Cost Share Program by Blue Cross Blue Shield.

Aspirin for headache.... 30 cents, medication for cough……. $3, antibiotics for flu…… $40. Being treated at some of the top notch hospitals.... an extra $1000. They say all good things in life are free, as long as you are not going to a hospital.

Recently Blue Cross Blue shield of Massachusetts introduced Hospital Choice Cost-Share Program. It is based on a system of High Cost hospitals and High Value hospitals. This year it was determined by CMS that all hospitals met the quality bar in Massachusetts. 

So these hospitals were than classified on the basis of cost meaning High Cost versus High Value hospitals. If you choose this program and if you decide to go to “high cost hospital”, you will end up with a higher co pay after their deductible. So far I hope this is not too confusing.

OK here goes, various hospitals charge different amount for the same services. So let’s say for a certain test one hospital charges you $1000 and another hospital charges to $600 for the same service. If you choose a Higher Cost Hospital you will pay your standard deductible + $450 co pay, for a lower cost hospital you pay only your co pay. However, if you go for the same test again within a year, for a Higher Cost Hospital you will pay $450 co pay, for a lower cost hospital you pay zero dollars. If you choose this program your premiums would not hike as much for next year.

Now if you decide to see the top 15  providers in Massachusetts, you would have to pay a higher out of pocket expense almost $1000, including hospitals like Brigham and Women’s Hospital, Harvard and University of Massachusetts Hospital (UMASS). Not so for Beth Israel Deaconess Hospital, Harvard (BIDMC) which was considered to be a low cost institute. I can relate to these issues as I saw it first hand when I was working at BIDMC and also at UMASS.

What impact this would have nationwide is still yet to be determined. I think if this becomes a trend with other insurance agencies and Medicare too, it may result in a paradigm shift in the way some hospitals do their billing. As we all know hospitals bills are not an easy thing to deal with regardless of what insurance you have. I wrote about this issue here (Bankruptcy, You Could Be Next).

Blog You Later.

About the picture: My very first day at UMASS many many many years ago.
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Human Factor. Sepsis

 I recently received this email from a follower regarding sepsis,

I read your blog regarding the necessity of urging hospitals to develop a protocol as a preventable measure in the early detection of sepsis in a patient. 

You blog rings very true to my family and as we buried our mother last month.  A victim of sepsis.  She was scheduled to be released from the hospital within the next two days, when the hospital realized at that point that her overall condition had started to rapidly deteriorate.

We are at a loss as to the hospital's late discovery about the severe infection our Mom had detected and the hospital's seemingly either misguided or complete misunderstanding of the early signals for sepsis”.

I think this is occurring more than we anticipate. One way to prevent this from happening is to have a good screening system in place. Patients should be screened for SIRS (Severe Inflammatory response syndrome) not only in the ER but also on the floor with the change of shift. As we know, SIRS is the initial phase of sepsis followed by Sepsis, Severe sepsis, Septic shock and finally multi-organ failure.

SIRS consists of

1.      Heart Rate more than 90/min.

2.      Respiratory rate more than 20/min.

3.      White blood cell count more than 12000 or less than 4000.

4.      Temperature less than 36 degrees or greater than 38 degrees.

A number of hospitals are implementing this screening protocol. I hope we should be able to do that too. I will keep you posted as we move along.

Blog you later.

About the picture:  Big Island while I was lava hopping. Temperature around 1,200 °C. 

Sepsis. Hospitals, Mind Your $$$.

As we are talking about sepsis here. 


In a recent study published at Archives of Internal Medicine, it was concluded that just because your institution can throw more money for sepsis protocols does not mean that it will result in decrease mortality.

Considering some of the bigger institutes has spent millions of dollars in creating these protocols. This means from hiring full time nurses who only responds to sepsis codes to hiring big consulting firms to establish and run these programs.

It was unclear from the study that why some institutions do better even without higher expenditure but with lower mortality rate.

Something to think about.

Blog you later.


Round Rainbow by Olafur Eliasson at Hirshorn Collection. Did you get it?

Sepsis Protocol.

 Sepsis is a condition which causes derangement in cardiovascular compartments, problems with inflammatory and hematological processes, which is due to an infection or injury resulting in severe morbidity or even mortality.

There is a “Surviving Sepsis Campaign” led by European Society of Intensive Care Medicine, international Sepsis Forum and Society of Critical Care Medicine. The goal is to decrease the mortality associated with sepsis syndrome.

We are taking an initiative to decrease the mortality associated with sepsis and I am part of this team to create a protocol for our hospital. Unfortunately sepsis has not been recognized as we have other conditions like cancer, strokes and cancers. It is imperative to identify this problem early  and manage properly.

These are some facts which everyone should know about sepsis.

-          Sepsis is the leading cause of death in non cardiac ICUs.

-          Severe sepsis causes more deaths than deaths due to colon, breast, prostate and pancreatic caner….. all combined.

-          Mortality due to sepsis almost matches that of a heart attack (Myocardial infarction).

There are several great treatment protocols based on Rivers ET AL study, which basically concludes that early goal directed therapy decrease mortality in septic patients.

We are in the process of creating a protocol based on this study which can suit our needs. However, I feel the problem is not finding the right protocol; the problem is correct and consistent implementation. You can have the greatest of protocols but it would be of no use if the implementation is based on unrealistic expectations or lack of resources.

In the next 15 days we will work on these issues

-          Creation of time line to work on these schedules.

-          Screening procedure to identify sepsis.

-          Procedure to create time zero.

-          Creating code sepsis protocol.

-          Creating a “one click” order for sepsis protocol.

-          Education for medical staff.

-          Evaluation of resources available to reach these goals.

Well it is a good start. Let’s see when we reach there.

Blog you later.

About the picture: During FCCS course.

Love Bugs And Medical Myths.

If you are a Florida resident you can not miss our famous love bugs a.k.a honeymoon flies or kissing bugs or its real name …….Pelica Neartica. Come March and you can see these bugs everywhere in pairs here in Florida. They are an annoyance not only because they are awkwardly stuck to each other but also ruin your car paint when they splatter on it.   You try to remove the corpses for the first few years and then it just becomes a lifestyle. Great caution is required while a riding a bike, as you get a free protein bolus every time you open your mouth

There is a famous urban legend here that these bugs were created by University of Florida to fight mosquitoes. The myth is, that somehow this experiment failed and these bugs got out and spread all over Florida. I actually believed it. So every time I would see these bugs I would curse USF softly. Very recently I found out that USF has nothing to do with this and these bugs probably came through cargo ships in 1940s.

This got me thinking what else I believed in for the longest…..for example I believed…..

-          All post menopausal women should be on hormonal replacement therapy (HRT). Until we found out that HRT increases the chances of uterine cancer.

-          I believed that childhood vaccination can cause autism, a famous study published in “Lancet” , until I found out this January that it was a complete fraud and the study was retraced.

-          I thought all patients with osteopenia needed be on biphosphonates to prevent bone loss …. Until I found out that they can cause significant Jaw bone necrosis.

-     Antonio Moniz was awarded Nobel Prize for Physiology in 1949 for his discovery of lobotomy in  psychosis.  By 1951, 20,000 lobotomies were performed. There was a gradual decline in this procedure… after the discovery of  the miracle drug Chlorpromazaine in 1954. Everybody believed in this med….eventually this too declined after it was found that it can cause Tardive Dyskinesia .. a disorder resulting in repetitive body movements.

Do not think for a second that I am saying that we should not believe in evidence based studies. My point is  that we should keep our inner critique alive at all time. We should maintain our ability to question and never permanently close any doors. I believe the same is true for everything in life. 

There are very few eventualities in life.

About the picture: Not a love bug. 

Weekend Mortality

Recently there has been a lot of talk about higher mortality over weekends. A British study, published in the Journal of Quality and Safety Care in June of 2010 concluded that there is a seven percent increase in mortality rate for patients who are admitted through the emergency room over the weekends as compared to patients who are admitted over weekdays. This was a large multi-center study conducted at 163 hospitals. 

An other study published at Journal of American Society of Nephrology also concluded almost the same results. The study concludes that over the whole length of hospitalization, mortality risk is 7% higher for larger hospitals and 17% at community hospitals. As you can see this was found to be higher for small hospitals as compared to large hospitals.

Recently I attended a critical care committee meeting. There was a mortality report about our hospital, I was glad to hear that our mortality data for the hospital was not part of this mix.

However, I can see why this could happen. There are some factors which I can see contributes to these phenomena. 

- Staffing issues,

- Reduced coverage among physicians

- Limited imaging studies.

- Problems with scheduling patients for GI procedures.

- Inability to perform cardiac stress tests.

- Out patient clinics are closed, so there is delay in diagnosing critical health issues.

- Hospital cultures in small hospitals are still managed by physicians who are not full time hospitalist.

(Maybe I am biased here as I am a hospitalist).  

This studies should not be taken lightly, there may be a lot behind this. Do let me know if you have experienced the same problems.

Blog you later.

About the picture: If I am not wrong I think this work was called "Rumors" 

Skins.

Every year I see more cases where young adults are involved with either violence, drug complications or reckless acts resulting in various medical dilemmas. 

Newton's third law of motion states that every action has an equal and opposite reactions. This came to my mind as I briefly watched the new show on MTV "Skins". As you may know skin refers to rolling paper (so you can catch the drift), this show is a copy of a British show with the same name.

Los Angeles Times reported this " Nothing more than an R-Rated teen soap minus any truly resonant characters".  Basically the show is all about teens using school as a hang out where they can do drugs, smoke and make fashion statements. Learning is not really a part of schooling as far as this show is concerned. All parents and teachers are imbeciles or out dated and belong to a different world.

My point is this, you are what you grow. I read an interesting article the other day, it was about how your children become what you expect from them. If you have lower expectations they would probably prove you right. However, if you have higher expectations they will likely achieve them. So next time think of them as  Einstein rather than "Jackass".

I guess I am preaching to the choir, I guess we all know that there is a problem, maybe this makes me a boring father, well so be it. The questions is what are we doing about it? What are you doing?

Blog you later.

About the picture:  I like the attentiveness of this child, no matter whatever he is being taught.                         Smithsonian Museum, Washington.

Hospital Food..... Yummy.

I have never met anyone who craves for ever so infamous hospital food. Hospital food is equivocally bad everywhere in the world.... until recently.

I recently visited a local hospital. I came across a menu card there. I would have never guessed that this is a room service menu card for the patients. With a menu like that, you will surely attract a certain kind of patients.

Do see the menu.