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The ACA: We Told You So! November 4, 2013

Posted by jomaxx in : health care reform, health insurance, health insurance access, health insurance reform, health reform, Physicians , add a comment

After the last election this site argued that the Affordable Care Act (ACA) was doomed to suffer major problems [1] .  Well, here we are, for better or worse in the midst of the chaos.

It is now estimated that as many as 10-15 million Americans who had individual policies will see them cancelled by the end of 2013.  It is also now very clear why President Obama was willing to give a one year waiver to business as it is estimated that perhaps as many as 90 million Americans covered by employer plans will be cancelled when the waivers expire at the end of 2014.

The prospect of some 100 million plus Americans “not being able to keep their insurance or doctor” is a far cry from the often repeated promise that if you “liked your plan you could keep it”.  It was known from day one, in 2010, that this was not the case and embedded within the voluminous ACA’s 2,200 plus pages (and now 15,000 plus pages of regulations) was the nail in the coffin for all of these plans.

We now  know that so-called grandfathered  plans were sabotaged by the fact that almost any change in the policy made by a subscriber would void it’s grandfathered status and thus lead to cancellation.

On top of that, claims as to the cost savings over the next decade appear to be not only exaggerated, but bogus.  Most now expect costs to surge and the ACA to add to the deficit and debt over the next decade.

What can be done?  Well, at the least we need to begin the campaign to “fundamentally change” the ACA if not eliminate it. That would begin by expanding policy options, including Health Savings Accounts (HSA) account options in some form on all accounts to encourage individual responsibility and self-reliance.

The “other shoe” that is just beginning to fall is the number of physicians that will refuse ACA insurance and the number that will retire or limit their practices.  This, along with the expansion of Medicaid and ACA policies will flood the market and create extensive waiting times and ques for services.

The downward spiral of government intervention in healthcare has begun.  We can only hope to make changes early enough to prevent total collapse, which is the goal of many on the left, so that their much cherished single payer (read government-run and controlled) health system can be forced on the public.

Health care reform law goes forward, but problems loom


Hospital Performance Improved But Are Measurements Accurate? September 17, 2011

Posted by jomaxx in : health care news, health care reform, health reform, Hospitals, medicine, patient care, Physicians, Public Health , add a comment

Is performance or reputation more important?

Does reputation equate to performance?

Are the data being measured of real patient care value?

A new report released by the Joint Commission on Accreditation of Hospitals (JCAH) suggests that on a variety of fronts hospitals are doing a better job of patient care. They looked specifically at five areas of care: heart attack, heart failure, pneumonia, surgical, children’s asthma.  The report shows that in terms of several quality measures, such as administering antibiotics in a timely manner to surgical or ICU patient, giving aspirin to heart attack patients on admission to the ER and the like, overall hospitals have improved in last couple of years.

The new report identifies 405 hospitals out of over 3,000 (14%) accredited by the JCAH.   Those selected had to achieve a compliance score of at least 95% in one or more of the five key areas monitored during this review.  Some hospitals achieved these scores in only one category, others in two, three or more.  The complete list has been published.

Of note is the finding that none of the 17 medical centers listed by U.S. News & World Report on its “Best Hospitals Honor Roll” this year are on the Joint Commission’s list of 405 hospitals that received at least a 95% composite score for compliance with treatment standards. About one-third of a hospital’s score in the U.S. News methodology is also based on its reputation as gauged by a survey of physicians.

The findings bring into question how deserving these institutions are of their reputations.  Still other measures of quality are out there including Medicare’s Hospital Compare site which lists among other things, mortality and morbidity rates for hospitals based on Medicare data.

It should also be noted that many hospitals that did not make this list still scored very highly and only missed the list by a few percentage points.  In fact it could well be that the difference in some cases was not performance at all, but simply lack of detailed documentation, which is really all JCAH and Medicare can go by in their respective data compilations.

The entire “science” of medical comparative outcomes is still really in it’s infancy, with many confounding factors needing to be considered and analyzed to achieve a true picture of outcomes and valid comparisons between facilities and treatments.  Still, it is clear that with increasing data collection, better analytical evaluation can be undertaken and a more informed patient and provider population will result.

Report Finds Improved Performance by Hospitals – http://is.gd/STHqr4

2010 Top Performers on Key Quality Measures – http://is.gd/YK09jV

Hospital Compare – http://is.gd/QfMaQ9

Family Doctors Sue CMS, RUC Over Alleged Price Fixing August 16, 2011

Posted by jomaxx in : Devices, health care news, health care reform, Medicare, Physicians, politics, Public Health , add a comment

A 74-page law suit, filed this week in U.S. District Court in Maryland by six Georgia physicians, claims that the RUC (Relative Value Scale Update Committee) violates the Federal Advisory Committee Act’s requirements for representation, transparency, and methodological rigor.  These plaintiffs claim, the RUC has systematically overvalued many specialty procedures while undervaluing primary care. They contend that the existing payment structure that RUC has dominated is a huge driver of healthcare costs.  They argue that the health care system as a result has too many specialists doing too many unnecessary procedures and the price that we pay doctors has been fixed by this secret little committee of the AMA, which they feel is illegal.  They also note that CMS (Centers for Medicare & Medicaid Services) has accepted more than 90% of recommendations made by the RUC.  They further contend, that this fact and the resulting higher income for specialists has discouraged medical students from primary care and exacerbated the nation’s shortage of generalist physicians.

The current chair of the RUC, Barbara Levy, MD, acknowledged the lawsuit in an official statement but did not refer to any specific allegations. Instead, she focused on the fact that the RUC is an independent panel of physicians from all medical specialties, including primary care, who make recommendations to CMS as all citizens have a right to do. These volunteers provide physicians’ voice and expertise to Medicare decision-makers through their recommendations. Of course, in reality, there is really no other highly organized entity that functions in the manner of the RUC. The plaintiffs say they have tried to go through the traditional process of petitioning the AAFP  (American Academy of Family Physicians) and the AMA (American Medical Association).   They say that their complaints were ignored by the AMA, and the AAFP who sits on the RUC committee.  The fact that the AAFP and other specialty groups sit on the committee makes using professional societies as advocates for change essentially impossible.

Another overlooked fact is that this group also passes judgement on new medical technologies and the payments that should accompany them.  In lieu of CMS’s almost universal acceptance of RUC recommendations, this makes innovators of medical technology a prisoner to the RUC process,  which includes obtaining a CPT code which is necessary for payment by any insurer including Medicare and Medicaid.  Failure to obtain such a code, even if the new device or product is FDA approved, is essentially a death sentence from a market perspective for any new innovation as there will be essentially no revenue available to support its use.

While this system ostensibly protects the public to a degree, that is a false assumption.  It falls to the FDA (Food and Drug Administration) to determine the safety and efficacy of drugs and devices. Certainly, there have been complaints about the performance of that duty by FDA. However, in no way is the RUC or AMA tasked with these duties.  Nevertheless, they can act as a de facto regulator by failing to ‘recommend’ to CMS that a code be established for payment.  Additionally, in line with the lawsuit allegations, even when the RUC and CPT committees do recommend a code for payment, they then recommend a rate of payment, thus setting a value on those services.

This is part and parcel of the contention by the plaintiffs in the lawsuit, that the RUC artificially undervalues certain procedural or office codes to the benefit of some and detriment of others. To be sure, valuing medical services is difficult under the system that currently exists.   That said, it would appear that transparency and accountability are lacking in that the RUC, as an ‘arms length’ entity is not directly contracted to CMS, yet CMS, despite this, seems to use the RUC as their ‘rating agency’ when it comes to new procedures, codes and the values placed on those codes. Therefore, despite any formal relationship, the working relationship would appear to suggest that it is in fact contractual at least in the operational sense.

It will be very interesting to see  how the courts rule in this case, since depending on the ruling, we could have a continuation of the status quo, or open up an entire process to review, revision and potentially replacement . . . obi jo

Primary Care Physicians File Lawsuit to Bring More Transparency to RUC Process – Physicians Allege That Relationship Between CMS, RUC is Illegal – http://is.gd/eGdrW8

A Legal Challenge to CMS’ Reliance on the RUC – http://is.gd/XFFsWV

Doctors Sue HHS, CMS Over ‘Secretive’ Payment Committee – http://is.gd/OWDGob

AAFP Calls for RUC Reforms, but Won’t Back Suit – http://is.gd/zCptzV

RBRVS: Resource-Based Relative Value Scale – http://is.gd/O9IF8I

RUC Members 2011 – http://is.gd/WNeRK0

AMA/Specialty Society RVS Update Committee – http://is.gd/VOGnbR


American Surgeons Consider Suicide More Than We Realize January 22, 2011

Posted by jomaxx in : health care news, health reform, medicine, Mental Health, Physicians, Public Health , add a comment

Suicidal Ideation Of Concern Among American Surgeons *

Rate 1.5 to 3 times higher than in general public

A recent study has indicated reasons for concern about the rate of suicidal thought among practicing surgeons in the United States.1 Suicide is a higher cause of mortality for physicians in general compared with other professions as well as the general public.  It would appear that a combination of general work related stress, job burnout, depression and pressures brought about by medical or surgical errors takes it toll.  The constant threat of litigation over imagined or real malpractice seems to be a major issue, particularly among surgeons for whom the risk of such actions is the greatest.  It also appears that surgeons are less likely to seek professional help for their depression than the general public and that the rate of suicidal thought is significantly higher among surgeons than the general public. 1, 3, 4, 5

One in 16 surgeons reported suicidal ideation in the preceding year according to data reported in the Archives of Surgery.  The study was based on a questionnaire sent to members of the American College of Surgeons.  Nearly 8,000 surgeons responded. Among surgeons 45 and older, the rate was 1.5 to 3 times higher than the general US population.  Persons who are highly educated, employed and married have lower rates of suicidal thoughts.  This makes these findings more startling as surgeons in the study were mostly married (88%), clearly highly educated, and essentially fully employed.   Also of interest was the finding that suicidal thoughts were higher in surgeons in the 45-54 age group than in younger individuals, the exact reverse of the usual findings in the general population where 45-54 year olds have lower rates of suicidal ideation than  younger persons. Historically, the suicide risk rate among physicians has been reported as higher in female physicians, but the results of this study found no differences between the sexes in the risk of suicidal thought. Depression has long been associated with suicidal thoughts and actions.  However, burn out has only recently begun to be recognized as a major factor leading to depression, suicidal thought and action.  Previous studies in medical students had demonstrated the impact of burnout as well. 1, 2

It is of concern that highly trained physicians and surgeons would not seek mental health services to deal with burnout, depression and suicidal thought. The most common reason given for this is that there appears to be great concern about licensing and loss of one’s professional career.  Licensing boards are generally focused on physician impairment as opposed to physician illness and treatment, so that the fact of a diagnosis of depression would generally not be sufficient to warrant any action in most cases, especially if treatment is ongoing.  Still, many physicians, surgeons in particular, have great distrust of medical licensing boards as well as other professional monitoring organizations. This may well stem from the very nature of surgical training, practice and art, where a surgeon is solely responsible for his/her actions in the operative theater, as well as the outcome,

be it positive or negative. 1, 3, 4, 5

Health reform actions at the federal and state level will no doubt only add to the burden as more and more persons are brought into the mainstream of the medical care system.  Additionally, the rapidly expanding ranks of the elderly, due to the aging of the baby boomers is having an impact on the numbers of patients needing treatment and surgical interventions. All of this is occurring amidst an environment where medical school enrollments and residency training slots have not expanded rapidly enough to keep pace with demand.  Of particular concern is the effect of burnout in pushing experienced surgeons 50 and over into early retirement or reduced workload situations.  Another factor in play is the hostile reimbursement environment that forces physicians to deal with a plethora of varying rules across a spectrum of thousands of health insurance plans.  This is in addition to the intense pressures on payment implemented at the federal level though Medicare and at the state level though Medicaid.

All in all, a very worrisome picture is painted by this study.  We can only hope that bringing this data to light will encourage surgeons who may be facing some of these issues to seek help just as any patient would – and as they would advise their own patients to do.  We need all the experienced physicians and surgeons we can get, and we need them to be healthy in body and mind . . . obi jo and jomaxx

* Suicidal Ideation Raises Concern Among American Surgeons

1. Special Report, Suicidal Ideation Among American Surgeons (Arch Surg 2011;146(1):54-62)

2. Burnout and Suicidal Ideation among U.S. Medical Students

3. Study: Errors lead surgeons to contemplate suicide

4. Surgeons and suicide: a study in burnout

5. Depression, Burnout Make Surgeons Mull Suicide

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Health Insurers Charged with Increasing Anti-Competitive Behavior November 25, 2010

Posted by Obi Jo in : health care news, health care reform, health insurance, health insurance reform, Hospitals, Insurance, patient care, Physicians, politics, Public Health, Tax Policy , add a comment

Justice Department Sues Blue Cross of Michigan

Recently, a case involving Blue Cross Blue Shield of Michigan (BCBSM) has received attention in the press (USA Today, Detroit Free Press, Kaiser Health News).  The case involves alleged attempts by Blue Cross of Michigan to inhibit competition in the health insurance marketplace.  Specifically, the case in question focuses on TheraMatrix, a physical therapy provider.  They apparently were able to carve out coverage contracts with major employers such as automakers for physical therapy services.  That brought about a host of reactions from BCBSM and local hospitals aligned with Michigan’s dominant health insurance carrier. 1,2,3,4,5,6

This case highlights among other issues, most favored nation (MFN) status in contracts offered by BCBSM to potential participating hospitals.  These types of clauses in health insurance contracts are under attack in general, and specifically in this case, are the subject of a legal action brought by the United States Justice Department as well as the State of Michigan against BCBSM. 6,7

Additionally, it has been reported that insurers nationally have been hoarding huge reserves of cash, far in excess of actuarially required amounts to meet future demands.  The reasons for this are not clear, but one can of course speculate that this excess cash is being invested to increase profits for health insurers. 8

It has been argued that one of the best ways to deal with health insurers in the private market is to view them in the same light as a utility.  That would allow them to be regulated not just in terms of their solvency and adequacy of reserves, but also in terms of their rate structure in relation to those issues and their overall profitability.  It is clear that regulated utilities still make money, earn profits and yield returns for their investors.  The same would be true of regulated health insurers. 9

Elsewhere in the nation, Blue Cross Blue Shield of Louisiana (BCBSLA), that states largest insurer, and East Jefferson General Hospital (EJGH) in the New Orleans market have been engaged in a war of words following failed negotiations over a new contract.  BCBSLA argues that EJGH wanted higher payments for services than other local hospitals.  EJGH argues that BCBSLA is building excess reserves while cutting services and raising premiums.  The two sides ended their contract last month leaving many locals without access to one of the areas major hospitals. 10,11,12

The issues raised by the recent news regarding anti-competitive behavior, excess cash and profits, along with continuing rate increases all point to a market which has run amuck.  Free markets are generally best, however, when vital services are at stake, necessary regulation must be implemented.  The fact that in many states, one or two major health insurers hold sway over the majority of the market raises classic anti-trust questions. 13,14

Currently, the health reform bill fashioned by Congress that was passed along partisan lines last December, does not resolve these issues.  In fact, in many ways, in complicates them.  Still the bill fails to address issues of rate structure, premium increases, profitability, and anti-trust issues, which are of major concern when discussing health insurance reform.

Removal of anti-trust exemptions, along with the ability of health insurers to sell across state lines would be major steps toward improving access to affordable private coverage.  However, this can only come to pass if there is proper exercise of regulatory control over health insurance rates as outlined above.  Only these reforms will secure both the private health insurance market and the needed changes the citizenry deserves. 15

  1. Did Blues bully cost-saving firm in Michigan?
  2. Case against Blue Cross shows difficulty of cutting health costs
  3. BCBS Of Michigan Alleged To Have Crushed Pilot Physical Therapy Program It Saw As Competition
  4. TheraMatrix
  5. Blue Cross Blue Shield of Michigan
  6. Feds accuse Mich. Blue Cross of anti-competitive contracts
  7. UNITED STATES OF AMERICA and the STATE OF MICHIGAN, Plaintiffs, v. BLUE CROSS BLUE SHIELD OF MICHIGAN, a Michigan nonprofit healthcare corporation, Defendant (Case 2:10-cv-14155-DPH -MKM Document 1 Filed 10/18/10)
  8. Consumer group: Insurers kept surplus while hiking premiums
  9. Details on “the plan”
  10. East Jefferson General Hospital seeks arbiter in dispute with insurer
  11. East Jefferson General Hospital
  12. Blue Cross Blue Shield of Louisiana
  13. Healthcare Sector Comes Under Increased Government Antitrust Scrutiny
  14. Are Insurance Companies Still Exempt From Antitrust Laws?
  15. Health Insurers Charged with Increasing Anti-Competitive Behavior

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Practicing Physicians Advisory Council Discontinued in Health Reform Bill November 22, 2010

Posted by Obi Jo in : health care news, health care reform, health reform, Medicare, medicine, Physicians, Public Health, Tax Policy , add a comment

Affordable Care Act Cuts Out Physician Input – Secretary of HHS Given Full Discretion over Fees and Reimbursement

It would appear, that the more we learn about the new health reform bill, the more we have to be concerned about.  In a brief sentence, deep within the bill, we are informed that Section 1868(q) of the Social Security Act (42 U.S.C. 1395ee(A) is repealed. 1

Well, now just who would know what that is all about?  It seems that Congress at one time, felt it important that a panel of PRACTICING physicians, who actually live and work under the payment rules of Medicare, should get together quarterly, to discuss with HHS and CMS issues related to billing, coding and reimbursement. The common sense behind this makes one wonder how Congress ever came up with this in the first place.

When one goes to the CMS site to review this topic, one finds this text:

‘In accordance with H.R. 3950, section 3134(b)(2) of the Patient Protection and Affordable Care Act, repeals section 1860(a) of the Social Security Act (42 U.S.C. 1395ee(a)), which provided for the establishment of the Practicing Physicians Advisory Council (PPAC), and specified the PPAC’s composition and meeting schedule. The date of enactment of this provision is March 23, 2010. Therefore, the PPAC is being discontinued and the June meeting will not be held.’ 2,3

In other words, those who wrote the health bill (now who was that?) determined that it was in the best interests of health care to eliminate any face-to-face discussion between physicians and bureaucrats at CMS. No doubt, since the health bill now gives all discretion to the Secretary of HHS in regard to determining fee related matters; it was best to remove any pesky interference.  Heaven forbid we should actually have input from doctors working in the real world, under these regulations and payment policies give any feedback.

It is exactly this kind of broad latitude given to the Secretary of HHS, in the absence of any modifying input from those actually providing care and services that has prompted concern, indeed fear, from many.  With physician shortages likely to become exacerbated by any expansion of access, the elimination of practicing physician input would seem to be unwise at best, and at worst, a designed move to eliminate objection to the likely severe cost cutting that the Secretary of HHS is going to undertake.  It has also prompted negative commentary in the media. 4,5

We can only hope that his provision will be removed and the input from practicing physicians will again be sought after and respected . . . obi jo and jomaxx

1. H.R.3590Patient Protection and Affordable Care Act

2. Practicing Physicians Advisory Council


4. Practicing doctors are losing a voice

5. Affordable Care Act Cuts Out Physician Input

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Adult Vaccinations: Neglected Preventative Medicine September 29, 2010

Posted by Obi Jo in : health care news, health care reform, health insurance reform, health reform, Medicare, medicine, Pharmaceuticals, Physicians, Public Health, women , add a comment

The CDC believes that far too few adults are maintaining vaccinations or getting vaccinated at all. C.D.C. recommends that ALL people 19 and older receive immunizations against as many as 14 infectious diseases, while remembering that not all adults require every vaccine. Most of the time, adults rarely think about getting shots unless they are injured or plan travel to an undeveloped country.

For example, this year alone, over 11,000 cases of whooping cough (pertussis) have been reported nationwide. Infections are near record levels in California and 9 infants have died. No doubt some of these young children had not received all of their vaccinations.  Still, it is firmly believed that some of those deaths could have been prevented if more adults had also been immunized.

CDC studies currently show that only 7% of Americans over age 60 have received the herpes zoster vaccine to prevent shingles.  Shingles is a painful nerve infection which can become a chronic pain issue and cause debilitation. The widely publicized vaccine against the two types of human papilloma virus that cause 70% of all cervical cancers has to date only been received by an estimated 11% of young women.

More concerning is data from a study by the National Foundation for Infectious Diseases conducted in 2007 which showed that 40% responded that if they had been vaccinated as a child they no longer needed any other vaccinations.  Even worse is that some 18% said that vaccines were not necessary for adults at all.

One aspect of the new health care law should be of some help in removing barriers that may be keeping adults away from vaccinations.  The new health plan mandates that group and individual health plans along with Medicare provide preventive health services, including immunizations recommended by the C.D.C., at no charge. For insured persons, that will mean no co-payments, co-insurance or deductibles. However, that is not the entire story. If your insurance is through a group or individual health plan, your plan must be new, or have been substantively changed, in order for the new requirements to apply. Also, some of the CDC recommendations, those which are most recent, will not be covered initially.

From the standpoint of disease prevention, vaccines are cheap.  One trip to the emergency room due to a significant case of the flu or pneumonia can generate bills totally in the thousands of dollars. Flu shots are almost always to be found for about $20 and for many individuals, are often found at no charge.  Pneumonia vaccines cost around $70 to $80 versus potentially much more if you get pneumonia.

Many local pharmacies, including most of the large chain pharmacies offer vaccinations.  Some even have so-called “retail clinics” and administer a wide range of vaccines.  The most well known include CVS MinuteClinics and Walgreens Take Care Clinics. A wide range of vaccines can be obtained at these pharmacies.  Prices vary but some examples include: hepatitis A ($110-$120) and B ($100-$110), meningitis ($140-$150), pneumonia ($70-$80) and DPT (diphtheria, pertussis and tetanus ($80-$90). There are literally thousands of pharmacies nationwide offering these services, with many open daily.  Usually appointments are not necessary nor are prescriptions.  Some larger chains even offer travel vaccines with specified lists for defined areas of travel. In all states, pharmacists are licensed to give flu shots after taking some basic courses.  Many states allow pharmacists to administer a full range of vaccines as well.

This raises the question, why can’t I get these shots from my doctor? In many cases you can, but increasingly, the cost of vaccines are not covered for physicians at a rate commensurate with what they must pay.  Also, administration costs are barely if at all covered by many insurers.  Recently, flu shots were available at the local family doctor here, but were not “advertised” and given only if established patients asked.  This was actually done as a courtesy. So it would appear that vaccines have made the jump to the public health arena completely.  This is good news overall, as the broader the range of persons vaccinated against communicable disease, the better for all, regardless of age. This is especially true in an age where inter-continental and international travel occur thousands of times daily . . . jomaxx and obi jo

Cost and Lack of Awareness Hamper Adult Vaccination Efforts – http://www.nytimes.com/2010/09/25/health/25patient.html?_r=1&emc=tnt&tntemail0=y

Saving Lives:Integrating Vaccines for Adults into Routine Care – http://www.nfid.org/pdf/publications/adultimmcta.pdf

Grantee Immunization Websites – http://www.cdc.gov/vaccines/spec-grps/prog-mgrs/grantee-imz-websites.htm

Vaccinations for Adults:You’re NEVER too old to get immunized! – http://www.immunize.org/catg.d/p4030.pdf

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Communications Technology Speeding ER Care Delivery August 20, 2010

Posted by Obi Jo in : E Health, EHR (electronic health records), health care news, health care reform, health reform, Hospitals, medicine, Nursing, patient care, Physicians, Public Health , add a comment

Despite the many difficulties and costs involved in the gradual movement of medical records systems to fully digital mode, it appears that where implemented, digital data systems are making quite a difference.   A new study shows that patients treated at hospital emergency rooms that use all-digital-records systems are more likely to have shorter stays than at hospitals with paper or basic digital-records systems. The study was based on data from the 2006 National Hospital Ambulatory Medical Care Survey.  It found that people spent 22.4% less time and were treated 13.1% more quickly at hospitals with complete electronic health-records systems compared with other hospitals. It also found that hospitals with basic computerized records were less efficient than other hospitals. Emergency-room wait times at those semi digital hospitals were 47.3% longer for patients with an urgent or semi-urgent matter. Of course, training of medical staff, physicians and nurses, is critical to both acceptance and overall ease of use of any system implemented.

Another trend just gaining ground is the use of “apps” for various mobile phones and PDA’s as well as computer web site updates related to emergency room access and wait times.  A suburban Boston hospital has introduced a new way for patients to avoid long emergency room waits — texting.  MetroWest Medical Center located outside of Boston in Framingham, launched the state’s first texting program that allows potential patients to find out ER wait times before making the trip to the hospital. The hospital began the service last week in hopes of building its market share and improving ER performance — and by extension, patient satisfaction. Since that time, people have sent in more than 450 text requests from their cell phones for wait times at the medical center’s emergency rooms at Framingham Union Hospital and Leonard Morse in Natick. Average wait times as of yesterday afternoon were 24 minutes and 6 minutes, respectively. The medical center measures wait times from when patients check in to when they see a doctor. Ochsner Clinic, based in New Orleans, with affiliated throughout southeast Louisiana has also moved to the use of “apps” as well a maintaining a real time online report of wait times at the ERs in their various medical facilities.

Of course, in a real life and death emergency, it is hard to imagine anyone using any of these services since a call to 911 or an immediate trip to the hospital would seem more prudent.  For less than life threatening emergencies, however, this would seem to be common sense concept, to reduce waiting and its associated frustration and tension which affects both care givers and patients.  Health information technology and the use of newer applications that were not originally designed for health care (texting, mobile downloads, web based monitoring) will make the difference going forward.  Real health reform will come from true innovation in technology and subsequent adaptation with service based innovations as well . . . obi jo and jomaxx

Texting, On-Line Updates Assist Patients Seeking Timely ER Care – http://www.associatedcontent.com/article/5708630/texting_online_updates_assist_patients.html

Digital hospital records tied to higher efficiency – http://www.azcentral.com/arizonarepublic/business/articles/2010/08/20/20100820digital-hospital-records-more-efficient.html

Hospital starts texting service for ER wait times – http://www.boston.com/news/health/blog/2010/08/hospital_starts.html

CURRENT EMERGENCY ROOM WAIT TIMES – http://www.ochsner.org/emergency

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Health Reform, Immigration Reform Linked August 2, 2010

Posted by Obi Jo in : health care news, health care reform, health insurance, health insurance reform, health reform, Hospitals, Insurance, insurance access, medicine, Nursing, patient care, Physicians, politics, Public Health, Underinsurance, uninsured, women , add a comment

The recent hoopla over the Arizona immigration law has brought the issue of illegal immigration front and center.  In the area of health care, the issue of illegal immigration is a major one, right up there along with other health system issues.  Recently, federal judge Bolton put several portions of the Arizona law on hold. Our goal here is not to debate that or the law, but to focus on the health system consequences of uncontrolled illegal immigration. Arizona Governor Jan Brewer (R) has said the problems and costs associated with illegal immigration remain dire, and she pressed the point in asking the appeals court for a review of Judge Bolton’s ruling.  Despite the fact that President Obama has emphatically denied that the new health reform bill will cover illegals, the fact is that the problem is already upon us.

One of the pressing issues effecting all border states is that of anchor babies.  In many cases, people come here to have babies, they come here to drop a child. It’s a process called “drop and leave.” To have a child in America, they cross the border, go to the emergency room, deliver the baby, which is automatically an American citizen. Many feel that this shouldn’t be the case, saying that this attracts people here for all the wrong reasons.

The impact of immigration on our public health is often overlooked. Although millions of visitors for tourism and business come every year, the foreign population of special concern is illegal residents, who come most often from countries with endemic health problems and less developed health care. They are of greatest consequence because they are responsible for a disproportionate share of serious public health problems, are living among us for extended periods of time, and often are dependent on US health care services, which are citizen taxpayer funded.

Public Health Risks

Illegal immigrants, unlike those legally admitted for permanent residence, undergo no medical screening to assure that they are not bearing contagious diseases. The rapidly swelling population of illegal aliens in the US has also set off a resurgence of contagious diseases that had been totally or nearly eradicated by our public health system.

According to Dr. Laurence Nickey, director of the El Paso heath district “Contagious diseases that are generally considered to have been controlled in the United States are readily evident along the border. The incidence of tuberculosis in El Paso County is twice that of the U.S. rate.”  Dr. Nickey also states that leprosy, which is considered by most Americans to be a disease of the Third World, is readily evident along the U.S.-Mexico border and that dysentery is several times the U.S. rate.  People have come to the border for economic opportunities, but the necessary sewage treatment facilities, public water systems, environmental enforcement, and medical care are not available on the Mexican side of the border, causing a severe risk to health and well being of people on both sides of the border.

The pork tapeworm, which thrives in Latin America and Mexico, is showing up along the U.S. border, threatening to ravage victims with symptoms ranging from seizures to death. The same [Mexican] underclass has migrated north to find jobs on the border, bringing the parasite and the sickness—cysticercosis—its eggs can cause cysts that form around the larvae usually lodge in the brain and destroy tissue, causing hallucinations, speech and vision problems, severe headaches, strokes, epileptic seizures, and in rare cases death.

The problem, however, is not confined to the border region.  Illegal immigrants have rapidly spread across the country into many new economic sectors such as food processing, construction, and hospitality services. Typhoid struck Silver Spring, Maryland, in 1992 when an immigrant from the Third World (who had been working in food service in the United States for almost two years) transmitted bacteria through food at the McDonald’s where she worked. River blindness, malaria, and guinea worm, have all been brought to Northern Virginia by immigration.

Contrary to common belief, tuberculosis (TB) has not been wiped out in the United States, mostly due to illegals. In 1995, there was an outbreak of TB in an Alexandria, VA, high school, when 36 high-school students caught the disease from a foreign student. The four greatest immigrant magnet states have over half the TB cases in the U.S.  In 1992, 27% of the TB cases in the United States were among the foreign-born; in California, it was 61% of the cases; in Hawaii, 83%; and in Washington state, 46%. The Queens, New York, health department attributed 81% of new TB cases in 2001 to immigrants.

”We’re running an H.M.O. for illegal immigrants and if we keep it up, we’re going to bankrupt the county” said Los Angeles County supervisor Michael D. Antonovich in a quote from the  New York Times (May 21, 200).  “What is unseen is their [illegal aliens’] free medical care that has degraded and closed some of America’s finest emergency medical facilities, and caused hospital bankruptcies: 84 California hospitals are closing their doors”, (Madeleine Peiner Cosman, Ph.D., Esq. “Illegal Aliens and American Medicine,” Journal of American Physicians and Surgeons, Spring 2005)

Costs of Medical Care

Immigrants are often uninsured, underinsured and 43% of non-citizens under 65 have no health insurance. That means there are 9.4 million or more uninsured immigrants, a majority of whom are in the country illegally (15% of the total uninsured in the nation in the mid-1990s). The costs of medical care for uninsured immigrants is passed onto the taxpayer, straining the financial stability of the health care community.

Another problem is immigrants’ use of hospital and emergency services rather than preventative medical care. Utilization rate of hospitals and clinics by illegal aliens (29%) is more than twice the rate of the overall US population (11%). As a result, the costs of medical care for immigrants are staggering. The estimated cost of unreimbursed medical care in 2004 in California was about $1.4 billion per year. In Texas, the estimated cost was about $.85 billion ($850 million), and in Arizona the comparable estimate was $.4 billion ($400 million) per year.

One frequent cost to US taxpayers is delivery of babies to illegal alien mothers. A California study put the number of these anchor baby deliveries in the state in 1994 at 74,987, at a cost of $215 million. At that time, those births constituted 36% of all Medi-Cal births, and they have grown now to more than 50% of the annual Medi-Cal budget. In 2003, 70% of the 2,300 babies born in San Joaquin General Hospital’s maternity ward were anchor babies. Medi-Cal in 2003 had 760,000 illegal alien beneficiaries, up from 2002, when there were 470,000.

The Emergency Medical Treatment and Active Labor Act (EMTALA) requires every ER to treat those who enter with an emergency, including cough, headache, hangnail, cardiac arrest, herniated lumbar disc, drug addiction, alcohol overdose, gunshot wound, automobile trauma, human immunodeficiency virus (HIV)-positive infection, mental problem, or personality disorder. The definition of emergency is flexible, vague and patient defined.  It is vague enough to include almost any condition. Any patient coming to a hospital ER must be screened and treated until ready for discharge, or stabilized for transfer whether or not insured, documented, or able to pay. A woman in labor must remain to deliver her child.

The hospital must have specialists on call at all times for all departments that provide medical services and specialties within the hospitals capabilities. EMTALA is an unfunded federal mandate. Stiff fines and penalties may be imposed on any physician or hospital refusing to treat any patient that a zealous prosecutor deems an emergency patient, even though the hospital or physician screened and declared the patients illness or injury non-emergency. Government pays neither hospital nor physician for treatment. In addition to the fiscal attack on medical facilities and personnel, EMTALA is a club with which to pummel politically unpopular physicians by falsely accusing them of violating EMTALA.

American hospitals have been set up to welcome anchor babies. Illegal alien women come to the hospital in labor and drop their “little anchors”, each of whom pulls its illegal alien mother, father, and siblings into permanent residency simply by being born within our borders. Anchor babies are, and instantly qualify for public welfare aid. Between 300,000 and 350,000 anchor babies annually become citizens because of the Fourteenth Amendment to the U.S. Constitution which states that all persons born or naturalized in the United States, and subject to the jurisdiction thereof, are citizens of the United States and the State wherein they reside.  Recently, Senator Lindsey Graham (R-SC) has suggested a new amendment to the constitution to amend the and rectify this unintended consequence of the 14th amendment.

New immigrants coming to America from Europe via Ellis Island, were stripped naked, examined and observed for signs of contagion. Legal immigrants prior to 1924 were examined for infectious diseases upon arrival and tested for TB.  Those infected were shipped back to their country of origin. Even today, immigrants must demonstrate that they are free of communicable diseases and drug addiction to qualify for lawful permanent residency green cards. In contrast, illegal aliens simply cross our borders without any medical examination whatsoever, carrying with them any number of communicable diseases. Many illegals who cross our borders have tuberculosis. That disease had largely disappeared from America, thanks to excellent hygiene and powerful modern drugs such as isoniazid and rifampin. TBs swift, deadly return now is lethal for about 60% of those infected because of new Multi-Drug Resistant Tuberculosis (MDRTB). Until recently MDR-TB was endemic to Mexico.  MDR-TB is resistant to at least two major drugs. Ordinary TB usually is cured in 6 months with 4 drugs that cost about $2,000.  MDR-TB takes 24 months with many expensive drugs that cost around $250,000, with toxic side effects. Each illegal with MDR-TB coughs and infects 10 to 30 people, who will not show symptoms immediately. Latent disease explodes later.

Chagas disease, also called American trypanosomiasis or kissing bug disease is transmitted by the reduviid bug, which prefers to bite the lips and face. The protozoan parasite that it carries infects 18 million people annually in Latin America and causes 50,000 deaths.

Leprosy, the scourge of Biblical days and medieval Europe, horribly destroys flesh and faces.  It was called the disease of the soul.  Lepers quarantined sounded noisemakers when they ventured out to warn people to stay far away. Leprosy, Hansens disease, was so rare in America that in 40 years only 900 people were afflicted. Suddenly, in the past three years America has more than 7,000 cases of leprosy. Leprosy now is endemic to northeastern states because illegal aliens and other immigrants brought leprosy from India, Brazil, the Caribbean, and Mexico.

Dengue fever is exceptionally rare in America, though common in Ecuador, Peru, Vietnam, Thailand, Bangladesh, Malaysia, and Mexico. Recently there was a virulent outbreak of dengue fever in Webb County, Texas, which borders Mexico. Though dengue is usually not a fatal disease, dengue hemorrhagic fever routinely kills.

Polio, once eradicated from America, now reappears in illegal immigrants, as do intestinal parasites. Malaria was obliterated, but now is re-emerging in Texas. About 4,000 children under age five annually in America develop fever, red eyes, strawberry tongue, and acute inflammation of their coronary arteries and other blood vessels because of the infectious malady called Kawasaki disease. Many suffer heart attacks and sudden death. Hepatitis A, B, and C, are resurging. Asians number 4% of Americans, but account for more than half of Hepatitis B cases.

At the end of the day, our immigration policy has not only a powerful political and economic effect, but a major public health impact. It is not in the interests of America or its legal citizens to continue to be exposed to the risks of illegal immigration. Clearly, the federal government has abdicated by its inaction, its role in controlling the border, immigration and protecting the health of the public at large.

One proposal in the literature is referred to as CRAG: A Proposal to Prevent Medical Cataclysm. It consists of four points:

  1. Close Americas borders
  2. Rescind the citizenship of anchor babies
  3. Aiding and abetting illegal aliens is a crime and should be prosecuted as such
  4. Grant no new amnesties

Clearly, it will take bold leadership and political courage to address the reality of this issue.  We can only hope that the electorate and Congress will have the spine to stand up to the threat and meet the challenge . . . obi jo and jomaxx

Emotions Flare After Immigration Law Is Blocked – http://www.nytimes.com/2010/07/30/us/30arizona.html?scp=3&sq=Health%20costs%20of%20illegal%20aliens&st=cse

Obama: No Health Care For Illegal Immigrants – http://www.cbsnews.com/8301-503544_162-5178652-503544.html

Rising health care costs put focus on illegal immigrants – http://www.usatoday.com/news/washington/2008-01-21-immigrant-healthcare_N.htm

Illegal Immigration Costs California Over Ten Billion Annually – http://usgovinfo.about.com/od/immigrationnaturalizatio/a/caillegals.htm

Graham eyes ‘birthright citizenship’ – http://www.politico.com/news/stories/0710/40395.html

Illegal Immigration and Public Health – http://www.fairus.org/site/PageServer?pagename=iic_immigrationissuecenters64bf

Chagas disease – https://health.google.com/health/ref/Chagas+disease

Leprosy – http://www.who.int/mediacentre/factsheets/fs101/en/

Dengue fever – http://en.wikipedia.org/wiki/Dengue_fever

Polio and Post-Polio Syndrome – http://www.nlm.nih.gov/medlineplus/polioandpostpoliosyndrome.html

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AMA: Health Insurers, Make Your Physician Rating Measures Public! July 20, 2010

Posted by Obi Jo in : health care news, health care reform, health insurance, health insurance access, health insurance reform, Insurance, insurance access, Insurance Profits, Medicare, medicine, Patents, patient care, Physicians, Public Health , add a comment

Doctors are openly criticizing  growing efforts by health plans and health insurers to direct patients toward certain physicians based on perceived cost or quality, arguing that the rankings may be unreliable and unfair. In response to new evidence that patients are receiving inaccurate physician profiles from health insurers, the American Medical Association (AMA) delivered letters today to the nation’s largest health insurance companies asking for immediate action to improve the accuracy, reliability and transparency of physician ratings.

The AMA sent letters to 45 health insurance companies nationwide asking them to verify that their physician rating programs are accurate by allowing outside experts to analyze them.  Forty-seven (47) state medical societies also signed the letters. The AMA is concerned that health plans are not providing customers with accurate information when they rate physicians based on cost and quality. Physician ratings have grown in popularity as insurers seek to provide more information to members and employers to evaluate the quality and cost of services. The AMA cites a March study by the RAND Corp. published in the New England Journal of Medicine that indicated physician ratings by health insurers can be wrong up to two-thirds of the time for some groups of physicians.  In that study the final conclusion was that current methods for profiling physicians with respect to costs of services may produce misleading results.

Patients should always be able to trust that insurers are providing accurate and reliable information on physicians,” said AMA President Cecil Wilson in a statement. Robert Zirkelbach, spokesman for America’s Health Insurance Plans said that insurers are working closely with providers to develop these measures. “This is an ongoing process that is continually improving.”    That comment however, begs the question of just who is it that is making up the measures?   Who has input?  Are physicians and others involved in an open process, or is this a closed door endeavor.  Health plans after all, are funding agents, taking in premiums and making payment for services.  They keep the margin – which goes up if doctors have fewer visits, order less tests and do fewer procedures.  So, is ” quality” really being measured by most health insurers, or in the end, is it overall cost to the health insurer that rules the day?

Having said all that, we know that the primary rating measure for insurer is cost – read, what they have pay out to providers (doctors, hospitals, labs, etc.).  Yes, they look at other things such as certification, specialization, office hours, convenience for patients, locations and the like.  But in the end, they look and profile based on visits, tests and procedures.   Health plans quantify these measures via the CPT coding system and they then look at overall costs.  In the end, the most “cost efficient” doctors (read cheapest), are for the most part who are found on select panels.  This process reached a peak with the failed HMO craze of the 80’s and early 90’s.  More and more, open panels have become the norm.  However, in light of a likely squeeze on health insurance profits, health plans are looking to resurrect many of these programs to limit physician panels and therefore limit access of their subscribers.  The end result will be to reduce costs – as well as increase health plan profits.

Measurement of physician and surgeon “quality” in the end, is exceedingly difficult, beyond the most obvious of measures such as overall mortality and morbidity associated with interventions performed by an individual physician.  We applaud the AMA and other medical societies for publicly calling out health plans and health insurers.  They should and MUST make their profiling measures public so that they can be independently reviewed for accuracy, veracity and reliability.  Also, physicians need to know what they are being judged on by these payers, and patients must have confidence that these ratings and rankings are of some real value . . . jomaxx and obi jo

AMA and State Medical Societies Call on Insurers to Publicly Document the Accuracy of Physician Cost Profiling – http://www.ama-assn.org/ama/pub/news/news/physician-cost-profiling.shtml

AMA presses insurers on doc-rating programs – http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20100719/NEWS/307199967

Doctors Slam Insurers Over Their Rankings – http://online.wsj.com/article/SB10001424052748704720004575377523886401684.html

Physician Cost Profiling — Reliability and Risk of Misclassification – http://content.nejm.org/cgi/content/short/362/11/1014

AMA wants Humana, others to consider quality more in ranking doctors – http://www.courier-journal.com/article/20100719/BUSINESS/7190349/1003/rss03

AMA battles insurers over doctor ratings – http://www.startribune.com/lifestyle/health/98797709.html?elr=KArksD:aDyaEP:kD:aUt:aDyaEP:kD:aUiD3aPc:_Yyc:aU7DYaGEP7vDEh7P:DiUs

Medical Groups Criticize Insurers on Rating Doctors – http://prescriptions.blogs.nytimes.com/2010/07/19/medical-groups-criticize-insurers-on-rating-doctors/

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