March 16, 2009 Five Palm Beach County hospitals cited for denying ER care: Violations point to wider crisis in ER specialty care The 24-year-old waited 12 hours with an open leg fracture as hospital after hospital declined to provide treatment. Injured in a moped accident, the patient needed an orthopedist. The specialist at Palms West in Loxahatchee said the wound was open too long. At Wellington Regional Medical Center, the on-call orthopedist tried to pass the case to another hospital. The specialist at JFK Medical Center in Atlantis said no, and so did the chief executive officer. The three hospitals were among five in Palm Beach County cited last year for violating a federal law to prevent patient dumping. Federal records show the hospitals denied about 30 patients emergency specialty care they should have provided. Compared with about 450,000 emergency department visits in 2007, the number of patients is small. The violations, though, offer a snapshot of how emergency patients get passed among hospitals and highlight a broader crisis in emergency specialty care. A shortage of specialists or their unwillingness to handle emergencies is plaguing much of the state and parts of the nation. Florida stands out with the most complaints of patient dumping, accounting for about a third of the almost 750 tallied nationwide by the Centers for Medicare and Medicaid Services. The federal law, passed 22 years ago, seeks to prevent hospitals from sending uninsured patients to other facilities for care. "The fact of the matter is that people are not getting the care they so deserve in a county that is so wealthy," said Dr. Jean Malecki, director of the Palm Beach County Health Department. "We have to put private agendas aside and be here for people." Only JFK and Palms West responded to requests for comment on the violations. Both HCA Healthcare Corp. hospitals, they issued a joint statement, saying they "have aggressively worked on subspecialty recruitment in our service areas. Issues related to subspecialty coverage have greatly improved in the last year. These and other measures taken have satisfied regulatory requirements." Doctors point to several crippling factors: the sky-high cost of malpractice insurance, low reimbursements for care or no pay at all from growing ranks of the uninsured and the omnipresent fear of being sued. Taking emergency calls is not automatic as it was years ago, meaning patients might wait a long time while emergency departments scramble to find a specialist. A case in point is gastroenterology. Good Samaritan Medical Center in West Palm Beach was cited after its gastroenterologists on Sept. 26 refused to care for a jaundiced patient with a distended stomach and shortness of breath. Hospitals that provide elective specialty care are required by law to offer it in emergencies. According to a federal report, two specialists called were out of town. Another three refused to see the patient. A sixth specialist was in the emergency department but when the attending physician asked for a consult, the gastroenterologist replied, "Never." Nine hours after being screened — after seven hospitals were called — the patient was transferred to another hospital. Federal reports summarize what happened but do not include patient or doctor names. Last year, 26 complaints were filed, according to the state. Of the other hospitals cited, JFK, Wellington Regional and St. Mary's Medical Center had two violations each. Palms West had the most, at three violations. None of the hospitals was fined or lost its Medicare license, the potential consequences of violations. Few hospitals lose their licenses. Instead, they submit corrective plans and outline how to prevent future problems. Most hospitals have tried to remedy their own staffing shortages by paying specialists to treat emergency patients. Those hospitals typically aren't the ones cited for violations, said Dr. Richard Greenwald, vice president for academic affairs at Boca Raton Community Hospital. "By definition, if you get cited then you don't have full coverage," said Greenwald, though he added, "We're all a couple of resignations away from not having coverage" for neurosurgery and hand surgery, the two hardest-to-staff specialties. Three years ago, a group of surgeons and hospital CEOs crafted a regional call plan to deal with the confusion. Patients would be sent immediately to the hospital known to have a specialist available. Progress has been slow because of the intricacy of pleasing doctors and hospitals involved and the complexity of clearing legal hurdles, said Dwight Chenette, chief executive officer of the Health Care District of Palm Beach County, which took over the effort to avoid antitrust concerns. Local efforts, though, got a boost recently when the federal government announced proposed changes to the anti-patient dumping law so hospitals could organize regional call schedules. Even if the law changes, hospitals here must sign on to the idea to make it work. "This is about community need, about providing a service to the patient," Chenette said. But, "It's going to change the marketplace, which is going to have everyone looking at their own interests." (South Florida Sun-Sentinel) Read the original article. New study shows home care nurses drive more miles for their job each week than the average UPS driver A study by the Washington D.C.-based National Association for Home Care and Hospice shows that the nurses, therapists, home care aides and others who serve elderly and disabled patients in their homes drive, on average, more miles annually than many driving professionals including UPS drivers. "Caring for over seven million patients annually with 428 million visits, these dedicated providers of home care and hospice are feeling the same pain at the pump as other consumers, but they carry the added burden of the Administration's deep cuts into Medicare and Medicaid benefits, says Val J. Halamadaris, President of the National Association for Home Care and Hospice (NAHC*). "These draconian cuts ignored the cost of living increases, chief among these is the rising price of gasoline, a commodity most essential for these traveling 'road warriors' of mercy. Home care patients are homebound, they are so sick, so chronically ill, they cannot leave their homes without assistance. If nurses do not get in their cars to visit them, there is no way to reach them. What will be precipitated is a full- scale national emergency," added Halamadaris. The study shows that the number of miles driven by healthcare providers in the home care industry reached 4.8 billion miles in 2006. (Compared with 2 billion for UPS annually) With the expansion in the use of lower-cost home care services as the average age of the U.S. population rises, the need for these services will continue grow exponentially. While health care costs, in general, continue to rise, increasing gasoline costs have led to accelerating transportation costs for those caregivers traveling to their homebound patients. The study reviewed the number of miles driven by home health agencies, hospices, and other providers of in-home health care services. Most of this care is funded through Medicare and Medicaid programs, where fixed payment rates have not been adjusted to accommodate the increase in the cost of gasoline. The study also found that in all areas of the country, those home care providers have curtailed service areas to reduce driving, closed off care access in remote parts of a state, lost care giving staff that cannot afford commuting costs, and reduced face-to-face visits to patients to conserve limited resources. At the same time, these providers report that their patients cannot travel to physician offices or diagnostic testing sites for needed care beyond that provided in their homes. These changes in patient services make home care providers even more essential when they are the primary caregivers. Increases in other expenses, such as insurance, salaries and supplies, have also been on the rise. Further, in January 2008, the Administration imposed a regulatory cut of 2.75 percent on Medicare home health payments, nearly negating the market-based inflation update for this year. Additionally, similar cuts to home health payments in 2009, 2010, and 2011 are planned. The findings underscore the need for a series of actions to address the growing crisis in home care. Halamandaris recommends that Congress take action now through the following steps: Recognize home telehealth interactions as bona fide Medicare home health services. Require the Secretary of Health and Human Services to revise the method for calculating annual market-based inflation updates and establish a temporary fuel cost add-on. Commit to preserve the annual inflation updates for home health and hospice as provided under the Medicare law. Reinstate the 5 percent rural add-on for home health services delivered to patients residing in rural areas. Medicare pricing frozen as Congress leaves town With congressional leaders engaged in heated brinkmanship, the Bush administration yesterday gave a reprieve to thousands of doctors expecting to get hit Tuesday with a 10.6 percent cut in Medicare payments. The Department of Health and Human Services will essentially freeze the current pricing system because Congress left town yesterday for a midsummer break without approving a price fix, Secretary Mike Leavitt announced. Congressional aides said the freeze could last 10 days. If the legislative dispute lasts beyond the new deadline, Leavitt said he hopes to retroactively pay doctors once the dispute is resolved. Friday, each side accused the other of playing politics with Medicare, the program that covers many health-care costs for the nation's elderly and some people with disabilities. Feelings were particularly raw after a Thursday night Senate vote in which members yelled at one another on the floor and left Democrats one vote short of the 60 needed to pass their version of the Medicare fix. The payment cuts to doctors are part of a 1997 balanced budget deal that trims the money going to Medicare, but the doctors have regularly staved off the cuts. They argue, through their lobby, the American Medical Association, and the AARP, that slashed payments would prompt many doctors to drop out of the system. Private insurance companies make a similar argument for Medicare Advantage, a program of private fee-for-service insurers and HMOs that is targeted in the Democrats' bill. By reducing funding for Medicare Advantage, the Democrats would pay for postponing the pay cut to doctors for 18 months. The legislation could result in $14 billion less for insurers over five years, though an estimate by a conservative House Republican caucus put the tally at $47.5 billion over 11 years. The White House has threatened a veto over Medicare Advantage cuts, arguing that the Senate Finance Committee is close to working out a compromise without cutting payments to private insurers in that program. After the Senate reconvenes July 7, it will have three days to pass a fix before the HHS freeze is lifted. (Washington Post) Read the original article. Weighing the costs of a CT scan’s look inside the heart CT scans, which are typically billed at $500 to $1,500, have never been proved in large medical studies to be better than older or cheaper tests. And they expose patients to large doses of radiation, equivalent to at least several hundred X-rays, creating a small but real cancer risk. And yet, more than 1,000 other cardiologists and hospitals have installed CT scanners. Many are promoting heart scans to patients with radio, Internet and newspaper ads. Time magazine and Oprah Winfrey have also extolled the scans, which were given to more than 150,000 people in this country last year at a cost exceeding $100 million. Their use is expected to soar through the next decade. But there is scant evidence that the scans benefit most patients. Increasing use of the scans, formally known as CT angiograms, is part of a much larger trend in American medicine. A faith in innovation, often driven by financial incentives, encourages American doctors and hospitals to adopt new technologies even without proof that they work better than older techniques. Patient advocacy groups and some doctors are clamoring for such evidence. But the story of the CT angiogram is a sobering reminder of the forces that overwhelm such efforts, making it very difficult to rein in a new technology long enough to determine whether its benefits are worth its costs. Some medical experts say the American devotion to the newest, most expensive technology is an important reason that the United States spends much more on health care than other industrialized nations — more than $2.2 trillion in 2007, an estimated $7,500 a person, about twice the average in other countries — without providing better care. No one knows exactly how much money is spent on unnecessary care. But a Rand Corporation study estimated that one-third or more of the care that patients in this country receive could be of little value. If that is so, hundreds of billions of dollars each year are being wasted on superfluous treatments. At a time when Americans are being forced to pay a growing share of their medical bills and when access to medical care has become a major political issue for states, Congress and the presidential candidates, health care experts say it will be far harder to hold down premiums and expand insurance coverage unless money is spent more wisely. The problem is not that newer treatments never work. It is that once they become available, they are often used indiscriminately, in the absence of studies to determine which patients they will benefit. Some new treatments, like the cancer drug Gleevec and implantable heart defibrillators, undoubtedly save lives, contributing to the United States’ reputation for medical breakthroughs. But others — like artificial spinal disks, which can cost tens of thousands of dollars to implant but have not been shown to reduce back pain in many patients, and Vytorin, a new cholesterol drug that costs 20 times as much as older medicines but has not been proved superior — have been criticized for not justifying their costs. And sometimes, the new technologies prove harmful. Physicians were stunned, for example, when clinical trials showed last year that expensive anemia medicines might actually hasten death in kidney and cancer patients. Such drugs are used more widely in the United States than elsewhere. The problem of inadequate study is especially serious for medical devices and imaging equipment like scanners, which typically are not as strictly regulated as prescription drugs. Under Food and Drug Administration regulations, the makers of CT scanners — CT is short for computed tomography — do not have to conduct studies to prove that their products benefit patients, as drug makers do. The manufacturers must certify only that the scanners are safe and provide accurate images. Once the FDA approves a test or device, Medicare rarely demands evidence that it benefits patients before agreeing to pay for it. But last year, Medicare officials raised questions about the benefits of CT heart scans and said it would demand more studies before paying for them. But after heavy lobbying by cardiologists, Medicare backed down. Private insurers, while initially reluctant to pay for the tests, are also covering them. Physicians in this country have a free hand in deciding when to use new technology like CT angiography. Some are conservative. But others, especially doctors in private practice who own their scanners, use the tests aggressively. Further, each scan creates an additional lifetime risk of cancer that is somewhere between 1 in 200 and 1 in 5,000, said Dr. David J. Brenner, director of the Center for Radiological Research at Columbia University. Younger patients and women are at higher risk. Cardiologists who support widespread use of CT heart scans argue that they can reduce the need for other tests — like conventional angiograms, which can find plaque but require a catheter to be threaded through the arteries. Conventional angiograms are more expensive than CT scans and carry their own risks. If a CT heart scan finds plaque that a doctor intends to treat with a stent, a conventional angiogram will still be necessary to determine where and how to implant the stent. So a CT scan does not always eliminate the need for a conventional angiogram. The most valuable use of a CT angiogram may be when a patient comes to an emergency room complaining of chest pains but has few other symptoms of a heart attack. The test can quickly rule out heart trouble. But such patients represent a minority of those receiving CT heart scans. Cardiologists who oppose wide use of the scans agree that they can sometimes find dangerous blockages that require immediate surgery in asymptomatic patients. But they said such cases are extremely rare — not common enough to justify using the scans routinely, given their cost and radiation risks. Use of CT scans accelerated after 2004, when manufacturers introduced a new generation called 64-slice scanners, which are fast enough to capture images of a beating heart. Already, more than 1,000 hospitals and an estimated 100 private cardiology practices own or lease the $1 million CT scanners, which can be used for the angiograms and for other imaging procedures. Once they have made that investment, doctors and hospitals have every incentive to use the machines as often as feasible. To pay off a scanner, doctors need to conduct about 3,000 tests, industry consultants say.Fees from imaging have become a significant part of cardiologists’ income — accounting for half or more of the $400,000 or so that cardiologists typically make in this country, said Jean M. Mitchell, an economist at Georgetown University who studies the way financial incentives influence doctors. Besides generating profits themselves, the scans enable cardiologists to find blockages in patients who have no symptoms of heart problems. Doctors can then place stents in patients who would not otherwise have received them, generating additional revenue of $7,500 to $20,000 per patient. While clinical trials have not shown that stents benefit patients with no symptoms of heart disease, they are still routinely inserted in such patients when tests find significant blockages. Cardiologists joke that the phenomenon is ―ocular stenosis‖ — blockages that can be seen are stented. The Centers for Medicare and Medicaid Services had decided to push back. The agency, which this year will spend more than $800 billion on health care, rarely questions the need to pay for new treatments. But last June, Medicare said it was considering paying for CT heart scans only on the condition that studies be done to show they had value for patients. Concerned about the overall proliferation of imaging tests, Medicare said it might require a large-scale study to determine the scans’ value. The next month, Medicare issued the draft of its proposal, saying that it would pay for the scans only if a large-scale study were conducted. The CT society, along with other prominent medical groups whose members performed scans, set to work lobbying the agency and members of Congress. ―There are a lot of technologies, services and treatments that have not been unequivocally shown to improve health outcomes in a definitive manner,‖ Dr. Barry Straube, Medicare’s chief medical officer, explained when announcing that the agency would keep covering the tests. In other words, the lack of evidence that the CT scans provide measurable medical benefit would not stop Medicare from paying for them. Doctors are also discussing the creation of registries to track patients who have had CT angiograms. But now that Medicare has backed down, skeptics say it is unlikely that anyone will conduct a major clinical trial to determine if patients who receive CT heart scans have better medical outcomes than those who do not. (NY Times) Read the complete story. SterilMed’s scope exchange launches on-line store SterilMed’s Scope Exchange announced the launch of a new, customer-interactive on-line store at www.sterilmedequipmentsales.com. The search options allow facilities to browse by category of equipment (flexible, rigid, camera, video), equipment type (colonoscope, gastroscope, etc.), or manufacturer. All pre-owned equipment has been thoroughly inspected, refurbished and tested to meet manufacturer’s specifications. The site features full shopping capabilities so the purchase can be made on-line. Or, it can provide background reference before contacting one of SterilMed’s nationwide sales representatives for any questions. SterilMed is a medical device reprocessor, equipment repair service provider and pre-owned endoscope equipment specialist. Hospital readmissions publicly disclosed with new rating tool Florida became the first state in the country to publicly disclose how often patients have to go back to hospitals because of errors, infections and other potentially preventable problems. The information, called "readmission rates," was unveiled last week on FloridaHealthFinder.gov. It follows a push by Medicare and health care improvement groups to stop paying hospitals for illnesses that should never have happened. State officials say the data can be invaluable for consumers trying to make better choices. The agency announced a partnership with Florida Hospital Association to use the data to improve care. It gives hospitals information even they lacked: What happens when their patients end up at competitors. The state looked at cases where a patient went to a hospital for any of 54 procedures, then was readmitted within 15 days for something related to the first visit. Statewide, it found 60,707 patients readmitted out of 877,228 cases from April 2006 through March 2007 -- about 7 percent of the time. For each hospital, the state's analysts looked at the severity of each case and determined the likelihood it could result in a readmission. It then took the actual number of readmissions and calculated whether the hospital performed better, worse or as expected. The Web site also includes hospital-specific data on costs, mortality rates and other elements of care. You can look up a specific hospital or all the hospitals in a county at the Web site: www.floridahealthfinder.gov. Choose "Compare Hospitals and Ambulatory Surgical Centers" on the right and then follow the site's directions. (Sarasota Herald-Tribune) Study suggests a little milk could go a long way for your heart New research links drinking lowfat milk to lower risk for heart disease. Grabbing as little as one glass of lowfat or fat free milk could help protect your heart, according to a new study published in the American Journal of Clinical Nutrition. Researchers found that adults who had at least one serving of lowfat milk or milk products each day had 37 percent lower odds of poor kidney function linked to heart disease compared to those who drank little or no lowfat milk. To determine heart disease risk, researchers from several universities in the United States and Norway measured the kidney function of more than 5,000 older adults ages 45 to 84. They tracked eating patterns and tested albumin-to-creatinine ratio (ACR) – a measure that when too low, can indicate poor kidney function and an extremely high risk for cardiovascular disease, according to the American Heart Association. Researchers found that people who reported consuming more lowfat milk and milk products had lower ACR, or healthier kidney function. In fact, lowfat milk and milk products was the only food group evaluated that on its own, was significantly linked to a reduced risk for kidney dysfunction. The study authors cited other research suggesting milk protein, vitamin D, magnesium and calcium may contribute to milk's potential heart health benefits. An overall healthy diet, including lowfat milk and milk products, whole grains, fruits and vegetables was also associated with a benefit – 20 percent lower ACR or healthier kidney function. The National Kidney Foundation estimates that kidney disease affects about 26 million Americans – and kidney disease is both a cause and a consequence of cardiovascular disease, the number one killer of Americans. An estimated one out of three adults is currently living with some form of cardiovascular disease. Milk provides nine essential nutrients, including calcium, vitamin A, vitamin D, protein and potassium. The U.S. Dietary Guidelines for Americans recommend drinking three glasses of lowfat or fat free milk each day.
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