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In upper New York state, the physicians are making extra money by lowering healthcare costs utilizing a system called Value of Care. The doctors are graded on patient satisfaction and the cost effectiveness of their treatment. The insurers are providing recommended treatments for certain diseases using less expensive tests and drugs. If the physician follows the directives they earn bonuses. The doctors are paid at 90% of what they are supposed to be paid and if they are good little boys and girls, they get a percentage of the remainder.
In a HealthLeaders Magazine roundtable discussion the hospital leaders discussed how to bring physicians into the formation and running of various hospital service lines. If they can do this efficiently the hospitals will take away the main incentive for physicians to want to start their own specialty hospitals. (Please see story on Nurses, below.) The hospitals need to provide full data to the physicians to make them true partners in the running of the service. The hospitals can not only talk to a few physicians, they have to involve all the physicians in that service line so they are not accused of playing favorites. This is especially true where there are competitive groups in that line. The bottom line is customer satisfaction and the customer is the physician. If they are not happy, they will look to ways to become more involved, both financially and in the administrative arena. That usually means starting their own hospitals or surgical centers.
The AMA was never thought to be a friend of physician unions, and they proved the theorem. They spent $3.5 million to fight the Oakland, California, based Union of Physicians and Surgeons and after five years had the grand total of 38 physicians. The effort failed and the union has been abandoned by the AMA and is operating independently.
As all know, revenues from insurers are low and overhead for practices continue to grow. Physicians are looking for new forms of income and have found imaging centers. Group practices have begun to put in their own CT or MRI scanners either in house or in a trailer that comes weekly. This, if structured correctly, can add income to the group. It will also remove income from the hospitals but there will be no economic credentialing here since they would be dealing with primary care physicians who control where patients go for services. Top
An article in HealthLeaders on a Press Ganey survey of 4,699 nurses in both teaching and community hospitals revealed that nurses focused on customer service and especially the role of senior leadership in listening to their need for support. This is more important than pay in the recruitment and retention of nurses. In those instances in which senior leadership is not responsive to the needs, the nurses would not help recruit new nurses to the institution.
The nurses union in Kansas City has chastised HCA Midwest Hospitals for their quality of care. This includes staff cutbacks making it more likely the nurses will have to do the administrative scut work. The hospital network has responded by stating they have added more nurses in the past year. Of course, the two items are apples and oranges. The union wants California style nurse ratios.
To date, state regulators have only received 49 complaints regarding California hospitals breaking the nurse-patient ratio law. Two hospitals were cited for not having the proper ratio. There were also 60 requests for waivers with 23 approved and 29 denied. This may change as a judge has recently upheld the union position that the law holds during breaks. The nurses also are not happy with the words "licensed nurses" which allow LVNs to care for patients. This is a turf battle disguised as a quality of care situation. A side view of the law that has not yet been tested in court is the problem of "negligence per se." This is if malpractice occurs and the records show the staffing does not comply with state law, the malpractice caps may not apply. Top
The Physicians Insurers Association of America reports that the amount of over $1 million claim payment have doubled since 1978. It has now reached 8% of all payouts. The average payout went from $200,000 in 1996 to $328,000 in 2003. Only about 1% of the 8000 cases studied by the group ended up with any payment for the plaintiff. Therefore the money spent defending the other 99% of cases should never have been spent and many if not most of the cases never filed.
In Connecticut, some physicians are about to impose a malpractice surcharge on their patients. This would be in the form of charges for things they currently do for free, like filling out forms, refilling prescriptions and e-mails. These are non-covered events in their contracts and in federal medicine. However, some OBs are considering a surcharge of $500 per pregnant patient. This in all likelihood would be illegal for those women in managed care unless their co-payment or deductible is very high. The state Attorney General is willing to get cease and desist orders to the physicians who put the surcharges on the newly pregnant patients.
In Florida, a new poll shows most of the population agrees with the trial lawyers that physician who have malpractice cases should have their licenses stripped if they settle or lose three cases. The study was commissioned by the trial lawyers and so was slanted toward their position. The poll showed that 48% wished the lawyers fees to be capped and that 75% felt the doctors should get their license stripped.
The use of true apologies by physicians and hospitals for medical malpractice can reduce the amount of suits and money expended. John Hopkins has saved 30% by using this method. Insurers are against the policy as only two states, Colorado and Oregon, have state laws forbidding the use of apologies against the physicians in law suits.
Massachusetts' physicians are getting their yearly malpractice insurance premium raise. This one averages 11%. The largest percentage increase goes to the radiologists due to missing breast tumors on mammography.
Illinois Republican legislators are again up in arms about the malpractice crisis in the state, but to no avail. As long as the state remains in the hands of the trial lawyer controlled Democratic party there will be no changes. The patients from southern Illinois will not be seen either by the local physicians nor by those across the river in Missouri for fear of malpractice claims.
The major liability company in Oklahoma will raise rates next year by 50% and then will not raise them again until 2007, which may be a good time for physicians to plan to transition out of the state if they don't do it now. Top
The Wall Street Journal had an article about the fallacies of the Canadian healthcare system. There is a private component in the system that can only be used for non-essential services, the definition of which is ever expanding. The Canadian Prime Minister, Paul Martin, is a member of the private clinic and gets physicals there. The private clinics may also be used only by those who have on-the-job injuries so they may get back to work faster and prisoners. There is currently a case before the Canadian Supreme Court that the Canadian method of health care is illegal. The article also states that Canada spends the most of its GNP on healthcare but has a failing medical infrastructure with less physicians per capita and the oldest x-ray machines in the cohort of nations.
Manitoba is the first province to report on its medical errors. In a nine month period last year 19 patients died due to medical error and over 6000 were injured. The expectation is that these numbers will go up in time as professionals become more comfortable reporting mistakes. It was reported that in 2000 over 24,000 patients died from preventable medical mistakes. Top
The insurance companies have found the huge loophole in almost all state's insurance laws, the purchase by one insurance company of another that insures individuals. After the close, the original company says it is no longer insuring individuals and they must be insured by its new company. The new company treats all these individuals as new clients and either will not insure them if they have pre-existing conditions or make them pay huge increases in their rates. This is apparently legal in almost all states except Maryland, which closed the legal loophole. A few other states have stated that if the "cherry picking" happens that the individuals may be placed in other companies for the same rates and for the same benis.
Providence Health Plan in Oregon has started to pay physicians for email visits. The fee is $40 of which the patient pays $10. This is not for federal patients and to date is only for primary care patients. The insurer has gone the opposite route from what others are doing. They are only paying for extended counseling when if done live would result in a delay in care, relapses taking significant physician time and those patients with chronic conditions. They will not cover the simple things. The payment is about half of what the insurer would have to pay if the physician saw the patient. All the liability falls to the physician.
On the other coast in the People's Republic of Massachusetts, an insurer is paying some groups for simple visit questions and not long convoluted questions. The payment here is $5-$10 patient co-pay and an additional $25 for the e-visit. No payment for refills or very quick emails. This cuts out many diabetics emailing their blood sugar for how to adjust their insulin.
CalPERS, the largest payor outside the feds, has axed 38 California hospital for being too expensive. This includes five of seven Sharp San Diego hospitals and 13 Sutter Hospitals. Also cut was Cedar-Sinai in Los Angeles. The move may eventually lead to severe patient pushbacks.
Blue Cross and Shield of Rhode Island finally is raising payments after ten years. The rate will be at the Medicare rate if the physician is below Medicare rate. The insurer also fired its CEO.
In an interesting article in the New York Times, they report that health insurance premiums will go up less this year, 10% versus 16%. The reason is the increase in deductibles, less hospital costs last year allowing more profits for the insurers and growing competitive pressure among the insurers in order to attract new members. Top
HCA has gone from the builder of outpatient and specialty institutions to the title of snitch. They have reported to the government those facilities that they believe are breaking the ill-conceived 18 month moratorium on Medicare billed specialty hospitals by physicians. Of course, HCA only does this when their facilities might be impacted.
California has closed Angels Hospital in Rancho Cucamonga after investigating patient deaths at the institution. The hospital at opened less than a year ago and the state was warned then by one of it's inspectors about possible problems. The hospital had called 911 regarding a patient in-house because it had no physician available to treat the patient. It also is accused of using contaminated instruments and failure to provide nutrition to a seriously ill patient. The 55 bed hospital had six patients and no emergency room when it was closed. The hospital was owned by the wife of a physician who had his license surrendered after being charged for negligent care in cosmetic surgery and insurance fraud.
Political pressure again is playing a role in the ill-fated and poorly run King/Drew Los Angeles Hospital. The hospital was supposed to close its neonatal unit but has not. The hospital supporters are ignoring the poor care, lying administrators and terrible conditions and instead are going back to the race card. This has caused a re-look at the logistics of the closure and a delay of the closure by several months. The residency program in the neonatal unit has been slated for non-accreditation. (See Recent Legislation for information regarding their JCAHO accreditations)
Monrovia Community Hospital in California has shut its doors. The 49 bed hospital with 100 employees ran out of money. There is also a legal battle regarding who owns the hospital.
In North Broward, Florida, the North Broward Hospital District, a political organization, guaranteed a politically connected Orthopedic group $1.26 million for covering the ED. This is 25% less than the old contract but they will also pay more per patient so the contract may actually cost more than previously. There were no competitive bids sought nor given for the contract. The group has held the contract of the past 16 years. The old contract called for a per diem rate of $4678 to be on call and see all Ortho patients. The gross amount also had $350,000 toward the group's malpractice insurance and $50,000 to the head to be medical director. The new contract give $2910 for call, cuts the malpractice to $290,000 and deletes the medical director contract. However, the group now gets money for patient care.
Sheridan Hospital in Wyoming has decided not to build an outpatient surgical center in direct competition with its physicians. Instead, the two sides are looking into a joint venture arrangement. This is much more intelligent than the Ohio, Arkansas and Idaho hospitals alienating their staffs by economic credentialing. Top
The Florida Medical Board has been blasted by the bastion of medical ethics, Ralph Nader's Public Citizen. They do not believe the Board is disciplining enough physicians based on raw numbers and not anything else. The Federation of State Medical Boards ranks Florida in the top ten in the country. It is interesting that Public Citizen gets its numbers from the Federation and then uses them for its own political purposes. Top
In upstate New York, a group of managed care company representatives and a state funded surgical panel released non-binding guidelines on stomach stapling for morbid obesity. The guidelines state a patient should have a body mass index of 40 unless they have co-morbidities and then it can be reduced to 35. The guidelines state that only those surgeons that have done over 100 cases and at least 25 per year should do the surgery only at hospitals that have the facilities specifically designed for these obese patients. Top
DISCLAIMER: Although this article is updated periodically, it reflects the author's point of view at the time of publication. Nothing in this article constitutes legal advice. Readers should consult with their own legal counsel before acting on any of the information presented.