DAILY UPDATE

How HCA turned trauma into a money-maker

An unprecedented analysis of state records by the Tampa Bay Times has found that HCA trauma centers, as a group, are charging injured patients tens of thousands of dollars more than Florida's other trauma centers. The difference has nothing to do with the level of care provided. Instead, HCA is capitalizing on a marketplace that is unchecked by politicians or regulators. That has allowed one of the nation's largest for-profit hospital chains to bill injured patients record fees, the Times has found.

Getting treated at a hospital has always been expensive. And certified trauma centers, which are designed to treat the most severe injuries, naturally have higher costs.

But HCA has taken high charges to a whole new level.

The Times analyzed billing records going back to 2012 for every trauma center in the state. The newspaper reviewed what each of the 66,000 trauma patients was charged during that time and consulted with experts to assign a severity score to each patient based on a widely accepted statistical model. Among the findings:

·         HCA charges, on average, far more than other trauma centers in Florida. The chain's injured patients got an average bill of $124,806 — $40,000 more than the average at other trauma centers.

·         The overcharging starts the moment patients arrive, with a special "trauma response" fee that gets billed on top of every treatment and procedure. HCA's cover charge goes as high as $33,000. The rest of the state's average: $6,754. Then, the company charges more than other hospitals for imaging scans, lab tests and drugs.

·         The higher bills are not the result of having more seriously injured patients. When it comes to severity of injury, HCA patients are, on average, the same as the state as a whole.

·         HCA's trauma fees are especially high for people with minor injuries. For patients whose injuries are least likely to be fatal, HCA's six trauma hospitals have charged more than $29 million in response fees alone. That's more than the state's 20 other trauma centers combined.

The formula has paid off for HCA, according to confidential documents obtained by the Times. They show the state's largest private insurer, Florida Blue, has paid HCA, on average, almost twice what it paid other trauma centers.

HCA has opened trauma centers in Bradenton, Ocala, Fort Pierce, Clay County, Pasco County and Miami. But it is driving up charges across the state by emboldening other hospitals to raise their own fees. And everyone pays the price when the high cost of healthcare gets passed on through health insurance premiums.

Since HCA established its first Florida trauma center in 2009, the statewide tab for treating patients at trauma centers has increased by $1 billion, state records show. Not every dollar charged was collected. But state data clearly shows an explosion in charges, driven in part by hospitals levying record amounts for the trauma response fee.

The fee was created in 2002 to help trauma centers in Florida and across the nation recoup the cost of specialized care. With virtually no government oversight, the fees have spiraled out of control. Since 2006, the average fee charged by all Florida trauma centers has ballooned by 20 times the rate of inflation to more than $10,000 per patient. Much of that increase was driven by HCA's huge new fees.

Trauma has long been viewed as a money-losing community service provided by hospitals, which often get government subsidies for providing the care.

In the past five years, the state has allowed HCA to launch an unparalleled expansion. The chain wants to open more. HCA is now the state's largest provider of trauma services, treating one in five trauma center patients across Florida.

In a statement provided by HCA officials, the company said looking at what patients get charged is misleading. Insured or not, no one pays the full bill. Company officials said their hospitals provide discounts to low-income patients and help them qualify for government programs. For uninsured trauma patients, the statement said, "we are paid less than $300."

HCA also defended the company's trauma response fees, which it said reflect the true costs of offering trauma services.

In 2010, top HCA executives held a news conference in Tampa to make a surprising announcement. They planned to open a network of trauma centers across the state.

Trauma centers are specialized units within a hospital's emergency room. They are designed to care for potentially catastrophic injuries, including those from car accidents, debilitating falls and gunshot wounds.

For decades, such cases were viewed as the money-losing domain of large nonprofit hospitals. But HCA saw things differently. Having a trauma center boosts a hospital's prestige and profile. It also attracts doctors with specialized training and ensures a steady stream of patients to keep beds filled. HCA executives said they weren't expecting to collect huge profits. But they had a formula to make trauma work.

The Times has learned that HCA negotiated lucrative contracts with leading insurers triggered when patients are charged a response fee. Insurers commonly pay set rates for medical care. But confidential documents obtained by the Times show that Florida Blue pays HCA hospitals a percentage of what it charges to trauma patients — meaning the more the company charges, the more it stands to get paid.

Key deals were struck before it was clear how high the company's prices would go. The documents show that Florida Blue paid HCA an average of $117,150 for each trauma patient. That's nearly double the $60,147 per trauma case Florida Blue paid to other state trauma centers.

Florida Blue has renegotiated the percentage it pays. Citing non-disclosure requirements, officials would not say how much less HCA gets paid.

The price of care has increased in every community where HCA has opened a trauma center. Of the five Florida trauma hospitals with the highest average total charges, four were run by HCA, according to the Times' analysis of state-collected data. One of those hospitals, HCA's Orange Park Medical Center, closed its trauma center in February 2013.

The company's trauma center in Miami, Kendall Regional Medical Center, is No. 1. On average, it has billed patients $145,849 since January 2012. Tampa General Hospital is the only non-HCA trauma center among the five most expensive. It placed third with an average bill of $122,354.

Tampa General is certified by the state as a Level 1 trauma center, signifying that it meets the state's most rigorous trauma center requirements. All of HCA's hospitals are Level 2, a lower designation. The bottom line: If you get injured and wind up in an HCA trauma center, you likely will be charged more for your care.

Emergency care has become a key marketing point for HCA hospitals. Billboards with live clocks announce wait times to be seen in its emergency rooms. And the company is in the midst of a public campaign promoting its trauma network.

The message: HCA is here to bring access to life-saving care close to home. This means relatives won't need to travel as far to see their injured loved ones. Patients will get to expert doctors faster than ever before. It's a sales pitch that has won HCA the support of local politicians, emergency responders and many regular citizens, who can think of no good reason to turn down a trauma center in their back yards.

Meanwhile, competing trauma centers are suing to shut down HCA's new trauma centers. They accuse the state of letting HCA needlessly expand the trauma system. Visit Tampa Bay Times for the full story.

Deloitte and NNEACC announce collaboration to offer value-based care solution

Deloitte announces a collaboration with the Northern New England Accountable Care Collaborative to deliver services, technology, analytics and insights to enable value-based care. NNEACC will offer a solution called "Insight" that will help U.S. healthcare providers make the shift to a health system defined by population health and risk-based contracts.

Founded by Dartmouth-Hitchcock Health System, Eastern Maine Healthcare Systems, Fletcher Allen Health Care, MaineHealth and Dartmouth College, NNEACC is a value-based care collaborative providing leading solutions that enable health providers to manage population health.  Since its inception, NNEACC has been leveraging ConvergeHEALTH by Deloitte's data management and analytics solutions to support its framework for accountable care.

The combined offering leverages ConvergeHEALTH's data integration, analytic and workflow technologies with NNEACC's proprietary predictive models, stratification algorithms and outcomes research capabilities to help improve population health management outcomes, reduce unwarranted variation in healthcare, improve care coordination, leverage evidence-based guidelines and manage clinical and financial risk. 

"The platform is designed to integrate and analyze EMR, claims, HIE and operational data to enable member health systems to coordinate patient care, drive provider performance improvements and engage patients to achieve the health care triple aim of better care, better health and at lower cost," said Jason Girzadas, national managing director of life science and health care, Deloitte Consulting LLP. 

Doug Beaudoin, principal, Deloitte Consulting LLP's national managing director of health care providers, said, "The shift from volume to value where we will be incented to drive recovery and wellness versus treating an episode of illness will be a fundamental change driving the need for integrated, longitudinal insights and intellect – our ConvergeHEALTH and NNEACC collaboration will address that critical need."  

The NNEACC solution is already operating in Vermont, New Hampshire and Maine via a SaaS-based model that facilitates benchmarking and collaboration among its members to identify and implement best practices for care delivery.  The solution is offered as both a subscription and on premise option for health systems. Visit Biz Journals for the release.

Migraine 'headband' wins FDA approval

A headband delivering electrical nerve stimulation can prevent onset of migraine headaches and can be marketed for that purpose in the U.S., the FDA said Tuesday. Called Cefaly, the Belgian-made device is the first to win FDA approval for migraine prevention and is also the first transcutaneous electrical nerve stimulation (TENS) system OK'd for any type of pain prevention, as opposed to acute treatment, the agency said.

The device is battery-powered and worn around the head, with the actual TENS stimulator centered on the forehead just above the eyes. It delivers a small, steady current to trigeminal nerve branches. Patients will be instructed to use the device once daily for a maximum of 20 minutes. It is approved for adults only.

Approval was based primarily on the PREMICE trial, in which 67 adult patients were randomized to wear either the Cefaly device or a nonfunctional sham. When turned on, the device typically causes a tingling sensation, but the trial investigators sought to maintain blinding by not asking participants what it felt like and by trying to keep them from talking with each other.

Patients assigned to the real device showed a decline from baseline of about two headache days per month, compared with no change in the control group. A responder analysis showed that 38% of patients receiving stimulation had at least a 50% reduction in monthly headache days, compared with 12% of the control group.

The Cefaly device was previously approved in Europe and Canada. The device's manufacturer, STX-Med of Herstal, Belgium, submitted results of a patient satisfaction survey conducted among more than 2,000 users in Europe, indicating that most regular users believed they had experienced "very significant improvement" and only 4% reported adverse effects. Visit MedPage Today for the report.

CVS probed in alleged loss of painkillers

CVS Caremark Corp. could face as much as $29 million in fines for allegedly losing track of prescription painkillers at four of its California stores, from which authorities said thousands of pills may have been sold on the black market. Officials at the U.S. Drug Enforcement Administration and the California Board of Pharmacy said Monday that more than 37,000 pills were apparently taken from CVS stores in Modesto, Fairfield, Dixon and Turlock, CA.

Meanwhile, CVS pharmacists in Southern California said they've been instructed by the drugstore chain to get their paperwork in order so that no other prescription meds are found to be missing.

Casey Rettig, a special agent in the DEA's San Francisco office, said warrants were served on the four California CVS stores last May. She declined to comment further because the agency's investigation is still open.

Virginia Herold, executive officer of the state Board of Pharmacy, which licenses and oversees all drugstores in California, said each of the missing pills — all painkillers, such as Vicodin— could have a street value of as much as $10.

Lauren Horwood, a spokeswoman for the U.S. attorney's office in Sacramento, said CVS faces 2,973 possible violations of the federal Controlled Substances Act for alleged discrepancies between the company's records and its inventory of prescription drugs.

The maximum fine for these violations could be $29 million, she said. Horwood said CVS has yet to respond to a letter sent last month by her office. The letter outlines the alleged violations and seeks more information from the company.

Officials, requesting anonymity because of the sensitivity of the matter, described the loss of painkillers as a big problem throughout the pharmacy business. In some cases, the drugs have gone missing because pharmacists "self-medicate," they said. But in most cases, the officials said, lower-level pharmacy workers, such as technicians, have made off with the drugs and then sold them to others.

Such thefts typically come to light after pharmacies perform routine inspections of their inventory. They're required by law to report any missing meds within 14 days of discovery.

According to formerly sealed affidavits submitted as part of the DEA's application for search warrants, an investigator for the agency, Brian Glaudel, said the Sacramento district office became aware in late 2012 of losses of numerous hydrocodone tablets from CVS stores in the region.

The pending investigations stem from a case involving a CVS store in Rocklin, northeast of Sacramento. Glaudel said CVS notified officials in December 2012 that a pharmacy worker in the Rocklin store was seen hiding a bottle of hydrocodone in her pants. The worker subsequently admitted to CVS managers that she had stolen more than 20,000 hydrocodone tablets, Glaudel said.

The worker was arrested and charged with embezzlement, he said. It's unclear whether the stolen hydrocodone was recovered in the Rocklin case.

Glaudel said DEA investigators went over records for other CVS stores in the area and found more than 16,000 hydrocodone tablets missing from the Turlock store, 11,000 from the Fairfield store and almost 5,000 each from the Modesto and Dixon stores.

Michael DeAngelis, a CVS spokesman, said the investigations are aimed at "assuring compliance with state and federal requirements for administrative record keeping related to invoices and inventory for controlled substances." He said CVS regularly tells its pharmacists to "maintain certain records and paperwork," and recently sent them reminders.

This is the second time in the last year that CVS has found itself facing stiff fines for questionable oversight of prescription drugs.

The chain and its Oklahoma subsidiary agreed to pay $11 million last April to avoid civil charges that they failed to keep accurate records of drugs being received from wholesalers and dispensed to customers.

CVS said after that settlement was announced that the allegations against the company involved "administrative record-keeping matters," and that "neither the DEA nor the U.S. attorney claimed that any patient's health or safety was put at risk."

In June, the DEA disclosed that Walgreen Co. had agreed to pay $80 million in fines to end a probe into allegations it failed to prevent prescription meds from going astray from some of its Florida stores. It was the largest-ever civil penalty paid under the Controlled Substances Act. Pharmacies can be fined up to $25,000 for each violation of the law. Visit Los Angeles Times for the article.

Inconsistency seen as barrier to stopping resistant bacteria

Hospitals around the country vary considerably in how they define and address an important class of antimicrobial-resistant bacteria, and this inconsistency may be contributing to the rise of resistant strains, according to a new report in Infection Control and Hospital Epidemiology (ICHE).

In a related development, survey results released by the Association of State and Territorial Health Officials (ASTHO) indicate that about 70% of state health departments make an effort to promote antimicrobial stewardship, but only a few states have formal policies on that topic.

The ICHE study was a survey of hospitals' approaches to multidrug-resistant gram-negative bacteria (MDR GNB), which include such common healthcare-associated pathogens as Acinetobacter, Pseudomonas, and the Enterobacteriaceae family, which includes Klebsiella pneumonia, among other species. The survey was directed to 170 hospitals in the Society for Healthcare Epidemiology of America (SHEA) Research Network in an effort to assess how they define and deal with MDR GNB.

Sixty-six hospitals (39%) from 26 states and 15 other countries responded to the survey, according to the report. More than 80% of those reported having experience with each of the resistant strains mentioned. More than 78% said they had encountered GNB resistant to all antibiotics except colistin, an older drug that's known for kidney toxicity.

The hospitals reported many different specific definitions of MDR with respect to the different pathogens: 14 for Acinetobacter, 18 for Pseudomonas, and 22 for Enterobacteriaceae species.

The most common definition for multidrug resistance was resistance to three or more classes of antimicrobials, but other definitions included resistance to one or more specific antibiotics or antibiotic classes or susceptibility to two or fewer antibiotics (other than polymyxin or tigecycline).

The varied definitions influenced decisions on isolating patients. For example, 48% of hospitals used isolation for Enterobacteriaceae species only if they were resistant to more than three antimicrobial classes, while 15% set the isolation bar lower for those species.

Isolation practices also varied considerably by pathogen, the researchers found. For example, more than 90% of hospitals isolated patients infected with carbapenem-resistant Enterobacteriaceae (CRE), while 74% isolated those with extended-spectrum beta-lactamase (ESBL)–producing bacteria. The duration of isolation—if used—also varied, ranging from the period of active illness to indefinite.

The authors comment that an international panel of experts published proposed definitions of MDR, extensive drug resistance, and "pandrug" resistance in 2012. Despite this, "We found that approximately one third of respondents were not using the proposed definition of MDR for isolation purposes," they write.

"Differences in definitions and practices for multidrug-resistant bacteria confuse healthcare workers and hinder communication when patients are transferred between hospitals," Marci Drees, MD, MS, lead author of the study, commented in a SHEA press release.

"The danger these inconsistencies represent affects not only individual hospitals, but the broader community because patients are frequently transferred between healthcare centers, including long-term care facilities, furthering their spread," she added.

The aim of the ASTHO survey was to assess what measures health departments are using to promote antimicrobial stewardship and what incentives and tools the agencies need. The effort targeted healthcare-associated infections (HAI) coordinators in the 50 states, Washington, D.C., and Puerto Rico; 36 of the 52 departments (69%) responded, according to a summary posted by ASTHO.

Twenty-five states, or 69%, reported that they engaged in antimicrobial stewardship activities, such as education and training, communications, surveys, collaborations, or demonstration projects. Most of the efforts targeted healthcare workers in hospitals and long-term care facilities. Just five states reported having developed or implemented a policy on antimicrobial stewardship, according to the report. The states were not named in the ASTHO report. Visit CIDRAP for the report.

MEDICAL WORLD AMERICAS 2014 offers continuing education credits to healthcare practitioners from across the industry

Medical practitioners can earn up to 13 AMA/ANCC continuing education credits during three high-impact days at the MEDICAL WORLD AMERICAS Conference and Expo, scheduled for April 28 – 30, 2014, at the George R. Brown Convention Center in Houston, TX. 

The event, produced by renowned Texas Medical Center, the Greater Houston Convention and Visitor Bureau, and Messe Düsseldorf North America (the U.S. subsidiary of the organizer of MEDICA, the world’s largest medical event) offers the opportunity to earn credits in five specialty tracks and five plenary sessions:  Oncology; Cardiology; Healthcare-Associated Infections; Hospital Occupational Health and Safety Hospital Disaster Preparedness.

MEDICAL WORLD AMERICAS presenters include a wide range of noted medical authorities from top-notch institutions including the Mayo Clinic, Cedars-Sinai Medical Center, Memorial Sloan Kettering Cancer Center, Texas Heart Institute, Stanford University, Duke University, the University of Texas, Cleveland Clinic, MD Anderson Cancer Center, and the Centers for Disease Control and Prevention.

As part of the event, participants will also receive access to the MEDICAL WORLD AMERICAS 2014 exposition, an expansive showcase of hundreds of state-of-the-art medical devices, technologies, products and services, providing them with a comprehensive view of the future of the industry. 

For more information about visit or exhibiting at MEDICAL WORLD AMERICAS 2014 and its robust educational program, visit www.medicalworldamericas.com.

Obamacare deadline looms as sign-ups hit 4.2 million

President Barack Obama appealed to uninsured Americans to sign up for medical coverage before a March 31 deadline while his administration said 4.2 million people had enrolled in health plans through February.

Youth enrollment continued to expand, with 1.1 million people ages 18 to 34 signed up by March 1, an increase of 268,475 in a month, U.S. health officials said in a report. Obama made a special effort to reach young adults yesterday, exchanging barbs with comedian Zach Galifianakis while pitching the healthcare law on the actor’s parody web talk-show “Between Two Ferns.”

A survey this week found the number of uninsured dropped since Jan. 1 when plans sold on the new health exchanges took effect. About 15.9 percent of Americans lack coverage this year, down from an all-time high of 18 percent in 2013, Gallup Inc. said March 10.

“That wasn’t a coincidence or something that just happened on its own,” U.S. Health Secretary Kathleen Sebelius said yesterday in a conference call with reporters. “What we’re finding is that as more Americans find out just how affordable marketplace insurance can be, more are signing up to be covered.”

The Congressional Budget Office estimates that about 6 million people will sign up this year for private plans under the new insurance marketplaces created by the Patient Protection and Affordable Care Act known as Obamacare. Another 8 million are expected to join Medicaid, the government program for the poor that is being expanded in at least 25 states. The goal of the 2010 law is to reduce the country’s estimated 48 million uninsured.

“Millions more Americans” are expected to sign up for private plans before the March 31 enrollment deadline, said Julie Bataille, a spokeswoman for the Centers for Medicare and Medicaid Services. Her agency has beefed up computer systems supporting the federal enrollment site, healthcare.gov, in anticipation of higher traffic, she said.

Administration officials said they have no information on how many people were uninsured before they signed up under the Affordable Care Act, instead pointing to the Gallup survey and other studies by independent groups. About 27 percent of people enrolling in February were previously uninsured, according to a March 6 survey by the consulting firm McKinsey & Co.

After March 31, open enrollment in private health plans is closed for 2014 and people can only sign up if they experience life changes such as getting married or losing a job. Americans who don’t carry insurance starting April 1 will be liable for tax penalties of as much as 1 percent of their income.

The administration isn’t allowed under the health law to extend the deadline, Michael Hash, the director of the Office of Health Reform at HHS, told reporters. The CBO says it expects the government to collect $2 billion in penalties next year.

The new data on enrollment show that about 943,000 people signed up for private plans in February compared with 1.1 million in January. Administration officials expect a surge of enrollment this month as the deadline approaches, similar to the burst in December, when 1.8 million signed up before an end-of-the-month deadline for coverage starting Jan. 1.

California continues to lead the nation in enrollment, with 869,000 people in private plans. Florida is second with 442,000 -- the most of any state that relies on the federal enrollment system, healthcare.gov.

The administration said 83 percent of those who selected a plan are eligible to receive financial assistance to help pay premiums or other plan costs. About 25 percent of people who have enrolled are from ages 18 to 34, a key demographic because young adults are generally healthier than older people. Insurers need as many young people on their rolls as possible to balance the cost of caring for older, sicker people and avoid future premium increases.

The administration is plowing resources into contacting young adults. Valerie Jarrett, a senior adviser to Obama, gave interviews yesterday on three radio programs aimed at young people and the White House hosted an event with entrepreneurs, researchers and graduate students that it called “#GeeksGetCovered.” Obama’s appearance on “Between Two Ferns” drew 6.1 million viewers as of 5 p.m. New York time yesterday at the site that produced it, funnyordie.com. Visit Bloomberg for the article.