California is one of a handful of states that publicly reports surgeons’ names and risk-adjusted death rates on a procedure known as the “isolated coronary artery bypass graft."
Michael Koumjian, a heart surgeon for nearly three decades, said he considered treating the sickest patients a badge of honor. The San Diego doctor was frequently called upon to operate on those who had multiple illnesses or who’d undergone CPR before arriving at the hospital.
Recently, however, Koumjian received some unwelcome recognition: He was identified in a public database of California heart surgeons as one of seven with a higher-than-average death rate for patients who underwent a common bypass procedure.
“If you are willing to give people a shot and their only chance is surgery, then you are going to have more deaths and be criticized," said Koumjian, whose risk-adjusted death rate was 7.5 per 100 surgeries in 2014-15. “The surgeons that worry about their stats just don’t take those cases."
Now, Koumjian said he is reconsidering taking such complicated cases because he can’t afford to continue being labeled a “bad surgeon."
California is one of a handful of states — including New York, Pennsylvania and New Jersey — that publicly reports surgeons’ names and risk-adjusted death rates on a procedure known as the “isolated coronary artery bypass graft." The practice is controversial: Proponents argue transparency improves quality and informs consumers. Critics say it deters surgeons from accepting complex cases and can unfairly tarnish doctors’ records.
“This is a hotly debated issue," said Ralph Brindis, a cardiologist and professor at UC-San Francisco who chairs the advisory panel for the state report. “But to me, the pros of public reporting outweigh the negatives. I think consumers deserve to have a right to that information."
Prompted by a state law, the Office of Statewide Health Planning and Development began issuing the reports in 2003 and produces them every two years. Outcomes from the bypass procedure had long been used as one of several measures of hospital quality. But that marked the first time physician names were attached — and the bypass is still the only procedure for which such physician-specific reports are released publicly in California.
California’s law was sponsored by consumer advocates, who argued that publicly listing the names of outlier surgeons in New York had appeared to bring about a significant drop in death rates from the bypass procedure. State officials say it has worked here as well: The rate declined from 2.91 to 1.97 deaths per 100 surgeries from 2003 to 2014.
“Providing the results back to the surgeons, facilities and the public overall results in higher quality performance for everybody," said Holly Hoegh, manager of the clinical data unit at the state’s health planning and development office.
Since the state began issuing the reports, the number of surgeons with significantly higher death rates than the state average has ranged from six to 12, and none has made the list twice. The most recent report, released in May, is based on surgeries performed in 2013 and 2014.
In this year’s report, the seven surgeons with above-average death rates — out of 271 surgeons listed — include several veterans in the field. Among them were Daniel Pellegrini, chief of inpatient quality at Kaiser Permanente San Francisco and John M. Robertson, director of thoracic and cardiovascular surgery at Providence Saint John’s Health Center in Santa Monica. Most defended their records, arguing that some of the deaths shouldn’t have been counted or that the death rates didn’t represent the totality of their careers. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)
“For the lion’s share of my career, my numbers were good and I’m very proud of them," said Pellegrini. “I don’t think this is reflective of my work overall. I do think that’s reflective that I was willing to take on tough cases."
During the two years covered in the report, Pellegrini performed 69 surgeries and four patients died. That brought his risk-adjusted rate to 11.48 deaths per 100, above the state average of 2.13 per 100 in that period.
Pellegrini said he supports public reporting, but he argues the calculations don’t fully take the varying complexity of the cases into account and that a couple of bad outcomes can skew the rates.
Robertson said in a written statement that he had three very “complex and challenging" cases involving patients who came to the hospital with “extraordinary complications and additional unrelated conditions." They were among five deaths out of 71 patients during the reporting period, giving him an adjusted rate of 9.75 per 100 surgeries.
“While I appreciate independent oversight, it’s important for consumers to realize that two years of data do not illustrate overall results," Robertson said. “Every single patient is different."
The rates are calculated based on a nationally recognized method that includes deaths occurring during hospitalization, regardless of how long the stay, or anytime within 30 days after the surgery, regardless of the venue. All licensed hospitals must report the data to the state.
State officials said that providing surgeons’ names can help consumers make choices about who they want to operate on them, assuming it’s not an emergency.
“It is important for patients to be involved in their own health care, and we are trying to work more and more on getting this information in an easy-to-use format for the man on the street," said Hoegh, of the state’s health planning and development office.
No minimum number of surgeries is needed to calculate a rate, but the results must be statistically significant and are risk-adjusted to account for varying levels of illness or frailty among patients, Hoegh said.
She acknowledged that “a risk model can never capture all the risk" and said her office is always trying to improve its approach.
Surgeons sometimes file appeals — arguing, for example, that the risk was improperly calculated or that the death was unrelated to the surgery. The appeals can result in adjustments to a rate, Hoegh said.
Despite the controversy it generates, the public reporting is supported by the California Society of Thoracic Surgeons, the professional association representing the surgeons. No one wants to be on the list, but “transparency is always a good thing," said Junaid Khan, president of the society and director of cardiovascular surgery at Alta Bates Summit Medical Center in the Bay Area.
“The purpose of the list is not to be punitive," said Khan. “It’s not to embarrass anybody. It is to help improve quality."
Khan added that he believes outcomes of other heart procedures, such as angioplasty, should also be publicly reported.
Consumers Union, which sponsored the bill that led to the cardiac surgeon reports, supports expanding doctor-specific reporting to include a variety of other procedures — for example, birth outcomes, which could be valuable for expectant parents as they look for a doctor.
“Consumers are really hungry for physician-specific information," said Betsy Imholz, the advocacy group’s special projects director. And, she added, “care that people receive actually improves once the data is made public."
But efforts to expand reporting by name are likely to hit opposition. Officials in Massachusetts, who had been reporting bypass outcomes for individual doctors, stopped doing it in 2013. Surgeons supported reporting to improve outcomes, but they were concerned that they were being identified publicly as outliers when they really were just taking on difficult cases, said Daniel Engelman, president of the Massachusetts Society of Thoracic Surgeons.
“Cardiac surgeons said, ‘Enough is enough. We can’t risk being in the papers as outliers,’" Engelman said.
Engelman said the surgeons cited research from New York showing that public reporting may have led surgeons to turn away high-risk patients. Hoegh said research has not uncovered any such evidence in California.
In addition to Koumjian, Robertson and Pellegrini, the physicians in California with higher-than-average rates were Philip Faraci, Eli R. Capouya, Alexander R. Marmureanu, Yousef M. Odeh. Capouya declined to comment.
Faraci, 75, said his rate (8.34 per 100) was based on four deaths out of 33 surgeries, not enough to calculate death rates, he said. Faraci, who is semi-retired, said he wasn’t too worried about the rating, though. “I have been in practice for over 30 years and I have never been published as a below-average surgeon before," he said.
Odeh, 45, performed 10 surgeries and had two deaths while at Presbyterian Intercommunity Hospital in Whittier, resulting in a mortality rate of 26.17 per 100. “It was my first job out of residency, and I didn’t have much guidance," Odeh said. “That’s a recipe for disaster."
Odeh said those two years don’t reflect his skills as a surgeon, adding that he has done hundreds of surgeries since then without incident.
Marmureanu, who operates at several Los Angeles-area hospitals, had a mortality rate of 18.04 based on three deaths among 22 cases. “I do the most complicated cases in town," he said, adding that one of the patients died later after being hit by a car.
"Hospital patients don’t care" about the report," he said. "Nobody pays attention to this data other than journalists."
“It seems to me it’s not nearly enough” to keep plans affordable for those with chronic illness, said Timothy Jost, emeritus law professor at Washington and Lee University and an expert on health reform.
The latest Senate health proposal reins in costs by effectively splitting the individual insurance market, with healthy people diverted into stripped-down plans and chronically ill individuals left with pricey and potentially out-of-reach options, insurance analysts said.
This draft — a fresh attempt by the Republican Party to undo the Affordable Care Act — injects more uncertainty into plans for people with preexisting conditions such as cancer, asthma, diabetes or other long-term ailments. Those people, insured through ACA marketplaces now, could be more isolated than in an earlier version of the Senate bill.
For such patients, “I would be pretty nervous,” said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. “You will have separate pools — one that only healthy people can get into and one for you. That pool is liable to get increasingly expensive — in fact, very expensive over time.”
The two biggest insurer trade groups went further on Friday, saying in an unusually strong-worded letter that “millions of more individuals will become uninsured” if the proposal becomes law.
Plans sold to individuals and families through the Obamacare exchanges cover some 10 million people, many with chronic disease.
A draft bill released Thursday added a proposal from Texas Sen. Ted Cruz that would let insurers sell health coverage outside the ACA exchanges with no provisions for prescription drugs, mental illness, hospitalization or almost any other benefit.
Such plans would be far cheaper than comprehensive coverage and almost certainly draw younger, healthier people away from high-benefit insurance, analysts said.
Without healthy customers subsidizing the sick, premiums and other costs would soar for plans that accept chronically ill patients, experts said. The Senate draft includes $70 billion over a decade to help pay those costs, but it’s far from clear that would be enough.
Insurers were struggling last week to grasp the implications of the legislation, studded with ambiguous language. One big takeaway: The Senate’s version of health care would undermine historical assumptions and drastically shift risk in the individual market.
Letting carriers sell low-cost, low-benefit plans to healthy consumers “is simply unworkable in any form and would undermine protections for those with pre-existing medical conditions, increase premiums and lead to widespread terminations of coverage for people currently enrolled in the individual market,” America’s Health Insurance Plans and the Blue Cross Blue Shield Association, two lobbying groups, said in a Friday letter to the Senate.
The Republicans are nowhere near success with this plan. Already two of the 52 Republican senators — Kentucky conservative Rand Paul and Maine moderate Susan Collins — have said they won’t support the bill. One more defection would sink it, and a delay caused by the surgery of Arizona Republican John McCain gives opponents more time to build resistance.
Senate leaders had scheduled a vote for this week but postponed it to give McCain time to recover from treatment of a blood clot near his eye.
Meanwhile, the nonpartisan Congressional Budget Office is likely to issue its assessment of the bill this week. The CBO had said an earlier Senate bill would increase the number of people without health insurance by 22 million by 2026.
The Republican plan offers a freer insurance market — something the party has long favored — while purporting to protect those with existing illness. Insurers selling stripped-down plans would be required to also offer traditional Obamacare plans covering preexisting conditions.
You will have separate pools — one that only healthy people can get into and one for you.
But such coverage risks becoming a high-cost ghetto for the chronically ill, experts said. It would likely become unattractive to carriers and unaffordable to members who could face paying thousands of dollars for premiums and thousands more out-of-pocket before coverage kicks in.
Even though insurers selling unregulated plans would be required to offer full-coverage plans to all comers, they could limit their risk with time-tested maneuvers to repel the sick, said Ana Gupte, who follows health care stocks for Leerink Partners.
“They usually find ways to minimize enrollment” such as jacking up premiums or cutting broker commissions for certain coverage, she said.
Nor would there likely be much choice in high-benefit Obamacare plans, she said. Under the Senate bill, carriers seeking to sell skimpy coverage would have to offer only one high-benefit “gold” plan and a medium-benefit “silver” plan as traditionally sold under the Affordable Care Act.
Even then, the legislation would allow state officials to alter Obamacare standards for out-of-pocket maximums and essential health benefits.
That even could allow richer plans intended for the chronically ill to drop coverage of prescription drugs, mental illness, maternity care or other items.
The bill includes two measures intended to keep costs in high-benefit Obamacare plans from spiking out of control. One is the $70 billion in federal subsidies to help cover the expense of the pool of sick people.
“It seems to me it’s not nearly enough” to keep plans affordable for those with chronic illness, said Timothy Jost, emeritus law professor at Washington and Lee University and an expert on health reform.
The other is a six-month waiting period for applicants wanting to buy full coverage who don’t already have it.
That’s supposed to induce healthy people to buy high-coverage plans and help subsidize the sick. Otherwise they risk a coverage gap if they become gravely ill or hurt, raising the chance they would have to pay thousands out-of-pocket for any unexpected medical expense.
But that incentive to buy comprehensive coverage is far weaker than Obamacare’s mandate, which fined people for not having insurance, Jost said. The Republicans’ bills would scrap the mandate.
“I just don’t think it’s going to be terribly effective,” he said.
Senate Republican leaders Thursday released their revised bill to “repeal and replace” the Affordable Care Act, but they acknowledged that furious days of negotiation have not yet secured the 50 votes necessary to pass the measure over unanimous Democratic objections.
Sen. John Cornyn (R-Texas) the No. 2 GOP leader, told reporters that while backers of the measure did not yet have the GOP votes needed, “we will by the time we vote.”
The revised draft was presented to Republican senators at a closed meeting Thursday morning. Among its many provisions, it would cap federal funding for the Medicaid program, covers more than 70 million low-income Americans, and give states authority to waive insurance regulations in the ACA.
Senate Majority Leader Mitch McConnell (R-Ky.) has been struggling for more than two weeks to satisfy holdouts from both wings of the party. Conservatives complain that the draft bill unveiled last month did not go far enough to repeal many of the ACA’s regulations, while moderates argue that structural changes and cuts to the Medicaid program for the poor are too deep.
So far, two of the 52 Republican senators have declared they will not even vote for the preliminary motion that would begin formal debate: conservative Rand Paul of Kentucky and moderate Susan Collins of Maine. “Still deep cuts to Medicaid,” Collins tweeted. “Will vote no on” motion to proceed to the bill.
Collins told reporters separately that she cannot support the bill, and criticized Senate leaders for the way they produced it. Such a fundamental change to Medicaid should have a full set of legislative hearings, she explained. Even fully repealing the ACA would not cap spending for Medicaid in the way the Senate bill is proposing. “Repealing Obamcare would not change the underlying Medicaid program,” she said.
The ACA expanded Medicaid, but the Senate changes would cut it back well beyond that expansion.
One more “no” vote would stop the bill in its tracks, even with a potential tie-breaking vote from Vice President Mike Pence. Several moderate senators emerged from the closed meeting saying they were still undecided, including Shelley Moore Capito (R-W.Va.) and Lisa Murkowski (R-Alaska).
Leaders did, however, apparently satisfy some of their more conservative members by making some changes proposed by Ted Cruz (R-Texas). Cruz touted after the meeting that the legislation includes provisions to allow people to use tax-preferred health savings accounts to pay insurance premiums (which are currently banned). It would also allow anyone to purchase a plan that covers only catastrophic health expenses (which the ACA limits to those under age 30) and permit insurers to offer plans that do not conform to many of the regulations in current law. Those rules include the ACA’s requirements for coverage of specific health benefits as well as bans on insurers charging sick people more and limiting out-of-pocket costs.
Senate leaders offered to spend more money on people who could be adversely affected by the insurance changes, including an additional $45 billion to combat opioid abuse, but moderates said it does not solve the problem.
“There’s money,” Collins told reporters, “but too many uses for that money.”
Democrats remained steadfastly opposed to the measure. “The meat of this bill is exactly the same as it was before, and in some ways, they’ve somehow managed to make it even worse,” said Minority Leader Chuck Schumer (D-N.Y.).
Even if leaders round up the needed votes, there are still a number of obstacles between this draft bill and President Donald Trump’s signature. They include:
Procedural Restrictions
Republicans are trying to pass their health bill using a special budget process that lets them avoid a filibuster and the usual requirement to get 60 votes for passage. But strict rules govern what can and cannot be included in such a “budget reconciliation” bill. Democrats this week are arguing to the Senate parliamentarian that many sections of the bill should not be allowed, including those that would impose abortion restrictions and modify the private insurance regulations included in the ACA.
Cost Estimates
The Congressional Budget Office is the official scorekeeper for Congress. It said the first version of the Senate bill would result in 22 million more uninsured people by 2026.
CBO is expected to offer its score of the bill next week, but some Senate Republicans on Thursday said that rather than wait for that, they might ask the Department of Health and Human Services to do it instead. That would be likely to produce a number more favorable to Republicans.
Democrats saw that option as a partisan play by Republicans. “It’s gaming the score,” said Sen. Sherrod Brown (D-Ohio). “Why don’t they just have the score written in McConnell’s office by his staff?”
House Passage
Whatever the Senate produces must be acceptable to a majority of the House, or else the two chambers could get bogged down in weeks or months of negotiations. But changes that would make the Senate bill more acceptable to moderates there would likely not be able to get through the more conservative House. Leaders are walking a thin tightrope.
On the other hand, Republicans continue to be driven by the imperative of keeping their seven-year promise to overturn the health law.
“Virtually every Republican in this body has supported the effort to repeal and replace Obamacare more or less since the day it was signed into law,” Senate Finance Committee Chairman Orrin Hatch (R-Utah) said on the floor. “This legislation, while far from perfect, would fulfill the vast majority of those promises.”
Public opposition to the Republican effort to replace the Affordable Care Act grew stronger this month, but a core group of Republicans remained in support, according to a poll released Friday.
Sixty-one percent of the public said this month they did not like the GOP health care effort, now undergoing a revised push in the Senate. That was a 6 percentage point increase from the Kaiser Family Foundation’s monthly tracking results in June, when 55 percent expressed unfavorable opinions. (Kaiser Health News is an editorially independent program of the foundation.)
The poll also found opposition was becoming more passionate, with more of the public viewing the plan “very” unfavorably. The Affordable Care Act maintained the support of half the populace, nearly double the 28 percent of people who backed the GOP efforts. Two of three people opposed major reductions in Medicaid that are included in the GOP plans.
Nonetheless, a majority of Republicans and supporters of President Trump continued to favor the GOP plan, which would increase the number of uninsured as it alters Medicaid and the private insurance markets that have been running since 2014. In fact, in this month’s poll more Republicans said health care is headed in the right direction than believed that in April, before the House passed its version of the health care replacement bill.
Still, most Americans said they would prefer Republicans and Democrats to work together on health care — 71 percent said they would like to see a bipartisan effort to fix the ACA.
The poll of 1,187 adults was conducted July 5 - 10, about a week after the Congressional Budget Office issued its report on the GOP draft legislation. The margin of error was plus or minus 3 points.
The hospital trust fund forecast is secure enough that it would not trigger an ACA provision to make automatic cuts to the program, HHS Secretary says.
The Trump administration said Thursday that the financial outlook for Medicare’s hospital insurance trust fund improved in the past year due to health costs rising more slowly than expected and predictions that enrollees will use hospital services less often.
The report said that trust fund would last through 2029, one year later than what was projected last year. Two years ago, 2030 was the projected depletion date.
Medicare Part B premiums — which cover visits to physicians and other outpatient costs — should remain stable next year, the trustees said. About a quarter of Part B costs are paid for by beneficiary premiums with the rest from the federal budget.
In contrast, the Part A hospital trust fund is financed mostly through payroll taxes.
The report, from the trustees of the Medicare program, noted that projected costs of the program assume the Affordable Care Act stays in place. President Donald Trump and Republicans in Congress are trying to overhaul the law, which when enacted in 2010 added several years to the fiscal life of the trust fund.
Health and Human Services Secretary Tom Price, one of four Medicare trustees, also said the hospital trust fund forecast was secure enough that it would not trigger an ACA provision to make automatic cuts to the program. Those cuts are required by the ACA when spending is expected to exceed certain benchmarks.
Despite the slightly improved outlook, the trustees warned that the aging of the baby boom population and rising health care costs will cause Medicare expenses to increase from 3.6 percent of gross domestic product in 2016 to 5.6 percent of GDP in 2041, and then level off somewhat to 5.9 percent by 2091.
As in previous trustee reports, the latest analysis warned that Washington should address the financial challenges of Medicare as soon as possible to avoid having to cut benefits to millions of retirees and seniors.
The trustees said national health expenses have slowed considerably in recent years, although it is uncertain if this is a result of the Great Recession, which ended in 2009, or efforts taken by the federal government and private sector to change doctor and hospital reimbursement programs. Senior administration officials said some of the slowing growth in Medicare was due to Obamacare saving money through its accountable care organizations, which pay doctors and hospitals a lump sum each month to care for senior citizens.
Medicare provides health coverage to nearly 57 million people, including seniors and people with disabilities. It has added 5 million people since 2013.
“For 51 years, Medicare has played a crucial role in providing healthcare for America’s senior citizens,” Price said in a statement. “Unfortunately, on its current trajectory, Medicare’s hospital insurance trust fund will be depleted in just over a decade. … As the Trustees Report says, this means that reform to the program is needed.”
Medicare spending were about $679 billion last year. The hospital insurance trust fund helps pay hospital, home health services, nursing home costs and hospice costs.
Should the White House call on the IRS to offer a safe harbor for chronic disease medications, patients may visit the pharmacy more often despite the high deductibles.
The pharmaceutical industry could see windfall profits from a little-noticed tweak to the insurance market tucked into the Trump administration’s draft executive order on drug prices, experts say.
The short, technical paragraph calls for the Internal Revenue Service to allow patients with high-deductible health plans to receive care for chronic diseases, including drugs, before meeting their deductibles.
This allowance, known as a “safe harbor,” could be welcome news for patients with chronic conditions like diabetes or asthma stuck with skimpy plans. For example, a diabetes patient could fill her prescription for insulin with just a copay, even if she hadn’t spent enough on medical bills for her insurance coverage to kick in. But in the long term, experts say, extending a safe harbor to chronic care would encourage more employers to adopt these skimpy plans, while shielding the pharmaceutical industry from pressure to lower drug costs.
“It’s hard to view this as anything but a substantial win for pharma,” said Kim Monk, a partner and pharmaceutical expert at Capital Alpha Partners, which tracks laws and regulations for financial institutions.
High-deductible health plans have surged in the past five years. The U.S. Centers for Disease Control and Prevention estimates almost 40 percent of patients ages 18-64 must pay $1,300 before receiving insurance coverage, and families must pay at least $2,600. And when faced with high drug prices, more of these patients skip filling prescriptions. Of the millions of insured Americans who struggle to pay their medical bills, 41 percent skip filling a prescription due to cost according to a 2016 Kaiser Family Foundation poll. (Kaiser Health News is an editorially independent program of the foundation.)
These high-deductible health plans are likely to grow if the GOP health plan becomes law, according to the Congressional Budget Office.
But should the White House call on the IRS to offer a safe harbor for chronic disease medications, patients may visit the pharmacy more often despite the high deductibles.
“Yes, this provision could alleviate some of the pharmaceutical industry’s concerns about the increased cost-sharing patients with high-deductible plans could expect under the Republican health care bills,” said Rachel Sachs, an associate professor of law at Washington University in St. Louis who studies the pharmaceutical industry. “As the draft order notes, if high-deductible plan enrollees with chronic conditions can lower out-of-pocket costs for some of their medications, they will be more likely to adhere to their treatment regimens.”
The language of the draft executive order could signal a significant expansion of drug coverage for the growing population with high-deductible plans, according to Stacie Dusetzina, assistant professor of pharmacy and public health at the University of North Carolina-Chapel Hill. Under the Affordable Care Act, preventive drugs were covered before the deductible was met, but the provision was “quite narrowly defined and did not include medications that are used to prevent the progression of disease,” Dusetzina said. “Instead, it was more about preventing the disease altogether. In that way, the executive order could have a big impact on patient access to drugs.”
But unlike coverage under Medicaid or under a plan with a higher actuarial value, the IRS would determine what care and medications are covered. It’s not yet clear whether the safe harbor would extend to essential HIV drugs, insulin or expensive drugs that treat rare diseases.
“You’re asking the IRS to define something the IRS has never had to define before,” said Monk.
The draft executive order explains that the expanded coverage is “for the purpose of helping patients adhere to clinical regimes and thereby reducing the cost of care.” For instance, a patient who can afford an inhaler is less likely to be admitted to the hospital for wheezing. But whether this compliance reduces the cost of care in the long term depends on treatment costs and drug costs, Sachs said.
The safe harbor for chronic care has been championed by the Smarter Health Care Coalition, a partnership linking industry heavyweights including America’s Health Insurance Plans (AHIP), the insurers’ lobbying group; the U.S. Chamber of Commerce; Novo Nordisk; and Pfizer.
The safe harbor will make high-deductible health plans more attractive to employers, according to Tracy Watts, a senior partner at benefits firm Mercer, which could prompt insurers to supply them. “Such a change would go a long way toward encouraging more employers to offer [high-deductible] plans and would boost enrollment,” Watts wrote in a blog post.
The White House has not issued an official executive order on drug prices yet. The draft order, first obtained by The New York Times, has been overshadowed by the political drama over the health bill on the Hill.
Major trade groups have largely avoided shedding political capital on the congressional health care fight — among the most conspicuously absent: PhRMA, the Biotechnology Innovation Organization and the Association for Accessible Medicines, the generic-medicines lobby.
Pharmaceutical companies would see a $2.7 billion annual tax break, but that money would be eclipsed by losses in revenue from Medicaid and Medicare, as well as the drop in demand for health care from the millions of newly uninsured, Moody’s concluded in March.
PhRMA won’t yet say whether it supports the chronic-care safe harbor. “We can’t speak to what the administration will do on this issue and don’t think it would be appropriate to speculate,” said Holly Campbell, deputy vice president of public affairs at PhRMA.
The plans are recent additions to the Medicare Advantage market. “There’s a conflict there,” says a senior attorney with the Center for Medicare Advocacy.
Around the country, a handful of nursing home companies have begun selling their own private Medicare insurance policies, pledging close coordination and promising to give clinicians more authority to decide what treatments they will cover for each patient.
These plans are recent additions to the Medicare Advantage market, where private plans have become an increasingly popular alternative to traditional fee-for-service coverage. Unlike other plans, these policies offered by long-term care companies often place a nurse in the skilled nursing facility or retirement village, where they can talk directly to staff and assess patients’ conditions. Some provide primary care doctors and nurses to residents in the homes or in affiliated assisted living facilities or retirement villages with the aim of staving off hospitalizations.
“The traditional model is making decisions based on paper, and in our model, these decisions are being made by clinicians who are really talking to the staff and seeing the patient,” said Angie Tolbert, a vice president of quality at PruittHealth, which began offering its plan to residents in 10 of its nursing homes in Georgia last year. “It’s a big shift in mindset.”
Not everyone finds such plans superior. Some patients who are in disputes with the insurers have faulted the nursing home staff — who work for the same company — for not helping challenge decisions about coverage. They complain that the company holds an unfair advantage over Medicare beneficiaries.
“There’s a conflict there,” said Toby Edelman, a senior attorney with the Center for Medicare Advocacy.
In an Erickson Living retirement village in Silver Spring, Md., Faith Daiak signed up for an Erickson Advantage plan sold by a nurse whose office was in the main village building, according to her son, J.J. Daiak. After a bout with the flu last February weakened her enough to need a 10-day hospitalization, she was sent to her village’s skilled nursing facility. There, the insurer repeatedly tried to cut short her stay.
Erickson Advantage first said it would stop paying for Daiak, 88, because she wasn’t getting healthier in the nursing facility. Her son appealed by pointing out that Medicare explicitly said as part of the 2014 settlement of a class-action lawsuit that patients do not have to be improving to qualify for skilled nursing care.
Daiak’s appeal was denied, but the issue was sidelined in March when her rapid weight loss in the nursing home sent her back to the hospital, he said.
After Daiak returned to the nursing home with a feeding tube in her stomach, the insurer again tried to curtail her time there, saying she did not need that level of care. The family successfully appealed that decision after noting that Medicare’s manual said feeding-tube maintenance required the skilled care of a nursing facility.
In April, Erickson Advantage again said it would not continue paying for Daiak’s stay. It reversed that decision after Kaiser Health News asked the company about the case, J.J. Daiak said. He said the plan did not explain its turnaround.
Dolphine Williams (left) and Rita Coopersmith visit Faith Daiak in the Riderwood-ArborRidge Skilled Nursing Facility in Silver Spring, Md., on May 12, 2017. (Courtesy of the Daiak family)
While this Medicare Advantage plan touts its “team that knows you personally and wants to help,” J.J. Daiak said he found the registered nurse at Erickson’s Silver Spring community not helpful. “All I see is her trying to get Erickson out of having to pay for the nursing home,” he said. He subsequently switched his mother to traditional Medicare coverage with a supplemental Medigap policy, which she had until this year.
Erickson Living, the parent company of the nursing home and insurer, declined to discuss individual cases but noted that Medicare has given its insurance plans the best quality rating of five stars. In a written statement, the company said that “medical service determinations for Erickson Advantage members are based on reviews by licensed clinical staff and clinical guideline criteria. Our primary focus is always on ensuring that the healthcare being provided for our residents matches a patient’s needs and established clinical treatment protocols.”
Edelman said the dispute was particularly troubling because Erickson’s retirement villages are marketed on the promise that the company will care for seniors in all stages of aging. “They don’t tell you what they won’t pay for,” she said.
Popular Alternative
There are nearly 18 million enrollees in the overall Medicare Advantage market. Medicare pays private insurers a set amount to care for each beneficiary. In theory, this payment method gives the insurers motivation to keep patients from needing costly medical services such as hospitalizations.
A subset of Medicare Advantage plans are designed exclusively for people who either require or are expected to require at least 90 days of skilled services from nursing homes, assisted living facilities or other long-term care institutions. UnitedHealthcare directly offers three-quarters of these plans with about 40,000 enrollees, far more than those offered by nursing home companies. Matthew Burns, a UnitedHealth spokesman, said the majority of the company’s plans are rated four stars or better on Medicare’s five-star quality scale.
“Our plans offer members quality and peace of mind — and they are considered above average to excellent by CMS quality and performance standards,” he said in a statement.
United also underwrites Erickson’s policies, which have around 200 enrollees, and were the first Advantage plans offered by a long-term care operator. Under the arrangement, Erickson Advantage decides when a nursing home stay is covered.
Nick Williams, PruittHealth’s care integration officer, said its Medicare insurance plan has resulted in 30 percent fewer hospitalizations among residents since it began last year. The company intends to expand the insurance coverage to residents at 42 of its other nursing homes in Georgia. Other nursing home chains are experimenting with this model in Missouri, South Carolina, Virginia and elsewhere.
Anne Tumlinson, a Washington health care industry consultant who specializes in long-term care, said that when a nursing home’s company is on the hook for the cost of hospitalizations of their patients, it is more likely to make efforts to prevent them.
“It gets them out of hospitalizing people at the drop of the hat,” she said. “If you live in a nursing home or are living in assisted living and they have one of these plans going, they’re going to be investing heavily in 24/7 access to primary care.”
She said big insurers have so many different types of enrollees that they are less focused on the particular needs of nursing home patients. “They’re too big, they’re bureaucratic, and they are insurers, not providers,” she said.
The Costs Patients Face
In Hingham, Mass., Suzanne Carmick has been frustrated with the Erickson plan’s unwillingness to pay for most of her mother’s prolonged stay. Last October, 98-year-old Lorraine Carmick went into Erickson’s nursing home after a hospitalization. Eleven days later, Erickson Advantage notified Suzanne Carmick it would stop paying for the facility because it said her mother was strong enough to move with the help of a rolling walker. Under Medicare’s rules, nursing home stays are not covered if a patient does not need daily physical therapy. Erickson said two or three days was sufficient for Carmick.
Suzanne Carmick appealed the decision, saying Erickson exaggerated her mother’s recovery, noting that she had dementia, an infection and was wearing two stiff leg braces. She said getting therapy five days a week provided in the nursing home would help her mother recover faster.
“She still cannot stand up or sit down or go anywhere … without an aide helping her by pulling her up or setting her in a chair,” Carmick wrote. “She is improving but is now supposed to stop or decrease PT [physical therapy], and she must start paying out-of-pocket?”
After a week’s extension, the nursing home began billing her mother at its daily rate of $463, which rose to $483 this year as Lorraine Carmick remained in the nursing home. A Medicare appeals judge subsequently ruled Erickson’s action was justified, based on the testimony from the nursing home staff — all Erickson employees. If the insurer had covered a maximum stay, Carmick would have avoided more than $30,000 in bills she now owes. Suzanne Carmick said her mother has been on a wait list for six months for a bed on a less expensive floor in the nursing facility.
“It is a closed system where the skilled nursing facility, physicians and Medicare Advantage plan are all one and the same,” she said. “The Erickson Advantage plan is turning out to be quite a disadvantage at this point.”
The analysis provides a critical piece of the puzzle behind more than 100 sometimes fatal infections in cardiac surgery patients since 2013, researchers said. At least five other manufacturers also sell heater-coolers in the U.S. and they all share a design that could pose a risk for infections, experts say.
Contamination at a German factory that makes crucial machines used during open-heart surgery is the likely source of a global outbreak of deadly infections tied to the devices, the largest analysis to date shows.
Scientists using whole-genome sequencing matched the DNA fingerprints of samples taken from infected heart-surgery patients from several countries, including the U.S., to samples from the devices, called heater-cooler units, in multiple hospitals — and at the production site.
The study, published Wednesday in The Lancet Infectious Diseases journal, concludes that heater-cooler devices made at the LivaNova PLC plant in Munich, Germany, were contaminated during production.
The analysis provides a critical piece of the puzzle behind more than 100 severe — and sometimes fatal — infections in cardiac surgery patients worldwide since 2013, researchers said.
“Our study closes the missing gap,” said Stefan Niemann, a professor with the German Center for Infection Research and one of the study’s co-authors.
However, officials with LivaNova said that the study was too limited to draw conclusions.
“LivaNova is concerned that the article expresses a level of certainty about a point source tie to the manufacturing process that is not warranted by the data,” spokeswoman Deanna Wilke wrote in an email.
Scientists from Germany, the Netherlands and Switzerland analyzed 250 DNA samples of Mycobacterium chimaera, an organism typically found in soil and tap water.
The review included samples from 21 infected patients in Switzerland, Germany, the Netherlands and the United Kingdom, and data from another 12 in the U.S. and Australia. The analysis included samples from heater-cooler devices by LivaNova and a second German brand, Maquet, plus hospital water sources and environmental sources.
Scientists found a high degree of similarity in samples from the patients and from the LivaNova heater-cooler units and the LivaNova factory.
The authors noted that they were not able to link individual patients to particular heater-cooler units because they lacked enough water and air samples to document transmission. Infections have been linked to contaminated water in the devices that is then misted into the air.
They also warned against ending investigations into the problem too soon. Researchers found that some hospital water systems and Maquet heater-coolers were contaminated, raising concerns about local contamination.
Vincent Karst, 55, of York, Pa., was among those infected with Mycobacterium chimaera. Known as Vinnie, the father of five and grandfather to 15 appeared to do well after open-heart surgery in March 2015. But, according to a lawsuit, he fell mysteriously ill and had to be re-hospitalized with what doctors later said was an infection tied to the heater-cooler unit used during his operation.
Karst died in May from complications of the infection, his lawyer said.
Patients in several other states have filed lawsuits claiming they were infected, too.
Karst’s surgery used a Sorin 3T heater-cooler, a device that circulates water to warm or cool patients’ blood during bypass operations. More than 250,000 operations using the devices are performed each year in the U.S., and about 60 percent are done with the Sorin 3T models approved for sale in 2006. After a 2015 merger, Sorin became LivaNova.
At least five other manufacturers also sell heater-coolers in the U.S. — and they all share a design that could pose a risk for infections, experts say.
The heater-cooler devices use fans to regulate airflow. If the water in the system is contaminated with bacteria, the machines can send the germs into the air, where they can settle in open surgical sites or on cardiac implants before insertion. One complicating factor is that it can take months or even years to detect the slow-growing infections.
Early reports of infections tied to heater-cooler units date to 2002, and Food and Drug Administration officials have said they were aware of the problem by 2014. At least 15 people in the U.S. have died, according to reports submitted to the agency.
But the FDA waited more than a year to warn the public about the risk — and even longer to provide recommendations for action to hospitals and patients. Critics contend that if the agency had intervened earlier, more patients would have avoided infections, even death.
The agency now warns that for 3T devices manufactured before September 2014, there is strong evidence of common contamination at the manufacturing site in Germany. But spokeswoman Stephanie Caccomo said local contamination can also occur and hospitals should “perform appropriate follow-up measures.”
Lawrence Muscarella, a Pennsylvania patient-safety consultant, said he’s concerned that a focus on contamination at the factory might lead hospitals to relax their vigilance about what are often called Nontuberculous mycobacteria, or NTM, infections.
“[They] might incorrectly conclude that what’s to blame for these infections is contamination at a company’s manufacturing plant, something the hospital can do nothing about, rather than understanding that hospitals can reduce the risk of NTM infections in open-chest patients,” he said.
At the University of Iowa Hospitals and Clinics, where six patients developed infections tied to heater-cooler units, experts solved the problem by putting the devices in a room connected to — but separate from — the operating room, said Dr. Michael Edmond.
“I don’t think we can safely say the machines can be decontaminated,” said Edmond, a clinical professor of infectious diseases. “The only safe mitigation strategy is you have to separate the air that comes out of that machine from the air in the operating room.”
Since the hospital took that action in January 2016, no new infections have been detected.
Patient advocates predict that would lead to fewer enrollees, more shutdowns of rural facilities, reduced payments to doctors and fewer programs for people with health needs or disabilities.
ATLANTA - Each day as Ginger Peebles watches daughter Brenlee grow, she sees the importance of having a hospital close by that delivers babies.
Brenlee’s birth was touch-and-go after Peebles realized something was wrong. “I couldn’t feel the baby move, and my blood pressure was sky-high,” said Peebles, a nurse.
Dr. Roslyn Banks-Jackson, then an OB-GYN specialist at Emanuel Medical Center in Swainsboro, Ga., diagnosed preeclampsia, a potentially lethal complication of pregnancy, and induced labor to save Peebles and the baby. Brenlee was born on Oct. 28, 2014, completely healthy.
Had Peebles given birth the following year, she might not have been so fortunate, she said. Emanuel shuttered its labor-and-delivery unit the next spring, becoming one of a handful of such units in the state to close from 2010 to 2015, most because of budget problems. Another is expected to close this month, said Daniel Thompson, executive director of the Georgia OBGyn Society.
Republican bills to replace the federal health law would worsen rural areas’ financial straits through reductions in Medicaid funding. Patient advocates predict that would lead to fewer enrollees, more shutdowns of rural facilities, reduced payments to doctors and fewer programs for people with health needs or disabilities. In the aggregate, such changes threaten the health of thousands of state residents, especially those in rural areas.
“I’ve seen changes, and I’ve seen cuts, but I’ve never seen changes like what’s being proposed in this bill,” said Eric Jacobson, executive director of the Georgia Council on Developmental Disabilities. “This is the first time it’s been this scary.”
Possible Strains On A Lean Budget
One of the key aims of the House and Senate bills is reversing the Affordable Care Act’s expansion of Medicaid. But the legislation also would institute changes to the federal-state health program for low-income residents that could devastate states such as Georgia that didn’t expand Medicaid. Georgia already ranks 45th in the nation in per capita Medicaid spending, according to the Georgia Budget and Policy Institute.
The bills would switch Medicaid from an entitlement — in which the federal government agrees to pay its share of costs for anyone who qualifies for the program — to a system in which the federal government by 2020 would limit its payments and reimburse states based on a per capita formula.
The nonpartisan Congressional Budget Office concluded in a report released June 29 that the Senate plan would slash 35 percent of expected federal Medicaid funding by 2036.
“Cuts now would cripple rural Georgia,” said Dr. Ben Spitalnick, president of the Georgia chapter of the American Academy of Pediatrics.
He said that is because most primary care visits, which include OB-GYN, pediatric and adult care, in the state’s sparsely populated areas rely heavily on Medicaid reimbursements.
The federal cutbacks would have to be offset by the state. But that means taking money from other programs or raising taxes. As a result, state officials facing those shortfalls would likely scale back an already lean Medicaid coverage.
“If you cut back, [people] still go to the hospital, they’ll still need care. No matter what you do, the buck stops somewhere,” said Renee Unterman, a Republican state senator who chairs the health and human services committee. In the end, she added, the cost for that uncompensated care gets passed to taxpayers and consumers through higher health costs and insurance premiums.
Georgia’s rural hospitals have proved vulnerable. Five closed in the past five years and another two merged. Plus, several have closed their emergency rooms.
That translates to a loss of doctors in affected counties. Of Georgia’s 159 counties, 79 do not have an OB-GYN specialist, and 65 do not have a pediatrician, according to 2015 figures from the Georgia AAP and the Georgia OBGyn Society.
Close to 1.7 million Georgians, or nearly 1 in 5 state residents, live in these areas, according to figures from the Rural Health Information Hub.
Improving Pay For Doctors
For 15 years, Georgia Medicaid reimbursed primary care doctors at only 60 percent of the amount that the federal Medicare program reimbursed similar services, said Ward.
But in 2015, the Legislature implemented three rounds of pay increases to primary care doctors, including pediatricians and OB-GYNs, to bring them in line with the Medicare reimbursement.
Many of these doctors are now concerned those rates would be the first to be lowered. “That’s our big fear,” said Rick Ward, executive director of the Georgia chapter of the AAP. “We just clawed our way back and to deal with it again would just be unbelievable.”
Key among those concerns are prenatal care in rural areas. With a maternal mortality rate that is among the worst in the country, OB-GYNs are worried that the cuts would eliminate fragile solutions to doctor shortages that the state has implemented.
For example, pregnant, low-income women in 17 counties around Augusta can arrange for a ride in a van, paid for by Medicaid, for their prenatal visits at the medical school at Augusta University. The service has been vital in keeping these women healthy and insuring successful births. Advocates fear it is the type of program that could face problems if Medicaid funding becomes tight.
People With Disabilities Fearful
Advocates for residents with disabilities worry that home health care would be likely to suffer from the cuts.
That’s because while states are required under Medicaid to pay for nursing home stays, care for people living at home has been optional.
About 38,000 people in the state get the services, also called community-based benefits. Qualifying takes years, and benefits are not guaranteed, even for people who are eligible. Almost 10,000 Georgians are on the waiting list, according to Jacobson, because there is not enough money in the Medicaid budget to cover everyone.
One of those who is getting coverage is Joshua Williams, 22, who has severe cerebral palsy and needs constant care at home and school.
“I’m terrified” that funding cuts could end the program, said his mother, Mitzi Proffitt, 53. “I’d have to quit my job” to take care of him. Williams’ stepfather, Jack Proffitt, 65, has advanced cancer and cannot provide much assistance.
Joshua Williams, who receives home health care services through Medicaid, is worried about funding changes being considered by Congress. But he is counting on President Donald Trump to keep disability benefits in place because "he said he has heart." (Photo by Virginia Anderson/KHN)
Nursing home or institutional care for a year, on average, is $172,280, said Jacobson, while the average home health care is $28,901.
Williams, who is on the dean’s list at East Georgia State College in Swainsboro and loves NASCAR, also admits to being “very scared.” He said if his coverage is discontinued, he would have to drop out of college, ruining his hopes of becoming a sports broadcaster. He is eager to get a part-time job until he graduates.
“I want to work. I don’t want handouts,” he said.
A supporter of President Donald Trump’s, Williams said he is counting on the president to keep disability benefits in place and to ensure that health care is affordable for all.
“He thinks that if Trump knew his story, he’d get on this and fix things,” said Mitzi Proffitt.
“I like him because he’s a businessman, but he said he has heart,” Williams added.
Critics of the practice, who include some surgeons and patient-safety advocates, say that double-booking adds unnecessary risk, erodes trust and primarily enriches specialists.
The controversial practice has been standard in many teaching hospitals for decades, its safety and ethics largely unquestioned and its existence unknown to those most affected: people undergoing surgery.
But over the past two years, the issue of overlapping surgery — in which a doctor operates on two patients in different rooms during the same time period — has ignited an impassioned debate in the medical community, attracted scrutiny by the powerful Senate Finance Committee that oversees Medicare and Medicaid, and prompted some hospitals, including the University of Virginia’s, to circumscribe the practice.
Known as “running two rooms” — or double-booked, simultaneous or concurrent surgery — the practice occurs in teaching hospitals where senior attending surgeons delegate trainees — usually residents or fellows — to perform parts of one surgery while the attending surgeon works on a second patient in another operating room. Sometimes senior surgeons aren’t even in the OR and are seeing patients elsewhere.
Hospitals decide whether to allow the practice and are primarily responsible for policing it. Medicare billing rules permit it as long as the attending surgeon is present during the critical portion of each operation — and that portion is defined by the surgeon. And while it occurs in many specialties, double-booking is believed to be most common in orthopedics, cardiac surgery and neurosurgery.
The issue was catapulted into public consciousness in October 2015 by an exhaustive investigation of concurrent surgery at Harvard’s famed Massachusetts General Hospital by The Boston Globe. The validity of the story has been vehemently disputed by hospital officials who defend their care as safe and appropriate.
The article detailed concerns by some doctors and other hospital staff about complications — including one patient who was paralyzed and two who died — possibly linked to double-booking over a 10-year period. It described patients waiting under anesthesia for prolonged periods and surgeons who could not be located, leaving residents or fellows to perform surgeries without supervision.
Patients who signed standard consent forms said they were not told their surgeries were double-booked; some said they would never have agreed had they known.
The practice has also figured prominently in cases in South Florida, Nashville and, most recently, Seattle.
Critics of the practice, who include some surgeons and patient-safety advocates, say that double-booking adds unnecessary risk, erodes trust and primarily enriches specialists. Surgery, they say, is not piecework and cannot be scheduled like trains: Unexpected complications are not uncommon.
All patients “deserve the sole and undivided attention of the surgeon, and that trumps all other considerations,” said Michael Mulholland, chair of surgery at the University of Michigan Health System, which halted double-booking a decade ago. Surgeons might leave the room when a patient’s incision is being closed, Mulholland said. A computerized system records the doctor’s entry and exit.
“It doesn’t do any good to check out your surgeon if they’re not even going to be in the room,” said Lisa McGiffert, director of Consumers Union’s Safe Patient Project. “We all know about the dangers of multitasking. This adds a layer of danger if you have the most expert person coming in and out.”
Indiana orthopedic surgeon James Rickert regards double-booking as a form of bait-and-switch. “The only reason it has continued is that patients are asleep,” said Rickert, president of the Society for Patient-Centered Orthopedics, a doctor group.
“Having a fellow so you can run two rooms helps augment your income,” he added. “You can bill for six procedures: You do three and the fellow does three.” The critical portion of the operation required by Medicare and designated by the surgeon can mean “running in and checking two screws for 10 seconds.”
Defenders of the practice, which has been the subject of a handful of studies with mixed results, say it can be done safely and allows more patients to receive care.
“It’s extremely important for us to make sure [all surgeries are] done with the highest quality,” said Peter Dunn, Mass General’s executive medical director of perioperative administration. Officials at his hospital, Dunn said in a recent interview, have “never traced back a quality issue” to concurrent surgery, which involves a minority of procedures.
Mass General complies with all applicable guidelines and regulations, Dunn said. The hospital now explicitly requires doctors to inform patients if an operation will overlap as part of the consent process, which may occur just before the start of surgery.
In January, a Boston jury found that a Mass General spine surgeon who failed to inform a 45-year-old financial analyst that he was running two rooms was not responsible for the patient’s subsequent quadriplegia.
Divided Attention
No one knows how many of the nation’s 4,900 hospitals that receive Medicare payments — about 1,000 of which are teaching hospitals — allow the practice, the Senate Finance Committee noted in a recent report. The committee called on hospitals to adopt stronger policies and consent forms that go beyond opaque boilerplate statements that grant broad permission without specifying who is doing what. And the report noted that concurrent surgery may also occur in outpatient surgery centers and non-teaching hospitals and that it can involve patients who are not covered by Medicare.
The practice surprised some primary care doctors and a veteran medical ethicist.
“I certainly knew that for many procedures, residents might be involved,” said Arthur Caplan, a professor of bioethics at NYU School of Medicine. (NYU Langone Medical Center does not permit concurrent surgery.) “But I was a little taken aback that the attending surgeon was not in the room.”
Proponents say that overlapping operations can improve efficiency and better utilize a surgeon’s valuable time.
“Much of surgery is team-based,” said David Hoyt, executive director of the American College of Surgeons (ACS), which last year issued guidelines governing concurrent surgery. Largely similar to Medicare rules, the guidelines state that surgeons should inform patients of overlapping operations.
Robert Cima, a colorectal surgeon and medical director of surgical outcomes research at the Mayo Clinic, agrees. Overlapping surgery has been used safely since Mayo’s inception more than 100 years ago, he said. A recent study he co-authored found that 11,000 overlapping operations at Mayo did not have a higher death rate than non-overlapping surgeries.
Allowing qualified junior doctors to perform parts of an operation, Cima said, is vital in “training the next generation of surgeons.” Determining what portion of an operation is critical should be left to the individual surgeon, he said, not defined by Medicare or insurers, because it can vary from patient to patient.
But L.D. Britt, a past president of the ACS and chairman of surgery at Eastern Virginia Medical School in Norfolk, says that efficiency has little to do with concurrency. “Unless you’re closing, that surgeon should be there,” he said. “Most [surgeons] are doing it for lifestyle.”
Indiana’s Rickert and Britt say they are troubled by what they regard as a double standard: Very few surgeons would consent to the practice for themselves or a relative. “This happens to the Medicaid patient,” Rickert said, “not the partner’s wife.”
He advocates that Medicare and insurers define the critical portion requiring the presence of an attending surgeon as being everything between the making of an incision and the start of its closure, a task frequently performed by residents. “The critical components should not depend on whether the surgeon has opera tickets that night.”
Ghost Surgery?
Some surgeons say they are troubled by the resemblance of double-booking to a practice known as “ghost surgery,” in which patients learn, usually after something goes wrong, that someone other than the surgeon they hired performed their operation.
In April, a Seattle jury awarded an anesthesiologist and her husband $8.5 million for botched abdominal surgery that disfigured his penis. After his operation, the couple discovered that a crucial part of the procedure was performed by a fellow, not the senior surgeon to whom he had explicitly granted consent.
“I always prided myself in telling patients I would be there from the moment they went to sleep to the moment they woke up,” said Stanley Shapshay, a head and neck surgeon in Albany, N.Y., who co-authored a 2016 editorial opposing simultaneous surgery.
Many things can go wrong during “noncritical” portions of an operation, particularly if a resident or fellow is unsupervised, said Shapshay, a professor of otolaryngology at Albany Medical College. A major artery or nerve can be cut accidentally, he said. “By the time the surgeon [arrives, the damage] has already been done.”
Trainees, Shapshay observed, vary. “Some are very good, some are OK and some need more experience.”
His view was reinforced by his experience at a hospital in the Southeast several years ago. A senior surgeon he was visiting left in the middle of an operation, after telling a family that surgery had gone well. While he and Shapshay were having coffee, the surgeon received an urgent page and had to rush back to the OR to deal with a serious breathing problem. The family was later told only that an unexpected event had occurred, not that the attending had been out of the room.
“That illustrated to me very clearly that you don’t leave the OR until the patient has left the OR,” Shapshay said.
Adequate informed consent is essential, said Robin Diamond, senior vice president for patient safety and risk management at the Doctors Company, a California-based malpractice insurer that has begun tracking malpractice claims related to overlapping surgery. She expects such lawsuits will increase.
“I think it can be done safely and has been safe in many cases,” said Diamond, who has degrees in nursing and law. But surgeons who plan to run two rooms should obtain explicit consent from patients at least a week ahead of surgery, she said, not the day before or the day of, as is common, to allow time to reconsider.
“It’s a basic patient right to know” who is doing their operation, Diamond said.
Patients don’t seem enamored of overlapping surgery. A recent study based on an online survey by Harvard researchers found that fewer than 4 percent of 1,454 people had heard of concurrent surgery and that only 31 percent supported the practice; 95 percent said it should be disclosed in advance.
A Surprising Result
After the fallout at Mass General, officials at U.Va. decided it was time to largely eliminate concurrent surgery in all specialties; the practice had been most common in orthopedics.
In return for an end to simultaneous surgeries, hospital executives agreed that orthopedic surgeons would not be “disadvantaged,” said Richard Shannon, executive vice president for health affairs at U.Va. Part of the process involved overhauling the way surgeries were scheduled.
“It was an important wake-up call,” Shannon said of the controversy. “We wanted to redesign our system to eliminate the risk” as part of a larger patient-safety push.
Eliminating most concurrent procedures, Shannon said, actually resulted in an increase of 560 surgeries in 2016 over 2015, using the same number of operating rooms. “Concurrency was masking an efficiency problem,” said Shannon, who plans to publish the results of U.Va.’s efforts. “There was a lot of waste.”
“This debunks the urban legend” that overlapping surgery is more efficient, he said. “Like many things in health care, if you apply a rigorous disciplined approach, you may get an answer you didn’t expect.”
Rickert and others advise patients who want to avoid overlap to ask detailed questions well in advance and to put their request in writing and on the consent form.
“If you say, ‘I want only you to do the surgery,’ doctors will typically do it,’” Rickert said. “They want the business.”
He also recommends asking, “Are you going to be in the room the entire time during my surgery?” and then repeating that statement in front of the OR nurses the day of surgery. “If the doctor’s not willing to say yes, vote with your feet.”
If a surgeon says he or she will be “present” or “immediately available,” a patient should ask what that means. It may mean that the surgeon is somewhere on a sprawling hospital campus but not in — or even near — your operating room.