The new Case Western Reserve University Health Education campus will eventually include Case Western's medical, dental, and nursing schools, as well as Cleveland Clinic's in-house medical school. "The idea is to create a 'mini campus' that gives each school its own identity but fosters collaboration," says one of the architects.
CLEVELAND — There's a new building going up on the campus of the Cleveland Clinic. A very big building.
The structure will house the new Case Western Reserve University Health Education campus, eventually including Case Western's medical, dental and nursing schools, as well as Cleveland Clinic's in-house medical school.
"The idea is to create a 'mini campus' that gives each school its own identity but fosters collaboration," said Chris Connell, one of the architects.
The building, which will cost almost half a billion dollars, will provide an estimated 8.5 football-fields' worth of space and enough concrete to build a 75-mile-long sidewalk. It is expected to be open to the first classes of students in 2019.
But this part of the project is less the beginning and more the culmination of a long-running effort at Case to train different types of health professionals how to work together. Health care in the 21st century is increasingly being provided by teams, say the projects' advocates, yet most health care professionals don't encounter their "teammates" until they are well along in their training.
"Health care is no longer a gladiatorial sport, where you had the one health care provider; you know mano a mano, one on one, battling a disease," said James Young, a cardiologist who heads the Cleveland Clinic Lerner College of Medicine. "I'm involved with heart transplantation and mechanical devices for the heart," he said. "Boy, you can't do it by yourself."
On this particular day, about a mile away from the construction site, a small group of students from the medical, dental, nursing, and social work schools were gathered on Case's main campus around a conference table. Every student in every health professions school is required to attend a seminar like this twice a year — one of the ways in which the training programs are already encouraging collaboration.
At this particular session, the students are tasked with figuring out how to best treat a (hypothetical) patient — a 35-year-old woman with hypertension, obesity and diabetes. She has come to the (fictitious) clinic with a series of injuries she said she got falling down a flight of stairs. Meanwhile, her boyfriend is in the lobby acting disruptively.
The students discuss and argue about which of the patient's problems to address first, and what to do about the boyfriend. They don't end up reaching a consensus, but faculty overseeing the group say that's OK.
"I think that's fabulous," said Kristin Victoroff, an associate dean at the dental school. "It is actually an indicator of a functioning group, where's there enough trust in the group where you can say what you really are thinking."
But that's not the only way the university is trying to foster "interprofessional" education. For example, at a free oral health clinic elsewhere in Cleveland, dental students and nurses collaborate to treat real patients. Other activities bring students together to discuss problems that cross professional lines, like obesity or pain.
"We all have to deal with pain whether it's dentists or social workers or nurses," said Carol Savrin, an administrator at the Case nursing school.
Efforts such as these to train doctors, nurses and other health professionals together have been tried for years. And they haven't always been successful.
"I think they come in with some preconceived or stereotyped notions of what a doctor [or] a social worker is," said Scott Wilkes, an assistant dean at the Case social work school.
Yet getting everyone on the same page is critical to preventing medical mistakes, said Patricia Thomas, a vice dean at the Case medical school.
In studying the problem, she added, "the root of many of our errors had to do with the fact that our professions were not working effectively together for patient care."
Administrators say that is why the new building is so important.
It's not just the formal training together, said Victoroff of the dental school, "I'm excited about the informal interactions that are going to happen."
"The ways it's structured now, the large practices will do well and the small practices will do badly," says Paul Ginsburg, director of the Center for Health Policy at the Brookings Institution.
Dr. Lee Gross is worried. He has practiced family medicine in North Port, Florida, near Sarasota, for 14 years. But he and two partners are the last small, independent practice in the town of 62,000. Everyone else has moved away, joined larger groups, or become salaried employees of hospitals or health companies.
"We're struggling to survive," Gross, 47, said. "Our kind of practice is dying in this country, and medicine itself is changing so rapidly that doctors everywhere seem to be burning out."
Indeed, in their professional journals, at conferences, on social media and health care blogs, and in comments to federal regulators, the nation's doctors are expressing growing anger and frustration.
The focal point of their angst is a 2015 federal law that changes the way Medicare pays doctors.
"This is a big change, we know," said Tim Gronniger, deputy chief of staff at the Centers for Medicare & Medicaid Services. But, he added, "the current way we pay doctors incentivizes them in bad ways — to waste resources, for example."
The law has bipartisan support and does not come with the political tension of the ACA. Still, the Obamacare battles have shown that broadly reshaping health care is no easy task.
That would total between $875 billion to $1.1 trillion of the $3.5 trillion expected to be spent on health care in the U.S. in 2016.
The law sets up two payment tracks. All doctors must choose one, except for those who see too few Medicare patients or whose income from Medicare is too low.
On one track, doctors whose performance and quality of care exceeds benchmarks get bonuses up to 4 percent of their total Medicare reimbursements. Those will start in 2019, based on evaluations of care delivered in 2017, and will rise a maximum of 9 percent by 2022. By the same token, physicians who score poorly on quality benchmarks — which include requirements for the use of electronic health records — face penalties at the same levels.
The amount the government spends on the bonuses — estimated at $833 million for 2019 — must be balanced by the penalties, keeping the program "budget neutral." However, Congress also authorized an extra $500 million a year bonus pool through 2024 for doctors judged "exceptional."
On the other path, doctors choose to join larger practices or organizations — called "alternative payment models" — that would be held accountable for the quality of care delivered by all the doctors in the organization.
Congress' intent, experts say, was to push doctors to join such larger organizations, which generally are considered better equipped to manage and coordinate care, improve quality and lower costs than are solo or small groups of doctors.
Doctors get a 5 percent annual bonus between 2019 and 2024 if they join an alternative payment organization, along with any bonuses or penalties the organization chooses to mete out. Starting in 2026, doctors in such organizations will continue to get a small annual payment adjustment from Medicare that's larger than doctors who don't choose the alternative path — 0.75 percent versus 0.25 percent.
Physicians' concern is that the new payment system — laid out in a 962-page proposed regulation in April — will put doctors in solo or small practices at high risk of incurring payment penalties and will push thousands into larger practices and alternative payment organizations.
"The ways it's structured now, the large practices will do well and the small practices will do badly," said Paul Ginsburg, director of the Center for Health Policy at the Brookings Institution.
During a public comment period, the American Medical Association and dozens of other physician trade organizations and every state medical association said the system needs to be simplified and must "accommodate the needs of physicians in rural, solo, or small practices in order to enhance their opportunities for success and avoid unintended consequences."
One of those unintended consequences, the AMA says, is that penalized doctors would limit the number of Medicare patients they see, or drop Medicare.
"I have no idea what I'm going to do yet," says Dr. Jean Antonucci, a primary care physician who has a solo practice in Farmington, Maine. Half her patients are covered by Medicare. "If I'm going to lose money, I'll have to see what my options are. I don't want to limit how many Medicare patients I see."
Antonucci and Gross say they want to preserve their small practices. "I don't want to spend the bulk of my time doing paperwork or collecting data on my patients," said Antonucci. "That's what the doctors in my community who are employed [in larger groups] seem to spend most of their time doing."
Some experts agree that the burden to report quality-of-care to the government is significant.
"We don't yet have a good system to measure the performance of individual physicians," says Robert Berenson, a physician and fellow at the Urban Institute and former director of Medicare payment policy for the federal government. "And yet we are going to peg billions of dollars in payment to such measurement. It's a little crazy."
A study published in March in the journal Health Affairs calculated the scope of that data collection now. It found physicians and their staffs spend $40,000 per doctor per year — $15.4 billion nationwide — collecting and reporting information about their care to Medicare, private insurers and others.
Gronniger says CMS has, in the proposed rule, scaled back the number of measures doctors must report. "We are eager to work through the issues doctors' groups have raised," Gronniger said.
Even so, the AMA and other physician groups are pushing CMS to delay the start for collecting quality-of-care information from next January until at least July. Medicare administrators have pledged to issue final regulations by Nov. 1.
"This is all very complex," said AMA President Andrew Gurman. "A lot of doctors are very frustrated … but we are committed to trying to make the new law work."
NewYork-Presbyterian Hospital, one of the nation’s largest academic medical centers, received nearly $16 million, more than any other hospital, according to data released by the Centers for Medicare & Medicaid Services.
A year after paying nearly $1.5 billion to more than a third of U.S. hospitals to resolve longstanding Medicare billing disputes, the Obama administration has disclosed who got paid.
NewYork-Presbyterian Hospital, one of the nation's largest academic medical centers, received nearly $16 million, more than any other hospital, according to data released by the Centers for Medicare & Medicaid Services.
The second largest amount went to North Shore University Hospital in Manhasset, N.Y., which received $14.5 million. CHI Memorial Hospital in Chattanooga, Tenn., ranked third — $10.9 million — but two other New York-area hospitals rounded out the top five. Long Island Jewish Medical Center received $10.8 million and NYU Langone Medical Center was paid $10.5 million, the CMS data show.
In total, 2,022 hospitals shared in the government payout, which settled 346,000 claims for reimbursement for treating Medicare patients admitted on or before Oct. 1, 2013. The largest payments resolved thousands of claims at once. Memorial Hospital's settlement covered nearly 3,000 claims.
The settlements were a compromise to reduce a swollen backlog of disputes over what hospitals argued they were owed. At one time, pending cases under appeal stretched more than two years.
The resolutions followed the government's offer in 2014 to pay the hospitals 68 percent of the value of inpatient claims that had been caught in Medicare's hearings and appeals process, some for years.
The new CMS data show 35 hospitals received more than $5 million each, but most were paid far less. The median payment — meaning half the hospitals got more and half got less — was $307,642, according to a Kaiser Health News analysis. The data was released in response to a Freedom of Information Act request made last year by KHN.
Medicare pays private contractors known as recovery audit contractors, or RACs, to review hospital claims for improper payments. If hospitals disagree with RACs' decisions, they can appeal. Most RAC reviews have focused on costly inpatient-status claims, questioning whether certain patients should have been admitted to hospitals. Many audits determine that short patient stays should have been billed at less-costly outpatient rates.
Last year's settlement indicated that many hospitals preferred to settle quickly for a discounted amount rather than keep claims tied up in appeals for what could have been months or even years. Hospitals that declined to settle with Medicare still had the option to continue their appeal.
Hospitals and RACs have long battled over audits and appeals. RACs — which are paid a fee for every audit that recovers money for Medicare — argue they are protecting taxpayer dollars and ensuring that hospitals are paid for appropriate patient services. Hospitals criticize the RAC process as burdensome and liken contractors to bounty hunters focused on making money for themselves.
CMS has said 18 percent of appealed claims were overturned in favor of hospitals between Oct. 1, 2013 and Sept. 30, 2014, but the American Hospital Association reported in 2014 that self-reported data by its members showed hospitals had won 66 percent of appeals since 2010.
The $1.5 billion paid in last year's settlements contrast with more than $9.6 billion collected by RACs from 2010 through September 2015. More than 90 percent of collections by RACs were from hospitals.
A growing number of doctors, hospitals, patient advocates and state and federal policymakers are pushing to educate consumers and clinicians, and ensure procedures are followed that focus on prevention and early detection.
After Rory Staunton fell at the gym and cut his arm in March of 2012, the 12-year-old became feverish and vomited during the night, complaining of a sharp pain in his leg. When his parents called his pediatrician the next day, she wasn't worried. She said there was a stomach virus going around New York City, and his leg pain was likely due to his fall.
However, she advised his parents, Orlaith and Ciaran Staunton, to take the youngster to the emergency department because he might be dehydrated. There hospital workers did some blood work, gave him fluids and sent him home.
The next day Rory's pain and fever were worse. His skin was mottled and the tip of his nose turned blue. The Stauntons raced back to the hospital, where he was admitted to intensive care. The diagnosis: septic shock. Rory was fighting a system-wide infection that was turning his skin black and shutting down his organs. On Sunday, four days after he dove for the ball in gym class, Rory died.
"It was frightening to think that something could kill my son so fast and it would be something that I had never heard of," said Orlaith Staunton.
She's not alone. Sepsis kills more than 250,000 people every year. People at highest risk are those with weakened immune systems, the very young and elderly, patients with chronic diseases such as diabetes, cancer or kidney disease and those with illnesses such as pneumonia or who use catheters that can cause infections. But it can strike anyone, even a healthy child like Rory.
Sepsis is a body's overwhelming response to infection. It typically occurs when germs from an infection get into the bloodstream and spread throughout the body. To fight the infection, the body mounts an immune response that may trigger inflammation that damages tissues and interferes with blood flow. That can lead to a drop in blood pressure, potentially causing organ failure and death.
Yet many people don't know about sepsis. Meanwhile, health care providers struggle to identify it early. There's no simple diagnostic test and many symptoms — elevated heart and respiratory rates, fever or chills, pain — are common ones that are present in many conditions.
Now, a growing number of doctors, hospitals, patient advocates and state and federal policymakers are pushing to educate consumers and clinicians and ensure procedures are followed that focus on prevention and early detection.
The Stauntons established a foundation to raise awareness about the deadly infection, and in 2013 New York became the first state to require all hospitals to put in place procedures for its early recognition and treatment. This month, Illinois Governor Bruce Rauner signed a law requiring similar actions by hospitals in that state.
"Early treatment is vital," said Dr. Anthony Fiore, chief of the epidemiology research and innovations branch at the CDC's Division of Healthcare Quality Promotion. "It's an emergency that you need to deal with, like heart attack and stroke."
When sepsis advances to septic shock, characterized by severely low blood pressure, each hour of delay in administering antibiotics decreases the odds of survival by an average of 7.6 percent, one study found.
In 2013, sepsis, or septicemia as it's sometimes called, accounted for nearly $24 billion in hospital costs, the most expensive condition treated. Up to half of people who get it die. Many cases are related to health care, such as catheter use or an infection acquired in the hospital. But contrary to the common perception, approximately 80 percent of cases develop outside the hospital or at a nursing home, according to the new CDC study.
As the front line in identifying these cases, emergency departments typically have sepsis protocols in place to screen for the disease.
"The work you do in those first three to six hours in the emergency department makes more difference in cost than the whole next several weeks in the ICU," said Dr. Todd L. Slesinger, emergency medicine residency program director at Aventura Hospital and Medical Center in Aventura, Fla., who co-chairs a task force on sepsis at the American College of Emergency Physicians, which has developed a tool to help emergency department staff screen and treat the condition.
Last fall, the federal Centers for Medicare & Medicaid Services started requiring hospitals to measure and report on efforts to screen for and treat the illness. In addition, Medicare sets penalties for a variety of hospital-acquired conditions, including high rates of post-operative sepsis.
Patient advocates and policymakers agree that patients themselves are key to improving its prevention and early detection. Good hygiene can help prevent sepsis, including cleaning wounds. If someone gets injured, look for signs of sepsis, including rapid breathing or heart rate, confusion, fever or chills and pale or discolored skin.
Don't assume health care providers have it covered, experts advise. If you or someone you're caring for has these symptoms, ask the health care provider directly: "Do you think it might be sepsis?"
Geriatric ERs have the potential to lower health care costs because staff can more carefully discern who needs to be admitted and who can be cared for outside of hospital walls.
This article first appeared August 23, 2016 on the Kaiser Health News website
NEW YORK — The Mount Sinai Hospital emergency room looks and sounds like hundreds of others across the country: Doctors rush through packed hallways; machines beep incessantly; paramedics wheel stretchers in as patients moan in pain.
"It's like a war zone," said physician assistant Emmy Cassagnol. "When it gets packed, it's overwhelming. Our sickest patients are often our geriatric patients, and they get lost in the shuffle."
But just on the other side of the wall is another, smaller emergency room designed specifically for those elderly patients.
Patients like Hattie Hill, who is 105 years old and still living at home. A caregiver brought her in one rainy day in late spring because she had a leg infection that wasn't responding to antibiotics. Hill, who also has arthritis and a history of strokes, said she prefers the emergency room for seniors because she gets more attention.
"I don't have to wait so long," she said. "And it's not so loud."
Packed emergency rooms are unpleasant for everyone. But they can be dangerous for elderly patients, many of whom come in with multiple chronic diseases on top of a potentially life-threatening illness or injury.
"Who is going to suffer the most from these crowded conditions?" asked Ula Hwang, associate professor in the emergency medicine and geriatrics departments at the Mount Sinai School of Medicine. "It is going to be the older adult … the poor older patient with dementia lying in the stretcher with a brewing infection that is forgotten about because it's crazy, chaotic and crowded."
Seniors who come into traditional emergency rooms are frequently subjected to numerous and sometimes unnecessary tests and procedures, according to research and experts. They stay longer and their diagnoses are less accurate than younger patients. And they are more frequently admitted to the hospital by ER doctors overwhelmed by the constant influx of very sick patients.
"You've got this surge of more and more older adults coming to the emergency departments," said Kevin Biese, co-director of geriatric emergency medicine at the University of North Carolina School of Medicine. "Yet there hasn't necessarily been this recognition that [they need] different screening, different treatment and they are going to have different outcomes."
Geriatric emergency rooms, which are slowly spreading across the country, provide seniors with more expertise from physicians, nurses and others trained specifically to diagnose and care for the elderly, researchers said.
The staff in these specialized ERs collaborate closely not only to treat the seniors' immediate health problems but also to reduce their risk of confusion, bed sores and over-medication. Senior ERs are designed to be more quiet and tranquil.
Geriatric ERs have the potential to lower health care costs because staff can more carefully discern who needs to be admitted and who can be cared for outside of hospital walls, Hwang and others said. That tends to reduce hospitalizations among the elderly.
Mount Sinai, which opened its geriatric emergency room in 2012, is part of a nationwide effort to find a better way to treat elderly patients. The first geriatric ER opened in New Jersey in 2008, and now there are more than 100 such units nationwide. Several others are being planned, including in California, North Carolina, Connecticut and Texas.
Geriatric ERs vary widely. Some are separate units with trained staff; others are merely sections within traditional emergency rooms with extra hearing aids and other senior supplies. But professional medical organizations have developed guidelines to standardize design, staffing and patient screening.
The boomlet in geriatric emergency rooms stems in part from an increase in older patients with complex conditions who are seeking care in regular ERs. That has caused some providers and hospitals to seek more effective and efficient ways to treat them.
About 20.4 million patients over the age of 65 were treated in emergency rooms in 2011, up from 15.9 million a decade earlier, according to a national hospital survey conducted by the Centers for Disease Control and Prevention. As the population ages, older patients are expected to make up an increasing share of ER patients.
The Affordable Care Act also has fueled the expansion of senior emergency rooms. The law assesses penalties when too many patients return to a hospital too soon after discharge. Facilities have tried to reduce readmissions in part by providing better emergency care and triage.
Now, that growth could continue as hospitals face additional pressure to provide more efficient and less costly care to their Medicare patients. The Centers for Medicare and Medicaid Services announced in January that within two years, half of all traditional Medicare payments will go to providers based on quality of care rather than quantity of services.
Emergency departments are the perfect places to make changes that could help control spending, because they are gateways between home and costly hospitalizations, Hwang said. About 60 percent of elderly patients who get hospitalized come through the emergency room, according to a 2013 Rand Corporation study. A quarter of those hospitalizations are preventable, according to one 2012 federal study.
"Hospitals that before didn't think there was any need for this are saying, 'Can you help us create a geriatric ED?'" Hwang said.
Hospitals also may view specialized emergency departments as a marketing tool to reach the growing elderly population.
The geriatric emergency room at Mount Sinai is set up differently than traditional emergency rooms. It has thicker mattresses to help reduce the chance of bed sores, raised toilet seats, hand rails in the hallways and reduced-noise curtains.
The department is allotted 20 beds, but the main hospital sometimes steals them for other patients. That leaves some older ER patients waiting in the hallway.
Over a two-day period in May, dozens of older patients were treated for falls, dizziness, severe pain and shortness of breath.
John Fornieri, 80, came in after falling on his floor at home. Fornieri, an artist with arthritis and a heart condition, said he nearly lost consciousness. An x-ray showed he had broken a hip.
Fornieri said he was grateful that the geriatric emergency room staff was trained to care for the elderly. "Seniors need a different kind of attention," he said. "We can't see and we can't hear like we used to. We can't even talk the same."
Denise Nassisi, a physician who runs the geriatric ER, said her patients are at greater risk of falling, medication errors and infections than younger patients. Seemingly routine injuries can have devastating effects. Broken arms, for example, can make it difficult for elderly people to care for themselves.
Many also have dementia or other cognitive impairments that make it harder to get an accurate account of their medical history and the reason for their ER visit, she said. About half of the patients arrive unaccompanied by relatives or caregivers.
In the past, Nassisi said, doctors frequently just admitted the patients, leaving it to the hospital staff to do a more complete workup. But now, Nassisi and her team of social workers, therapists, nurses and others try to screen, diagnose and treat patients more thoroughly in the ER, she said.
Part of their job is to determine whether older patients can be safely discharged. That means they aren't automatically admitted to the hospital, which would raise their risk of confusion and loss of independence. "We are trying to change the culture of just admitting," Nassisi said.
A patient doesn't need a clean bill of health to be discharged. One 81-year-old patient came in for a toothache but also had a long list of illnesses: coronary artery disease, chronic pulmonary disease, arthritis, high blood pressure, prediabetes and high cholesterol. She was released with pain medication, antibiotics and an appointment with a surgeon.
Another patient, who was 83 and had high blood pressure, anxiety and cancer, had fallen in her kitchen. She, too, was discharged after staff ensured she could walk on her own and had help at home.
As providers determine where the patients should be treated, they also try to prevent them from becoming delirious, developing additional problems or taking potentially harmful medications.
Physician assistant Jaclyn Schefkind evaluated Hill, the 105-year-old patient.
"How are you doing?"
"Bad," Hill said, wincing in pain.
Schefkind looked at Hill's leg, red and swollen. She said they were going to get her some stronger antibiotics and something to relieve the pain.
"Let's start with Tylenol," Schefkind said. "I don't want to give you something too strong because it's not safe when you're older."
Shortly afterward, the team decided the best place to admit Hill so doctors could get her infection under control. A nurse pulled Hill's blanket up to her chin, packed up her belongings and rolled her through the door toward the main hospital.
Interpreters routinely help people who speak limited English understand what's happening in the hospital. They become even more indispensable during patients' dying days. But specialists say interpreters need extra training to capture the nuances of language around death.
This article first appeared August 22, 2016 on the Kaiser Health News website
MORENO VALLEY, Calif. — Alfredo David lay in bed, looking deflated under an Avengers blanket, as a doctor, two nurses, and medical interpreter Veronica Maldonado entered his hospital room. He wrapped up a call from his wife, then fiddled idly with his phone.
He had received distressing news from the team at the Riverside University Health System Medical Center: His sharp abdominal pains and difficulty eating, previously diagnosed at another hospital as gastritis, were actually caused by metastatic cancer. The tumor was growing. David, 45, was not going to recover.
Maldonado pulled up a chair for herself and another for palliative care specialist Dr. Faheem Jukaku, and the two sat at David's eye level. Pointing to an MRI image of David's abdomen, Jukaku explained in English how surgeons would attempt to ease his symptoms the next day. Maldonado translated Jukaku's words into Spanish, modulating her tone of voice to match the doctor's delivery.
David listened — seeming resigned, but grateful that some relief might be on the way. Occasionally he'd ask a question in Spanish about the procedure, which Maldonado translated back to Jukaku. Asked about his earlier misdiagnosis, he rolled his eyes.
David, a mechanic and father of three teenagers, understands some English. But he said Maldonado's help had been crucial to deciding on his new course of treatment. Thanks to her, he said in Spanish as she translated, "I don't have any misunderstandings. I'm more at peace."
Interpreters routinely help people who speak limited English — close to 9 percent of the U.S. population, and growing — understand what's happening in the hospital. They become even more indispensable during patients' dying days. But specialists say interpreters need extra training to capture the nuances of language around death.
Many doctors and nurses need the assistance of interpreters not only to overcome language barriers but also to navigate cultural differences. Opportunities for miscommunication with patients abound. Words don't always mean the same thing in every language.
Medical staff, already nervous about delivering bad news, may speak too quickly, saying too much or too little. They may not realize patients aren't comprehending that the team can no longer save their lives.
"That's when it gets interesting," Maldonado said. "Does the doctor understand that the patient isn't understanding?"
At Riverside and some other hospitals, interpreters have completed special training and work closely with palliative care teams to help patients and their families decide when the time has come to stop trying to cure a disease and start focusing on comfort and quality of life.
Palliative care is unusual among medical specialties, said Dr. Neil Wenger, an internist who is chair of the ethics committee at the UCLA Medical Center. Rather than curing or eliminating disease, its purpose is to manage symptoms for patients who are not expected to recover.
Physicians and nurses talk at length with dying patients and their families about their wishes, collaborating with social workers, chaplains and hospice workers. Under any circumstances, the clinical shift from curing disease to treating symptoms can be difficult for doctors and patients. Advance care planning — a process used to help patients understand their prognoses and explore preferences for future care — is more like psychotherapy than a routine medical consult, Wenger said.
"This is not a straightforward set of questions," he said. "You ask a question, and the next question is dependent on the response. It's very easy to use the wrong words and startle the person and put them off. It's a dangerous conversation."
When there's a language or culture gap, Wenger added, the interaction becomes much more difficult. Both sides can fail to recognize important nuances, such as body language and variations in the meaning of words.
Wenger said that he finds it hard to speak with patients about palliative care through an interpreter because, in his experience, unexpected turns in the conversation and difficult emotions can literally get lost in translation.
Others say that interpreters are key for helping patients make sense of palliative care — that they just need extra training to be good at it.
Kate O'Malley, a senior program officer at the California Health Care Foundation, said she started thinking about interpreters when the Oakland, Calif.-based foundation funded new palliative care programs in safety net hospitals throughout the state. It found that vast numbers of patients did not speak English as their primary language.
At Los Angeles County-USC Medical Center, for instance, 68 percent of palliative care patients in 2011 spoke a first language other than English. At San Francisco General Hospital, that number was 45 percent; at Riverside County Medical Center, 33 percent.
"One of the key tenets of palliative care is to have goals-of-care discussions," O'Malley said. So when patients speak a different language, "How do you do that?" Her team found that palliative care providers sometimes brought in interpreters to assist, but that many of them didn't have the knowledge, training, or vocabulary to convey key concepts.
Take the idea of hospice, the comprehensive palliative care services available to patients in their last months, often at home. For people from Mexico, the Spanish equivalent hospicio "conjures up the image of the worst nursing home you could ever imagine, where people are disabled and left for dead," said Dr. Anne Kinderman, who runs the palliative care service at Zuckerberg San Francisco General Hospital. "If I come into the room and say, 'I'm here to tell you about this great thing called hospicio,' there's a cognitive disconnect," she said.
Interpreters have to learn how to bridge that gap. "You have to know how to present [hospice] in Spanish," said Viviana Marquez, supervisor of the department of language and cultural services at Riverside, and Maldonado's boss. "It's not a matter of finding an equivalent word, because there is none. You have to get into a deeper explanation."
Without that kind of clear communication, many Latino families never understand that hospice isn't a place but rather a suite of comfort-focused extra services, available at home, that relatives usually can't provide on their own, said Beverly Treumann, a medical interpreter in Los Angeles who now works as head of quality assurance for the Health Care Interpreter Network, an Emeryville, Calif.-based cooperative that lets member hospitals share interpreters through videoconferencing.
Treumann said she once trained an interpreter who had refused hospice for her own mother because of such a misunderstanding. "This interpreter, she was heartbroken," Treumann said. "The family took care of the mother — but without the extras that hospice could provide. The mother suffered because the concept wasn't explained adequately."
Cultural differences can breed other misunderstandings too, Kinderman said. Families from many parts of the world approach health care decisions as a group. That can make a palliative care concept like a health care proxy — a person who makes medical decisions when a patient becomes incapacitated — hard for them to grasp.
Hoping to bypass all these potential minefields, the California Health Care Foundation recruited Kinderman and other experts to help develop a palliative care curriculum for interpreters.
It introduces the palliative care concept, defining terms and providing vocabulary to help interpreters accurately convey key ideas. It encourages interpreters to alert physicians when they suspect a patient and his family don't understand what they are told. It also includes materials to help interpreters deal with their own complicated emotions during palliative care encounters.
Marquez said that all 10 of the Riverside medical center's interpreters have completed some version of the curriculum, which is taught in person or on the web.
For Maldonado, who has been interpreting for about five years, working with palliative care patients has become a passion.
She attends the palliative care team's weekly meetings, working closely with staff and patients. If Maldonado is around when a difficult conversation arises, she's the first person Marquez sends to interpret. If Maldonado or another interpreter who is comfortable with palliative care work is not available, Jukaku said, "we try to postpone the talk."
Last year, Maldonado taught a palliative care training course for interpreters. The session, held at the Moreno Valley hospital, attracted around 50 participants from throughout Southern California.
The participants wanted to talk about terminology and "vicarious trauma" — the emotional toll that interpreting for palliative care patients can take. They shared self-protection techniques. Marquez recommended using the third-person voice instead of the customary first person: rather than directly translating the doctor's words and saying "I recommend," an interpreter might create emotional distance for herself in difficult moments by saying, "your doctor recommends."
Maldonado said she, too, has trouble sometimes containing her feelings when families are distraught or have trouble accepting that a patient may soon die. "Later in the day I say, 'Oh my God … can I vent?' I have to vent."
But Maldonado also noted that raw emotion from the families means she is doing her job well.
"When we get the tears and the reactions," she said, "we know we've rendered the message."
The original bill required drug manufacturers to notify state agencies and health insurers within 60 days of federal approval of a new drug with a price tag of $10,000 or more per year or for one course of treatment and provide information justifying those prices.
This article first appeared August 17, 2016 on the Kaiser Health News website
After being approved by a key committee last week, a bill that would have required drug companies to justify treatment costs and price hikes was pulled by its author on Wednesday.
California state Sen. Ed Hernandez (D-West Covina) said that he introduced the bill "with the intention of shedding light on the reasons precipitating skyrocketing drug prices." But amendments by an Assembly committee last week make it difficult to accomplish this goal, he said in a statement.
"The goal was transparency, making sure drug companies played by the same rules as everyone else in the health care industry," he said.
The original bill required that drug manufacturers notify state agencies and health insurers within 60 days of federal approval of a new drug with a price tag of $10,000 or more per year or for one course of treatment and provide information justifying those prices. It also required these companies to provide notice before they increased the price of a drug by more than 10 percent. It was approved by the Senate in June.
But amendments by the Assembly Appropriations committee raised the reporting threshold for drug price increases to more than 25 percent. The amendments also removed the requirement for drug companies to provide justification for the price increases and delayed by a year when these notifications would have to go into effect.
"I would have preferred to see the Legislature tackle the need for pharmaceutical pricing transparency this year, but I respect Senator Hernández's decision," said Assemblywoman Lorena Gonzalez (D-San Diego), chair of the Assembly Appropriations committee. "I believe the amended version of SB 1010 [the bill] would have provided a first-in-the-nation framework this year that could have been built upon in the future."
Hernandez said he will continue to work closely with health advocates and community organizations until they "get it right."
"This is an issue that will not go away and the public demands answers," he added.
The bill had gathered support from patient, labor, education and business groups and was opposed primarily by the pharmaceutical industry. The opponents have said the bill places the responsibility solely on drug companies, ignoring that other organizations also affect drug prices, including wholesalers, distributors, health plans and other purchasers.
Some groups representing seniors and patients with chronic diseases had also expressed concerns about the legislation.
"The voters are with us and will be even more so in the future," said Anthony Wright, executive director of Health Access California, a Sacramento-based health care advocacy group. "Every new high-priced drug or unjustified price spike increases public attention and anger, not to mention contributes to rising health premiums."
Supporters referred to the bill as a solution to battling rising health care costs. Allowing insurers and state purchasers to know the cost of drugs at least 30 days in advance would enable them to better negotiate prices, supporters had said.
Key state drug purchasers include the California Public Employees' Retirement System and Medi-Cal, the state's version of the Medicaid program for low-income people.
Researchers have said that while drug price transparency measures alone, such as Hernandez's bill, would not bring health care costs down, they could help prevent drug companies from raising prices without explanation.
Similar proposals in other states have included requiring drug companies to report closely held research and development costs to government agencies. California joins other states where efforts have been stalled this year.
Hernandez's bill is separate from a ballot initiative on drug prices also garnering publicity this summer. That initiative, Proposition 61, would prohibit the state from paying more for prescription drugs than the lowest prices negotiated by the U.S. Department of Veterans Affairs.
License delays have plagued nursing boards across the nation in recent years in Georgia, Maryland and, more recently, Ohio, where thousands were reportedly waiting on backlogged license applications as of early August.
This article first appeared August 17, 2016 on the Kaiser Health News website
Ivana Russo submitted her application for a California nursing license on April 22, nearly a month before she graduated from a nursing program at Brightwood College in San Diego. She expected it to take 10 to 12 weeks for the state to process her paperwork and authorize her to take the licensing exam.
As of early August, 15 weeks later, the licensing board still had not reviewed her file and could not tell her when it would. Russo called the agency, often, to ask about the status of her application. It was hard to get a staff member on the phone. When she did, she said, "Every time I got a different story."
State officials claim that hiring new nurses is a crucial workforce concern for California, yet at least 2,000 recent nursing graduates like Russo remain in licensing limbo, with their applications taking as long as 24 weeks for the Board of Registered Nursing to process.
Experienced nurses from other states who apply for California licenses also wait months for the go-ahead to work.
The current delay in California comes on the heels of a related slowdown in 2014 and is a major inconvenience for the nurses who want jobs and a hassle for the hospitals that want to hire them. And critics say at least some of the problem stems from the flawed $96 million implementation of a computer system called BreEZe which, as its name suggests, was intended to streamline professional licensing.
"We have positions for them, but we can’t let them in without licenses in hand."
Patricia McFarland, CEO of the Association of California Nurse Leaders, an advocacy group, described the computer system as poorly conceived and inefficiently deployed, citing it as a significant contributing factor in the delays. Moreover, she said, the licensing board doesn't have a big enough staff to handle the volume of license applications it receives.
"We can't license our graduates," McFarland lamented. "Nurses want to retire, they want to train the next generation. We have hospitals investing in residency programs and they can't start the new nurses they want to hire. At the end of the day, who's suffering? Our nurse graduates and our patients."
Veronica Harms, a spokeswoman for the nursing board and for the Department of Consumer Affairs that oversees it, said the department had resolved early glitches with the new computer system. But she acknowledged that the system is still labor-intensive and time consuming, and she agreed more staff is needed to speed the licensing process.
Harms said that the board's new executive officer, Joseph Morris, who started July 10, "has acknowledged the backlog of applications and is determined to work with [the department] in finding long-term solutions."
The nursing board is responsible for licensing the state's more than 417,000 registered nurses, or RNs. It conducts background checks, verifies educational bona fides and authorizes nurse graduates to take the National Council Licensure Examination, or NCLEX, which candidates must pass to get their nursing license. In fiscal year 2015-2016, the board issued 23,743 licenses, more than half to new nurses.
This year's delays are not the first at the board, which suffered a slowdown in 2014 after it and nine other state licensing agencies adopted the "off-the-shelf" BreEZe system. Once launched, the system malfunctioned, upending workflow and creating more tasks for staff.
A February 2015 report on the system by the California State Auditor concluded that the consumer affairs department "failed to adequately plan, staff and manage the project for developing BreEZe." The audit recommended that the nursing board analyze its application process to determine its need for additional resources.
But McFarland, of the nurse leaders' association, said the state audit was a "game of dodge ball" in which the consumer affairs department and state IT leaders refused to accept responsibility for a real fix.
The audit showed that most of the 10 state boards that implemented BreEze in 2014 were "generally dissatisfied" with it. All 10 were unhappy with the ;system's reporting capability, and eight of them said the system actually made their operations less efficient.
Today, BreEZe is used by 18 state boards, bureaus and committees, including the Medical Board of California, the Dental Board and the Board of Behavioral sciences.
The nursing board reports on its website which applications it is currently reviewing — but only by dates received, not by name. Applicants cannot click to find out where their individual applications stand in the process or how much longer they should expect to wait. And the website warns that "contacting the Board for application status while within these timeframes may cause processing delays."
As of Aug. 8, the board was processing applications filed between March 16 and March 31, according to the website. Nursing graduates said it seems to have been working on March applications for some time.
On July 27, Russo asked if showing up in person might help expedite her case. The worker on the phone said she didn't think so.
"I'd drive eight hours up to Sacramento if it meant I could move this forward even one week faster," Russo said. Promising offers come and go, she said, but she can't start a job until she has her license.
She said she had to withdraw or cancel interviews with a subsidiary of Rady Children's Hospital-San Diego and the Center for Discovery La Jolla, a residential treatment facility.
Other nursing grads are also feeling confused and frustrated as their job searches get mired in the state's licensing logjam.
Lara Golden, who recently earned a Master of Nursing degree from the University of Virginia, applied for her California license on April 13. She had postal receipts, but when she called the board in June they couldn't find her paperwork. So she flew from Virginia to California to submit a second set of fingerprints in person. Seven weeks and many phone calls later, Golden is still uncertain when her application will be reviewed.
Fremont resident Angel Li received her bachelor's degree in nursing from Washington State University in Spokane in May. She submitted an application to the nursing board on March 15. After hearing nothing for 12 weeks she, too, started calling the agency.
"I kept waiting and waiting and calling back, which is not an easy task," she said. "Sometimes they just hang up due to the high call volume."
In May, Li said she had a promising interview for a pediatrics position at a Southern California hospital. The manager wanted to hire her, but said she couldn't move ahead until Li had a license.
Golden is supposed to start a residency program at a UC hospital but fears she won't have her license in time.
"I have people calling me crying," said Kathy Harren, regional chief nursing officer at Providence Health and Services, Southern California. "We have positions for them, but we can't let them in without licenses in hand."
Nancy Blake, critical care services director at Children's Hospital Los Angeles, said that as of Aug. 9, 22 nurses out of the 57 her hospital has hired for its nursing residency program, which starts September 26, still had not been cleared by the nursing board to take the licensing exam. Under normal circumstances, only two or three candidates would not yet have taken the test by this point in the summer, she said.
Blake, who hit roadblocks while renewing her own license earlier this year, worries that young nurses will get discouraged — and that hospital staffing will suffer. "A lot of the boomers are retiring," she said. "I believe we're on the cusp of a nursing shortage."
A 2014 survey by the state nursing board acknowledged as much, reporting that nearly half of California's nurses were over 50 and that many younger nurses were having trouble getting work. It is "essential that recently graduated RNs find employment opportunities so they are prepared to take on the roles of retiring RNs," the report urged.
Susan Odegaard Turner, founder of Turner Healthcare Associates, a consultancy in Thousand Oaks, said California now has more of the newly trained nurses it needs but still has not solved the problem.
"We got more nurses. But now they can't get their license," Turner said. "This is a different kind of shortage. We've produced them, but they're not working."
Patients whose prescription refills were aligned were more likely to follow their medication regimens. These findings come as more states pass laws that support the concept by requiring health insurance plans to cover partial refills of medication, and to charge pro-rated copays when they do so.
This article first appeared August 8, 2016 on the Kaiser Health News website
You have your red pill and your green pill. There's the one you take at breakfast, the one you take before bed and the one you have to take six hours after eating. All told, it is a lot to keep track of. And remembering the refills, all of which often happen at different times of the month, gets so complicated that sometimes you forget — and simply go without.
For the quarter of Americans with multiple ailments, this scenario is very familiar. It is also part of the reason, experts suggest, close to half of people with chronic conditions don't take their medications as directed by their doctors. This noncompliance costs the health care system hundreds of billions of dollars.
But a study published Monday in Health Affairssuggests a possible fix: syncing up prescription refill timelines for patients who take multiple medications.
"We have so many things going on and so many complexities in our daily lives that reducing one level of complexity, and getting rid of issues related to forgetfulness — that's a huge service," said Jalpa Doshi, an associate professor at the University of Pennsylvania's medical school, and the study's lead author.
Researchers began with a group of patients who were Medicare Advantage plan members, were taking medications for diabetes, hypertension or cardiac disease, and who participated in Humana's pharmacy mail-order service. They then randomly assigned 2,500 of them to an "intervention invitation group." Of those, 691 were reachable and agreed to enroll in this "pilot prescription synchronization program." A separate 695 were not contacted and made up a control group that continued to receive prescriptions as usual.
Patients whose prescription refills were aligned were more likely to follow their medication regimens, with overall rates of adherence increasing by 3 to 10 percentage points between September 2013 and December 2014. For those in the control group, adherence increased by only 1 to 5 percentage points. Improvement was greater for people who, at the start of the study, were already less likely to take medications correctly. For this group, syncing prescriptions boosted adherence by between 23 and 26 percentage points, as opposed to between 13 and 15 in the control group.
These findings come as more states pass laws that support the concept by requiring health insurance plans to cover partial refills of medication, and to charge pro-rated copays when they do so. Such measures make it possible for consumers and physicians to work together to make sure that prescription refill cycles match up.
That policy change can make a huge difference for people on multiple chronic prescriptions, Doshi said — a circumstance particularly common among elderly patients.
"If I'm an elderly person who needs care and support, I need someone to go to the pharmacy, or drive me. That in itself is a huge issue," she said. Even with mail-order prescriptions, remembering when individual ones end and making sure to keep them on schedule is a huge challenge. And if patients aren't getting their medications on the correct schedule, they can hardly take them as directed, she said.
Some independent researchers, however, were quick to point out that these findings are only a first step and that additional research is necessary. But if these results hold, the approach could help make a dent in unnecessary health expenses and keep chronically ill patients healthier.
They also cautioned against placing too much weight upon these findings. For instance, there's the self-selecting nature of people who had their prescriptions synced. Because they opted into the program, they may have been people already looking for ways to improve their medication habits, said Walid Gellad, co-director of the Center for Pharmaceutical Policy and Prescribing at the University of Pittsburgh. That could have inflated the improvement researchers found.
He added, though, that the practice seems promising.
"Intuitively, it would be great if you could get all the medications at the same time, rather than having to figure out when each one was due" for a refill, said Gellad, who wasn't involved with the study. "It's really patient-centered, and a good way to simplify things."
The study also doesn't link greater medication adherence to patients getting or staying healthier. That makes it hard to measure how much syncing prescriptions would really help consumers, noted Hayden Bosworth, a professor of medicine at Duke University.
But, that said, "with these particularly effective drugs — there's no question that if you take them, you're going to have benefits," he added. Bosworth also was not involved with the study.
Other research has strongly associated better adherence with improved patient health, said Niteesh Choudhry, a professor of medicine at Harvard Medical School, who was also not involved.
Meanwhile, it's still unclear how many patients actually want the service. In the study, only about 28 percent of customers opted to have their medications aligned. That could undermine the practice's potential.
The study's authors attributed that reluctance to what they call "status quo bias" — the idea that people are generally reluctant to deviate from a system they have in place.
Plus, the study only looked at Medicare Advantage patients who got mail-order prescriptions. That's a very specific group, said Choudhry. It's possible that when you extend out, the potential to benefit from prescription syncing changes.
And it's unclear who is most likely to benefit. This study looked at older patients, who are already more likely to adhere to their medications. More research should examine whether younger people — who are worse about taking their pills — could stand to gain from prescription syncing, Choudhry said.
No matter what, Bosworth said, the practice must be part of a larger strategy. Given how many people don't take their medications properly, there's no single silver bullet.
"Medication adherence is one of the largest public health problems we have," he said. "I don't think this is going to get us there, but it is part of the puzzle."
While hospital efforts to use ride-hailing services are still small, providers think the potential for growth is large. In some cases, the cost is even covered by Medicaid and other insurance plans.
Edith Stowe, 83, waited patiently on a recent afternoon at the bus stop outside MedStar Washington Hospital Center in the District of Columbia. It's become routine for her, but that doesn't make it any easier.
Stowe, who lives about five miles from the hospital, comes into the medical center twice every three months to get checkups for chronic kidney failure. She doesn't own a car and relies on buses. During rush hour, buses are more frequent, and she can keep the commute to about 30 minutes. But when she has to come in the middle of the day, it takes her at least an hour to get in and another hour to get home.
"It's pretty good except for waiting during non-rush hours," she said. "When that happens I don't plan anything else for the day."
For people without access to private transportation, getting to medical appointments can be a challenge, especially if they have chronic conditions that require frequent appointments.
Some hospitals and medical providers think that the hot-new technology in town — ride-hailing services such as Uber and Lyft — can address this problem by making the trips easier and, in some cases, it is even covered by Medicaid and other insurance plans. Partnerships between ride-hailing companies and hospitals are emerging around the country. While the efforts are still small, some hospitals and medical transportation providers think the potential for growth is large.
MedStar Health, a nonprofit health care system with hospitals in Maryland and the district, began a partnership with Uber in January that allows its patients who use Uber to access the ride service while on the hospital's website and set up reminders for appointments. Medicaid patients who may not have access to the Uber app can also arrange the ride by calling the hospital's patient advocates.
National MedTrans Network, a transportation system that provides non-emergency medical rides for patients and medical providers in a number of states, expanded its services through a partnership with Lyft last year in New York, California and Nevada.
Hackensack UMC, a hospital in New Jersey, the Sarasota Memorial Hospital in Florida, and Relatient, a health care communication company have also announced partnerships with Uber in the past year. Veyo, a San Diego startup, says it is offering a ride-hail-like technology for health care appointments in Idaho, Arizona, Texas, Colorado and California.
"We probably had 50 different systems across the country reach out to us and ask us 'How did you do it?'" said Michael Ruiz, chief digital officer for MedStar. "I would say that it has been a seismic shift for the people who have used the service and the places we've provided it."
Patients' costs for the services vary. For Medicaid patients, transportation for non-emergency medical visits are covered, although the extent of reimbursement depends on state rules. Traditional Medicare does not cover non-emergency medical transportation, although some private Medicare Advantage plans may offer some benefits.
Getting To Your Doctor
When going to a medical appointment becomes a hassle, patients are likely to miss the visit, and that can help lead to untreated symptoms or worsening health.
"Transportation can make it difficult for people to see health care providers on a regular basis," said Ben Gerber, an associate professor of medicine at the University of Illinois at Chicago who has studied patient transportation issues. "It is important to see health care professionals regularly, especially for patients with diabetes or asthma."
In a 2013 analysis of 25 studies, Gerber and colleagues found that 10 to 51 percent of patients reported that lack of transportation is a barrier to health care access. One of those studies showed that 82 percent of those who kept their appointments had access to cars, while 58 percent of those who did not keep appointments had that access. Another study reported bus users were twice as likely to skip on appointments compared to car users.
In addition to concerns about patients' health, those absences can also be expensive for medical institutions, which lose revenue from the missed appointment.
Hospitals and managed care organizations do offer a variety of options to assist with transportation for non-emergency medical appointments. Health centers often work with volunteer drivers to pick up and drop off patients.
Patients can call them ahead of time to arrange a ride, but these services generally require advance planning, which becomes a problem when the patient needs to go in for an unscheduled appointment or if the patient forgets to book ahead.
Some patients also end up calling 911 for non-emergency situations, potentially diverting resources that could be used for others with more pressing needs.
Timely Services
The National Medtrans Network partnership with Lyft began after an incident in February 2015. One of its clients, an elderly woman, was left waiting for a ride to a hospital in New York in freezing weather for 30 minutes. The contracted provider failed to show up.
"It was almost a dangerous situation," said CEO Andrew Winakor. When his company was notified of the situation, officials immediately called a ride-hail service. The ride arrived within six minutes. Winakor said Medtrans officials realized they had to find a transportation option that could respond immediately to canceled rides.
But ride-hailing services do have some disadvantages. Wheel-chair friendly rides are still limited to a few cities. They also depend on the availability of drivers, which might be scarce in rural areas and low-income communities.
MedStar in Washington, dealt with the problem in one of its hospitals in rural Maryland, where there was a lack of Uber drivers, when a patient there had to travel to the flagship hospital in D.C. for an outpatient surgery at 6 a.m.
"Our social workers worked with the folks at Uber to be able to coordinate the ride to pick this patient up at 4:30 am, and coordinate the ride back," Ruiz said.
Buses, vans and local public transportation for people in wheelchairs come and go frequently in MedStar Washington Hospital Center's bus center. Stowe is satisfied with the transport options available. While she hasn't used Uber before, she said it is something she wouldn't mind trying especially when it gets cold outside.
"There are times when you come out and you really don't feel that well. If Uber is here, it'd be really nice to have it," said Stowe.