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Health Policy

Hospitals Overhaul ERs to Reduce Mistakes

Often chaotic and overcrowded, with scant data available about new patients, the emergency room is among the top hospital departments responsible for malpractice suits—and diagnostic errors account for 37% to 55% of cases in studies of closed claims.

The average payments and legal expenses for ER cases have more than doubled over the past two decades, according to the Physician Insurers Association of America, a nonprofit trade association whose members cover about 60% of emergency physicians.  This Wall Street Journal article explores pilot programs in different hospitals across the United States working to make corrective changes in emergency room procedures.

Changes include adopting new triage systems to ensure doctors and nurses jointly see at-risk patients soon after they arrive, requiring physicians and nurses to huddle to make sure no information is overlooked, and using time-outs at discharge to prevent patients with unresolved problems from leaving the ER.

Some interesting points to note, emphasizing the impact emergency room care and costs have upon health care in the United States:

  • Insurance broker Aon Corp. estimates malpractice suits arising from emergency-room incidents in 2009 alone will cost hospitals $1 billion.
  • While emergency-room errors often happen because a doctor misjudges symptoms, in almost all cases of missed or delayed diagnoses essential pieces of information weren’t available at the time the doctor made a decision, according to Dana Siegal, program director of risk-management services for Crico/RMF Strategies, whose parent company insures hospitals affiliated with Harvard University. Crico/RMF is working with 16 hospitals on a project to improve communication between doctors and nurses. Mannequins will be used to simulate various emergencies, and participants discuss what could have been done differently.
  • The changes to emergency-room systems come as ERs face a growing work load. In a survey released last month, the American College of Emergency Physicians said 80% of its members are reporting increased visits to emergency rooms and more than 90% expect increases next year.
  • David Seaberg, president-elect of the group, says a growing shortage of primary-care physicians is driving many patients to the ER.

Read more…

In Florida, HMOs Would Treat Medicaid Patients

As explored in this New York Times article, a crucial experiment in the future of Medicaid is playing out in Florida, where both houses of the Legislature are vying to find ways to drastically cut costs, manage care and reduce waste and fraud.

The cuts and changes being sought by the Republican-led Legislature and encouraged by the new Republican governor, Rick Scott, a wealthy former hospital company executive, are deeper than those in many other states.

In the past 11 years, the cost of Medicaid in Florida has grown to $21 billion from $9 billion and amounts to a third of the state budget. The federal government pays more than half the tab.

Relying loosely on a five-year-old pilot program to shift care to HMOs, Florida lawmakers are poised to scrap the traditional model in which the state pays doctors for each service they perform. Instead, almost all of Florida’s Medicaid recipients would be funneled into state-authorized, for-profit HMOs or networks run by hospitals or doctors. HMOs or networks would also manage the long-term care of the elderly, shifting them away from nursing homes and leading to an expansion of in-home care. Lawmakers who support the bill say the state needs this flexibility in curtailing the exploding cost of Medicaid. Read more…

Patients Are Not Consumers

Paul Krugman, (Nobel Prize for Economics, 2008),  in a New York Times Op Ed piece, has a few things to say about perspectives on health care. Some excerpts we found interesting:

Here’s my question: How did it become normal, or for that matter even acceptable, to refer to medical patients as “consumers”? The relationship between patient and doctor used to be considered something special, almost sacred. Now politicians and supposed reformers talk about the act of receiving care as if it were no different from a commercial transaction, like buying a car — and their only complaint is that it isn’t commercial enough.

What has gone wrong with us?

Medical care, after all, is an area in which crucial decisions — life and death decisions — must be made. Yet making such decisions intelligently requires a vast amount of specialized knowledge. Furthermore, those decisions often must be made under conditions in which the patient is incapacitated, under severe stress, or needs action immediately, with no time for discussion, let alone comparison shopping.

That’s why we have medical ethics. That’s why doctors have traditionally both been viewed as something special and been expected to behave according to higher standards than the average professional. There’s a reason we have TV series about heroic doctors, while we don’t have TV series about heroic middle managers.

The idea that all this can be reduced to money — that doctors are just “providers” selling services to health care “consumers” — is, well, sickening. And the prevalence of this kind of language is a sign that something has gone very wrong not just with this discussion, but with our society’s values. Read more…

As Health Costs Soar, G.O.P. and Insurers Differ on Cause

As Congress continues to debate the new health care law, health insurance costs are still rising, particularly for small businesses, as noted in this New York Times article. As Congress continues to debate the new health care law, health insurance costs are still rising, particularly for small businesses. Republicans are seizing on the trend as evidence that the new law includes expensive features that are driving up premiums. But the insurance industry says premiums are rising primarily because of the underlying cost of care and a growing demand for it.

As an example:

  • In New Hampshire, more than 90 percent of private employers have fewer than 50 employees.
  • This year, groups of more than 20 workers have been experiencing premium increases of around 20 percent.
  • Smaller groups are seeing increases of 40 percent to 60 percent or more.

Some insurance industry lobbyists say the new federal health care law is driving up premiums. But Vincent Capozzi, senior vice president for sales and customer service at Harvard Pilgrim, said that:

  • Only one percentage point of the increases here was attributable to the federal law, mainly its requirement for free coverage of preventive services.
  • Another percentage point results from new state laws requiring coverage of hearing aids and certain treatments for autism, Mr. Capozzi said.

Most of the remainder, he said, reflects increases in the use and cost of medical care by small-group customers, with adjustments for demographic characteristics like age. Read more…

Amid War on a Mystery Disease, Patients Clash With Scientists

In addition to providing an update on chronic fatigue research, this article in the Wall Street Journal summarizes some interesting points about the larger question of how illnesses are defined and the interplay between that and treatment research. As MCNTalk noted several weeks ago (What’s in a Name? For Illnesses, it’s Fodder for Debate) treatments may vary depending upon a physician’s diagnostic measurements. In a posting earlier this week (Gene Work Yields New Treatment For Lupus) MCNTalk further explored dilemmas raised by a condition’s definition.

Points to ponder:

  • The Internet has given patients the ability to organize and rapidly disseminate medical information—and rumors as well. Patient advocacy groups are increasingly powerful, involved in central endeavors such as funding research and collecting samples critical to experiments.
  • In the case of chronic fatigue treatment, Stuart Le Grice, head of the National Cancer Institute’s Center of Excellence in HIV/AIDS and cancer virology, is skeptical about XMRV’s role in the disorder. He is sympathetic to patients but he insists that science can’t be rushed. Desperate patients who want immediate answers risk diverting attention from essential research. “There’s a danger of deflecting us from what we really want to do,” Dr. Le Grice says.
  • There has never been any consensus on what causes the syndrome. Many doctors believe that there can be different triggers, including viruses and genetic vulnerability. There are still some doctors who believe the condition is psychiatric, a stance many patients believe has discredited them and slowed down efforts to find treatments.
  • The clashes between patients and scientists come as science in general becomes more polarized, according to a study published in the Journal of Risk Research last year. Researchers found that when scientists’ conclusions conflict with a community’s cultural values, people don’t accept the scientific consensus. “The phenomenon we are looking at is a cultural war over facts,” says Dan Kahan, director of the Cultural Cognition Project at Yale Law School, who co-authored the study last year.

Read more…

Gene Work Yields New Treatment For Lupus

As noted in the Wall Street Journal, the Food and Drug Administration approved the first new drug for lupus in more than 50 years, a milestone in the effort to mine data from the human genome to discover and develop new medicines. This development is important for a variety of reasons which highlight various situations within the world of how illnesses are defined and treated. Specifically the article notes that:

  • There’s a huge range in the number of people suffering from Lupus, depending upon how the disease is defined: Estimates of how many Americans are affected range from 161,000 to 1.5 million.
  • One version of the drug entered clinical trials in 2000.  So little was known about how to evaluate a new lupus drug, however, that it took the company, outside experts and the FDA took a year to design clinical trials that would determine whether Benlysta helped patients or not.
  • Benlysta, the drug in question, is one of the first drugs discovered based on mapping of genomic data to make it through to FDA approval.
  • The price of the drug will be about $35,000 a year per patient, which the company said was in the range of other biologic therapies used to treat similar diseases.
  • Clinical studies also showed those receiving Benlysta suffered more deaths and serious infections compared with patients not on the drug. (Patients using Benlysta will receive a medication guide that will outline the risks associated with the product.)
  • Before Benlysta, the FDA last approved drugs to treat lupus in 1955.
  • Nine out of ten people with Lupus are women.

Read more…

Hospitals With Robots Do More Prostate Cancer Surgery

Hospitals that buy surgical robots end up performing more prostate cancer operations, suggesting that technology has become a driving force behind decisions about men’s cancer care, new research shows.

The study, published in the journal Medical Care and explored in the New York Times, is the latest report to suggest that how men are treated for prostate cancer appears to be influenced by a variety of factors, including the technology and marketing goals of hospitals and doctors, rather than scientific evidence on benefits and risks.

The new study, conducted by researchers at New York University and other institutions, was a fairly large one, tracking surgical robot purchases at 554 hospitals, along with the treatment given to more than 30,000 men given a prostate cancer diagnosis from 2001 to 2005.

Interesting notes:

  • Buying a robot led to an average increase of 29 operations a year per hospital.
  • Hospitals that own a surgical robot may be that the technology helps a hospital lure potential surgical patients away from the competition.
  • The data also suggest that once a hospital obtains a robot, patients who might be candidates for non-surgical options are more likely to be steered toward robotic surgery instead.
  • A surgical robot used for prostate cancer costs $1 million to $2.25 million, according to the N.Y.U. study. In addition, hospitals spend $140,000 annually for a service contract and $1,500 to $2,000 per patient on disposable instruments.

The researchers found that treatment patterns varied markedly across the clinical sites studied, and those differences could not be explained by measurable factors like severity of disease or patient age. Read more…

Revisiting IME Ethics and standards

Revisiting IME Ethics and standards

As founder of MCN and a practicing physician, I am proud of what we do as a company and hold high expectations for ourselves, our consultants and indeed our clients. I write this note with a bit of trepidation, but I have never been known as one to shrink from issues.

What I am addressing is by no means the norm in many or most cases, but there are ethical situations that should not be part of our industry, even at the smallest level. Please review this post in the spirit that it is meant – to improve what we do. Please don’t shoot the messenger. But by all means, feel free to comment on this posting, or privately to me.

It has been almost two years since a major expose in the New York Times regarding certain practices in that region.  For those who wish to read this series, please visit:

http://topics.nytimes.com/top/reference/timestopics/subjects/w/workers_compensation_insurance/index.html this page has all the links. Here are links to the individual articles over 3 days:

http://www.nytimes.com/2009/03/31/nyregion/31comp.html?ref=workerscompensationinsurance

http://www.nytimes.com/2009/04/01/nyregion/01comp.html?ref=workerscompensationinsurance

http://www.nytimes.com/2009/04/02/nyregion/02comp.html?ref=workerscompensationinsurance

To my knowledge the matter to a large degree “blew over” in that I am not aware of any significant regulatory or other outcomes on this issue or sanctions against the company featured, though I have heard that they have changed names.

I believe that it may be time to revisit standards in performance of IMEs, especially in regions of the country where we have observed that certain practices that we regard as improper and indefensible may indeed continue to be practiced by certain consultants and IME companies. Not asking, for example, how it can be that they receive and accept examination reports at price points, length and quality that would not be possible elsewhere in the country.  All clients deserve the highest quality standards from those they rely upon for important services, which in the case of IME’s means unbiased, thorough, evidenced-based assessments performed by engaged and dedicated consultants.

With recent disruption in the industry, including a very large consolidation of a number of smaller companies, it is our hope that those who oversee large numbers of IMEs will endorse some or all of the points we are raising, and take appropriate actions in their own companies to insure integrity in all exams. Likewise all doctors who examinations must perform at the highest medical standards and not allow a lower standard for IME’s.

The basic principle is to do right by clients, claimants and society. And since we facilitate medical examinations, let doctors do their jobs properly and insist that high standards be followed and maintained.

Clients who order exams generally receive quality exams, but they should still ask questions if they see possible issues, and use common sense. Doctors who do exams, whocan’t or won’t practice in a way that treats each claim and claimant as individuals, with respect and dignity, give the process enough time, write original reports where critical thinking is employed, and remember why they entered (or should have entered) the profession, should not do exams. There are certain acts that MCN finds unacceptable. We believe all involved in the business should feel likewise and take appropriate measures to ensure that substandard performance does not occur. In no particular order they include:

Exams that are too brief: We believe that a reasonable rule of thumb is that an IME should take no less than 30 minutes— and often much longer—to perform. We generally schedule an hour in our own facilities, sometimes a bit less, but never more than two an hour, and we question at times whether this is optimal. The time must allow for review of appropriate records, a history from the claimant, a focused and appropriate physical or mental status examination, and an original report. We have observed with our own eyes the extreme of the company cited in one of the articles I liked cited above scheduling 12 exams in an hour, with an expectation of perhaps 4 no shows and therefore approximately 8 exams to be done. This timeframe is simply impossible. Further, I think that it is also impossible to do 4 proper exams in an hour. Attempting to cut corners on time does not work; it leads to claimants who feel rushed and not heard, reports that are shoddy, and conclusions that are inarticulate if not inaccurate.

Use of Boilerplate in substantive content areas: The history, examination and conclusions must be original. Templates can provide a framework to follow or serve as an introduction or disclaimer. But the words used in an exam should be original. Measurements should be real and reflect human variation. Normal findings if quantified should reflect a range of normal. While a 90 degree flexion for example, might be normal, normal flexion will be vary from 90 degrees, while still in a normal range. So the number would be expected to not be 90. Yet I have observed reports where normal variation appears absent. No two exams should ever look the same in language when it comes to the history, examination or conclusions.

Reports that are too brief: I am not prepared to state how long an exam should be, but can state with a high level of comfort that an assessment of a complex injury with records to review, a history to cite and an examination and assessment to record generally ought to be more than 2-3 pages.

Ghost-writing of reports or examination performance: It is the physician’s job, and his/her’s alone, to take the history, review records, perform a substantive examination and issue the final report. And it should be the physician contacted for the exam who completes this work. It may not be delegated. While rare, we have seen instances where this is not followed, despite clear guidelines on the matter. The physician must not sign their name on the work of others. While it may be the practice of a particular physician to delegate certain practice tasks, that is not the standard in IMEs, and certainly not something to be imposed upon an unaware client or IME company.

Ordering unnecessary tests, especially when personal or corporate gain may be involved: It is no secret that society has been looking very carefully at real or perceived conflict of interests in medical services. Fortunately our clients call us and ask for exams and we don’t drive the demand. But we do expect that consultants make a determination as to whether a particular study is needed. Interestingly, when it comes to typical orthopedic type examinations, we find that the common frequency of ordering of studies in situations where testing is not on site is less than 5%. However we have learned that in situations where physician practices or certain IME companies have X-ray equipment on site, the incidence of use increases to approximately 35%. This is a massive variable and suggests that something may be amiss. The only indication for a study should be if it is necessary for a quality report. Often it is not, or prior studies are more than adequate. If a consultant is ordering common films uncritically, or clients see this taking place, questions should be asked. We believe that clients should consider exercising the option of requiring approval for studies, to insert a bit of friction in the process, especially if X-rays appear to be a norm with a particular setting, consultant or company.

Think about the New York Times test: The homily that one should never do something that they would not mind seeing on the front page of the New York Times holds true. And as you can see above, aberrant behavior in our field made the front page two years ago. Or to frame this in another manner, don’t do anything in our businesses or tolerate practices that we would not subject our immediate family members and best friends to. Some of what I have observed over the years would suggest that if this were the case, some people really dislike their friends and families, to allow certain practices to not only take place, but persist.

Some of these practices have been defended on the basis that questionable claims and claimants may justify them. To this I only can shake my head. Yes there are questionable claims and claimants but this in no way justifies lowering our standards of dignity and respect for what we do as physicians and companies.

Other justifications have included the belief that this is what the client wants and that they are price sensitive and therefore a hurried approach, done cheaply and below standard is therefore acceptable. I don’t believe that clients want claimants to be mistreated, and while price may be an issue, clients realistically understand that quality does carry a price and one can’t cut corners in key areas and achieve a defensible and acceptable product. I believe there may be business risk in the long-term if questionable practices are tolerated. Also, the practice of medicine is the province of physicians, and just as a client would not tell a doctor how to provide treatment, the client hopefully should rely upon ethical and trained physicians to be the final arbiter on examination performance and quality.

The consequences of inattention to ethical medical examination practices creates an uneven playing field in the provision of IME’s; those who do quality work and those who don’t. Some IME provider will take a pass on work at a price that could only be provided sub-optimally. Fortunately we at MCN and many of our ethical competitors are blessed with great consultants and clients who value integrity in the work they do and the examinations they expect. We as a company will continue to strive for the highest standards of integrity. We invite all consultants, clients and competing companies to set similar bars of expectation.

In closing, I invite a dialogue, comments, even respectful challenges to these ideas. We also may have missed some additional issue and areas bearing attention. Please raise them.

Brian L. Grant, MD

Chair and Medical Director, MCN

Oxycontin Express

We were told about this documentary video about the proliferation of pain clinics that basically prescribe narcotics in South Florida, attracting addicts from many other states. Very powerful and worth watching. This is available on several sites, including YouTube by searching the key words “oxycontin express.”  We previously addressed the regulatory issues contributing to this problem.

Talk Doesn’t Pay

As explored in a post last week, the practice of medicine is rapidly changing in the United States from a cottage industry to one dominated by large hospital groups and corporations, but new the transition can be accompanied by a telling loss of intimacy between doctors and patients. And no specialty has suffered this loss more profoundly than psychiatry, as noted in this New York Times article.

The Times article highlights the practice of Dr. Donald Levin of Doyletown, Pennsylvania.  Trained as a traditional psychiatrist at Michael Reese Hospital, a sprawling Chicago medical center that has since closed, Dr. Levin, 68, first established a private practice in 1972, when talk therapy was in its heyday.

Then, like many psychiatrists, he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart. Then, he knew his patients’ inner lives better than he knew his wife’s; now, he often cannot remember their names. Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional.

Brief consultations have become common in psychiatry, said Dr. Steven S. Sharfstein, a former president of the American Psychiatric Association and the president and chief executive of Sheppard Pratt Health System, Maryland’s largest behavioral health system.

“It’s a practice that’s very reminiscent of primary care,” Dr. Sharfstein said. “They check up on people; they pull out the prescription pad; they order tests.” The switch from talk therapy to medications has swept psychiatric practices and hospitals.

Points to ponder and background for the transition:

  • Specifically, a 2005 government survey found that just 11 percent of psychiatrists provided talk therapy to all patients, a share that had been falling for years and has most likely fallen more since.
  • Insurance company reimbursement rates and policies frequently discourage talk therapy.
  • A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session.
  • Competition from psychologists and social workers — who unlike psychiatrists do not attend medical school, so frequently begin their practice with less education-related debt — is a reason that talk therapy is priced at a lower rate. There is no evidence that psychiatrists provide higher quality talk therapy than psychologists or social workers.

And the effect on the patients?

  • Recent studies suggest that talk therapy may be as good as or better than drugs in the treatment of depression, but fewer than half of depressed patients now get such therapy compared with the vast majority 20 years ago.

And are 15-minute sessions adequate for evaluating how well medications are working?  “I’m good at it,” Dr. Levin noted, “but there’s not a lot to master in medications. It’s like 2001: A Space Odyssey, where you had Hal the supercomputer juxtaposed with the ape with the bone. I feel like I’m the ape with the bone now.” Read more…