News
The Southwest Journal of Pulmonary, Critical Care & Sleep periodically publishes news articles relevant to pulmonary, critical care or sleep medicine which are not covered by major medical journals.
Trump Administration Assaults NIH and WHO-RFK Jr’s Nomination Hearing Scheduled
Given all the commotion that has been occurring in Washington over the Gaetz and Hegseth nominations, preparations for mass deportation, birthright citizenship, and government DEI programs, several healthcare news stories have flown under the radar. Below is a summary.
Science is reporting that yesterday the Trump administration imposed several restrictions on the National Institutes of Health (NIH) which will have an impact on grants and scientific exchange (1). These included the abrupt cancellation of meetings including grant review panels, communications “pause”, a freeze on hiring, and an indefinite ban on travel. The moves have generated extensive confusion and uncertainty at the nation’s largest research agency, which has become a target for Trump’s political allies. For example, officials halted midstream a training workshop for junior scientists, called off a workshop on adolescent learning minutes before it was to begin, and canceled meetings of two advisory councils. Panels that were scheduled to review grant proposals also received eleventh-hour word that they wouldn’t be meeting. Without such meetings, NIH cannot make research awards.
The hiring freeze is governmentwide, whereas a pause on communications and travel appears to be limited to the Department of Health and Human Services (HHS), NIH’s parent agency. Such pauses are not unprecedented when a new administration comes in. But some NIH staff suggested these measures, which include pulling job ads and rescinding offers, are more extreme than any previously.
HHS announced a communications ban through 1 February. It orders a stop on the publishing of regulations, guidance documents, grant announcements, social media posts, press releases, and other “communications,” and the canceling of speaking engagements. Any exceptions must be applied for and approved through the president’s appointees.
The various directives have shaken the vast community of extramural scientists NIH supports. “[We] have not seen anything concrete from NIH yet,” said one scientist at a major academic medical center. “But just like about everyone in science, we are worried and waiting.”
The fears of many in global health also came true. Within hours of taking the oath of office, President Trump signed an executive order announcing his decision to withdraw the United States from the World Health Organization (WHO) (2). The executive order also directs the Secretary of State to “cease negotiations” on the WHO Pandemic Agreement, an international treaty to better prepare the world for future pandemics, which has been in difficult negotiations for years. Ironically there’s a chance Trump may have inadvertently helped those negotiations: “Ironically [the treaty] might have a better chance without the U.S., as countries may unite in opposition to Trump and all he stands for.”
In October 2020, the New England Journal of Medicine, in an editorial signed by 34 editors, denounced the Trump administration's handling of the COVID-19 pandemic (3). The article marked the first time in the medical journal's 200-year history that it had condemned or supported any political candidate. In the editorial, the journal strongly criticized the Trump administration's rejection of scientific expertise; its attempts to politicize and undermine the FDA, NIH, and CDC; and its decision "to ignore and even denigrate experts" within government institutions.
“I’m struck by just how silly and petty this is,” says Refugees International President Jeremy Konyndyk, an expert on battling disease emergencies who serves as a high-level adviser to WHO (2). Trump previously tried to pull the U.S. out of WHO in 2020 “because he needed a scapegoat for his own failings on COVID-19” and apparently hasn’t gotten over his grudge against the agency, Konyndyk says. “It’s not the way a nation that considers itself a great power should behave.”
After weeks of watching his fellow nominees advance to hearings and votes, Robert F. Kennedy Jr. will finally get his moment in the Capitol spotlight as he faces his long-awaited Senate confirmation hearing (4). Kennedy’s hearing to lead the Department of Health and Human Services is scheduled for Jan. 29 at 10 a.m. He will face questions from members of the Senate Finance Committee, which directly oversees the department.
During his first term as president, Donald Trump and his administration repeatedly politicized science by pressuring or overriding health and science agencies to change their reporting and recommendations so as to conform to his policies and public comments (5). This was particularly true with regard to the COVID-19 pandemic. The recent NIH and WHO decisions and RFK Jr’s nomination appear to represent little more than political payback to the medical and scientific communities.
Richard A. Robbins MD
Editor, SWJPCCS
References
- Wadman M, Kaiser J. Trump hits NIH with ‘devastating’ freezes on meetings, travel, communications, and hiring. Science. January 22, 2025. Available at: https://www.science.org/content/article/trump-hits-nih-devastating-freezes-meetings-travel-communications-and-hiring (accessed 1/22/25).
- Vogel G. ‘Cataclysmic’: Trump’s decision to leave WHO causes uproar among global health experts. Science. January 21, 2025. Available at: https://www.science.org/content/article/cataclysmic-trump-s-decision-leave-who-causes-uproar-among-global-health-experts (accessed 1/22/25).
- Editors. Dying in a Leadership Vacuum. N Engl J Med. 2020 Oct 8;383(15):1479-1480. [CrossRef] [PubMed]
- Aneeta Mathur-Ashton A. RFK Jr. Finally Got a Confirmation Hearing. What Comes Next? US News & World Report. Jan. 23, 2025. Available at: https://www.usnews.com/news/national-news/articles/2025-01-23/why-did-it-take-so-long-for-robert-f-kennedy-jr-to-get-a-confirmation-hearing (accessed 1/23/25).
- Plumer B, Davenport C. Science Under Attack: How Trump Is Sidelining Researchers and Their Work. New York Times. Dec. 28, 2019. Available at: https://web.archive.org/web/20210215173844/https://www.nytimes.com/2019/12/28/climate/trump-administration-war-on-science.html (accessed 1/23/25).
CMS Proposes Increased Reimbursement for Hospitals but a Decrease for Physicians in 2025
The Centers for Medicare & Medicaid Services (CMS) released its proposed changes to the fee schedule for 2025 on July 10. Hospital compensation will increase by 2.6% from 2024 for hospital outpatient services and 2.8% for inpatient services (1). In contrast, physician payment will DECREASE 2.8% (2). This continues the trend in CMS reimbursement. Over the past 20 years, physician pay has plummeted by 26% when adjusted for inflation while hospital reimbursement has surged by 70% (3).
The proposal drew quick criticism from the American Medical Association (AMA) and the Medical Group Management Association (MGMA) (3). "With CMS estimating a fifth consecutive year of Medicare payment reductions — this time by 2.8 percent — it's evident that Congress must solve this problem," AMA President Bruce Scott, MD, said. "In addition to the cut, CMS predicts that the Medicare Economic Index — the measure of practice cost inflation — will increase by 3.6 percent. Facing this widening gap between what Medicare pays physicians and the cost of delivering quality care to patients, physicians are urging Congress to pass a reform package that would permanently strengthen Medicare." MGMA's Senior Vice President of Government Affairs, Anders Gilberg, said the 2.8% reduction to the conversion factor would be alarming in the best circumstances, but to propose doing so at a time when 92% of medical groups report increased operating costs and are otherwise struggling to remain financially viable is critically short-sighted. Gilberg added "Medicare physician reimbursement is on a dire trajectory and these ongoing cuts continue to undermine the ability of medical practices to keep their doors open and function effectively — the need for comprehensive reform is paramount".
Over the time period of decreasing physician reimbursement, there has been a dramatic change in physician employment. Now 77% of physicians are employed, a dramatic increase from 26% only 10 years ago (5). The reason most often cited has been declining reimbursement. Although cost containment is often cited as a reason for the decline in physician payments. It should be apparent that CMS’ “cost containments” have done little to stem the rising costs of healthcare (6). Some have associated increasing physician employment for decreasing access and quality of care (4,7).
A recent comment from George Parides asserts “what is happening now is what the government, Centers for Medicare and Medicaid Services (CMS) and all hospital systems want to happen. They want full, and I mean FULL control of all physicians …” (8). Nothing has really changed with the proposed changes in fee schedules. The trend of healthcare away from a charitable, not-for-profit 501c to a not-for-profit in name only business focused on revenue and profits continues (7).
Richard A. Robbins MD
Editor, SWJPCC
References
- CMS. CY 2025 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Proposed Rule (CMS 1809-P). July 10,2024. Available at: https://www.cms.gov/newsroom/fact-sheets/cy-2025-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center (accessed 7/11/2024).
- CMS. Calendar Year (CY) 2025 Medicare Physician Fee Schedule Proposed Rule. July 10, 2024. https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2025-medicare-physician-fee-schedule-proposed-rule (accessed 7/11/2024).
- Cass A. CMS pitches 2.8% physician payment cut for 2025. Medscape. July 10, 2024. Available at: https://www.beckershospitalreview.com/finance/cms-pitches-2-8-physician-payment-cut-for-2025.html?origin=BHRE&utm_source=BHRE&utm_medium=email&utm_content=newsletter&oly_enc_id=6133H6750001J5K (accessed 7/11/24).
- G Grossi. Dr David Eagle: CMS Reimbursement Cuts Encourage Trend of Independent Physician Exodus. American Journal of Managed Care. Feb 12, 2024. Available at: https://www.ajmc.com/view/dr-david-eagle-cms-reimbursement-cuts-encourage-trend-of-independent-physician-exodus (accessed 7/11/24).
- Physicians Advocacy Institute. Updated Report: Hospital and Corporate Acquisition of Physician Practices and Physician Employment 2019-2023. April 2024. Available at: https://www.physiciansadvocacyinstitute.org/Portals/0/assets/docs/PAI-Research/PAI-Avalere%20Physician%20Employment%20Trends%20Study%202019-2023%20Final.pdf?ver=uGHF46u1GSeZgYXMKFyYvw%3d%3d (accessed 7/11/24).
- McGough M, Winger A, Rakshit S, Amin K. How has U.S. spending on healthcare changed over time? Peterson-KFF Health System Tracker. December 15, 2023. Available at: https://www.healthsystemtracker.org/chart-collection/u-s-spending-healthcare-changed-time/#Total%20national%20health%20expenditures,%20US%20$%20Billions,%201970-2022 (accessed 7/11/24).
- Robbins RA. A Call for Change in Healthcare Governance. Southwest J Pulm Crit Care Sleep. 2024;28(6):91-93. [CrossRef]
- Parides GC. Only a Snowball’s Chance in Hell: Comment on A Call for Change in Healthcare Governance. Southwest J Pulm Crit Care Sleep. 2024;28(6):94. [CrossRef]
California Bill Would Tighten Oversight on Private Equity Hospital Purchases
According to Medscape California lawmakers are considering a bill that would tighten oversight of private equity and hedge fund buyers of hospitals and healthcare facilities (1). Private equity investment in hospitals and physician groups has been under scrutiny in recent months after a slew of high-profile failures, including bankruptcies and hospital closures. California lawmakers have drafted a bill that would require private equity firms and hedge funds to give the state attorney general written notice before purchasing a healthcare facility or provider group. The attorney general would have to approve the transaction. Buyers would also be required to submit written notice to any federal or state agency as required by law within 90 days of the transaction, and the attorney general could extend that period. The bill gives the attorney general the power to halt an acquisition if there is a "substantial likelihood of anticompetitive effects" or if it would affect access of healthcare services delivered to the community.
Physician groups would also be affected by the bill; private equity groups or hedge funds would be prohibited from controlling the practice and the practice physicians would not be able to sign a deal with an entity partially or wholly directed by a private equity group or hedge fund if those firms provide other services to the physicians for a fee.
Richard A. Robbins MD
Editor, SWJPCCS
Reference
- Dyrda L. California Bill Would Tighten Oversight on Private Equity Hospital Purchases. Medscape. June 10, 2024. Available at: https://www.beckershospitalreview.com/finance/california-bill-would-tighten-oversight-on-private-equity-hospital-purchases.html#:~:text=California%20lawmakers%20have%20drafted%20a,have%20to%20approve%20the%20transaction (accessed 6/10/24).
Private Equity-Backed Steward Healthcare Files for Bankruptcy
Arizona Attorney General Kris Mayes (1) has launched an investigation into what led to Dallas-based Steward Health Care filing for Chapter 11 bankruptcy protection on May 6. The health system also recently shared that it is $9 billion in debt and has plans to sell all 31 of its hospitals, four of which are in Arizona and have a proposed auction date of June 28, according to a May 10 news release from Ms. Mayes (1).
Steward relied on backing from private equity investors to quickly acquire dozens of community hospitals, including facilities in Massachusetts, Texas, Florida, and Arizona. Steward has been the focus of a year-and-a-half-long CBS News investigation revealing how private equity investors have siphoned hundreds of millions of dollars from community hospitals with devastating public health consequences (2). Records reviewed by CBS News showed Steward hospitals around the country left a trail of unpaid bills, at times risking a shortage of potentially lifesaving supplies.
Steward's Arizona hospitals include: Florence (Ariz.) Hospital, Mountain Vista Medical Center in Mesa, Ariz., St. Luke's Behavioral Health Center in Phoenix, and Tempe (Ariz.) St. Luke's Hospital. Along with the hospitals, Steward also operates multiple medical practices across the state.
“Arizonans deserve to know more about the circumstances that led to Steward's bankruptcy filing," Ms. Mayes said in the release (1). "I am deeply concerned about the potential impact this could have on Arizona patients and medical providers. No matter who ultimately ends up owning and operating these facilities, I am committed to ensuring that no Arizonan is harmed by this bankruptcy, and I will fight to ensure that these hospitals remain open at all times to care for patients without any degradation of service."
Richard A. Robbins MD
Editor, SWJPCCS
References
- Arizona Attorney General. Attorney General Mayes Announces Investigation into Steward Health Care’s Bankruptcy. May 10, 2024. Available at: https://www.azag.gov/press-release/attorney-general-mayes-announces-investigation-steward-health-cares-bankruptcy (accessed May 11, 2024).
- Schooley M, Hager C, Kaplan M. Steward Health Care files for Chapter 11 bankruptcy. CBS Boston. May 7, 2024. Available at: https://www.cbsnews.com/boston/news/steward-health-care-bankruptcy/ (accessed May 11, 2024).
Former US Surgeon General Criticizing $5,000 Emergency Room Bill
Business Insider is reporting that Dr. Jerome Adams, US surgeon general from 2017-2021, is complaining about the $5,000 bill after treatment at the Mayo Clinic Arizona emergency room (ER) for dehydration (1).
Figure 1. Dr. Jerome Adams former surgeon general of the United States and currently Director of Health Equity Initiatives at Purdue University.
Local media has been slow to pick up on this story with none of the local television, radio, or newspaper sources reporting on the former surgeon general’s ER visit. Adams first shared his experience on X (formerly Twitter) in a post that went viral. In an interview conducted February 26 with Business Insider, Adams said he was taken by ambulance to the ER in January after becoming lightheaded while hiking. He had labs drawn, received 3 bags of intravenous fluid and was discharged. The shock came when he received the bill. He decided to fight and has been spending hours on the phone with hospital billing reps to get a clearer picture of why he was charged so much. The bill likely will climb higher since Adams has not been billed for the ambulance that took him to the ER. Adams said the experience has been "mentally taxing".
It's unclear why Adams' bill was so high since he said he had not received a breakdown of the charges. ER bills are notoriously expensive and can vary drastically from hospital to hospital. Adams said he was billed for a Level 5 visit, which is a code used for patients with the most complex and highest level of severity, such as chest pain or stroke symptoms. Level 5 visits fetch higher payments because they require more resources and time. Adams said he was fighting the bill because he believed his visit should have been coded at a lower level.
Another issue is that Adams is enrolled in a $7,500 deductible health plan. High-deductible plans have become more common as employers have shifted the cost of medical care to their workers. A survey by Kaiser Family Foundation (KFF) found the average annual deductible for individuals in one of these plans attached to a health savings account was $2,518 in 2023.
Adams said that with all these obstacles, it was no wonder many Americans ended up with medical debt. "If I'm in this situation with my knowledge and with my financial resources and with my bully pulpit, then the average Joe doesn't stand a chance. The system is just broken", Adams said. Medical debt is a widespread problem. An analysis by KFF and the Peterson Center on Healthcare reveals that 20 million people in the US owe medical debt, and 14 million people owe $1,000 or more. Research has shown that medical debt is a leading cause of personal bankruptcy (2).
Congress has provided some relief from unexpected medical bills. The No Surprises Act, which went into effect in 2022, is supposed to keep patients from getting stuck with a surprise bill if they inadvertently receive care from an out-of-network doctor but does not cover a situation similar to Adams’. Adams said patients should have a better sense of what they'd be required to pay ahead of getting care and more clarity about their options when they get a big bill. He also said, “patients shouldn't face drastically different costs for the same care at different facilities. People are so scared of these bills due to lack of transparency. They actually just don't go in at all until it truly does become an emergency. There are many flaws in the system that would've caused other individuals to have gone into debt, have their credit ruined, or have to make choices about things they needed to do. I've got three high schoolers, two kids heading to college. If I wasn't in my income bracket, I might be making a choice as to whether or not to pay my medical bill or to pay my kid's tuition”.
Richard A. Robbins MD
Editor, SWJPCCS
References
- Shelby Livingston S. A former US surgeon general says he went to the ER for dehydration and ended up with a $5,000 bill. He called the healthcare system 'broken.’ Business Insider. Feb 27, 2024. Available at: https://www.businessinsider.com/former-surgeon-general-medical-bill-shows-broken-healthcare-system-2024-2 (accessed 3/4/24).
- Himmelstein DU, Warren E, Thorne D, Woolhandler S. Illness and injury as contributors to bankruptcy. Health Aff (Millwood). 2005 Jan-Jun;Suppl Web Exclusives:W5-63-W5-73. [CrossRef] [PubMed]
Nurses Launch Billboard Campaign Against Renewal of Desert Regional Medical Center Lease
The California Nurses Association and National Nurses United have launched a billboard campaign against the lease renewal of public-owned, Palm-Springs-based Desert Regional Medical Center to Dallas-based Tenet Healthcare (Figure 1) (1).
Figure 1. National Nurses Union billboard off Highway 111 West of Palm Springs near the I-10.
The billboard campaign is in response to the posting of two videos that showed a water leak in Desert Regional's neurological intensive care unit and an infestation of cockroaches in the emergency department break room (2,3). Desert Regional is a public hospital governed by an elected district board. Tenet Healthcare is a private company that leases and runs the hospital. The nurses’ union said Tenet has a long-standing practice of short-staffing Desert Regional, which they said has caused patient safety issues (1). Tenet is currently in the process of renegotiating another 30-year lease with the hospital, which would include the option to purchase the hospital from the Desert Healthcare District at the end of the new lease (1).
Desert Care Network — composed of Tenet-operated hospitals Desert Regional, JFK Memorial in Indio, CA, and Hi-Desert Medical Center in Joshua Tree, CA — provided the following statement: "The California Nurses Association continues to spread misleading information about Desert Regional. These claims are unwarranted, and these tactics will not change Desert Regional's unwavering commitment to the Coachella Valley. Our hospital takes maintenance and cleanliness standards seriously. This includes addressing repairs needed due to people flushing non-flushable cleaning wipes or issues after heavy rains such as pest control. Consistent with sound operational protocols, we proactively closed areas for a short time to remediate issues. These unrelated occurrences were addressed immediately and disclosed promptly to the staff and the Desert Healthcare District" (4).
Desert Regional’s governing Board of Directors are elected to four-year terms by Palm Springs voters. No statement has been made to date by the Board or have any statements been made by state healthcare inspectors such as the California Department of Health or national healthcare inspectors such as the Joint Commission and Centers for Medicare & Medicaid Services. Although lack of cleanliness does not necessarily equate with lack of quality, cleanliness if often used as a substitute measure for safe healthcare, much like restaurant cleanliness is used as a measure for safe food.
Richard A. Robbins MD
Editor, SWJPCCS
References
- Tayor M. California nurses use billboard to voice opposition to hospital sale. Becker’s Hospital Review. February 29, 2024. Available at: https://www.beckershospitalreview.com/nursing/california-nThe urses-use-billboard-to-voice-opposition-to-hospital-sale.html?origin=BHRE&utm_source=BHRE&utm_medium=email&utm_content=newsletter&oly_enc_id=6133H6750001J5K (accessed 3/2/24).
- National Nurses United. Ceiling Leaks in Neurological ICU at Desert Regional Medical Center. February 24, 2024. Available at: https://vimeo.com/914927727?share=copy (accessed 3/2/24).
- National Nurses United. Cockroaches at Desert Regional Medical Center. February 24, 2024. Available at: https://vimeo.com/914925049/f9d46c5890?share=copy (accessed 3/2/24).
- Sasic E. Desert Regional nurses launch billboards to spotlight concerns; hospital pushes back. Palm Springs Desert Sun. February 27, 2024. Available at: https://www.desertsun.com/story/news/health/2024/02/27/desert-regional-nurses-launch-billboard-campaign-palm-springs-area-hospital-news/72752162007/ (accessed 3/2/24).
$1 Billion Donation Eliminates Tuition at Albert Einstein Medical School
Albert Einstein College of Medicine in the Bronx joins NYU Grossman School of Medicine in becoming tuition free. Einstein’s tuition was eliminated by a $1 billion donor gift from Ruth Gottesman EdD (1). Dr. Gottesman, a retired clinical Professor Emeritus of Pediatrics (Developmental Medicine) at Einstein, has been a specialist in learning disabilities at the school since 1968 and is currently Chair of the Einstein Board of Trustees and also serves on the Montefiore Health System board. Announced to the cheers of the assembled student body, Dr. Gottesman announced that beginning in August, tuition will be free "in perpetuity". Tuition at the school is nearly $59,000 per year, leaving nearly 50% of the students owing more than $200,000 after graduating.
Dr. Gottesman’s fortune came from her husband, David "Sandy" Gottesman an early investor in Omaha, Nebraska-based Berkshire Hathaway, Warren Buffet's multinational conglomerate. Mr. Gottesman died in September 2022 at the age of 96 leaving his widow with a large stock portfolio and instructions to “do whatever you think is right with it”.
The gift evolved from Dr. Gottesman’s close friendship with Dr. Philip Ozuah, the pediatrician who oversees the medical college and its affiliated hospital, Montefiore Medical Center (Figure 1).
Figure 1. Dr. Philip Ozuah and Dr. Ruth Gottesman.
In early 2020, the two sat next to each other on a 6 a.m. flight to West Palm Beach, Fla. It was the first time they had spent hours together. They spoke about their childhoods — hers in Baltimore, his, some 30 years later, in Nigeria — and what they had in common. Both had doctorates in education and had spent their careers at the same institution in the Bronx, helping children and families in need. During the COVID-19 pandemic, Dr. Gottesman’s husband became ill with the virus. In the weeks that followed, Dr. Ozuah began making daily house calls — in full protective gear — to check in on the couple as Mr. Gottesman recovered.
Dr. Gottesman and Dr. Ozuah’s friendship and his commitment to assisting his patients even in threatening times likely led Dr. Gottesman to her amazing contribution. Dr. Gottesman said that not only would future students be able to embark on their careers without the debt burden, but she hoped that her donation would also enable a wider pool of aspiring doctors to apply to medical school. “We have terrific medical students, but this will open it up for many other students whose economic status is such that they wouldn’t even think about going to medical school,” she said.
Richard A. Robbins MD
Editor, SWJPCCS
Reference
1. Goldstein J. $1 Billion Donation Will Provide Free Tuition at a Bronx Medical School. NY Times. February 26, 2024. Available at: https://www.nytimes.com/2024/02/26/nyregion/albert-einstein-college-medicine-bronx-donation.html (accessed 2/27/24).
Cite as: Robbins RA. $1 Billion Donation Eliminates Tuition at Albert Einstein Medical School. Southwest J Pulm Crit Care Sleep. 2024;28(2):24-25. doi: https://doi.org/10.13175/swjpccs011-24 PDF
Kern County Hospital Authority Accused of Overpaying for Executive Services
Becker’s Hospital Review is reporting that the Bakersfield, CA-based Kern County Hospital Authority, is accused by the local employee union of overpaying two private firms that provide its top executives (1). The union alleges that Cantu Management Group and Meridian Healthcare Partners - both based in Bakersfield - have exceeded contractual amounts by 40 percent to 147 percent, leading to $23 million in overpayments over the past four years. Andrew Cantu of Cantu Management Group is also the CFO of Kern County Hospital Authority and its management representative for independent audits. Russell Judd served as the hospital's CEO until December 2021, and remains president and owner of Meridian Healthcare Partners.
A 9-page report alleges the hospital failed to disclose management compensation accurately, to properly correct the issue when notified, and attempted to conceal the overpayments. The union claims to have repeatedly brought questions about the hospital's financial management to the hospital and received "no substantive response." The union hired Scott McHone, a certified forensic accountant, to better understand the financials alongside their investigative team.
The union report indicates that Meridian Healthcare Partners was overpaid. Mr. McHone and the investigative team found that invoices filed with the California Department of Health Care Access and Information show the hospital paid the firm $39.9 million, although the union says the invoices it received documented only $19.3 million. The day after the union requested these payment records, the hospital's legal department took action to remove Meridian's name from financial disclosures, according to the report.
Kern County Hospital Authority denies all allegations. The hospital further stated that the services offered have been beneficial to patients, but did not directly comment on the compensation discrepancies.
Richard A. Robbins MD
Editor, Southwest Journal of Pulmonary, Critical Care & Sleep
Reference
- Kayser A. California Hospital Accused of Overpaying for Executive Services. Becker’s Hospital Review. June 28, 2023. Available at: https://www.beckershospitalreview.com/compensation-issues/california-hospital-accused-of-overpaying-for-executive-services.html?origin=BHRE&utm_source=BHRE&utm_medium=email&utm_content=newsletter&oly_enc_id=6133H6750001J5K
SWJPCCS Associate Editor has Essay on Reining in Air Pollution Published in NY Times
Dr. Dona Upson
Dona Upson MD, an associate editor of the SWJPCCS from Albuquerque, recently had a Guest Essay published in the NY Times (1). In the opinion piece titled “The Government Is This Close to Reining in Some of the Worst Air Pollution” Dr. Upson states that the science is clear that when oil and gas are extracted and transported from wells, methane and other pollutants, including volatile organic compounds, leak out. These form ozone and may exacerbate asthma and COPD, cause cancer and birth defects, and affect the nervous system. Emissions from oil and gas production also produce nitrogen oxides, which can exacerbate lung disease. Methane is also a powerful greenhouse gas, over 80 times more potent than carbon dioxide in its warming power, though its life span in the atmosphere is much shorter. One of the fastest and cheapest ways to reduce these emissions and improve health is to prevent methane leaks, venting and flares, which would also go a long way in reducing ozone pollution.
According to Dr. Upson the federal government has a huge opportunity to reduce methane emissions, improve health and slow climate change. The first and most important way is through a rule proposed by the Environmental Protection Agency (EPA) to cut pollution, including methane, from new and existing oil and gas operations nationwide. Outside of the EPA the Bureau of Land Management has proposed a rule to limit venting, flaring and leaks of natural gas on public lands. Dr. Upson argues in her essay for support of both these rules.
Reference
- Upson DJ. The Government Is This Close to Reining in Some of the Worst Air Pollution. NY Times. March 14, 2023. Available at: https://www.nytimes.com/2023/03/14/opinion/air-pollution-oil-gas-methane.html?unlocked_article_code=LsW56AyPBUFnQsdIIrFwy1HaNHxISpGdOo0FpzCnqqqP1YfKdSWQWrYoynSV01-SQEQyrA5w2wi-sVQGEROE0EwLWjE-3BChLi8DB4Oe5oxhLRyMnMMG7MpddaOr7EGGc_U-aqOX8XbiFd65ISJze9VOeElVgCqstnghXBz6Q2-H0DE1GBXPOniX-vrTep6gnAwAykHSM8zOkCBLmW95ctQT6HSKVyDO9ucEUFkvD_3njOYXmq6eCS4ZajhnvvO02qZQ2kUnw8E8bu72-MBdexXamik2wvUkk7gtc_nJMaVWhHiBLWGV33W2EE635C8xGF9TLtA0MvjDNm4mdYsq1-iP6O4Jqkw&smid=em-share (accessed 3/28/23).//
Amazon Launches New Messaged-Based Virtual Healthcare Service
A story in Medscape came at an opportune time yesterday (1). The article announced that Amazon had launched its latest version of virtual medical care on Tuesday, November 15, in 32 states. Called Amazon Clinic, the service omits phone and video calls but instead works through secure messaging between patients and providers. Just after finishing the story, my daughter called and wanted to know if she could buy antibiotic containing eye drops over the counter. She says that she has had “pink eye” (conjunctivitis) for about 2 weeks. Her symptoms of itchy, red eyes without discharge were mostly relieved by an over-the-counter tetrahydrozoline HCl 0.05% drops (Visine). She did not want to go to an emergency room for such a minor issue and had a demanding schedule the following day making a doctor’s appointment difficult. I told her she probably had a viral conjunctivitis but suggested that she could try the virtual clinic since she lives in a state where the Amazon virtual clinic is available. She did contact them and below she reports her experience.
After signing into her Amazon account, she did not have a “Clinic” selection on the banner at the top of her Amazon home page. She searched Amazon using “Amazon clinic” and a page popped up directing her to the appropriate website. After selecting a diagnosis (“pink eye”), she spent about 15 minutes filling out forms which asked demographic information as well a brief history of her present illness, past medical history, and previous therapies. She also took a “selfie” as well as a photo of her driver’s license. Within about 10 minutes she heard back from a nurse practitioner and a prescription was called into a pharmacy of her choice. She was extremely pleased with the service which saved her time and only cost $35.
The service is intended for straightforward health needs in patients under 65. The virtual clinic services a list of 18 common conditions including asthma and smoking cessation. Patients with 5 established conditions (asthma, hypertension, hyperlipidemia, hypothyroidism, and migraine) can also seek medication refills. The service does not accept insurance and works on a fee basis that includes follow-up messages with providers for up to 2 weeks. After paying Amazon directly, patients can submit receipts for reimbursement by their insurer if they have one. Visit costs vary by state, condition type, and provider. Wait times for receiving a first response from a provider are also published.
The service is not available in Arizona but is in each Arizona-bordering state as well as Hawaii. Amazon's venture into health care is evolving. It offers a pharmacy service but this would have taken 4 days to have the prescription delivered in my daughter’s case. Amazon plans to shut down its telehealth service known as Amazon Care by the end of the year but recently signed a deal to acquire One Medical's telehealth service and brick-and-mortar primary care clinics according to Becker's Hospital Review (2).
Richard A. Robbins MD
Editor, SWJPCCS
References
- O’Mary L. Amazon Launches Messaged-Based Virtual Healthcare Service. Medscape Business of Medicine. November 15, 2022. Available at: https://www.medscape.com/viewarticle/984089?src=WNL_bom_221120_MSCPEDIT&uac=9273DT&impID=4885555 (accessed 11/20/22).
- Naomi Diaz N. - "Healthcare seen as safe bet in Amazon's cost-cutting review. Becker's Hospital Review. Thursday, November 10th, 2022. Available at: https://www.beckershospitalreview.com/disruptors/healthcare-seen-as-safe-bet-in-amazon-s-cost-cutting-review.html (accessed 11/20/22).
Hospitals Say They Lose Money on Medicare Patients but Make Millions
The VA patient waiting scandal in Phoenix is well documented. What is also well documented is that at least 70% of VA medical centers were engaged in similar schemes. Now a report prepared for the North Carolina State Treasurer’s Office revealed that many state hospitals and lobbyists are also guilty of misrepresentation. The hospitals did not lose billions of dollars on Medicare patients as they previously claimed, but in fact made large profits from 2015 to 2020 (1).
“What we’re seeing is the biggest transfer of wealth in my lifetime in North Carolina,” North Carolina state Treasurer Dale Folwell said at a press conference on Oct. 25. “It’s a transfer of wealth especially from lower fixed-income people to these big multibillion-dollar corporations who disguise themselves as nonprofits”(2). “North Carolina hospital lobbyists claimed they lost $3.1 billion on Medicare in 2020—the same year hospitals reaped $87 million in Medicare profits,” North Carolina State Health Plan (NCSHP) stated (2). NCHSP said North Carolina hospitals charge privately insured patients 280 percent of Medicare, which forces patients and employers to pay thousands of dollars more for medical care. A range of 55 to 66 percent of more than 100 hospitals profited off Medicare from 2015 through 2020 in North Carolina, the report stated. “While many hospitals’ margins fluctuated, only 15 hospitals consistently lost money on Medicare, and 35 hospitals posted profits over all six years,” the report said (1). North Carolina ranked sixth overall in the states with the most profitable Medicare margins for five of those years, averaging between -0.3 percent and 2.5 percent Medicare margins, the report stated. Arizona ranked 13th.
“This raises serious concerns over hospitals’ commitment to their patients and their charitable mission, and the steep costs passed on to nearly 740,000 members of the State Health Plan,” the state treasurer’s office said in a press release (2). “The hospital cartel is overcharging you because they can, not because they need to,” Folwell said, adding that hospitals have been hiding behind Medicare, claiming huge losses to justify “kneecapping” their patients (2). “This is the Wild West,” Folwell said. “Nobody’s watching it. Nobody’s holding them accountable. We need a commitment from the cartel to get back to their original mission and to stop putting profits over patients.”
Despite this statement, many researchers have found that billions have poured into hospitals through the Coronavirus Aid, Relief, and Economic Security (CARES) Act. The CARES act created the Centers for Medicare and Medicaid reimbursement plan that allowed for hospitals that adhered to protocols for treating COVID-19 to reap up to $500,000 per patient, beginning with a positive COVID-19 test, the use of a National Institutes of Health-approved antiviral drug called remdesivir, putting the patient on a ventilator, and ending with the hospital listing COVID-19 as the cause of death on a death certificate. According to a report from TN Liberty Network, an independent think tank comprising 28 researchers, hospitals have taken lucrative payoffs from the federal government throughout the last several years (3).
In addition to the CARES Act, the Coronavirus Response and Relief Supplemental Appropriations Act provided another $178 billion in relief funds to health care providers and hospitals, with more relief funds siphoned to states from the American Rescue Plan Act beginning in March of 2021, $8.5 billion of which went to health care providers.
The North Carolina Healthcare Association (NCHA) responded to the report, stating that “Instead of bringing transparency and clarity to the public, Treasurer Folwell has created an incomplete and complicated report that fails to address how he will provide more affordable healthcare to state employees and retirees,” NCHA said. “North Carolinians deserve truthful and transparent information. This report fails to deliver it.” (2).
References
- North Carolina State Health Plan For Teachers And State Employees, Rice University’s Baker Institute For Public Policy, and the University Of Southern California’s Sol Price School Of Public Policy. Overcharged North Carolina Hospitals Profit on Medicare. 2022. Available at: https://www.shpnc.org/media/3011/download?attachment (accessed 10/29/22).
- McGregor M. North Carolina Treasurer’s Office Says Hospitals Reaping Billions from Medicare Despite Claiming Otherwise. Epoch Times. October 28, 2022. Available at: https://www.theepochtimes.com/north-carolina-treasurers-office-says-hospitals-reaping-billions-from-medicare-despite-claiming-otherwise_4824332.html (accessed 10/29/22).
- DePriest AJ. Blood Money in U.S. Healthcare. Financial Incentives: The Use of “Covered Countermeasures”. TN Liberty Network. August 8, 2022. Available at: https://acrobat.adobe.com/link/review?uri=urn:aaid:scds:US:a22410b7-3189-4a4a-b59a-50bdfb023de9 (accessed 10/29/22).
Trust in Science Now Deeply Polarized
The Associated Press is reporting that Republicans' faith in science is falling as Democrats rely on it even more, with a trust gap in science and medicine widening substantially during the COVID-19 pandemic, new survey data shows (Figure 1) (1).
Figure 1. Percentage of adults who say they have a great deal of confidence in the scientific community.
Overall, 48% of Americans say they have "a great deal" of confidence in the scientific community, the 2021 General Social Survey data shows. Sixty-four percent of Democrats say that, compared with roughly half as many Republicans, 34%. The gap was much smaller in 2018, when 51% of Democrats and 42% of Republicans had high confidence.
It's the largest gap in nearly five decades of polling by the General Social Survey, a widely respected trend survey conducted by NORC at the University of Chicago that has been measuring confidence in institutions since 1972. The most recent survey was conducted Dec. 1, 2020, through May 3, 2021, and includes interviews with 4,032 American adults. Results for the full sample have a margin of error of plus or minus 2 percentage points.
That is unsurprising to more than a dozen scientists reached for comment by The Associated Press, but it concerns many of them. "We are living at a time when people would rather put urine or cleaning chemicals in their body than scientifically vetted vaccines," University of Georgia meteorology professor Marshall Shepherd told the AP in an email. "That is a clear convergence of fear, lack of critical thinking, confirmation bias and political tribalism."
Science used to be something all Americans would get behind, Rice University historian Douglas Brinkley said. "But we now see it falling prey to the great partisan divide," he said. "The world of science should be a meeting house where right and left can agree on data. Instead, it's becoming a sharp razor's edge of conflict."
The deepening polarization was not evident for other institutions asked about on the poll, according to Jennifer Benz, deputy director of The Associated Press-NORC Center for Public Affairs Research. "It's certainly plausible that this is a result of how politicized the pandemic became in the months between when it emerged and when the survey ran," Benz said. "It is definitely a stark change for these particular trends on confidence in scientific leaders and leaders in medicine, to see this degree of polarization."
Kelvin Droegemeier, former science adviser to President Donald Trump, said he thinks the pandemic increased the general public's insight into how scientific research works but the ever-evolving science probably seemed chaotic at times and the urgency of the pandemic complicated policymaking. "We hear 'follow the science,' but which results? The challenge lies in how to best use the scientific results, recognizing that what appears to be an 'answer' one day may be overturned, wholly or partly, another day," Droegemeier told the AP in an email.
That messiness, sometimes weak communication and political philosophies play into the trust gap, said Marcia McNutt, president of the National Academy of Sciences, which was set up by President Abraham Lincoln to offer the federal government expert advice. Scientists and policy makers tend to be conservative — not politically but in terms of being cautious and wary of risk — pushing safety, masks and vaccines while "Republicans as a group value individual liberty," McNutt said.
John Holdren, who was President Barack Obama's science adviser, said he blames GOP leaders' "nonstop denial and deception." The consequence of declining trust in the scientific community among Republicans is clear: AP-NORC polling shows Republicans continue to be less likely than Democrats to be vaccinated. Sudip Parikh, chief executive officer of the American Association for the Advancement of Science, the world's largest general science organization, said it's clear that science has become a wedge issue for many politicians. Some have tied themselves to it, he said, and others have seen value in shooting at it "because it helps them politically."
Parikh said he found it ironic that much of the distrust in science is spread by technology — social media, smartphones — that only exists because of scientific advances. Astrophysicist Neil deGrasse Tyson agreed: "The struggle continues, trying to get the general public to embrace all of the science the way they unwittingly embrace the science in their smartphones."
At the SWJPCCS we look at these numbers as disturbing. Rather than mistrust one wonders if political expediency might be a better term. Unfortunately, it has cost many, predominately Republicans, their lives (2). Faith in a demagogue can be potentially fatal.
Richard A. Robbins, MD
Editor, SWJPCCS
References
- Borenstein S, Fingerhut H. Americans' Trust in Science Now Deeply Polarized, Poll Shows. Associated Press. January 26, 2022. Available at: https://www.usnews.com/news/politics/articles/2022-01-26/americans-trust-in-science-now-deeply-polarized-poll-shows (accessed 1/26/22).
- Leonhardt D. Omicron Threatens Red America. NY Times. December 17,2021. Available at: https://www.nytimes.com/2021/12/17/briefing/omicron-spread-red-america.html (accessed 1/26/22).
SWJPCC Associate Editor Featured in Albuquerque Journal
Dr. Dona Upson forwarded an article from Sunday’s edition of the Albuquerque Journal featured Michel Boivin, a SWJPCC Associate Editor, in an article titled, “Exhaustion in the ICU: Doctors reflect on state’s nearly 5,000 COVID-19 deaths” (1). Boivin and his wife Teri Heynekamp, a married couple who were many years at the University of New Mexico, shared their thoughts last week on New Mexico nearing 5,000 COVID-19 deaths (Figure 1).
Figure 1. Lovelace doctors Michel Boivin and Teri Heynekamp, a married couple, walk through the intensive care unit at Lovelace Medical Center in Albuquerque. They and other doctors shared their thoughts last week on New Mexico nearing 5,000 COVID-19 deaths. (Eddie Moore/Albuquerque Journal)
Yesterday was Day 587 of the COVID-19 pandemic in New Mexico, just another brief hospital scene amid 19 months of loneliness, fatigue and grief. “We feel exhausted,” Heynekamp said in an interview, “like a type of exhaustion that I’ve never experienced in my life.” Doctors and other health care providers say their workload has hardly let up. Even the arrival of safe, effective vaccines, some doctors say, has provided little relief, introducing a new dynamic instead — the knowledge that most of today’s COVID-19 deaths are preventable. People who weren’t fully vaccinated accounted for 96% of the deaths in a recent four-week period.
Dr. Steve McLaughlin, chairman of the Department of Emergency Medicine at the University of New Mexico School of Medicine, said hospital leaders throughout the country are trying to address burnout among their workforce and “moral injury” — a concept usually applied to refugees and soldiers in wartime. In health care, moral injury refers to the distress endured by doctors and others as they’re forced to provide less care than normal. The preventable nature of most COVID-19 deaths, some doctors say, has added to the psychological toll.
Heynekamp said they and other providers have faced patients and family members who doubt the severity of the disease. Some families ask for a specific medicine, such as ivermectin, an anti-parasite drug not approved for COVID-19 treatment. A recent ICU patient, Heynekamp said, insisted his COVID-19 infection wasn’t worse than the flu. Others want to go home against medical advice, she said, and some families reject vaccination even after a loved one dies. “There’s so much anger toward health care providers,” Heynekamp said. “There’s so much animosity. There’s so much mistrust. “We’ve never dealt with that before.” Boivin put it this way: “The way that social media rewards disinformation and spreading lies at the expense of people’s lives has been unbelievably frustrating, as well as time consuming.”
The stress on health care providers goes well beyond coronavirus infections. New Mexico has had a long-standing shortage of doctors and nurses, especially in rural areas, and fewer beds per capita than the nation as a whole. Dr. Michel Boivin, a critical care physician at Lovelace, said a key challenge now is the scarcity of space available in larger hospitals to accept patients from smaller ones. “I had a guy who needed a pacemaker,” Boivin said, “and he was sitting in a rural New Mexico hospital for a whole day with his heart barely beating.” Before the pandemic, he said, there would have been no wait for a pacemaker-related transfer.
According to Dr. Sarah Medrick at the University of New Mexico, their state has one of the highest vaccination rates in the country (Table 1) (2).
Table 1. Vaccination Rate by State (2).
They urged people to get vaccinated, wear masks indoors and wash their hands. “I feel a lot of empathy for the families who are still losing their loved ones,” McLaughlin said. “I think it’s important to remind people that the pandemic is not over, and we have to continue to focus on the things we know can keep people safe and prevent additional deaths.” As Heynekamp walked through the seventh-floor ICU at Lovelace, she noted that she had stood in many of the rooms and watched patients say goodbye, often through a video call to loved ones.
It was, she said, a lonely way to die.
References
- McKay D. Exhaustion in the ICU: Doctors reflect on state’s nearly 5,000 COVID-19 deaths. Albuquerque Journal. October 24, 2021. Available at: https://www.abqjournal.com/2440183/doctors-reflect-on-states-nearly-5000-covid19-deaths.html (accessed 10-25-21).
- COVID-19 Vaccine Statistics. Our World in Data. Available at: https://www.google.com/search?q=covid-19+vaccination+rate+in+Arizona&rlz=1C1GCEA_enUS969US969&ei=jdF2YeeSEZ-e0PEP7MCJCA&ved=0ahUKEwinjYi49OXzAhUfDzQIHWxgAgEQ4dUDCA4&uact=5&oq=covid-19+vaccination+rate+in+Arizona&gs_lcp=Cgdnd3Mtd2l6EAMyBggAEBYQHjIFCAAQhgMyBQgAEIYDOgcIABBHELADOgUIABCABEoECEEYAFCl3hJYmuUSYK_sEmgBcAJ4AIABnAGIAbgGkgEDMS42mAEAoAEByAEIwAEB&sclient=gws-wiz (accessed 10-25-21).
Cite as: Robbins RA. SWJPCC Associate Editor Featured in Albuquerque Journal. Southwest J Pulm Crit Care. 2021;23:104-6. doi: https://doi.org/10.13175/swjpcc049-21 PDF
CDC Warns of Increased Ivermectin Overdoses
The US Centers for Disease Control and Prevention (CDC) is warning of an increase in cases of ivermectin overdose due to people self-prescribing the drug in an effort to prevent or treat COVID-19 (1). Ivermectin is used to treat river blindness and intestinal roundworm infection in humans and to de-worm pets and livestock.
A study published earlier this year showed that ivermectin killed SARS-CoV-2 in cells in vitro. The authors proposed that the medication be investigated as a cheap and easily available treatment for COVID-19. However, subsequent studies have failed to find any benefit in humans (3).
In a new communication to its Health Alert Network, the CDC says cases of overdose and misuse are rising (1). More than 88,000 prescriptions were written for the drug ivermectin in the week ending August 13, an increase of 2400% over the weekly average prior to the COVID-19 pandemic (Figure 1).
Figure 1. Ivermectin prescriptions by week (from CDC, reference 1).
Unfortunately, the signs of overdose are nonspecific but can include gastrointestinal symptoms (nausea, vomiting, and diarrhea), hypotension and altered mental status (change in consciousness, confusion, hallucinations, seizures, coma).
The CDC is asking doctors to alert their patients to the risks of ivermectin, particularly ivermectin products intended for veterinary use. Physicians might suspect ivermectin in a patient with unexplained symptoms and are encouraged to contact their local poison control for assistance.
References
- CDC. Rapid Increase in Ivermectin Prescriptions and Reports of Severe Illness Associated with Use of Products Containing Ivermectin to Prevent or Treat COVID-19. August 26, 2021. Available at: https://emergency.cdc.gov/han/2021/han00449.asp (accessed 8/27/21).
- Caly L, Druce JD, Catton MG, Jans DA, Wagstaff KM. The FDA-approved drug ivermectin inhibits the replication of SARS-CoV-2 in vitro. Antiviral Res. 2020 Jun;178:104787. [CrossRef] [PubMed]
- Popp M, Stegemann M, Metzendorf MI, Gould S, Kranke P, Meybohm P, Skoetz N, Weibel S. Ivermectin for preventing and treating COVID-19. Cochrane Database Syst Rev. 2021 Jul 28;7:CD015017. [CrossRef] [PubMed]
Cite as: Robbins RA. CDC Warns of Increased Ivermectin Overdoses. Southwest J Pulm Crit Care. 2021;23(2):62-3. doi: https://doi.org/10.13175/swjpcc038-21 PDF
Poisoning by Hand Sanitizers
The CDC has recommended hand sanitizers as part of their strategy to prevent spread of the COVID-19 pandemic. However, some sanitizers contain high amounts of methanol and some people are drinking the sanitizers to get an alcohol high. Others have believed a rumor, circulated online, that drinking the highly potent and toxic alcohol can disinfect the body, protecting them from COVID-19 infection (1).
Banner Poison and Drug Information Center at Banner University Medical Center in Phoenix alerted the state health department, who brought in the CDC and FDA to investigate. In the CDC's Morbidity and Mortality Weekly Report from Aug. 14, the first 15 cases seen in Arizona and New Mexico were reported (2).
The FDA first alerted consumers about toxic hand sanitizers in mid-June, when the agency warned against the use of hand sanitizer products with methanol made by Eskbiochem. By Aug. 12, that list had grown to 160 brands. Prominent amongst these has been sanitizers manufactured by Global SAPI de CV from Mexico and sold under the name Blumen (3)
Besides methanol, the FDA warns, some hand sanitizers contain insufficient levels of ethyl alcohol or isopropyl alcohol, the acceptable active ingredients for hand sanitizers. In some cases, the companies with methanol in their products have voluntarily recalled them, following the FDA's recommendation. For others, the FDA has issued an import alert to stop the product from entering the country. While some hand sanitizers are marked "FDA approved," the FDA says that is a fraudulent claim, as there are none approved by the FDA.
Methanol, also called wood alcohol, can be toxic when ingested or very rarely when absorbed through the skin. Early clinical effects of methanol and ethanol poisoning are similar (e.g., headache, blurred vision, nausea, vomiting, abdominal pain, loss of coordination, and decreased level of consciousness), but persons with methanol poisoning might develop severe anion-gap metabolic acidosis, seizures, and blindness. If left untreated methanol poisoning can be fatal (5). Survivors of methanol poisoning might have permanent visual impairment, including complete vision loss; data suggest that vision loss results from the direct toxic effect of formate, a toxic anion metabolite of methanol, on the optic nerve (3).
The 15 adult patients with reported methanol poisoning including persons who were American Indian/Alaska Native (AI/AN). All had ingested an alcohol-based hand sanitizer and were subsequently admitted to a hospital. Four patients died and three were discharged with vision impairment. Persons should never ingest alcohol-based hand sanitizer, avoid use of specific imported products found to contain methanol, and continue to monitor FDA guidance (3). Clinicians should maintain a high index of suspicion for methanol poisoning when evaluating adult or pediatric patients with reported swallowing of an alcohol-based hand sanitizer product or with symptoms, signs, and laboratory findings (e.g., elevated anion-gap metabolic acidosis) compatible with methanol poisoning. Treatment of methanol poisoning includes supportive care, correction of acidosis, administration of an alcohol dehydrogenase inhibitor (e.g., fomepizole), and frequently, hemodialysis.
Richard A. Robbins MD
Editor, SWJPCC
References
- Kathleen Doheny K. Toxic Methanol in Hand Sanitizers: Poisonings Continue. Medscape. August 17, 2020. Available at: https://www.medscape.com/viewarticle/935835?nlid=136939_5761&src=wnl_dne_200818_mscpedit&uac=9273DT&impID=2512049&faf=1#vp_1 (accessed 8/18/20).
- Yip L, Bixler D, Brooks DE, et al. Serious Adverse Health Events, Including Death, Associated with Ingesting Alcohol-Based Hand Sanitizers Containing Methanol - Arizona and New Mexico, May-June 2020. MMWR Morb Mortal Wkly Rep. 2020;69(32):1070-1073. Published 2020 Aug 14. [CrossRef] [PubMed]
- FDA. FDA updates on hand sanitizers consumers should not use. Current as of 8/18/20. Available at: https://www.fda.gov/drugs/drug-safety-and-availability/fda-updates-hand-sanitizers-consumers-should-not-use (accessed 8/18/20).
Cite as: Robbins RA. Poisoning by hand sanitizers. Southwest J Pulm Crit Care. 2020;21(2):54-5. doi: https://doi.org/10.13175/swjpcc047-20 PDF
Healthcare Layoffs During the COVID-19 Pandemic
Despite overcrowding of the ICUs with patients infected with coronavirus (COVID-19, SARS-CoV-2), hospitals have halted or downsized other operations. Phoenix-based Banner Health, which is Arizona's largest private employer, will impose "short-term" furloughs and pay cuts for some employees (1). Other major hospitals and hospital systems including the Mayo Clinic Arizona, Dignity Health, Tucson Medical Center and Carondelet have announced similar cost-cutting reductions. Banner Health, which has approximately 43,000 employees in Arizona, is starting the furloughs this week. The nonprofit company anticipates that the measures will affect 5% to 7% of its workforce, or up to 3,000 Arizona employees. The company says the furloughs are temporary and employees will be eligible for unemployment benefits, including an extra $600 per week provided by Arizona via the federal CARES Act. All senior leaders, including senior vice presidents, presidents, vice presidents and CEOs, will take up to a 20% reduction in pay beginning in May, Banner said. The company will pause hiring for most non-clinical, non-revenue-generating positions across the organization. This includes newly created jobs as well as vacant roles in the corporate office and facilities. The company will continue to post and recruit for positions that are essential to meet the needs of COVID-19.
An analysis by the Arizona Hospital and Healthcare Association shows Arizona hospitals are reporting revenue losses of 30% to 40% because of the cancellation of elective procedures and a reduction in emergency department visits. Hospitals had an operating margin, the difference between revenues and expenses, that averaged 2.7% in 2016 (2). The hospital association has asked Arizona’s governor, Doug Ducey, to relax his executive orders on halting elective surgeries and on expanding hospital bed capacity, citing recent modeling projections that indicate Arizona will not be as hard-hit by the disease as previously was predicted.
It is unclear how other healthcare organizations other than hospitals are managing during the COVID-19 pandemic. Our small pulmonary practice has been shut down since mid-March although we are doing some telemedicine. Yet compared to the large healthcare systems, we have managed to retain all our employees at a full-time basis as of today. Our group did apply for a small business loan to the Federal government which was denied.
Richard A. Robbins, MD
Editor, SWJPCC
References
- Innes S. Banner Health, Arizona's largest health system, to implement pay cuts and furloughs. Arizona Republic. April 20, 2020. Available at: https://www.azcentral.com/story/money/business/health/2020/04/20/banner-health-implement-pay-cuts-and-furloughs-arizona-coronavirus-covid-19/5165992002/ (accessed 4/21/20).
- Moody's Investors Service. Moody's: preliminary FY 2016 US NFP hospital medians edge lower on revenue, expense pressure. Moody's. 16 May 2017. https://www.moodys.com/research/Moodys-Preliminary-FY-2016-US-NFP-hospital-medians-edge-lower--PR_366813 Accessed 4/21/20.
Cite as: Robbins RA. Healthcare layoffs during the COVID-19 pandemic. Southwest J Pulm Crit Care. 2020;20(4):135-6. doi: https://doi.org/10.13175/swjpcc029-20 PDF
Practice Fusion Admits to Opioid Kickback Scheme
Practice Fusion, a San Francisco-based health information technology developer, will pay $145 million to resolve criminal and civil investigations relating to its electronic health records (EHR) software (1). The Department of Justice announced on January 27th that the company admitted it solicited and received kickbacks from a major opioid company in exchange for utilizing its software to influence physicians prescribing opioid pain medications. The pharmaceutical company is widely speculated to be Purdue Pharma which faces U.S. Justice Department probes and sprawling litigation over allegations it played a central role in the deadly opioid crisis (2).
The DOJ said Practice Fusion extracted kickbacks from pharmaceutical companies in exchange for implementing a clinical decision support (CDS) system in its electronic health records (EHR) software designed to increase prescriptions for their drug products. In exchange for “sponsorship” payments from pharmaceutical companies, Practice Fusion allowed the companies to craft CDS alerts to increase sales of the companies’ products, resulting in alerts that did not always reflect accepted medical standards. In their criminal probe of opioid makers, federal prosecutors have indicted pharmaceutical company executives, physicians and pharmacists. This is the first criminal action against an EHR vendor and no indictments of any Practice Fusion executives were made.
Founded in 2005, Practice Fusion offers an EHR tailored for smaller, independent physician practices. It supports practices that comprise 112,000 health care workers who see 5 million patient visits per month. Practice Fusion had expected to go public at a valuation of about $1.5 billion, but was instead acquired in 2018 by Chicago-based Allscripts for $100 million in cash.
Our practice at Arizona Chest and Sleep Medicine uses Practice Fusion in its outpatient clinics. None of us were aware of receiving any alerts advising prescribing opioids.
References
- Johnson T. S.F.-based Practice Fusion Inc. admits to opioid kickback scheme. San Francisco Business Times. January 28, 2020. Available at: https://www.bizjournals.com/sanfrancisco/news/2020/01/28/s-f-based-practice-fusion-inc-admits-to-opioid.html (accessed 2/3/20).
- Spector M, Hals T. OxyContin maker Purdue is 'Pharma Co X' in U.S. opioid kickback probe – sources. Reuters. January 28, 2020. Available at: https://www.reuters.com/article/us-purdue-pharma-investigation-opioids-e/exclusive-oxycontin-maker-purdue-is-pharma-co-x-in-us-opioid-kickback-probe-sources-idUSKBN1ZR2RY (accessed 2/3/20).
Cite as: Robbins RA. Practice Fusion admits to opioid kickback scheme. Southwest J Pulm Crit Care. 2020;20(2):63. doi: https://doi.org/10.13175/swjpcc010-20 PDF
Arizona Medical Schools Offer Free Tuition for Primary Care Commitment
The University of Arizona (UA) Colleges of Medicine in Tucson and Phoenix will offer free tuition starting in the spring semester for qualifying medical students agreeing to practice primary care (1). To be considered for free tuition, applicants must be an Arizona resident and current full-time medical student. A minimum commitment of 2 years practicing in an underserved Arizona community must be started within 6 years of graduation from medical school and completed within 10 years of graduation.
The money will come from part of the $8 million annual funding approved by the Arizona Legislature in May. According to the press release, nearly 100 students or about 10% of the student body could get free tuition at the two medical schools. Currently, tuition is $31,652/year in Tucson and $33,402 in Phoenix.
Arizona currently meets only 40% of its primary care physician (PCP) need, according to the Health Resources and Services Administration. Arizona ranks 42nd among states for total active PCPs at 77.9 per 100,000 (the US average is 91.7) according to the university's physician workforce report published in October.
In addition to enlarging the primary care workforce, the waived tuition is meant to reduce financial barriers to even applying to medical school with the looming promise of student debt. Nearly half of medical school graduates owe more than $200,000 in medical school loans, according to the latest Medscape Residents Salary and Debt Report.
UA joins a growing list of medical schools offering free tuition including New York University, the University of Houston, Kaiser Permanente, and Weill Cornell. None of the others require practicing primary care as a requirement for receiving the free tuition.
Reference
- Marcia Frellick M. U of Arizona offers free med school tuition for primary care. Medscape. December 6, 2019. Available at: https://www.medscape.com/viewarticle/922275?nlid=132930_5461&src=wnl_dne_191209_mscpedit&uac=9273DT&impID=2196790&faf=1 (accessed 12/9/19).
Cite as: Robbins RA. Arizona medical schools offer free tuition for primary care commitment. Southwest J Pulm Crit Care. 2019;19(6):163. doi: https://doi.org/10.13175/swjpcc071-19 PDF
Determining if Drug Price Increases are Justified
Drug prices continue to increase but the reasons for the increases are often nebulous. The Institute for Clinical and Economic Review (ICER) evaluated the pricing in partnerships with SSR Health Inc, a research firm, calculated the increases excluding discounts and after-market rebates (1). It was the first such annual report by the Boston-based research group, which assesses the cost-effectiveness of drugs.
A list of 78 drugs with price hikes at more than twice the rate of medical inflation was developed. From this list 9 drugs were selected for detailed review because they had the largest increase in drug spending due to a net price change. ICER reviewed these 9 drugs to determine if the price increases were supported by new clinical evidence based on new indications or data suggesting superiority over other drugs. Of these 9 drugs, ICER concluded 7 did not have justification for the price increases.
Advair, Glaxo’s beta agonist/steroid combination was the only bronchodilator on the list but was not selected for detailed review. Rituxan, a drug which can be used to treat granulomatosis with polyangiitis (GPA, formerly known as Wegener's Granulomatosis) and microscopic polyangiitis (MPA) was one of the drugs selected for review and ICER concluded the price increase was not justified.
ICER acknowledged it was difficult to determine the actual increase in spending on the drugs, but said it was confident that the seven drugs cost increase were more than other drugs (2). "If manufacturers weren't raising prices if they haven't shown a new important benefit, I think that would help," ICER Chief Medical Officer David Rind said. He added that he hoped pricing drugs based on new benefits could help slow cost hikes.
Not surprisingly pharmaceutical companies with drugs on the list were critical of the report. Gilead, Lilly, Pfizer and Roche were all critical of the report or defended their drug pricing policies (2). Both California and Vermont now have laws tracking substantial drug price increases, requiring drug manufacturers to submit information that might justify increases above a certain threshold (1). ICER hopes their report is a first step in providing the public and policymakers with information they can use to advance the public debate on drug price increases.
Richard A. Robbins, MD
Editor, SWJPCC
References
- Institute for Clinical and Economic Review. Unsupported price increase report: 2019 assessment. October 8, 2019. Available at: https://bit.ly/31XIdyk (accessed 10/11/19).
- Humer C. Humira, Rituxan top list of U.S. drugs with biggest price increases: report. Reuters Health News. October 9, 2019. Available at: https://www.reuters.com/article/us-usa-healthcare-drugpricing/humira-rituxan-top-list-of-u-s-drugs-with-biggest-price-increases-report-idUSKBN1WN1BE (accessed 10/11/19).
Cite as: Robbins RA. Determining if drug price incrases are justified. Southwest J Pulm Crit Care. 2019;19(4):123-4. doi: https://doi.org/10.13175/swjpcc064-19 PDF
Court Overturns CMS' Site-Neutral Payment Policy
On Tuesday of this week (9/17/19) a federal district court judge ruled in favor of an American Hospital Association (AHA) and Association of American Medical Colleges (AAMC) complaint that the Centers for Medicare & Medicaid Services (CMS) had overstepped its bounds by implementing site-neutral payments in January. US District Judge Rosemary M. Collyer said in her decision, "The Court finds that CMS exceeded its statutory authority when it cut the payment rate for clinic services at off-campus provider-based clinics" (1).
Under its site-neutral policy, CMS had begun paying the outpatient provider-based departments of hospitals the same for visits that it paid to independent physician practices. Previously, the hospital providers had been paid significantly more for these services than to community practices and the change in CMS policy was expected to level the playing field between independent offices and hospital-employed practices. In addition, it lowered the incentive of healthcare systems to acquire more physicians and their practices, according to some health policy experts.
The difference in costs is substantial with hospitals charging 2-6 times more than an independent physician office (2). The site-neutral payments were expected to cost hospitals $760 million in 2020, according to the suit.
The Medicare Payment Advisory Commission had advised Congress that hospitals were buying physician offices and converting them to off-campus provider-based departments partly because payments were higher than independent physician offices. In the Bipartisan Budget Act of 2015, Congress allowed hospitals to bill CMS at the higher outpatient department rate if they existed prior to Nov. 2, 2015. The law permitted CMS to change the payment system for newly established hospital-based outpatient departments. However, one expert told Medscape Medical News last year that this provision of the budget act hadn't had much impact, because many hospitals just added newly recruited physicians to the PBDs that had been grandfathered in (1).
Asked to comment on the court ruling, a CMS spokesperson told Medscape Medical News, "We are aware of the decision and are determining next steps" (1). The AHA and the AAMC were jubilant. In a joint statement, they said, "We are pleased with the District Court's decision that the Department of Health and Human Services exceeded its statutory authority when it reduced payments for hospital outpatient services provided in grandfathered, off-campus, provider-based departments. The ruling, which will allow hospitals to maintain access to important services for patients and communities, affirmed that the cuts directly undercut the clear intent of Congress to protect hospital outpatient departments because of the many real and crucial differences between them and other sites of care."
John Cullen, MD, president of the American Academy of Family Physicians, said in a statement that the AAFP is disappointed with the court ruling. "The decision preserves a system that both costs patients more in out-of-pocket expenses and limits their choice of physicians by paying hospital outpatient departments more for the same services provided by community-based physicians." he said. He added, these payment disparities across sites of service "force many community clinics to close their doors or sell their practices to hospitals. The small private practices, which provide high-quality care at a lower cost, are most at risk as a result of this decision." Robert Doherty, senior vice president, governmental affairs and public policy, for the American College of Physicians, tweeted, "This is very bad news for all the patients harmed by hospitals adding 'facility fees' for visits to doctors in practices they acquired."
Richard A. Robbins, MD
Editor, SWJPCC
References
- Terry K. Court overturns CMS' site-neutral payment policy; doc groups upset. Medscape Medical News. September 19, 2019. Available at: https://www.medscape.com/viewarticle/918744?nlid=131645_5401&src=wnl_dne_190920_mscpedit&uac=9273DT&impID=2101100&faf=1#vp_2 (accessed 9/19/19).
- Carey MJ. Facility fees: the farce everyone pays for. Medical Economics. August 16, 2018. Available at: https://www.medicaleconomics.com/blog/facility-fees-farce-everyone-pays (accessed 9/19/19).
Cite as: Robbins RA. Court overturns CMS' site-neutral payment policy. Southwest J Pulm Crit Care. 2019;19(3):101-2. doi: https://doi.org/10.13175/swjpcc060-19 PDF