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                                                                                        Huffington Post – August 6, 2008

  The American Health Care System Is in Pieces,
 But Some of the Pieces Are Doing Remarkably Well
By Joe McCannon and Maureen Bisognano
The American health care system is          often fails to manage those               don't just exceed their peers by
broken. Despite the world's most            conditions that we know how to            small increments; they do so by
advanced medical technology and             prevent or treat ("amenable"              miles. Studying these exceptional
the heroic efforts of devoted               conditions), resulting in premature       states, cities and facilities might be
clinicians, health care is too              death and suffering.                      the key to meaningful progress.
expensive, unjustly inaccessible and                                                  Some ideal subjects for study
seriously harmful to many of the            · Minorities, low-income and              include:
citizens it seeks to serve. Politicians     uninsured adults and children are
and purchasers are exasperated,             much more likely than other               · States like Massachusetts, which
practitioners are beleaguered, and          Americans to experience delays,           has provided health insurance to
patients and families are rightly           receive poor-quality care and suffer      more than one million new
dismayed.                                   damaging health outcomes.                 individuals in the last year;
                                                                                      Michigan, where a project to reduce
And just when it seemed like the            · Infant mortality rates in the US are    hospital infections saved more than
news couldn't get worse, the                double the rates in other comparable      1,500 lives and avoided more than
Commonwealth Fund's 2008                    countries.                                $160 million in costs; and New
National Scorecard on US Health                                                       Jersey, where 150 health care
System Performance, released this           Variation is the report's dominant        organizations reduced the incidence
week, finds that across a broad             theme: the care that is delivered         of bed sores by more than 70%.
spectrum of measures the country            reliably in one state, city or facility
has not only failed to improve but          is simply unavailable in the next.        · Regions like Montgomery County,
the U.S. has lost ground compared           What is even more puzzling is that        Maryland, where the Primary Care
to other countries. The litany of bad       the quality of care in one place          Coalition is addressing the needs of
news must always start with the             bears no relationship -- and              uninsured and under-insured
completely unacceptable fact that           sometimes even an inverse                 individuals and reducing the need
40% of Americans are uninsured or           relationship -- to the amount of          for emergency care by reaching out
underinsured, but other news is just        money that is spent per patient           through a broad range of
as alarming:                                there. No matter where we examine         community-based partners and
                                            the system -- studying waiting times      activities, and providing
· The US spends more per capita on          or access, studying hospitals, office     inexpensive ways for otherwise
health care than any other                  practices or nursing homes -- what        unconnected providers to share
industrialized nation, but its overall      we observe are stark differences in       information online.
performance rating (an index that           performance. The sources of these
accounts for systems' quality,              differences are controversial, but        · Systems like Bellin Health in
efficiency, access, equity and the          while debates rage, patients suffer       Green Bay, Wisconsin, which has
public's health) is just 65 out of 100.     and fragmentation persists.               achieved both high quality and
                                                                                      some of the lowest overall costs of
· The US ranks last in the                  Ironically, this fragmentation has        care in the US by shifting their
industrialized world on rates of            revealed some paths to genuine            focus from providing health care
"mortality amenable to health care"         improvement. The parts of the US          alone to promoting healthier
-- that is, the nation's care system        health care system that perform well      lifestyle in the community,
businesses and schools; and               intense focus on the practical work      successful community, city, state
Ascension Health, based in St.            of making improvement -- these are       and system available to the entire
Louis, which in 2003 set the bold         the characteristics of high              nation. Data on health system
goal of preventing 900 avoidable          performers at every level of care.       performance around the nation is an
deaths in its hospitals and five years                                             important start, but we must also
later exceeded that goal by more          A common -- and disappointing --         create a system that studies
than three times.                         response to variation in                 exceptional performers -- inside and
                                          performance is to publicly               outside of the US -- and makes their
What is happening in these places?        recognize high-performing states,        strategies and breakthroughs shared
What is the secret to their great         cities and facilities while              property as we work together to
success? A state like Iowa, last year     admonishing the poorer performers.       improve the quality of the health
ranked by the Commonwealth Fund           Simply knowing who does well isn't       care in the nation.
as second in the nation for its           enough to stimulate necessary
overall health system performance,        change, any more than knowing            The primary task for any
gives us some clues. First, they are a    who the best pianist is helps a          fragmented system is integration.
model of genuine cooperation. All         beginner play an elaborate concerto.     The creation of a single-payer
stakeholders in Iowa health care --       Likewise, financial incentives - the     health care system could make the
providers, purchasers, payers,            knee-jerk solution offered as a          greatest progress toward that goal
policymakers, providers of care and,      panacea by countless commentators        but, failing that, a model where
crucially, patients and families --       and policymakers in the last seven       every state, city and facility acts as
come together around the same             years -- are alone insufficient to       a laboratory for shared
table to architect a system of            trigger improvement, just as             improvement promises to accelerate
improved care. Second, their aims         offering that same beginner millions     the rate of change that we so badly
are shared and comprehensive; they        of dollars to play that concerto will    need.
judge the progress of the whole           do little to guarantee a better
state, as measured by the well-being      performance. Incentives in health        Joe McCannon is Vice President
of all Iowans. Third, rather than         care may be helpful, but without         and director of the 5 Million Lives
simply setting bold goals they invest     commensurate investment in               Campaign at the Institute for
in resources, like the Iowa               learning they can be divisive and        Healthcare Improvement. Maureen
Healthcare Collaborative, that            discouraging, doing little to help the   Bisognano is the Institute's
connect stakeholders to one another       patients and families that deserve       Executive Vice President and Chief
and support them in the hard work         better.                                  Operating Officer; she is also a
of designing better care and                                                       member of the Commonwealth Fund
adapting good practice to their local     Instead, our next challenge is to        Commission on a High
settings. Genuine cooperation,            remove barriers to learning, making      Performance Health Care System.
shared system-level aims and              the insights and experience of each

                                                                                   Los Angeles Times – August 6, 2008

                      FBI raids three California hospitals
                          in probe of Medicare fraud
By Cara Mia DiMassa and Richard Winton
FBI agents served search warrants         defraud the Medi-Cal and Medicare        The hospitals allegedly were aided
this morning on three hospitals as        programs out of millions of dollars."    by a patient recruiting operation on
part of an investigation into alleged                                              skid row that plucked homeless
Medicare fraud involving homeless         The raids cap what law enforcement       people from the streets and
patients who were recruited from          sources told The Times was a nearly      delivered them with fake medical
skid row.                                 two-year investigation of alleged        conditions to the hospitals.
                                          medical fraud on skid row.
Los Angeles City Atty. Rocky                                                       Beginning at 8 a.m., agents working
Delgadillo plans later today to           The city attorney's office alleged       with the federal Department of
announce civil litigation -- filed this   that the hospitals tried to fill empty   Health and Human Services, the
morning -- against the three              beds in a bid to boost their finances.   Internal Revenue Service and the
hospitals and their operators in what                                              California Department of Justice
officials said was a "scheme to                                                    raided City of Angels Medical
Center, Los Angeles Metropolitan           But the city attorney now alleges          Medical Center, and its owner/
Medical Center and Tustin Hospital         that those patients had been               operators Robert Borseau and Rudra
and Medical Center.                        recruited "by runners" who directed        Sabaratnam. Estill Mitts, the owner
                                           them to an assessment center on 7th        and manager of Metropolitan
At City of Angels, FBI agents and          Street, where their Medicare and           Healthcare LLC and the president of
members of the Los Angeles                 Medi-Cal benefits eligibility were         the 7th Street Christian Day Center,
County Sheriff's Department's              checked and a "fabricated                  which was until recently located on
major-crimes squad, providing              description of conditions" was             skid row, is also named in the suit.
backup, entered the building shortly       prepared by non-doctors so they
after 8. Employees gathered in             could be eligible for treatment. All       Both Sabaratnam and Mitts were
small groups in the lobby, where           five of the patients were admitted to      arrested this morning, according to
they had been told to wait. Sitting at     Metropolitan Medical Center.               Eimiller.
tables with colleagues or talking on
cellphones, most said they were            Each of the patients received $20 to       City attorneys allege that the Tustin
puzzled by the search.                     $30 when they returned to the              hospital was guaranteed 40 to 50
                                           assessment center after spending           patients a month while City of
"At first, when I saw all these            one to three days in the hospital,         Angels got 25 to 30 patients month.
agents in all their shirts, I thought it   according to the suit.                     Metropolitan Medical Center
must be a training exercise," said                                                    received patients whenever beds
one employee who refused to give           "Within the past four years,               were available, according to the
his name, saying he didn't want            hundreds, if not thousands of other        suit. City attorneys allege the
trouble with his boss. "But then I         homeless persons in Skid Row have          admitting Drs. Rundall, Thaler and
realized it was the real thing. They       been recruited, hospitalized, treated      Tajik did not see their patients until
told me I couldn't go back to my           and discharged in a manner                 shortly before their discharge. City
work area."                                substantially similar . . . as part of a   attorneys allege that, for patient
                                           long running scheme to bilk the            referrals Mitts' group was paid
Near the entrance to the hospital's        Medicare and Medi-Cal programs             $20,000 per month each from
administrative offices, dozens of          out of millions of dollars by causing      Metropolitan Medical Center and
federal, state and local law               unnecessary hospitalization for paid       Tustin, while City of Angels paid
enforcement personnel gathered,            recruits," the lawsuit alleges.            between $400 to $1,000 a week to
their shirts bearing the logos of their                                               the recruiting group.
agencies. Half an hour into the            "Today, we are sending the message
search, a team of computer                 that those who would seek to               The suit also alleges that Tustin
forensics experts from the U.S.            defraud our health care system, and        hospital's chief financial officer
Department of Health and Human             those who would callously exploit          personally received a $3,500-a-
Services arrived with large                mentally-impaired and drug                 month kickback from Mitts' group
briefcases on rollers. Medical center      addicted homeless men and women            to ensure that Tustin continued to
employees estimated that there were        to turn a profit will be prosecuted to     take homeless patients from the skid
at least 50 members of the search          the fullest extent of the law," said       row center.
team.                                      City Atty. Rocky Delgadillo in a
                                           statement. "These criminals thought        The street recruiter typically
Two men were arrested in the raids,        they could get away with this              received $40 for each homeless
including a top executive at City of       scheme because -- they figured -- no       recruit with Medicare eligibility and
Angels. FBI spokeswoman Laura              one cares about the homeless on            $20 for each recruit with Med-Cal
Eimiller said the reason for the           Skid Row. They were dead wrong."           benefits, the suit alleges.
arrests would be announced later.
                                           Among those named in the suit are          Authorities have expressed concern
Metropolitan Hospital in 2006 was          Pacific Health Care Corp.; Los             about schemes that use the area's
accused by the Los Angeles Police          Angeles Metropolitan Medical               homeless population to defraud the
Department of using ambulances to          Center, its CEO John Fenton and            federal government. State and
"dump" five patients in one day            admitting physician Frederick              federal investigators have broken up
onto the streets of the downtown           Rundall; Tustin Hospital and               two food stamp scams, one of which
skid row area against their will after     Medical Center, its CEO Daniel             involved a merchant who allegedly
their discharge from the hospital. At      Davis, Chief Financial Officer             gave homeless people 50 cents on
the time, officials at the hospital        Vincent Rubio and admitting                the dollar for their stamps then
strongly denied any wrongdoing.            physicians Kenneth Thaler and Al-          charged the entire value -- $6
                                           Reza Tajik; and City of Angels             million -- to the government.
In 2006, officials filed charges        Last month, in a separate federal        rent, legal fees and interest expenses
against the owner of a MacArthur        lawsuit stemming from alleged            related to operations of Bayview
Park-area clinic for allegedly          Medicare and Medicaid false claims       Hospital, which was operated by
rounding up homeless people on          involving a Chula Vista psychiatric      firms Sabaratnam and Borseau
skid row with Medi-Cal or               hospital, the U.S. 9th Circuit Court     controlled. The court rejected an
Medicare cards and giving them a        of Appeals upheld a $15.6-million        appeal by Sabaratnam and Borseau
battery of medical tests charged to     award against Sabaratnam, Borseau        arguing the federal government had
government programs. Authorities        and firms they operated.                 not proved the disputed claims were
allege that the bogus tests cost                                                 false.
taxpayers at least $1.6 million and     According to the court's decision,
perhaps much more.                      the defendants submitted a series of
                                        false claims in the late 1990s for

                                                                                  New York Times – August 3, 2008

                Hospitals deporting uninsured patients
By Deborah Sontag
JOLOMCÚ, Guatemala — High in            Since returning home, Jimenez, who       oversight, leaving ample room for
the hills of Guatemala, shut inside a   sustained a traumatic brain injury,      legal and ethical transgressions.
one-room house, Luis Alberto            has received no medical care or
Jimenez has no idea of the legal        medication — just Alka-Seltzer and       Some advocates for immigrants see
battle that swirls around him in the    prayer, said his 72-year-old mother.     these repatriations as a kind of
lowlands of Florida.                    In the past year, his condition has      international patient dumping.
                                        deteriorated with routine seizures.
Beaming at his toothless mother, his                                             Hospital administrators view such
sole caregiver, Jimenez remains         "Every time, he loses a little more      cases as costly, burdensome patient
cheerily oblivious that he has come     of himself," said his mother,            transfers that force them to shoulder
to represent the collision of two       Petrona Gervacio Gaspar.                 responsibility for the dysfunctional
flawed U.S. systems, immigration                                                 immigration and health-care
and health care.                        Jimenez's benchmark case exposes a       systems. In many cases, they said,
                                        little-known but apparently              the only alternative to repatriation is
Eight years ago, Jimenez, now 35,       widespread practice. Many U.S.           keeping patients indefinitely in
an illegal immigrant working as a       hospitals are repatriating seriously     acute-care hospitals.
gardener in Stuart, Fla., suffered      injured or ill immigrants because
devastating injuries in a car crash     they cannot find nursing homes           "What that does for us, it puts a
with a drunken Floridian. A             willing to accept them without           strain on our system, where we're
community hospital saved his life,      insurance. Medicaid does not cover       unable to provide adequate care for
twice, and, after failing to find a     long-term care for illegal               our own citizens," said Alan Kelly,
rehabilitation center willing to        immigrants, or for newly arrived         vice president of Scottsdale
accept an uninsured patient, kept       legal immigrants, creating a             Healthcare in Arizona.
him as a ward for years at a cost of    quandary for hospitals, which are
$1.5 million.                           obligated by federal regulation to       Medical repatriations are happening
                                        arrange post-hospital care for           with varying frequency, and varying
What happened next set the stage        patients who need it.                    degrees of patient consent, from
for a legal battle with nationwide                                               state to state and hospital to
repercussions: Jimenez was              U.S. immigration authorities play        hospital. No government agency or
deported, not by the federal            no role in these private                 advocacy group keeps track of these
government but by Martin                repatriations. Most hospital officials   cases, and it is difficult to quantify
Memorial Hospital. After winning a      said that they do not conduct cross-     them.
state court order that would later be   border transfers until patients are
declared invalid, Martin Memorial       medically stable and that they           There is enough traffic to sustain at
leased an air ambulance for $30,000     arrange to deliver them into a           least one repatriation company,
and "forcibly returned him to his       physician's care in their homeland.      MexCare, operating nationwide
home country," as one hospital                                                   with a "network of 28 hospitals and
administrator described it.             But the hospitals are operating          treatment centers" in Latin America.
                                        without governmental assistance or       It bills itself as "an alternative
choice for the care of the unfunded      guardians — and the liability of the   if they receive Medicare payments,
Latin American nationals."               hospitals who undertake them.          and most hospitals do — to transfer
                                                                                or refer patients to "appropriate"
Many hospitals engage in                 "We're the rhesus monkey on this       post-hospital care.
repatriations of seriously injured       issue," said Scott Samples, a
and ill immigrants only as a last        spokesman for Martin Memorial.         But in most states, the government
resort. "We've done flights to                                                  does not finance post-hospital care
Lithuania, Poland, Honduras,             The average stay at Martin             for illegal immigrants, for
Guatemala and Mexico," said Cara         Memorial is 4.1 days and costs         temporary legal immigrants or for
Pacione, director of social work at      $8,188. Patients rarely linger. In     legal residents with fewer than five
Mount Sinai Hospital in Chicago.         addition to trauma patients, there     years in the United States.
"But out of about a dozen cases a        are uninsured immigrants with
year, we probably fly only a couple      serious health problems.               Martin Memorial's lawyer, Robert
back."                                                                          Lord Jr., said hospitals should not
                                         "In our emergency room, we don't       be forced to assume financial and
Other hospitals routinely send           turn anyone away," said Carol Plato    legal responsibility for these cases.
uninsured immigrants, legal and          Nicosia, director of corporate         "It should be a governmental
illegal, back to their homelands.        business services. "The real           burden, or the government should
One Tucson, Ariz., hospital tried to     problem is if we find an underlying    step in and otherwise exercise its
fly a U.S. citizen, a sick baby whose    problem, and now we have six of        authority for deportation or
parents were illegal immigrants, to      them, six patients who showed up in    whatever it wants to do."
Mexico last year; the police,            renal failure and that we are now
summoned by a lawyer to the              seeing three times a week for          In Jimenez's case, the hospital's
airport, blocked the flight.             dialysis.                              doctors determined appropriate
                                                                                post-hospital care meant traumatic-
Sister Margaret McBride, vice            "I don't want to sound heartless. A    brain-injury rehabilitation.
president for mission services at St.    community hospital is going to give    Hospital-discharge planners
Joseph's in Phoenix, which is part of    care. But is it the right thing? We    searched to no avail for a
Catholic Healthcare West, said           have a lot of American citizens who    rehabilitation program or nursing
families were rarely happy about the     need our help. We only make about      home.
decision to repatriate relatives. But,   3 percent over our bottom line if
she added, "We don't require             we're lucky."                          Michael Banks, a local lawyer
consent from the family."                                                       representing Jimenez's guardian —
                                         Martin Memorial reported a total       a cousin by marriage — took the
In the spring, St. Joseph's planned to   margin of 3.6 percent over its         position that the hospital had a
send a comatose, uninsured legal         bottom line last year and 6 percent    responsibility to provide Jimenez
immigrant back to Honduras, until        in 2006. According to the most         with the rehabilitation, even if it
lawyers got involved. While they         recent statewide data, the nonprofit   meant paying a rehabilitation center.
were negotiating with the hospital,      medical center also reported assets
Sonia del Cid Iscoa, 34, who has         of $270.6 million in 2006, with its    But the hospital declined, as Lord
been in the United States for half       senior executives earning more than    put it, "to take out our checkbook"
her life and has seven U.S.-born         $4 million in salaries and benefits.   and subsidize Jimenez's care at
children, came out of her coma. She                                             another institution. "Once you take
is back in her Phoenix home.             Tax-exempt hospitals are expected      that step, for how long are you
                                         to dedicate an unspecified part of     going to do that — a year, 10 years,
Unlike Iscoa and Jimenez, most           their services to charity cases, and   50 years?"
uninsured immigrant patients in          Martin Memorial devoted $23.9
repatriation cases do not have           million in 2006, about 3 percent,      Eventually, the Guatemalan health
advocates fighting for them, and         average for Florida, according to      minister wrote a letter assuring
they are quietly returned to their       state data.                            Martin Memorial that his country
home countries.                                                                 was prepared to care for Jimenez.
                                         Jimenez was an expensive charity
Jimenez's case is apparently the first   case. In cases like his, where         After the guardian and the hospital
to test the legality of cross-border     patients need long-term care,          reached an impasse, Martin
patient transfers undertaken without     hospitals are not allowed to           Memorial took the matter to court,
the consent of the patients or their     discharge them to the streets.         asking a state judge to compel
                                         Federal regulations require them —     relatives to cooperate with its
repatriation plan. In June 2003, a       public rehabilitation hospital within   Given that Jimenez was in
hearing was held before Circuit          weeks.                                  Guatemala, that action came too late
Judge John Fennelly.                                                             for him.
                                         Fennelly granted the hospital's
George Bovie III, a lawyer for           petition.                               It might affect others, though. The
Martin Memorial, told the judge:                                                 decision has become what is known
"This is a case about care for a man     Banks filed a notice of appeal and      legally as a case of first impression
in this country illegally who has        asked for a stay while the appeal       on the issue of hospital
reached maximum medical                  was pending. The judge asked the        repatriations.
improvement at our hospital and is       hospital to file a response by 10
ready to be discharged and whose         a.m. on July 10 before he ruled on      Based on the appeals-court ruling,
home government" is prepared to          the stay.                               Jimenez's guardian is pursuing
receive and treat him.                                                           suing the hospital. In a subsequent
                                         A few hours before that response        ruling, the judges said the hospital
Banks said in response, "Your            was due, an ambulance picked up         can be sued for punitive damages
Honor, this is a case about a            Jimenez and drove him to the St.        and for the cost of his medical care.
hospital that has failed to do its job   Lucie County Airport, where an air
properly," adding that the hospital      ambulance was waiting to transport      John DeLeon, a lawyer who advises
sought to "have this court legitimize    him back to Guatemala.                  the consulates of Mexico, Honduras
its patient dumping."                                                            and Guatemala in Miami, said he
                                         The hospital's lawyer declined to       now refers to the case when he
By the time of the hearing, Jimenez      comment on why the hospital did         receives calls from hospitals
was essentially a boarder at the         not wait for the judge to rule on the   looking to discharge seriously
hospital, wheeling around the            stay.                                   injured or ill immigrants.
hallways and hanging out at the
nursing stations.                        Gregory, the nurse, traveled to         "I now write ... a letter that says,
                                         Guatemala with Jimenez, bringing a      'Listen, don't take action to dump
Diana Gregory, a nurse who               wheelchair, a week's worth of           this individual because you'll be
supervises case management and           medications,                            risking legal action. The law is now
discharge planning, said in a recent     "lunch/snacks/juices/treats," and an    that hospitals can't dump immigrant
interview that Jimenez became "like      emergency passport signed with a        patients without securing
family" to hospital workers, who         fingerprint, according to discharge     appropriate aftercare.' "
bought him birthday cakes, knitted       records.
him blankets and gave him toys.                                                  Jack Scarola, another lawyer
                                         He arrived in Guatemala, and an         representing Jimenez's guardian,
According to hospital records,           ambulance took him to the National      said he empathized with the
however, it was not all pastries and     Hospital for Orthopedics and            hospital's "significant economic
presents. Jimenez grew depressed         Rehabilitation.                         burden" but said it was the "quid
and showed signs of regression.                                                  pro quo" of accepting Medicare and
Gregory said Jimenez developed           Although it is the only public          Medicaid funds to help finance the
some disturbing habits, including        rehabilitation hospital in the          hospital's services. About 45
spitting, yelling, kicking and           country, it dedicates just 32 beds to   percent of Martin Memorial's net
defecating on the floor.                 rehabilitation and does not offer the   operating revenues came from
                                         specialized brain-injury treatment      Medicare and Medicaid last year,
In court, his doctor, Walter Gil,        that Jimenez needed.                    based on state data.
testified that Jimenez would benefit
from returning to the intimacy of his    In May 2004, a Florida appeals          "Also," he continued, "they chose
family.                                  court overruled Fennelly. The 4th       the wrong way to deal with it. ...
                                         District Court of Appeal found that     There is no program in place to
Dr. Miguel Garces, a prominent           the Florida state judge had             appropriately distribute care to
Guatemalan physician and public-         overstepped his bounds because          undocumented persons who are
health advocate, said in a deposition    deportation is the prerogative of the   catastrophically injured, and there
that serious rehabilitation "is almost   federal government. The court also      should be. But you don't stick a
nonexistent" in Guatemala outside        declared that no evidence supported     brain-injured immigrant on a private
private facilities. He predicted         the hospital's assertion that Jimenez   plane and spirit him out of the
Jimenez would be taken in and            would receive appropriate care in       country."
released from the country's one          Guatemala.
                                                                                   Los Angeles Times – August 4, 2008

                     Doctors talk shop on medical blogs
By Melissa Healy
For physicians of a certain age, the     information for doctors as well as        the nation's more than 700,000
weekly teaching session known as         patients."                                physicians and 2.9 million nurses,
grand rounds is a ritual steeped in                                                they are a gathering place like no
formality and tradition. Presided        But as physicians increasingly use        other.
over by the profession's graybeards,     blogs to talk shop and vent their
grand rounds are attended with           frustrations online, patient privacy      Here, members of the community
white coats on and clinical details in   has become an issue, says Lagu,           jettison the facade of clinical
hand.                                    who is a Robert Wood Johnson              authority; abandon forbearance with
                                         Foundation Clinical Scholar and an        obstinate or demanding patients;
Here, young physicians learn to          internal medicine specialist. "It's       and flout the convention of paying
accept their elders' old-school          time for us to take some                  homage to the profession's most
admonishments with reverence and         responsibility and really think of        senior practitioners.
humility.                                how we can maintain the integrity
                                         of this process."                         "Like everything else on the
Grand rounds on the Internet,                                                      Internet, it's just kind of the Wild
however, is another thing                The Health Insurance Portability          West," says Dr. Allen Roberts, an
altogether. A weekly compilation of      and Accountability Act, or HIPAA,         emergency room doctor from Fort
the Internet's best medical blog         gives patients strong privacy             Worth who is better known in the
postings, it is part classroom, part     protections, but the 1996 law             blogosphere as the author of the
locker room, part group therapy          predates the medblog phenomenon,          GruntDoc blog. "It's very leveling . .
session and part office party -- a       leaving gray areas for bloggers who       . you can write in print what you
free-wheeling collection of rants,       write about their patients.               would never say to a surgeon's face
shop talk, case studies and learned                                                about him being an overweening
commentary (along with the               In a 2006 study, Lagu and her             jerk."
occasional recipe, movie review or       coauthors found 271 blogs written
vacation slide show).                    by physicians or nurses. Roughly          Though many medblogs are filled
                                         42% of those blogs included               with clinical observations and links
This rotating Internet roundup,          descriptions of interactions with         to studies, some posts are deeply
hosted each week by a different          individual patients, and almost 17%       personal and often downright ribald.
medical blogger, is the center ring      "included sufficient information for
of a colorful and growing circus of      patients to identify their doctors or     In a recent Friday night posting on
blogs written by medical                 themselves." Three of the blogs           the blog Ob/Gyn Kenobi, an
professionals and posted for all to      showed recognizable photographic          obstetrician who identifies herself
see. It is making the practice of        images of patients.                       as Dr. Whoo admonished pregnant
medicine more transparent to                                                       patients -- under the heading
patients and, at the same time,          And in a sign that blogs may              "Seriously, people . . ." -- not to
raising ethical questions about          increasingly become a means of            place an emergency call to the
safeguarding patient privacy.            indirect marketing by                     doctor if they had just had sex and
                                         pharmaceutical and device makers,         had a creamy discharge (but no pain
"Medical blogs have the opportunity      11.4% had postings promoting              or bleeding) afterward.
to be such a benefit to patients,"       healthcare products. Few, however,
says Dr. Tara Lagu, author of an         said anything about an author's           "It is semen, you rocket scientist,
article on the subject published         conflict of interest.                     and we really, really did not need to
online last week in the Journal of                                                 know that," she fumed on the blog.
General Internal Medicine. "By           Medical blogs are the place to            "Think before you page," forcing
revealing the struggles we have,         eavesdrop on what doctors and             doctors to take time away from
they can really open patients' eyes      nurses are talking about in break         family and home "to hear about the
to how to interact with doctors, they    rooms and at conferences and to           effluent from your nether regions
can connect patients and nurses who      read what medical professionals           after your feelgood Friday night."
can be isolated from each other and      think about the latest clinical studies
they can be an important source of       or healthcare proposals making            A growing number of people -- by
                                         headlines. For a growing number of        no means all of them medical
professionals -- seem to enjoy           Cleveland Clinic and Case Western         Lagu says that bloggers' intentions
reading the unfiltered candor of a       Reserve University, are primarily         are mostly good, but it's not clear all
profession long hidden behind the        teaching tools.                           are doing enough to protect patients'
white coat and forbidding air of                                                   privacy and to avoid undermining
authority.                               But Lagu says physicians who blog         patients' trust in physicians.
                                         may not be doing all they can to
"It really gives a glimpse behind the    protect the identity of patients          Experts fear, for example, that
medical curtain that otherwise the       described in postings. She cited          commercial interests could damage
general public wouldn't see," says       several cases in which patients had       the integrity of the medical
Dr. Kevin Pho, an internal medicine      been disparaged by disgruntled            blogosphere unless the profession
specialist in Nashua, N.H., and          physicians. Her study also found 45       agrees on when and where a
author of the widely respected blog      blogs -- 16.6% of the 271 she             blogger's conflicts of interest should
Kevin, M.D. "Some of the opinions        combed through -- that included           be divulged. Tom Rosenstiel,
are very raw and in some cases           posts describing interactions in          director of the Washington, D.C.-
don't reflect on the profession in a     enough detail that patients, or           based Project for Excellence in
very positive way. But they do           family and friends, could recognize       Journalism, says public relations
reflect reality; we often say what       themselves.                               firms are known to have some
people don't like to hear."                                                        bloggers on retainer to ensure
                                         Several bloggers interviewed said         favorable mentions of their clients.
When Roberts -- GruntDoc -- sat          they are wary of identifying patients     And Lagu cited an online survey of
down at his computer in 2002 and         and take pains to avoid it. Roberts       healthcare bloggers, in which 29%
began posting a running                  says he frequently changes the            of respondents said they had been
commentary on his professional life,     gender, age or other descriptions of      approached by public relations
he knew of four, maybe five, other       patients. Dr. Robert Donnell, a           professionals to endorse certain
physicians doing the same, he says.      hospital-based physician in               products. The survey, prepared by
                                         Arkansas who writes under his own         the commercial group Envision
Today, the world of medical blogs        name at Notes From Dr. RW, says           Solutions LLC, also found that 52%
is a place so crowded that Roberts       he avoids reference to any clinical       had written at least one post
says he doesn't know most of their       cases in which he's been personally       endorsing such products.
authors. According to Lagu's             involved.
analysis, roughly 65% are penned                                                   Medical blogging is such a new
anonymously, while the rest of the       Virtually every medical blogger           feature, Lagu adds, that it has
authors identify themselves by           acknowledges in his or her posts the      scarcely been noticed by the
name. Some use their blogs to blow       case of Flea, a physician blogger         profession's graybeards -- medical
off steam and share their                who anonymously posted on his             community leaders who would
experiences in a profession that         practice, including damning details       ordinarily initiate debate on
most agree has become more trying        of a malpractice suit against him. In     appropriate behavior of their
in recent years; others use it as a      the course of the case, the plaintiff's   peers.Amid that leadership vacuum,
link to studies they find interesting;   attorney -- recognizing the doctor        she holds, the medical blogosphere
about half, Lagu says, make forays       by the details in his posts --            has become much larger and more
into the political realm of healthcare   confirmed he was the author and           cacophonous, and patients' medical
policy; and a few, including one         used his own words against him.           secrets are clearly being spilled in
sponsored by the highly respected                                                  the process.

                                                                                     Associated Press – August 3, 2008

       Americans look abroad to save on health care
By Linda A. Johnson
Consumers increasingly are trying        The number of people heading              forecast by health care consultants
alternatives to their local hospitals    abroad for "medical tourism" could        at the Deloitte Center for Health
and doctors, from going abroad for       jump tenfold in the next decade, to       Solutions.
less-costly surgery to seeking quick,    nearly 16 million Americans a year
basic care at new clinics in             seeking cheaper knee and hip              Meanwhile, the number of retail
drugstores and discounters, experts      replacements, nose jobs, prostate         clinics operating in pharmacies, big-
say.                                     and shoulder surgery, and even            box and discount stores and
                                         heart bypasses, according to a            supermarkets has jumped from
about 200 in 2006 to nearly 1,000        Many of these countries actively         Midwest have been trying to match
last month, according to a second        market their programs in wealthier       costs for foreign surgery to retain
report from the Deloitte center.         nations and have new, 21st-century       patients.
                                         hospitals. Most of their physicians
While growth is slowing and some         are trained in the United States and     Taylor and Keckley note that some
early players funded by venture          know all the latest techniques,          of the country's most renowned
capitalists have folded or been          according to Keckley and Michael         teaching hospitals - Johns Hopkins,
bought out, major retailers such as      Taylor, a global health consultant at    Cleveland Clinic, Harvard, Duke
Wal-Mart Stores Inc., CVS                Towers Perrin.                           and others - have started
Caremark Corp. and Walgreen Co.                                                   partnerships where they do the pre-
have announced plans to open             But in the event of botched surgery      and after-care at their facilities,
hundreds more clinics in their stores    or complications later, who takes        either for consulting and other fees
in the next few years.                   care of the patient?                     or in exchange for part ownership of
                                                                                  the foreign hospital.
The two reports show potential big       "That's one of the two big question
savings for U.S. consumers - and         marks about this, and the other is       Big-name partnerships also can be
probably their health insurers -         liability," said Keckley.                crucial in the retail clinic business,
would come at the cost of American                                                which is barely a decade old. Some
hospitals and doctors losing billions    When patients work with                  small, independent groups such as
of dollars a year in revenue.            specialized brokers who arrange the      SmartCare Health Clinics have shut
                                         surgery, travel and hotel, contracts     down, but retail giant Wal-Mart
"Significant numbers of people are       sometimes provide for a doctor or        recently signed deals with
willing to vote with their feet to try   hospital back home to handle             RediClinic and various hospital
something different, whether it's        follow-up care and spell out who is      systems to open co-branded clinics,
retail clinics or medical tourism,"      liable if a lawsuit follows, he said,    with 400 planned by 2010,
said Paul Keckley, the center's          but that's inconsistent.                 according to Deloitte.
executive director. "U.S. providers
are having to pay attention."            "In many ways, it's still the Wild       In the past two years, CVS
                                         West," Keckley said.                     Caremark and Walgreen each
He cites patient dissatisfaction with                                             bought retail clinic operators and
high costs, long waits in the doctor's   About 750,000 Americans headed           are expanding, with CVS Caremark
office or to get a procedure, and        abroad for major health care last        planning 2,500 clinics eventually.
reports about errors and quality         year and an estimated 1.5 million
problems in U.S. health facilities as    will do so this year, according to the   Such clinics are staffed by nurse
fueling both trends.                     report.                                  practitioners or physician assistants,
                                                                                  who can handle minor injuries, ear
Surgery in some of the countries         "I think that's very optimistic," said   and throat infections and other
that have become hubs for medical        Towers Perrin's Taylor, who says         problems far faster than most
tourism, from Thailand and               host countries probably are inflating    doctors or emergency rooms.
Singapore to Mexico and Brazil,          their reported numbers of American       Appointments aren't necessary, wait
can cost less than half the U.S.         patients.                                times are usually 15 minutes, visits
price, even when including outlays                                                often are twice as long as in a
for airfare, hotel and meals abroad.     At least one Blue Cross/Blue Shield      doctor's office, most services cost
In a few cases, procedures overseas      plan is encouraging medical tourism      $50 to $75, and they accept
can cost one-tenth as much,              and U.S. hospitals are reacting to       insurance.
Keckley said.                            the trend. According to Taylor,
                                         some teaching hospitals in the

                                                                                  Wall Street Journal – August 6, 2008

            Options Expand For Avoiding Crowded ERs
By Laura Landro
When a heavy metal door swung            want to take her chances in a            Instead, she drove to an urgent-care
over her 14-year-old son's foot,         crowded hospital emergency room          clinic inside a Wal-Mart in Yulee,
ripping the nail almost completely       or wait for an appointment at the        Fla., near her rural home. Within
off his big toe, Tina Mobley didn't      pediatrician's office the next day.      minutes, the doctor on duty numbed
the pain with an injection, removed       the number of emergency                  Some urgent-care clinics say they
the nail, and cleaned and bandaged        departments decreased to 3,795           don't see the need to pay the
the injury.                               from 4,176, while the annual             thousands of dollars the
                                          number of visits to ERs rose by          accreditation process can cost. But a
Patients who need immediate care          20% to 115.3 million, according to       standard accreditation program
for injuries and illness, be it a nail-   the most recent data from the            developed by the Joint Commission
gun puncture or a severe stomach          Centers for Disease Control and          could make it easier for urgent-care
bug, are increasingly turning to          Prevention.                              clinics to strike better deals with
walk-in urgent-care clinics. These                                                 insurance companies and health
facilities aim to fill the gap between    Voluntary Accreditation                  plans. Though insurers are
the growing shortage of primary-                                                   increasingly including clinics in
care doctors and a shrinking number       But as the number of urgent-care         their networks because of the cost
of already-crowded hospital               clinics has grown, so have concerns      savings, they tend to reimburse the
emergency departments, with no            about their quality and safety, as       clinics at lower rates than urgent-
appointment necessary and                 well questions about the risks of        care clinics say they need to cover
extended evening and weekend              patients substituting urgent-care        costs of longer hours, larger staffs
hours. Urgent-care clinics are            centers for an ongoing relationship      and expensive equipment.
staffed by physicians, offer wait         with a primary-care doctor who
times as little as a few minutes and      coordinates care and follows them        "We'd look far more favorably at an
charge $60 to $200 depending on           over time. While physicians who          urgent-care clinic that was
the procedure -- a fraction of the        work at clinics must be licensed like    accredited than one that wasn't,"
typical $1,000-plus emergency             any other doctor, clinics aren't         says Troy Brennan, chief medical
department visit. Some offer              typically licensed or regulated by       officer at insurer Aetna. By
discounts and payment plans for the       states and can vary widely in the        undergoing the rigors of an
uninsured; for those with coverage,       services, hours, staffing and            evaluation, "it means an
co-payments vary by insurance plan        equipment they offer. Some have          organization is taking a hard look at
but may be less than half the             undergone voluntary accreditation        a variety of safety issues that should
amount of an ER visit, which can          programs to evaluate quality and         be involved in caring for someone
range from $50 to $200.                   safety, but no national standards        who is acutely ill," he notes. While
                                          exist to determine the range of          Aetna says patients shouldn't seek
While the Yulee clinic that treated       services an urgent-care clinic should    treatment in an urgent-care facility
Ms. Mobley's son is one of three          offer or the steps they should take to   if their condition requires
operated inside Wal-Mart stores by        ensure safe, high-quality care.          emergency services, and encourages
Jacksonville, Fla.-based Solantic,                                                 them to call their doctor first, "if it
urgent-care centers aren't to be          Recently, the Urgent Care                is a good high-quality urgent-care
confused with the new crop of retail      Association of America, a trade          center that can keep someone out of
health clinics popping up in              group representing 3,141 urgent-         the emergency department who
drugstores, which are run by nurse        care professionals, struck an            doesn't need to be there, that is a
practitioners who prescribe               agreement with the Joint                 good thing."
medicine for minor illnesses and          Commission, the non-profit group
provide vaccinations. Urgent-care-        that accredits hospitals and other       Efforts are now under way by
center physicians and other medical       health-care organizations, to take       members of the urgent-care trade
staffers can put casts on broken          over accreditation and publish           association to develop urgent care
bones, sew up lacerations, provide        national quality standards by 2010.      as a recognized subspecialty of
intravenous fluids for dehydrated         Lou Ellen Horwitz, executive             family practice or emergency
patients, and deploy advanced life-       director of the association, says the    medicine. Several teaching hospitals
support equipment for both adults         aim is both to avoid future              are now offering post-graduate
and children. They often have             regulation and to establish              fellowships in urgent care to
equipment not available in                guidelines that can help patients and    medical interns, and two medical
physicians' offices, such as X-rays.      health plans evaluate urgent-care        journals are dedicated to urgent-care
                                          centers. She also stresses that          issues. The Orlando-based
There are currently more than 8,000       patients should always have a            American Board of Urgent Care
urgent-care centers around the            relationship with a primary-care         offers to certify physicians in urgent
country, including about 1,200            doctor and use urgent-care clinics       care for a fee, but it isn't formally
affiliated with hospitals, and that       when they can't get an appointment       recognized by the American Board
number is expected to expand. By          during office hours.                     of Medical Specialties.
contrast, between 1995 and 2005,
Avoiding the Wait                      patients for hours or days in the ER    beginning of a blood clot in the
                                       when they should be admitted to the     cavity at the base of her brain that
Urgent-care centers first appeared     hospital -- a problem urgent-care       resulted in a nine-day
about 20 years ago, but didn't catch   clinics won't solve. "One of our        hospitalization. Ms. Solomon says
on widely among consumers, who         concerns that people can't recognize    she was impressed by how quickly
preferred to see their own doctor or   when they have an emergency or          she was seen and transferred to the
seek care in a hospital ER. But the    don't," says Dr. Lawrence. "A           hospital, and with Dr. Keller, who
industry began resurging in the mid-   patient who says they are having        later went to check on her in the
1990s, and demand has increased in     indigestion and goes to an urgent-      intensive-care unit.
recent years as more consumers         care clinic may really be having a
experience long waits in the           heart attack."                          Stephen Kovacs, the medical
emergency room, or wait weeks to                                               director and co-owner of Urgent
get an appointment with their own      "We don't encourage patients with       Care of Green County, with several
doctor, says Robin Weinick, a          chest pain to go to urgent-care         clinics in Owasso, Claremore and
researcher at Massachusetts General    centers, but the reality is that we     Bixby, Okla., urges patients to
Hospital's Institute for Health        need to be prepared for anything        "research a facility first to be sure
Policy.                                that walks through our doors," says     they are going to be seen by a
                                       Lee Resnick, president of the           physician and that the facility will
Urgent-care centers have most          urgent-care association and director    be able to provide all of the
frequently chosen busy intersections   of University Hospitals Urgent          necessary services that might be
or strip malls, but they are also      Care, a five-clinic urgent-care group   required," such as X-rays, scans,
opening in rural areas with few        in suburban Cleveland. The clinics      intravenous fluids for dehydrated
other medical providers. In addition   are affiliated with University          patients and advanced life-support
to chains such as Solantic and Mesa,   Hospitals Case Medical Center. In       equipment. His clinics also work
Ariz.-based NextCare Inc. clinics      many cases, Dr. Resnick says,           closely with patients' primary-care
are being opened by physicians and     urgent-care clinics diagnose more       physicians, sending records from
hospitals looking to expand their      serious illnesses like cancer for       urgent-care visits and coordinating
business or ease crowding in their     patients who come in for a              care with specialists in the area.
own ERs. Of the 115.3 million          seemingly lesser complaint, and
emergency-room visits in 2005,         recognize heart attacks or strokes in   Some patients use the urgent care
according to the CDC, only 5.5%        time to get patients by ambulance to    centers often enough to strike up a
needed to be seen immediately, with    an ER, where they can be fast-          long-term relationship. Shelly
9.8% triaged as needing to be seen     tracked through the admission           Rogers says Dr. Kovacs has treated
within 14 minutes, 33% within 15       process.                                her kids for accidental burns and
minutes to an hour, and 21% as                                                 broken bones, and diagnosed her
"semi-urgent," needing to be seen      Transfer to Hospital                    husband Doug's sore throat as a
one to two hours. About 14% were                                               benign cyst on his thyroid. After he
evaluated as "non-urgent," meaning     Recently, for example, 24-year-old      cared for her during several
they could be treated in anywhere      Carly Solomon arrived at one of Dr.     episodes related to her own
from two to 24 hours.                  Resnick's clinics with a pounding       complicated medical history, Ms.
                                       headache, dizziness, nausea and         Rogers has started to think of him as
But Linda Lawrence, president of       blurred vision. Julie Keller, the       her personal physician. At times
the American College of                physician on duty, determined her       when both spouses were out of
Emergency Physicians, says the         condition was more serious than a       work or had trouble getting
majority of patients who show up in    bad migraine; though the clinic had     insurance to cover treatment, Dr.
the ER belong there until their        the equipment to do a brain scan,       Kovacs didn't charge them for care,
conditions can be evaluated.           she summoned an ambulance. By           or helped them set up a payment
Overcrowding, she says, is due to      the time it arrived, Ms. Solomon        plan. "They really get to know you,
hospitals' practice of "boarding"      had begun having seizures, the          and they pay attention," she says.