An oral surgeon is under investigation in Charlotte West Virginia for reuse of IV tubing. He was turned in to the Board by a nurse who quit his practice the week prior. He has agreed to discontinue the practice. The question is not whether it is the best method, since all would agree that a completely new IV per patient is the best, but whether it is a practice that is done. The tubing reused is the one the farthest from the patient, not the one that goes into the IV needle. The IV solutions with air filters only allow the flow of fluid one way and not backward into the reservoir. Top
With the patient nurse ratios now in law, the main problem is where the hospitals will get the nurses to conform to the law as well as how to pay them. Of course one needs to find and hire them as the first step. The LA Times tells how hospitals are paying bonuses for nursing hires, placing new graduates in areas that they normally would not qualify for, pay for their moving expenses and tuition reimbursement. There is a hospital in the northern part of the state, Redding, that is paying a $15,000 sign on bonus for those with critical care experience. In Salinas, a rural area in expensive Monterey County, a hospital is paying $5000 sign on plus $5000 for moving expenses and tuition if they go to school in the county. Cedars-Sinai in LA does not pay signing bonuses since it may create a resentment from the nurses already working there. There may be a catch as an ED nurse at San Francisco's St. Luke's Hospital found out. He quit due to the hospital having complete control over which shifts worked and when. He now works in Kansas City. The other problem with the lack of nurses is that some believe one needs to graduate from a college program instead of a hospital nursing program. This thinking by nurses will only delay the needed hiring of the nurses. They could go to school later for their degree, if they wished.
California nurses are being trained to spy on their hospitals and turn them in to the state if they violate the new patient ratios that are supposed to start soon. It should be interesting if there are less patients which nurses will be temporarily laid off first. It should also be interesting what they say when services will need to be shut down due to the national lack of nurses. Top
In North Carolina, physicians are not taking Medicare patients as readily as before. The government's 5.4% decrease in reimbursement makes the time for the Medicare patient more valuable for someone else's use. The physician has by now figured out that he/she is a businessperson and cannot lose money on a transaction. Some have not. They are called either broke or HMO physicians and their parent is broke. The same people who believe that the practices that charge a premium for their services are creating two tiered medicine should also be decrying this as the reverse. Seniors are going to clinics or getting their care via the ED.
Washington State is planning to have the physicians pay for Medicaid interpreters for non-English speaking patients. The State is also cutting the price they are paying to pharmacists for filling prescriptions. The pharmacists are currently getting 11% below the AWP plus $4.25 per prescription. The proposed rules are for a change to a 20% discount on brand names and 65% on generics. I wonder who will be left to treat and write the prescriptions that can not be filled.
In a typical turf battle the physicians in Ocala, Florida are battling the
Ocala Regional Medical Center (ORMC) administrator. The hospital is a
for-profit Tenet hospital where autocracy reigns supreme. ORMC is opening
another hospital five miles away under the same ownership and management.
Somehow, during all this building the hospital management forgot to tell the
physicians that if you remain on our staff, you will need to cover the other
hospital as well. During this same time frame the physicians forgot to ask
about staffing the hospital. The compassionate administrator has laid down
an ultimatum, "You are on the staff or you're not". If you do not
cover the second hospital, you will lose your privileges at ORMC. Now I
must say that five miles is not a major distance to cover. The second
hospital will be covered by hospitalists, so the primary do not have to go there
for rounds. The problem I see are two-fold. The first is the usual
Tenet take it or leave it I don't care about the medical staff approach.
The second is the forced resignation of the physicians that will not go to the
second hospital. I have never heard of physicians losing their hospital privileges
due to a geographic problem. I also do not know if the medical staff has
voted on having one staff or if they need to vote on the issue. Since the
hospital is one entity with two campuses, the staff may be forced to be the
same. I believe the hospital has the upper hand here, but will hopefully
lose market share to a competitor. The competitor is across the street and
is also building a second institution. The difference is the second one is
an Emergency Center where patients will be seen and then transferred after stabilization
to the hospital.
Continuing on Tenet, it is one of the hottest stocks on the exchange. Revenue has jumped 16% in the last quarter and operating margins are up to 20%. It is a shame that their CEOs are Simon Legrees, but I guess that's how you get to be successful.
In Albany, New York the physicians at the Albany Medical Center are angry at the cutting of 350 jobs by administration. The cost cutting move has angered the physicians enough to demand a say in the decision making process. In December the administration notified 98 physicians and 250 staff members that their positions would be cut June 30, 2002. The physicians are considering a vote of no confidence in the administration.
In Philadelphia a dispute over fees between a private anesthesia group (United Anesthesia) and Blue Cross caused a non-renewal of a contract between the entities. This means that patients having surgery with anesthesia provided by United will be paid directly at out of network rates and will owe United their full fee. Blue Cross has agreed to reimburse United for all surgeries scheduled prior to the contract deadline, all second and third trimester pregnancies and other "continuity of care situations. The anesthesiologists who have not received a raise in rates for five years asked for a 40% rate increase. The national average for anesthesia is $45 for 15 minutes or $180 per hour. United has asked for $48 per 15 minutes or $192 per hour. As pro physician as I am, I cannot understand why the hospital contract with the anesthesiologists does not state that United will accept all contracts that the hospital accepts. Top
Congratulations to the Pennsylvania Trial Attorneys. They have stalled the physician sponsored bill in the state legislature for another month and the physicians have not been able to sustain their lobbying, according to the Philadelphia Business Journal. The paper states the blame falls on the physicians and those they have hired to do their lobbying. I am not as sure as the paper. There was a compromise reached earlier but it had almost no tort reform. This means it would have lead to more problems very soon. You can only go after this reform once. The compromise had some good elements as well. It had a minor reduction in the amount of malpractice insurance required, but to a reasonable level, a semi-collateral source rule, structured payments. These were passed by the Senate but the House had the true tort reform in their passed legislation. The probability of a resolution between the two bodies is low. If it is not resolved, it may be a time for the physicians to take vacation en masse.
The Cleveland Plain Dealer has a story regarding a 55 year old solo family practitioner that is retiring on June 30, one day before her malpractice insurance jumps 80% to $45,000. The article states the physicians who are looking to retire or change careers are those in the middle portion and with the most experience.
In West Virginia the Bluefield Regional Medical Center has lost 12 physicians in the past eight months. These were mostly specialists who left due to the malpractice climate of the state. The hospital board has given a $5 million loan to a partnership between the hospital and an indemnity company to help provide malpractice insurance for the practicing physicians. The other hospitals are also starting to take hit as the end of the year will bring to a close those insured with St. Paul. The physicians who have been with St. Paul for a time get their tail paid for. If they start with a new company that tail coverage will restart. This means that those physicians in their late fifties will either have to continue to practice for the years necessary for their tail to be paid or retire. The new young physicians will not want to come to the state due to the malpractice situation.
Nevada is having its own malpractice crisis. The rates have been raised enough that some trauma surgeons at southern Nevada's only trauma center have dropped off the panel. The Los Vegas University Medical Center may be forced to close from 7 pm to 7 am due to the lack of trauma surgeons. There may be other non-covered slots as well leading to the closure of the entire trauma system. So far, 2 of the 12 trauma surgeons have quit. Another four will do so by March 12. A potential solution being proposed is to have the Center hire the surgeons on a part time basis and pay their malpractice premiums for up to $50,000. The physicians are now independent contractors and carry their own malpractice insurance. Since the Center is a government entity damages are limited to $50,000. The entity is self insured so there are no upfront costs in the hospital but they would be liable for the defense and liability costs.
The Nevada Legislature is concerned enough to have the state insurance commissioner create a joint underwriting association to help reduce premiums. This they state would be a short term solution and would get a report to act on tort reform at a later session.
Texas should not be left out. In the Rio Grande Valley near Brownsville, The Texas Attorney General, now running for the US Senate, was told that the area physicians are twice as likely to be sued as the remainder of the country. Of those sued, 8 of 10 receive no payment since they were not researched well by the plaintiff attorneys. However, this does not take into account the time and emotional strain these lawsuits take on the physicians. The Attorney General stated that if elected he will work to implement tort reform on a national basis. I wonder what he tells the Trial Lawyers.
The Florida physicians went to their sojourn to the state capitol to ask for malpractice relief. They were met by a small vocal group of protesters who wanted to argue with the physicians. The Trial Lawyers blamed the insurance companies and their investments for the raise in premiums. Does any of this sound familiar? I'm sure this little trek was successful and Florida will immediately pass true tort reform, he says tongue in cheek. Top
The New York Times has an article on whether or not there is too much medical testing in asymptomatic patients. The co-chair of the US Preventative Services Task Force states that the annual exam where we get checked "from soup to nuts" is not needed every year. She doesn't say how often. It should also be mentioned that the organization is backed by HMOs who do not want to pay for treatment if something is found. Another quote is by the dean of nursing who believes that counseling on nutrition and other risk factors is the key. Of course, people don't remember most of what is told to them 15 minutes after leaving the office. The preventative health person believes women should get a Pap smear and a mammogram every several years but SHE doesn't know about a PSA. Always look at who the people are who are giving the information and if they state their biases. Top
The LA Times states that more companies are dumping their managed care plans and going with self-insurance. This is fine as long as it is financially sound with adequate reserves. Last year a self-funded plan went belly up. All believe that when the patient realizes that they will be responsible for a larger share of the costs, they will become more responsible for not going to the physician for every little thing and a $10 co-pay. In the past two years the amount of companies that have self-insured have doubled from 6% to 13%.
In another story focused on California, the LA Times states that HMOs are losing market share. In the past year the percentage has gone from 55% to 48%. This is the first time the percentage has dropped below 50% in eight years. This is due to the increased price for less benefits. Most are going to PPO or point of service options. The MSA option, which is becoming prevalent in the rest of the country, has not found its way to California as yet. Nationally the percentage of people covered by HMOs fell from 31% to 23%.
PacifiCare, the major senior HMO, has received sell ratings and the stock has dropped 25%. They lost $26.4 million in the last quarter. They are attempting to reduce costs by dropping unprofitable HMOs. The dropped 17% of their commercial and 10% of their senior business.
CalPERS, the giant public employee retirement system used its muscle of 1.2 million insured last year to get "only" a 9.2% increase in health insurance premiums. They also reduced the HMOs used. Now they are looking at either self-insuring or only using two or three HMOs. There are no California HMOs that cover the entire state. The organization wants value (read, cheap) and is willing to sacrifice choice. They don't state whether their insureds will be as anxious to sacrifice their choice. The problem will be that people no longer want a restrictive policy, they now want choice in their physicians and they are willing to pay for it. The days of the $10 co-pay is gone. People will now know how much health care costs and how to prioritize their spending. The consumers will be consumers as they are for other goods looking at price and making decisions. Health care is not now nor has ever been an entitlement except for government programs. This will mean an increase in MSAs and a consideration of dropping physician payments. If the cost of a monthly family insurance premium is over $500, how much can be saved by dropping physician coverage. The cheapest form of healthcare is the physician bill. If one could save $100 per month with no physician insurance or with a large deductible, it would not take long to more than pay for itself.
Using two year old data, Medicare has stated that more people have picked the Medicare+C than Medigap coverage. They state this is due to the pharmacy coverage. The study shows that from 1996-99 there was a 5.1% increase in Medicare+C enrollment. That figures out at 1.4% per year, a rousing success. Maybe the increase in drug benefits is the reason why that in the following years the Medicare+C plans went out of business in many states and counties. What I read into this study is that people want choice and are not willing to give it up.
The second largest Medical Group in Sonoma County, California has folded. This was an administrative arm of Memorial Hospital. About half of the primary care physicians are in one group and will remain so. The going got touch as the managed care organizations did their squeeze. St. Joseph Foundation could no longer exist on the money being paid and so needed the closure. This removes HMOs who rely on medical groups for contracts from the area. This transfer of the costs of administration back to the physician will increase the revenue per doctor by about 10%. This leaves only Sutter Medical Group in the county.
California Blue Shield is becoming more physician friendly. They have announced that effectively immediately there will be a loosening of restrictions on paying when a service has not been pre-authorized or if the payment has been challenged by the insurer. They will also remove the all or none rule.
Indiana's largest ENT group has filed a complaint with state regulators regarding Anthem and has also sent a mailing to 2000 other Indiana physicians. The ENT Group states it is owed hundred's of thousands of dollars and wants all to know about it. The Anthem spokesperson did the usual double speak," There is a contract issue here and we are working through it." Duh!
PhyCor is back! They now, having failed miserably owning physician practices, want to manage those practices that are failing under hospital management. Why any physician would want or allow this company to mange them is beyond me. Top
USA Today has a story about how hospitals are trying to out-specialize each other for the high paying patients. As each hospital adds a service, the competitor adds it so they will not be left behind. This may lead to less general hospitals and more specialty hospitals, such as heart or cancer centers. This trend could be bad for patients, especially in the heart business. If a hospital does not do about 300 heart cases a year their percentage of morbidity and mortality are increased over those that do over that amount. Also there are only so many good heart surgeons around and even less well trained cardiac nurses. There is always the possibility of the patients needing the services rise as the beds proliferate. Those who believe that can not happen only need to look at Chicago Edgewater Hospital where several physicians are going to jail, the hospital is bankrupt and the trial of the management company begins soon, all for paying for patients.
In a unusual move New Jersey has shut down the 140 bed Memorial Hospital of Salem, New Jersey. They will be allowed to continue their ED and emergency surgery only. The reason for the shutdown was unsanitary conditions. There was poor patient nursing care, inadequate sterilization of instruments and drug prescriptions were incomplete and illegible. I don't understand why they allowed the ED and emergency surgery to continue. I also don't understand why the hospital way able to reopen in two days. The problems were being addressed but were not fixed. I would not to have my or my family's surgery at that hospital until all problems have been fixed. Top
It is now less than six months until all covered entities, yes that's you, need to either be compliant in their billing or apply for an extension with full plans and cost estimates of how they will be compliant. It is just over one year until all covered entities, yes that's you, will need to be compliant with the privacy component. Will you be ready? How much will it cost? Now is the time to begin to look at your practices and institutions to see what you will need and to determine the budget and how to spread the money expended out over time. The rules use the word "reasonable" about 250 times. What does that mean? What are the potential penalties for non-compliance? This is not Y2K, a one time event. This is forever. DON'T JUST SIT THERE AND MOAN! START TO LOOK AT YOUR PRACTICES AND PHYSICAL PLANTS! 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.