Grand Rounds XL

Grand Rounds XL are at the Health Business Blog this week.

Where’s master?

Studying

OOPS

A Costly Out-of-Network Surprise | WSJ | 6.24.05

What Happens When Your Hospital Is In-Network, But the Anesthesiologist Isn’t?

When Tom DiBari and his wife took their infant son, Jackson, for heart surgery in January, they had checked that both the hospital and the surgeon were in their insurance company’s network. So how did they end up getting billed for nearly $15,000 in charges for out-of-network care?

It turns out that during Jackson’s eight-hour surgery at Morgan Stanley Children’s Hospital of NewYork-Presbyterian, a second surgeon was brought in who wasn’t part of the network that’s maintained by the family’s insurance company, Aetna Inc. The family was charged for almost all of that second surgeon’s $15,000 bill, Mr. DiBari says. Aetna has agreed to pay 10%, says Mr. DiBari, who says he plans to appeal the insurer’s decision. (Citing patient-privacy regulations, Aetna declined to comment on the specifics of the situation.)

For people with health insurance who expect that their major health costs will be covered, out-of-network doctor bills from hospital visits can prove a costly surprise.

This issue occurs at many hospitals, and with many insurers. Often, the out-of-network physician is somebody such as an anesthesiologist or radiologist, who helps with a patient’s care but isn’t the main doctor in charge, say insurers and hospitals.…

OOPS = out-of-pocket services = out-of-plan-services

A good article about a very common problem. In an emergency setting the OOPS provider will usually be covered, and if not an emergency setting dealing with the OOPS provider prospectively with the payer may alleviate or lessen any problems. There are many situations where the service is unique or the number of in-plan providers is very small or singular at a particular hospital—the payers should take that into account on appeal.

Less Harm, Fewer Lawsuits

Once Seen as Risky, One Group of Doctors Changes Its Ways | WSJ | 5.21.05

Anesthesiologists Now Offer Model of How to Improve Safety, Lower Premiums Surgeons Are Following Suit

Anesthesiologists pay less for malpractice insurance today, in constant dollars, than they did 20 years ago. That’s mainly because some anesthesiologists chose a path many doctors in other specialties did not. Rather than pushing for laws that would protect them against patient lawsuits, these anesthesiologists focused on improving patient safety. Their theory: Less harm to patients would mean fewer lawsuits.

Over the past two decades, anesthesiologists have advocated the use of devices that alert doctors to potentially fatal problems in the operating room. They have helped develop computerized mannequins that simulate real-life surgical crises. And they have pressed for procedures that protect unconscious patients from potential carbon-monoxide poisoning.

All this has helped save lives. Over the past two decades, patient deaths due to anesthesia have declined to one death per 200,000 to 300,000 cases from one for every 5,000 cases, according to studies compiled by the Institute of Medicine, an arm of the National Academies, a leading scientific advisory body.

Malpractice payments involving the nation’s 30,000 anesthesiologists are down, too, and anesthesiologists typically pay some of the smallest malpractice premiums around. That’s a huge change from when they were considered among the riskiest doctors to insure. Nationwide, the average annual premium for anesthesiologists is less than $21,000, according to a survey by the American Society of Anesthesiologists. An obstetrician might pay 10 times that amount, Medical Liability Monitor, an industry newsletter, reports.…

A 1999 report by the Institute of Medicine noted that “few professional societies or groups have demonstrated a visible commitment to reducing errors in health care and improving patient safety.” It identified one exception: anesthesiologists.

“If there were any specialty where you said, ‘Show me who has done anything right,’ I would point to the anesthesiologists,” says Neil Kochenour, medical director at the University of Utah Hospitals and Clinics. “They have really made some inroads and some impact.”

Medical errors are a leading cause of death in the U.S., killing between 44,000 and 98,000 Americans each year, according to various studies.…

In part by analyzing claims, the anesthesiologists were able to document the extent to which patients were dying because of a simple mistake: Anesthesiologists were inserting the patient’s breathing tube down the wrong pipe. Rather than putting it down the trachea, which leads to the lungs, they were accidentally inserting it down the esophagus, which leads to the stomach. The problem was, there was no way to determine quickly whether the tube was in the right pipe. Patients often simply turned blue or their blood turned dark. By then, it was usually too late to save them.…

Failing to adhere to ASA recommendations can expose hospitals to malpractice liability. By 1990, says Dr. Pierce, almost all American hospitals had pulse oximeters and capnographs.…

Other specialties have noticed how the anesthesiologists have fared. Dr. Griffen of the College of Surgeons says that more surgeons have begun to see a connection between improving patient safety and lowering malpractice premiums. The college’s closed-claims study so far involves about 350 cases, and the group hopes it will grow to 500 this year.…

With what the ASA has accomplished it is hard to make any arguments about premium reduction without similar purposeful quality awareness and interventions. Kudos ASA.

Diva Scores

Regulators Fine Kaiser Unit $200,000 | LAT | 6.21.05

The state imposes the penalty for breaching patient confidentiality in exposing health records on the Web.

State regulators Monday fined a division of Kaiser Permanente $200,000 for exposing on the Internet the confidential health records of about 150 patients for as long as four years.

The nation’s largest nonprofit health insurer began a test program to make medical records of some of its members available electronically to physicians, and to give members access to their own records over the Internet.

But the Kaiser website in 1999 included confidential patient information, such as addresses, phone numbers and lab tests, that was available for public viewing. Oakland-based Kaiser did not remove the site until it was brought to the attention of federal authorities in January 2005, according to the California Department of Managed Health Care.

And Kaiser told patients about the medical records just three months ago, after it was reported in the media, the state said.

“Not only was this a grave security breach, Kaiser did not actively work to protect patients until after they had been caught,” said Cindy Ehnes, director of the state agency. “We’re imposing this fine because we consider this act to be irresponsible and negligent at the expense of members’ privacy and piece of mind.”…

A former Kaiser Web coordinator, Elisa D. Cooper, 35, first brought the security breach to the public’s attention by posting links to the site on her blog. The Berkeley resident then notified civil rights authorities. Kaiser then sued her, accusing her of invasion of privacy and breaking a confidentiality agreement; that suit is still pending in Alameda County Superior Court. Cooper was let go by Kaiser in 2003.…

See Diva’s saga here.

If “MasterCard International reported…more than 40 million credit card accounts of all brands might have been exposed to fraud through a computer security breach at a payment processing company…[.]” MasterCard Says 40 Million Files Put at Risk, New York Times, June 18, 2005. What do you imagine the security breaches from healthcare will be? More or less? Compare the IT and security infrastructures between the banking and credit industries with healthcare. We should be very scared!

TEQ

The e-Health Revolution | Time | 6.20.05

It’s medicine that the health-care system needs desperately. Backed by the Bush Administration, prodded by employers and under pressure to contain costs and improve service, the medical community is finally–and rapidly–plugging into the new world of electronic health records, in which your personal health information shows up wherever you do–at your doctor’s office, the emergency room, the MRI machine, even your home. “Resistance is at an all-time low,” says Neal Patterson, CEO of Cerner, an e-health company based in Kansas City, Mo. Cerner and Allscripts are racking up quarter after quarter of double-digit sales growth.

Underscoring the new urgency to shift to e-health was the joint press conference held in Washington last week by Senators Hillary Clinton and Bill Frist, two potential presidential candidates who otherwise rarely get near enough to pass a communicable disease. They’ve got together, however, to introduce legislation that would provide seed money for local health networks and eliminate the biggest hurdle to beaming medical records to where they are needed: the lack of interoperability among the myriad systems now in use. Medical record keeping in the U.S. is in the “Dark Ages,” Clinton complained. “We need to have the information easily accessible.”

The U.S. government is leading this charge into the medical information age–robustly and, by most accounts, effectively–because it pays 46% of the nation’s medical bills. Dr. Mark McClellan, former head of the FDA and now director of the Centers for Medicare and Medicaid Services, is making paperless medicine mandatory for physicians who want to participate in the agency’s potentially remunerative pay-for-performance scheme.…

The bottom line is that better health care may not happen in the U.S. without better health-care information technology. Sooner or later all of us will probably be carrying around our medical history in a key-ring device or an ATM-type card or maybe even a surgically implanted chip. The benefits could be extraordinary. IBM sees opportunities to apply massive computing power to help doctors make diagnoses and treatment decisions. New standard practices could be communicated to doctors within months rather than 15 years, the current lag between discovery and practice. Pharmaceutical companies with access to anonymous health data could improve and speed up drug development. There may even be a buck or two in it for consumers from what has been called information liquidity: If you want access to my data, pay me. Best of all, we could finally throw away those damned clipboards.

Clinton press release

Frist press release (PDF)

The Health TEQ Act
Section by Section Summary
June 16, 2005

Part I — Health Information Technology Infrastructure Development

Section 1 — Establishment of National Coordinator; Recommendation, Adoption and Implementation of Health Information Electronic Exchange Standards

This section creates a new title within the Public Health Service Act (PHSA) for the coordination and oversight of health information technology activities at the Department of Health and Human Services (HHS). It establishes, in statute, the Office of the National Coordinator of Health Information Technology (ONCHIT), which was announced by the Administration in April 2004. Among other duties, the National Coordinator is directed to carry out a range of activities to help develop a nationwide interoperable health information technology infrastructure that reduces health care costs, improves quality, facilitates health care research and the reporting of public health information, and ensures that patient health information is secure and protected.

This section also establishes a collaborative public-private process for the recommendation and adoption of standards for the electronic exchange of health information in conjunction with the National Institute for Standards and Technology (NIST).

It also directs the Secretary of Health and Human Services (Secretary) and ONCHIT to designate a private entity or entities that will certify and assist with the implementation of both mandatory public and voluntary private standards. This section of the legislation also ensures that the Secretary and ONCHIT coordinate spending across agencies of the federal government, including HHS, to facilitate the electronic exchange of health information.

Section 2 — Encouraging Secure Exchange of Health Information Among States

This section directs the Secretary to conduct a study of privacy laws and practices to determine how the variation among such state laws and practices may impact the electronic exchange of health information among states, between states and the federal government, and among private entities. Based on the findings of the study, the Secretary is required to make recommendations on harmonizing state laws to promote the secure electronic exchange of health information nationwide. It also authorizes the Secretary to award grants to states to develop and implement policies that will facilitate the electronic exchange of health information with a priority in awarding grants to reducing barriers related to privacy, confidentiality, and the security of health information.

This section of the legislation also directs the Secretary to conduct a study of laws relating to licensure of medical professionals and how the variation of state licensure laws may impact the electronic exchange of health information. It also reauthorizes Section 330L(b) of the PHSA to continue grants to states to develop and modify licensure laws to address remote treatment utilizing health information that is exchanged electronically. Finally, this section clarifies that the privacy, confidentiality and security protections included in the Health Insurance Portability and Accountability Act of 1996 extend to health information exchanged electronically under the provisions of this Act.

Part II — Encouraging the Implementation of Interoperable Electronic Health Information Systems

Section 1 — Grants for the Implementation of Regional or Local Health Information Technology Plans

This section allows the Secretary, in consultation with ONCHIT, to award competitive grants to implement regional or local health information plans that improve healthcare quality and efficiency through the use of interoperable heath information technology consistent with standards. To receive a grant, eligible entities must be comprised of a consortium of community stakeholders and adopt policies that demonstrate a commitment to open and fair participation. This section authorizes $125 million per year for five years for this purpose.

Section 2 — Safe Harbor for the Provision of Permitted Support

This section creates a narrow statutory safe harbor from the federal “Stark” self-referral and Antikickback laws for standard compliant hardware, software and support services. The safe harbor applies to physicians and other health care providers as long as these tools are used to exchange health information as part of a system designed to improve health care quality and safety, reduce medical errors, reduce health care costs, improve care coordination, simplify administrative processes, and promote transparency and competition.

Section 3 — Safe Harbor for Group Purchasing

This Section directs the Secretary to establish a narrow safe harbor from federal antitrust laws to allow providers to collectively purchase standard compliant hardware, software and support services for the electronic exchange of health information.

Section 4 — Permissible Arrangements between Health Plans and Providers

This section directs the Secretary to establish guidelines to permit arrangements between health plans and providers where savings from the implementation and utilization of health information technology systems that may accrue to the plans are shared with providers, provided the arrangements are designed to improve health care quality and safety, reduce medical errors, reduce health care costs, improve care coordination, simplify administrative processes, and promote transparency and competition.

Part III — Adoption, Implementation and Use of Quality Measures

Section 1 — Standardized Measures

This section directs the Secretary, Secretary of Defense, Secretary of Veterans Affairs and the heads of other relevant federal agencies to adopt uniform health care quality measures to assess the effectiveness, timeliness, patient centeredness, efficiency and safety of care delivered across federal healthcare programs, including Medicare, Medicaid and the State Children’s Health Insurance Program (S-CHIP). It also requires reporting of quality measures by providers participating in federal healthcare programs and allows the Secretaries to aggregate, analyze and disseminate quality data for the purposes of providing information to consumers, professionals, officials and researchers.

Section 2 — Value Based Purchasing Programs; Sense of the Senate

This section directs the Secretary to establish a value-based purchasing pilot program under Medicare to encourage the reporting of health care quality data and facilitate the payment of providers based on performance. After two years, the Secretary may expand the program and implement it nationwide. This section also provides that it is the Sense of the Senate that any modifications to the Medicare fee schedule for physician services should include provisions to encourage the adoption of health information technology standards and the reporting of standardized quality measures.

It also directs the Secretary to conduct a value-based purchasing program to encourage the electronic collection and exchange of quality measure data reports within the Medicaid program. Finally, it directs the Secretary to aggregate and share information with providers under the Medicare program regarding resource utilization.

Section 3 — Quality Improvement Organization Assistance

This section permits the Secretary to direct Quality Improvement Organizations under contract through the Medicare program, to assist healthcare providers in implementing systems for the electronic exchange of health information.

Lube Job

Report: Surgical tools at hospitals were washed in hydraulic fluid, not detergent | San Diego Tribune | 6.13.05

RALEIGH, N.C. – About 3,800 patients at two hospitals run by Duke University Health System were operated on last year with instruments that were washed in hydraulic fluid instead of detergent, hospital regulators said.

Duke Health Raleigh and Durham Regional hospitals put patients in “immediate jeopardy” in November and December by not detecting the problem, despite complaints from medical staff about slick tools, according to a report by the Centers for Medicare & Medicaid Services.

The hospitals did not fix the problem for weeks, said the agency, which oversees patient care at hospitals that receive payments from federal insurance programs.…

However, dozens of patients who were exposed to the surgical instruments have reported lingering health concerns ranging from fatigue and joint pain to problems requiring hospitalization, the The (Raleigh) News & Observer reported Sunday.

At least 50 patients who developed complications have taken their concerns to lawyers, though no one has sued Duke or the hospitals. Two lawsuits have been filed against the elevator company and the detergent supplier.…

Duke Health officials declined to comment further, citing possible lawsuits.

Surgical tools cleaned improperly | News & Observer | 1.7.05

Hydraulic fluid inadvertently used by two Duke hospitals

The letters to patients were sent Tuesday and Wednesday. Katie Galbraith, a spokeswoman for Durham Regional, said the hospital already has had more than a dozen calls from concerned patients.

They should have nothing to worry about, said Dr. William Rutala of Chapel Hill, an expert on disinfection and sterilization at UNC.

“Steam sterilization is an extraordinarily robust process,” Rutala said in an interview. “You can do a lot of things wrong and still have a sterile instrument.”

Patients treated at Duke Health Raleigh Hospital between Nov. 4 and Dec. 30 might have been exposed to the instruments. The same goes for Durham Regional patients seen between Nov. 24 and Dec. 22. Patients would not have been exposed unless they had a body-invasive procedure, such as surgery or catheterization.

Dr. Keith Kaye, director of infection control for the Duke health system, said rates of infection among patients treated at the two hospitals are being monitored. So far, the system has seen no increase, he said.

The hospitals have asked patients who notice any signs of infection, such as fever, pain or redness at the site of the incision, to notify them.…

Parsing the mistake

The hospitals are working with Cardinal Health, the Ohio company that supplies the Duke health system with detergent and other hospital supplies, to understand how the mistake happened.

The health system has determined that a Durham elevator company, Automatic Elevator, emptied hydraulic fluid into several empty detergent drums while performing maintenance at Duke Health Raleigh Hospital in mid-September, said Carla Parker Hollis, a hospital spokeswoman.

Automatic Elevator confirmed the hospital’s explanation.

Apparently, those drums then were mistaken for surplus stock and returned by the hospital to Cardinal Health. Cardinal Health later redelivered the same drums to the two hospitals, said Jim Mazzola, a spokesman for Cardinal Health. “Our next step is to understand how this happened,” he said.

Hospital employees initially didn’t notice anything amiss because the hydraulic fluid and the detergent are both odorless and about the same color, Parker Hollis said. Even an oily residue on the instruments was not terribly unusual, because they are routinely treated with a lubricant to prevent rusting.…

Hydraulic Fluid Injury | White & Stradley, LLP

Duke Health Raleigh and Durham Community Hospitals

In the fall of 2004, surgical instruments at Duke Health Raleigh Hospital (formerly Raleigh Community Hospital) and Durham Regional Hospital were contaminated with USED HYDRAULIC FLUID. The hospitals used the contaminated instruments in surgical procedures from approximately October to December 2004. Patients exposed to the contaminated instruments should have been notified by Duke University Health Systems, the operator of both hospitals involved.

White & Stradley, LLP is in the process of investigating this incident. Our preliminary investigation has revealed that the hydraulic fluid likely contained dangerous material including, PCBs and heavy metals and may have contained dioxins. The extent to which these chemicals were present on the contaminated instruments in currently unknown. Additionally, the number of post-surgical complications appears to be higher than normal among patients exposed to the contaminated instruments. White & Stradley, LLP represents a number of persons exposed to the contaminated instruments.

IF YOU HAVE BEEN EXPOSED TO CONTAMINATED SURGICAL INSTRUMENTS AT DUKE HEALTH RALEGH OR DURHAM REGIONAL HOSPITALS, contact White & Stradley, LLP…

“[P]ossible lawsuits” and “likely contained,” you just got to love those qualifiers.

iHealthing

Los Angeles Times Examines Popularity of Physician Blogs | iHealth Beat | 6.10.05

The Los Angeles Times on Monday examined the increased number of physician blogs. Some physicians use blogs to discuss patient issues or political and social concerns, and others use them to provide treatment advice or commentary on medical research.…

According to the Times, about 300 physicians have blogs, but most do not inform their patients about them. An unnamed Philadelphia family medicine physician who has a blog called the Examining Room, said, “We have to maintain an air of professionalism in the office. But on the Internet we are much more candid about what we are thinking about health care and patient care.”…

Made it into the beat…

Corporate Blogging

Blogging Becomes A Corporate Job | WSJ | 5.31.05

Digital ‘Handshake’?

In its short lifespan, blogging has largely been a freewheeling exercise in online self-expression. Now it is also becoming a corporate job.

A small but growing number of businesses are hiring people to write blogs, otherwise known as Web logs, or frequently updated online journals. Companies are looking for candidates who can write in a conversational style about timely topics that would appeal to customers, clients and potential recruits.…

Blogging as a job has emerged as companies of all stripes increasingly see the Web as an important communications venue. Blogs allow firms to assume a natural tone rather than the public-relations speak typical of some static Web pages, and readers are often invited to post comments. While some companies are hiring full-time bloggers, others are adding blogging duties to existing marketing or Web-editing positions.…

Bloggers needed in the corporate arena | Miami Herald | 6.13.05

reprint of WSJ article

Blogs, wikis and forums, encompassing the spectrum of current popularized content management systems, are going to be indispensible tools for all types of organizations for both internal and external communications.

Professional Independence

AMA pursues doctor hiring reform | Miami Herald | 6.10.05

In a move that could have widespread effects on the nation’s healthcare industry, the American Medical Association’s Board of Trustees is recommending the development of proposed legislation that would forbid corporations and hospitals from directly employing physicians.…

Corporate Practice of Medicine (Word) | AMA

The Board of Trustees recommends that the following be adopted…:

1. That our AMA develop model legislation prohibiting lay corporations, including hospitals, from directly employing physicians, and make this model available to state and national medical societies; (Directive to Take Action)
2. That our AMA revise its current model legislation regarding hospitals’ use of economic credentialing to address recent economic credentialing strategies, and make this model available to state and national medical societies; (Directive to Take Action)
3. That our AMA develop model legislation, based on SB 1325 that was recently enacted in California, which would protect medical staffs from board interference regarding specific medical staff activities (e.g., election of officers and retention of independent legal representation), and make this model legislation available to state and national specialty societies. (Directive to Take Action)

Seems Medicine has a lot to learn from Law — Rule 5.4 Professional Independence of a Lawyer.

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