W.H.O. Issues a Checklist to Make Operations Safer

The World Health Organization issued a list of safety checks last week that aims to reduce complications and deaths from the rising numbers of operations now being performed worldwide. The list entails safety checks that will improve anesthetic safety, avoid infections and improve communication among surgical team members. According to W.H.O., these safety checks could halve the rate of surgical complications.

With the new safety checks, standards of practice in hospitals will mostly like change…the question is how it will change it.

Read the full article

Please Watch "Sick Around The World" on Frontline

If you didn't get a chance to watch the latest episode of Frontline on PBS, I highly recommend that you take the time to see it. It will help you to understand how other advanced countries have organized their health care systems, and the strengths and weaknesses of each approach.

You can watch it online by Clicking Here

This piece advances our knowledge of how health care provides better access at lower cost in other countries, while maintaining acceptable standards of quality. It dispels the belief by many Americans that only the profit motive can drive people and organizations to excel -- particularly in health care. It also shows how universal coverage can work, without necessarily going to a single payer system -- even in countries like Germany that are far more liberal than the U.S.

We can learn a lot from this program as we ready ourselves for the challenging task of transforming our health care system in the next several years.

Independent Medical Review Legislation Needed At Federal Level

The article below provides yet another example of how external medical review legislation and oversight is highly fragmented in this country, and needs unification at the national level. It also points to the need for national patient's bill of rights legislation that requires all health insurance payers to submit their appeals to independent medical review, in order to ensure fair and objective evaluation and health insurance coverage decisions.

April 04, 2008

Suit Challenging Role of Regulators in Health Plan Disputes Rejected
California Healthline - http://www.californiahealthline.org/

A panel of the 3rd District Court of Appeals unanimously rejected a consumer lawsuit, ruling that the Department of Managed Health Care does not have to help patients challenge health plans when they are denied medical care or refused coverage for specific treatments, the Los Angeles Daily Journal reports.

The panel issued the ruling on Feb. 29 but agreed to publish portions of the opinion on Tuesday after DMHC officials said they were looking to set a precedent.

Plaintiffs in the lawsuit sought to require the department, which regulates HMOs, to heighten its role in patient-health plan disputes.

Lynne Randolph, a spokesperson for DMHC, said the plaintiffs mistook the duties of the agency and the law does not require the agency to "be the go-between."

Michael McClelland, senior counsel for DMHC, said he hoped the published opinion would inform consumers of their right to an independent medical review in cases where members disagree with health plans' coverage decisions.

Read The Entire Article

National Physican Performance Standards Will Improve Patient Safety

According to this article, at long last it looks like there will be single set of performance metrics that will help payers and consumers to get objective information on physicians, BEFORE they decide to use them. If this is done right, it will be a very good thing, raising the level of transparency and supporting the continued move toward consumerism.

What we'd like to see go along with this, is a clear set of national standards surrounding peer review, that will guide hospitals and medical groups to more effectively evaluate their practitioners' performance. This is sorely needed, since many under-performing physicians are still not being scrutinized through objective, evidence-based peer review. Furthermore, with national peer review standards, ALL physicians would be effectively evaluated on a systematic basis; not only for sentinel events, but also as an integral step in credentialing, re-credentialing, granting new privileges, and as a part of periodic departmental performance evaluations.

National Standards to Rank Physicians Planned


By REED ABELSON, The New York Times
Published: April 1, 2008

Doctors and health insurers called a tentative truce Tuesday in their long-standing dispute over how health plans rank physicians’ efforts in taking care of patients.

The parties said on Tuesday that they would develop a national set of standards to measure physician performance.

While insurers increasingly have been measuring doctors’ performance through public report cards or designating tiers of physicians that try to steer people to certain doctors, so far such rating efforts have been controversial. Doctors complain that the health plans have focused too much on cost, without regard to the quality of care physicians actually provide, and that rankings are often inaccurate.

Read Entire Article

Good External Peer Review Could Have Prevented This

This physician's surgical errors were allegedly widely known to his fellow practitioners, yet no one said anything. The role of medical staff and the peer review committee is to make sure that under-performing doctors like this one are identified and evaluated through the peer review process. If the person is in a position of power or authority where his/her peers are fearful of retaliation, having an external peer review policy and vendor in place will ensure transparency and accountability.

Dr. Patel could face more than 100 years in prison, if convicted
06:44 PM PDT on Tuesday, March 11, 2008 By kgw.com and AP Staff

First New York, then Oregon, and now Australia. Dr. Jayant Patel has left a bloody trail of mistakes as a surgeon, finally resulting in manslaughter charges.
His arrest Tuesday morning started the legal clock ticking on an extradition request by Australia, where he was director of surgery at Bundaberg Base Hospital in Queensland from 2003 to 2005.

KGW Patel Arrest Story
For more information on how External Peer Reviewand
Hospital Peer Revieworganizations can help you prevent this type of catastrophe visit AllMed.

Payers Should Reward Hospitals That Are Serious About Patient Safety

This article is another example of how health insurance payers are putting more pressure on hospitals to reduce unnecessary errors as a condition for reimbursement. This raised level of accountability for quality and patient safety improvements will benefit us all in the long-term, and is something that is long overdue. However, we'd like to see payers push for a more robust set of hospital quality measures and the presence best practices, and tie their reimbursements to them consistently. For example, a hospital that is consistently using systematic external peer review (a best practice which too few hospitals follow today) should be rewarded with better reimbursements than one that is not, since they're not meeting the intent of the new Joint Commission standards for focused and ongoing professional practice evaluation.

Featured Story February 21, 2008

More Health Plans Adopt 'Never-Event' Policies That Don't Reimburse for Treatment Needed to Correct Medical Errors

Reprinted from HEALTH PLAN WEEK (formerly Managed Care Week), the industry's leading source of business, financial and regulatory news of health plans, PPOs and POS plans.

More payers say they are adopting so-called "never-event" payment policies, under which providers will not be reimbursed for procedures and treatments needed as a result of certain preventable errors made in hospitals. But choosing which errors to focus on, incorporating language into hospital contracts and auditing hospitals' claims can pose challenges, experts warn.

Read the rest of the article: http://www.aishealth.com/Bnow/hbd022108.html

Health Insurers Can Use IROs to Fairly Review Policy Cancellations

The article below from the LA Times provides an example of how health insurance carriers may increasingly be held liable for canceling health insurance policies for their members, based on "pre-existing conditions." In this case, the CEO of the company has rightly agreed to subject all future policy cancellations to external, independent review. In today's environment, health plans can ill-afford to be perceived as making self-serving policy cancellations, expecially in the middle of expensive treatment regimens. At the same time, when they are forced to provide benefit coverage for claimants that are clearly excluded according to plan language definitions, everyone ends up footing the bill.

In this type of situation, the only real way to determine what is fair is to review the medical evidence in the case. An Independent Review Organization (IRO) is set up to do just this kind of work. For health insurance payers, using an IRO for policy cancellation determinations represents an ounce of prevention that can be worth a ton of cure.

Health Net ordered to pay $9 million after canceling cancer patient's policy

By Lisa Girion, Los Angeles Times Staff Writer
February 23, 2008

One of California's largest for-profit insurers stopped a controversial practice of canceling sick policyholders Friday after a judge ordered Health Net Inc. to pay more than $9 million to a breast cancer patient it dropped in the middle of chemotherapy.

The ruling by a private arbitration judge was the first of its kind and the most powerful rebuke to the state's major insurers whose cancellation practices are under fire from the courts, state regulators and elected officials.

Read the rest of the article by clicking here:
http://www.latimes.com/business/la-fi-insure23feb23,1,5039339.story?page=1&ctrack=1&cset=true

Drug Errors & Over-Utilization - The Role of IROs

Drug errors inside hospitals and drug over-utilization are both critical issues that need to be dealt with in order to improve patient safety and reduce health care costs. The article below provides a snapshot of one aspect of this problem. As an IRO, we help hospitals, PBMs and health plans eliminate these problems, by providing independent medical reviews and hospital peer reviews that help them better manage drug delivery and costs. In the hospital environment, erroneous prescriptions can be reduced if practitioners know that their work is subject to regular outside review. For health insurance payers, drug utilization review is rapidly becoming a hot topic, since pharmacy benefits account for a large percentage of the increase in costs. IROs help bring accountability, transparency, objectivity and cost containment into the picture, which makes the system work better for everyone. --AGR

1 in 10 patients gets drug error
Study examines six community hospitals in Mass.
By Patricia Wen
Globe Staff
February 14, 2008
One in every 10 patients admitted to six Massachusetts community hospitals suffered serious and avoidable medication mistakes, according to a report being released today by two nonprofit groups that are urging all hospitals in the state to install a computerized prescription ordering system. Read the rest of the article at: http://www.boston.com/news/local/articles/2008/02/14/1_in_10_patients_gets_drug_error/

Applying Six Sigma to Hospital Peer Review

It's time to raise the discussion on how to apply six sigma quality principles to the medical peer review process in hospitals. While many "experts" are touting the value of apply lean six sigma methodologies to health care (see article below), nowhere is there more opportunity for improvement in hospital performance improvement and patient safety than in peer review. While some hospital groups have a repeatable peer review process that consistently and objectively measures practitioner performance, we talk to medical staff and peer review committee members every day who indicate the need for a holistic overhaul at their hospitals.

To achieve this, hospital leaders should start by studying six sigma principles and initiating a dialogue on how to apply them to their peer review committees. The application of these principles have positively impacted many industries, and which could be easily applied to peer review in order to raise performance, accountability and transparency. --AGR

Lean & Six Sigma: Fixing Healthcare a Process at a Time
By Carolyn Pexton

iSixSigma

With so many different issues facing the U.S. healthcare system the task of “fixing” it can seem insurmountable. Every healthcare executive knows the litany of challenges: rising costs, inadequate insurance coverage, capacity constraints, patient safety concerns, workforce shortages, increased competition, optimization of new technologies, etc. Some industry experts want a complete overhaul of the nation's healthcare system, while others tout information technology as a cure or consumer-directed healthcare as the inevitable wave of the future. Then again, for some people the problems appear so big that genuine, pragmatic and sustainable solutions are hard to envision.http://healthcare.isixsigma.com/library/content/c071121b.asp

NY Times Article on Spine Surgery

Back pain and its cure have resisted an easy answer since humans first stood up off all fours. Spine surgery is often less than successful, and the search for artificial discs, to replace discectomy (removal) and fusion has been recently a very hot topic.

The New York Times recently reveled that the so called science that got one such artificial disc FDA approved was severely compromised by conflict of interest issues, not to mention lousy science.

It turns out, per the report, that many of the physicians who inserted the discs and then reported on their benefit had, through a clever financial pass through, potential large gains if the discs were to be approved. Do you think their opinion of whether your pain had been relieved, whether the operation was a ‘success’, an improvement over other ways of doing the same thing, might be affected by the money they stood to gain if the FDA found the device effective, based on their own reports?

Furthermore, the statistical reporting of the effectiveness of the device somehow omitted 10 percent of the patients who got it. Would you guess those were the ones who really benefited? Or the opposite. Where did they go? Do you guess that omitting 10% of the initial sample had a numerical effect on how well the device worked?

Read the Article

Re-certification improves doctors' performance

This week Reuters reported on a study showing that the time elapsed since a primary care doctor's last board certification coorelated with a decline in the quality of care he provides. The study examined the electronic records of patients being treated for hypertension, an important factor in the quality of care.

The expected action by a doctor would be to step up treatment if a patient's blood pressure was high. The expected treatment was highest among internists who and passed their boards the year prior (27 percent). For every decade past doctors' certification dates, the researcher found a 21 percent drop in the possiblity that the doctors would take the expected action.

Patient's Rights Legislation Paying Off for Consumers

Patients whose healthcare treatment is deny by their insurance company have about 50-50 chance of reversing that decision says Lori Andrews, a health law professor at Chicago-Kent College of Law in Parade magazine.

Andrews notes that while the win rate can vary from state to state, about 50 percent of the patients’ challenging their denials are getting them reversed.

In part, this is due to 43 states and the District of Columbia passing Patients’ Bill of Rights acts and the increasing role of independent medical review organizations (IROs) in helping these patients get the treatment they deserve. Often healthcare-plan providers deny treatment based on issues other than the medical necessity of a treatment. Just a few of these reasons include ambiguous plan language, out-of-date exclusions and meeting financial or business objectives at odds with healthcare delivery.

Conflict of Interest In Hospitals Under Growing Scrutiny

This article points out the increased scrutiny of physicians' financial conflict of interest in hospital settings, and how it can lead to over-utilization. It also goes on to point out the opposite argument -- that physicians who are stake holders in a hospital's success tend to act in the best interests of both the hospital and patients.

One point that the article fails to mention is how conflict of interest can impact the objective evaluation of practitioner performance within the context of the hospital peer review process. We hear many medical staff members point to peer review committees that fail to properly scrutinize the performance of fellow practitioners, as a result of financial ties. On the other hand, we are also aware of sham peer review carried out due to economic rivalries.

Whichever situation you have experienced, the fact is that peer review inside the hospital is fraught with potential conflicts of interest, that can be easily identified and eliminated. The key is having the right combination of leadership, by-laws, policies and procedures and a clear commitment to using external peer review when necessary. IROs (independent review organizations) have a clear role to play in eliminating conflicts and improving hospital quality. --AGR

Featured Story January 18, 2008

Physician Financial Relationships, Conflicts of Interest Are Expected to Top List of 2008 Enforcement Targets

Reprinted from REPORT ON MEDICARE COMPLIANCE, the nation's leading source of news and strategic information on false claims, overpayments, compliance programs, billing errors and other Medicare compliance issues.

While some familiar areas are among probable 2008 targets of enforcement agencies, expect the focus to broaden, say experts. So while areas such as hospital-physician relationships will continue to garner scrutiny from the HHS Office of the Inspector General (OIG) and the Department of Justice (DOJ), whistle-blowers and health fraud investigators may also turn their attention to areas such as admission necessity, behavioral health and evaluation and management (E/M) coding.

Lawyers expect physician financial relationships to be at the top of the enforcement list. "The intense scrutiny on physician financial relationships and conflicts of interest will continue unabated in 2008," says former senior OIG attorney Howard Young. "The medical device industry may face the brightest spotlight with ongoing criminal and civil anti-kickback investigations continuing into surgeon consulting and other arrangements. And more so than in past years, this may be the year in which DOJ and OIG pursue enforcement actions against physicians who receive the alleged industry kickbacks."

Errors to cost hospitals

The Wall Street Journal reported this week that big insurers, including Aetna Inc. and WellPoint Inc., are moving to ban payments for care resulting from serious errors during hospital stays, including wrong limb operations and others. Following the federal Medicare program, these insurers are also looking at common medical errors. Medicare announced last summer that beginning in October this year, it will cease paying any extra costs of treating preventable infections or injuries that occur during a patient's hospital stay, such as bedsores, falls, objects left in bodies after surgery, surgical-site infections, blood incompatibility,

While the big insurers are targeting errors for more grievous mistakes, hospitals are concerned that the focus on more common errors will drive up their costs, because they have to implement processes and procedures to prevent such errors. Hospital's also fear this opens the door to expand payment denials for other mistakes.

Click here for a list of procedures that insurers are already denying.

Individual Mandates The Cornerstone of Health Care Reform

This article argues against "individual mandates" as a core principle of the proposals for universal health care coverage that are being implemented by states (including California), and which are being considered by the leading presidential candidates. While I understand the author's concern, I believe that his rationale doesn't hold water. Requiring all citizens to hold health insurance does not either imply or require the development of a large bureaucracy to track and enforce it. What it does do, is get everyone into the nation's risk pool, with the effect of reducing overall costs to our health care system and ensuring they are shared more equitably by all.
What do you think?

Individual Mandates for Health Insurance: Slippery Slope to National Health Care
by Michael D. Tanner
Excerpted from The Cato Institute Website

Proposals for achieving universal health insurance coverage are once again receiving serious attention. Among the ideas attracting bipartisan support is an individual health insurance mandate, a legal requirement that every American obtain adequate private health insurance coverage. People who don't receive such coverage through their employer or some other group would be required to purchase their own individual coverage. Those who failed to do so would be subject to fines or other penalties.

Michael Tanner is director of health and welfare studies at the Institute.
More by Michael D. Tanner

Proposals for an individual mandate respond to a legitimate concern about "free riders," the uninsured who nonetheless receive treatment and pass the costs on to taxpayers or individuals with insurance. In practice, however, an individual mandate is likely to be unenforceable because it would involve a costly and complex bureaucratic system of tracking, penalties, and subsidies.

More important, an individual mandate crosses an important line: accepting the principle that it is the government's responsibility to ensure that every American has health insurance. In doing so, it opens the door to widespread regulation of the health care industry and political interference in personal health care decisions. The result will be a slow but steady spiral downward toward a government-run national health care system.

Read the rest of the article here.

Presidential Candidates On Healthcare

U.S. Presidential Candidates' Health Care Plans: A Side-By-Side Comparison
Posted July 9, 2007 | 03:18 PM (EST)
huffingtonpost.com

By Susan J. Blumenthal, M.D., Jessica B. Rubin, Michelle E. Treseler, Jefferson Lin, and David Mattos*

"The next president of the United States will confront major health policy decisions that will affect the lives of all Americans. With the first of the presidential caucuses and primaries only six months away, the pressure is on for the candidates to provide Americans with their plans to improve the nation's health care system -- and rightfully so. Despite spending over $2 trillion a year on health care -- 18% of the U.S. GDP and twice as much as any other nation -- the United States ranks only 45th in life expectancy and 37th in a World Health Organization study on the performance of national health systems. 1,2 The U.S. federal government currently spends more on health care than on Social Security and national defense combined, the next most expensive items, but Americans get the right treatment only 55% of the time.3 Expenditures on health care in the United States -- already the highest per person in the world -- are predicted to nearly double by 2016, to $4.1 trillion, or 20% of GDP. That means, if this trajectory is not altered, in less than a decade, 20 cents out of every dollar produced in America will be spent on health care. Currently, more than 75% of health care dollars are spent on patients with chronic diseases, yet an estimated 80% of all chronic diseases are caused by preventable factors, such as smoking, obesity, and physical inactivity.4,5 But despite these statistics, less than 5 cents of every health care dollar is spent on prevention and public health.

A recent poll conducted by the Kaiser Family Foundation found health care to be the second most mentioned issue that Americans would like to hear presidential candidates discuss and for the government to address.6 Iraq remains the foremost concern, yet it is important to note that health care tops the list of Americans' domestic priorities. This means that no presidential hopeful can effectively meet the needs of the American people without addressing the essential issues of access, affordability, efficiency, and quality of our nation's health care system. As evidenced in the recent debates, both Democratic and Republican presidential candidates are seeking to demonstrate to the American people an understanding of health care issues and their far-reaching impact on the health, economy, and security of our country."

Read the rest of the article at http://www.huffingtonpost.com/susan-blumenthal/us-presidential-candida_b_55460.html

This article does a good job of articulating the challenges the next President will face in addressing the health care crisis that we currently face. "Access, affordability, efficiency, and quality" are critical issues that must be addressed in the next 4 years, if we are to avoid long-term economic demise.

Independent Review Organizations (IROs) are uniquely positioned to address each of these critical issues, through the delivery of services to all key constituents in the health care payor supply chain, as well as large provider organizations. IROs work with payors to reduce/eliminate over-utilization, while ensuring that consumers receive the health care coverage they deserve. This has a direct impact on health plans' ability to keep cost increases lower, will protecting the integrity of resource allocation decisions. IROs increasingly are helping hospitals to improve practitioner performance and quality, through external peer review.

As active participants in improving health care, we are both concerned and excited by the opportunities that exist for the next President to lead a true paradigm shift in our nation's health care system. It's important that we watch each candidate closely and elect the leader who has proven his/her ability as a change agent, and who is willing to take on the powerful interests that stand firmly behind the status quo.

Software Diagnosis and Quality

According to a 2003 study published in The Journal of the American Medical Association, at least one in 12 patients who die were diagnosed incorrectly. While doctors face some hard to diagnose cases, will turning to technology to bridge this gap make a difference in these numbers, or healthcare quality? Younger doctors are more comfortable with technology and are ready to rely on it. As the doctors from the baby boom retire, will automated diagnosis become more the rage?

Other businesses use software to automate business processes, but we have to question how these same processes are used in medicine, especially for diagnosis. If anything, depending on softare for diagnosing a patient confuses the issue of responsiblity. When there's a wrong diagnosis, who's responsible, the doctor, hospital, software manaufacturer? Should diagnostic software be used only for those cases that are hard to diagnose or easy to diagnose? Will the be capable of learning like doctors? What about a software bug that misdiagnoses a disease that leads to the wrong treatment? What's the role of peer review when diagnosis, and perhaps even treatment, is automated?

The diagnostic use of software raises lots of questions. A Jan. 4 ScienceLine article, "Doctor’s Diagnosis, Version 2.0" touches on some of these questions. -MM

The Poliner Case - A Lawsuit That Could Have Been Avoided With External Peer Review (?)

Most health care attorneys and hospital medical staff professionals have read about the Poliner case in Texas. While some would argue that this case is old news, nevertheless, it is still a landmark case which we can all learn from -- particularly as it relates to the do's and don'ts of effective peer review. The article below is one of many on the subject for those interested. From the outside, it seems amazing how easy it would have been for the hospital and medical staff to avoid this situation altogether, by bringing an IRO (Independent Review Organization) in to perform external peer review at the first signs of alleged practitioner performance deficiencies. Today, many medical executives committees and medical staff leaders are adopting this as a best practice, to ensure fast, objective, "same specialist" evaluation of physician performance. As the fears (and threats) of sham peer review become more prevalent, calling in external resources to provide hospital peer review in sensitive cases can eliminate real or perceived bias. In this case, one could argue that external peer review would have easily prevented this unfortunate situation from every occurring. -AGR

Texas cardiologist wins $22.5 million in suit against Dallas Presbyterian Hospital and three staff cardiologists
October 19, 2006
Shelley WooFrom: Heartwire, TheHeart.org
Dallas, TX - A Texas judge has upheld an earlier ruling against the Presbyterian Hospital of Dallas and three of its cardiologists but reduced to $22.5 million the overall damage award originally granted to a fourth cardiologist, Dr Lawrence Poliner. A jury had earlier decided on the princely sum of $366 million for Poliner after finding in favor of his claims against Presbyterian Hospital and the three physicians on charges of breach of contract, defamation, business disparagement, tortious interference with a contract, and intentional infliction of emotional distress. The defendants are appealing the decision to the United States Court of Appeals for the Fifth Circuit, the hospital announced today. Peer review: Protecting patients or physicians? The case dates back to 1998, when Poliner's cath lab privileges were suspended after a hospital peer-review process concluded that he should voluntarily stop performing cardiac catheterizations due to concerns about his safety record and technique. But Poliner, who sued in 2000, challenged that the so-called peer-review process had been biased, since the panel conducting his review comprised cardiologists competing for patients and referrals at the same hospital. His original lawsuit named 10 physicians as defendants but was ultimately reduced to Dr James Knochel, internal medicine chair, Dr Charles Levin, head of the cardiac catheterization lab, and Dr John Harper, chief of cardiology.

Read the rest of the article at http://www.theheart.org/article/748435.do

Court curbs insurers' ability to rescind medical policies

Here's an interesting article that shows how health insurance payers are under siege...Independent Review Organizations are a perfect solution to helping them do a better job of making benefits decisions, BEFORE a situation like this occurs. Health insurance carriers use IROs to make more informed claims decisions that protect patients and subscribers.

A ruling restricts the ability of California health plans to cancel coverage after patients run up medical bills.
By Lisa Girion
California health insurers have a duty to check the accuracy of applications for coverage before issuing policies -- and should not wait until patients run up big medical bills, a state appeals court ruled Monday.

The court also said insurers could not cancel a medical policy unless they showed that the policyholder willfully misrepresented his health or that the company had investigated the application before it issued coverage.

The unanimous decision by a panel of the 4th District Court of Appeal in Santa Ana is the latest blow to California insurance companies and the way they handle policy cancellations after patients get sick and amass major medical claims.

The insurers' practices are under scrutiny by the state Legislature, the Department of Insurance, the Department of Managed Health Care and the courts. In recent months, state agencies have fined, cited and sued the state's major health insurers for the way they have handled cancellations and treated policyholders.

Read More

UCLA Study Finds Limitations in Publicly Reported Quality-of-Care Indicators for Heart Failure Patients

UCLA News

Academic researchers reported that all five standard hospital-based performance measures used to gauge quality of care for hospitalized heart failure patients may not be the best benchmarks, since none were significant predictors of patient mortality during the critical 60 to 90 days immediately following hospital discharge.

Published in the Jan. 3 issue of the Journal of the American Medical Association, the study found that none of the current measures used by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which accredits hospitals, and by the federal government through the Center for Medicare and Medicaid Services (CMS) to assess hospital performance were associated with a lower risk of mortality during the days immediately following hospital discharge, when adverse events are most likely to occur.

Read More

What Money Doesn't Buy in Healthcare

www.nytimes.com

In a packed hearing room at the Food and Drug Administration last week, a panel of cardiac experts met to consider what was obviously an important question: Has one of the most popular treatments for heart disease in fact been killing some of the patients it is meant to help?

Three years ago, doctors began using a new device called a drug-coated stent — a tiny metal tube — to keep blocked heart arteries open. It cost a lot more than an uncoated stent, but because it seemed to be far more effective, it quickly began to dominate the stent market. Last year, Johnson & Johnson and Boston Scientific together sold more than one million drug-coated stents. They have become a primary treatment for this country’s No. 1 cause of death.

In recent months, though, researchers found a disturbing pattern. People with a drug-coated stent seemed unusually vulnerable to blood clots in later years. The new stents solved one problem, but they may have created another. So the F.D.A. summoned its cardiology advisers to review the evidence.

After listening to testimony, they concluded that for healthier patients with simple forms of heart disease, the benefits of drug-coated stents appeared to outweigh the risks. The picture was less clear for people with diabetes, multiple blocked arteries or other complications. In the end, the panel concluded that doctors and patients needed to be aware of the risks and that researchers should continue collecting data. The entire affair — from the invention of the new stent to the willingness to reconsider it — was in many ways an impressive display of American medicine.

Yet it was also a nearly perfect example of what’s wrong with our health care system.

Read More

Five Companies to Launch Electronic Health Files

http://www.latimes.com

WASHINGTON — Five major U.S. corporations have joined forces to create a "medical Internet" on which some 2.5 million people can compile their personal health records in one location, providing convenient access to everything from prescriptions and cholesterol readings to family medical histories.

The system, unveiled Wednesday, could reduce the chances of medical mistakes, improve treatment of chronic illnesses and eventually save billions of dollars by avoiding duplicative services, its designers say. Currently such information — often cumbersome paper records — is scattered among the files of a patient's doctors, pharmacists and other care providers, making it difficult to coordinate treatment.

If the experiment works, experts say, most of the country could follow suit in five to 10 years, though privacy advocates say stronger safeguards are needed.

Read More

Independent Review Organizations for Peer Review

http://www.physiciansnews.com

It’s no secret hospital peer review is a broken process. Its intent – improving the quality of care for patients by protecting them from substandard medical care – is an admirable goal and one that doctors and hospital risk managers agree on. Everyone wants patients to have consistent, high quality treatment. Peer review tries to assure this by having the same specialty and practicing doctors not involved in the procedure in question look over the case. In theory, doctors trained and practicing in a specialty can examine the problematic event and provide objective, unbiased determinations on its cause. They should consider whether the treatment was medically needed; whether it followed the standards of care; whether there was a sentinel event; and if so what was its cause. However the theory conflicts with application.

Unfortunately, institutions handling peer reviews internally soon find many flaws in the process. Internal peer reviews impact doctors’ time, bring out competitive and personal biases and, more often than not, the doctors conducting the reviews are not working in an equivalent subspecialty.

Read More

JCAHO Accrediting "Tourism" Hospitals

http://www.newsday.com/

A number of major hospitals involved in medical tourism have been accredited by the Joint Commission International, affiliated with the Joint Commission on Accreditation of Healthcare Organizations, or JCAHO. JCAHO accredits U.S. hospitals. However, hospitals that don't seek accreditation from the Joint Commission International might be accredited by different organizations in their own countries.

Anne Rooney, executive director for international services at the Joint Commission International in Oak Brook, Ill., said the program is "heavily modeled on the JCAHO standards but there are differences to allow for differences" in medical practices and customs in other countries.

"The organization that is accredited has gone through a rigorous external evaluation process," Rooney said, noting that the commission's imprimatur is "the gold standard around the the world."

But worldwide, Rooney said, the Joint Commission International has accredited fewer than 100 hospitals. Bumrungrad International Hospital in Bangkok, Thailand, and the Apollo Hospital in Chennai, India - both known for rolling out the red carpet and arranging lavish accommodations for medical tourists - are among them.

Hospital Peer Review Process Puts San Diego Hospital On Probation

http://www.mercurynews.com/

A San Diego hospital was placed on probation on Wednesday after a review found its pancreas center failed to perform a sufficient number of transplants, making it the latest in a string of transplant centers facing scrutiny in California.

Sharp Memorial Hospital can still perform pancreas transplants and receive organs during its probationary period, hospital officials said.

The action came after a confidential peer review by a committee of the United Network of Organ Sharing, which runs the nation's transplant system under a federal contract.

A July meeting with hospital staff uncovered deficiencies in the pancreas program including a period of inactivity when no transplants were performed for more than six months, UNOS said.

Sharp Memorial transplanted only one pancreas patient last year despite having 12 people on the waiting list. Other pancreas transplant programs in the United States performed between one to eight operations during the same period.

Malpractice Reporting Controversy In Guam

http://www.kuam.com/

Additionally Dr. Landstrom says the board cannot verify if a physician is completely truthful in his or her application for licensure or renewal. After requesting the information from the hospital, the board is pursuing legal action with its attorney. "He's working on a subpoena so we can get that information. We shouldn't have to do that," stated the physician. "We should be able to share information back and forth equally and it just looks like another stumbling block for us to do our job."

GMH quality management administrator/risk manager Ray Vega, however, has a different take on federal reporting requirements. He maintains the agency is not required to report to the Guam Board of Medical Examiners unless a physician has had his/her hospital privileges suspended or taken away for more than thirty days or if the restriction, suspension, or termination of privileges is a result of peer review. Vega added that GMH does not report to the NPDB because the hospital believes that medical settlements made on behalf of GMH are not considered reportable under the system's requirements.

Additionally GMH administrator Peter John Camacho tells KUAM News the hospital is willing to provide the information requested by the board, but he has an obligation to ensure the privacy of physicians to prevent the hospital from being sued for releasing information.

Managed Health Care In South Africa

http://free.financialmail.co.za/

Under managed care, savings are generated by ensuring that only necessary, cost-effective treatment is prescribed in line with clinical protocols and drug formularies. To ensure these rules are adhered to, schemes contract doctor networks that agree to play by MHC rules in exchange for patient volumes and/or a premium on the standard consultation fee and/or a share in down-the-line savings to the scheme.

McLeod says schemes in SA have introduced all the easy MHC tools such as hospital pre-authorisation and chronic medicine programmes, but there is still little contracting and risk-sharing between funders and provider networks.

In the US, MHC includes the use of selective networks of contracted providers; ways of encouraging members to use the networks; and some risk-sharing with those networks. "This is the crucial and missing part of MHC in SA, because it is only through developing MHC programmes, which give doctors a stake in the outcome and force them to weigh up their decisions clinically and cost-effectively that you get the change in behaviour that brings the real win," she argues.

By US standards, SA still has a fee-for-service environment that is loosely managed. A study by US consulting actuaries Milliman USA found that in such an environment funds could expect to pay R100 for a claim compared with R80 in a moderately managed environment where there was some risk-sharing. The real win comes in a vertically integrated environment (where doctors, hospitals and a funder are located within one organisation such as some of SA's mine hospitals). There the cost falls to R50.

This explains why cost escalation persists in SA in the face of rapidly rising managed-care costs.

Verdict Against Hospital Over Peer Review Affirmed

http://www.prnewswire.com

In early 1998, Dr. Poliner's competitors began raising "concerns" about
some of Dr. Poliner's cases, ultimately resulting in a suspension of his
cardiac catheterization privileges-effectively denying him the ability to
treat his patients or attract new ones, the lawsuit claims. The peer review
committee charged with considering the complaints against Dr. Poliner
consisted primarily of his competitors.

Later that year, the hospital's medical board voted to restore Dr.
Poliner's privileges after several nationally known cardiology experts
testified that Dr. Poliner's care of his patients met or exceeded the
standard of care, and that his suspension was unwarranted. Despite the
return of privileges, the board upheld the original suspension "based on
the evidence available to him [Dr. Knochel] at the time."

"Judge Solis has ratified jurors' very strong feelings that their
verdict should send a very strong message to Presbyterian and other
hospitals that this type of conduct should stop," says Mr. Lynn.

"This has been a long and difficult process for Dr. Poliner," says
original lead trial counsel Charla Aldous. "Not many people would have had
his determination and resolve. Hopefully, the jury and court's decision
will have a positive impact on the peer review process throughout the
country."

One Trillion Dollars Of Healthcare Waste

http://www.pittsburghlive.com/

Half of all health care dollars spent -- $1 trillion -- is wasted on poor quality care, safety issues and a perverse incentive plan that rewards mistakes, a leading reformer said Wednesday.

"The problem with health care is that it has become unaffordable -- and passively or actively you, employers, have the system you paid for," said Robert Mecklinburg, whose 86-year-old Virginia Mason Medical Center in Seattle was forced earlier this decade to closely examine its operations when health insurer Aetna told the provider it was too expensive.

Mecklinburg, chief of medicine at Virginia Mason, spoke at the Pittsburgh Business Group on Health's seventh annual health care symposium at the Marriott Pittsburgh City Center Hotel, Downtown.

The only way for the health care system to be fixed is for employers, those paying the bill, to stand up and say "we're not paying," said Richard P. Shannon, chairman of Allegheny General Hospital's Department of Medicine.

URAC Summit To Be Held In San Diego

http://biz.yahoo.com/

Health care management executives, quality leaders and medical professionals from across the nation will share innovative practices and address the evolving role of health care organizations at URAC's 7th Annual Quality Summit, Oct. 11-13 in San Diego. The Annual Summit attracts the country's industry pioneers and top thought leaders to examine issues at the forefront of quality and health care today.

The theme of the national Summit is "Discover New Ways to Focus on Quality." Through keynote speakers, expert panel discussions and breakout sessions, the Summit will focus attention on three critical topics in health care: consumer empowerment and protection; leadership in care coordination; and best practices in quality and accreditation initiatives.

"The consumer is taking on a more independent, responsible role in health care, and the corresponding role of health care management organizations is changing as well," said Alan P. Spielman, URAC's president and chief executive officer. "URAC's focus is to bring together the recognized leaders in quality health care to inspire ideas and lead in-depth discussion, so participants will walk away with solid business solutions that address issues in consumerism, care coordination and best practices in accreditation initiatives."

The rise of consumerism is attracting more emphasis in the health care environment. On day one of the Summit, URAC will host a general session panel discussion, led by nationally respected experts and leaders in health care to discuss the changing role of the consumer. The presentation, entitled "The Role of Consumerism in Redesigning Health Care Delivery," will offer insight from the perspectives of health plans, purchasers, and consumers. Panel speakers are Vicky Gregg, CEO, BlueCross BlueShield of Tennessee; Arnold Milstein, MD, U.S. thought leader, Mercer Health & Benefits; and Grace-Marie Turner, president, Galen Institute.

"Consumerism as we know it today is going to change over time," Gregg said. "But as far as health plans are concerned, I think the two words that are going to be tied to consumerism, regardless of products and features that may be developed, are transparent and supportive."

Many South African Deaths Due To Hospital Negligence

http://www.iol.co.za/

The committee found that 1 059 of the total number of deaths for the period under review were "directly" avoidable. These preventable deaths were linked mainly to hypertension (331), postpartum haemorrhage (261), pregnancy-related sepsis (158) and antepartum haemorrhage (100). A further 91 deaths were "anaesthetic related".

'Aids is the leading killer of women - that is clear in the report'
At district hospitals, 53,8 percent of deaths were attributed to negligent health officials, while the proportion at regional and provincial hospitals was 48,3 percent and 36,5 percent respectively. These statistics related to 3 079 of the total number of deaths that were assessed for administrative problems.

Unsuccessful resuscitation accounted for 22,3 percent of deaths, while HIV and Aids accounted for 36 percent, or 1 226, of all deaths. It is important to note, however, that the HIV status of more than 1 800 mothers was not known.

A third of all deaths was attributed to "administrative factors" such as a lack of ambulances to transport women between hospitals (9,7 percent), a lack of appropriately trained staff (12,8 percent), insufficient intensive care beds or emergency laboratory services (11,2 percent) and inadequate supplies of blood for transfusions (9,2 percent).

JCAHO Hospital Study At Odds With U.S. News Hospital Report

http://www.modernhealthcare.com/

Results of a recently published hospital quality study by the Joint Commission on Accreditation of Healthcare Organizations showed its ratings of hospitals based on treatment of heart patients was at odds with the rankings of hospitals appearing in the popular U.S. News & World Report best hospitals list, reopening the debate about whether process or outcomes measures are the better gauge of performance.

The JCAHO, which uses process evaluation, found in its study of U.S. News' rankings that 13 hospitals in the country performed better than more than 80% of the hospitals on the magazine's list of the 50 best heart and heart-surgery hospitals. U.S. News relies on hospital outcomes, such as mortality rates, and other methods in creating its rankings.

The JCAHO's effort follows a different study published earlier this year that said process-based quality evaluation methods such as the JCAHO's aren't a good predictor of mortality rates for certain conditions (July 3/10, p. 16).

And the JCAHO study, evaluating what is arguably the most established and widely read series of consumer-oriented reports on hospital performance, also comes as the JCAHO is pushing for a higher profile with the general public as a source of data on hospital performance and quality.

URAC's 3 Consumer Benefit Briefs (Press Release)

http://biz.yahoo.com/

URAC, the independent, nonprofit leader in promoting health care quality through its accreditation and certification programs, is expanding its emphasis on ways to further protect and empower consumers in an increasingly more consumer-driven health care benefits and management environment. The three issue briefs tap into the expertise of nationally recognized thought leaders to examine the issues from the perspectives of purchasers, consumers and health plans.

Consumer protection and empowerment have become a leading focus of the accreditation agency. In June 2005, URAC released its Consumer Education and Support (CES) standards, the nation's first accreditation standards to address quality within health plan products with consumer-directed features. In 2006, URAC released its next generation of accreditation standards across 11 of its accreditation programs, including new requirements for Consumer Safety Quality Improvement Projects for medical management programs. Through its accreditation programs, URAC is promoting consumer empowerment by establishing benchmarks for appropriate practices in engaging consumers as they purchase and use health plans, whether traditional or consumer-directed plans.

The issue brief released today, entitled "Health Plans Partner with Purchasers in Consumerism Drive," features observations and insights from Vicky Gregg, chief executive officer of BlueCross BlueShield of Tennessee, and John P. Weis, co-founder and chief executive officer of Quest Analytics, the software company that has linked with Health Grades, Inc. to provide a standardized method to measure and report quality outcome information on hospitals nationwide.

While consumerism is on the rise, consumer empowerment has not yet arrived. The market is still transitioning from one in which purchasers and health plans make most decisions on behalf of consumers. And the tools consumers need to make the best choices, based on both cost and quality, are still evolving.

"In the marketplace today, there's receptivity on the part of employers that consumers should have more skin in the game," Gregg said. "Health plans see increasing demand from purchasers for ways to move in this direction. Most large groups we work with view this period as a transition and are asking us, 'what are the steps that take us towards a more consumer-directed plan?' But one of the key challenges we still face is the receptivity of the actual consumer."

The second issue brief, "Consumerism Takes Center Stage As Newest Solution to Health Care's High Costs" takes the purchaser's perspective on the rapid rise of consumer-directed health care plans. The issue brief features the voices of Jerry Burgess, president and chief executive officer of the Knoxville, Tenn.-based HealthCare 21 Coalition, and Arnold Milstein, MD, MPH, medical director of the Pacific Business Group on Health and U.S. Thought Leader for Mercer Health & Benefits.

The third issue brief, "Transforming Health Care: A Consumer-Centered Model Takes Hold in the Information Age" is positioned from the consumer perspective. It features the voices of Grace-Marie Turner, founder and president of the Galen Institute, the Washington, D.C.-based public policy research organization, and Craig Froude, executive vice president and general manager of WebMD Health Services, a part of WebMD.

Consumer-directed health plans -- high-deductible plans combined with a health reimbursement arrangement (HRA) or health savings account (HSA) -- are a small but rapidly-growing segment of the health care market. Between January 2005 to January 2006, the number of enrollees and dependents covered by these plans increased from about 3 million to between about 5 and 6 million, according to an April 2006 report from the Government Accountability Office(1). Traditional health plans are also taking steps to better educate and inform consumers in the new consumer-oriented environment.

"Consumerism has experienced rapid growth, but overcoming some of these barriers will take ongoing innovation in the marketplace to ensure consumers get the information and tools they need to be comfortable as champions of their own health," said Alan P. Spielman, URAC's president and chief executive officer. "URAC is uniquely positioned to provide leadership through education and accreditation to ensure quality initiatives enhance consumerism. We are already seeing leadership emerging from health plans that are transforming their practices in ways that are measurable through URAC's Consumer Education and Support accreditation."

Study Says Physicians Unable To Self-Evaluate

http://www.forbes.com/

In fact, physicians who were judged by outsiders to be the worst performers in a given area often gave themselves especially high marks, researchers report.

"There is a subset of clinicians who appear, either by training or personality, unable to judge themselves," said study lead researcher Dr. David Davis, a professor of health policy management and evaluation at the University of Toronto, in Canada.

The findings suggest that outside evaluators might be better equipped to review a physician's performance, then direct him or her to areas that need improvement with continuing medical education.

Medical Review Of Calgary Emergency Rooms Ordered

http://calsun.canoe.ca/

CHR chair David Tuer has requested an independent board, the Health Quality Council of Alberta (HQCA), undertake a review of the services that came under fire last month when a city woman, Rose Lundy, suffered a miscarriage in a crowded waiting room at Peter Lougheed hospital.

Dr. David Megran, chief medical officer of the CHR, said a comprehensive review of the system was already in the works, but the Lundy case brought further urgency to the need to address growing problems.

"It was another reminder to us that we needed to do something," he said.

"This is a complex problem -- our frontline staff in emergency and urgent-care facilities are working very hard, are very skilled and they're under a great deal of stress.

Indepedent Review Finds Pathology Errors Lead To Australian Deaths

http://www.smh.com.au/

An independent review of thousands of pathology tests conducted at Tamworth Hospital found 217 patients' tests, some involving diagnoses for serious diseases such as cancer, had significant variations that may have adversely altered treatment and, of those, 38 were seriously affected.

The review was sparked when a routine audit in February 2004 revealed that a pathologist, Farid Zaer, had misdiagnosed over 200 patients at Wollongong Hospital.

He was suspended and the matter was referred to the NSW Medical Board for further investigation - at that time, the then Illawarra Area Health Service wrote to the New England Health Service, where Dr Zaer had previously been employed.

Who Will Pay For Hospital Construction Boom?

http://www.post-gazette.com/

Big bucks for bricks and mortar is a cause for concern, Mr. Volavka said, because it comes at a time when more people are losing health insurance because of the rising cost of health care. Construction costs work their way into that overall health care bill, he said, even though premium payers -- including those who are priced out of the health insurance market -- aren't at the table when hospitals decide to build.

At the same time, it's somewhat difficult to pinpoint precisely which building projects raise capacity concerns. Most of the new construction doesn't significantly add to the supply of hospital beds. The new Children's, for example, simply is replacing beds at the existing pediatric hospital in Oakland that will be closed.

Instead of adding beds, many of the new projects are adding space by expanding emergency rooms, cancer centers and operating rooms -- services that drive the utilization of health- care resources but don't add to the bed count.

"These are expenses that don't add beds, but they add to your capacity to fill beds," Mr. Volavka said.

Why all the construction?

For one, medical centers are getting older and are lacking the latest technology. Much of the construction simply allows hospitals to reconfigure their existing service lines, said Debra Riefner, senior vice president for corporate banking at National City Bank.

JCAHO Guidelines For Evaluating Heart Hospitals

http://www.modernhealthcare.com/

A number of hospitals ranked on U.S. News & World Report's annual list of the 50 best cardiac hospitals "fall short in routinely applying evidence-based care for their heart patients," according to a study by the Joint Commission on Accreditation of Healthcare Organizations. The JCAHO reviewed 2004 data on 774 hospitals and identified 13 that did better in adhering to treatment guidelines than 41 of the hospitals on the U.S. News list. Overall, 313 hospitals met the guidelines as well as the top 25 hospitals on the magazine's list, the JCAHO said in a report published in the Aug. 8 issue of Circulation.

URAC Committee Meets to Set Standards for Pharmacy Benefit Management Programs (Press Release)

http://www.prnewswire.com/

Patient safety and access issues,
information and financial disclosure, medication therapy management and
drug use management were the topics of discussion as a multi-stakeholder
committee charged with developing requirements for the nation's first-ever
accreditation programs for pharmacy benefits management met in Washington,
D.C. the last week in July.

The 34 members of URAC's Pharmacy Benefit Management Standards
Committee represent a wide range of players in the field: employers,
consumers, pharmacy consultants, health plans, independent retail pharmacy,
pharmacy benefits management organizations, pharmacy professional
organizations, labor, and even large public purchasing groups such as the
Office of Personnel Management and the Ohio Public Employees Retirement
System.

"We want to give members of the committee from every perspective an
opportunity to voice their positions on all the issues we have before us,"
said John J. Jones, RPh, JD, chairman of the committee and vice president
of government affairs and pharmacy policy at Prescription Solutions, a PBM
based in Irvine, Calif., part of Ovations Pharmacy Solutions. "All members
have an opportunity to bring up legitimate issues so we can address them.
It is important for us to hear a wide representation of interests so we
have a spirited debate on the issues."

Two work groups initiated efforts to create standards falling within
two broad categories. The Operations Work Group discussed standards for
operational integrity; communications, customer service and disclosure; and
pharmacy network. The Clinical Work Group discussed drug use management;
benefit design administration; patient safety; formulary development; and
medication therapy management.

URAC, the independent, nonprofit health care accrediting organization
well-known as a leader in promoting health care quality through its
accreditation and certification programs, announced in June formation of
the Committee. The Committee is charged to advise URAC on the creation of
four related accreditation programs for health plans and pharmacy benefits
management organizations providing services to both Medicare and
commercially insured populations. The committee will meet throughout the
fall and will seek additional input through public comment opportunities.
URAC's goal is to complete the development process and launch the
accreditation programs in 2007.

"The creation of standards can focus efforts on prescription benefits
management issues of key importance today, such as initiatives to improve
patient safety and to provide better access," said Alan Spielman, URAC's
president and chief executive officer.

Some Hospital Doctors Don't Wash Their Hands Enough

http://www.trinidadexpress.com/

Handwashing continues to be a key factor in controlling the spread of MRSA and this is why Dr Ashok Rattan, Medical Microbiologist based at the Caribbean Epidemiology Centre (CAREC), is now appealing to local doctors and healthcare workers to start washing their hands more frequently.

"One of the best methods of controlling MRSA is handwashing, handwashing, handwashing," Rattan emphasised during an interview at his office at CAREC last week. "Before and after touching the patient handwashing must be mandatory. But though it is a simple act, it is normally not followed."

Rattan said that "there has been many studies trying to understand why many doctors do not wash their hands. The doctors are more reluctant to wash their hands, it is the nurses who wash best. The doctors always seem to have excuses why they don't wash," he said.

He said that patients should also not be afraid to demand that their doctor "wash his hands before touching them."

Dr Rattan said that while doctors usually wear gloves "those are for his protection, and not the patient's. That is so that he does not get any infection from the patient. But if he touches the patient then the gloves should be discarded and then he should wash his hands before putting on a another pair of gloves to tend to another patient. That way bacteria are not spread from patient to patient."