 | Mother's Maiden Name |
| Terrible MRI Accident |
| Pennsylvania Nurse Contest |
| Kaiser to Pay Nurses More |
| Nursing Programs |
| EMTALA Continues |
| CMA Report Again |
| Health Insurance |
| Managed Care Continues its Fall |
| Correction? |
| Quality of Care Measure |
| Hospitals |
| IOM Report in Error? |
| Malpractice |
| Rising Costs=Good Medicine? |
| Boutique Medicine |
| Pharmaceuticals |
All of us have been asked this question. The problem is the answer is public. I belong to several LISTSERVS and one of the participants showed us a site where one can, for a small fee, find all the information about who was born and who died in California since 1905. I checked out the free part of the site and within seconds pulled up my father's name, county of death and SSN. The birth section had the mother's and father's name, date of birth and where born. The site for a payment will also tell you what the FBI has on you. Another participant wrote that he was a telemarketer in his young days. When he spoke to anyone, the telemarketing organization had the person's SSN number on their screen. He also stated that on another website he found his name, all his addresses and phone numbers for the past 12 years. They even had him associated with close relatives in four other states. Since he was a veteran, he went to another site and again found the information on he and his friends. All your health information is in a registry in Massachusetts. Don't ever think you are a private person with private information. You're not. Since we can not do anything about the collection, hopefully we can do something about the use and abuse of the information. Top
A six year old boy was killed while undergoing an MRI. Someone inadvertently left a metal oxygen tank in the room. The metal tank was pulled like a rocket to the magnet and crushed the boy's skull. PLEASE MAKE SURE THIS DOESN'T HAPPEN IN YOUR MRI. CHECK AND DOUBLE CHECK THE PATIENT AND THE ROOM FOR ANY METAL OBJECTS. Top
Pennsylvania hospitals and nursing organizations are holding a contest for the best essays on why nurses would go into nursing again. The purpose is to collect and distribute the stories to entice others into the field. The essays are to be about the most memorable moments and professional rewards of their careers. So far there are no entrants. Just kidding. Top
Kaiser has announced a substantial increase in nurses pay. The RN wage will increase 14% over the next year. The problem is they are still below parity with their competitors, which were 17% above Kaiser. As nurses become more scarce the rule of supply and demand takes hold quickly and Kaiser has hundreds of nursing positions to fill. These positions are now filled with the more expensive temporary employees. The nurses union is happy but still want at least parity and of course better working conditions.
The Sacramento hospitals believe that new regulation dictating nursing ratios may cost up to $2.8 million per hospital per year. This figure is from the Policy Institute of California. The union wants 1:3 ratio for post-operative med/surg units while the hospitals want 1:10 ratio. The nurses union states the cost would be offset by a reduction of shifts covered by temporary, part-time or overtime nurses.
Sunrise Hospital in Los Vegas has fired two nurses for refusing to work a shift. The story states that the nurses refused when one nurse of the five scheduled called in sick. They apparently left prior to finding out there was a replacement nurse coming in. Two night nurses had to work overtime to cover the nurse's shift. The nurses are now attempting to get their jobs back by the use of union rallies and talk that they did this for patient care. If they did it for patient care they should have stayed. Having people work overtime is not the safest thing as all nurses know. Now, we all know we can not believe what we read in a paper, on-line or what unions or hospitals say. The real issue is what does the contract between the hospital and the union state. Nothing else matters. Top
If nursing societies are continuing in their pledge to only use nurses with a college degree, an accelerated course of one year will do that. The St. Louis School of Nursing has been doing this for 30 years. There are now 72 total-immersion programs in the United States. These are usually college graduates from other lines of work who wish to transfer into nursing and not spend five years doing it.
In another tact to attract nurses Abington, Pennsylvania Memorial Hospital School of Nursing is giving free rides for students. The perks include child-care, flex scheduling, starting salary of $41,000 and a sign-on bonus of $3000. The school has a $20 million campaign to recruit and retain nurses. So far the school has attracted 48 new students ( they graduated 12 last year). It is a 2 year school with a base requirement of one year of college. At another Pennsylvania System, Main Line Health is giving bonuses up to $25,000 over three years
A story from Jacksonville, Florida tells of businesses going overseas to get nurses. The major drawback is the paperwork which takes at least two years. One Jacksonville hospital is expecting 48 Filipino nurses next spring. The nurses must pass English competency tests, a national credentialing test and approval of the Florida Board of Nursing plus all the immigration red tape.
The GAO in no surprise has found a growing shortage of nurses in the United States. They say in typical bureaucratic terms that more detailed data is needed to assist in planning and targeting corrective efforts. The report can be found on http://www.gao.gov under Today's Report.
Kaiser is planning to back the nurses request for 1:4 staffing versus the current 1:10 standard. They believe it could cost the organization between $120-$200 million yearly. Kaiser believe it would take up to five years to reach that level. This stance is opposed to it's 1999 memo stating "There is no research conducted on the effect of ratios on patient outcomes." The militant CNA is afraid that to reach the goal, Kaiser will use LVNs instead of RNs.
In Cincinnati the adult education nursing program is to be cut. The Board of Education has a mandate to continue the program but the school says it will delete it to focus the money on the district's 42,600 students. The program is for LPNs and nurse's aides. The program was $300,000 in the red and had a 60% drop out rate. The LPN tuition is $6,856 per student for 45 weeks.
In New Jersey there is a requirement that all home health aides undergo background checks by the police and FBI. So far about half have passed. The other half are still being checked. There have been 421 people that failed and are not allowed to work alone in the home with patients. The 421 either had lied on their application or had felonies in the past. Top
Ralph Nader's Public Citizen has announced with great fanfare that from 1997 to 1999 there have been 527 hospitals in 46 states have been cited for EMTALA violations. The report does not state the reasons for the violations but many are asking for insurance information before or during a medical screening examination which may delay the screening. This is a violation of the law. Hospitals respond by stating the amount of violations is obviously an infinitesimal percent of the total amount of people seen in the emergency department each year. They also state that hospitals do not admit or turn away patients, physicians do. Some local papers across the country are detailing the cases in their areas. The major reasons given in the stories are non-admission for a life threatening condition, failure to find specialists to treat the patient, non-stabilization and screening issues.
Florida is having a meeting of the hospital executives to help to determine how to have more physicians be on the on-call panel and see patients in the ED. Hospitals are having difficulty with hard to recruit specialists taking back-up for less than life saving situations. Among the proposals are to follow the California lead of paying physicians to be on call. Another proposal is to make ED backup a condition of licensure. The hospitals can't do this of course. That is a State function but it would be cheaper for the hospitals. They may also lose their hard to recruit specialists to other states with the same humidity and mosquitoes. One doctor who was dropped from United Health has refused to see any person in the ED with that plan. Top
Although I usually am friendly toward the state medical societies, the California Medical Society continues to come out with the same report stating physicians are leaving the state due to managed care. Indeed some may but the amount of physicians in the state have risen according to the Medical Board of California. The University of California-San Francisco study also found an increase in the amount of physicians practicing in the state. There is no question that it is more difficult to open your own office due to managed care, but I have sold four practices since the first of the year in a small area to new physicians either moving to the state or physicians moving from other parts of the state. One of the main problems in the area is the cost of living and the inability to attract new physicians with large medical school debt to the area.
In fairness to the CMA there was just an article showing the number of physicians in Sonoma County has hit its lowest point in 20 years. This is not surprising since this encompasses the area next to the Napa Valley, which is a very expensive to live. The study by the Sonoma County Medical Association showed 813 of 1300 physicians were in active practice. This is a ratio of 177 per 100,000 residents. Five years ago it was 216. Twenty years ago, when it was a sleepy area, it was 173. The major drops were in FP, radiology, psychiatry, ENT and ED.
In a study by the AHRQ it was found to everyone's surprise that physician satisfaction with their professional lives has declined substantially in the past 15 years. This study was actually funded by Robert Wood Johnson Foundation. What a waste of money.
Another study, this in the People's Republic of Massachusetts, has shown the doctors in private practice have seen a decrease of $20,000 in the past eight years. The New England area has the lowest median income for physicians in the country. The cost of their malpractice insurance during the same time has risen 35%. It also showed the average age of the physician is older meaning the young physicians are leaving. They're smart. Even the applications to the medical schools have dropped 5000 in the past 4 years. The study is critical of the MCOs but do not discuss the political climate in the state. In a bright statement by Dr. Sam Ho the medical director of PacifiCare Health when asked about the situation "We know so many physicians that really appreciate the fact that their patients have affordable health care." Now I understand why their stock is doing the header. Top
In an ironic note the Milwaukee county Medical Society can no longer afford medical insurance for its five employees. Currently it pays $50,000 per year. In order to try to reduce the cost they are merging the employees with the 64 employee state medical society. The lease back arrangement would hopefully reduce the premiums by about 50%. The insurance reduction would be passed on to the members by lowering the dues to attempt to lure new members into the organization.
Stanford is transferring its graduate students with dependents out of the HMO system and into PPOs. This will affect about 250 students and may cost an additional 60%. The remainder of the graduate students without dependents are already in PPOs and are not affected. Originally Stanford told their students that they may qualify and how to apply for Medicaid. Now, they are giving aid to the students to pay for the higher costs of the PPO.
Aetna has taken Stanford at its word and pulled its HMO. As of the time of this newsletter Aetna will have transferred all 3,500 members to other medical groups in the area. Top
Managed Care Continues its Fall
Managed care, as defined by HMO capitation payments, continue to fold across the country. In the latest blow Aetna has gotten out of the HMO business in several areas from Georgia. They will stay in the discounted fee for service PPO arena. The spiral is when a company pulls out there will be increases in costs to the employer. The employer passes those costs on to their employees, not their customers if they want to stay competitive. As the employee costs rise the HMO restrictive policies become equal in cost to less restrictive PPO policies and people again switch, causing more HMOs to drop.
Minnesota for the past 10 years believed that only a few health care companies were better than many smaller ones. There were four systems: Allina, Blue Cross and Shield, Fairview and HealthPartners. These systems insure 90% of the population and own most of the state hospitals and clinics, with a huge amount of power. But, alas, healthcare costs are rising in Minnesota twice as fast as the rest of the country. The costs, once well below the national average, are now at the average. Other insurers are kept out of the market since they can not get hospital contracts. Also, the law states that only non-profit companies to operate HMOs. There is also a large potential for conflicts where an HMO will give higher rates to hospitals they own and give lower rates to competing hospitals.
Medical Select Management, an IPA in Dallas, Texas owes about $40 million to its physicians. There are about 1700 physicians in the IPA. The IPA contracts with Aetna, US Healthcare and PacifiCare. The former two stated they will pay physicians directly for all services after July 1, 2001. The state is combing the books due to misstating its financial information.
In yet another Texas city, Quantum Southwest Medical Associates has filed for Chapter 11 bankruptcy. This is an organization of 40 primary care physicians in 18 locations in and around San Antonio. The company has assets of $15 million and debts of $27 million. Try making that up on volume! The CEO said something profound "health care cost is really going up, but reimbursements haven't." Several hospitals stopped taking Quantum's patients in January due to non-payment of debts.
Texas has yet another medical group, the Heritage Southwest Medical Group in Dallas, in trouble. It has been put under scrutiny by the Texas Department of Insurance. This is for not making timely payments. PacifiCare has begun to bypass Heritage and pay the physicians directly for care. Blue Cross and Shield have terminated their contract with Heritage.
Texas has a another bankrupt Chapter 7 IPA. This is the Corpus Christi Network of Physicians. This was the last of the Corpus Christi IPA. All the others had gone out of business earlier. The IPA owed $1.2million to the physicians who will now receive zero. The article states that of the two Dallas IPAs one is in bankruptcy and the other is under State management (see above). The physicians will now have to negotiate their own contracts.
Not to be outdone, The University of Texas Medical Branch at Galveston is eliminating 150 jobs from its own HMO since the HMO is slowly going under the Gulf of Mexico. The university has discontinued four of eight contracts that are non-profitable. The main contracts they are keeping are a Medicare and a pediatric contract. They are even dumping their own employees as Humana will be the only HMO game in town.
Some go out as other enter. Buffalo, New York physicians of two large medical group have combined into an IPA for contract negotiations. The IPA will be 215 physicians. The physicians believe, as others before them, that size does matter. They think they can raise reimbursements and decrease operational expenses. The other IPAs in the area are mostly affiliated with hospitals or HMOs, two other wonderful partners.
A large California medical group made up of three IPAs are dropping Health Net in October. The contract covers 35,000 people. Negotiations have been going on for the past six months. The IPAs hope the patients will choose another plan and Health Net hopes that the doctors will cave. My bet is Health Net will cave and there will be a contract, since they will be left out of a populous area of California's Ventura County.
Health Net isn't doing well in Orange County either. They announced they will not renew their contract with St. Joseph Health System. The problem occurred when Bristol Park Medical Group left St. Joseph to form its own independent operation. Bristol had 40% of the St. Joseph network physicians. Health Net will now seek a contract with Bristol Park directly.
Maxicare, the bankrupt HMO, has pulled its Medicare+Choice plan from Los Angeles and Orange County after trying unsuccessfully to sell the business. It ended its Riverside and San Bernadino programs last year. It should just go away and like Charlie on the MTA, never return.
Matrix, the financially troubled IPA in Fresno, is not financially troubled any more. It is now in bankruptcy. It had its only contract indirectly pulled earlier this year by PacifiCare. Matrix is of course suing PacifiCare but it was the financial situation of Matrix that led to the pulling of the contract. PacifiCare is suing Matrix for overpayments.
The largest pediatric group in Santa Rosa, California has dropped all HMO contracts due to low payments. They state they lose between $10 and $50 on each patient seen. The HMOs state they have enough pediatricians to provide care without switching patients to PPOs. That may be true today but what happens when more get spine transplants and stand up for their rights.
In Savannah, Georgia a large group that accounted for 23% of the Business Group medical visits dropped the contract. The business group was paying too little. The medical group stated they were being paid less for immunizations than they paid for the drug. Another example of physicians finally standing up and saying "no".
Medicaid in Carolina is to stop payments for three months due to lack of funds. The Raleigh Journal reported that the hospitals said OK, we'll wait and not reduce services. There was no report regarding the physicians continuing to provide care during the three months. Medicaid will get more State funding and increased premiums in October.
Blue Shield has been negotiating with three hospitals in San Jose, California and has been unable to come up with a solution. The contact ended July1 and the hospitals San Jose Medical Center, Regional Medical Center of San Jose and Good Samaritan have been notified that they have been terminated. Patients have been told to go to O'Connor Hospital in San Jose, Los Gatos Community Hospital or St. Louise in Gilroy. These three hospitals are not convenient to the San Jose residents affected. The patients affected number about 75,000 and the affected hospitals account for about 40% of the San Jose hospital beds. Blue Shield has notified their subscribers to contact their physicians as to whether they may still deliver their babies or need a different hospital and OB. If patients had a procedure scheduled after July 1 or ongoing treatment they need to call their physicians to determine whether their care would be covered. Blue Shield also had attempted to shift patients from the San Jose Medical Group for financial instability but were not allowed to do that by the State Department of Managed Care.
In Chicago, Advocate Health Care the area's biggest healthcare provider and United Healthcare are stating they will break off relations (that sounds sexual). Of course, it is a negotiating ploy. They have to October 1 to get it together and even longer if they want. Now it is the time for the scare tactics and to remind people why they should not be in these plans to begin with. Last year United lost the contract with Rush and four affiliated hospitals. If they lose this contract they still have 100 hospitals and 15,000 physicians under contract.
Blue Cross has cancelled all HMO contracts in Napa County. The only IPA there went broke and there's nobody left to contract with Blue Cross. Now its PPO time. Blue Cross is also dropping its HMO in Tehama and Shasta Counties since the IPA there is closing shop.
In Cincinnati the anesthesiologists are leaving for greener pastures. The hospitals have had to hire temporary anesthesiologists for their patients. There is increased delays in elective surgery which leads to less surgery, less hospital income and less surgeons willing to come to town. Children's Hospital (the second busiest pediatric hospital in the country) has doubled its nurse anesthetists to help alleviate the problem. Cincinnati has a low pay scale for physicians. Maybe the answer is either to increase the pay scale or to eliminate paid positions and let the physicians be independent contractors, as in other parts of the country. This means the hospitals lose control and therefore that won't happen.
Dynamis Healthcare has released its midyear report on hospital closures. Last year a total of 20 hospitals closed at midyear. This year the number is 24. Ohio leads the nation with four closures in the first half of the year. The majority were non-profit and urban. Dynamis sees a trend that hospitals are attempting to semi close and "right size" themselves into viable if smaller entities. Top
In a Wall Street Journal article it was shown how the rise in money to treat heart attack patients has risen $12,000 from 1984 to 1998. That significant rise due to the increased use of available technology such as surgery and cardiac intervention was translated into slightly over one year longer post MI. Is one year worth $1000 per month or $33 per day. I think so. The same increased spending was not found to be true in breast cancer where the cost is up $25,000 in the same time period but the average increase in life was only four months. This is equivalent to about $208 per day. The article does not mention the quality of life. Top
I received an email correction to a story from the July 15 Recent News. I will reprint the article, the correction email and my response.
Connecticut Hospital Deal Worries Women
Hartford's St. Francis Hospital is planning on purchasing Essent Healthcare. The problem is the recent Catholic Bishop pronouncement that will forbid any sterilization or abortion procedures at Catholic hospitals. This is not usually a problem for vasectomies or abortions since they are not done in hospitals but in clinics or offices. It does effect the ability of women to obtain tubal ligations since they are many times performed post delivery. In a public meeting Essent representatives stated there would be no curtailment but a spokesperson for St. Francis would not comment, except to say that if the merger/sale does not go through there will be no hospital to worry about.
The VP of Business Development at Sharon Hospital responded by stating "St. Francis is not buying Essent. Essent Healthcare is purchasing Sharon Hospital. Essent Healthcare is exploring a tertiary relationship with St. Francis on behalf of Sharon Hospital."
My response was "I apologize if the facts of who is buying who is in error. The gist of the story is the Bishops rule and the women lose." Top
Blue Cross has decided to give bonuses based on satisfaction. What happens if other insurers do the same thing but with competing standards. What is the standard of patient satisfaction? The other healthcare insurers have had quality measures including patient satisfaction in place for years. Some say there is no bonus for the good patient satisfaction but with improved satisfaction comes more patients and therefore more money. Of course, the plans call in customer or consumer satisfaction and not patient satisfaction. Maybe if they change the words back to patient, and treat them as the same, they wouldn't have to worry about this type of bonus. Top
Alta Bates Summit Hospital in Berkeley and Oakland California, a Sutter affiliate, is laying off 300 employees ( about 8% of the workforce) due to financial considerations. No cuts will be in the nursing staff. The hospitals have hired the famous or infamous Hunter Group to help right the sinking ship. They seem to get a lot of business from Sutter hospitals.
The East Bay Business Times talked about the East Bay hospitals and their JCAHO scores. They showed that most East Bay hospitals scored well below the national average. Eden Hospital, Doctor's Hospital, St. Rose, Mt. Diablo and John Muir Hospitals all scored higher than the 92.39 average. Alta Bates, three Kaiser hospitals, and Washington Hospital all scored in the 80s. The laggard was Summit with 77. They didn't mention the newest Sutter affiliate St. Luke's Hospital in San Francisco's last score of 72, the lowest I have ever heard of. The JCAHO states one should not focus on the score but the accreditation. Tell that to the hospitals. The article did not discuss the alternatives to JCAHO accreditation, the costs in terms of manpower and actual money for consultants, etc. There are other organizations that can accredit with much less cost and the same result. I believe those hospitals with the high scores probably do not need to be accredited since they utilize quality into their everyday practices. The others need the tri-annual inspections since they are only in compliance with standards if they have to be. Top
The IOM report stated two years ago that about 100,000 hospital patients die each year from medical errors. No confirmation of the numbers have been done until now. The AMA has come out with its own numbers and while they are still unacceptable, they are a little more reasonable. They state the number is between 5000 to 15,000 per year. The researcher's comment about the IOM report is to be careful what you implement since the cost may not be justified. The recent studies agreed in gross percentage with the IOM study, that 22% of deaths might have been preventable and 6% were probably or definitely preventable. The difference is that in almost all cases where a reviewer thought there was a error caused death, the group did not agree. The new study also showed that if care would have been optimal that only 0.5% of patients would have lived over 3 months. The study may be found in JAMA. Top
Several months ago I published several postings on the problem of malpractice insurance in West Virginia. Now the Governor has written to all the state's physicians that if they feel they are being gouged by their companies, they should go with the companies in the surrounding states. The Insurance Commissioner has convinced the largest insurer in the state to back off its threat to re-write all its policies since it was charging four times the legal rate for coverage. The newspaper states that only a small percentage of W. Virginia physicians have been sued for malpractice and, as in most states, the physicians win the vast majority of cases. The paper did not address the toll of money these suits cost and more importantly the toll on the life of the person affected. Top
Starting several years ago in the Northwest, the boutique medicine business got its start. This is payment for care by the patient to the physician. This is not payment by a consumer via a health plan to a provider. This has evolved into a company in Florida charging $1500 for care like it was given prior to health insurance mandates by the government and insurers. The patient will be seen at a time convenient for them, for as much time as necessary, to get one day service on lab tests and personalized service if hospitalized. Another article talks about the prestigious California Hill Medical IPA and Palo Alto Clinic doing the same thing. This would entail a separate corporation for Hill since it is an IPA and must only accept the money paid by the insurers. The CEO believes the idea has merit since there are many physicians wanting out of managed care and many wealthy people in the areas serviced by Hill.
Some people think this is immoral. These same people believe all should drive the same car no matter what you are willing to pay. It goes to the question, "Is healthcare a privilege or a right?". The moralistic answer is different for different people. The legal aspect is whether or not a provider can charge above Medicare prices. This answer is also in the eye of the beholder, but probably it is legal. The patients who pay the money are happy. The physician is happy. The insurer pays no more than they would have in any case. The extra money is for non-covered items such as preventative care. This has been done for many years by hospitals who advertise and encourage wealthy non-citizens to come to their institutions for their medical care. They charge and receive well above Medicare prices. Of course, these people are not covered by Medicare so they may not be in the same kettle, but that will be decided at a future date by the courts or Congress. Top
The People's Republic of Massachusetts is now attempting to get into the discount pharmaceutical buying business. This would have all the State agencies working together to negotiate drug pricing. This untested theory was passed by the legislature twice but the prior Governor refused to put it in. The new Acting Governor will consider this as a money saving venture. The problems are the State now has multi-year contracts for drug purchasing and there are already pharmaceutical benefit managers in place to negotiate for multiple clients. This program may also be counter to the Republic's Prescription Advantage program which charges a monthly premium to get discount drugs. If those seniors that are healthy opt for the new program without monthly premiums it may spell disaster for the Advantage program. 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.