Senate committee unveils sweeping healthcare bill package

From Modern Healthcare:

On the most visible level, this package is the Senate vehicle for the much debated ban on surprise medical bills. However, this discussion draft doesn’t settle the contentious question of how Congress should implement the ban and instead posits three ideas that the committee still needs to decide upon.

The first option would require a hospital to guarantee patients that, for practical purposes, all its physicians are in-network. To make good on this guarantee, physicians could either contract with the hospital’s insurers or stay out of network but submit their charges through the hospital so the insurer gets only one bill and the hospital has to incorporate the doctor’s fee. Specialists and those that employ them have opposed this idea.

Under the second option, insurers, hospitals or physicians could choose arbitration to resolve disputed charges higher than $750, and the arbiter would have to look at median insurer-negotiated rates from the same geographical area as a guideline.

The third option is identical to the proposal the House Energy and Commerce Committee offered last week: An insurer would pay the surprise bill at the median contracted rate for that region to the hospital or doctor in question.

There’s no clear way to fix surprise medical bills

From Axios:

Solving surprise billing isn’t just about protecting the patients who receive those bills. It’s also about addressing market distortions that drive up premiums.

  • Threatening to leave an insurer’s network gives providers more leverage to negotiate higher rates, experts say, driving up costs across the board.
  • “The problem is that we’ve allowed these specialties to engage in behavior that has so distorted the market that correcting it is rather salient for those folks,” the American Enterprise Institute’s Ben Ippolito said.

How Great Nursing Improves Doctors’ Performance

From the Harvard Business Review:

In our research, we looked at the association  between superior nursing (as indicated by Magnet status) and hospital scores on the national HCAHPS patient satisfaction survey as well as within Press Ganey’s database of over 2,000 health care organizations. HCAHPS gathers patients’ feedback on many aspects of their hospital experience from the hospital environment, quality of the food, and staff responsiveness to how well doctors and nurses communicate with them (Do they listen? Are they respectful? Do they explain things well?).  The survey also asks for an overall rating of the hospital. Ratings are often expressed in terms of the “top box” score — the percentage of patients who give the hospital a superior score on a given measure. We found that Magnet hospitals outperformed the non-magnet hospitals on patients’ “likelihood to recommend” top box scores (75.7 compared to 70.8) and we saw a similar spread on the “overall rating score” (76.0 vs. 72.8). We also saw a smaller but significant difference on patient assessment of physician concern about the patient’s questions or worries, which gauges courtesy and respect, listening, and explaining.

Press Ganey’s proprietary survey also revealed a meaningful association between Magnet status and higher patient ratings of physicians’ skill, response to concerns, time spent with the patient, friendliness and courtesy and other measures.  Mean scores for Magnet facilities ranged from 84.6 for “time physician spent with you” to 93.2 for “skill of the physician” while mean scores for non-Magnet facilities ranged from 83.6 to 92.1 for the same questions. These may appear to be subtle differences but they are meaningful. Even a few points change in mean score has a dramatic effect on the percentile rank due the tight compression of scores nationally; for example, an increase of just two points on a mean score (from, say about 88 to 90) can mean the difference between being in the 50th percentile versus the 75th.

Evidence Doesn’t Support the ‘Hour-1 Sepsis Bundle,’ Say European Emergency Physicians

Press Release:

 Currently available evidence does not support the recent “Hour-1 Bundle” recommendation to perform five initial treatment steps within the first hour in patients with sepsis.That’s the position of the European Society of Emergency Medicine (EUSEM), published in the May/June issue of the AnchorEuropean Journal of Emergency Medicine, official journal of EUSEM. The journal is published in the Lippincott portfolio by Wolters Kluwer.  

While acknowledging the importance of early recognition and treatment of sepsis, “The EUSEM wishes to express its concerns regarding the low level of evidence that underlies these guidances, and potential implication from an emergency physician point of view,” according to the position paper by a panel of leading European emergency medicine specialists. The lead author is Prof. Yonathan Freund of Sorbonne Université and Hôpital Pitié-Salpêtrière, Paris.

Concerns About ‘Unexpected Harm’ from Updated Sepsis Recommendations

In 2018, the Surviving Sepsis Campaign (SSC) issued an updated set of recommendations for initial treatment of sepsis and septic shock. The SSC is a global cooperative effort to improve treatment and reduce the risk of death from sepsis. Sepsis is a common and potentially life-threatening condition, occurring when the immune system mounts an overwhelming inflammatory response to infection.

The 2018 update introduced an “Hour-1 Bundle” of steps that healthcare professionals should begin as soon as time of triage: measuring blood lactate level, performing blood cultures, and starting treatment with antibiotics, intravenous fluids, and vasopressors if indicated.

The recommendation to perform these five steps within the first hour represents an acceleration of treatment, compared to the 3-hour target recommended in the 2016 SSC guidelines. Even the definition of “time zero” moved forward: from the time of sepsis recognition to the time of triage in the emergency department.

The new EUSEM position paper is an “expression of concern” over the updated recommendations. Noting the prominent role of emergency physicians in initial recognition and care of patients with sepsis, the EUSEM position paper highlights the low to moderate quality of evidence supporting the Hour-1 Bundle. “[T]he empirical basis for the reduced timeframe of the sepsis bundle is too weak to be mandatory,” Prof. Freund and coauthors write.

The authors note deficiencies in other recommendations as well, raising questions about the benefits of early lactate measurement and intravenous fluids. Rather, they conclude, starting antibiotics as soon as the likely diagnosis of sepsis is made seems to be the key factor responsible for the improvement in outcomes with early treatment.

The EUSEM statement questions whether it is practical to start all elements of the sepsis bundle within the first hour – especially since up to one in five patients initially diagnosed with sepsis are ultimately found to have a noninfectious diagnosis. Prof. Freund and colleagues also express concern about possible unintended consequences of setting the “Hour-1 Bundle” as the standard of care. They write, “In emergency medicine, unrealistic time targets taken as quality indicators may cause unexpected harm.”

“[C]ompletion of the sepsis bundle within one hour after triage is not evidence based and may even be potentially harmful,” Prof. Freund and coauthors conclude. “Therefore, EUSEM cannot support the new SSC guidance, but emphasizes the early recognition of sepsis and timely administration of antibiotics in appropriately selected patients within 1 hour of triage.”

Click here to read “European Society of Emergency Medicine position paper on the 1-hour sepsis bundle of the Surviving Sepsis Campaign”

DOI: 10.1097/MEJ.0000000000000603


About the European Journal of Emergency Medicine

The European Journal of Emergency Medicine is the official journal of the European Society for Emergency Medicine. It is devoted devoted to serving the European emergency medicine community and to promoting European standards of training, diagnosis and care in this rapidly growing field. Published bimonthly, the Journal offers original papers on all aspects of acute injury and sudden illness. With a multidisciplinary approach, the European Journal of Emergency Medicine publishes scientific research, topical reviews, news of meetings and events of interest to the emergency medicine community.

About the European Society for Emergency Medicine

The European Society for Emergency Medicine (EUSEM) is a non-profit making scientific organization with an aim to promote and foster the concept, the philosophy and the art of Emergency Medicine throughout Europe. The main objective of EUSEM is to help and support European countries to implement the specialty of Emergency Medicine.  Born as a society of individuals in 1994 from a multidisciplinary group of experts in Emergency Medicine, since 2005 EUSEM also incorporates national society members. There are currently 36 European national societies of Emergency Medicine.

The Struggle To Hire And Keep Doctors In Rural Areas Means Patients Go Without Care

From NPR (hat tip: Deb):

new poll by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health found that one out of every four people living in rural areas said they couldn’t get the health care they needed recently. And about a quarter of those said the reason was that their health care location was too far or difficult to get to.

Rural hospitals are in decline. Over 100 have closed since 2010 and hundreds more are vulnerable. As of December 2018, there were more than 7,000 areas in the U.S. with health professional shortages, nearly 60 percent of which were in rural areas.

Until broadband access improves, telemedicine won’t help rural communities

From Reuters:

Telemedicine has been touted as a solution to the dearth of doctors in rural America. But the same places where residents must drive many miles to see a physician often also have limited broadband access, a new study suggests.

About 25 percent of Americans live in rural communities while a mere 10 percent of physicians practice there, said the study’s lead author, Coleman Drake, an assistant professor in the department of health policy and management at the University of Pittsburgh Graduate School of Public Health. And making matters worse, people who live out in the country tend to be older and sicker than their urban counterparts.

“Over the last decade especially, there has been considerable interest in the potential for telehealth to make it easier to access healthcare,” Drake said. “We wondered if telemedicine really could help bridge the gap in access to care. And we discovered that in a lot of rural areas, the lack of access to broadband is potentially limiting access to telehealth.”

Google Researchers Trained an Algorithm To Detect Lung Cancer Better Than Radiologists

From Gizmodo:

On Monday, Google AI researchers along with healthcare researchers published research showing that they’ve successfully trained a deep learning algorithm to detect lung cancer with a 94.4 percent success rate.

The findings were published in the journal Nature Medicine on Monday, which indicated that aside from just a high accuracy rate, the algorithm outclassed radiologists under certain circumstances. According to the study, the system achieved that success rate on 6,716 cases from the National Lung Cancer Screening Trial with similar accuracy on 1,139 independent clinical cases.

The researchers conducted two studies—one in which a prior scan was available, and one in which it wasn’t. In the former scenario, the deep learning algorithm—which was trained on computed tomography scans of people with lung cancer, without it, and with nodules turned cancerous, the New York Times reported—had a higher identification rate than six radiologists, and in the latter, the humans and machine were even.