hospital’s board and is director of MedStar’s spine program, reported receiving
royalties of nearly $155,000 last year from contracts with two companies he is
associated with.
At LifeBridge, relationships ranged from catering services
with no reported value provided by Miss Shirley’s owner David Dopkin, a Sinai
Hospital of Baltimore board member, to $9.2 million in leasing and construction
services from the company of Thomas Obrecht, who serves on the boards of
LifeBridge Health and Northwest Hospital Center Inc. In an email, Obrecht said
he joined the board to use his experience in business and real estate to help
guide “an organization focused on helping people in Baltimore and across
Maryland.”.. (I)
“Legislation to overhaul the University of Maryland Medical
System board was amended to require all current board members be fired.
The bill has bipartisan support and has significantly
changed since it was first introduced. The measure, as amended, is headed to
the House floor.
A House committee voted unanimously Friday in favor of
legislation to completely overhaul the UMMS board. The board remains under fire
following reports nine of its 30 members benefited from business deals with the
hospital system, including a children’s book contract with Mayor Catherine
Pugh.
Pugh returned $100,000 she made in profits, resigned from
the UMMS board and recently made a public apology.
The legislation calls for the termination of all the current
board members.
“They will be terminated in two different batches, so
that we separate some in June and some in October,” House Health and
Government Operations Committee Chairwoman Shane Pendergrass said.
The committee adopted an amendment mandating that no elected
officials can serve on the board. Committee members paid close attention to
ways to find out how these no-bid contracts happened…
The bill covers much ground, including limiting the number
of board members to 25, prohibiting members from using their position for
private gain and prohibiting sole source contracts. Financial disclosure
statements and notification of any potential conflicts of interest would become
a requirement by law.” (J)
“On the last day of Maryland’s General Assembly session,
lawmakers gave final approval to sweeping legislation that would reform the
University of Maryland Medical System’s board of directors amid revelations of
single-source contracts for some board members.
The legislation — which comes after Baltimore Sun reporting
sparked an outcry over the board’s practices, including a $500,000 deal to buy
Mayor Catherine Pugh’s self-published “Healthy Holly” books — would bar no-bid
contracts for board members, force all members to resign and reapply for their
positions (if they want to return), and mandate an audit of contracting
practices.
By a vote of 46-0, Maryland’s senators approved the
legislation sponsored by Baltimore Democratic Sen. Jill P. Carter.
The bill now goes to Republican Gov. Larry Hogan for his
consideration; he supports reforms for UMMS. (K)
“After weeks of mounting pressure, Mayor Catherine Pugh of
Baltimore resigned on Thursday amid a widening scandal involving hundreds of
thousands of dollars worth of children’s books that she wrote and that the
University of Maryland Medical System paid for while she was serving on its
board of directors.
Her resignation comes days after the Baltimore City Council
proposed amending the city charter to make it possible to remove her, and after
the F.B.I. raided her two homes and her office at City Hall…” (L)
“Robert A. Chrencik, president and CEO of Baltimore-based
University of Maryland Medical System, has resigned, effective April 26,
according to the Baltimore Sun.
The health system’s board placed Mr. Chrencik on a leave of
absence March 25, as a scandal unfolded involving board members profiting from
contracts with hospital networks they oversee.” (M)
“The University of Maryland Medical Center has requested a
$75 million rate increase from state regulators, a nearly 5 percent increase.
The request was made before news broke of the University of
Maryland Medical System’s inside deals with its board members.
Since then, Catherine Pugh resigned her position on the
board and as mayor of Baltimore, and the system’s CEO Robert Chrencik stepped
down.
“The rate increase requested by UMMC is necessary to provide
funding for ongoing investment in operations and mission-driven goals – vital
initiatives that enable the hospital to deliver first-class care to our
patients,” a UMMS spokesperson said in a written statement. “Ultimately, this
is about UMMC being able to meet the complex needs of our patients while
continuing to serve as a safety net provider for the West Baltimore community.”
State Sen. Jill Carter, (D-Baltimore City) said the timing
of the request could not be worse.
“Right now, of course, there’s going to be a perception that
this rate massive rate increase somehow is a result of the self-dealing,” Sen.
Carter said. “Maybe they should hold off until some of the investigations are
done or the internal or external audits are done, that the legislation called
for that.”” (N)
“The chairman of the embattled University of Maryland
Medical System board of directors announced his resignation Tuesday — along
with two other board members — as an additional contract with one of the
departing board members was revealed.
Board Chairman Stephen Burch, who attended a contentious
meeting in March with Republican Gov. Larry Hogan and Democratic state Senate
President Thomas V. Mike Miller over the board’s contracting practices,
announced his resignation effective July 1.
Burch, who also served as a member of Democrat Catherine
Pugh’s transition team when she became mayor of Baltimore, was joined in
resigning from the UMMS board by Kevin O’Connor and Dr. Scott Rifkin.
O’Connor’s resignation is effective July 1, while Rifkin’s
takes effect immediately.
The system said in a statement that Rifkin and the hospital
network had an “active agreement” in which his company “provides
software for a pilot program designed to reduce hospital readmissions.”..
Federal, state and local investigations are underway.
System President and CEO Robert Chrencik — who was paid
$4.3 million in total compensation in 2017 — resigned last month. Pugh
resigned last week from her office as mayor of Baltimore.” (O)
“Former Baltimore mayor Catherine Pugh and her colleagues on
the University of Maryland Medical System board were not the only ones who
profited from business deals with the hospitals they oversaw.
At least two dozen people who sit on boards of smaller,
affiliated institutions in the massive system had contracts with those
institutions, in some cases worth hundreds of thousands of dollars annually,
according to financial disclosures.
The contracts show the pervasiveness of the kinds of deals
that led to Pugh’s resignation as mayor this month and, lawmakers say, point to
challenges that remain as they grapple with how to make the system more
accountable.
Among those who had deals with hospitals they oversaw were a
Harford County veterinarian who has made nearly $3 million since 2013 from
rental leases; a vascular surgeon whose Bel Air practice made $2.4 million
since 2013; and the former president of an ambulance company whose contracts
were worth at least $1.3 million since 2010.
Michael Schwartzberg, a spokesman for UMMS, said those
relationships are “all appropriate and consistent with fair market value.” Some
of the contracts predated members’ service on the boards, he said; others were
signed after members joined their respective boards. He said some deals were
competitively bid and did not provide information about others.
There were at least two dozen local board members who had
contracts with the hospitals they oversaw, according to the disclosure forms,
which in some cases listed the specific amount their contracts were worth but
in others required a range, such as “greater than $100,000.” The commission
said it was missing forms from UM Rehabilitation & Orthopaedic Institute.”
(P)
Gov. Larry Hogan has decried contracts that board members of
the University of Maryland Medical System held with the organization they were
tasked with overseeing and promised to “clean house.”
But state law long has called for housecleaning along the
way, specifying that board members can’t serve more than two consecutive
five-year terms. Hogan (R) and his predecessors, who appoint the board members,
allowed some to stay well past a decade.
A spokesman for the governor, who took office in 2015, said
Thursday that term limits will be enforced from now on.
“These practices were handed down from both Republican and
Democratic administrations,” spokesman Michael Ricci said in an email.
“Governor Hogan is working to put an end to them so we can help restore public
trust in UMMS.”
Members who lingered on the board include former state
senator Francis X. Kelly, whose insurance company held some of the largest
contracts that are under review as part of a broad investigation of the
hospital board.
Kelly, who did not respond to requests for comment, joined
the board in 1986 and most recently was reappointed by Hogan in 2016. He took a
voluntary leave of absence from the board while auditors probe the contracts.”
(Q)
“The University of Maryland Medical System (UMMS) Board of
Directors reviewed and voted unanimously to approve a new Conflict of Interest
Policy. This is another milestone as the organization continues to improve
Board governance and oversight while managing conflicts of interest
appropriately. The new Policy is adherent to recently passed Maryland legislation
and is effective July 1, 2019.
“This is another major step forward as we improve Board
governance, change corporate culture and put UMMS on a strong path forward,”
said Interim President and CEO John Ashworth. “We thank the legislators for
their work in guiding this policy during the session and helping us focus on
providing a sound, long-term foundation for a sustainable, effective Board.”
Of note, the Policy includes:
A prohibition on sole source contracting with any UMMS Board
member
Requirements for the recusal of non-independent Board
members from certain deliberations and decision-making activities
Provisions that restrict relevant Board leadership positions
to independent Board members
Detailed procedures for the disclosure of interests by UMMS
Board members, officers and management level employees
The process for identifying and addressing conflicts of
interest
The process for handling violations of the Conflict of
Interest Policy
A requirement that every Board member attest to compliance
with the Conflict of Interest Policy
The new Conflict of Interest Policy was delivered to
Governor Hogan and the presiding officers of the Senate and House of Delegates
today, as required by Maryland law. The Policy will also be presented to the
UMMS affiliate boards for review and approval within 60 days.” (R)
“Four top executives at the University of Maryland Medical
System have resigned amid investigations into accusations of self-dealing among
the hospital network’s board members, the system announced Thursday.
Those resigning are Megan Arthur, the system’s primary
lawyer; Jerry Wollman, the chief administrative officer; Christine Bachrach,
the system’s chief compliance officer; and Keith Persinger, the chief
performance improvement officer.” (S)
“Maryland Gov. Larry Hogan named Wednesday his initial batch
of new appointees to the troubled board of directors at the University of
Maryland Medical System, the first step toward reorganizing the board following
a scandal over board members having lucrative contracts with the 13-hospital
system.
The volunteer board came under fire in March when The
Baltimore Sun reported a third of its 30 members or their companies had deals
with the hospital system, some of which were not competitively bid. They
included then-Mayor Catherine Pugh of Baltimore, a Democrat who made hundreds
of thousands of dollars selling children’s books in a sole-source arrangement
with UMMS. She later resigned from the board and as mayor amid multiple
investigations into the book deals.
In a separate action Wednesday, the hospital board elected
new leadership from among its current members and invited four members who
voluntarily took leaves of absence to return.
The new appointments to the board are required under a law
state legislators passed this year that mandated several reforms at the
hospital system. All previously appointed board members must step down by the
end of the year, to be replaced or reappointed by the governor.
All new board members are subject to confirmation votes by
the state Senate, but can serve until the Senate votes on their appointments.
They will take office July 1.
Board members can serve up to two five-year terms. In the
past, board members often stayed past the end of their terms if a governor
didn’t replace them.
“I pledged that I would appoint new board members who will
serve with integrity and accountability, and today, I am delivering on that
promise,” Hogan, a Republican, said in a statement. “This is another critical
step as UMMS works to restore public trust.”
The medical system board met Wednesday morning and elected
James “Chip” DiPaula Jr. as chairman and Alexander Williams Jr. as vice
chairman. They’ll serve in those roles for the remainder of the year. Former
Chairman Stephen A. Burch was among several board members who resigned amid the
scandal.
DiPaula, who Hogan appointed to the board in 2016, is a
former state budget secretary and chief of staff to then-Gov. Robert L. Ehrlich
Jr., a Republican. DiPaula later founded an e-commerce firm.
Williams is a retired federal judge who has been tapped for
other leadership roles, including chairman of the state’s Commission to Restore
Trust in Policing and co-chairman of a commission on redistricting that drew up
a proposed map for Maryland’s 6th Congressional District. Hogan appointed
Williams to the hospital system board in 2015.
In a statement released by UMMS, DiPaula said members of the
board “regret the actions and poor decisions which have jeopardized confidence
in the system.”
The new board members nominated by Hogan are:
» Eliza Basnight, senior vice president of supply chain for
the American Red Cross. Previously, she was chief of staff for the U.S. Mint
under the Obama administration and head of the Center for Women Veterans at the
U.S. Department of Veterans Affairs.
» Kathleen A. Birrane, an attorney with the firm DLA Piper
who previously was the top lawyer for the Maryland Insurance Administration.
» Dr. Joseph Ciotola, health officer for Queen Anne’s County
and medical director for that county’s Department of Emergency Services.
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enforcement in Baltimore region, Gov. Hogan ‘monitoring the situation’ »
» Matthew Clark, Hogan’s chief of staff. Clark will hold a
seat that is reserved for the governor or the governor’s designee.
» Wanda Queen Draper, former director of the Reginald F.
Lewis Museum of African-American History and Culture in Baltimore.
» Jason Frankl, senior managing director of FTI Consulting,
where his work includes helping companies defend against activist investors and
takeover attempts.
» Glenn T. Harrell, retired senior judge of the Maryland
Court of Appeals.
» Dr. Joyce M. Johnson, a physician who retired from the
U.S. Public Health Service, where she held the rank of rear admiral and was director
of health for the U.S. Coast Guard.
» Bonnie Phipps, senior vice president and group operating
executive for Ascension Health, a Catholic health system that operates in 21
states and the District of Columbia, including Southwest Baltimore’s St. Agnes
Hospital, where she was president from 2005 to 2015.
» Joseph T.N. Suarez, a director at Booz Allen Hamilton, a
business consulting firm.
» John T. Williams, chairman and CEO of Jamison Door Company
in Hagerstown. He previously served as a newspaper and TV executive.
In addition to mandating a gradual replacement of the
current board and requiring term limits, the new law banned no-bid contracts
for board members and required a state audit of the hospital system’s
contracting practices.” (T)
“Francis Kelly Jr., the former Maryland state senator whose
insurance company benefited from contracts with the University of Maryland
Medical System while he served on the hospital network’s board of directors ,
announced Friday that he will give up that seat.
“It has been a tremendous honor for me to have served
on the UMMS Board for nearly 35 years, under six different Governors,”
Kelly wrote in a resignation letter to board chairman Stephen Burch. “I
have decided it is time to move on, and allow someone else the fantastic
opportunity of serving.”
Kelly and his sons, John and David, who served on
UMMS-affiliated boards, took voluntary leaves of absence in April as probes
were opened to review the health system’s contracts with businesses affiliated
with board members.
In the resignation letter, Kelly said his sons have also
decided not to return to their board positions.
The UMMS board voted Wednesday to ask Kelly and three other
members on leave to rejoin the board, after an outside probe of the contracting
scandal placed most of the blame with former hospital system chief executive
Robert Chrencik, who resigned in April.
Several state lawmakers raised concerns about the board’s
decision, however, and said board members who had contracts with the system
should not return to the board.
“[W]e feel that the best way to serve the system and
its affiliated hospitals at this time is not come back onto these boards,”
Kelly wrote in a letter to John Ashworth III, the interim president and chief
executive.
Kelly & Associates Insurance Group has had
multimillion-dollar transactions with the medical system since at least 2005,
the first year for which financial disclosure records are available, handling
more than $100 million in premiums.” (U)
“A review of contracts the University of Maryland Medical
System had with members of its board of directors and their companies revealed
more no-bid and self-dealing practices — including that executives pressured
staff to use board members’ products — and blamed former CEO Robert Chrencik
and other system leaders.
“Many of these contracts were not competitively bid, were
not declared to be necessary by the board or senior leaders, and, if vetted,
were without full transparency to the entire board,” concluded the review by
Nygren Consulting, which was hired and paid by the 13-hospital network.
The report released Wednesday reviewed business deals with
nine board members and found:
» Seven of nine of the deals were entered into without
competitive bids;
» In four cases, the board of directors was not properly
informed of the business relationships;
» The board member who was in charge of auditing financial
dealings himself had a no-bid deal;
» In at least two instances, staff felt pressured to promote
the use of software from companies that would have benefited individual board
members financially.
The report focused its harshest criticism on deals with four
board members that hospital officials described as “personal services”
contracts: Former Baltimore Mayor Catherine Pugh, who was paid $500,000 for her
self-published children’s books; Robert Pevenstein, a consultant who was paid
more than $100,000 a year; John W. Dillon, who was paid $892,000 since 2013 for
providing “healthcare consulting services;” and Dr. Scott Rifkin, who runs a
health care software company.
The system commissioned the review in response to
revelations in The Baltimore Sun, beginning in March, about the contracting
practices.
“These arrangements reflect a pattern by management of
making decisions without full board approval,” the report found of members’
contracts. “The board was insufficiently informed and, for the most part, had
no specific advance knowledge that would have caused the board to consider
alternatives that would have forestalled or eliminated perceived and real
self-dealing.” “ (V)
“The report on self dealing among UMMS board members comes
after the departures of the system’s CEO and board members, including former
Baltimore Mayor Catherine Pugh. Controversy arose over board members —
including Pugh — who made money in business deals with the system.
Regarding Pugh’s “Healthy Holly” book arrangement,
Nygren wrote, “Our review has determined that management did not present
the book purchases to the board or any committee for prior approval, as
required by then-in-effect Conflict of Interest policies, and the purchase was
not subject to any competitive bidding process.”
The report concluded that then-CEO Robert Chrencik
“agreed to enter into an agreement with Ms. Pugh without consent of the
board.”
Between 2010 and 2018, UMMS agreed to pay a total of
$500,000 for the self-published books Pugh authored. She repaid $100,000.
The report also investigated other former board members and
found similar violations of board policies.
UMMS said in a statement that the report details “both
management and various board members share responsibility for the lack of
transparency and strong, modern governance policies that resulted in improper
relationships.”
UMMS said the following recommendations have been or will be
adopted:
A new, comprehensive Conflict of Interest Policy was
authored by Nygren and accepted by the Board of Directors. The policy was
delivered to Maryland’s governor, Senate president and Speaker of the House on
May 31.
A Governance Committee will be chartered as a permanent
Committee of the Board, and tasked with overseeing all board practices,
policies and relationships. All appropriate guiding documents will be authored.
A new, research-based “competency” model will be
implemented to ensure the makeup of the board is determined based on two levels
of competencies: those required of each individual member, and those required
by the Board as a whole. This will ensure the board is representative of the
communities it serves and has the experience and skills necessary to advance
the organization’s strategic direction and mission.
The education process related to disclosures and conflicts
will be redesigned and will include an official “Code of Conduct” to
ensure all board members and senior management are acutely aware of compliance
requirements moving forward.
Board committees will be restructured so chair positions of
the Finance Committee and the Audit and Compliance Committee are held by
separate individuals, and the chair of the latter maintains no financial or
contractual relationship with the organization.
“While Nygren confirmed that outside business interests
between a board member and a nonprofit Board of Directors are not uncommon or
illegal, great care and caution must be given to ensure there is proper vetting
and no real or perceived conflicts of interest. To that end, any proposed
professional services agreements with board members will be revealed to the
full board, carefully vetted with the Board’s Audit and Compliance Committee
and reported to the Compliance Officer. The new Conflict of Interest Policy
will be strictly adhered to in all cases. Additionally, the system will no
longer allow any board member to engage in a personal services agreement,
regardless of circumstance,” the UMMS statement read.” (V)
“The recent ethical lapses within the University of Maryland
Medical System and its board have been appalling, with much of the focus on
former Baltimore Mayor Catherine Pugh, state legislation passed to improve
board oversight and resignations of certain board members.
Scant attention has been paid, however, to an elephant in
the room: Most of the board members were, as required by statute, appointed by
Gov. Larry Hogan, with some improperly reappointed beyond the two-term legal
limit. And many of them, including several of the 11 newly appointed board
members, donated to his campaign as individuals or through affiliated
businesses — some in apparent excess of campaign finance limits — for a
combined total of over $115,000.
While donors receiving appointments isn’t inherently
unlawful, it undermines public confidence, particularly when combined with the
fact that some of these donor-appointees, including former state Sen. Frank
Kelly Jr., appear to have received generous “insider” contracts from UMMS.
And, despite the governor’s professed outrage over UMMS’
dealings, he recently vetoed an important bill that would improve transparency
and strengthen accountability of the Governor’s Appointments Office, whose
primary purpose is to vet political appointees to represent Mr. Hogan on boards
and commissions and in a small handful of high-level leadership positions in
state agencies.
The governor prefers to point the finger at UMMS for its
failed internal controls, but he, too, should have known that many of his
appointees had business dealings with UMMS. His appointments office requires
all appointees to complete a form that probes for conflicts of interest and
problematic affiliations.
In examining the governor’s campaign finance records,
publicly available from the State Board of Elections, I found at least eight
UMMS board members — Stephen Burch, R. Alan Butler, John Coale, James “Chip”
DiPaula Jr., Barry Gossett, Mr. Kelly, Robert Pevenstein and Walter Tilley Jr.
— who donated to Governor Hogan the $6,000 maximum permitted by law.
Businesses apparently connected to Mr. Tilley, James
Soltesz, Mr. DiPaula and Robert Rauch also contributed a combined $16,000 to
Governor Hogan’s campaign.
Four board members or related businesses appear to have
contributed above the $6,000 legal limit in total over a four-year period:
Kelly Integral Solutions LLC, contributed $11,000 — all
while Kelly & Associates received a lucrative UMMS contract reportedly
worth $16 million. (Mr. Kelly is among those who recently announced his
resignation from the board.)..
In order to boost accountability, and in response to
numerous complaints of politicization of the state workforce, I introduced and
passed legislation (Senate Bill 751) during this past session that would
increase transparency regarding the information gathered by the appointments
office by requiring annual aggregated reporting back to the General Assembly.
The governor vetoed it.” (X)
“For its report, Nygren reviewed system documents and
interviewed about 60 people, including current and former board members,
executives and staff. Here are some of the firm’s key findings:
1) Blaming the old boss.
Chrencik was blamed for cutting deals with individual board
members without the full board’s approval. In four cases, the board was not
properly informed of the deals…
2) Most deals with board members weren’t competitively bid.
Seven of nine of the deals with individual board members
were entered into without competitive bids…
3) Who’s doing oversight?
The board member who was in charge of monitoring financial
dealings himself had a no-bid deal. Robert Pevenstein, who was chairman of both
the audit and finance committees, had several arrangements with the system,
including for-profit relationships for the firms Profit Recovery Partners and
Optime, as well as a consulting deal. He was paid more than $100,000 a year…
4) Staff felt uncomfortable.
In at least two instances, UMMS employees felt pressured to
promote the use of software from companies that benefited individual board
members financially…” (Y)
