Healthcare in the USA today.

[missy]

"

Yet Another Issue Is Disrupting the Healthcare Workplace​

— Responding to portal messages in "real time" is just the latest assault​

by Harry Severance, MD January 10, 2023

Now that patients have online access to their medical information there have been several articles and posts published recently about the increase in patientsopens in a new tab or window seeking -- in real time -- information and explanations about clinical results appearing on their charts. There are also reports now appearing noting that many healthcare facilities are increasingly seeking to billopens in a new tab or window patients for these interactions.
Growing Work Loads: A Case Study

I have been working with one physician colleague concerning evolving changes in his long-standing healthcare workplace and his accelerating feelings of frustration, burnout, and dissatisfaction.
He tells me now that a "final straw" has just been added: real-time health portal messages.
He reports that he used to derive satisfaction from his work, feeling that he was helping people -- the reason, he states, that he sought a career in healthcare. However, the evolving changes in his long-time workplace have now essentially destroyed all that.
Over time, he's seen other changes to his workplace too. The changes began when the facility switched physician contracts to "employee" status. Shortly after, his clinic administrator upped the cap on the number of allowable clinical patient evaluations, first from 4 to 5 per hour and more recently, up to 6 per hour. He told me the per hour cap was originally set based on the complexity and type of patient seen in this clinic. However, in his view the higher caps appear to be an attempt by the facility to increase revenue.

Within the 6 per hour, he reports that usually one to two are new patient evaluations. The facility administration has additionally announced that they expect the majority of interactions to be billed as a "level 3" (or higher).
(A level 3 clinical established follow-up has a typical time of 15 minutesopens in a new tab or window with an actual performance range of 20-29 minutes in 2021, and a new patient E/M level 3 typical time is 30 minutes with the 2021 range averaging 30-44 minutes.)
Six patients each at 15 to 29 minutes per patient, per each 60 minutes? You do the math.
While it's true that administrators frequently overbook clinic visits due to no-show patients who then leave holes in the schedule, this particular clinic has always had a very low percentage of no-shows. This patients per hour computation also does not factor in any additional time for any procedures that might have to be performed.
The physician is also expected, during these time periods, to periodically walk over to an adjacent clinic area to interact with and review the progress of the NP that he is now required to supervise.

He reports that moving to a six patients/hour schedule with these parameters and NP coverage has significantly degraded his ability to keep up, and he reports that his administrator told him recently that she was forced to report him for the increasing delays in patients being seen in a timely fashion in his clinic.
He has attempted multiple times to voice his concerns about these changes to the facility leadership through the appropriate channels, but has not yet even received an acknowledgement, much less a reply to his concerns.
Now, on to the "last straw." Recently, increasing numbers of patients phone calls have been coming into the clinic related to lab tests, imaging studies, and other performance data that this clinic's patients can now access online.
As the number of calls increase and as the facility investigates "billing" for these interactions, he reports that the facility has decided he needs to answer these calls "in real time" as they come in, and take whatever time necessary to fully explain lab and test results to these patients.

Previously, before returning these calls, he had been trying to review and familiarize himself with the report results such as lab tests, or other imaging studies that have been queried -- especially if the results might provide bad news. He would return these calls after his last on-site patient left the clinic, along with the multiple preauthorization peer-to-peer calls he is required to perform with insurance companies.
Yet, despite the new demand to respond right away, he has not been given more time in the clinical schedule to review the information or take the calls. He is still being held to the 6 patients/hour time frame -- and being dinged when he falls behind.
He finds the new approach to these calls profoundly stressful for both him and the patient, and they are leading to distraction and potential loss of focus when he returns to the next on-site patient waiting to be seen. He's concerned this distraction could contribute to medical errors.

He has also tried to share his concerns about increased medical risks with the administration -- but again, with no response.
A Dwindling Workforce
The combination of the increase in patients-per-hour, supervision of mid-level personnel, and now patients calling in during clinical time for results has become, for him, the last straw.
In evaluating his current options, he is not able to migrate to other geographically local facilities due to a non-compete clause he was required to sign when the practicing physicians at his facility were converted to "employee" status, with facilities aggressively attempting to enforce such clauses in his locale.
So, while he felt he was in a previously successful mid-career timeline, he is now considering leaving clinical practice and moving into a non-patient care setting -- or even non-medical setting.
Another good physician (with excellent patient reviews and performance ratings) chewed up by the dystrophic, toxic healthcare workplace. Of course, he's not alone -- too many other doctors and nurses likely feel similarly.

So, it's surprising to me that I am increasingly asked on a regular basis why more and more doctors and nurses are quitting healthcare and why the specter of unionization is starting to appear in the healthcare workplace.
Harry Severance, MD,opens in a new tab or window is an adjunct assistant professor in the department of medicine at Duke University School of Medicine in Durham, North Carolina.
"

 

[missy]

"

Drug Prices Are Too Damn High​

— It's been a long road to Medicare price negotiation ... and there's still work to be done​

by N. Adam Brown, MD, MBA September 1, 2023

Brown is an emergency medicine physician and business expert.
Remember the "Rent is Too Damn High Partyopens in a new tab or window" from the early 2000s, which starred New York City mayoral and gubernatorial candidate Jimmy McMillan? While this single-issue campaign didn't find electoral favor, it was attention-grabbing, even earning features on Jimmy Kimmel and Saturday Night Liveopens in a new tab or window.
I've been thinking about the campaign's message as the fever surrounding pharmaceutical pricing has spiked. I not only raise this campaign with my University of North Carolina MBA students when we discuss the issue, I've also asked them to write a paper taking a position: Are drug prices too high, or are they on the mark?

While I don't tell my students what to conclude, I believe the answer is clear.
Like housing prices, drug prices are too high. And that's exactly what the Biden administration concluded as well.
Drug Prices Are Damn High
The cost of prescription drugs in the U.S. consistently eclipses prices in other countries. They are a staggering average 156% higheropens in a new tab or window, in fact.
Drug companies argue domestic costs are higher because the U.S. drives medical innovation and we subsidize care in other countries. They say, given the substantial challenges of drug development, including high rates of trial failures and lengthy research timelines, recouping research investments is crucial if we want future breakthroughs. We should make other countries pay first before doing anything else here, they argue.
While that may be true, it is also true that current prices are too damn high for most Americans to get the care they need.

Consider these statisticsopens in a new tab or window:

• 66% of American adults rely on prescription medications.
• 40% of Americans say they struggle to pay for medications.
• Many Americans skip doses or cut pills in half to make their prescriptions last longer.
• 90% of Americans say their drug costs are higher or the same as the year before.
• The top five drug companies last year made more than $80 billion in profit.

There are downstream effectsopens in a new tab or window when a patient doesn't take their medications. Diseases and disorders worsen, leading to more expensive conditions. That leads to higher spendingopens in a new tab or window by patients, insurance companies, and taxpayers (because of Medicare and Medicaid).
EpiPens and insulin serve as stark examples of too-high prices. In the case of insulin, a life-sustaining medication for millions, the inexplicable price hikesopens in a new tab or window over the past years have left many in dire straits. Prices for EpiPens have surgedopens in a new tab or window to astonishing heights. It is difficult to believe profits from these two relatively well-known drugs are driving innovation. In reality, they are likely padding bottom lines. Americans cannot live without these medications. Why not exploit that fact? Especially when, as in the case of many life-saving medications, you have a monopolyopens in a new tab or window on the market. Soaring costs are often less about innovation and production expenses and more about capitalizing on a captive market.

How Did We Get Here?
In 2003, the Bush administrationopens in a new tab or window introduced Medicare Part D, which aimed to reduce elderly Americans' drug cost burden. Over the years, this law expanded and gradually closedopens in a new tab or window the infamous Medicare Part D "donut hole," providing relief to countless beneficiaries (although the hole still exists).
But there was a catch: the legislation that authorized Medicare Part D did not allow the federal government to negotiate drug prices. It banned this tool from being used, in fact.
Democrats in Congress at the time warnedopens in a new tab or window this ban would mean Medicare Part D would fuel drug industry profits while doing little to increase innovation or improve care. That is exactly what happened, and because the government could not negotiate, U.S. taxpayers paid what drug companies charged, and Medicare beneficiaries paid higher copays for lifesaving drugs.
Over the years, the healthcare industry has tried to compensate for the absence of price negotiation and curb rising drug prices. One method was by leveraging pharmacy benefit managers (PBMs)opens in a new tab or window, entities that act as intermediaries and negotiators between patients, pharmacies, and insurance companies. Unfortunately, these middlemen only introduce complexities into the market that contribute to escalating drug costs.

And, as the healthcare market has become more vertically integrated (today, it is hard to separate PBM from insurers), drug prices still rose. (That's right, those pesky near-monopolies strike again...)
In Comes the Inflation Reduction Act
Even though the U.S. Department of Veterans Affairsopens in a new tab or window has been able to negotiate drug prices for years, the Centers for Medicare & Medicaid Services (CMS) only won that right with last year's passage of the Inflation Reduction Act (IRA). Until then, CMS was only able to determine what drugs the agency would buy.
Two parts of the IRA focus on drug pricing: pricing caps and negotiating with drug companies. Both components take an incremental approach to reform, so it will be a while before taxpayers and patients see the true effects of this change. (Still, when taken in its entirety, the Congressional Budget Office predicts the IRA will save taxpayers $238 billionopens in a new tab or window over the next 10 years.)

Here is what the IRA doesopens in a new tab or window with regard to pricing caps:

• Mandates insulin must be available at $35/month per covered prescription
• Ensures access to recommended adult vaccines without cost-sharing
• Institutes a yearly cap ($2,000 in 2025) on out-of-pocket prescription drug costs in Medicare
• Expands the low-income subsidy program (LIS or Extra Help program) under Medicare Part D to 150% of the federal poverty level starting in 2024

The IRA goes further with regard to Medicare Part D drug price negotiations and limiting the rate at which drug companies can raise prices. CMS just announced the first 10 drugsopens in a new tab or window for which it plans to negotiate the "maximum fair pricing," with implementation by 2026.
As expected, some drug manufacturers have filed lawsuitsopens in a new tab or window asserting the IRA is unconstitutional. While they cite First Amendment rights violations and others, these companies are probably not worried about their free speech rights. They more likely are worried about declining revenue. Drug manufacturers want to continue to charge U.S. taxpayers more for drugs than they do other countries, and they want to continue to make significant profits. They don't want anyone on the opposite side of the negotiating table.

As noted above, drug company supporters argue the U.S. government's role in negotiating drug prices could stifle innovation. While profitability is the engine of innovation, how much profitability is needed to innovate is not clear. The smallest drug companies with the least revenue actually have the most drugs in developmentopens in a new tab or window. Early-stage biopharma companies (not those targeted by Medicare negotiations) are responsible for 80% of the drug pipelineopens in a new tab or window. The profits from the largest drug companies (those targeted by Medicare) mostly go to stock buy-backs, not innovation.
Even in the name of innovation, patients and taxpayers should not be forced to take the price given to them. The federal government sets parameters of pricing for all sorts of vendors all the time. Consumers, represented by CMS, deserve to have a seat at the negotiating table.
N. Adam Brown, MD, MBA,opens in a new tab or window is a practicing emergency medicine physician, founder of ABIG Healthopens in a new tab or window, and a professor at the University of North Carolina's Kenan-Flagler Business School. Previously he served as president of emergency medicine and chief impact officer for one of the nation's largest national medical groups.
"

 

[missy]

"
WSJ opinion
Follow

[COLOR=var(--headline-font-color)]The Doctor Is In, but the Patient Is Out of State​

​

[COLOR=var(--secondary-text-color)]New Jersey puts patients at risk by restricting their telehealth options. I’m suing to change that. [/COLOR]​

[/COLOR]


By
Shannon MacDonald
Jan. 19, 2024 2:02 pm ET


YOU MAY ALSO LIKE

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[COLOR=var(--secondary-text-color)]Wonder Land: Covid-19 disrupted people’s private lives. Biden addressed concerns with a $6 trillion spending spree that's had little effect on them. Images: SMG/Zuma Press/AFP/Getty Images Composite: Mark Kelly
[COLOR=var(--primary-text-color)]Boston
State emergency orders during the Covid pandemic made it possible for patients in one state to consult with doctors in another via telephone and internet. Those orders have now expired, however, and that flexibility has ended. With limited exceptions, doctors can practice medicine only in states where they are licensed and where their patients are physically present.
In 2009, I began treating a 9-year-old from New Jersey who had been diagnosed with a brain tumor, medulloblastoma. His oncologists felt he needed the treatment and expertise of a big-city hospital, so they referred him to me. Though the boy and his family traveled between states for appointments, he remained my patient at all times. I fielded his parents’ questions, discussed his imaging, and proposed new therapies when others failed. He received state-of-the-art treatment and benefited from the continuity of care across state lines (though he relapsed and died years later).
Instead of enlightening local governments about the benefits of telemedicine, the pandemic highlighted what physicians are forbidden to do. While I never hesitated to pick up the phone to call the boy’s parents and give them advice, I wouldn’t legally be able to do that now because New Jersey has decided that a simple phone call constitutes the practice of medicine. Giving medical advice to an out-of-state patient over the phone can put me at risk of losing my license, and, in states such as California and New Jersey, of criminal charges as well.
At the initiation of a telemedicine visit, doctors at some hospitals must now ask patients where they are, document the location in the medical chart, and end the visit if the patient is in another state. Hospital lawyers may even instruct physicians to avoid giving medical advice by phone to their in-state patients who are temporarily out of state for vacation or work, a scenario that could affect any of us. This is callous and in conflict with a physician’s ethical obligations.
In response, many patients drive to “telemedicine parking lots” in states where their physicians are licensed. Sick people are sitting in their cars and talking to their doctors using cellphones when they could be in the comfort of their homes.
At the outset of the pandemic, some state medical boards feared that telehealth would enable out-of-state doctors to poach patients from local physicians, especially in rural communities. State health authorities also didn’t want the hassle of pursuing malpractice claims across state lines. These concerns were unfounded. Fees and carve-outs—for example, restricting interstate telemedicine to specialty care or requiring referrals—could address these issues without undue limits on access, as could a requirement that physicians adhere to the laws of the state in which the patient is located.

The benefits of telemedicine outweigh any hypothetical concerns. Rural areas lack specialists, but rural residents need specialized healthcare as much as anyone. Distant specialists, accessible to rural residents by phone, shouldn’t be thought of as competitors to rural physicians but as resources capable of extending patients’ lives.
Without interstate telehealth, I’d have to become licensed in all the states where my patients live if I wanted to continue treating their rare childhood cancers or bone tumors. Because I believe strongly in the benefits of telehealth, I have obtained licenses in six states through the Interstate Medical Licensure Compact. Doing this took months, cost thousands of dollars, and still leaves me unable to care virtually for patients in 43 states. The process is so cumbersome that less than 1% of physicians use it.
Because of those burdens and my inability to care legally for my patients unless they travel to my states of licensure, with the help of the Pacific Legal Foundation I am suing the medical board in New Jersey to end its restrictions on access to specialty telehealth care. I am challenging New Jersey’s rules that only physicians licensed in-state may care for patients using telehealth. The Constitution gives Congress the authority to regulate interstate commerce and prohibits states from erecting barriers on their own. The First Amendment also prohibits states from singling out certain speech for limitation. Calls with patients before and after treatment are simply conversations.
Military doctors have long been able to practice medicine across state lines. In 2018 it became legal for sports-team doctors to practice medicine during out-of-state away games. If we can make a law that allows treatment across state lines for a National Football League player, can’t we consider it for a child with a brain tumor?
As a doctor, I want to provide the proper care for my patients no matter where they are, and I shouldn’t have to risk losing my license—or jail time—to do so. Because states have failed to modernize physician licensure, it’s time for the courts to weigh in.
Dr. MacDonald is a radiation oncologist at Mass General Brigham and an associate professor at Harvard Medical School.
"[/COLOR][/COLOR]

 

[LilAlex]

^ Did not read the whole thing but there are licensure restrictions that drive this. Your doc needs to be state-licensed in the US in the state where they are providing care -- unless they are providing care under a national umbrella like the Department of Veterans Affairs. Same with legal advice and some other things.

Seems strange to think of state-to-state variations in how medicine is practiced -- vs. law where it is obviously all dependent upon the unique legal and tax structure of each state. But this gets at the whole abortion thing: legislators can't force doctors to practice medicine bad medicine -- except through the creation of bad state laws.

 

[Amber St. Clare]

Karl, I see a nurse practitioner too for something and I also find her well qualified and I’m very satisfied.

I got the flu for Christmas and was treated by a PA. I can say in all honesty that she spent much more time and attention on me than most doctors I have seen recently. And unfortunately, because my health went into the crapper I've seen A LOT of them. My neurologist was the only other doctor who actually took her eyes off the computer, listened and answered all our questions. I had to call on a Sunday and was amazed when she called back within 1/2 hour.
When I was hospitalized I think the 'consults" lasted no more than 45 seconds. I kid you not.

 

[Slickk]

I too have had very competent PAs who have spent far more time with me than Drs. I almost prefer them nowadays. I did have a wonderful infectious disease Dr who spent 1.5 hrs with me on my initial visit. I felt so comfortable and understood by the time I left. So rare.

 

[Ibrakeforpossums]

It's a sh*tshow. Former administrator was a crooked MBA, current one is an incompetent RN. We're independent, not part of any ACO, and we're struggling. And six patients an hour is not possible. It's criminal.
The nurse who takes your call to your doctor is a hero, believe me.

 

[missy]

I agree with all those who have said their PA, NP are great. It's not the degree. It's the specific person treating you. If they are good, conscientious etc. There are great MDs and not so great MDs. There are great NPs and not so great NPs. There are great PAs and not so great PAs etc and so on and so forth. Unfortunately healthcare in the USA has become more big business than caring for the specific individual and putting them first. I have observed a lot over the past four plus years and let me tell you I am not wrong. The care many are getting now is abysmal and we have all the non healthcare people involved to thank for this. The corporations who only are about profits. The non medical people running hospitals and such. And the health insurance companies who never have your best interest at heart. Never. It always comes down to dollars first. Just being the realist I am. One must always advocate for oneself and fight for your good healthcare.

I agree with @Ibrakeforpossums it *is* criminal

 

[missy]

^ Did not read the whole thing but there are licensure restrictions that drive this. Your doc needs to be state-licensed in the US in the state where they are providing care -- unless they are providing care under a national umbrella like the Department of Veterans Affairs. Same with legal advice and some other things.

Seems strange to think of state-to-state variations in how medicine is practiced -- vs. law where it is obviously all dependent upon the unique legal and tax structure of each state. But this gets at the whole abortion thing: legislators can't force doctors to practice medicine bad medicine -- except through the creation of bad state laws.

Sorry Alex, just seeing your reply. The state laws suck. Big time. During the pandemic many laws were suspended so those who needed healthcare (not easily accessed due to distance) could get good healthcare. This was a big plus and benefited many. And now the laws are back in place and are becoming more and more restrictive. And who are the people paying the ultimate price? The patients. The laws do NOT protect us as they falsely say. No. It protects the healthcare providers and the big businesses that run them in each state so they do not lose profits. The patients never come first. That is wrong. Not everyone lives in an area with competent healthcare providers. And it is unacceptable that they cannot get good healthcare now. Due to the pre pandemic laws being put back in effect. It should not be this way. For example if you are an MD and deemed competent to practice in one state you should be allowed to practice in all states. Cmon. Let's work for the patients best care and not against their best interests. IMO. And unfortunately drs are being forced to practice less than great care due to time constraints etc put on them by people who are not in the profession. People who have NO business dictating the care of patients. Yet the reality is they do and it absolutely affects good care. IMO of course. Yours might vary but I am up close and front and center and I observe a lot. It's appalling tbh. Unacceptable. And all the MDS I speak to feel exactly the same.

 

[missy]

From Medscape
"

Mega Malpractice Verdicts Against Physicians on the Rise​

Publish date: February 2, 2024
By Alicia Gallegos


In December, in what’s known as the “Take Care of Maya” case, a Florida jury returned a record $261 million verdict against Johns Hopkins All Children’s Hospital, St. Petersburg, Florida, for its treatment of a young patient and her family after an emergency room visit.

A month earlier, in New York, a jury ordered Westchester Medical Center Health Network to pay $120 million to a patient and his family following delayed stroke care that resulted in brain damage.

Mega malpractice awards like these are rising against physicians and hospitals around the country, according to new data from TransRe, an international reinsurance company that tracks large verdicts.


“2023 blew away every record previously set among high medical malpractice verdicts,” said Richard Henderson, senior vice president for TransRe. “If we look at the 50 largest verdicts in 2023 and average them out, we have a higher monetary amount than any other year.”

In 2023, there were 57 medical malpractice verdicts of $10 million or more in the United States, the data showed. Slightly more than half of those reached $25 million or more.

From 2012 to 2022, verdicts of $10 million or more ranged from 34 in 2013 to 52 in 2022, TransRe research found.

While New York, Illinois, and Florida typically saw the highest dollar verdicts in previous years, so-called “nuclear” verdicts now occur in states like Utah and Georgia where they once were uncommon, said Robert E. White Jr., president of TDC Group and The Doctors Company, a national medical liability insurer for physicians.

A rollback of tort reforms across the country is one contributor, he said. For example, Georgia’s cap on noneconomic damages is among those that have been ruled unconstitutional by courts. Utah’s cap on noneconomic damages still stands, but the limit was deemed unconstitutional in wrongful death cases. In 2019, a portion of Utah›s pre-litigation panel process was also struck down by the state’s Supreme Court.

“We used to be able to predict where these high verdicts would occur,” Mr. White said. “We can’t predict it anymore.”

Research shows a majority of malpractice cases are dropped or settled before trial, and claims that go before juries usually end in doctors’ favor. Plaintiffs’ attorneys cite large jury verdicts in similar cases to induce settlements and higher payouts, Mr. White said.

And while mega verdicts rarely stick, they can have lasting effects on future claims. The awards lead to larger settlement demands from plaintiffs and drive up the cost to resolve claims, according to Mr. Henderson and Mr. White.

“Verdicts are the yardstick by which all settlements are measured,” Mr. White said. “That’s where the damage is done.” The prospect of a mega verdict can make insurers leery of fighting some malpractice cases and motivate them to offer bigger settlements to stay out of the courtroom, he added.

Why Are Juries Awarding Higher Verdicts?​

There’s no single reason for the rise in nuclear verdicts, Mr. Henderson said.

One theory is that plaintiffs’ attorneys held back on resolving high-dollar cases during the COVID pandemic and let loose with high-demand claims when courts returned to normal, he said.

Another theory is that people emerged from the pandemic angrier.

“Whether it was political dynamics, masking [mandates], or differences in opinions, people came out of it angry, and generally speaking, you don’t want an angry jury,” Mr. Henderson said. “For a while, there was the halo effect, where health professionals were seen as heroes. That went away, and all of a sudden [they] became ‘the bad guys.’ ”

“People are angry at the healthcare system, and this anger manifests itself in [liability] suits,” added Bill Burns, vice president of research for the Medical Professional Liability Association, an industry group for medical liability insurers.

Hospital and medical group consolidation also reduces the personal connection juries may have with healthcare providers, Mr. Burns said.

“Healthcare has become a big business, and the corporatization of medicine now puts companies on the stand and not your local community hospital or your family doctor that you have known since birth,” he said.

Plaintiffs’ attorneys also deploy tactics that can prompt higher verdicts, Mr. White said. They may tell a jury that the provider or hospital is a threat to the community and that awarding a large verdict will deter others in the healthcare community from repeating the same actions.

Juries may then want to punish the defendant in addition to assessing damages for economic harm or pain and suffering, Mr. White said.

“I am concerned that jurors are trying to right social wrongs rather than judging cases on the facts presented to them,” added Mike Stinson, vice president for policy and legal affairs for the Medical Professional Liability Association.

Third-party litigation financing also can lead to mega verdicts. That’s an emerging practice in which companies unrelated to a lawsuit provide capital to plaintiffs in return for a portion of any financial award. The firms essentially “invest” in the litigation.

“What this does is provide an additional financial backdrop for plaintiffs,” Mr. Henderson said. “It allows them to dig in harder on cases. They can hold out for higher numbers, and if nothing else, it can prolong litigation.”

Do High Awards Actually Stick?​

Multimillion-dollar verdicts may grab headlines, but do plaintiffs actually receive them?

Rarely, said TransRe, which tracks the final outcomes of verdicts. In many cases, large verdicts are reduced on appeal.

In the Maya case, which involved child protection authorities, a judge later lowered the damages against Johns Hopkins All Children’s Hospital by $47.5 million.


A federal judge in October, for example, rejected a record $110 million medical malpractice award in Minnesota, reducing it to $10 million. The district judge ruled the award was “shockingly excessive” and that the plaintiff should either accept the $10 million award or retry the case.

After a verdict is awarded, the defendant typically challenges the award, and the case goes through the appellate pipeline, Mr. Henderson explained. A judge may reduce some elements of the verdict, he said, but more often, the plaintiff and defendant agree on a compromised figure.

Seattle medical liability defense attorney Jennifer Crisera has experienced this firsthand. She recalled a recent case where a plaintiff’s attorney demanded what she describes as an unreasonable amount to settle a claim. Ms. Crisera did not want to give exact numbers but said the plaintiff made an 8-figure demand and the defense offered a low 7-figure range.

“My impression was that plaintiff’s counsel believed that they could get a nuclear verdict from the jury, so they kept their settlement demand artificially high,” she said. “The division between the numbers was way too high. Ultimately, we had to let a jury decide the value.”

The plaintiff won the case, and the verdict was much less than the settlement demand, she said. Even so, the defense incurred trial costs, and the health provider was forced to endure the emotional stress of a trial that could have been avoided, Ms. Crisera said.

Higher medical malpractice premiums are another consequence of massive awards.

Premium rates are associated with how much insurers pay on average for cases and how frequently they are making payouts, Mr. White said.

Medical liability insurance premiums for physicians have steadily increased since 2019, according to data from the Medical Liability Monitor, a national publication that analyzes liability insurance premiums. The Monitor studies insurance premium data from insurers that cover internists, general surgeons, and obstetrician-gynecologists.

From 2019 to 2023, average premium rates for physicians increased between 1.1% and 3% each year in states without patient compensation funds, according to Monitor data.

“Nuclear verdicts are a real driver of the industry’s underwriting losses and remain top of mind for every malpractice insurance company,” said Michael Matray, editor for the Medical Liability Monitor. “Responses to this year’s rate survey questionnaire indicate that most responding companies have experienced an increase in claims greater than $1 million and claims greater than $5 million during the past 2 years.”

However, increases vary widely by region and among counties. In Montgomery County, Alabama, for instance, premiums for internists rose by 24% from 2022 to 2023, from $8,231 to $10,240. Premiums for Montgomery County general surgeons rose by 11.9% from 2022 to 2023, from $30,761 to $34,426, according to survey data.

In several counties in Illinois (Adams, Knox, Peoria, and Rock Island), premiums for some internists rose by 15% from $24,041 to $27,783, and premiums for some surgeons increased by 27% from $60,202 to $76,461, according to survey data. Some internists in Catoosa County, Georgia, meanwhile, paid $17,831 in 2023, up from $16,313 in 2022. Some surgeons in Catoosa County paid $65,616 in 2023, up from $60,032 in 2022. Inflation could be one factor behind higher liability premium rates. Claim severity is a key driver of higher premium rates, Mr. White added.

“We have not seen stability in claims severity,” he said. “It is continuing to go up and, in all likelihood, it will drive [premium] rates up further from this point.”




"

 

[kenny]

UGH! What a fustercluck!

 

[LilAlex]

The laws do NOT protect us as they falsely say

Maybe you think I was advocating for this? I was not. I was just explaining how state licensure works for physicians. I do not see that changing -- certainly not in some states where there is a perception that "coastal" medicine is a grave threat.

...a Florida jury returned a record $261 million verdict against Johns Hopkins All Children’s Hospital, St. Petersburg, Florida, for its treatment of a young patient and her family after an emergency room visit.

Yeah, this is nuts. Bankrupting an entire health care system is not going to serve anyone's interest. A close relative sustained life-changing injuries when he was struck by a car this past year. Not one penny. A dear colleague was permanently brain-injured when they were rear-ended at a stop-light. Not one penny. OTOH, if you are fortunate enough to be injured by a rich person or a rich corporation in the US, your attorney's will get themselves you a big payday. Even when a plane goes down and the airline is at fault, they do not pay out a quarter-billion per passenger like this settlement you are quoting.

 

[missy]

Maybe you think I was advocating for this? I was not. I was just explaining how state licensure works for physicians. I do not see that changing -- certainly not in some states where there is a perception that "coastal" medicine is a grave threat.



Yeah, this is nuts. Bankrupting an entire health care system is not going to serve anyone's interest. A close relative sustained life-changing injuries when he was struck by a car this past year. Not one penny. A dear colleague was permanently brain-injured when they were rear-ended at a stop-light. Not one penny. OTOH, if you are fortunate enough to be injured by a rich person or a rich corporation in the US, your attorney's will get themselves you a big payday. Even when a plane goes down and the airline is at fault, they do not pay out a quarter-billion per passenger like this settlement you are quoting.

No I understood you were not advocating for it. More madness happening. The government is cracking down on compounding pharmacies. And it’s hurting so many people. It’s unreal. There are meds we need compounded for various reasons not the least among them the fact that mainstream pharmacies can’t get many back ordered meds. That’s where compounding pharmacies are critically needed. I’m so exhausted with dealing with all the red tape. Shame on the government. Instead of protecting people they just put their noses where they do not belong.

I am so sorry about your colleague and your relative.

 

[missy]

"

Emergency rooms are not okay​

It has now reached a crisis point. It is killing people.​

KRISTEN PANTHAGANI, MD, PHD AND KATELYN JETELINA FEB 8

​

​

We are slowly coming down from a peak in respiratory illness. This past winter was a real test. How will our hospitals—the safety net of our society—fare, given the combination of:

1. Year 4 of a pandemic with a new threat to our repertoire,
2. A recent surge of respiratory viruses,
3. An aging population, and,
4. A massive infrastructure problem decades in the making.

The answer is in—our hospitals are overwhelmed. And it has now reached a crisis point. It is killing people.
Emergency medicine doctors across the country have been sounding the alarm. Americans are noticing it too. In a recent poll, nearly half of Americans said they avoid the ER—avoid critical care they need—given the wait times.
Here’s what is happening on the front line and how to fix it.

A dangerous hospital overload problem called “boarding”​

The emergency room (ER) is the front door of the hospital. Patients come and are quickly seen by a physician, who addresses medical emergencies and other needs. After evaluation and treatment, many are well enough to go home, and some require admission to the hospital. Those admitted patients are seen by the inpatient team of doctors and taken to a hospital bed upstairs.

​

Figure by YLE
But what if there are no open beds upstairs? Those patients wait in the ER until a bed opens. These patients are called “boarders.”

​

Figure by YLE
Over the last two decades, this problem has grown and grown, causing a nasty clog. We haven’t fixed it, and it’s now overwhelming ERs nationwide.

The fallout​

Boarding patients are waiting hours, days, or even weeks in the ER. It creates an unsafe environment for patients:

• Dangerous medical errors: ER boarding is associated with increased medical errors, worse patient outcomes, and higher risk of in-hospital death. A recent study found that an extra hour of boarding was associated with a 16.7% increase in the odds they would require a higher level of care in the hospital (i.e., they were going to the floor, but now need the ICU.)
• Death: In a nationwide survey, multiple ER physicians reported deaths that occurred because their ER was overwhelmed with boarding. For some, the backlog of patients is so bad that patients are dying in the waiting room before they can see a doctor.

Here’s why:

1. Waiting too long. Critically ill patients in the waiting room may not be recognized fast enough, and patients may leave because of the wait, only to come back the next day much sicker than before.
2. Unsafe nursing ratios. Unlike inpatient floors and the ICU, there are often no caps on the number of patients an ER nurse is assigned. In the ICU, each nurse has 1-2 patients. In the ER, a single nurse can have 7 patients or more, some requiring ICU level of care.
3. No inpatient doctor. Normally when a patient is admitted to the hospital, the ER doctor’s role ends and the inpatient doctor takes over, freeing up the emergency physician to see new patients. For boarding patients, often there is no inpatient doctor. Instead, emergency physicians are ordering critical medications and checking on boarding patients when they can. But realistically, they can only do so much while still responding to all the new cardiac arrests and strokes coming through the door.

​

Why is boarding happening?​

The primary problem is not the number of patients coming to the ER. It’s the lack of open beds upstairs. A recent NEJMcommentary provided some insight:

• No buffer in the hospital. To optimize revenue, hospitals try to keep their beds full, which means there’s little buffer for predictable surges of patients.
• Weekend delays. Many hospital operations stop on weekends. Patients who otherwise could be discharged are delayed because a service they need is not available.
• Prioritizing elective surgeries. Elective surgeries bring in more money, so sometimes hospitals prioritize beds for surgeries instead of sick patients waiting in the ER.
• Nursing home shortages. Sometimes patients are ready to be discharged, but no nursing home bed is available. (Or a bed is available, but their insurance hasn’t approved it yet.)
• Staffing shortages. As we learned during the pandemic, it doesn’t matter if we have an open bed upstairs if there isn’t staff for it.

How do we fix this?​

Hospitals are financially disincentivized from fixing this problem. We need regulatory institutions to step in. The Centers for Medicare and Medicaid Services (CMS) is a strong player as they certify hospitals to receive Medicare funds, define safety standards, can require public reporting of hospital data, and manage many “pay for performance” programs. If CMS approves a new quality measure focused on boarding, it has the potential to do 3 things:

1. Get data. We do not have national data on the boarding crisis because hospitals are not required to report it. We are dependent on on-the-ground anecdotes, which hospital staff are often afraid to share. CMS can require public reporting of this data.
2. Set standards. Currently, there are no standards defining how long patients can board in the ER or how many patients a single ER nurse can cover.
3. Create better financial incentives. Once publicly reported, quality measures may be used in pay-for-performance programs that would reward hospitals that best manage capacity challenges by minimizing boarding.

A new CMS clinical quality measure on boarding is finally in the works, but it’s not yet approved. For a limited time (until February 16, 2024), the public can comment on this proposed measure and provide input. Typically, only parties invested in ignoring the problem comment. I’m asking you to change that:

• ER physicians/nurses/staff: Look at the proposed metrics to track boarding, and provide any input you have here. These are metrics that hospitals would be required to report if the CMS measure is approved.
• Everyone else: If you don’t have the time or experience to comment on the specific metrics, then go to the second page of the survey, and tell your stories about ER boarding. Thousands of responses from all of you will show CMS this is a giant problem that needs to be fixed.

Bottom line​

Emergency rooms are the only place in the U.S. healthcare system that will never turn a patient away. And we don’t want them to. But a backlogged ER is the canary in the coal mine—our inadequate healthcare infrastructure showing its massive cracks. It is unsafe, and we must fix this.



"


This was our experience with my dad. He was in the ER for over 24-48 (?) hours...admitted to the hospital but waiting for a room. 89 yo with a broken femur and surrounded by many others sick with Covid and in a similar situation. All waiting for rooms and all in beds in the ER. Admitted but no rooms available. In a NYC hospital

 

[missy]

"

Senators Thrash Pharma CEOs for Pricing Drugs Higher in the U.S.​

— Sen. Bernie Sanders blamed "corrupt" system, well-paid lobbyists​

by Cheryl Clark, Contributing Writer, MedPage Today February 9, 2024

Senators pummeled the CEOs of three of the largest pharmaceutical companies with demands that they explain why one in four Americans can't afford their prescription drugs, prices of which are higher in the U.S. compared with other wealthy nations.
"How many die as a result of that? How many suffer unnecessarily? Nobody knows. But my guess, it is in the millions," said Sen. Bernie Sanders (I-Vt.), chair of the Senate Health, Education, Labor, and Pensions Committee, which on Thursday held its second hearing on the topic of high drug costs.

Facing the lawmakers were Johnson & Johnson CEO Joaquin Duato, MBA, and Merck CEO Robert Davis, JD -- who had refused to appear before the committee until Sanders threatened in January to subpoena them -- and recently named Bristol Myers Squibb CEO Christopher Boerner, PhD, who had volunteered to appear.
Sanders gave examples of the companies' "outrageous" prices, noting that Bristol Myers Squibb's anticoagulant apixaban (Eliquis) costs $7,100 a year in the U.S., but just $900 in Canada and $650 in France; Johnson & Johnson's arthritis drug ustekinumab (Stelara) costs $79,000 in the U.S. but $20,000 in Canada and $12,000 in France, and Merck's cancer drug pembrolizumab (Keytruda) costs $191,000 in the U.S. but $112,000 in Canada and $91,000 in France. The bulk of the companies' international profits are coming from U.S. sales, Sanders said.
Furthermore, the drug prices have been increasing much faster than inflation, he added.
The companies' executives would say "it's not their fault, and that the PBMs [pharmacy benefit managers] are forcing Americans to pay much higher prices," Sanders said. And they'd point to the high cost to develop new drugs, "and how often the research they undertake for new cures is not successful. They're right."

But, Sanders continued, "let's be clear. The overwhelming beneficiary of these high drug prices is the pharmaceutical industry."
He pointed out that Bristol Myers Squibb spent $3.2 billion more on stock buybacks and dividends in 2022 than it spent on research and development, while Johnson & Johnson spent $46 billion more on stock buybacks and dividends than it spent on research and development since 2012. "In other words, these companies are spending more to enrich their own stockholders and CEOs than they are in finding new cures and new treatments," he noted.
How Do They Get Away With That?
High CEO compensation was also in Sanders' crosshairs during the more than 3-hour discussion.
In 2022, Johnson & Johnson's CEO received $27 million; Merck's CEO was paid $52 million, and Bristol Myers Squibb's CEO took home $41 million, he said.

"The United States government does not regulate drug companies, with very few exceptions," he said. "The drug companies regulate the United States government ... in a corrupt political system" in which their well-paid lobbyists -- 1,800 last year in D.C. -- "make sure Congress did their bidding."

For the past 25 years, the entire pharmaceutical industry spent over $8.5 billion on lobbying and more than $745 million on campaign contributions, Sanders said. "If you want to know why you're paying the highest prices in the world, America, that's why."
The CEOs generally defended their pricing policies, blamed external forces such as insurance companies and pharmacy benefit managers, touted their coupon and patient assistance programs, and stressed the high cost of drug development.
Duato said the average cost to bring a drug through clinical trials is more than $2 billion.
Boerner noted his company's drugs transformed HIV/AIDS "from a death sentence into a chronic condition." Moreover, its immunotherapy drugs nivolumab (Opdivo) and ipilimumab (Yervoy) "harnessed the body's immune system to fight cancer" and "changed the median life expectancy from less than 9 months to over 6 years."
In 5 years, said Davis, Merck has helped nearly 800,000 patients get their products for free, "an estimated value of $7.8 billion."

He blamed "underlying systemic and structural issues," as well as "vertically consolidated players ... whose negotiating strength has increased dramatically," and growing gaps between list and net prices.
Comments like that prompted Sen. Tammy Baldwin (D-Wis.) to speak up when her turn came, saying that it's hard to follow the money flow.
She touted a bill she is sponsoring with Sen. Mike Braun (R-Ind.) that would require pharma disclosures for certain spending, such as for research and development, executive pay, advertising, and stock buybacks, whenever a pharmaceutical company wanted to raise the price of a drug by a certain amount.
Baldwin recalled a conversation with former HHS Secretary Alex Azar, JD, former president of Eli Lilly, with whom she had shared a letter from a constituent with two sons who had diabetes and couldn't afford the medication they needed.
"What do I tell this dad?" she asked him. "Azar responded, 'it's complicated,'" she said. "I can't tell my constituents that we can't address this because it's complicated."

When she tried to get experts to "follow the money, nobody could," she added.
Not all of the committee members saw fault with the pharma companies' positions.
And one, ranking member Sen. Bill Cassidy, MD, (R-La.) called the entire hearing a "show trial" that was "unserious and cynical."
"Everybody on this panel cares about the high cost of prescription drugs and wants to work on real solutions," Cassidy said. But "this hearing is not about finding legislative solutions," in part because the committee rejected the offer to invite top executives with subject matter expertise. Instead, the committee decided to "publicly attack private citizens for being successful under capitalism ... and demand these CEOs come before the committee for a public, verbal stoning."
Cassidy said the problem is far greater and more complex than individual companies.
However, most of the senators who spoke during the hearing wanted more answers from these executives, and a better understanding of how drugs' price points change from research lab to the patient.

Patent Gimmicks
Sen. Maggie Hassan (D-N.H.) noted her concern about how pharma companies maintain exclusive rights to sell their drugs after they should expire.
Pharmaceutical companies "are doing everything they can to keep their prices and their profits sky high," she said. One way they do that is by filing "hundreds of frivolous patents that lock in their exclusive right to sell their drugs for decades. By playing games like this with the patent system, companies block low-cost alternatives, like generics, from coming to market."
She pointed out that pembrolizumab has 168 patents, many of which are "patent gimmicks and loopholes [that] delay other companies from selling lower-cost versions of these medications, all the while raising the price ... year after year after year."
"Human health and life is priceless," she said. "If that's the metric here, you will always have an excuse for increasing prices for these life-saving drugs."

"

 

[missy]

"

Needy families are losing government benefits​

Social safety net programs are supposed to help Americans in crisis, such as those who don’t have jobs; families struggling to put food on the table; and parents who can’t afford medical care for their children. But evidence shows that experiencing a crisis, especially related to housing, is actually associated with more difficulty getting health-related government aid, not less. This is particularly true for children. A paper published in the journal Pediatrics this month found that children whose families were forced to move due to rising rents, evictions or financial reasons were more likely to lose government benefits, such as Medicaid and food assistance. That means less access to medical care and necessary nutrition. “The move can harm health,” says Kathryn Leifheit, an assistant professor of pediatrics at the University of California, Los Angeles’s medical school, who was the study’s lead researcher. Leifheit’s team analyzed data gathered from Baltimore and Philadelphia and found that 26% of kids who moved for money-related reasons lost access to Medicaid or food assistance. That’s higher than the rate for kids who moved for other reasons, or kids who didn’t move at all. The link between evictions and losing Medicaid coverage is well-documented, Leifheit says. A 2022 study documented that connection in New York City. But Leifheit’s research shows the association also exists for other government food aid programs – the Supplemental Nutrition Assistance Program, or SNAP, and the Special Supplemental Nutrition Program for Women, Infants, and Children, otherwise known as WIC. Leifheit was surprised at the large percentage of kids who lost benefits even though they didn’t move — that stood at 20%. There are a number of reasons that might happen, she says — people might need to go to an office in person to keep receiving benefits, which can be difficult. Requirements for remaining in various programs can differ. “There’s a tremendous administrative burden that we put on people,” Leifheit says. “Even if you’re not moving, it’s just hard to stay in these systems.” The federal government has been changing policies implemented during the Covid-19 pandemic that made it easier for people to stay enrolled in these programs. For example, automatic Medicaid enrollment stopped last year; so far, at least 16.9 million people have lost coverage, according to KFF. Leifheit’s paper didn’t show if moving caused people to lose benefits, or if the benefit changes forced people to find a new home. The latter would be concerning, she says, because so many people have lost access recently. “A lot of families, at a population level, en masse, are losing benefits, all at once,” Leifheit says. “We might see a subsequent wave of cost-driven moves.” – Ike Swetlitz "

 

[AprilBaby]

I feel very blessed to have fabulous healthcare in my area. The local Dr went into the big conglomerate as did almost everyone else but he stayed the same patient, kind, listening Dr. He refers me to others like him. Everything I have needed I have gotten in less than 2 weeks. Blood work and results online same day, the same for X-rays and CT. I’m having an MRI Tuesday and if I need surgery I will get it in the next two weeks. I am one of the few that has no complaints about my healthcare.

 

[Amber St. Clare]

I was seriously sick for over a year and the final costs {excluding scripts} came to a little less than $750,000. {5 operations}. It costs $2,000 just to go to admittance and get a plastic band on your wrist. Like AprilBaby I have incredible health insurance and had to pay less than $1,000; but believe me, our insurance premiums are sky high.

While I was in the er I was amazed to hear other complaints--constipation, sore throat, earache-- taking up time and resources for those who are in real need of urgent care.

I don't know what the answer is, but something has to give.

 

[missy]

"

How the Change Healthcare Cyberattack Affects Oncology Care​

Publish date: March 7, 2024
By
Patricia McKnight

An ongoing cyberattack, lasting more than 2 weeks, has had a substantial impact on cancer practices and their patients in the United States. Change Healthcare, a subsidiary of UnitedHealth, took its systems offline after a cyberattack by BlackCat/ALPHV ransomware group.
The American Hospital Association said that this massive interruption is the “most significant cyberattack on the US healthcare system in American history.”

What Is the Change Healthcare Attack? ​

On February 21, Change Healthcare experienced an outside cybersecurity threat. When it became aware of the issue, the company disconnected its systems to prevent any further issues. Change Healthcare said that it has a “high level” of confidence that the cyberattack did not affect Optum, UnitedHealthcare, and UnitedHealth Group systems, stating it was an isolated attack on Change Healthcare. However, Change Healthcare has not said whether patient information has been compromised.

Who Is Behind the Attack? ​

In a statement, Change Healthcare announced that BlackCat/ALPHV identified itself to the company, claiming responsibility for the cybercrime. According to the US Department of Justice, BlackCat/ALPHV is the second most prolific ransomware-as-a-service entity in the world, with over 1000 victims of cybercrimes across the globe.
This news organization reached out to the Cybersecurity and Infrastructure Security Agency (CISA), a component of the US Department of Homeland Security, for comment on whether CISA or other agencies had taken any previous action to stop the group after other attacks.
“CISA is working with our partners and Change Healthcare to support remediation, assist impacted organizations, and share timely information to reduce the likelihood of similar intrusions,” Eric Goldstein, executive assistant director for cybersecurity, responded in a statement.

How Has the Attack Affected Oncology Practices? ​

Change Healthcare is a technology company that provides services to hospitals and clinics across the country, including pharmacy claims transactions, clinician claims processing, patient access and financial clearance, clinician payments, and prior authorizations.
The Community Oncology Alliance (COA) said that the cyberattack has caused a massive disruption in claims processing. COA also said that practices have reported the disruption of benefits verification for patients, prior authorizations, and financial assistance from the attack.
“It’s impacting pretty much every facet of the practice and practice management,” said Nicolas Ferreyros, managing director of policy, advocacy, and communications at COA. “Right now, practices are making do, they’re working around these challenges.”
However, Ferreyros cautioned, continuing to manage these challenges “is absolutely, 100% unsustainable” for oncology practices.
“Very soon you’re going to find practices that are having to make tough decisions about what to do, how are they going to make payroll, are they going to take financial risks on filling prescriptions and treating patients?” he added.

What Are Current Workarounds for Clinicians? ​

Change Healthcare recommends that clinicians use manual methods such as calling the payer’s provider service line to check patients’ claim status and complete eligibility verification and prior authorizations.
The Department of Health & Human Services has issued guidance to Medicare Advantage organizations and Part D sponsors asking them to “remove or relax prior authorization, other utilization management, and timely filing requirements” while systems are offline. The department is also asking Medicare Advantage to offer advance funding to clinicians who have been affected the most.

How Common Are Attacks Like These?​

In 2023, a record-setting 725 healthcare security breaches were reported to the Department of Health & Human Services Office for Civil Rights, according to a report from The HIPAA Journal. The number of breachers has increased yearly. Last year, an average of 370,000 healthcare records were breached every day.

"

 

[Avondale]

Stumbled upon this today, it's relatively new. Don't know if the subject has been discussed in the thread before, but it's a well made video anyway.

 

[Inked]

"

How the Change Healthcare Cyberattack Affects Oncology Care​

Publish date: March 7, 2024
By
Patricia McKnight

An ongoing cyberattack, lasting more than 2 weeks, has had a substantial impact on cancer practices and their patients in the United States. Change Healthcare, a subsidiary of UnitedHealth, took its systems offline after a cyberattack by BlackCat/ALPHV ransomware group.
The American Hospital Association said that this massive interruption is the “most significant cyberattack on the US healthcare system in American history.”

What Is the Change Healthcare Attack? ​

On February 21, Change Healthcare experienced an outside cybersecurity threat. When it became aware of the issue, the company disconnected its systems to prevent any further issues. Change Healthcare said that it has a “high level” of confidence that the cyberattack did not affect Optum, UnitedHealthcare, and UnitedHealth Group systems, stating it was an isolated attack on Change Healthcare. However, Change Healthcare has not said whether patient information has been compromised.

Who Is Behind the Attack? ​

In a statement, Change Healthcare announced that BlackCat/ALPHV identified itself to the company, claiming responsibility for the cybercrime. According to the US Department of Justice, BlackCat/ALPHV is the second most prolific ransomware-as-a-service entity in the world, with over 1000 victims of cybercrimes across the globe.
This news organization reached out to the Cybersecurity and Infrastructure Security Agency (CISA), a component of the US Department of Homeland Security, for comment on whether CISA or other agencies had taken any previous action to stop the group after other attacks.
“CISA is working with our partners and Change Healthcare to support remediation, assist impacted organizations, and share timely information to reduce the likelihood of similar intrusions,” Eric Goldstein, executive assistant director for cybersecurity, responded in a statement.

How Has the Attack Affected Oncology Practices? ​

Change Healthcare is a technology company that provides services to hospitals and clinics across the country, including pharmacy claims transactions, clinician claims processing, patient access and financial clearance, clinician payments, and prior authorizations.
The Community Oncology Alliance (COA) said that the cyberattack has caused a massive disruption in claims processing. COA also said that practices have reported the disruption of benefits verification for patients, prior authorizations, and financial assistance from the attack.
“It’s impacting pretty much every facet of the practice and practice management,” said Nicolas Ferreyros, managing director of policy, advocacy, and communications at COA. “Right now, practices are making do, they’re working around these challenges.”
However, Ferreyros cautioned, continuing to manage these challenges “is absolutely, 100% unsustainable” for oncology practices.
“Very soon you’re going to find practices that are having to make tough decisions about what to do, how are they going to make payroll, are they going to take financial risks on filling prescriptions and treating patients?” he added.

What Are Current Workarounds for Clinicians? ​

Change Healthcare recommends that clinicians use manual methods such as calling the payer’s provider service line to check patients’ claim status and complete eligibility verification and prior authorizations.
The Department of Health & Human Services has issued guidance to Medicare Advantage organizations and Part D sponsors asking them to “remove or relax prior authorization, other utilization management, and timely filing requirements” while systems are offline. The department is also asking Medicare Advantage to offer advance funding to clinicians who have been affected the most.

How Common Are Attacks Like These?​

In 2023, a record-setting 725 healthcare security breaches were reported to the Department of Health & Human Services Office for Civil Rights, according to a report from The HIPAA Journal. The number of breachers has increased yearly. Last year, an average of 370,000 healthcare records were breached every day.

"

I am the controller of an oncology practice, this issue has been a big problem for us. It's also trickling down to ancillary services we use, so small businesses that count on us as a customer and rely on our business for their businesses are also affected.

It is insane to me that ransomware has become a business. Some degenerate behind a computer locks up all your data until you pay them a $500,000 ransom in bitcoin, why cant they be caught??!! Frustrating.

 

[missy]

"

The Silent Exodus: Are Nurse Practitioners and Physician Assistants Quiet Quitting?
Publish date: September 11, 2024
By Kelly K. James

While she cared deeply about her work, Melissa Adams*, a family nurse practitioner (NP) in Madison, Alabama, was being frequently triple-booked, didn’t feel respected by her office manager, and started to worry about becoming burned out. When she sought help, “the administration was tone-deaf,” she said. “When I asked about what I could do to prevent burnout, they sent me an article about it. It was clear to me that asking for respite from triple-booking and asking to be respected by my office manager wasn’t being heard ... so I thought, ‘how do I fly under the radar and get by with what I can?’ ” That meant focusing on patient care and refusing to take on additional responsibilities, like training new hires or working with students.

“You’re overworked and underpaid, and you start giving less and less of yourself,” Ms. Adams said in an interview.

Quiet quitting, defined as performing only the assigned tasks of the job without making any extra effort or going the proverbial extra mile, has gained attention in the press in recent years. A Gallup poll found that about 50% of the workforce were “quiet quitters” or disengaged.


It may be even more prevalent in healthcare, where a recent survey found that 57% of frontline medical staff, including NPs and physician assistants (PAs), report being disengaged at work.

The Causes of Quiet Quitting
Potential causes of quiet quitting among PAs and NPs include:

Unrealistic care expectations. They ask you to give your all to patients, handle everything, and do it all in under 15 minutes since that’s how much time the appointment allows, Ms. Adams said.
Lack of trust or respect. Physicians don’t always respect the role that PAs and NPs play in a practice.
Dissatisfaction with leadership or administration. There’s often a feeling that the PA or NP isn’t “heard” or appreciated.
Dissatisfaction with pay or working conditions.
Moral injury. “There’s no way to escape being morally injured when you work with an at-risk population,” said Ms. Adams. “You may see someone who has 20-24 determinants of health, and you’re expected to schlep them through in 8 minutes — you know you’re not able to do what they need.”
What Quiet Quitting Looks Like
Terri Smith*, an NP at an academic medical center outpatient clinic in rural Vermont, said that, while she feels appreciated by her patients and her team, there’s poor communication from the administration, which has caused her to quietly quit.

“I stopped saying ‘yes’ to all the normal committee work and the extra stuff that used to add a lot to my professional enjoyment,” she said. “The last couple of years, my whole motto is to nod and smile when administration says to do something — to put your head down and take care of your patients.”

While the term “quiet quitting” may be new, the issue is not, said Bridget Roberts, PhD, a healthcare executive who ran a large physician’s group of 100 healthcare providers in Jacksonville, Florida, for a decade. “Quiet quitting is a fancy title for employees who are completely disengaged,” said Dr. Roberts. “When they’re on the way out, they ‘check the box’. That’s not a new thing.”

“Typically, the first thing you see is a lot of frustration in that they aren’t able to complete the tasks they have at hand,” said Rebecca Day, PMNHP, a doctoral-educated NP and director of nursing practice at a Federally Qualified Health Center in Corbin, Kentucky. “Staff may be overworked and not have enough time to do what’s required of them with patient care as well as the paperwork required behind the scenes. It [quiet quitting] is doing just enough to get by, but shortcutting as much as they can to try to save some time.”

Addressing Quiet Quitting
Those kinds of shortcuts may affect patients, admits Ms. Smith. “I do think it starts to seep into patient care,” she said. “And that really doesn’t feel good ... at our institution, I’m not just an NP — I’m the nurse, the doctor, the secretary — I’m everybody, and for the last year, almost every single day in clinic, I’m apologizing [to a patient] because we can’t do something.”

Watching for this frustration can help alert administrators to NPs and PAs who may be “checking out” at work. Open lines of communication can help you address the issue. “Ask questions like ‘What could we do differently to make your day easier?’” said Dr. Roberts. Understanding the day-to-day issues NPs and PAs face at work can help in developing a plan to address disengagement.

When Dr. Day sees quiet quitting at her practice, she talks with the advance practice provider about what’s causing the issue. “’Are you overworked? Are you understaffed? Are there problems at home? Do you feel you’re receiving inadequate pay?’ ” she said. “The first thing to do is address that and find mutual ground on the issues…deal with the person as a person and then go back and deal with the person as an employee. If your staff isn’t happy, your clinic isn’t going to be productive.”

Finally, while reasons for quiet quitting may vary, cultivating a collaborative atmosphere where NPs and PAs feel appreciated and valued can help reduce the risk for quiet quitting. “Get to know your advanced practice providers,” said Ms. Adams. “Understand their strengths and what they’re about. It’s not an ‘us vs them’ ... there is a lot more commonality when we approach it that way.” Respect for the integral role that NPs and PAs play in your practice can help reduce the risk for quiet quitting — and help provide better patient care.

*Names have been changed.

A version of this article first appeared on Medscape.com.

"

 

[Sunrises Sunsets]

I believe the answer to this sh*tshow, as someone else labeled it, is to take healthcare businesses to not for profit status and get the stock market out of the pockets of people needing medical care, prescriptions and services. Why should some anonymous person jam their hands in your wallet when medical services and products are required?

I suggest research on profit and not for profit medical companies. I personally think the stock market is a huge pyramid scheme costing people far more money for everything they touch. The stock market was originally designed to help raise necessary capital for companies that required more money to grow or improve. Now almost all companies are in market strictly for greed and it is eating our lunches across the board.

You also can't jam millions of people into a medical system that is nowhere near prepared for such change. It is a mess out there.

 

[missy]

https://www.mdedge.com/hematology-o...cd=WNL_EVE_241005_mdedge&uac=96935CJ&sso=true


“Cancer Doesn’t Wait’: How Prior Authorization Harms Care

October 2, 2024|Hematology And Oncology

Lisa Marshall

FROM JAMA NETWORK OPEN

Fantine Giap, MD, sat across from a 21-year-old with a rare sarcoma at the base of her skull.

Despite the large tumor, nestled in a sensitive area, the Boston-based radiation oncologist could envision a bright future for her patient.

She and the other members of the patient’s care team had an impressive cancer-fighting arsenal at her fingertips. The team had recommended surgery, followed by proton therapy — a sophisticated tool able to deliver concentrated, razor-focused radiation to the once apple-sized growth, while sparing the fragile brain stem, optic nerve, and spinal cord.

Surgery went as planned. But as the days and weeks wore on and insurance prior authorization for the proton therapy never came, the tumor roared back, leading to more surgeries and more complications. Ultimately, the young woman needed a tracheostomy and a feeding tube.

By the time insurance said yes, more than 1 year from her initial visit, the future the team had envisioned seemed out of reach.

“Unfortunately for this patient, it went from a potentially curable situation to a likely not curable situation,” recalled Dr. Giap, a clinician at Massachusetts General Hospital and instructor at Harvard Medical School, Boston. “I wanted to cry every day that she waited.’’

While a stark example, such insurance delays are not uncommon, according to new research published in JAMA Network Open.

The study of 206 denials in radiation oncology concluded that more than two-thirds were ultimately approved on appeal without changes, but often these approvals came only after costly delays that potentially compromised patient care.

Other studies have found that number to be even higher, with more than 86% of prior authorization requests ultimately approved with few changes.

‘’It gives you the idea that this entire process might be a little futile — that it’s just wasting people’s time,’’ said Fumiko Chino, MD, coauthor on the JAMA study and now an assistant professor in radiation oncology at MD Anderson Cancer Center in Houston. ‘’The problem is cancer doesn’t wait for bureaucracy.’’


Barriers at Every Step
As Dr. Chino and her study coauthors explained, advancements like intensity-modulated radiation therapy and stereotactic radiosurgery have allowed a new generation of specialists to treat previously untreatable cancers in ways that maximize tumor-killing power while minimizing collateral damage. But these tools require sophisticated planning, imaging, simulations and execution — all of which are subject to increased insurance scrutiny.

‘’We face barriers pretty much every step of the way for every patient,’’ said Dr. Chino.

To investigate how such barriers impact care, Dr. Chino and colleagues at Memorial Sloan Kettering Cancer Center — where she worked until July — looked at 206 cases in which payers denied prior authorization for radiation therapy from November 1, 2021 to December 8, 2022.

The team found that 62% were ultimately approved without any change to technique or dose, while 28% were authorized, but with lower doses or less sophisticated techniques. Four people, however, never got authorization at all — three abandoned treatment altogether, and one sought treatment at another institution.

Treatment delays ranged from 1 day to 49 days. Eighty-three patients died.

Would some of them have lived if it weren’t for prior authorization?

Dr. Chino cannot say for sure, but did note that certain cancers, like cervical cancer, can grow so quickly that every day of delayed treatment makes them harder to control.

Patients with metastatic or late-stage cancers are often denied more aggressive treatments by insurers who, in essence, “assume that they are going to die from their disease anyway,” Dr. Chino said.

She views this as tragically shortsighted.

‘’There’s actually a strong body of evidence to show that if you treat even metastatic stage IV diseases aggressively, you can prolong not just quality of life but also quantity,’’ she said.

In cases where the cancer is more localized and insurance mandates lower doses or cheaper techniques, the consequences can be equally heartbreaking.

‘’It’s like saying instead of taking an extra-strength Tylenol you can only have a baby aspirin,’’ she said. ‘’Their pain is less likely to be controlled, their disease is less likely to be controlled, and they are more likely to need retreatment.’’

Prior authorization delays can also significantly stress patients at the most vulnerable point of their lives.

In another recent study, Dr. Chino found that 69% of patients with cancer reported prior authorization-related delays in care, with one-third waiting a month or longer. One in five never got the care their doctors recommended, and 20% reported spending more than 11 hours on the phone haggling with their insurance companies.

Most patients rated the process as ‘’bad’’ or ‘’horrible,’’ and said it fueled anxiety.

Such delays can be hard on clinicians and the healthcare system too.

One 2022 study found that a typical academic radiation oncology practice spent about a half-million dollars per year seeking insurance preauthorization. Nationally, that number exceeds $40 million.

Then there is the burnout factor.

Dr. Giap, an early-career physician who specializes in rare, aggressive sarcomas, works at an institution that helped pioneer proton therapy. She says it pains her to tell a desperate patient, like the 21-year-old, who has traveled to her from out of state that they have to wait.

‘’Knowing that the majority of the cases are ultimately approved and that this wait is often unnecessary makes it even tougher,’’ she said.

Dr. Chino, a breast cancer specialist, has taken to warning patients before the alarming insurance letter arrives in the mail that their insurance may delay authorizing their care. But she tells patients that she will do everything she can to fight for them and develops a back-up plan to pivot to quickly, if needed.

‘’No one goes into medicine to spend their time talking to insurance companies,’’ said Dr. Chino.

The national trade group, America’s Health Insurance Plans (AHIP), did not return repeated requests for an interview for this story. But their official position, as stated on their website, is that “prior authorization is one of many tools health insurance providers use to promote safe, timely, evidence-based, affordable, and efficient care.”

Both Dr. Giap and Dr. Chino believe that prior authorization was developed with good intentions: to save healthcare costs and rein in treatments that don’t necessarily benefit patients.

But, in their specialty, the burden has proliferated to a point that Dr. Chino characterizes as ‘’unconscionable.’’

She believes that policy changes like the proposed Improving Seniors’ Timely Access to Care Act — which would require real-time decisions for procedures that are routinely approved — could go a long way in improving patient care.

Meanwhile, Dr. Giap said, more research and professional guidelines are necessary to bolster insurance company confidence in newer technologies, particularly for rare cancers.

Her patient ultimately got her proton therapy and is ‘’doing relatively well, all things considered.’’

But not all the stories end like this.

Dr. Chino will never forget a patient with a cancer growing so rapidly she could see it protruding through her chest wall. She called for an urgent PET scan to see where else in the body the cancer might be brewing and rushed the planning process for radiation therapy, both of which faced prior authorization barriers. That scan — which ultimately showed the cancer had spread — was delayed for months.*

If the team had had those imaging results upfront, she said, they would have recommended a completely different course of treatment.

And her patient might be alive today.

‘’Unfortunately,” Dr. Chino said, “the people with the very worst prior authorization stories aren’t here anymore to tell you about them.”

*Correction, 10/4/24: An earlier version of this article erroneously stated that Dr. Chino called for surgery for her patient. She actually called for a PET scan and an urgent radiation start."