Governor Jeb Bush of Florida has appointed an independent person to review his decision regarding the reinsertion of the feeding tube into Terry Schiavo. I applaud the Governor for his ability to see his decision may have been erroneous. I wonder about his choice of the independent investigator. I would have chosen a bioethicist or a neurologist. He chose an University of South Florida expert on health care financing. Top
Some physicians are adding surcharges to pay for their insurance overhead. Their payments from the insurance companies are not keeping pace so the money has to come from somewhere. The charges come from after hours calls and additional paperwork. This is a nationwide phenomenon. Some physicians are still silly enough to believe they can continue to absorb the costs with the same revenue. The only way they can increase revenue is to increase the number of patients seen at the expense of good medicine.
A North Dakota pediatric neurosurgeon settled a malpractice suit in 1999 and told a reporter that he could not discuss the details because the case was sealed. The reporter then wrote a hatchet job piece on the physician. After the story was printed Dr. Monasky called the paper to express his displeasure about the one sided report. The paper then ran a second story standing behind its original one. The medical community took out a full page ad in the paper attacking the paper. The doctor then sued the paper for defamation. Prior to the trial the paper printed a retraction and an apology. The paper also paid $61,000 to pay the physician's legal fees for the case against them.
Public Citizen, another hatchet job organization with no thought processes, is at it again. Now they are accusing poor Kansas of being a public enemy for not disciplining enough physicians. The top hatchet person thinks medical boards should not attempt to rehabilitate physician but just kick them out. Dr. Wolfe, the hatcheteer, uses raw numbers only to come to his one sided conclusions. The Kansas Board had no argument with the list showing them in the middle. They feel they don't want to be at the top or the bottom of the list. Like Goldilocks, the middle is just right.
In the new federal rules on interpreters, the feds made a mistake. They state that if the physician treats even one Medicaid and/or State Children's health Insurance Program, (SCHIP) patient they must provide and pay for all patients with language problems interpreters. All physicians should stop seeing these patients unless they work in a clinic where they don't pay personally for the service. The recent rule changes kept this burden in place but did change the rules for non-Medicaid or SCHIP patients. Now, the physician may take into account other factors for non-English speaking patients. The first is how often they come in. The next is how important the visit is. The third is the available resources. Small practices do not have to provide the service when the cost substantially is more than the benefit. The physician may now use a family member as an interpreter as long as the patient agrees. The physician still may not charge extra for the interpreting service.
In Massachusetts and the Cincinnati areas their is a low retention and recruiting rate for physicians. Why, one might ask? MONEY, is the answer. The insurers in those areas have over the course of years slowly ratcheted down the reimbursements. This come from the Physician Compensation Report. Those that come to the areas only come due to pre-existing ties to the area or they can not get a job anywhere else.
Speaking of money, a new survey was released on paying for on-call physicians. Now 40% are paying for on-call duty as compared to 28% last year and 19% the year prior. As for the type of payment it depends on whether or not the physician was to stay in the hospital or only to be on call. Some hospitals are paying about $2000 for anesthesia to stay in house and $1000 for them do just be on call. For the past year the rates have been steady. Most hospitals (68%) individually contract with physicians. Another 23% us a percentage of the specialty market rate. The last 9% use the same amount for all those who take call. These are just to take call. When the physician does have to come in 41% negotiate individually how much the physician gets to keep. 27% pay the physician fair market rate. About 23% get what they bill and 9% get a flat fee. Some physicians are illegally banding together to get some or more money from hospitals. They know that even if the hospital turns them in to the FTC, the hospital will still have to pay market rate for a period of time and all relationships between the physician and hospital will have gone by then. The specialists would by that time have left the hospital for another or more likely for the office or ambulatory surgical center. Many hospitals have gone to the hospitalist system especially from 7 am to 7 pm, when most physicians are working in their offices.
The Wall Street Journal ran a story about a physician in Greensville, Tennessee, and another one in Ocean Springs, Mississippi, who takes no insurance and only takes cash in their low cost office. They are able to charge less due to the lack of need for multiple nursing or billing personnel. They also make less but are happier in what they do.
A year old boutique medicine practice in Louisville, has paid back its initial investors and is now making a profit. They are doing physicals for many managers of businesses and have already signed up at $4000 per individual and $6000 per couple over two hundred people and are growing by about 15 per week.
Two Texas physicians believe non-hospital emergency rooms can be money makers and not money losers. They opened one emergent-urgent care center with its own x-ray and lab and are now opening three others. The physicians are ED doctors and believe they can reduce costs by reducing the ED hassles and red tape. The centers can not hospitalize and would need to transfer any patient after stabilization. They also do not receive ambulances. Currently they are only open until 10 pm but soon hope to be a 24/7 operation. Then one that's open is affiliated with a specialty hospital and has use of their CT scanner. Texas doesn't regulate the facility since it is classified as an urgent care center.
What are emails for the practicing physician? Some believe they are a pain. Others believe they are not only helpful to the relationship but also to the pocketbook. It is only a small amount of patients that want to communicate with their physicians via email, about 3 in 10 of those capable. The Regence Group found that the length of the emails increased over time, especially with mental health patients. Kaiser found the emails were quicker than phone calls and decreased office visits. The Kaiser representative stated that insurers should be careful about paying per email. He's afraid that the physician will send out 500 emails a week to see how everyone is doing.
In a sad story, the San Jose Mercury News has reported that local Vietnamese senior are loaded into buses and shipped to Los Angeles County for "free health check-ups, a free lunch and free nutritional supplements. When they get there the greedy medical personnel do all tests, whether necessary or not and bill Medicare for the care. Medicare does not pay for routine check-ups. It is also illegal to offer gifts for medical treatment. The physicians and others should be made to disgorge their illegal money but pay a large fine and potentially spend time in jail. Their medical and/or nursing license should also be suspended or revoked. Top
Tenet continues to feel the heat. Their Los Angeles hospitals are now being reviewed to see if only medically necessary heart surgeries are being performed. The hospitals at Daniel Freeman, USC and Centinela have all had a substantial increase in heart surgery over the past few years. At the same time that the federal investigation of the Los Angeles hospital is underway, Blue Cross has come out with a report that the Tenet hospitals in Redding and Modesto had performed a high percent of unnecessary heart surgeries on its members. The problem with the Blue's report is that it only looked at 52 surgeries and extrapolated from there. This is not only unscientific, but has no fairness attached to it and is only used for publicity. Blue Cross has stopped elective heart surgeries on their members at those two hospitals.
California has audited its payment to the Tenet Redding Hospital and believe they have overpaid the hospital by $12 million. This will lead to a review of all Tenet facilities. The discrepancies were in the wrong billing codes or those services billed for which could not be documented. The hospital has already repaid $8.9 million and will appeal the state's position.
The Tenet Hospital in San Pablo, California, has lost millions of dollars due to a California Nurses Strike that has lasted over one year. They originally had to pay significantly more for part time nurses. Now, they have enough new hires and nurses that have come back to have a stable work force. They even have enough for meeting the nurse deployment scheme. They will not give in to the striking nurses and those nurses have already taken other jobs, either full or part time. They also only have another six months of Cobra benefits. Top
Speaking of nurses, the Institute of Medicine has announced that it is their belief that the current hospital climate is a breeding ground for mistakes. The IOM recommends that nurses work no more then 12 hours per day and no more than 60 hours per week. The report also states that the hospitals should avoid using agency nurses as they are not familiar with the environment.
The Bureau of Labor Statistics has issued a report stating the shortage of nurses has become even worse. In the Bay Area there is a 20% vacancy rate. The average age of nurses is 45. Many of the experienced nurses are planning to retire. There is a great shortage of training programs for new nurses due in part to the training institutions.
The Pasadena, California Star News has an article stating its local hospitals are close to meeting the staffing needs of the new law. Huntington Hospital is offering rewards for referrals including a chance to win $10,000. Another hospital stated their vacancy rate for nurses is 6% and the average for southern California is 10%. California ranks 49 out of 50 states in the number of RNs per capita.
The Los Angeles Times has reported that the Los Angeles County hospitals may not be able to reach the amount of nurses need to comply with the January regulation. The hospitals will seek an exemption from the law and more time for implementation.
In the past year 100,000 nurses have been hired by hospitals. That's the good news. The bad news is that almost all the new hires were either foreign born or over 50 years of age. Nurses younger than 35 dropped by 8% last year and those between 35 and 49 only grew by 4%. Top
In another frustrated area of the country, the physicians in the Sport Medicine North practice attempted to work with the hospital to make them more efficient. They were stonewalled and are now opening their own specialty orthopedic surgical center. The hospital is not happy but like most hospitals the administration only wanted to protect their bottom line and did not care about the physician problems. The hospital complains that the new center will skim off the best paying patients and they are right. The center will not accept Medicaid patients but this is due to the Massachusetts state law, not a decision by the physicians.
In another hospital the radiologists came to the hospital to ask permission to open an outpatient imaging center. They got tossed and a new radiology group was hired from Michigan. I'm sure they will give excellent service from a thousand miles away. The original group opened their own center and the hospital is now running newspaper and radio ads for patients to reject the 9-5 boutiques.
hospitals: To compete or cooperate?
Kaiser Permanente, who have been raising their rates by double digits the last few years has reported their income increased 72% over the past year. Net income went up 42%. This is in spite of a 1% membership decline. I guess one can make it on volume but increasing fees also helps. It is too bad that those in private practice can not do the same thing.
PacifiCare has come up with the best plan ever to save them money. They are instituting HealthCredits. This program will give employees points to enter drawings if they do good health management. PacifiCare will not give any money to the employers to institute this program so it will cost the insurer nothing. If the employees go for it, PacifiCare may (notice the word may) be able to give the employer some discount on their premiums. Don't hold your breath. Top
The Brigham and Woman's Hospital has suspended all laproscopic gastric stomach stapling due to a patient death. The hospital believes that GIA misfired causing some of the staples to come out prematurely. The hospital will continue to perform the procedure in an open fashion, using the same type of stapler but not the small one used in laproscopic procedures. This makes no sense as the procedure is established and there is an known risk from all surgeries. I would doubt that anyone would undergo the procedure in an open manner when it can be done safely via the laproscope in trained hands. Later information from this case showed that the staples failed in one area and this was recognized at the time of surgery. The patient was opened and the area oversewn. The surgeon failed to oversew the entire suture line and it was the area that he did not oversew that popped open later and leaked stomach contents.
The FDA has recognized the problem with all staplers and stated there have been a total of 112 deaths related to them. This is alot but compared to the denominator of over 100,000 per year, the percentage is small. The FDA has decided, due to the fact that the staplers are so good so much of the time, not to recall them, but to use an educational campaign for surgeons.
Politics lives in DC. To no one's surprise Greater Southeast Hospital has regained its medical license, but not its accreditation. The hospital has been besieged with problems and loss of accreditation by the JCAHO and the District. These problems have now been "cured", sayeth the District. In spite of the hospital being cured, their license has been amended to only cover 150 patients until such time has the improvements can be proved to be sustained. The hospital will appeal the lesser number of inpatient beds. It is now licensed for 303. The hospital is in private hands and is in bankruptcy proceedings. The hospital is currently losing over $2.5 million per month that could be going to its creditors. The city plans to subsidize a new hospital by Howard University close to Southeast.
Mathews Hospital in Charlotte has decided to do an exclusive contract for its cardiology services. They will contract with Mid Carolina Cardiology who have close ties with the parent company. This will close out referrals of about 30 other cardiologists. The hospital states it is being done to help with confusion in its one cardiology lab. They don't talk about the volume or the need to increase the lab size and numbers. This is more likely a competition move since Presbyterian Healthcare, the owner of Mathews, is a direct competitor with Carolinas Healthcare. Carolinas Healthcare signed an exclusive contract with Sanger Cardiology to the exclusion of Mid Carolina. Mid Carolina sued Carolinas but instead of going to court Mid Carolina joined with Sanger and another Cardiology group. That lasted for six months and then Mid Carolina dropped out of the conglomeration and went back to Presbyterian. Charlotte Cardiology has practiced at Mathews for 30 years and are being shut out due to the political situation. It is interesting but I'm not sure how believable that Mid Carolina states they are not in negotiations with Mathews.
The only Level I Trauma Center in Oklahoma is changing its stripes. The Oklahoma university Medical Center has lost $9 million in caring for trauma victims in the past three years. They will downgrade to a Level III emergency room.
In Philadelphia, two hospitals have at least temporarily closed their trauma centers. The reason for one was a nursing strike and for another a lack of surgeons. There are nine other trauma centers in that part of the state. Hahnemann is the one with the loss of surgeons. They lost two. One went to another hospital and one went into the pharmaceutical industry. They say they can reopen with one but are attempting to get three. They see 40-60 patients per month.
The Santa Paula Hospital in California is going belly-up. The are losing hundreds of thousands a month and the County has rejected taking over the hospital because of their large debt. The hospital still hopes as a last choice to merge with Community Hospital in Ventura, which is still embroiled in its own internal political problems.
Blue Cross had audited 23 records at Tenet hospital in Modesto California and found non-medically needed cardiac surgery in almost half. They cut off the hospital from doing cardiac surgery on their patients and are planning to terminate their contract with the hospital. The hospital has done its own outside review of the cases and found that all had received appropriate care. I guess the question is which of the lying consultants to believe? Top
A new company in San Diego started by an employee of Scripps transports illegals back to Tijuana to a hospital that specializes in treating Mexican nationals from US hospitals. The American hospitals pay the company to transport and arrange treatment for the illegals. The difference in price is huge. The typical charge in the US is about $1700 but in Mexico is about $450. The organizations that support the illegals are not happy about the removal of their constituents back to their homeland for care, but they don't pay or lose money. The company states that the transfers are all voluntary. The company, Nextcare, is planning to branch out from California to Texas. Top
The mammograms done at Park Avenue Medical Imaging in NYC may have missed lesions due to poor quality films or the wrong diagnostic tests being ordered. The State has recommended that women who have received mammograms from the clinic be retested. The reader has been placed on suspension and then resigned as a reader of mammograms. The study of the clinic's practices was done eight months ago but now released. This is not the first time Dr. Novello of the State has gotten in trouble for potentially false accusations. Top
The San Francisco Chronicle has a three piece opinion piece on healthcare. The first one is by Mr. Andrepoulos, who is director emeritus of the Office of Communication and Public Affairs at Stanford. He argues for Medicare for all as the single payor system of choice. As part of his argument he discusses the failed promise of managed care and the lowering of health care benefits to the workers. He also correctly points out that currently we have a healthcare system that has a 31% overhead as compared to Canada's 1.3%. He also points to Canada's spending of $1000 per person on healthcare without any uninsured and with drug benefits as compared to the US spending of $6000 without those perquisites. He does not mention the thousands of Canadians who come to the US each year to pay out of pocket for health care that either is not available in Canada or one must wait a dangerously long time for.
The second article is by Scott Holleran, the editor of Pulse, a newsletter for the free choice in medicine. He speaks about the current grocery strike in southern California over health care benefits. He states it is over the union who want its members to pay nothing for healthcare versus the employers who want the workers to pay a co-payment to help reign in costs. He also agrees that the managed care promise is now over, they did not cut costs nor deliver quality care. He believes that each person is basically responsible for their own healthcare and the stores are only responsible to pay for their overhead, which may be part of health insurance.
The third article is by Sally Lieber, a Democratic California Assemblyperson. Her piece states that she is worried that if the employers don't cover the healthcare, the people will end up on the dole and the state will have to pay for them. All know that the Democratic Assembly, Senate and Governor have caused a massive shortfall in the budget and the past Governor paid for it by being tossed out. She wants the employers to pay the state for the Medicaid benefits their employees receive instead of their sponsoring insurance. Is it any wonder why business is fleeing this state.
In a separate interview Oregon's ex-governor and ED physician Kitzhaber believes the current health care system is broken. He believes the problem lies in politics and that the main problem is who pays for those who can't. He believes that many times the system is penny wise and pound foolish. He gives an example of a person who because of budget cuts could not get a $12 prescription for his seizures. He ended up costing the system $5500 per day on a vent and in a persistent vegetative state. He then goes to the issue of rationing and states it is happening throughout the country due to a finite amount of money to spend. He believes the current argument in Congress over who pays for a prescription benefit is wrong. The issue should be why the drugs cost so much in the first place. He also believes the prescription question should be placed on the back burner until society figures out how to cover the basic care for the 40 million who have no insurance. He also believes that there should be a two tier system with the government paying for the floor and those who wish can purchase more. He used the example of public education where all pay for a basic floor for all until age 18. However, those who wish to pay extra for private education for their children may do so at their extra cost. He believes all should get the same basic package and if you want more, you pay for it. Top
Florida has stated that insurers must file for rate reductions of about 8% due to malpractice reforms enacted earlier this year. The insurers feel that they will still increase rates but the percent increase will be less that it would have been without the new laws. What this means is that if a company can justify a 20% increase they must only apply for a 12% increase.
In Oregon, the state's largest medical group has begun the push for a cap on damages for those who treat Medicaid patients. This would be set at $500,000, the same as is now the case at the University. The rationale is to encourage physicians to take Medicaid patients which they are now not doing. An interesting sidebar is the current Governor was on the Supreme Court when it unanimously struck down the last attempt at tort reform. They said it violated the constitutional right to a jury trail, which was not true. It only stunted the amount one could win at a jury trial.
Some rural physicians in Kentucky are losing their malpractice insurance. Three of the four OBs at one hospital have received notice of non-continuation of their policies. In the past two years over 800 physicians have either left the state or retired. Of those two groups about 1/3 of the former went to neighboring states and the same percent of the latter were under 65. Kentucky legislators did not pass tort reform this year.
The People's Republic of Massachusetts is thinking about taking malpractice claims out of the court system. Instead, the cases would be tried by a tribunal of administrative law judges who could award damages on a worker compensation like schedule based on state law. The only way it could get into the court system would be if the panel did not follow its own regs. The medical groups like the plan and the trial lawyers hate it. A pilot study is being planned and after it is over, the idea would be before the legislature. Patients in the pilot program hospitals would have to agree to the new system or seek treatment elsewhere.
Maryland is proposing caps on damages and attorney fees in malpractice cases. It will go to the state Assembly, where the trial lawyer's democratic friends have stated that it is a right wing plot to bail out insurance companies at the expense of victims of medical negligence. No partisanship here. Top
As his going away present to California, lame duck Governor Davis has appointed multiple people to positions that do not require Senate confirmation. These include $100,000 jobs on commissions that meet twice a year and on medical committees that the people know virtually nothing about. Governor elect Schwarzenegger can pull all those appointed that require Senate confirmation, but is probably stuck with the rest. Top
In a bizarre and hopefully isolated case a 16 year old illegal Mexican was missing for a week. The police were attempting to find him after the family reported him missing. The police called the New York City Metropolitan Hospital Center to ask if the boy was there. The Center disavowed any knowledge of the boy who was there all the time. They state that the privacy laws forbid them from telling the police the boy was there. This may be the case for New York, but not under HIPAA. This is not what the federal law intends. The law uses the word reasonable multiple times. The institutions are so afraid of a potential fine, they are willing to risk the bad publicity. Fortunately, someone at the hospital had enough smarts to say that the hospital's attitude was wrong and made an anonymous call to the police. 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.