Catholic Health Initiatives (CHI), a large nonprofit health system based in Colorado, has dropped plans to develop a “wholly owned and nationally driven” insurance business, reports The Wall Street Journal. Instead, it’s going to sell portions of the health-insurance business it has now.
Its announcement comes in the wake of some other big systems saying that they would get into the insurance business and others saying that they would get out.
Once more, fear and chaos triumph!
Fierce Healthcare reported that Dean Swindle, chief financial officer and president of its enterprise business lines for CHI, didn’t agree to an interview on the latest news, but told the WSJ in April that “it’s tough in the health plan business. You lose money. You make mistakes. You plow forward. It takes cash.”
Fierce reported: Many hospitals face difficulties establishing an insurance arm, Eric R. Wagner, executive vice president for insurance and diversified operation for MedStar Health… told FierceHealthcare last year: “There is more volatility associated with insurance. You need to be prepared mentally to take on that volatility and truthfully not to panic when you have a bad month.”
In addition to CHI, The Wall Street Journal noted that Tenet Healthcare, based in Dallas, and WellStar Health System and Piedmont Healthcare, both in Georgia, also will exit the insurance business because of financial losses.
Even as some staff reported improvements, Columbia. Md.-based MedStar Health still had computer problems days after a crippling hack locked up data on its systems.
The virus was “ransomware,” which encrypts files, making them inaccessible to the original users.Hackers have demanded an $18,500 payment for the keys to decrypt the data, The Baltimore Sun reported. Paper records are looking better and better….
When Charles Thompson of Greenville, S.C., checked into the hospital one July morning in 2011, he expected a standard colonoscopy. He never anticipated how wrong things would go.
Partway through, a doctor emerged from the operating room to tell Thompson’s wife, Ann, that there had been complications: His colon may have been punctured. He needed emergency surgery.
Thompson, now 61, almost died on the operating table after experiencing cardiac distress. His right coronary artery required multiple stents. He also relies on a pacemaker. “He’s not the same as before,” said Ann Thompson, 62. “Our whole lifestyle changed — now all we do is sit at home and go to church. And that’s because he’s scared of dying.”
When things like this happen, questions arise: Who’s responsible? If treatment makes things worse — meaning that a patient needs more care than expected — who pays?
It depends.
Despite provisions in the Affordable Care Act that put added emphasis on quality of care, entering the hospital still carries risk. Whether because of mistakes, infections or plain bad luck, those who go in don’t always come out better. More than 400,000 Americans die annually in part because of avoidable medical errors, according to a 2013 estimate published in the Journal of Patient Safety.
In 2008, the most recent year studied, medical errors cost the country $19.5 billion, most of which was spent on extra care and medication, according to another report. If a problem such as Thompson’s stemmed from negligence, a malpractice lawsuit may be an option. But lawyers who collect only when there’s a settlement or a victory may not take on a case unless it’s exceptionally clear that the doctor or hospital was at fault.
That creates a Catch-22, said John Goldberg, a professor at Harvard Law School and an expert in tort law. “We’ll never know if something has happened because of malpractice,” he said, “because it’s not financially viable to bring a lawsuit.”
That leaves the patient responsible for extra costs. Ann and Charles Thompson maintain that he experienced an avoidable error. The hospital denied wrongdoing, she said, but the physician’s notes indicated that they had been advised of the risks of the procedure, including injury to the colon.
The Thompsons tried pursuing a lawsuit but couldn’t find a lawyer who would take the case. The hospital and the doctor declined to comment, with the hospital citing patient privacy laws. Because of his heart problem, which led to the loss of his specialized driver’s license, Thompson lost his truckdriving job. He lost the health insurance he had through his job, depriving him of help in paying for follow-up care.
The couple paid close to $600,000 out of pocket, depleting their life savings. They struggled to pay other bills until Thompson was awarded disability benefits, his wife said. “You would expect if [health-care providers] make the mistake, they would make you whole,” said Leah Binder, president of the Leapfrog Group, a nonprofit organization that grades hospitals on their record of preventing errors, injuries, accidents and infections. “But that is not what happens. In health care, you pay and you pay and you pay.”
There’s no single rule for how hospitals handle the cost of care when patients have bad outcomes and fault is disputed, said Nancy Foster, vice president for quality and patient safety at the American Hospital Association. Some hospitals have rules requiring that a patient be told right away if something happened that shouldn’t have and, to the best of the institution’s knowledge, why.
Typically, those rules stipulate that if the hospital finds that it erred, the necessary follow-up care is free. Hospitals may not have an obvious financial interest in admitting guilt, though research suggests that patients are less likely to sue when hospitals are transparent about medical mishaps.
“If the [need for further] care was preventable, we’re waiving bills,” said David Mayer, vice president of quality and safety for MedStar Health, which operates 10 hospitals in the Baltimore/Washington area.
Virginia’s Inova Health System has a similar policy, said spokeswoman Tracy Connell. Most hospitals don’t have such rules, said Julia Hallisy, a patient-safety advocate from California.
That may change: A number of professional and safety groups are urging more hospitals to adopt them. Supporters include the American College of Obstetricians and Gynecologists, the American Medical Association, Leapfrog, the National Quality Forum and the Joint Commission, which accredits many health-care organizations. The federal Agency for Healthcare Research and Quality is also on board.
But even when they tell patients that something went wrong, hospitals may say it was unavoidable. Then, patients often pay for the consequences, directly or through their insurance. Determining error can be straightforward, Mayer said, in such instances as misdiagnosis or operating on the patient’s left leg when his problem was with his right leg.
Other times, providers follow correct procedures but things go wrong. Then, hospitals can deny culpability. “Some things happen, and it’s hard to tell if it could truly have been avoided,” Binder said. If hospitals don’t agree to pay for unexpected care, employers might push them to do so because absorbing such costs might eat into the firm’s profits.
On average, a privately insured patient cost about $39,000 more — $56,000 vs. $17,000 — in hospital bills when surgery led to complications than when it did not, according to a 2013 study in the Journal of the American Medical Association.
People with employer-based insurance — 147 million Americans this year — who have experienced complications or otherwise gotten worse while in the hospital should contact their benefits offices, especially if they can show hospital error, Binder said. If that doesn’t pan out, insurance plans may step in.
When insurers add hospitals to their networks, they sometimes stipulate how to handle certain errors. For some mistakes, the hospital may provide necessary follow-up care for free, part of a “bundled payment,” said Clare Krusing, a spokeswoman for America’s Health Insurance Plans, a trade group. For that to apply, complications must clearly stem from bad treatment. In other situations, patients can complain through the insurer, which should work with the hospital to determine who’s responsible.
Patients, Krusing said, shouldn’t pay for what’s out of their control. And if the hospital doesn’t provide financial assistance, insurance should cover these unexpected expenses once the patient has met his or her deductible.
“Patients don’t normally think about these issues — and who would? They don’t think of any of these issues until they’re right in the middle of it,” patient-safety advocate Hallisy said. “At that moment, they’re completely shocked and overwhelmed to think that this is how this works.”
MedStar Georgetown University Hospital during one of Washington’s paralyzing two-inch snowfalls.
In an obvious effort to build on its affluent clientete, “MedStar Georgetown University Hospital has applied to build a new six-story, $560 million building featuring a 33-bay emergency room, a surgical pavilion with expanded operating rooms, underground parking and a rooftop helipad, ” The Washington Post reported.
“This facility {is meant] to accommodate the natural growth in terms of our market: Northwest Washington, near-in Maryland, Chevy Chase and near-in Northern Virginia,” Richard Goldberg, M.D., president of the hospital, told The Post.
The Post noted that “MedStar’s application for approval would undoubtedly improve facilities at the existing hospital, but it comes as the District continues to struggle with broader geographic and racial health disparities.
“For instance, recent research from Rand Corp. with the support of the D.C. Cancer Consortium found far fewer providers offer cancer treatment and palliative care east of the Anacostia River, and that ‘cancer incidence and mortality among black residents of the District are dramatically higher than for white residents of the District.”’
“MedStar Georgetown is near two other highly rated hospitals that are competing for market share in Northwest D.C. and the nearby suburbs; it is two miles from George Washington University Hospital and three miles from Sibley Memorial Hospital, which has been affiliated with Johns Hopkins Medicine since 2010.”
“Meanwhile residents of the rest of the District have less enviable options for emergency and specialty medical care. Howard University Hospital, in Shaw, was the recent subject of a takeover after suffering deep financial losses. The beleaguered United Medical Center remains the only full-service hospital east of the Anacostia River.”
Patricia Quinn, director of policy at the D.C. Primary Care Association, told the paper that, in The Post’s words, “she hoped that officials from the District’s State Health Planning and Development Agency would push MedStar Health, a $4.6 billion, nonprofit health system, to do more to partner with community health organizations on cancer treatments and other services.”
During a recent physical, Jeff Gordon’s doctor told him that he may be pre-diabetic. It was a quick mention, mixed in with a review of blood-pressure numbers, other vital statistics like his heart rate, height and weight, and details about his prescription for cholesterol medication. Normally, Gordon, 70, a food broker who lives in Washington, D.C., would have paid it little attention.
But his physician, who recently joined MedStar Health, uses the system’s Web portal that allows him to share his office notes with patients. For Gordon, seeing the word “pre-diabetic” in writing made it difficult to ignore, and he took action.
He contacted MedStar about joining a pre-diabetes clinical study. In the course of taking the tests required to participate, the otherwise healthy septuagenarian found out his blood sugar wasn’t elevated enough to qualify.
Still, the experience of seeing the term in his doctor’s notes was a “wake-up call,” inspiring him to pay more attention to his diet and exercise. “It’s harder to ignore when it’s in your face,” he said.
This kind of note-sharing got a kick-start five years ago when researchers from Harvard Medical School joined forces with the Pennsylvania-based Geisinger Health System and Harborview Medical Center in Seattle to launch a high-profile pilot program called Open Notes. The initiative focused on encouraging healthcare providers to give patients access to doctors’ office notes and then tracked what happened when patients read them. Even before the project, some providers had independently shared notes, but since the organized effort began, interest has grown.
Now, Open Notes estimates about 5 million people see physicians who share notes as part of the initiative, said Tom Delbanco, a professor at Harvard Medical School who has been with the project since it launched. That includes doctors from more than 20 institutions across the country, consisting of major academic medical centers and health systems ranging from the Cleveland Clinic to the Veterans Health Administration to Wellspan, in Maryland and Pennsylvania. And even beyond the project’s participants, there is a trend among physicians — such as Gordon’s doctor — to move in this direction, too.
It’s part of the health system’s growing focus on patient engagement – the idea that more informed people will take better care of themselves, improving their health while lowering costs. This emphasis is driven in part by the federal health law, which links Medicare payments to how well hospitals and doctors do at getting and keeping patients healthy.
The trend is also fueled, experts suggest, by components in the health law and the earlier financial stimulus law that set out financial incentives for doctors to use electronic health records and better connect with patients online.
Advocates say that open notes could fundamentally shift the doctor-patient relationship by making it less paternalistic, putting patients in a position to catch mistakes and have more informed conversations with their physicians. But others worry the practice could curb honesty in what doctors write about their patients, or cause confusion if patients misinterpret what’s written.
What doctors write is hardly the stuff of state secrets. Some portions are technical to the point of dullness. Other portions offer clear, valuable advice.
In one note, shared by a patient who requested his name be withheld due to privacy reasons, a doctor wrote, in the context of a potential diagnosis of a hand deformity condition called Dupuytren’s contracture, that the patient’s “sensation is intact in the medial, ulnar and radial nerve distribution.” Hard to understand, yes, but still helpful to the patient for tracking the condition. Even more helpful, perhaps, is the physician’s summary of the condition: “It is very early, so we just need to monitor it.”
Some healthcare providers, though, worry patients might misuse the information – attempting to diagnose themselves or declining beneficial treatment because they misunderstand what’s written. That isn’t out of the question, said Jan Walker, a research associate at Harvard and Beth Israel Deaconess Medical Center, who also worked on the Open Notes project. “We certainly believe so far, the good far outweighs the bad,” she said.
Kenneth Burman, director of endocrinology at MedStar Washington Hospital Center, said he independently began sharing his notes with patients years ago, mailing them a private copy. When patients read their notes, he said, they can actually “understand the diagnosis and the recommendations.” Patients will look things up, he added, and occasionally correct references to things like family history, or add relevant details he might have missed.
Though he can’t document it, he said patients are generally better about following through with treatment if they get to read their notes. “It helps the patient understand the disease process and what the course of action should be,” Burman said.
How patients respond to this disclosure varies. Some use notes as helpful reminders while others use the information to challenge a physician’s recommendation and help rule out a diagnoses.
For Kent Snyder, 63, a lawyer from Portland, Ore., note-sharing was particularly helpful when he developed arthritis-like symptoms and vision trouble – part of an autoimmune condition doctors still haven’t been able to figure out.
Reading what his doctors had written, Snyder said, helped him focus conversations on “key salient issues” – for instance, correcting physicians about symptoms he’d actually experienced, which in turn allowed them to rule out potential diagnoses.
Looking at his notes, Snyder added, meant he better understood why doctors ordered certain procedures or treatments.
“It’s not just money – I don’t want to take an antibiotic unless I absolutely have to,” he said. “I don’t want to have a test if I don’t need it.”
Patients’ abilities to fix errors in their records could encourage providers to adopt note-sharing, especially if it could reduce the odds of doctor mistakes, said Steven Weinberger, CEO of the American College of Physicians, which represents internal-medicine doctors.
But while doctors and patients said they knew anecdotally of patients finding and fixing mistakes when looking at their notes, Walker said there’s no research measuring how common it is and what effect it could have on patient outcomes or satisfaction.
Some physicians worry that sharing notes could require them to change what they write so it’s easier for patients to understand, Weinberger said. Peter Elias, an Auburn, Maine-based physician, said colleagues often worry they might have to omit things for fear of confusing or upsetting patients. But, he added, sharing notes makes him have important conversations he might otherwise have skipped.
When patients see what doctors write, he said, “it makes the difficult conversations essential. You can’t skip them anymore.”
