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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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



(A) https://applied-learning.jhsph.edu/masters-in-patient-safety?utm_source=bing&utm_medium=cpc&utm_term=%2Bhopkins+%2Bpatient+%2Bsafety&utm_campaign=RWC_JHUBSPH_MPSH_Search-PPC_Paid+Search_Bing_NonBrnd_Broad_Regional_Program-Related_NULL_Secondary&utm_content=MPSH%7Chopkins+patient+safety%7CBMM&uadgroup=MPSH%7Chopkins+patient+safety%7CBMM&uAdCampaign=RWC_JHUBSPH_MPSH_Search-PPC_Paid+Search_Bing_NonBrnd_Broad_Regional_Program-Related_NULL_Secondary&msclkid=899417c1ef841b340f434bffe8588404&gclid=CODg-puY8N8CFQndswodxncPJA&gclsrc=ds
(B) https://www.hopkinsmedicine.org/patient_safety/index.html
(C) https://nursing.jhu.edu/excellence/quality-safety/index.html
(D) https://armstronginstitute.blogs.hopkinsmedicine.org/2013/03/25/a-roadmap-for-patient-safety-and-quality-improvement/
(E) https://www.hopkinsallchildrens.org/About-Us
(F) https://www.hopkinsallchildrens.org/about-us/patient-safety
(G) Johns Hopkins promised to elevate All Children’s Heart Institute, by KATHLEEN McGRORY and NEIL BEDI, http://www.tampabay.com/projects/2018/investigations/heartbroken/all-childrens-heart-institute/
(H) Top officials at Johns Hopkins All Children’s Hospital resign following reports of heart surgery deaths, by Tina Reed, https://www.fiercehealthcare.com/hospitals-health-systems/top-officials-at-johns-hopkins-all-children-s-hospital-resign
(I) Three more All Children’s officials resign following Times investigation, by By Kathleen McGrory and Neil Bedi, https://www.tampabay.com/investigations/2019/01/02/three-more-all-childrens-officials-resign-following-times-investigation/
(J) Johns Hopkins hires former prosecutor to investigate All Children’s Heart Institute,by Kathleen McGrory and Neil Bedi , https://www.tampabay.com/investigations/2019/01/09/johns-hopkins-hires-former-prosecutor-to-investigate-all-childrens-heart-institute/
(K) Problems At All Children’s Hospital Could Lead To More Transparency Rules, by STEPHANIE COLOMBINI, http://wusfnews.wusf.usf.edu/post/problems-all-childrens-hospital-could-lead-more-transparency-rules
(L) State and federal inspectors visit All Children’s after reports on heart surgery deaths, by Kathleen McGrory and Neil Bedi, https://www.tampabay.com/investigations/2019/01/11/state-and-federal-inspectors-visit-all-childrens-after-reports-on-heart-surgery-deaths/
(M) Doctors sue Children’s, alleging wrongful termination after raising concerns about child’s death, by Julie Anderson, https://www.omaha.com/livewellnebraska/health/doctors-sue-children-s-alleging-wrongful-termination-after-raising-concerns/article_185712cd-7156-5c9f-9ed3-52dafec9f0c4.html
(N) Bacteria In Newark Hospital NICU; Baby’s Death Being Probed: DOH, by Eric Kiefer, https://patch.com/new-jersey/newarknj/bacteria-newark-hospital-nicu-babys-death-being-probed-doh
(O) 5 NJ Facilities Under Microscope After Deadly Virus Outbreak by Tom Davis, https://patch.com/new-jersey/pointpleasant/5-nj-facilities-under-microscope-after-deadly-virus-outbreak
(P) Want health professionals to help reduce medical errors? Patient Safety Movement releases new curriculum, by Tina Reed, https://www.fiercehealthcare.com/hospitals-health-systems/new-patient-safety-curriculum-released-at-patient-safety-movement-summit
(Q) Community Hospitals Link Arms With Prestigious Facilities To Raise Their Profiles, by Sandra G. Boodman, https://khn.org/news/community-hospitals-link-arms-with-prestigious-facilities-to-raise-their-profiles/

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Jonathan M. Metsch, Dr.P.H.
[email protected]

Log on to the AUPHA Network: http://network.aupha.org
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2. Johns Hopkins All Children’s has 3 weeks to correct safety lapses or lose Medicare funding

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


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

• Federal officials threaten All Children’s funding, citing problems, by Kathleen McGrory and Neil Bedi, https://www.tampabay.com/investigations/2019/02/01/federal-officials-threaten-all-childrens-funding-citing-problems/

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A spokesperson said the hospital will meet the deadline.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Governing body

Quality assurance performance improvement

Medical staff

Infection control

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(A)       All Children’s says 13 heart surgery patients were hurt by care, by Kathleen McGrory and Neil Bedi, https://www.tampabay.com/investigations/2019/02/09/all-childrens-says-13-heart-surgery-patients-were-hurt-by-care/

(B)       Deadline is today for All Children’s to provide plan to fix ‘serious’ safety issues, by Andrew Krietz, https://www.wtsp.com/article/news/local/pinellascounty/deadline-is-today-for-all-childrens-to-provide-plan-to-fix-serious-safety-issues/67-0a5e912d-f31b-44ec-93dd-4a89a268c5f1

(C)       Johns Hopkins All Children’s submits corrective plan to CMS amid safety lapse probe, by Megan Knowles, https://www.beckershospitalreview.com/quality/johns-hopkins-all-children-s-submits-corrective-plan-to-cms-amid-safety-lapse-probe.html

(D)       All Children’s Hospital hatches plan to fix its problems, by Sarah Rosario, https://www.wtsp.com/article/news/health/all-childrens-hospital-hatches-plan-to-fix-its-problems/67-90ee8f7b-2c9d-442c-9779-1a6a383a8632

(E)       After All Children’s deaths, proposal aims to catch heart surgery problems, by Kathleen McGrory, Neil Bedi and Elizabeth Koh, https://www.tampabay.com/investigations/2019/02/19/after-all-childrens-deaths-proposal-aims-to-catch-heart-surgery-problems/

(F)       Feds accept Johns Hopkins All Children’s Hospital plan to correct conditions putting patients in jeopardy, by Veronica Brezina-Smith, https://www.bizjournals.com/tampabay/news/2019/02/22/feds-accept-johns-hopkins-all-childrens-hospital.html a.fn.andSelf

(G) Quality varies wildly among affiliates linked with US News top hospitals, JAMA study finds, by Meg Bryant, https://www.healthcaredive.com/news/quality-varies-wildly-among-affiliates-linked-with-us-news-top-hospitals-j/550472/

(H) Federal inspectors find unresolved problems at All Children’s, by Bedi and Kathleen McGrory, https://www.tampabay.com/investigations/2019/03/08/federal-inspectors-find-unresolved-problems-at-all-childrens/

(I) Editorial: More eyes on pediatric heart programs, https://www.tampabay.com/opinion/editorials/editorial-more-eyes-on-pediatric-heart-programs-20190308/

(J) CMS creates tool for surveyors to spot immediate jeopardy, by MARIA CASTELLUCCI,   https://www.modernhealthcare.com/safety/cms-creates-tool-surveyors-spot-immediate-jeopardy



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

PART 1. March 21, 2019

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Trump gave a boost to efforts on Wednesday.

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

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

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

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

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

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

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

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

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

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

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

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

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

And then the bill came.

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

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

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

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

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

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

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

PART 2. April 7, 2019

Zuckerberg hospital puts balance billing on hold

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

Friday, February 01, 2019

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

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

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

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

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

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

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

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

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

Immediate Changes

Temporarily halt all balance billing of patients

Effective immediately until a better plan is determined

Make financial assistance easier to get

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

Improve patient communications

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

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

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

Increase communication with patients and provide information about financial assistance opportunities

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

Make financial assistance easier to get

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

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

Streamline the process of applying for assistance

Protect patients’ financial health

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

Pursue agreements with private insurance companies

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

Ensure ZSFG prices and practices are fair

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

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

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

(A)San Francisco General Hospital Lacks A Good Way To Deal With Patients Who Are Actually Insured, https://californiahealthline.org/morning-breakout/san-francisco-general-hospital-lacks-a-good-way-to-deal-with-patients-who-are-actually-insured/

(B)Nasty surprise bills prohibited by new California law when people visit facilities in their insurance network , by Emily Bazar, https://www.sacbee.com/news/local/health-and-medicine/article157970259.html

(C)SF General’s insured patients suffer further trauma when bill arrives, by Heather Knight, https://www.sfchronicle.com/bayarea/heatherknight/article/SF-General-s-insured-patients-suffer-further-13543542.php

(D)A $20,243 bike crash: Zuckerberg hospital’s aggressive tactics leave patients with big bills, by Sarah Kliffsarah, https://www.vox.com/policy-and-politics/2019/1/7/18137967/er-bills-zuckerberg-san-francisco-general-hospital

(E)Zuckerberg Hospital ER Doesn’t Take Private Insurance, Sticking San Francisco Patients With Huge Bills, by Andrew Whalen, https://www.newsweek.com/zuckerberg-hospital-er-private-insurance-medicare-medicaid-mark-facebook-san-1282274

(F)Report: Zuckerberg Hospital Gouges Paying Patients to Pay For Illegals, by Kit Daniels, https://www.infowars.com/zuckerberg-hospital-offsets-healthcare-costs-of-illegals-by-gouging-privately-insured/

(G)A Fainting Spell After A Flu Shot Leads To $4,692 ER Visit,  http://health.wusf.usf.edu/post/fainting-spell-after-flu-shot-leads-4692-er-visit#stream/0

(H)Report: Zuckerberg Hospital Gouges Paying Patients to Pay For Illegals, by Kit Daniels, https://www.infowars.com/zuckerberg-hospital-offsets-healthcare-costs-of-illegals-by-gouging-privately-insured/

(I)Why there’s no surprise hospital bill backlash — yet, https://www.axios.com/hospital-medical-bill-backlash-21127cf3-cffc-4751-9ae5-cadda7b5d3c4.html

(J) Payer, hospital groups trade blame on surprise billing, by Les Masterson, https://www.healthcaredive.com/news/payer-hospital-groups-trade-blame-on-surprise-billing/544064/

(K)Taking Surprise Medical Bills To Court, by Julie Appleby, https://khn.org/news/taking-surprise-medical-bills-to-court/

(L))Prices at Zuckerberg hospital’s emergency room are higher than anywhere else in San Francisco, by  Sarah Kliff, https://www.vox.com/2019/1/22/18183534/zuckerberg-san-francisco-general-hospital-er-prices

(M) After Vox story, Zuckerberg hospital rolls back $20,243 emergency room bill, by Sarah Kiff, https://www.vox.com/health-care/2019/1/24/18195686/vox-zuckerberg-hospital-emergency-room-bill

(N)Trump boosts fight against surprise medical bills, by PETER SULLIVAN, https://thehill.com/policy/healthcare/427066-trump-boosts-fight-against-surprise-medical-bills

(O)Industry braces as more lawmakers seek to ban surprise billing, by Shannon Mushmore, https://www.healthcaredive.com/news/industry-braces-as-more-lawmakers-seek-to-ban-surprise-billing/547015/

(P) Sarah Kliff has spent the past year reporting on high ER fees. Ask her anything, by Lauren Katz, https://www.vox.com/health-care/2019/1/22/18188777/emergency-room-fees-health-care-costs

(Q)After Vox story, Zuckerberg hospital rolls back $20,243 emergency room bill, by Sarah Kliff, http://health.wusf.usf.edu/post/fainting-spell-after-flu-shot-leads-4692-er-visit#stream/0

(R)Zuckerberg hospital puts balance billing on hold, General Hospital Until Plan to Improve Long-Term Billing Practices is Implemented, https://sfmayor.org/article/mayor-london-breed-and-supervisor-aaron-peskin-announce-halt-balance-billing-zuckerberg-san

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.

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

(A)          After Vox story, California lawmakers introduce plan to end surprise ER bills, by Sarah Kliff, https://www.vox.com/2019/2/24/18236482/zuckerberg-hospital-surprise-bills-california

(B)          Controversial ZSFGH billing practice that left privately-insured owing thousands could be banned, by Laura Waxmann, http://www.sfexaminer.com/controversial-zsfgh-billing-practice-left-privately-insured-owing-thousands-banned/

(C)          Joint Surprise Billing Letter to Congress and Committee Leadership, https://www.aha.org/letter/2019-02-20-joint-surprise-billing-letter-congress-and-committee-leadership

PART 3. April 23, 2019

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

1. After Vox stories, Zuckerberg Hospital is overhauling its aggressive billing tactics, by Sarah Kliff, https://www.vox.com/2019/4/16/18410905/zuckerberg-san-francisco-hospital-bills
2. Publicity spurs billing revamp at Zuckerberg hospital, by Kelly Gooch, https://www.beckershospitalreview.com/finance/publicity-spurs-billing-revamp-at-zuckerberg-hospital.html
3. Zuckerberg Hospital Revises Insane Billing Practices After Media Exposés, by JOE KUKURA, https://sfist.com/2019/04/17/zuckerberg-hospital-revises-insane-billing-practices-after-media-exposes/
4. Emergency room off Las Vegas Strip makes waves with new business model, by Milbank News Writer, https://milbankmonitor.com/emergency-room-off-las-vegas-strip-makes-waves-with-new-business-model/14/04/2019/

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

Now they’re competing for heart doctors.

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

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

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

Here’s why….” (A)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Bezos said he gets eight hours of sleep:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

• (A)Why big tech companies keep hiring heart doctors, by Christina Farr, https://www.cnbc.com/2018/10/17/what-every-tech-company-needs-a-cardiologist.html
• (B)As Amazon Turns Its Gaze to Healthcare, the Industry May Be in for a Wild Ride, by Robert Haslehurst and Joseph Johnson, Managing Directors at L.E.K. Consulting, https://www.fiercehealthcare.com/sponsored/did-you-know-72-u-s-adults-go-online-to-find-health-information-and-did-you-know-41
• (C)Amazon and Apple are getting into medical clinics — here’s why, by Christina Farr, https://www.cnbc.com/2018/09/08/amazon-and-apple-are-getting-into-medical-clinics-heres-why.html
• (D)Amazon-Berkshire-JPM Health Venture Makes ‘Bold Statement’ With COO Hire, by Armie Margaret Lee,  https://www.thestreet.com/markets/amazon-berkshire-jpm-health-venture-makes-bold-statement-with-stoddard-coo-hire-14704518
• (E)Sentara CEO Howard Kern: What if Jeff Bezos ran Sentara Healthcare?, by Howard Kern, https://www.beckershospitalreview.com/hospital-management-administration/sentara-ceo-howard-kern-what-if-jeff-bezos-ran-sentara-healthcare.html
• (F)Hospital executives believe Amazon can deliver on its hype as a healthcare disrupter, https://www.fiercehealthcare.com/tech/provider-executives-survey-amazon-ceos-reaction-data-apple-google-telemedicine-mergers?mkt_tok=eyJpIjoiWXpjM1lqbGhabU15TmpjMCIsInQiOiJ3UHhJb2t5WVE1VHA0YU5ZQkFJVDl6aU9GUFAwNk4rcU1xU2dcL2RkSGpvc3FtVWI0WE9PQ0RON3V2eTJcL1RkTmtIaEoxR21LVG1Dbys0UVMrVFB0VkF2QlZEUEJIMElLRlFcL095TVFFWUgrVFZYNFk2Z28zdTZwODVBMmhod0JBViJ9&mrkid=654508
• (G)This is the ‘disruption’ large employers are hoping Amazon brings to healthcare, https://www.fiercehealthcare.com/hospitals-health-systems/disruption-large-employers-are-hoping-amazon-brings-to-healthcare?utm_source=Sailthru&utm_medium=email&utm_campaign=Issue:%202018-08-09%20Healthcare%20Dive:%20IT%20%5Bissue:16589%5D&utm_term=Healthcare%20Dive:%20IT
• (H)Toby Cosgrove warns innovators about healthcare industry: ‘They’ll hate it’, https://www.fiercehealthcare.com/hospitals-health-systems/toby-cosgrove-veterans-health-administration-innovation?mkt_tok=eyJpIjoiWXpka01tTmlaR1JtWXpRNCIsInQiOiJNc1RDSWlQaWk5MzFaZ2RJbThDTGN3ejRza3o5QWxaMnV2M0R5aFFYN2liUUlqVVdTRStMMitSSURzdVBTRGorSXo1UXlcL0NDQ2RCbmlTREFEZ0pJa01hUHJMTkQ1ZkdYUVpOTEJxMkw5c3Z0Z25FZkFJSVJcLzZlVTZGQTg4dENnIn0%3D&mrkid=654508
• (I)Jeff Bezos’ secrets for life and business, https://www.axios.com/jeff-bezos-amazon-secrets-rubenstein-1c4d2c5f-80ee-4389-99de-6501449d5ee5.html
• (J)Look out device makers — Amazon to sell glucose monitors, blood pressure cuffs, by Samantha Liss, https://www.healthcaredive.com/news/look-out-device-makers-amazon-to-sell-glucose-monitors-blood-pressure-cu/540739/
• (K)CEO Larry Merlo’s goal for CVS? Eliminate ‘white space’ Amazon could disrupt, by Morgan Haefner, https://www.beckershospitalreview.com/hospital-management-administration/ceo-larry-merlo-s-goal-for-cvs-eliminate-white-space-amazon-could-disrupt.html?origin=ceoe&utm_source=ceoe
• (L)Until Amazon Stores Have Doctors, CVS And Walgreens Needn’t Worry, by  Bruce Japsen, https://www.forbes.com/sites/brucejapsen/2018/09/20/until-amazon-stores-have-doctors-cvs-and-walgreens-neednt-worry/#6aff419693f3
• (M)Netflix co-founder urges Utah health executives to develop ‘tolerance of risk’, by Ben Lockhart, https://www.deseretnews.com/article/900031633/netflix-co-founder-urges-utah-health-executives-to-develop-tolerance-of-risk.html
• (N)Google turns 20: Here are 7 ways it’s changing healthcare, by Jessica Kim Cohen, https://www.beckershospitalreview.com/healthcare-information-technology/google-turns-20-here-are-7-ways-it-s-changing-healthcare.html
• (O)Does your doctor need to know what you buy on Amazon?, by MOHANA RAVINDRANATH, https://www.politico.com/story/2018/10/30/the-doctor-will-see-through-you-now-893437
• (P)Geisinger CEO Feinberg packs for Google months after shrugging off Amazon, by Tony Abraham, https://www.healthcaredive.com/news/geisinger-ceo-feinberg-packs-for-google-months-after-balking-amazon/541826/
• (Q)Sean Parker: Health care’s big breakthroughs aren’t going to come out of Google or Amazon, by  REBECCA ROBBINS, https://www.statnews.com/2018/11/13/sean-parker-health-cares-big-breakthroughs-arent-going-to-come-out-of-google-or-amazon/
• (R)Here comes Amazon, by DARIUS TAHIR, https://www.politico.com/newsletters/morning-ehealth/2018/11/28/here-comes-amazon-432975
• (S)Amazon private label healthcare offerings grow, by Meg Bryant, https://www.healthcaredive.com/news/amazon-private-label-healthcare-offerings-grow/542659/,
• (T)How healthcare leaders can spend less time on procurement and more time on care, by Chris Holt, https://www.healthcaredive.com/news/how-healthcare-leaders-can-spend-less-time-on-procurement-and-more-time-on/542610/
• (U)Disruptor of the Year: Amazon, by Samantha Liss, https://www.healthcaredive.com/news/disruptor-of-the-year-amazon/542153/
• (V)Before leaving Geisinger for Google, Dr. David Feinberg offered his plan to fix U.S. healthcare, by Robert Pearl, https://www.beckershospitalreview.com/hospital-management-administration/before-leaving-geisinger-for-google-dr-david-feinberg-offered-his-plan-to-fix-u-s-healthcare.html?origin=ceoe&utm_source=ceoe
• (W)Amazon moves into healthcare: A 2018 timeline, by Alia Paavola, Becker’s Hospital Review, December 20 ,2018

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

• What Having A Seat At The Table Really Means  https://remarkableleader.wordpress.com/2015/03/18/what-having-a-seat-at-the-table-really-means/

Revised: December 24, 2018 000000