September 1, 2011 News

They never learn. Hospitals in the Los Angeles area continue to dump patients in skid row. Now it's the VA that is accused of patient dumping. The problem is the VA is a federal institution and the city has no jurisdiction to investigate the hospital records. This is the second time the hospital has been accused of patient dumping. The VA states the patient refused to be discharged even though he was medically fit for same.

The Wyoming Medical Center has just lost a huge amount of federal money due to a physician owned hospital opening nearby. Wyoming Medical lost its "sole provider" status. A hospital opened by neurosurgeons have past the required 8% of total patient days needed to strip Wyoming of its sole provider status.

St. John's Mercy Hospital in Missouri is seeing the error of their ways. They suspended the privileges of four Washington, Missouri cardiologists and are now backpedaling as fast as they can since the cardiology group is opening a small hospital a mile away from a hospital owned by St. John. They are looking for Mercy.

There are other hospitals in trouble with their medical staffs. Shands Hospital in Florida has had to close their transplant program after three of the four transplant surgeons abruptly left the hospital. They do not say why the surgeons left and each went to different location.

St. Peter's Hospital in St. Helena, Montana has severe problems with it's medical staff. First 75% of the medical staff gave a vote of no confidence to the CEO and 65% gave a similar vote to the hospital board. The reason for the no confidence votes were not disclosed. The board then voted to support the CEO and the medical staff voted to form a committee called "Patient's voice" which tells something about the no confidence vote and have that committee meet with the board. The hospital plans to add six new physicians in the fall but the physicians state they must do more for the community. Maybe a call to the IRS may help as that may remove their non profit status.

I wrote the following item in my last update and received the ensuing reply from a hospital administrator.

Salem Hospital in Oregon has a major problem with its medical staff. The hospital is lying to its staff regarding the hospitalist program. Salem hospital has 65 employed physicians and 434 total providers. In the past Salem Hospital refused to let the non-employed OBs provide back-up. That problem was resolved but they no longer do OB at the hospital, only gynecology. They then replaced the non employed physician in charge of the non-invasive vascular lab with an employed physician. Now the hospital has hospitalists. At first they refused to allow the non-employed physicians to sign out on a part time basis to the hospitalists. They finally allowed the partial sign out but are now charging the non-employed physicians money to sign out. They are lying when they tell their physicians that this is required by law. It is not. The other hospitals in not only the immediate area but across the country do not charge to sign out. In fairness, most hospitals depending on the size, do not allow partial sign outs to hospitalists. This does, as the hospital states, make staffing a problem as they do not know how many hospitalists need to be on duty at any one time. Salem may soon lose some of its physicians to other more physician friendly hospitals in the area or afar.

"I’m a regular reader of your column, because as a hospital administrator I appreciate getting both a legal and private physician viewpoint on some of the big things that are happening. On this particular news item above, I had a harder time reaching the same conclusion that the hospital was lying. I don’t know anything about this particular story or the hospital or even Oregon in general, but you’ve got to know that hospital attorneys and their general counsel are extremely conservative in their interpretation of the law. As a credit to your profession, most administrators are reluctant to take advice from general counsel as anything other than bright line guidance to avoid an orange jumpsuit, despite the fact that in many cases (the one above included), it’s gray area guidance. I can probably imagine that one of the attorneys working on contracts for other employed physicians noted that the hospitalists provide call coverage benefits for them, and providing the same benefit to private practice physicians constituted an un-reimbursed tangible benefit to the private practice docs.

Of course, it’s reasonable to assume that the administrators want to provide first dibs on the busy hospitalists to their employed physicians. But unless the hospital is in a battle to squeeze the competitors out of the market, it’s in their best interest to keep the private groups happy with hospitalists to keep them from admitting to competitors. If anything, I think this would be a good leadership case study to figure out what the heck they are doing, how they got there, and what someone would do from here.

Thanks for the bi-monthly education!"

Thank you for your comments. My problem is when hospital attorneys advise administrators that to do something is illegal when in fact it is not. There is no law that would force a physician to pay to sign out to the hospitalist. The information may be a policy decision but not a legal one. To me a good attorney looks for a way to do something and not say it is illegal just because it does not fit squarely into a niche.

Hospitalists are for the most part either paid by the hospital to take care of hospital patients and be able to reduce the LOS or are private practice physicians who may be the local physicians and then moonlight as hospitalists when they are not working in their practices or at night. In either case the hospitalist physician is paid either by the hospital as an employee or by billing the patient's insurance as any other specialist would do. One does not pay a specialist to whom you have referred a patient.

I might add that this region has had multiple problems with a tight thumb by hospital administrators on physicians.

After the above was received and replied to, the Lund Letter had an article about another physician at the same Salem Hospital. This is Dr. Elizabeth Harmon, an Ob/Gyn who had her midwives stolen by the hospital two days after she lost her OB privileges for unknown reasons (the hospital wanted her midwives). The hospital had threatened any physician from standing up for her since they had a disruptive policy that will not allow physicians to speak about the hospital. She brought in another Ob/Gyn to help her but the hospital would not give this well trained physician privileges but gave their own physicians privileges. This is a hospital that physicians should not consider practicing with. They are not to be trusted.

Reuters has a story about higher healthcare costs ahead for employers. They say that big business will pass some of that on to employees. It appears insurance costs will continue to move up at almost 7.5% per annum.

Cook County, the home of the dead people that elected John Kennedy President, can not get their act together medically. First they renamed Cook County Hospital for a political hack and now they continue their ineptitude by hiring multiple consultants at millions of dollars a year to attempt to bring down costs. Of course over half of the patients are uninsured and the hospital also gets minimal money from the county to run the hospital. The county hired Navigant Consulting, one of the known consulting companies for cutting people off the rolls. They did what they were hired to do. They closed Oak Forest Hospital, a convalescent hospital affiliated with Cook County and reduced inpatients at Providence Hospital, a hospital that went belly up years ago but since it was the only hospital in the area that would accept the poor, it was kept. This meant that 1300 people lost their jobs. The County has hired a CEO from a consulting company and hired another company that was paid by how much money it cut. It is easy to cut expenses if you get paid for how much you cut. Pricewaterhouse, the consultant, is doing the billing instead of the inhouse people. If the county thinks they can make money on this hospital with the clientele it serves, they are sadly mistaken.

HealthLeaders has an article about how to get physicians to lead in the hospital. It tells the truth. Physicians do not trust suits. What they do trust is data. Therefore do not lecture to them but allow them to have the data and they will bring the hospital and physicians into alignment. That alignment may be skewed toward the physician if that is what the data suggests. However, the data will lead. This is becoming more important as quality becomes the payment driver. Hospitals have to hire physicians as the Chief Medical officer and give them their head to lead the staff toward better quality outcomes. Suits can not do this as they have no medical background. As younger physicians come on board they will pay more attention to a suit who is also an MD than their predecessors did. I know I was one. I was told the first day in the hospital by the first physician I met to leave, that we don't want you here. When this occurs the position is doomed to failure.

The Center for Studying Health Care Change has put out a statement that hospitalists may lead to more expensive hospital care. The hospitals may push the hospitalists to order more expensive care. The hospitalists have found if they do more they make more. This is true of most hospital employed physicians as they can no longer coast on past performance. Now they have to do a certain number of RVUs or have their pay reduced. The hospitals can also hike revenue from insurers when they negotiate terms with an insurer. They also get more from Medicare when physicians practice not in their own office but a hospital based facility. That is a real joke as there is no difference as they are in their own private office that happens to be owned by the hospital.

Dr. Hetal Brahmbhatt, an IM faculty member at East Tennessee State University has resigned while under investigation for favoring Indian residents over others.

The Chicago Tribune had an oped wanting all the hospitals and physicians to get on board with the idea of placing Medicaid patients in HMOs. The state is attempting to place 1/2 of the population in these organizations. The problem comes because the state wants the ones with the serious mental and physical ailments to be the first enrolled. That is leading to physicians and hospitals stating they will not take less money and more red tape for taking care of sicker patients. Top

Obama is a Constitutional lawyer, therefore he realizes that the US Supreme Court usually follows precedent. It is for this reason that he states that the Court will declare the individual mandate legal. It is a reasonable argument but the Court defines what constitutes overreaching in terms of the Commerce Clause. I still thin it is a 5-4 decision with Kennedy the usual deciding vote.

Kaiser Health News reports that it might not be bad if the "super congress" does not come up with a solution and money is taken from Medicare. The 2% cut would be about $12 billion for Medicare. The reason is that the money would come only from providers and not benefits.

Remember when Rep. Joe Wilson shouted out "You Lie!" during Obama's State of the Union address. He now states that he has been vindicated. Obama was stating that no illegal immigrants would get health care under Obamacare. In fact, under Obamacare money is given to community healthcare centers that treat illegal immigrants among others. Part of the money given to the centers is earmarked for treatment of migrant and seasonal farm workers, which many are illegals. The government says we are just giving money as always. It depends on which side one is as to the truth.

The feds are still working on the failed pre-existing insurance program. They can not get people to sign up for the program even after dropping the premiums somewhat. The cost is still to high and the proviso that the person must be uninsured for six months is a high fence.

However, the states with the same program are doing better than the feds. Twenty-seven states have their own pre-existing condition program. Pennsylvania leads the way but only with 3000 enrollees. The feds had set aside $5 billion for the program and expected 200,000 to enroll. To date under 22,000 have done so. I received an email today with a cartoon of Maxine. It states truthfully that the feds took over a brothel in Nevada for tax problems and it also went bankrupt. How do we expect the feds to run a big program if they can not even run a brothel.

In an interesting story CMS states that four of the ten medical group participating in the Physician Group Practice Demonstration Project will get a total of $29.4 million. It does not state why only these four will get the payments but does state that all ten will continue on in the new project.

In yet another major gaffe in the HIPAA field, Southern California Medical-Legal Consultants had put on the web an unknown amount of names, medical information and social security numbers that was easily found. One person called it felony stupidity, a great term. The information was not password protected and was done by human error. There will continue to be these acts of random stupidity as long as there are people and electronic medical records interacting.

The people of the People's Republic of Massachusetts who utilized community clinics and safety net hospitals are continuing to use them. They are using them in greater numbers due to inability to get appointments at physician offices, convenience and cost. However, this has overwhelmed the centers and they need to hire more providers at higher costs.

A presidential panel released their findings of atrocities done to people by the US government in Guatemala during the 1940s.The medical "researchers" gave sexually transmitted diseases to people to see what would happen. They exposed 1300 people but only gave about 700 treatments.

In a chilling document published in the BMJ Quality and Safety it has been shown that chemo nurses get accidentally exposed to the drugs causing potential infertility, secondary cancers and neurological problems. As most chemo is now given outpatient there is no good way to track exposure.

An article by Dr. Kenneth Cohn who is also a MBA tells of seven reasons why physician hospital alignment is difficult. The first is that physicians are never trained in team projects. The second is that employment may be something like tenure for a professor. It does not mean the physician will be on board with the hospital ideas. One must show the physician how to work with the hospital to better the care of their patients. Third is meetings. Physicians hate meetings where they are there only to bless something and not actually for input. They want to be consulted prior to the deal being done. They are also not happy about being away from their patients and losing money when the hospital personnel are being paid. Fourth is a different outlook on problem solving. The physician takes in data and comes to a decision. The administrator takes in the same data and comes to several alternatives. Fifth is the different definitions of long term. To a physician long term means 48 hours. He recommends hospitals utilize physicians in several week increments and not long term ideas. Sixth is that hospitals need to make their expectation clear up front. Mayo and others utilize a compact the physician reads and signs prior to joining a staff. If the physician has problems with the compact they should look elsewhere to be happier. Seventh and last is that physician mentors are not or under utilized. Mentors help fellow physicians stay at the hospital longer and be more team players. Physicians are leery of top down edicts and do better with mentors. Top

Blue Cross of Missouri has a problem. The major medical group of physicians in an IPA has broken off negotiations with the insurer. The insurer is now attempting to get individual physicians of the IPA to sign. To date, with only a week to go, only 21 of the 120 physicians have signed up. Each practice has between 15% and 30% of it's patients insured by Blue Cross. If the physicians do not sign they will be considered out of network and seeing them will cost patients more money. It then becomes whether the patient will switch physicians or insurer.

The Kaiser Family Foundation has put out a list of the most expensive insurance in the country. To no one's surprise the People's republic of Massachusetts leads the way with Vermont close behind. The more government interference and mandates the more expensive the insurance. Top

In a slanted article in the new England Journal of Medicine the authors have looked at one med mal insurance company that has insureds in all states. It is correct in that only 20% of claims for med mal get any money paid out to the plaintiff. It also correctly claims that most physicians, especially any surgeon, will be sued at least once during their career. It claims that the average payout is between $200,000 and $300,000. This may be true for the country but it various tremendously not only by state but in some states by venue. If a state does not have a cap for non economic damages the payouts will be much higher than for states with the cap. The article does not say anything about the costs to defend not only in dollars but in anxiety for the physician and his or her family. 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.