AllMed Healthcare Management Blog

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

2008-07-02T11:07:00.001-07:00

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

2008-04-16T08:45:00.000-07:00

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

2008-04-07T08:55:00.000-07:00

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

2008-04-02T12:16:00.000-07:00

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

2008-03-12T13:47:00.000-07:00

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

2008-03-03T11:43:00.000-08:00

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

2008-02-25T09:05:00.000-08:00

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

2008-02-14T10:34:00.000-08:00

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

2008-02-05T10:45:00.000-08:00

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

2008-02-01T14:17:00.000-08:00

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

2008-01-25T08:18:00.000-08:00

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

2008-01-21T11:31:00.000-08:00

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

2008-01-21T07:57:00.000-08:00

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

2008-01-17T12:37:00.000-08:00

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

2008-01-15T09:10:00.000-08:00

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

2008-01-14T08:09:00.001-08:00

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

2008-01-10T11:01:00.000-08:00

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 (?)

2008-01-08T11:22:00.000-08:00

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

2008-01-03T08:44:00.000-08:00

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.

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

2007-01-10T10:01:00.000-08:00

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.

What Money Doesn't Buy in Healthcare

2006-12-15T13:28:00.000-08:00

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.

Five Companies to Launch Electronic Health Files

2006-12-11T12:50:00.000-08:00

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.

Independent Review Organizations for Peer Review

2006-12-11T11:24:00.000-08:00

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.

JCAHO Accrediting "Tourism" Hospitals

2006-09-29T17:38:00.000-07:00

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

2006-09-29T17:21:00.000-07:00

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.