Kaiser Plans to Open "New" Medical School

The not-for-profit health maintenance organization (HMO) giant, Kaiser Permanente, announced plans to open a medical school in Southern California with the first class expected to enroll in the fall of 2019 (1). Kaiser is taking the unusual step of creating its own medical school instead of partnering with a university like recent deals made by North Shore-Long Island Jewish in New York and Beaumont Health in suburban Detroit. “We're not just launching another medical school,” Kaiser CEO Bernard Tyson said. “This is really a medical school in which we're bringing forward all the knowledge and wherewithal we've accumulated over the years as our physicians continue to innovate and drive population health and individual health.” Kaiser still has to work through the details of how the school will be funded and the amount of their investment. Kaiser's annual revenue was $56.4 billion last year, with an operating income of $2.2 billion (2).

Kaiser also announced that Dr. Christine Cassel would leave her role as CEO of the National Quality Forum to lead a team tasked with designing the school's teaching approach (1). Until 2013 Cassel was President and CEO of the American Board of Internal Medicine.

The Association of American Medical Colleges (AAMC) estimates a shortage of between 45,000 and 90,000 U.S. physicians by 2025 (3). “The opening of a new medical school will help address this shortage,” Dr. John Prescott, AAMC chief academic officer. However, Kaiser’s announcement is just the first step in building and operating a medical school, which must be accredited by the Liaison Committee on Medical Education, recognized by the U.S. Department of Education as the reliable authority for accrediting medical schools. “It’s a multistage process of moving from an idea to a fully accredited medical school,” Prescott said. “What Kaiser has done is announce its intentions. It’s years away from being a fully accredited school.”

Health care experts say opening its own medical school will provide a steady stream of physicians trained in the "Kaiser way" – a team approach of doctors, nurses, therapists and social workers working on behalf of patients (1). Prescott noted that the establishment of a school was a logical step forward for Kaiser (2).

Commercial interests are becoming increasingly involved in medical education. The University of Arizona's College of Medicine-Phoenix medical school was cited in June by the AAMC in four areas that needed to be addressed to avoid probation or loss of accreditation (4). Two of the four areas stemmed from uncertainties about Banner Health's alliance with the medical school after completing a $1 billion-plus acquisition of the two-hospital University of Arizona Health Network in Tucson.

The question is whether medical education will be independent from commercial interests. The physician should be first and foremost the patient’s advocate. However, the perception of many physicians is they are increasingly impaired in this role by the healthcare delivery systems in which they practice. A major concern is whether financial concerns of healthcare delivery systems might be the real motivation behind corporate interest in medical education. This conflict of interest should be a major concern to the AAMC and raises the important question of who will determine the medical education program in Kaiser's medical school-Kaiser or an independent medical school faculty?

Being a physician is a profession. Doctors should be trained to be doctors, not to be employees of healthcare delivery systems. The tone of the announcement is that Kaiser plans on training the latter.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Rubenfire A. Kaiser plans to take care model to the source: physician training. Modern Healthcare. December 17, 2015. Available at: http://www.modernhealthcare.com/article/20151217/NEWS/151219881?utm_source=modernhealthcare&utm_medium=email&utm_content=20151217-NEWS-151219881&utm_campaign=am (accessed 12/18/15).
2. Terhune C. HMO giant Kaiser Permanente plans to open a medical school in Southern California. Los Angeles Times. December 17, 2015. Available at: http://www.latimes.com/business/la-fi-kaiser-school-of-medicine-20151217-story.html (accessed 12/18/15).
3. Gordon LK. Managed care giant Kaiser to open medical school. Yahoo! Health. December 18, 2015. Available at: https://www.yahoo.com/health/managed-care-giant-kaiser-to-1323494699909174.html (accessed 12/18/15).
4. Alltucker K. UA pursues medical-school fixes for accreditors. Arizona Republic. December 10, 2015. Available at: http://www.azcentral.com/story/news/arizona/investigations/2015/12/10/ua-pursues-medical-school-fixes-accreditors/77106640/ (accessed 12/18/15).

Cite as: Robbins RA. Kaiser plans to open "new" medical school. Southwest J Pulm Crit Care. 2015;11(6):275-6. doi: http://dx.doi.org/10.13175/swjpcc156-15 PDF 

CMS Penalizes 758 Hospitals for Safety Incidents

The Centers for Medicare and Medicaid Services (CMS) is penalizing 758 hospitals with higher rates of patient safety incidents, and more than half of those were also fined last year, as reported by Kaiser Health News (1).

Among the hospitals being financially punished are some well-known institutions, including Yale New Haven Hospital, Medstar Washington Hospital Center in DC, Grady Memorial Hospital, Northwestern Memorial Hospital in Chicago, Indiana University Health,  Brigham and Womens Hospital, Tufts Medical Center, University of North Carolina Hospital, the Cleveland Clinic, Hospital of the University of Pennsylvania, Parkland Health and Hospital, and the University of Virginia Medical Center (Complete List of Hospitals Penalized 2016). In the Southwest the list includes Banner University Medical Center in Tucson, Ronald Reagan UCLA Medical Center, Stanford Health Care, Denver Health Medical Center and the University of New Mexico Medical Center (for list of Southwest hospitals see Appendix 1). In total, CMS estimates the penalties will cost hospitals $364 million. Look now if you must, but you might want to read the below before on how to interpret the data.

The penalties, created by the 2010 health law, are the toughest sanctions CMS has taken on hospital safety. Patient safety advocates worry the fines are not large enough to alter hospital behavior and that they only examine a small portion of the types of mistakes that take place. On the other hand, hospitals say the penalties are counterproductive and unfairly levied against places that have made progress in safety but have not caught up to most facilities. They are also bothered that the health law requires CMS to punish a quarter of hospitals each year. CMS plans to add more types of conditions in future years.

I would like to raise two additional concerns. First, is the data accurate? The data is self-reported by the hospitals and previously the accuracy of these self reports has been questioned (2). Are some hospitals being punished for accurately reporting data while others rewarded for lying? I doubt that CMS will be looking too closely since bad data would invalidate their claims that they are improving hospital safety. It seems unlikely that punishing half the Nation's hospitals will do much except encouraging more suspect data.

Second, does the data mean anything? Please do not misconstrue or twist the truth that I am advocating against patient safety. What I am advocating for is meaningful measures. Previous research has suggested that the measures chosen by CMS have no correlation or even a negative correlation with patient outcomes (3,4). In other words, doing well on a safety measure was associated with either no improvement or a negative outcome, in some cases even death. How can this be? Let me draw an analogy of hospital admissions. About 1% of the 35 million or so patients admitted to hospitals in the US die. The death rate is much lower in the population not admitted to the hospital. According to CMS' logic, if we were to reduce admissions by 5% or 1.75 million, 17,500 lives (1% of 1.75 million) would be saved. This is, of course, absurd.

Looking at hospital acquired infections which make up much of CMS' data, CMS' logic appears similar. For example, insertion of urinary catheters, large bore central lines or endotracheal intubation in sick patients is common. The downside is some will develop urinary, line or lung infections as a complication of these insertions. Many of these sick patients will die and many will have line infections. The data is usually reported by saying hospital-acquired infections have decreased saving 50,000 lives and saved $12 billion in care costs (5). However, the truth is that hospital-acquired infections are often either not the cause of death or the final event in a disease process that caused the patient to be admitted to the hospital in the first place. If 50,000 lives are saved that should be reflected in the hospital death rates or a savings on insurance premiums. Neither has been shown to my knowledge.

So look at the data if you must but look with a skeptical eye. Until CMS convincingly demonstrates that the data is accurate and that their incentives decrease in-hospital complications, mortality and costs-the data is suspect. It could be as simple that the hospitals receiving the penalties are those taking care of sicker patients. What this means is that some hospitals, perhaps the ones that need the money the most, will have 1% less CMS reimbursement, which might make care worse rather than better.

Richard A. Robbins, MD

Editor

SWJPCC

References

1. Rau J. Medicare penalizes 758 hospitals for safety incidents, Kaiser Health News. December 10, 2015. Available at: http://khn.org/news/medicare-penalizes-758-hospitals-for-safety-incidents/ (accessed 12/11/15).
2. Robbins RA. The Emperor has no clothes: the accuracy of hospital performance data. Southwest J Pulm Crit Care 2012;5:203-5.
3. Robbins RA, Gerkin RD. Comparisons between Medicare mortality, morbidity, readmission and complications. Southwest J Pulm Crit Care. 2013;6(6):278-86
4. Lee GM, Kleinman K, Soumerai SB, et al. Effect of nonpayment for preventable infections in U.S. hospitals. N Engl J Med. 2012;367(15):1428-37. [CrossRef] [PubMed]
5. Department of Health and Human Services. Efforts to improve patient safety result in 1.3 million fewer patient harms, 50,000 lives saved and $12 billion in health spending avoided. December 2, 2014. Available at: http://www.hhs.gov/about/news/2014/12/02/efforts-improve-patient-safety-result-1-3-million-fewer-patient-harms-50000-lives-saved-and-12-billion-in-health-spending-avoided.html (accessed 12/11/15).

Cite as: Robbins RA. CMS penalizes 758 hospitals for safety incidents. Southwest J Pulm Crit Care. 2015;11(6):269-70. doi: http://dx.doi.org/10.13175/swjpcc153-15 PDF

Honoring Our Nation's Veterans

Today is Armistice Day, renamed Veterans Day in 1954, to honor our Nation's Veterans. In Washington the rhetoric from both the political right and left supports our Veterans. My cynical side reminds me that this might have something to do with Veterans voting in a higher percentage than the population as a whole, but let me give the politicians this one. Serving our Country in the military is something that deserves to be honored. I was proud to serve our Veterans over 30 years at four Department of Veterans Affairs (VA) hospitals.

However, the VA has had a very bad year. First, in Washington there were the resignations of the Secretary of Veterans Affairs, Eric Shinseki; the undersecretary for the Veterans Health Administration, Robert Petzel; and the undersecretary for the Veterans Benefits Administration, Allison Hickey. Locally, in the light of the VA wait scandal there were the firing of the Phoenix VA Medical Centers director, Sharon Helman, and her deputies along with the retirement of her boss, Susan Bowers. Furthermore, there seem to be a never-ending string of scandals ranging from the mundane of greed-driven fraud to the more exotic of accusing a VA whistleblower of engaging in sexual threesomes. Despite a healthy increase in funding, there was the threat by VA administrators of closing VA hospitals to meet a VA budget shortfall. This resulted in Congress knuckling under to allow the use of emergency funds. Veterans groups are using billboards to accuse the VA of lying (Figure 1).

Figure 1. Billboard across from the VA October 12, 2015.

I could go on and on. However, the real question is not so much of what dirty deeds are being done, but how the VA administrators get away with it.

There has been both a lack of oversight and lack of accountability. Robert McDonald, who replaced Shinseki, has promised to punish the evil doers but has replaced action with the mantra "all is well" and has done nothing. In several instances wrong-doing has apparently been rewarded, such as Bowers replacement having lied to Congress (1). If the VA cannot police itself-and it apparently cannot-there are a multitude of regulatory agencies that have shirked their oversight responsibilities. I thought it was time to mention a few.

First, there are both the Veterans Integrated Service Networks, the regional VA offices, and VA Central Office itself in Washington. Both these organizations have been caught in the scandals and have done nothing. Second, there is Congress. The House Veterans Affairs Committee has seemed to make a sincere effort to identify some of the problems but Secretary McDonald and his cadre of 11,000 in Central Office has repeatedly stone-walled any investigation and Congress has done nothing. Third, there is the White House. The Obama Administration has seemed more interested in declaring the problem fixed than actually fixing the problem and has done nothing.

Those are the obvious but there are some less obvious regulatory failures. First, there are the multiple hospital inspectors. Within the VA is the Office of Inspector General (IG) who is charged with investigating wrong-doing within the VA. Locally they had been called to Phoenix multiple times including for the wait time scandal but have done nothing. The poor performance resulted in the resignation of the acting VA IG, Richard Griffin, under pressure. Second, there is the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO). The Phoenix VA Medical Center managed to go from a "top performer" in 2011 to noncompliant "with U.S. standards for safety, patient care and management" in 2014. Only the naive would believe that a hospital can transition that much in 3 years. There is also the Arizona Board of Medical Examiners and Nursing. Both doctors and nurses were involved in the cover-up of the wait scandal but these boards have done nothing. The VA is the largest system for training future physicians and nurses, and it seems that the future doctors and nurses might not be learning the highest professional and ethical standards. Nonetheless, the Accreditation Council for Graduate Medical Education (ACGME) and American Association of Colleges of Nursing have done nothing.

However, my personal disgust is highest for the Department of Justice (DOJ). It is known that seventy percent of the hospitals were fudging their wait data. The administrators, not the doctors or nurses, received bonuses for short wait times. None of the administrators have gone to jail or even been charged with fraud. None have even had to repay their bonuses. The DOJ has done nothing. If 70% of the doctors were caught faking data to received bonuses, I have every confidence that the legal eagles at DOJ would gleefully put each and every one on trial.

So what can be done? There appears to be no oversight. This was clearly illustrated in the report from the recent Human Resources (HR) team from Central Office sent to Phoenix to help with what can be kindly described as a dysfunctional department. They were essentially shown the door by the acting director, Glen Grippen, saying that he "calls the shots" (2).

The solution is that Mr. Grippen and others of his ilk should no longer call the shots. They have shown a consistent arrogance and disregard for our Nation's Veterans and those that serve them. He and others need oversight, not by a far-off committee in Washington as President Obama has proposed which will likely fare no better than Congress. Oversight could be best provided by local physicians and nurses who have interest in Veteran care but are not employed by the VA. This used to occur in many VA hospitals and was called the Dean's Committee. The dean of the local medical school along with the chairman of the departments of medicine, surgery, pathology, radiology, and others formed a committee that oversaw care at the VA. The committee had interests in the patient care of Veterans but also in the physicians who were faculty at the local medical school and the medical students, residents and fellows who were under their supervision. This committee was a victim of Ken Kizer's "prescription for change" in the 1990s. Now, this old system might be an antidote for Kizer's prescription which has seemed to turn poison.

The VA is pushing to hire more personnel to deal with wait times and lack of patient care. However, it is unclear how many of the new hires are doctors and nurses contributing to patient care and how many are administrators and bureaucrats.  My experiences and conversations with my colleagues convinces me that not all hospitals are as badly managed as those in the Southwest. Those considering a career at the VA need to carefully investigate each hospital to see if it is the type of place that the leadership will provide the resources to care for the Veterans, which is after all, the definition of leadership.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Wagner D. Department of Veterans Affairs names new regional health director. Arizona Republic. October 15, 2015. Available at: http://www.azcentral.com/story/news/arizona/politics/2015/10/15/department-veterans-affairs-names-new-regional-health-director/73900478/
2. Wagner D. VA team blasts Phoenix personnel office. Arizona Republic. November 2, 2015. Available at: http://www.azcentral.com/story/news/arizona/investigations/2015/11/02/va-team-blasts-phoenix-personnel-office/74763366/

Cite as: Robbins RA. Honoring our Nation's Veterans. Southwest J Pulm Crit Care. 2015;11(5):228-30. doi: http://dx.doi.org/10.13175/swjpcc141-15 PDF

Capture Market Share, Raise Prices

Two principles in medical economics central to the Affordable Care Act (ACA) were dealt blows by recently published studies. The first principle is the belief that economies of scale will result in lower prices. The theory is that larger insurers will have lower prices because they are more administratively efficient. The second principle is that provider-owned health plans, usually hospitals, will reduce premiums. The theory is that  by controlling doctors over charging health plans in a fee-for-service model will lower prices.

The first study published in Technology Science found that the largest insurer in each of the states served by HealthCare.gov raised their prices in 2015 by an average of over 10 per cent compared to smaller competitors in the same market (1). Those steeper price hikes for monthly premiums did not seem warranted by the level of health claims which did not significantly differ as a percentage of premiums in 2014.

The second study published by HealthPocket compared the lowest monthly premiums for provider-owned to nonprovider-owned plans within twelve counties across the US (2). The counties analyzed were spread across the eastern, central, and western regions of the U.S. Premiums were based on a 40-year-old, non-smoker profile. Insurance offered by health-care providers such as hospitals, was on average 12% more expensive compared to  traditional insurers. The data were also analyzed by the type of plan under the ACA: bronze, silver and gold. There were too few platinum plans to perform an analysis. Table 1 shows the local results in the three western states analyzed.

Table 1. Monthly premiums for Provider and Non-Provider Health Plans Under the ACA (2).

Silver plans account for two-thirds of plan selections on the ACA marketplaces during the 2015 annual enrollment period (3). Only the premiums for the bronze and silver provider-owned health plans in Arizona cheaper. Both in New Mexico and Utah all the provider-owned health plans and the more frequently selected silver plan in Arizona were all more expensive.

The premises of economies of scale and elimination of the fee-for-service reimbursement are both central to the ACA. Both appear to be myths. The results of these studies illustrate the sobering reality that the best intentions in reforming American healthcare do not necessarily produce the intent imagined. Despite the theoretical promise of reducing expenses by eliminating waste, both studies show an increase in healthcare costs, opposite the direction that traditional economics predict. Both larger companies and provider-owned health plans have a profit motive with numerous conflicts which likely accounts for these increases in premiums. Rather than allowing mergers and focusing on controlling physician behavior as strategies in reducing costs, it is time to focus on the insurers. Their strategy appears to be "capture market share, raise prices" and therefore their profits. This later premise agrees more with the data. Most of us who work in healthcare know this, it is time for those in Washington to pay attention to what is going on rather than their prejudices and political beliefs. 

Richard A. Robbins, MD*

Editor

Southwest Journal of Pulmonary and Critical Care

References 

1. Wang E, Gee G. Larger Issuers, Larger Premium Increases: Health insurance issuer competition post-ACA. Technology Science. 2015081104. August 11, 2015. Available at: http://techscience.org/a/2015081104 (accessed 8/31/15).
2. Colemen K, Gleeson J. Cheapest healthcare provider-owned insurance plans still 12% more expensive than cheapest insurance plans not owned by providers. HealthPocket. August 20, 2015. Available at: https://www.healthpocket.com/healthcare-research/infostat/fee-for-service-and-provider-health-plans#.VeRqLPlVhBd (accessed 8/31/15).
3. Health Insurance Marketplaces 2015 Open Enrollment Period: March Enrollment Report. ASPE Issue Brief. (March 10, 2015).

*The views expressed are those of the author and do not necessarily represent those of the Southwest Journal of Pulmonary and Critical Care, the American Thoracic Society or the Arizona, New Mexico, Colorado or California Thoracic Societies.

Cite as: Robbins RA. Capture market share, raise prices. Southwest J Pulm Crit Care. 2015;11(2):88-9. doi: http://dx.doi.org/10.13175/swjpcc115-15 PDF

Guns and Sleep

Gun deaths are a problem in America. Irrespective of one’s position on gun control, the statistics do not lie. According to the Centers for Disease Control and Prevention (CDC), there were 11,208 deaths caused by firearms in 2013 (1). The recent high profile cases in Cincinnati, OH, Lafayette, LA and Memphis, TN further highlight the issue. Obviously, each case of death by a firearm had its own set of underlying factors that contributed to the final fatal outcome, but one wonders whether sleep deprivation can be implicated in some of them.

Sleep duration in adults over the past approximately 30 years has been declining in the United States (2). A variety of reasons can be cited as underlying causes such as greater use of artificial lighting, an expanding 24 hour non-stop society, promotion of a work ethic that values “burning the midnight oil”, and use of electronic devices before bedtime (especially those that emit blue wavelength light). In addition, both legal and illegal drugs have important impacts on sleep quality and quantity. For example, amphetamines can cause insomnia and by extension a reduction in sleep time (3), and perhaps more importantly, caffeine will have the same effect if used to excess (4). The most recent recommendation from the American Academy of Sleep Medicine is for adults to sleep at least 7 hours per night (5). However, recent CDC data indicate that 29.2% of adults sleep less than 6 hours per night and are thus chronically sleep deprived (2).

Symptoms of sleep deprivation include longer reaction times, lapses in attention or concentration, poor short term memory, errors of omission and sleepiness. However, sleep deprivation also leads to confusion, stress, irritability and impulsivity. Importantly, decision making and the ability to formulate reasonable moral judgments are impaired. All of these negative impacts of sleep deprivation can lead to high-risk behavior. Thus, can it be posited that in some cases, sleep deprivation, perhaps fueled by the legal or illegal use of stimulant compounds, leads to impaired judgment and increased impulsivity, poor decisions and fatal shootings?

Several years ago, I was asked to be a defense expert in a case where a jilted wife fatally shot her husband’s lover. After learning about her husband’s affair, the wife had become distraught and unable to sleep for ~2 days. She then sought out the victim and shot her. Her sleep deprivation was used as a mitigating factor to reduce the charge from 1^st to 2^nd degree homicide. Although not a shooting, more recently, a Florida man was acquitted of the murder by suffocation of his father because he was sleep deprived after consuming a large amount of Red Bull (80 mg caffeine per 8.46 fluid ounces). Cases such as these have led to speculation that sleep deprivation may be an effective defense where the fatal act could plausibly be explained by a change in mood or cognitive impairment.

The potential impact of sleep deprivation is likely not limited to citizens accused of fatal shooting, but law enforcement officers as well. Police officers frequently work overnight or rotating shifts, and many accept overtime duty as well. A recent survey of 4957 police officers found that >40% screened positive for at least one sleep disorder with 28.5% being excessively sleepy, suggesting an element of sleep deprivation (5). Most troubling was that those who were identified as having a sleep disorder had a 51% greater likelihood of making an error or safety violation and a 63% greater chance of exhibiting other adverse work-related outcomes including uncontrolled anger toward suspects. Could some of the recently publicized adverse interactions between police officers and citizens be partially explained by lack of sleep?

Although a possible causal link between gun violence and sleep deprivation is speculative, there is no doubt that insufficient sleep is becoming endemic in our society and has significant personal and public health consequences. There should be a concerted effort on the part of public health officials, public and private institutions and individuals to reverse this trend by publicizing the adverse impact of insufficient sleep, undertaking policy measures to promote adequate sleep and set themselves as examples of healthy sleepers.

Stuart F. Quan, MD

Gerald E. McGinnis Professor of Sleep Medicine

Harvard Medical School

Brigham and Women's Hospital

Boston, MA

References

1. Centers for Disease Control. Fast stats. Available at: http://www.cdc.gov/nchs/fastats/homicide.htm (accessed 8/6/15). 
2. Ford ES, Cunningham TJ, Croft JB. Trends in self-reported sleep duration among US adults from 1985 to 2012. Sleep. 2015;38(5):829-32. [CrossRef] [PubMed]
3. Coghill DR, Caballero B, Sorooshian S, Civil R. A systematic review of the safety of lisdexamfetamine dimesylate. CNS Drugs. 2014;28(6):497-511. [CrossRef] [PubMed]
4. Drake C, Roehrs T, Shambroom J, Roth T. Caffeine effects on sleep taken 0, 3, or 6 hours before going to bed. J Clin Sleep Med. 2013 Nov 15;9(11):1195-200. [CrossRef] [PubMed]
5. Watson NF, Badr MS, Belenky G, et al. Joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society on the recommended amount of sleep for a healthy adult: methodology and discussion. J Clin Sleep Med. 2015;11(6):591-2. [CrossRef] [PubMed]
6. Rajaratnam SM, Barger LK, Lockley SW, Shea SA, Wang W, Landrigan CP, O'Brien CS, Qadri S, Sullivan JP, Cade BE, Epstein LJ, White DP, Czeisler CA. Harvard work hours, health and safety group. JAMA. 2011;306(23):2567-78. [CrossRef] [PubMed]

Reference as: Quan SF. Guns and sleep. Southwest J Pulm Crit Care. 2015;11(2):68-9. doi: http://dx.doi.org/10.13175/swjpcc107-15 PDF