Telemedicine and the Amazon Swim

Many physicians around the world will be participating in a unique telemedicine event. Martin Strel, Guinness World Record-holder for uninterrupted and distance swimming, will be swimming the Amazon River. It is an estimated 4,000 miles of anaconda-, piranha- and crocodile-infested waters and they will be providing medical assistance to help the legendary marathon swimmer from Slovenia.

He is dedicating the Feb. 1-April 11 Amazon swim to "the preservation of the rain forest, to raising awareness for Alzheimer's disease and other neurodegenerative disorders, and to promoting telemedicine as a valuable tool in bringing modern medicine to remote areas."

Team members will include a trauma surgeon and many other specialists including infectious diseases.

He will be in contact with the virtual team by communication from his boat and the 20 person support crew.

The adventure can be followed at amazon.swim.com. ~ AmazonSwim.com ~ The Amazon Swim, Martin Strel-professional marathon swimmer

There are also plans for a documentary movie. It will give telemedicine a boost as far as its usefulness.

Where does healthcare reform begin?

The way I see it, healthcare reform needs to begin with individuals.

After WWII, many companies needed workers but couldn’t compete with wages that were still being artificially elevated by the war era controls. Companies therefore used incentives which included medical benefits.

What began as an incentive program has morphed into the current healthcare fiasco we see everyday.

The only real solution for reform is to begin creating a new mindset and a paradigm shift in everyone’s thinking. This has to begin with the individuals and they must begin to shoulder more of the responsibility for directing and paying for their own healthcare.

Currently, our system does not reward people for being healthy and few people change their lifestyles or behaviors when it comes to obesity, smoking, preventative screening, exercise, etc.

Having nearly 60 years of free or nearly free healthcare has created the mindset of healthcare having little value compared to what it actually costs. This is what absolutely has to change before any real reform will occur.

The fundamental question of whether healthcare is a right remains the central tenet in the debate.

If it is considered a right, it loses its distinction between what is necessary and what is incidental. It also imposes obligations on employers, states, and governments to fulfill these rights.

Many businesses as well as government cannot shoulder this burden and shouldn’t have to.

Individuals need to be responsible for their health and their healthcare. If government is obligated to provide the healthcare, then individuals should be obligated to maintain their health along the government imposed mandates.

As the richest country in the world, we should be able to agree on a minimum set of healthcare standards that we provide and that everyone pays for through taxes or some other mechanism. We should have safety nets in place for the truly indigent and helpless.

Not meaning to sound cruel, neither the government nor the employers should be obligated to pay for all healthcare. Healthcare has never been a right and individuals are not entitled to every medical procedure available.

In all service oriented enterprises, individuals purchase the services they choose and accept the fact they cannot have everything. Healthcare remains a service oriented enterprise.

We have a long way to go in defining and implementing basic medical care, but until the cost is primarily paid by the individuals, I do not see many things changing.

National Review Online recently had an editorial on the President's plan for change that would be helpful.
http://article.nationalreview.com/?q=NmI0OGVlMzZlYWZiZjZlODY5MWEyMDVmNDFmNzVjNmU=

New Supplement Law

Legislation was recently passed into law requiring the makers of dietary supplements and other nonprescription drugs to report serious adverse affects to the government. They will be required to report these to the FDA within 15 days and it takes effect in December of 2007.

It also requires the packaging to have a U.S. phone number or address where consumers can report these events. Spokesmen for Consumer reports magazine said it was long overdue.

The supplement industry reported sales of $20.3 billion dollars in 2005 and this new law will provide some oversight to this industry. Up until now, these supplements are considered safe until proven otherwise by the FDA. This is completely opposite the drug industry. The drug industry has to provide safety data to the FDA before a drug can be released to the market.

There is no perfect system. Both OTC medications as well as prescription medicines have been found to be unsafe and taken off the market. This new law should at least bring more information to light and better inform the public.

2007 CMS issues

The biggest regulatory issue for hospitals in 2007 will be the ongoing phase-in of the new payment system for inpatient care.

In 2006, CMS made major changes related to the DRG system for inpatient services. They replaced the old DRG system with a system that bases payments on hospital costs rather than charges. They reclassified DRG's to more accurately reflect severity of illness in patients and will be phasing in the changes over several years.

Some hospitals will win while others lose under this new plan. Payments for some admissions will increase while others decrease causing concern for some facilities.

Some believe that depending on their case mix, specialty hospitals with less-intensive cases are likely to see a reduction in revenue. There is also speculation that community hospitals like Floyd that have emphasized cardiac care and other profitable business lines will experience similar reductions.

RTI International, an independent, non-for-profit corporation based in Research Triangle Park, N.C., will be releasing a study and making specific recommendations to the CMS sometime this month or in February on a complex issue known as “charge compression. Charge compression, as defined by the Medicare Payment Advisory Commission, results from the interaction of hospitals’ methods of setting charges and the CMS’ method of converting charges into costs. It is a complex issue and in the past, the federal agency generally used a single cost-to-charge ratio to convert charges for all services in a single revenue center—such as pharmacy—into costs.

But some hospitals have been known to mark up inexpensive products more than they do expensive products, which leads to charge compression. This has been a way hospitals got more money from the system, and that’s where the government’s concern lies. How much markup should there be for a Tylenol capsule?

Last year we talked about the new DRG system being contemplated, but as of now, CMS has backed off of replacing the 526 DRG’s with the larger system of all new, severity-adjusted DRG’s. They have adopted more limited changes, introducing 20 new DRG’s and redefining 32 existing ones for 2007

The CMS also has plans to base payments for ambulatory surgical centers on the same methodology for hospital outpatient departments. This is all part of a congressionally mandated effort to streamline Medicare.

The agency’s proposal is to set payments for ASCs at 62% of the outpatient rate at this rate; many ASCs will simply not be able to afford to provide services. Discussion is being held to increase the rate into the mid-70s (percentages) which would still achieve cost savings for the Medicare program.

The other change for 2007 is the continued phase-in of the so-called “75% rule” for inpatient rehabilitation hospitals like Southern Indiana Rehab. Under this regulation, 75% of the rehab hospital’s admissions in a given year have to come from at least one of 13 diagnoses in order to receive higher reimbursement rates for rehab services. The percentage is currently at 60% and will increase to 65% on July 1, and then max out at 75% the following July. Hospitals don’t necessarily support this rule because it limits what type of patients they can or will accept. If they have a choice between patients who fall in one of the 13 categories and one who doesn’t, they make choose the one who does in order to meet their 75% rule. It is hard to predict what type of patients you will be receiving at a rehab hospital.

Pay for Performance

The new CMS-led, pay-for-performance initiative will require physicians to submit annual data on 26 quality measures related to the care of patients with diabetes, congestive heart failure and coronary artery disease in order to be paid for services already performed on patients.

The Medicare payment system is going to basically withhold increases in physician reimbursement and then only pay those who are participating in the program when they submit the required data.

Certain preventive services, such as cancer screenings and immunizations would also be tracked.

The major cost of medical care in America is really in the hospitals and with drug costs. This new system is basically squeezing the wrong people.

We already have to jump through numerous hoops to get paid now. This will add more overhead costs to our offices when we are trying to find ways to reduce our costs in order to run the place profitably and to pay our employees.

More government oversight is not the answer to solving the healthcare problems and the Medicare shortages.

New Pet

The next time your child wants permission to get a new pet, be sure to ask exactly what they intend to bring home.

In a recent AP press report (Alligator Seized From Vermont Basement), agents for the Vermont Department of Fish and Wildlife had to seize a 17 year old 6-foot-4 pet alligator. It’s one thing to have a pet, but when it becomes large enough to eat you, someone has to draw the line.

Officials forced the owner give up its 125-pound pet gator because, as an expert noted, gigantic reptiles aren't the kind of things people need to keep in their basement. "They just don't warm up to people. They don't ever become friendly. They don't make good pets," Michael Ralbovsky of Rainforest Reptiles of Boston said after helping officials remove the cold-blooded beast.

Another Director "gone"

We have officially lost another Director at FMHHS. Our Director of the Dietary department officially resigned about a week ago.

The official report is she is taking another job elsewhere.

But what is the “rest of the story?”

Her resignation came shortly after a meeting with administration dealing with the staffing issues and the lack thereof in her department.

A recent blogger wrote the following on a previous posting:

Anonymous said...
Dietary Director told her staff,she coulden't take it any more!She had no support from adminstration.Herlast day is April 12th!She was told she had to get rid of three more people and run her department and keep morale up! All of us heard her say,I can't take it any longer.She wanted to accomplish what she started and now she's leaving us.What are we suppsed to do?The good leaders are leaving and the bad ones stay? They stay because adminstration can't or won't do anything about them.What is happening to our hospital?
3/16/2007 12:30:00 AM

Frustration levels continue to be rising with middle management as many see no end in the current struggles.

The Board may want to have an exit interview with this director and try to get a feel for the underlying sentiment of how the cutbacks are really affecting the operation of Floyd.

I give this Director credit for making a stand. Quality of Care is an issue and you cannot maintain the same quality we have been accustomed to in the past with this current environment.

She evidently is able to recognize what continued cuts are doing in the various departments.

We will miss her leadership and vision for the department.

Tribune's reporting

For those of you who choose not to get the printed version of the Tribune, here is a link to the article on the recent Board and Commissioners meeting
The News and Tribune - Hospital, Floyd County Commissioners talk finances

As you can see from the paper, there were very few details given to reporters. Answers were vague and the reporter did not seem to push for more specifics.

One thing very noticeable to many people is the fact that virtually all of the information recently coming out of Floyd is coming from the Chairman of the Board and not the CEO.

This is a radical shift from what has occurred in the past 10 plus years.

As with other area hospitals, the public relations department and/or CEO is usually the person or persons making the majority of public statements.

In my opinion, this change makes a statement that the Chairman appears to be running the show at the present time rather than the CEO.

Hopefully this means that issues are finally being addressed and appropriate changes will be made.

Recent Board-Commissioners Meeting

The Commissioners and the Board of Trustees did meet last Thursday to discuss issues related to the hospital.

They did for the first time meet privately without administration and were able to discuss some of the current concerns.

They also met that same evening with the administration and discussed ongoing staffing issues and the results of the consultant’s report.

For many of us, this is a very promising move. This private meeting allowed the Commissioners and the Board an opportunity to openly discuss some of the major concerns related to the recent financial problems and accounting issues that has left Floyd in a very precarious situation.

There was some discussion over the recent information posted on the blog last week about the same exact $11.5 million dollar number that appeared in an August 2006 article and the recent January announcement of the same number.

NA Health: Who knew what and when???

I certainly hope they continue to engage in open dialogue to answer some of the ongoing questions related to the finances as well as the CFO’s departure.

US Health Scorecard

Our system of healthcare is way below our potential. We have the capability to diagnose, treat, cure and prevent many diseases that other countries just think about, yet it seems there is an ever-enlarging divide between what we have and what is possible.

Our healthcare expenditures are almost $2 trillion dollars annually. This is about double of other countries on a per capita basis.

According to the Commonwealth report U.S. Health System Scorecard Makes Case for Change

Compared with other industrialized nations, the U.S. ranks 15th on deaths from preventable illnesses, and is near the bottom on healthy life expectancy

Only about half of Americans receive recommended preventive care and screening tests.

Quality: Total Average Score 71
Access: Total Average Score 67

Efficiency: Total Average Score 51
Equity: Total Average Score: 71
We should be able to do better

Continuing the status quo can no longer be an option. We must embrace change and be willing to listen to all ideas.

Patients need to be responsible for their own health and healthcare dollars. They need to have access to information that allows them to make informed, intelligent decisions.


We must find ways to integrate data and make it cost effective for physicians and hospitals. We must protect the data but also protect these people from lawsuits if information is stolen or accessed for reasons other than gross negligence.

Encourage providers to organize into networks and release the restrictions that prevent this. Physicians need to be able to negotiate collectively in defined areas if insurance companies can negotiate for their thousands of patients as a whole.

Promote greater standardization of care without producing “cookbook” medicine.


Healthcare providers can't change the system by themselves. Policymakers, insurers and employers all have important roles to play.

America could and should have the greatest healthcare system in the world, but we will have to work very hard to achieve that vision. The time to start is now.

Are we misleading patients and the public?

Should we assume that any hospital that is expert at clearing out coronary arteries would also serve food that helps maintain low cholesterol levels?

The North Shore-Long Island Jewish Health System in Great Neck, N.Y. is setting a precedent in their area by banning artery-clogging trans fats from all foods served at its facilities. This ban follows a similar ban at Montefiore Medical Center along with a citywide ban for restaurants that was approved by the New York City Board of Health.

The question arises as to if a healthcare organization has an obligation to serve healthy foods since they feed thousands of individuals daily including patients, employees, and visitors.

The Food and Drug Administration probably instigated these changes when it began requiring the listing of trans fats on food labels in January 2006.

Consumers became much more aware about the amount of trans fats in our diets as well as the link to high cholesterol.

How far do we go to get people to choose better? Many hospitals like Kosairs have a McDonalds in their lobby. Many others have unhealthy restaurants very close or on their campuses.

Does this imply the hospital is endorsing these places or should patients be responsible for their own decisions?

You can bet there will be a few lawsuits related to this issue.

Are we giving two different messages by being in the healthcare profession, promoting health and saying obesity is a huge medical problem, and then serving unhealthy food or allowing these restaurants on our campuses?

Medicaid reimbursement

This is a call to action for all physicians as there has been recent activity in the legislature on this specific issue.

TELL YOUR LEGISLATOR

• Medicaid has not had an across-the-board increase for physicians in 18 years, despite rising inflation, the growing costs of operating a medical office, and ever-increasing technology and insurance costs.
• Since the last Medicaid reimbursement increase, inflation has risen 63 percent.
• In 2004-05, 35.3 percent of solo practice physicians accepted no new Medicaid patients, compared to 29 percent in 1996-97.*
• Even after adjusting for inflation, physicians’ net income dropped 7 percent between 1995-2003.*
The above statements come from the Government Relations of the Indiana State Medical Association (ISMA).

A proposed bill failed to pass that would have increased the Medicaid reimbursement because of partisan politics.

Please read the information at this website and contact your elected officials.

Government Relations - Indiana State Medical Association

Commissioners and Board meet tomorrow

Tomorrow night the new County Commissioners will meet with the new Board of Directors for the first time at their quarterly meeting.

This will be the first opportunity to meet privately since they each have assumed their respective roles.

What is really nice to hear is that they are considering having an executive session with just the Board and Commissioners and no one else. This is an idea that had been discussed before but never allowed by previous chairmen because of personal preferences and relationships.

With the ongoing issues related to the finances, staffing and morale, it is an idea long overdue and very worthwhile.

The Commissioners have been hearing a lot from many individuals and some Board members have taken an active role in seeking out information about the current situation.

This will give each of them the opportunity to openly discuss what they have learned and continue to formulate the plan to rectify some of the problems.

My compliments to the Chairman and Commissioners for not avoiding conflict as so many others have in the past.

Who knew what and when???

We will probably never know the whole story related to Floyd's financial situation. As questions continually arise about who knew what and when the problems were known, we seem to be getting the “run-around”.

But if one looks to what has been reported in just the past year, there are some interesting questions and coincidences.

Looking at just two articles published locally; one from August of 2006 and one from February of 2007, we see some similarities. The number being quoted is not only similar, it is the exact same figure.

2006 article: Clark, Floyd County hospitals maintain "community" partnership
“Elaine Hayes, director of finance for Floyd Memorial, said the hospital provided $11.5 million last year in uncompensated care.”

2007 article: The News and Tribune - Floyd Memorial's bad debt rising
“Many patient bills from 2006 haven’t been collected yet, Miles said. The hospital always maintains a reserve fund to cover bad debt, but with Medicaid and insurance contributions dropping in some cases and with more patients who can’t pay anything, the hospital needs to add another $11.5 million to that fund.”

So the question still remains as to how long these problems have been known and why it has taken so long to address them and hold people accountable.

Further delays in rectifying the real problems jeopardize the future success of Floyd as well as its employees.

Let’s get the facts out and the cover-up unveiled so that the people responsible can be held accountable.

Clark wins award

Clark Memorial got rated as one of the better places to work as reported in the tribune last week. The News and Tribune - Clark Memorial named among Indiana's best employers

Does this say anything about the current situation at Floyd or are these rewards meaningless and just used as marketing ploys? As most of you remember, Floyd recieved this same award last year.

The Chamber of Commerce says they determine this ranking based on employer reports and comprehensive employee surveys. Employees do not recall filling out a survey for the Chamber of Commerce.

The article stated;

“Businesses named one of the best places to work were recognized for creating positive work environments in which employees feel valued,” said Martin Padgett, Clark Memorial President and CEO, in a news release from the hospital. “At Clark Memorial, we feel like we have created such an environment for our 1,400 team members and more than 500 physicians.”

Do you think with the current financial situation, cuts and possible layoffs that Floyd will win this award anytime again soon, or are these awards just randomly handed out for marketing purposes?

I'll trade you a kidney for a tractor

In a little stranger news, a report coming out of Pakistan says a man convinced doctors to remove his wife’s kidney in order to buy a tractor from the proceeds.

Organ donation remains unregulated in Pakistan and transplant specialists estimate that between 4,000 and 5,000 live kidneys are sold in Pakistan every year.

Evidently, she discovered the missing kidney when she was being evaluated for an unrelated problem. She confronted her husband and found he received $1100 for the kidney and used it to buy the tractor.

The case is under investigation and he could face up to 10 years in prison, but evidently, it will make a difference on if it happened before or after they were married.

Open discussion on hospital

It seems as though some readers are getting discouraged about the current topics being discussed.

I did say I would give the new Chairman and Board some time to formulate and implement a plan to rectify the current situation at Floyd. Many people are getting discouraged by the lack of definable action related to the $11.5 million dollar fiasco. All they see is more cuts and no plan for anything different.

The external audit has yet to be started and therefore we know little else of what will be found and how far back the problems go.

What we do know is that more cuts are being made and staffing is becoming an even bigger problem.

Morale is a major concern, turnover appears to be increasing and discontent is growing.

If this financial problem goes without someone being held accountable, more turmoil will arise as employees will lose any sliver of hope left that the things wrong in the organization are not addressed.

Open forum for discussion and comments.

Genetic profiling

Recently, an announcement by the department of Health and Human Services (HHS) has created somewhat of a scare. They said they were working to combine healthcare information technology with genetics and would like to standardize how this information could be stored become part of the national electronic health-record system under development at HHS.

Many believe it is likely to fail because of patient resistance. Combining both health and genetics patient records could lead to insurers limiting patient access to healthcare—or patients being charged more by insurers based on diseases or conditions to which they are genetically predisposed. It is unlikely people will accept that given the response the media took to wiretapping terrorists.

Standardizing the technology is laudable, but the chances of replacing today's largely paper-based records system with a system combining genetics and IT is very slim. The legal environment, the current payment system dominated by private-sector health insurance companies, and patient perception will prevent this from occurring for some time.

Much more work and study groups will be formed by the HHS before anything of real substance comes out of the proposal, but things will change eventually.

Is it real?

The Mayo Clinic Proceedings published an article in 2000 that summarized the scientific evidence that had accumulated on “Gulf War Syndrome”. After review of the initial data, the results of the preliminary studies concluded that, although many veterans had subjective feelings of illness, there was little objective evidence for a single condition afflicting Gulf War veterans.

Since that time more studies have been performed and now the Institute of Medicine (IOM) has issued the final of a series of comprehensive reports encompassing more than 14 years of scientific data. The authors of this review have stated that, “although deployed veterans report more symptoms and more severe symptoms than their nondeployed counterparts, there is not a unique symptom complex (or syndrome) in deployed Gulf War veterans.” Other findings published stated that mortality and rates of hospitalization were no higher among Gulf War veterans, and no increase in birth defects was seen. Some of the objective measures of disease such as pulmonary function testing and peripheral nerve electromyography also showed no differences between deployed veterans and their nondeployed peers.

The IOM’s authors did once again note that these Gulf War veterans experienced various symptoms and were diagnosed as having multi-symptom conditions, such as fibromyalgia and chronic fatigue syndrome and psychiatric disorders at a higher rate than their peers.

Many of the theories and hypotheses causing the infirmities are still under question. The Mycoplasma theory has not been confirmed nor has the chemical weapon theory. The IOM looked at a number of potentially toxic medications (eg, pyridostigmine), anthrax and other vaccines, depleted uranium, and chemical munitions but found them to be either of negligible significance or unverifiable and heavily tainted by recall bias. By far the most contentious issue has been the potential exposure to chemical agents, particularly resulting from the demolition of Iraqi chemical weapon stocks at Khamiseyah in March 1991. But even after a decade of review of military records, epidemiological investigation, and computer modeling there has been a failure to answer the simple questions: were servicemen significantly exposed to sarin and cyclosarin, and did anyone become ill from this exposure? The fact remains that studies to date of possibly exposed troops have not indicated any major health effects.

The latest IOM report represents the current understanding but is far from conclusive in any fashion. The controversy will remains and the underlying cause may never be known.

Since we now have another large group of veterans returning from the current war, we need to consider what factors lead to unusual post-conflict illnesses among veterans and how to care for these people.

Change in Daylight Savings

As a reminder to individuals and companies who are mostly computer based, beginning this year, the U.S. government has extended daylight saving time from the second Sunday in March through the first Sunday in November. This change, which begins March 11, 2007, may impact automatic processes throughout your network including those involving external backup devices which have their own proprietary operating systems.

It may be worthwhile to at least contact your vendors and inquire if there are any special steps that will need to be taken.

Lost data, major crashes and no reliable backup can be a disastrous problem as well as very expensive.

With more medical offices using computers, this is often overlooked in the day to day operations.

Boys with Breasts

There is a recent New England Journal of Medicine article NEJM -- Prepubertal Gynecomastia Linked to Lavender and Tea Tree Oils that reports on a study investigating 3 cases of gynecomastia (benign enlargement of the breasts) in prepubertal boys.

The key wording from the study was as follows:
Detailed questioning revealed that all three boys were using topical products containing lavender oil or lavender and tea tree oil. One boy’s mother was regularly applying a balm containing lavender oil on his skin. The second boy was using a hair styling gel and a shampoo both of which contained lavender oil and tea tree oil. The third boy was using lavender-scented soap and lavender-scented skin lotions. All three boys’ gynecomastia resolved after discontinuation of these products.

It has prompted researchers from the National Institute of Environmental Health Sciences to advise people to avoid repeated exposures to products containing these substances.

These products are believed to have estrogen like effects or anti-androgen effects as the primary reason for the disorder.

How do we compare?

As more information is being released about the $11.5 million dollar accounting error at Floyd, people are wondering if the financial picture that has been touted is really real.



Based on other nonprofit entities, there have been steady increases as seen in the above graph.

When the external audit is completed, we will have a better idea of whether we have been misled about the financial situation at Floyd.