late-breaking news from your medical association volume XX / no. 7 FALL 2013
state Adverse Events Draw $775,000 in Fines to 9 California Hospitals The most recent round of administrative penalties for hospital fines constituting immediate jeopardy includes two patient falls resulting in deaths, a wrong-site surgery, and a retained surgical object. At Sharp Memorial Hospital in San Diego, a surgical team took out a man’s healthy left kidney instead of his cancerous right one because the hospital did not make imaging studies available in the operating room and because the surgeon “forgot” how to log-in to see them before cutting into the patient. At Antelope Valley Hospital in Lancaster, a patient returned to the emergency department three times before doctors realized they had forgotten to remove a 9” x 6” surgical device. The device was not included in the instrument count. At Community Regional Medical Center in Fresno, a surgeon left the OR after instructing a physician’s assistant to finish the surgery, which the assistant was not trained to complete. The patient remains on life support. Since the penalties began in 2007, the state has assessed $413.3 million in fines.
DMHC Wins Lawsuit Against Physician The California Department of Managed Health Care has prevailed in a lawsuit the agency brought against a South Pasadena plastic surgeon in 2011 who repeatedly charged her insured patients for additional payments. The judgment, issued on September 26, orders Dr. Jeannete Matello to pay the DMHC $562,500 in civil penalties stemming from her attempts to inappropriately collect thousands of dollars from patients who had insurance policies regulated by the agency.
national Doctors in Residency Fail Tests of Common Courtesy According to a study conducted at Johns Hopkins Hospital and the University of Maryland Medical Center 2012, medical interns rarely bother with common acts of courtesy when they meet their patients at the hospital. In the study, interns failed to introduce themselves at the start of 60 percent of their patient encounters and failed to explain what role they play in their care with 63 percent, and failed to touch 35% of their patients either with a handshake or other reassuring gesture or with a physical exam. They failed to sit down to talk with 91 percent of their patients, and failed to ask 25 percent standard open-ended questions to elicit conversations that reveal more about the patients’ problems. When interns were asked to estimate how frequently they performed the above listed behaviors, the interns overestimated the percentage of times they complied by more than 50 percent.
Do Physicians Monitor “Yelp-type” Reviews? According to a recent study on benchmarking technology trends in healthcare conducted by ZocDoc, 85 percent of physicians monitor online reviews about themselves. In addition, an additional 35 percent look at their competitors’ reviews.
national Organ Donations Trend Down as Brain Deaths Slow Neurologic death became progressively less likely among individuals suffering brain injuries in western Canada from 2002 to 2012, with potentially worrisome implications for organ transplantation, researchers said. The percentage of patients at four referral centers in Alberta and British Columbia with severe brain injuries resulting from trauma, strokes, and other causes fell by half during the 11-year period—from 8.1% in 2002 to 4.2% in 2012. Most of the decrease was concentrated in patients with traumatic brain injury (TBI), which accounted for more than half of the 2,788 cases in the entire study. Whether the declines overall and in the TBI subgroup represented improvements in treatment was not clear from the study, but the researchers suggested that this was probably the case. Contemporary data indicate that donation after neurologic death accounts for about one-half of kidney transplants, more than three-quarters of liver transplants, more than 90% of pancreas and lung transplants, and all heart and small bowel transplants. Over approximately the same time period of the study, the researchers added, rates of deceased organ donations have stagnated or declined in some parts of Canada.
Medical Schools Report Record-Breaking Numbers The number of first-year medical students exceeded 20,000 for the first time, according to the Association of American Medical Colleges, with a total of 20,055 students enrolled in 2013 programs. The colleges of osteopathic medicine also reports 6,449 first-year students. The 2013 results reflect a 2.8 percent jump in first-time medical school enrollment and a 21.6 percent increase since 2002. Total medical school applications amounted to 48,014. Unless Congress lifts the 16-year-old cap on Medicare-supported physician training residency slots, not all medical school graduates will be able to complete their training and begin practicing medicine. It costs about $145,000 a year to train a physician, but Medicare supports only about $3.2 billion annually of the roughly $15 billion it takes to train physicians nationwide.
Patients with Private Insurance According to the Centers for Disease Control and Prevention, the number of citizens with private comprehensive insurance has dropped from a high of over 70.7 percent in 1997 to 60.3 percent in the first quarter of 2013.
Rand Study: ACA Will Reduce Out-of-Pocket Medical Spending for Many Americans According to a Rand Study, the largest increase in overall health costs is expected to be among people who become newly insured on the individual market and have incomes more than four times the federal poverty level. An estimated 3.3 million consumers are expected to spend $7,202 in 2016 under the Affordable Care Act, compared to $5,368 if the law were not in place. On the other end, the 11.5 million people who become newly insured by Medicaid will see their risk of spending at least ten percent of their income on medical costs drop from 45 percent to 5 percent.
Nurse Practitioners More Satisfied with their Job Choice Than Doctors According to a recent survey of nurse practitioners, 96 percent said they would chose to become a nurse practitioner again if they had a chance to start their careers over. Last month, the 2013 Great American Physician Survey revealed 40 percent of doctors would pick a different career if they had to do it all over again. A similar survey by Merritt Hawkins found only 13 percent of physicians are optimistic about the future of medicine The satisfaction discrepancy may be because physicians have seen their clinical autonomy and their reimbursement decline in recent years while many nurse practitioners have experienced the opposite trends.
Risk of Developing Breast Cancer According to the publication Managed Care, the risk of developing breast cancer in the next ten years by age is:
2
AGE Age 40
PERCENT 1.47%
INCIDENCE 1 in 68
Age 50
2.38%
1 in 42
Age 60
3.56%
1.in 28
Age 70
3.82%
1 in 26
FALL 2013
Top Ten Blogs for the Business of Health Care J. K. Wall, a healthcare reporter for the Indianapolis Business Times, listed ten blogs to keep a person fairly well-informed on national-level research and thought on key issues in health care. 1.
Health Affairs Blog: Mostly focuses on the financing and operations of health care than the medicine of health care. www.healthaffairs.org/blog
2. The Health Care Blog: A wide-ranging site filled with lots of different medical professionals discussing medical, financial, administrative and policy issues. www.thehealthcareblog.com 3.
Wonkblog: Select the health care tab. A leftward tilt. www.washingtonpost.com/blogs/wonkblog
4. NCPA Health Policy Blog: Insights on health news from John Goodman, the economist who dreamed up the idea of health savings accounts. The National Center for Policy Analysis always have good analysis and good reasoning to back up their positions on health care. www.healthblog.ncpa.org 5.
Economix/Uwe Reinhardt: Princeton University’s Uwe Reinhardt is another economist, like Goodman, who can put deep analysis into a highly readable form. Reinhardt and Goodman agree on little. www.economix.blogs.nytimes.com/author/uwe-e-reinhardt
6. The Incidental Economist: This blog features a mix of physicians, economists and health policy professors. It can also claim one of the only other Indianapolis-area bloggers on health care finance: Dr. Aaron Carroll, the director of the Indiana University School of Medicine’s Center for Health Policy & Professionalism Research. www.theincidentaleconomist.com/wordpress 7.
ThinkProgress: It’s worth reading to get a full-throated defense of Obamacare. www.thinkprogress.org/health/issue
8. CBO Blog: The Congressional Budget Office’s analysis of healthcare issues and the various bills introduced to reform the system. www.cbo.gov/topics/health-care 9.
AEIdeas: This conservative think tank is a good way to follow academic research and Wall Street analysis on the impact of Obamacare. www.aei-ideas.org/channel/economic-policy/health-care-economic-policy
10. Brookings: This is really not a blog, technically, but it’s a good round-up of the research and commentary by scholars at the center-left Brookings Institution. www.brookings.edu/research/commentary?topic=Health
Sleep Empties the Brain’s Dumpster Studies conducted by researchers at the University of Rochester found that in mice sleep plays a critical function that allows metabolic waste products to be cleared from the brain, which apparently cannot occur during waking hours. Real-time imaging in live mice— awake, sleeping normally, and under anesthesia—showed that both the natural and artificially induced sleep states were associated with 60% increases in interstitial space within the animals’ brains, with large corresponding increases in convective exchange of cerebrospinal fluid (CSF) with interstitial fluid. An extension of the findings is that the restorative function of sleep may be due to the switching of the brain into a functional state that facilitates the clearance of degradation products of neural activity that accumulate during wakefulness. The purpose of sleep has been among the biggest puzzles in the history of science. Until now, even the most advanced technologies have been unable to determine firmly why people die when deprived of sleep for long enough. Earlier studies have shown that beta-amyloid levels in interstitial fluid are higher in rodents and humans when they are awake than when they are asleep, which had prompted speculation that wakefulness promotes beta-amyloid release. Waking the animals led to sharp drops in periarterial (reflecting CSF channels) and parenchymal fluid influx into the animal’s brains, the researchers found. In a separate experiment, putting mice to sleep with anesthesia caused increases in fluid movement through CSF channels.
One in Five ICU Patients Get ‘Futile’ Care In a new report, UCLA critical care specialists say that 11 percent of 1,136 patients under their care in five intensive care units received aggressive treatment the doctors considered futile, at a cost of $2.6 million for three months, and another 8.6 percent were “probably” receiving futile care. The authors state that the report is intended to be a wake-up call about the use of medical technologies and tools. These tools need to be appropriately applied, and if not appropriately applied, medicine ends up extending the dying process, not benefiting the patient in the ICU, and probably not benefiting the family, and using resources that could be better used elsewhere. The article was published in JAMA Internal Medicine on September 9, 2013. FALL 2013
3
FIRST CLASS MAIL U.S. POSTAGE PAID SAN MATEO, CALIF PERMIT NO. 668
ADDRESS SERVICE REQUESTED RETURN POSTAGE GUARANTEED 777 MARINERS ISLAND BOULEVARD, SUITE 100 SAN MATEO, CALIFORNIA 94404
national Congress Moves SGR Forward Toward Repeal The Senate Finance Committee and House Ways and Means Committee have released a joint, bipartisan statement for repealing the sustainable growth rate (SGR) formula and replacing it with a new Medicare physician payment system. This is a discussion draft, and legislative language has not been released, so important details are not yet known. Some of the key provisions in the draft are: •
The SGR formula is repealed.
•
Annual fee schedule payment updates would be frozen for 10 years; annual positive updates would begin in 2024.
•
A new “value-based performance (VBP) payment program” would be used to adjust payments beginning in 2017. This new VBP program essentially combines all the current incentive and penalty programs (e.g., value-based modifier, meaningful use, PQRS) into one budget-neutral program. Payments could be increased or decreased significantly, depending on how well a physician scores relative to others on a composite performance score.
•
Physicians participating in certain alternative payment models, including the patient-centered medical home, would be exempt from the VBP program. Revenue thresholds are established for APMs other than the medical home model, and two-sided risk and a quality component would be required to qualify for a 5% bonus in 2016-2021.
•
Several proposals to “ensure accurate valuation of services” under the physician fee schedule are made.
•
Appropriate use criteria would be applied to certain imaging services; prior authorization requirements would be imposed on outliers.
The AMA is in the process of reviewing the proposal and identifying areas that need further clarification, in order to offer constructive recommendations for improving the framework of this draft.
4
FALL 2013