What is true? Several articles have come out in the same journal regarding the states with malpractice caps. In Health Affairs two articles were published. The first was by a economics professor at Dartmouth believes that state oversight of premiums and investment practices of insurers are more important in the premium rises. He found that in 184,000 cases the premiums grew at the rate of inflation, about 4% per year. She and the co-authors relied on the NPDB for its information. The NPDB does not record payment due to hospitals negligence where no physician is involved. This was common with Kaiser where the physician was not usually named or withdrawn during arbitration settlements. The study also did not take into account the rising costs of defending the suits. That is not reported to the Bank either. In the second article it was shown that physicians don't believe the first study. They gravitate to states with noneconomic caps. In states that had no caps there was a 83% increase in physicians per 100,000 population as opposed to a growth of 86% in those states who started having caps in the 1970s and a 102% increase in those states that started their med mal caps in the 1980s. This was the only variable of significance. When one looks at the high risk OB physicians the increase is about 8% in those states without caps and 40% in those with caps. There is also a correlation between strict caps and growth of physicians.
In two articles in JAMA, the first showed that doctors, especially those with over 20 years experience, moved to states with med mal caps. The other study showed physicians are ordering more tests and referring out potentially risky patients to avoid med mal suits. Top
One of the things that is going on in the country presently is the shift from cardiac surgery to less invasive stents. There are records available in all states that cardiac surgery is on the decline since the advent of the stent and even more so with the new drug eluting stents. This has caused hospitals to begin to lose money. Hospitals made a significant amount of money on cardiac surgery, especially when the new techniques got the patients out is several days under the same DRG. Now the same is beginning to be true for the stents. The reocclusion rate is much less for the new stents and their costs are four times higher than the old stents. The hospitals can bill for only one procedure no matter how many stents are used. This may be a huge money losing proposition for hospitals. To make matters worse for the cardiac surgical programs, in the not so distant future there will be stents to fix heart valves as well. One of the things that I am beginning to see is the fewer cardiac surgical procedures are being shared by the same number of surgeons in the individual hospital. This is causing a greater look at the use of economic credentialing by the competitors. Those with the power are slowly getting rid of the possibly better trained but less political savvy younger surgeons. Top
In Boca Raton, Florida, the Community Hospital had significant problems finding physicians to cover their emergency room. That is, until they offered money. They still have some gaps in neurosurgery and oral surgery but have stemmed the tide of physicians dropping their hospital affiliations.
Eight emergency room physicians resigned from Yakima Medical Center in Washington over patient care concerns. The state is investigating the physician's claims. In the meantime, the hospital has replaced the eight with physicians from Emcare in Texas, the same outfit that lasted about a week in a hospital in Minnesota. The physician's concerns were all from the hospital's cutting of services and lab mistakes.
The patients of the People's Republic of Massachusetts are getting the type of care they wish for-minimal. The waits for appointments are up to six weeks due to a scarcity of physicians. The physicians train at the hospitals in Boston and then leave the state. The reason is the lack of med mal reform and lower reimbursement than other states. The people have their legislature to thank for this.
The AMA Board of Trustees has recommended that corporations be forbidden to directly employ physicians. This is the same as is currently in California and 14 other states. The hospitals still employ physicians but it is through the 501 (c) 3 loophole. Speaking of the AMA, as all knows they continue to lose membership and money. They are attempting to make up some of the money by taking away the free on line web page. What this actually does is remove people who are interested in the organization from getting information and makes the AMA message less likely to be heard. A penny wise and pound foolish move.
A study has shown that high risk patients in states that have mandatory physician public reporting are less likely to receive angioplasty than those patients in states where the information is not made public. The physicians do not want their percentages to decrease, so more patients do not get the opportunity to be treated optimally. If physicians will not treat the high risk patient due to messing up their average, what does that do to the statistics and more importantly to the patients? Top
My favorite non hospital is back to lead off. At the infamous Drew/King non hospital in LA a story came out that Dr. George Locke, former chair of neurosurgery before being forced out, received about $11,000 in free medical care at the hospital including two surgical procedures. This is the same person who exaggerated the hours he worked on his time cards. He quit the hospital after the scandal and has repaid the hospital for his free care. The hospital agreed to provide a neutral response to any inquiry in order to get rid of him. He was pulling in seven figures at the time. One of the LA supervisors is not happy with the deal and has asked the California Medical Board to investigate the physician.
Now comes the final straw. Navigant Consulting, the consultants paid to navigate this non hospital back to a hospital has been found to be padding their bills. They bill for five days per week on site but are not there. This is the same thing for which the physicians were accused. Navigant is attempting to prove they did the things they were supposed to do but that is taking time away from their job. Also, Navigant has not acted on about 1/3 of the urgent recommendations they made four months ago.
The moratorium on specialty hospitals is over. It is unlikely to return but it is doubtful if there will be a big splurge of new hospitals. Also watch for the mean spirited AHA to push for state actions to stop the proliferation of their monopoly of nonprofits, which are anything but. The CMS wants to just look at the specialty hospitals but they should look at all hospitals for the change in DRG. The best way is to change the DRGs for all hospitals. This will take the incentive for skimming away since the payment will be less. It will also be fair toward the "community" hospitals if they get the "easy" case.
However, physicians are continuing to purchase bankrupt hospitals and these may become specialty hospitals in the future. In Atlanta, a group of physicians has just purchased a defunct hospital and changed it from a non-profit to a for profit institution.
The GAO states that there will be an additional 26 specialty hospitals opening in the next year in 10 states. this includes some that are physician owned as well as hospital owned.
The VA boondoggle hospitals are back in the news. In Dallas, Texas, the VA which has been in trouble before is at it again. The fleas outnumber by far the medical and nursing staff. One patient has made serious allegations about the care and the article sounded like the hospital administration did not do any investigation or remedy of the situation.
At the LA Veterans Hospital the problems were in the ED. The hospital responded to the allegations of substandard care by hiring more ER physicians for the day shift. They still have substandard coverage during the nights.
Tufts Medical Center in Boston is having a hard time getting enough patients, so they bought them. The hospital purchased the assets of a large primary care group in the area that will now refer to Tufts. The purchase of 164 physicians in the southeast part of the state and their 500,000 patients should help the struggling hospital. The purchase price was not disclosed but it should be in the multimillion dollar range. Beth Israel Hospital will also continue to receive patients from the physicians since there is no requirement to send any percent to the Tufts.
In Ohio, a hospital group has also purchased a physician group in the Cincinnati area that they want to be completely integrated as the Mayo Clinic. Does anyone remember that the Mayo Clinic is owned by physicians?
The California hospitals are again stating the sky is falling. This time it is because of the way the state may distribute federal Medicaid money. The hospitals will be required to actually justify the amount of Medicaid treatments they provide to qualify for the $2 Billion in funds, a novel idea. The California Hospital Association wants to continue to just collect without the reporting. If the hospitals report, an additional $670 million would be available and the potential loss of $280 million in current funds would be protected.
Marin General, the only non Kaiser hospital in the peacock feather county, has been given another reprieve by the Feds. They have a month leave to get their ship in order. The hospital is managed by Sutter Health. Most of the problems are in the pharmaceutical areas. Top
A 80 year old woman with Lou Gehrig Disease entered Mass General five years ago with a request for aggressive care as long as she could enjoy her children. She died still on a ventilator and after enduring broken bones and the loss of all ability to communicate. The hospital had gone to the courts twice to remove the ventilator. The first time the daughter won and the second time no ruling was issued since there was an agreement between the parties to disconnect the tube no later than June 30. She had not left her room in the hospital in many years. All this happened without the interference of the press, Congress or Jesse Jackson.
There is currently a court fight in Texas over the treatment of a young teenager with advanced Hodgkin's Disease. The parents do not want blood transfusions unless it is from the mother whose blood is incompatible with the patient. They also do not want any more chemo or radiation. The state took over guardianship of the youngster as they have the right to do. The parents attempted to evade the authorities but were found and the children are now in foster homes. The mother was arrested for interfering with child custody and released. I am sorry to report the new tests show the teenager is no longer in remission and the parents are now willing to go ahead with the radiation therapy.
The autopsy on Terry Schiavo was released and it showed the brain half the size it should be and that if fed as her parents wished she would have died. It also showed no evidence of abuse. Top
In California, a Sacramento judge has again ruled against the Governor on the issue of the state's rigid nursing ratios. What this means is the hospitals will continue to use traveling nurses. These nurses go from hospital to hospital with set time contracts. They cost the hospital more money but are necessary since there are not enough regular nurses to fill the quotas. The company that supplies the nurses gets the money and pays the nurses their salaries and benefits as well as travel and subsidy costs. The problem is the nurses do not know the hospitals they are assigned to nor the culture that changes from place to place. They are not welcomed with open arms by the administrators that have to pay the big bucks for them nor the in-house nurses who see them as interlopers. Top
TennCare has received the blessing of the feds for the reduction of drug benefits and service cuts. This means that potentially 96,000 of the contemplated 360,000 people that were to be removed from TennCare may be able to stay. The approval allows the state to limit prescription drugs to three generic and two brand name drugs per month with prior approval for any drug not on the formulary. The state has won all court challenges by the opposition at the appeals level. The same judge who has been overruled several times will hear the latest challenge at the end of the month. 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.