i t e m s o f i n t e r e s t f r o m t h e m e d i a
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.