Recently after a doctor’s appointment I went to a nearby lab to have blood drawn for routine tests. I asked the phlebotomist to wash her hands to which she replied she already had. She had washed her hands in another room after the last patient, done some other work, come into the room, put gloves on, then went and used a shared computer, before finally drawing blood. When I asked, she refused to wash her hands in front of me. So I refused to let her proceed. The same with the second tech. Finally the third washed her hands correctly in front of me. But not again before she left the room! I reported this to the absentee owner!
Do you ask “Doctor, Did You Wash your Hands?” If not, why not? Everyone knows, including our physicians, that proper hand washing is the most effective patient safety measure right? Your physician and other clinicians (e.g. nurses, PTs, lab techs drawing blood) should wash their hands before and after each patient, both times in front of you.
First some history. “Ignaz Semmelweis, a young Hungarian doctor working in the obstetrical ward of Vienna General Hospital in the late 1840s, was dismayed at the high death rate among his patients. He had noticed that nearly 20% of the women under his and his colleagues’ care in “Division I” (physicians and male medical students) of the ward died shortly after childbirth. This phenomenon had come to be known as “childbed fever.” Alarmingly, Semmelweis noted that this death rate was four to five times greater than that in “Division II” (female midwifery students) of the ward. One day, Semmelweis and some of his colleagues were in the autopsy room performing autopsies as they often did between deliveries. They were discussing their concerns about death rates from childbed fever. One of Semmelweis’ friends was distracted by the conversation, and he punctured his finger with the scalpel. Days later, Semmelweis’ friend became quite sick, showing symptoms not unlike those of childbed fever. His friend’s ultimate death strengthened Semmelweis’ resolve to understand and prevent childbed fever. In an effort to curtail the deaths in his ward due to childbed fever, Semmelweis instituted a strict hand washing policy amongst his colleagues in “Division I” of the ward. Everyone was required to wash their hands with chlorinated lime water prior to attending patients. Mortality rates immediately dropped from 18.3% to 1.3% in 1848 in Semmelweis’ division. (A)”
(1861) “…. Louis Pasteur was showing the world that microorganisms did indeed exist, that they acted on our world in myriad ways and that the ancient wisdom about “bad vapors” and spontaneous generation were wrong. Dead wrong. Prior to Pasteur and what would become known as “germ theory,” the prevailing theories held that organisms, like maggots and fleas, were spontaneously originated from other matter, like raw meat or diseased flesh….. Pasteur is credited with opening the world’s eyes to the new science of microbiology and ushering in a brand new form of preventive medicine: immunization. …Building on what Pasteur was discovering, British surgeon Lister began to use this new germ theory to demonstrate the lifesaving value of disinfectant. Despite his skill at surgery, Lister knew that half his amputee patients would die of infection after the procedure….. He began to treat his surgery equipment, before and after use, with carbolic acid. He also treated his patients’ wounds with it…..within two years, operative mortality decreased from nearly 50 percent to just 15 percent.” “Much of the greatness of Pasteur and Lister lies in their dogged persistence to spend 20 years convincing the rest of the medical world of the truth of their investigations,” ….. (B)
(1881) “What Dr. Towsend did next was something that Joseph Lister, despite years spent traveling the world, proving the source of infection and pleading with physicians to sterilize their hands and instruments, had been unable to prevent. As the president (Garfield) lay on the train station floor, one of the most germ-infested environments imaginable, Towsend inserted an unsterilized finger into the wound in his back, causing a small hemorrhage, and almost certainly introducing an infection that was far more lethal than Guiteau’s bullet.” (C)
“The shot in the back was not fatal, not hitting any vital organs. The bullet lodged behind the pancreas. “If they had just left him alone he almost certainly would have survived,” Millard said. Within minutes, doctors converged on the fallen president, using their fingers to poke and prod his open wounds. “Twelve different doctors inserted unsterilized fingers and instruments in Garfield’s back probing for this bullet,” Millard recounted, “and the first examination took place on the train station floor. I mean, you can’t imagine a more germ-infested environment.” American doctors at the time didn’t believe germs existed at all. And according to Dr. Jeffrey Reznick of the National Library of Medicine, they rejected the use of antiseptics pioneered by British surgeon Joseph Lister, for whom Listerine would later be named” (D)
FAST FORWARD 150 YEARS
“Hospital infections affect almost two million people in the United States every year, 100,000 of whom die. Up to 70 percent of these infections could be prevented if health care workers follow recommended protocols, which include hand hygiene…. “Why is it still so hard to get health care workers to wash their hands? Active resisters are people who like doing things a certain way for the simple reason that things have always been done that way. During one site visit, an infectious diseases doctor involved in preventing infections told us: Getting the surgeons to adopt things in general is problematic … they’re like baseball players, they’ve got superstitions…in their minds if it’s working, why should we change it. But at least you know who these people are since they speak up at meetings and actively resist changing behavior. The second type are what we termed organizational constipators. These individuals often have nothing against an initiative per se but simply enjoy exercising their power by refusing to change, albeit below the radar. The challenging aspect about organizational constipators is that the people above them think they are doing a good job, while those below them cannot believe they still have a job. Yet another barrier we found in our research is that many hospitals have a culture of mediocrity rather than a culture of excellence. These hospitals are content to be just good enough. Leadership is generally ineffective. Overperformers are rewarded with more work.” (E)
“…this sobering truth. When bacteria lurking on, for instance, a medical device, a bed rail, a bandage or a caregiver’s hands find their way into a patient’s body via a surgical wound, a catheter, a ventilator, or some invasive procedure, the disturbingly frequent result is a serious, sometimes devastating, infection.” (F)
“Hospital-acquired infections (HAI) cost $9.8 billion per year, with surgical site infections alone accounting for one-third of those costs, followed closely by ventilator-associated pneumonia at 31.6 percent….” (G)
“Hands are the most common vehicle for transmission of organisms and “hand hygiene” is the single most effective means of preventing the horizontal transmission of infections among hospital patients and health care personnel. ” (H) (I)
“How dirty is your Qwerty? It turns out that your computer keyboard could put a host of potentially harmful bacteria — including E. coli and staph — quite literally at your fingertips. Sure, it may sound like a hypochondriac’s excuse to stay away from the office. But a growing body of research suggests that computer mice and keyboards are, in fact, prime real estate for germs. It’s a phenomenon most recently illustrated by tests at a typical office environment in the United Kingdom. A consumer advocacy group commissioned the tests in which British microbiologist James Francis took a swab to 33 keyboards, a toilet seat and a toilet door handle at the publication’s London office in January. Francis then tested the swabs to see what nasty germs he managed to pick up. He found that four of the keyboards tested were potential health hazards — and one had levels of germs five times higher than that found on the toilet seat.” (J)
“Question: I recently had an appointment with a medical specialist. I got called into the clinic room where I waited for the doctor; and I noticed a few “wash your hands” posters. When he came in, I swear he didn’t use the hand sanitizer. I couldn’t be sure. And I didn’t want to ask – but I was kind of grossed out. What should I have done? Is it okay to question the doctor about hand washing? Answer: Your concerns about hand washing are certainly justified. Poor hand hygiene practices are largely to blame for the spread of germs within health care settings… If you ever suspect that your doctor, nurse or other health care provider forgot to use the hand sanitizer, by all means raise the question. But, in reality, most patients in your situation are reluctant to do so. “Very few people would ever be comfortable asking their health-care providers if they’ve cleaned their hands,” acknowledges Dr. Vearncombe. “Our patients feel very vulnerable,” she explains. “They are in an imbalanced power relationship with us, so it is really hard for them to ask.” Indeed, some patients fear that their treatment could be jeopardized if they challenge the doctors and nurses on even routine matters such as hand hygiene. Their care will certainly not be affected, but it’s a worry for them nonetheless. Surveys going back almost a decade found that Ontario patients didn’t want to be placed in the role of a police officer to ensure that doctors and nurses wash their hands. As a result of these surveys, most of the hand-hygiene education in Ontario has focused on the health care providers themselves. Since 2007-2008, Ontario hospitals have been required by provincial law to report their hand-hygiene rates. In some hospitals, such as Sunnybrook, designated staff members routinely observe interactions of health care providers with patients to track if they are actually washing their hands at the appropriate times.” Before mandatory reporting took effect, a study carried out at a few hospitals had revealed that hand-hygiene compliance rates were “abysmally low,” notes Dr. Vearncombe. The rate at Sunnybrook, for instance, was originally less than 40% – similar to many other hospitals. “We have made great increases in our hand-hygiene compliance, and the most recent results show our overall rate is now 87%.”.. A pilot study at Sunnybrook has been exploring what role patients could play. Three of the hospital’s inpatient wards were selected for the pilot. As part of the study, an information card was placed on the bedside table whenever a room was cleaned and prepared for a new patient. “This little card explained in lay language what to expect” when a health-care provider entered the patient’s room, says Dr. Vearncombe. The cards stated that “Your care provider should clean their hands: 1) Before contact with you; 2) Before a procedure; 3) After a procedure; and 4) After contact with you.” The cards also included the catchphrases: It’s okay to ask staff, ‘Did You Clean Your Hands?’ and Reminders help everyone! So, the next time you suspect a health-care worker may have skipped the hand sanitizer, don’t hold back. Everyone benefits when fewer germs are spread around.” (K)
“At Denver Health Medical Center, the CenTrak monitoring system is used on two of the medical-surgical wards, the medical intensive care unit, and the step-down care unit. On these particular units, all rooms are single occupancy. All nurses and healthcare technicians on these floors, as well as those on the float team, have badges. Additionally, select hospitalists, intensivists and residents also have badges to track their personal electronic hand hygiene adherence. “We monitor both waterless hand sanitizer and soap dispensers,” Young explained. “We have defined adherence with the technology to be performing hand hygiene within 60 seconds before or after entering the room and within 60 seconds before or after leaving the room.” Denver Health has used the electronic hand hygiene monitoring system as a means to both effect and measure change in hand hygiene. For example, it has used electronic hand hygiene to study the effect of poster placement on hand hygiene habits. It also has provided individual feedback to staff members on their hand hygiene rates and studied the change in electronic hand hygiene over time. The hospital has achieved quite a success with baseline hand hygiene adherence rates nearly doubling. While Denver Health measures multiple hand hygiene workflows, this particular example of improved compliance was in regard to its wash-in/wash-out protocol – the requirement for staff to wash their hands upon entering a room and again after their interaction with a patient. “Using data from the electronic hand hygiene compliance system, Denver Health was able to properly audit hand hygiene processes and provide additional training and education to staff where needed most,” said Young.” (L) “The 70-page report, “Guide to Hand Hygiene Programs for Infection Prevention,” outlines an eight-step multimodal program that hospitals can follow to ensure hand-hygiene program success. “It’s when all those components of hand-hygiene programs are working together effectively that we see the biggest change,” Timothy Landers, R.N., lead editor of the guide, said in a report announcement. However, the report makes it clear that without one component–the full support of hospital leadership–programs will continue to fail. “Leadership’s commitment to hand hygiene must be visible and engaging–to the organization and the public through formal communication, hand-hygiene education, promotions, and event sponsorship,” the report said. In addition to leadership support, the guide also recommends that hospitals follow these steps: Establish ongoing monitoring and feedback on infection rates, such as tracking endemic and emerging drug resistant pathogens. Create a multidisciplinary design and response team led by a senior administrator to emphasize that the organization is committed to hand-hygiene compliance. Provide ongoing education and training for staff, patients, families and visitors. The report suggests the use of instructive posters, pocket cards and brochures for training. Ensure hand-hygiene resources are accessible throughout the organization, including patient care corridors and at the entrance and exit of patient rooms. Reinforce hand-hygiene behavior and accountability. Some organizations have success conducting contests and recognizing healthcare workers who comply with the guidelines. Provide reminders throughout the healthcare setting. For example, the report suggests organizations provide real-time feedback from observers, coworkers, patients and visitors. Develop an ongoing monitoring program that includes feedback. Some organizations, the report said, post monthly compliance data on hospital units or their hospitals’ Web sites and discuss the findings with staff during meetings.” (M)
“Most evaluation reviews are generated after a major, life-threatening error occurs, which usually happens infrequently. Historically, when an evaluation determined that a process completed by personnel was deficient, problem-solving efforts focused on the identification of the specific individual(s) who “caused” the problem. Later, quality improvement efforts focused on developing a culture of safety and recognized that additional contributions to errors were due to complex, poorly designed systems. The advantage of an evaluation that reviews system problems is that it encourages health care professionals to report adverse events and near misses that might be preventable in the future, while balancing the identification of system problems with holding individual providers responsible for their everyday practices. Improvement is impossible without evaluation reports to provide data on the factors that contribute to mistakes and lead to subsequent individual and system changes that support safer practices. An evaluation strategy examining process measures include the following examples: Document staff use of maximum sterile barriers (cap, mask, sterile gown, sterile gloves, large sterile sheet) and aseptic technique for the insertion of central intravenous catheters or guidewire exchange. Document timing of antibiotic prophylaxis when used in surgical patients (e.g., within 1 hour of incision). Document if hand hygiene is performed and clean or sterile gloves are worn before assessing a catheter insertion site or changing a dressing on intravascular catheters. Document time elapsed from when patient culture (microbiology and susceptibility) results are reported and when the appropriate isolation precautions are instituted (patient room placement, signs, PPE used, disposable equipment used, medical record documentation, etc.). Ensure that staff (nurses, doctors, and housekeeping) enter a contact isolation room using the specified personal protective barriers (e.g., gloves, gown) on each entry. Ensure that staff properly remove PPE after leaving a patient’s room. Assess the annual rates of influenza vaccination for health care workers and other personnel eligible to receive vaccination; assess the rates of influenza vaccination for patients. Ensure that needle disposal containers are no more than three-quarters full at time of disposal. Periodically monitor and record adherence with the hand hygiene guidelines: the number of times personnel washed their hands divided by the number of hand-hygiene opportunities, computed by ward or by service. Provide feedback to personnel regarding their performance. Monitor the volume of alcohol-based hand rub (or detergent used for handwashing or hand antisepsis) used per 1,000 patient days. When outbreaks of infection occur, assess the adequacy of health care worker hand hygiene. When a patient with a known colonization or infection with a multidrug-resistant organism (e.g., MRSA, VRE) is transferred to your facility, evaluate effectiveness of system notification to health care personnel in the receiving facility. Record compliance with hospital policy for catheter-site dressing changes.” (N)
“Hospitals have several different options to consider when monitoring compliance. • Direct observation: This method involves monitoring the actual hand hygiene actions of staff. It can be done manually – with an actual person doing the monitoring – or it can be done with the assistance of technology such as smartphone apps. The smartphone apps can improve the likelihood of making covert observations and reduce the instances of Hawthorne effect, which is a social occurrence in which individuals alter or improve their behavior in response to their awareness of being observed. • Measuring product use: This is an indirect way of conducting observations by quantifying the amount of soap and sanitizer used. Mathematical models can be used to determine how many hand hygiene opportunities there were versus how often staff actually took advantage of these opportunities. • Electronic monitoring: Several different types of sensors are now available to measure handwashing compliance. While they can be expensive, a major benefit of electronic monitoring is it can provide administrators with real-time feedback on compliance prior to a healthcare worker’s interaction with patients.” (O)
“More than 5,200 nurses and other caregivers in 71 units at 42 hospitals across multiple states were given a radio frequency identification (RFID) badge that recorded when they triggered the ubiquitous sanitizer dispensers typically placed near the entrance to a room. Researchers monitored the tracking for as long as three and half years, ending in August 2013. There were an estimated 20 million hand-washing opportunities to study. The researchers focused on “total daily usage per unit bed,” a calculation in which the number of times total dispensers in a given hospital unit were used each day was divided by the number of beds in that unit. Nice Start… Personal tracking did indeed trigger an initial improvement. The daily usage of dispensers jumped from an average of 28.4 times per day in the 17 days before the tracking commenced, to 46 times a day at launch. Workers who did not receive a badge did not show any change in hand-washing habits. …But No Sustained Momentum Hand-washing continued to improve for more than a year and a half, but then peaked at month 20. As the graph above shows, three years into the project, usage had backslid to where it was in the first month. That said, the researchers calculate that it would be a full 10 years of waning compliance before hand hygiene habits fell to where they were before the monitoring program was introduced – though a sub-50 compliance rate is no one’s idea of optimal. Clearly, technology in a vacuum is not the solution. “Managers cannot simply ‘monitor and forget,'” the researchers wrote. “There is a need for ongoing managerial interventions to sustain the benefits of monitoring.” (P)
“HyGreen Inc., Gainesville, Fla., provides just-in-time coaching to health care workers when they forget to wash, and records the information in real time, says Elena Fraser, vice president of sales and marketing. “The instant the health care worker dispenses the hand wash, both the light-emitting diode on the top of the HHCM sensor and the badge turn green. At the same time, a wireless signal documents the worker identification, time and location and sends that information to the database,” she explains. When the health care worker steps into a zone that is created by a monitor over the patient bed, the monitor recognizes that the badge is green. Again, time, location and worker ID are transmitted to the database. If the health care worker forgets to wash his or her hands, the bed monitor will cause the badge to vibrate, which serves as a subtle reminder.” (Q)
“Vanderbilt already had a traditional hand-hygiene program in place, but it was doing little to improve hand-washing rates. So the doctors took a different approach, focusing on three important areas: Training. Every single hospital employee received training on correct hand-washing protocol, from clerical workers to chief surgeons. The training program placed much of its focus on the direct link between hand-washing and hospital-acquired infections. Communication. Peer-to-peer communication was key to making the program work. Staff members were encouraged to speak up and remind each other of correct hand-washing practices if they noticed lapses. If someone received a reminder, the only correct response was “Thank you.” Shared accountability. All staffers were held equally accountable for their unit’s success with achieving high hand-washing rates, even if they were visiting surgeons. Designated employees were tasked with monitoring how closely everyone followed established protocols, and units that didn’t meet established targets were encouraged to boost their performance as a whole. Staffers were also rewarded based on their collective performance in improving hand-washing rates.” (R)
“The My 5 Moments for Hand Hygiene approach defines the key moments when health-care workers should perform hand hygiene.This evidence-based, field-tested, user-centred approach is designed to be easy to learn, logical and applicable in a wide range of settings. This approach recommends health-care workers to clean their hands; before touching a patient; before clean/aseptic procedures; after body fluid exposure/risk; after touching a patient, and; after touching patient surroundings.” (S)
Few scientific studies have evaluated measurement techniques; a recent review of the reliability and validity of hand hygiene measures found that only 28% of research articles and guidelines related to hand hygiene measurement included any mention of reliability or validity. Methodology between studies varies a great deal, including how adherence or non-adherence is defined and how observations are carried out; in addition, sufficient details concerning the methods and criteria used are often lacking. The following are some of the specific challenges to measuring hand hygiene adherence: • Contact with patients and their environment takes place in many locations within organizations. • Opportunities for hand hygiene occur 24 hours a day, 7 days a week, 365 days a year and involve both clinical and nonclinical staff. • The frequency of hand hygiene opportunities varies by type of care provided, unit, and patient factors. • Monitoring is often resource intensive; infection preventionists, quality improvement staff, and other health care workers (for example, nursing, respiratory therapy) face numerous competing demands for their time and expertise. • Observer bias (such as the Hawthorne effect) is difficult to eliminate.” (T)
It’s a simple enough request, but for patients and families who feel vulnerable, scared or uncomfortable in a hospital room, the subject can be too intimidating to even bring up with a doctor or nurse: Have you washed your hands? Hospitals are encouraging patients to be more assertive, amid growing concern about infections that are resistant to antibiotics. Strict hand hygiene measures are the gold standard for reducing infections associated with health care. Acquired primarily in hospitals but also in nursing homes, outpatient surgery centers and even doctor’s offices, they affect more than one million patients and are linked to nearly 100,000 deaths a year, according to the Centers for Disease Control and Prevention. The CDC aims to engage both patients and caregivers in preventing dangerous hospital infections. Centers for Disease Control. Yet despite years of efforts to educate both clinicians and patients, studies show hospital staff on average comply with hand-washing protocols, including cleansing with soap and water or alcohol-based gels, only about 50% of the time. (U)
(2013) “At North Shore University Hospital on Long Island, motion sensors, like those used for burglar alarms, go off every time someone enters an intensive care room. The sensor triggers a video camera, which transmits its images halfway around the world to India, where workers are checking to see if doctors and nurses are performing a critical procedure: washing their hands.” (V)
(2012) “But there are skeptics. “Another potential issue with the video observation is a false accusation of failure to wash. Patient rooms and patients themselves are not being watched. Let’s say a nurse went into a patient’s room to tell him something and didn’t touch anything. A person in India watching a video from a camera focused on a door or sink would not be able to tell that. If the nurse doesn’t wash her hands when she leaves the room, is she going to be cross-examined? (W)
“Healthcare can benefit from the power of cameras to improve accountability,” Makary, Pawlik and Xu conclude. “In an era where 86% of nurses report having recently witnessed disruptive behavior at work, hand washing compliance remains highly variable, and many physicians do not use evidence based medicine, recorded video can be an invaluable quality improvement tool. If concerns about consent, privacy, and data security are dealt with carefully, video data can tell a story that simply cannot be matched by written documentation.” (X)
“Twelve boys and their soccer coach trapped in a cave in
northern Thailand are in good health, authorities said Tuesday, but it is
unclear when they will be able to leave the flooded cavern.
The boys, all members of a youth soccer team aged 11 to 16,
and their assistant coach, aged 25, were found late Monday by rescue divers
after a dramatic search lasting more than a week in the mountainous province of
Chiang Rai.
Provincial Governor Narongsak Osottanakorn told reporters
early Tuesday that all 13 of them had undergone health assessments and were
found to be in good condition on a scale of “red, yellow and green.” Most were
found to be in the green category…
Once extracted, the boys and their coach will be transferred
to Chiang Rai Region General Hospital, where the entire 8th floor is being held
for their arrival. Thirteen ambulances are on standby to transport them.
The boys are believed to have entered the Tham Luang cave
after soccer practice with their assistant coach, Ekkapol Chantawong, on what
was meant to be a half-day trek. But monsoon rains flooded several chambers and
blocked their exit.
The saga of the trapped team has gripped the nation as
search efforts snowballed from a small local team to a multinational emergency
response. U.S. and Australian military personnel came to support Thai
authorities, as well as technical experts from the U.K., China, Japan and
elsewhere.” (A)
“Their skinny faces illuminated by a flashlight, the Thai
soccer teammates stranded for nearly two weeks in a partly flooded cave said in
a video released Wednesday that they were healthy, as heavy rains forecast for
later this week threatened to complicate plans to safely extract the boys.
The 12 boys and their coach are seen in the video sitting
with Thai navy SEALs in the dark cave. The boys, many wrapped in foil warming
blankets, take turns introducing themselves, pressing their hands together in a
traditional Thai greeting and saying their names and that they are healthy…
Authorities said the boys, who had also been shown Tuesday
in a video shot by the British diver who discovered them, were being looked
after by seven members of the Thai navy SEALs, including medics, who were
staying with them inside the cave. They were mostly in stable condition and
have received high-protein drinks.
In all of the videos, the boys appeared in good spirits. In
the most recent video, a navy SEAL is shown treating minor cuts on the feet and
legs of the boys with antibiotic ointment. Several of the boys are seen smiling
as they interact with the navy SEAL, who cracks jokes.”
“On Tuesday, Thai officials told reporters that rescuers
were providing health checks and treatment, and keeping the boys entertained,
adding that none of those trapped were in a serious condition.
“They have been fed with easy-to-digest, high-energy
food with vitamins and minerals, under the supervision of a doctor,” Rear
Admiral Apagorn Youkonggaew, head of the Thai navy’s special forces, told
reporters.” (C)
You were recruited due to concerns about two controversial
challenges that apply to your organization.
How do you turn these “challenges into “opportunities?”
Find two other Compliance situations that need to be
addressed.
Opportunity 1
“Not-for-profit health systems—no strangers to paying top
dollar for talented executives—are using sophisticated methods to avoid the
penalties on high employee compensation.
Effective tax year 2018, the Tax Cuts and Jobs Act imposes a
21% excise tax on not-for-profit compensation that exceeds $1 million, a
threshold that encompasses just about all major not-for-profit health systems.
Total CEO pay, including bonuses, retirement and other
benefits, across the top 25 largest not-for-profit health systems averaged
about $5.1 million in 2016, the most recent year for which data are available.
That’s up from $4.5 million in 2015.
The tax is significant. This year, a $5.1 million salary,
for example, would hit a health system with a roughly $860,000 tax. Bernard
Tyson, CEO of Oakland, Calif.-based Kaiser Permanente, made about $10 million
in total compensation in 2016. A 21% tax on all of his pay over $1 million
would be $1.9 million—perhaps not a huge hit to a $73 billion organization.
St. Louis-based SSM Health’s former CEO Bill Thompson made
nearly $2 million in 2016, which would yield a roughly $200,000 tax this year.
Again, likely not significant for a $6.5 billion operation…
The law also includes a calculation whereby health systems
can be taxed for providing excessive parachute payments to high-paid employees
upon their departures. Patrick Fry, who retired as Sutter Health’s CEO in
January 2016, received $10.6 million in deferred retirement pay that year,
bringing his total compensation to nearly $13.5 million…
Luckily for them, health systems have savvy tax experts
recommending maneuvers that will reduce their exposure to the new tax. Even
then, systems must tread carefully to ensure they’re staying within the law.”
“Doctors and teaching hospitals raked in $8.4 billion in
payments from drug companies last year, according to data recently released by
the Centers for Medicare and Medicaid Services…
The physicians who received research-related payments number
in the hundreds of thousands — about 628,000, by CMS’s count. More generally,
they received $2.1 billion overall during the year…
Meanwhile, drug company payments went to about 1,100
teaching hospitals, including $1 billion in research payments and $751 million
in non-research payments…
The payments come despite the fact that many physicians, as
well as consumers, consider drug companies and medical device manufacturers for
rising healthcare costs. A study last fall by the Texas Medical Center Health
Policy Institute in Houston found that 19 percent of physicians blame drug and
device manufacturers for rising costs, while 47 percent blamed insurance
companies.”
“A drugmaker’s scheme to bolster sales of a potent
painkiller with kickbacks to doctors has caused legal problems for the company
but has left largely unscathed the physicians who pushed the drug on their
patients.
Insys Therapeutics has been sued by state and local
governments, private insurance companies and patients. Several former company
executives have been indicted or convicted for their roles in bribing doctors
to prescribe the fentanyl spray, Subsys.
At least a dozen civil lawsuits accuse individual doctors of
accepting kickbacks from Insys to prescribe the drug which is 100 times more
potent that morphine.
Those doctors prescribed the drug – intended only for those
with cancer pain – to patients with other ailments, leading to harmful
addiction and, in some cases, death.
Yet many of the doctors who benefited the most from the
Arizona-based drug company’s payouts still practice medicine without
consequences, a national Raycom Media investigation found. Insys did not
respond to requests for comment…
“When a pain management guy is getting $100,000 to go
to these dinners and they’re prescribing this for elbow pain or that hip pain,
that’s criminal,” said Randy Hood, a South Carolina lawyer who represents
several patients suing doctors who prescribed Subsys.
Speaker fees and other payments to doctors are legal unless
they are connected to the volume of drugs physicians prescribe, according to
the federal anti-kickback law…
Between 2013 and 2016, Insys paid 126 doctors at least
$50,000 each in speakers’ fees and for travel, entertainment or consulting,
Raycom Media’s analysis of federal physicians’ payments found.
Raycom mailed each of the doctors a letter with their
payment and prescription histories and asked them to comment.
The payments to these doctors may not be nefarious. One
oncologist, who never prescribed Subsys, said he was paid nearly $114,000 for
food, travel and clinical development services.
Collectively, Insys paid the doctors more than $14 million…
Of the highest paid doctors, only 18 were oncologists.
Nearly 60 percent were pain specialists. Eight were general
practice doctors such as family physicians or internal medicine specialists.
Two were sports medicine doctors…”
“A new report finds a large percentage of panel members that
review drug applications for the Food and Drug Administration accept payments
and other rewards from companies after their drugs are approved. The report led
by investigative correspondent Charles Piller appears in today’s issue of the
journal Science.
Piller and colleagues looked into the practice of drug
developers providing financial benefits to members of FDA advisory committees
after the panels review drug applications and vote to recommend approval.
Advisory committees, often comprised of physicians and academic scientists, are
recruited by FDA to independently evaluate drug applications in addition to the
agency’s professional staff. While FDA does not always follow the assessments
of these committees, an endorsement from these panels is often a predictor of
FDA approval.
The Science team looked into advisory panels that
recommended approval of 28 cardiovascular/renal or psychopharmacologic drugs as
well as treatments for arthritis from 2008 to 2014, and were later approved by
FDA. The reporters matched up participants on these panels to payments listed
in the Open Payments database, collected by Centers for Medicare and Medicaid
Services in the U.S. Department of Health and Human Services, from 2013 to
2016. The team also scanned conflict-of-interest disclosures in scientific and
medical journals, at least those not behind paywalls. (Editor’s note: Much of
Science magazine’s content is behind a paywall.) In their inquiries, the
reporters looked for payments from the companies whose products were reviewed,
as well as competitors of those companies making similar drugs.
The team found 107 advisers taking part in the committees
and recommending the 28 drugs for FDA approval. Of the 107 participants, 40 —
or 37 percent — received payments of $10,000 or more in compensation or
research support after they voted to approve the drugs, either from the
developers of the drugs or from competitors. In addition, 26 of the committee
participants earned at least $100,000 from these companies, and 7 gained $1
million or more. The reporters also found the 17 top earning advisers, those
making $300,000 or more, took in a total of $26 million over this period, of
which nearly all, 94 percent, came from the companies making the products they
reviewed or competitors.
An FDA spokesperson told Science in a statement that
advisory committee members must disclose prospective employers, but not
anticipated payments…”
Open Payments is a national disclosure program that promotes
a more transparent and accountable health care system by making the financial
relationships between applicable manufacturers and group purchasing
organizations (GPOs) and health care providers (physicians and teaching
hospitals) available to the public.
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/
Log on to the AUPHA Network: http://network.aupha.org
——————————
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/
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
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)
“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)
“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
