Smart COVID-19 modelling tool launched to assess visitor safety at Expo 2020

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Developed by researchers from Khalifa University, the “Expo 2020 Model” uses a series of data to reportedly assess safety for those visiting the World Expo event in Dubai.
Smart COVID-19 modelling tool launched to assess visitor safety at Expo 2020 published first on https://smartdrinkingweb.weebly.com/

Analysis: A Procedure That Cost $1,775 in New York Was $350 in Maryland. Here’s Why.

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For the past 18 months, while I was undergoing intensive physical therapy and many neurological tests after a complicated head injury, my friends would point to a silver lining: “Now you’ll be able to write about your own bills.” After all, I’d spent the past decade as a journalist covering the often-bankrupting cost of U.S. medical care.

But my bills were, in fact, mostly totally reasonable.

That’s largely because I live in Washington, D.C., and received the majority of my care in next-door Maryland, the one state in the nation that controls what hospitals can charge for services and has a cap on spending growth.

Players in the health care world — from hospitals to pharmaceutical manufacturers to doctors’ groups — act as if the sky would fall if health care prices were regulated or spending capped. Instead, health care prices are determined by a dysfunctional market in which providers charge whatever they want and insurers or middlemen like pharmacy benefit managers negotiate them down to slightly less stratospheric levels.

But for decades, an independent state commission of health care experts in Maryland, appointed by the governor, has effectively told hospitals what each of them may charge, with a bit of leeway, requiring every insurer to reimburse a hospital at the same rate for a medical intervention in a system called “all-payer rate setting.” In 2014, Maryland also instituted a global cap and budget for each hospital in the state. Rather than being paid per test and procedure, hospitals would get a set amount of money for the entire year for patient care. The per capita hospital cost could rise only a small amount annually, forcing price increases to be circumspect.

If the care in the Baltimore-based Johns Hopkins Medicine system ensured my recovery, Maryland’s financial guardrails for hospitals effectively protected my wallet.

During my months of treatment, I got a second opinion at a similarly prestigious hospital in New York, giving me the opportunity to see how medical centers without such financial constraints bill for similar kinds of services.

Visits at Johns Hopkins with a top neurologist were billed at $350 to $400, which was reasonable, and arguably a bargain. In New York, the same type of appointment was $1,775. My first spinal tap, at Johns Hopkins, was done in an exam room by a neurology fellow and billed as an office visit. The second hospital had spinal taps done in a procedure suite under ultrasound guidance by neuroradiologists. It was billed as “surgery,” for a price of $6,244.38. The physician charge was $3,782.

I got terrific care at both hospitals, and the doctors who provided my care did not set these prices. All the charges were reduced after insurance negotiations, and I generally owed very little. But since the price charged is often the starting point, hospitals that charge a lot get a lot, adding to America’s sky-high health care costs and our rising insurance premiums to cover them.

It wasn’t easy for Maryland to enact its unique health care system. The state imposed rate setting in the mid-1970s because hospital charges per patient were rising fast, and the system was in financial trouble. Hospitals supported the deal — which required a federal waiver to experiment with the new system — because even though the hospitals could no longer bill high rates for patients with commercial insurance, the state guaranteed they would get a reasonable, consistent rate for all their services, regardless of insurer.

The rate was more generous than Medicare’s usual payment, which (in theory at least) is calculated to allow hospitals to deliver high-quality care. The hospitals also got funds for teaching doctors in training and taking care of the uninsured — services that could previously go uncompensated.

In subsequent decades, however, hospitals did end runs around price controls by simply ordering more hospital visits and tests. Spending was growing. Maryland risked losing the federal waiver that had long underpinned its system. Also, under the waiver’s terms, Maryland’s hospitals were at risk for paying a hefty penalty to the federal government for the excessive growth in cost per patient.

That’s why in 2014 the state worked with the federal Centers for Medicare & Medicaid Services to institute the global cap and budget system in place today. Dr. Joshua Sharfstein, who was the state’s health and mental hygiene secretary, met skeptical hospital administrators to “sell the concept,” as he described it, assuring them the hospitals would still get reasonable revenue while gaining new opportunities to improve the health of their communities with money to invest in preventive services.

Studies show the program, which was further revised in 2019, generally worked at keeping costs down and generated savings of $365 million for Medicare in 2019 and over $1 billion in the prior four years. What’s more, working with a fixed budget has provided incentives for hospitals to keep patients out, resulting in programs like better outpatient efforts to manage chronic illnesses and putting doctors in senior housing to keep residents out of hospitals through on-site care.

Instituting this type of plan may be politically unacceptable statewide in other places today, given the much greater power now of hospital trade groups and large consolidated hospital networks. “Where hospitals are making money hand over fist, it’s a hard sell to switch,” Sharfstein said. “But where hospitals are facing economic pressure, there is much more openness to financial stability and the opportunity to promote community health.”

Sharfstein thinks the Maryland approach can be especially attractive for financially strapped rural and urban hospitals that treat mostly people on Medicaid and the uninsured.

Though Maryland is an oddity in the United States (the few other states that tried price controls in the 1970s abandoned the experiment long ago), many countries successfully use price guidelines and budget limits to control medical spending. Notable among them is Germany, whose health system is otherwise similar to the United States’, with multiple insurers. A landmark 1994 study comparing efforts here and abroad did find that the German system, for example, can be stingier at providing care that is expensive or elective.

But, referring in part to that issue, the study’s author concluded that costs are so high in the United States that the country “could probably lower our expenditures and see none of the problems that we found in our study for a number of years.”

Data also shows that operating margins, a measure of profit, are generally slimmer in Maryland than those of big health systems in the rest of the country. Johns Hopkins’ margin was 1.2% in fiscal year 2019, compared with 6.9% at the Mayo Clinic in Minnesota and 5.8% at the University of Pennsylvania Health System; Stanford Health Care’s was 7.1%.

But those margins can also reflect how much of its income a hospital chooses to spend on things like amenities and executive pay. Living with financial constraints may be at least partly why Johns Hopkins Hospital’s main entrance is pleasant but functional, lacking the elegant art-filled marble lobbies I often encounter at its peer hospitals.

My experience demonstrates that excellent care can be delivered to patients by a system that works within financial limits. And that’s something America needs.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Direct Primary Care, With a Touch of Robin Hood

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MODESTO, Calif. — Britta Foster and Minerva Tiznado are in different leagues as far as health care is concerned.

Foster, who married into the family that owns the $2.5 billion Foster Farms chicken company, has Blue Shield coverage as well as a high-octane primary care plan that gives her 24/7 digital access to her doctor for a $5,900 annual fee that also covers her husband and two of their children.

Tiznado is from Nayarit, Mexico, and has no insurance. She gets free primary care visits and steep discounts on prescription drugs, lab tests and imaging.

But Tiznado, 32, and Foster, 48, go to the same place for their care: St. Luke’s Family Practice, in this Central Valley city of about 217,000. St. Luke’s, a clinic with a staff of four in a nondescript shopping center, offers an unorthodox combination of concierge-style medicine for the well-off and charity care for the uninsured.

The annual fees that St. Luke’s collects from Foster’s family and some 550 other paying patients help cover free care for a somewhat larger number of uninsured patients, many of them, like Tiznado, Spanish-speaking immigrants who can’t get Medicaid because they lack documents.

The clinic does not accept insurance of any kind but requires its paying patients to have coverage for major medical expenses outside its scope of care.

The paying patients, whom St. Luke’s calls “benefactors,” say they are happy to participate in this “Robin Hood” model. It gives them highly personalized care with great access to their doctors and the emotional satisfaction of supporting those less privileged, the “recipients.”

Foster said it’s been a “huge, huge benefit” for her family to be able to text or call their doctor at any time and be seen on short notice: “Knowing that their group is here also to serve our community makes it all feel even more important.”

Tiznado, who visited the clinic one September morning for a scheduled monitoring of ovarian cysts, said St Luke’s “has helped us a lot — economically and in every way. I think if we moved somewhere else, I would continue coming here.”

But Tiznado and the other uninsured patients don’t get the same 24/7 access that benefactors do. The two groups used separate waiting rooms until the pandemic hit.

St. Luke’s is a local response to systemic U.S. health care problems including physician burnout, patient dissatisfaction and the fact that millions still lack care. Nearly 3.2 million Californians, including 1.3 million undocumented people, will be uninsured in 2022, although the state is gradually expanding Medicaid coverage to many immigrants. St. Luke’s is part of the movement for direct primary care, an alternative for doctors fleeing insurance-dominated medical groups.

Roughly 200 direct primary care practices start up each year in the United States, and there are currently 1,581 of them employing an estimated 3,000 doctors, according to Dr. Philip Eskew, founder of DPC Frontier, which provides resources for doctors who want to make the switch. That’s a tiny fraction of the nearly 209,000 primary care doctors in the U.S.

“We are indeed a small movement at this time,” Eskew said.

Their biggest challenges are regulatory. If the clinics take fees from people enrolled in Medicare, for example, their doctors must forgo Medicare reimbursement anywhere they practice. And some state regulators may consider direct primary care practices to be health plans and impose terms or restrictions that make it difficult or impossible for them to operate.

Doctors in direct primary care typically charge patients a monthly or annual fee in exchange for enhanced access via phone, text or video, shorter wait times and longer face-to-face visits. And they generally don’t accept insurance, thus eliminating the need to chase bills and treatment authorizations.

“In my old practice, we spent almost half our time collecting payments. I thought if we could just get rid of all that overhead, we could spend more time with patients — and it proved true,” said Dr. Bob Forester, the conceptual father and co-founder of St. Luke’s, who retired earlier this year.

Many direct primary care docs scoff at the high-tech investor-owned firms such as One Medical and Forward Health. They are widely viewed as direct primary care companies, but critics say they are more focused on expanding volume than on offering personalized service.

“Direct primary care is where a physician has a relationship with a patient. We do not have to be accountable to an investor, because our investors are our patients,” said Dr. Maryal Concepcion, a family doctor in the remote mountain town of Arnold, California, who recently left a commercial practice to launch her own one-woman direct primary care practice.

St. Luke’s paid patients must have insurance to cover hospitalization, surgeries, specialty care, imaging and prescription drugs.

The clinic is often able to find steep discounts for its uninsured patients. For example, Quest Diagnostics charges them only 10% to 15% of its regular price for lab work, said Dr. R.J. Heck, one of the two family physicians at St. Luke’s and co-founder of the clinic. It often refers uninsured patients who need operations to Cirugía sin Fronteras, a reduced-rate surgery center in Bakersfield.

St. Luke’s recently got a $75,000 grant for imaging, lab tests, X-rays and some prescription drugs from the Legacy Health Endowment, a local foundation. And it works with several radiology groups that provide discounts, Heck said.

Tiznado, who needs periodic ultrasounds for her ovarian cysts, said she pays around $150 for them. “If I did it in another place, it would cost between $900 and $1,200,” she said.

St. Luke’s nonprofit tax-exempt status encourages donations, including from local corporate benefactors such as Foster Farms and winemaker E. & J. Gallo. Some workers at donor companies are among St. Luke’s uninsured patients.

Tax-exempt status also confers a benefit on paying patients: They can take a tax deduction on the portion of their annual fees they don’t use for medical care. Every year, St. Luke’s sends them a statement that puts a dollar value, based on Medicare prices, on the services they received.

Forester said St. Luke’s arose from his concern for the uninsured and his disdain for bureaucratic systems. But “the bottom line,” he said, “is that the idea for St. Luke’s came in an inspired moment of prayer.” He and Heck launched it over 17 years ago as a Catholic-inspired medical office.

However, while Catholic symbols adorn the walls of St. Luke’s, many of its patients are not Christian, and Catholic medical doctrine is not central to its practice.

“There’s nobody coming in here and looking or telling us what we should or shouldn’t do,” said Dr. Erin Kiesel, the clinic’s other family doctor.

Kiesel said she wouldn’t prescribe an abortion, but she would tell somebody where to go if they asked — which nobody has.

Heck and Kiesel took big pay cuts to come to St. Luke’s. Kiesel makes about $60,000 less a year than in her previous practice. Having more time with patients, less paperwork and better work-life balance more than offsets the lower pay, she said.

Patients cited the personal relationships they’ve built with their St. Luke’s providers.

Paul Neumann, a patient of Heck’s for 25 years who followed him to St. Luke’s, said that relationship has been a godsend.

He told of returning from a trip to Rome in 2009 with a case of walking pneumonia. When his wife called Heck the next morning, he came to the house immediately.

Neumann, 84, pays St. Luke’s well north of $10,000 a year for himself, his wife and his son’s family.

“I’d be happy to write a check twice as large,” he said.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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This story can be republished for free (details).

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Understaffed State Psychiatric Facilities Leave Mental Health Patients in Limbo

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Many patients dealing with mental health crises are having to wait several days in an ER until a bed becomes available at one of Georgia’s five state psychiatric hospitals, as public facilities nationwide feel the pinch of the pandemic.

“We’re in crisis mode,’’ said Dr. John Sy, an emergency medicine physician in Savannah. “Two weeks ago, we were probably holding eight to 10 patients. Some of them had been there for days.”

The shortage of beds in Georgia’s state psychiatric facilities reflects a national trend linked to staffing deficits that are cramping services in the public mental health system. The bed capacity problem, which has existed for years, has worsened during the covid-19 pandemic, creating backlogs of poor or uninsured patients as well as people in jails who are awaiting placement in state facilities.

Many state workers, such as nurses, are leaving those psychiatric units for much higher pay — with temp agencies or other employers — and less stressful conditions. The departures have limited the capacity of state-run psychiatric units for patients, who often are poor or uninsured, forcing some people with serious mental illness to languish in hospital emergency rooms or jails until beds open up in the state systems, according to local leaders of the National Alliance on Mental Illness.

“Such patients are sometimes strapped down or held in isolation, and often receive little or no mental health services,” said Roland Behm, a board member of the Georgia chapter of the American Foundation for Suicide Prevention.

Nationally, the shortage of beds and mental health workers has collided with an increasing, pandemic-driven demand for mental health treatment.

“ERs have been flooded with patients needing psychiatric care,” said Dr. Robert Trestman, chairperson of the American Psychiatric Association’s Council on Healthcare Systems and Financing. “The current crisis is unprecedented in the extent, severity and sweep of its national impact.”

Virginia has severely curtailed admissions to state mental hospitals because of staffing shortages amid increased demand for services. “I have never seen an entire system bottleneck this bad,” said Kathy Harkey, executive director of the National Alliance on Mental Illness’ Virginia chapter. The strain is spilling over into the private system, she added.

A Texas advisory committee reported in July that a near-record number of people were on the waitlist for state hospital beds for forensic patients, meaning those involved in the court system who have mental illness.

Last month, National Guard soldiers returned to Oregon’s largest public psychiatric facility to shore up the workforce there.

In Maine, a committee of criminal justice and mental health officials has been working on adding state psychiatric beds and finding placements for people who need treatment for mental illness but are being held in jails.

The well-insured normally can choose private facilities or general hospital psychiatric wards, Trestman said. But in many cases, those beds are now filled, too.

Like the medical system overall, the behavioral health system is “under a great deal of strain,” said Dr. Brian Hepburn, head of the National Association of State Mental Health Program Directors. The workforce shortage is especially acute at inpatient or residential behavioral health facilities, he said, and that pressure extends to private providers.

States are now focused on suicide prevention and crisis services to reduce pressure on emergency rooms and inpatient services, Hepburn added.

In Georgia, roughly 100 beds in the state’s five psychiatric hospitals — or about 10% — are empty because there’s no one to take care of the patients who would occupy them. Space in short-term crisis units is also squeezed. The turnover rate for hospital workers was 38% over the past fiscal year, according to the state Department of Behavioral Health and Developmental Disabilities.

Beyond hospitals, Melanie Dallas, CEO of Highland Rivers Health, which delivers behavioral health services in northern Georgia, said the challenge of dealing with higher demand amid such a diminished number of staffers is unprecedented in her 33 years in the field. “Everybody is exhausted.”

Nationally, scores of nurses and other mental health workers have left state jobs.

It’s “hard work and it’s grueling,” said Hannah Longley, community program director of the Maine chapter of the National Alliance on Mental Illness. State work doesn’t offer “a significant salary and benefit package.”

A state hospital nurse in the U.S. typically makes $40 to $48 an hour, while the rate for a temp agency nurse runs $120 to $200, Trestman said.

“A lot of people are chasing the covid money,” said Netha Carter, a nurse practitioner who works in an Augusta, Georgia, state facility for developmentally disabled people. She said that temp agencies are offering “triple the pay” given by state facilities, though she’s staying put because she likes the kind of work she’s doing.

Kim Jones, executive director of NAMI in Georgia, said she has received more calls about people with mental health needs who can’t get long-term hospital services as the bed backlog increases.

Such waits for care can worsen patients’ conditions. Several years ago, Tommie Thompson’s son Cameron waited 11 months to get a state hospital bed in Atlanta while in jail. “By the time he got to the hospital, he was totally psychotic,” Thompson said.

The backlog in public services is playing out in jails across Georgia, with more people being kept behind bars because mental health facilities are swamped.

The Georgia Sheriffs’ Association said its members have relayed their difficulties in placing people in state-run treatment. “A lot of these folks don’t need to be in jail, but they’re stuck in there,” said Bill Hallsworth, the association’s coordinator of jail and court services. “There’s no place to put them.”

Hospital ERs also are feeling the shortage of state beds, said Anna Adams, a senior vice president of the  Georgia Hospital Association. People with mental illness arriving in the ER “tend to be at the end of the line,” said Robin Rau, CEO of Miller County Hospital in rural southwestern Georgia.

Rau said the bed backlog is horrible. “Covid has just exacerbated everything.”

Need Help?

If you or someone you know is in crisis, call the National Suicide Prevention Lifeline at 1-800-273-8255 or text HOME to the Crisis Text Line at 741741.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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This story can be republished for free (details).

Understaffed State Psychiatric Facilities Leave Mental Health Patients in Limbo published first on https://smartdrinkingweb.weebly.com/