Archive for the ‘Uncategorized’ Category


Posted: January 30, 2016 by Doc in Uncategorized


from the Huffington Post:

Typhoon Haiyan slammed into six central Philippine islands Friday, decimating buildings and homes and claiming lives.

One of the most powerful typhoons ever recorded, Haiyan (Yolanda in the Philippines) has caused thousands of fatalities, according to local officials.

Haiyan was the second category 5 typhoon to strike the Philippines this year.

“The devastation is, I don’t have the words for it,” Interior Secretary Mar Roxas said, according to Reuters. “It’s really horrific. It’s a great human tragedy.”

The organizations below are mobilizing and deploying major disaster relief efforts. See how you can lend support, and check back for further updates.

World Food Programme
The UN’s hunger-fighting organization has allocated an immediate $2 million for Haiyan relief, with a greater appeal pending as needs become apparent. The UN organization is sending 40 metric tons of fortified biscuits in the immediate aftermath, as well as working with the government to restore emergency telecommunications in the area. Americans can text the word AID to 27722 to donate $10 or give online. Learn more here.

Red Cross
The humanitarian and disaster relief organization has sent emergency responders and volunteers to provide meals and relief items. Already, thousands of hot meals have been provided to survivors. Red Cross volunteers and staff also helped deliver preliminary emergency warnings and safety tips. Give by donating online or mailing a check to your local American Red Cross chapter. Learn more here.

The Philippine Red Cross has mobilized its 100 local outposts to help with relief efforts. Learn more here.

The emergency response and global health organization is sending medical aid for 20,000 survivors, including antibiotics, wound care supplies and pain relievers. AmeriCares is also giving funds to local organizations to purchase supplies. Learn more here.

World Vision
The Christian humanitarian organization that specifically supports families living in poverty is providing food, water and hygiene kits at the evacuation centers. World Vision was also still actively responding to last month’s earthquake in Bohol, which fortunately was not struck by the eye of the storm. Learn more here.

ShelterBox, an emergency relief organization, provides families with a survival kit that includes a tent and other essential items while they are displaced or homeless. Learn more here.

Anticipating that children will likely be among the worst affected by the typhoon, UNICEF is working on getting essential medicines, nutrition supplies, safe water and hygiene supplies to children and families in the area. Learn more here.

Salvation Army
The Christian hunger and poverty-fighting organization is allocating 100 percent of all disaster donations for relief efforts “to immediately meet the specific needs of disaster survivors.” Text TYPHOON to 80888 to Donate $10 or give online.Learn more here.

Save The Children
The organization, which prioritizes kids’ needs, has sent relief kits for children and families, including household cleaning items, temporary school tents and learning materials. Learn more here.

Doctors Without Borders
The international medical humanitarian organization is sending 200 tons of medical and relief items, including vaccines, tents and hygiene kits. Learn more here.

Operation USA 
The Los Angeles-based nonprofit is sending much-needed water purification supplies to victims and seeking corporate partners to help with delivery. Donate $10 by texting AID to 50555 or give online. Learn more here.

American Jewish Joint Distribution Committee
The humanitarian assistance organization, which fights global poverty in 70 different countries, is sending disaster and relief development experts to aid in recovery. The organization is also empowering local partners in their efforts.Learn more here.

The Lutheran World Relief 
LWR, which fights poverty by improving global health and ensuring basic human rights are met, is working with local partners to provide water, shelter, financial resources and recovery efforts. LWR is appealing for $2.5 million for its typhoon relief fund. Learn more here.

Catholic Relief Services
CRS will provide shelter, water, toilets and more. The charitable arm aims to provide temporary housing for 32,000 families in three areas. Learn more here.

Team Rubicon
The nonprofit, which galvanizes first responders and veterans to help in times of crises, has sent a group of specialists to aid in search-and rescue, medical triage and medical relief. A second team will be deployed Nov. 12 to create a supply chain for field work. Learn more here.

International Medical Corps
The emergency response team is providing infection control, clean water and food to families in the hardest hit areas. Learn more here.

The International Rescue Committee
The organization, which specializes in humanitarian crises, is sending a relief team to help provide water and sanitation systems. Learn more here.

Ateneo de Manila Disaster Response Assistance

Habitat for Humanity: Help Rebuild the Philippines


Your Online Image: Policy From the ACP

by Sandra Adamson Fryhofer, MD from Medscape



A new policy statement from the American College of Physicians (ACP) and the Federation of State Medical Boards (FSMB)[1] takes a closer look at online patient/physician relationships in social media and other “Web 2.0” interactions. The policy does not address or examine telemedicine, e-prescribing or e-diagnosing, or electronic health record issues.

The study is published in Annals of Internal Medicine, but how appropriate that the paper made its debut at a site close to Silicon Valley.[1]

“You” Online

An online presence is becoming essential for health professionals. When is the last time you used a phone book to find a phone number or location? With smartphones getting smarter and tablets getting faster (and smaller), we all want access to information at our fingertips and on demand.

Just about everyone uses the Internet as their information source. Patients use it as a source of medical information. Physicians use it to stay current with the latest medical advances. In fact, a Pew Internet survey ranked seeking health information as the third most popular online activity.[2]

Staying connected is now an engrained part of our culture. Networking sites, media-sharing sites, and blog platforms have increased in popularity. But the introduction of social media is also changing the rules. The physician/patient interface is now a little more complicated. This policy paper sets some guidelines to make sure you don’t cross the line.

Connectivity — Without Crossing the Line

The policy paper includes a quick-look table matching available online activities with potential pitfalls and providing recommended safeguards. It’s a must-read. Protecting patient confidentiality and preserving trust are essentials for a positive patient/physician relationship.

Pitfalls of Texting

The policy paper also discusses the pitfalls of texting with immediate expectationsText messages are short and quick. Some pharmacies and insurers are piloting their use for pharmacy refills and appointments. Security and confidentiality are valid concerns. These technologies also present unintended expectations of immediate access (and answers). The truncated format limits detailed explanation and could increase odds that the message could be misconstrued. These reasons are why the policy paper cautions against routine texting for medical interactions — even for established patients.

Who Is Googling You?

Everybody’s doing it! Patients do it. Peers do it. Potential employers also do it (and so do medical school admission offices and residency training programs.) Your online image influences public, patient, and peer perceptions.

Do a self online audit. Find out what others are reading about you. The policy paper recommends doing this routinely and correcting inaccurate information. Unfortunately, they give no specifics as to how to accomplish the goal of rectifying mistakes and inaccuracies in what others have posted.

The paper does suggest a possible remedy for mitigating misrepresentations on physician ranking Websites. Although there is no way to have these deleted, the paper proposes establishing a professional profile “so that it ‘appears’ first during a search” as a means of controlling what patients read.

Pause Before Posting

Carefully consider the content of what you post. Because postings on the Internet are archived, they are essentially permanent. That’s why reflecting before reacting is a good idea.

Online perceptions include not only what is written about you, but also photos. Provocative or inappropriate postings indicate poor judgment and adverse consequences, including medical board complaints.

ACP and FSMB also advise against “airing frustrations” and “venting” in online forums. Such postings can be misconstrued and can come back to haunt you!

Know the Rules, and Follow Them

When transferring patient information electronically, be sure to stay compliant with the Health Insurance Portability and Accountability Act (HIPAA). Patients should also be made aware of the inherent security risks in communicating via email.

Some states’ laws (for example those in Hawaii) do not require a preexisting relationship for emailing between patients and physicians, a practice that is not supported by ACP or the FSMB. The policy paper also points out that some state medical boards consider emailing a violation if the physician is not licensed in the state in which the electronic communication is received. No source or specific examples were given, however.

To Friend or Not to Friend? Setting Personal/Professional Boundaries

The policy gives guidance for responding to online “friend” requests from patients: Don’t do it. The position paper specifically discourages “friending” patients on personal social media sites, such as Facebook. This blurs patient/physician boundaries.

Information from Industry

Having a separate personal and professional online presence can help mitigate this problem. It is acceptable to use professional profiles in networking and community outreach.

Patient-targeted Googling also raises red flags: “curiosity, voyeurism, and habit.” This type of digital tracking could undermine trust in the patient/physician relationship.

Final Words: Online Professionalism Is Paramount

Physicians are professionals. One of the premises of being a professional is that the public expects us to self-regulate. This policy paper provides a good starting point for online relationship discussions. These premises also apply to physicians in training. The authors acknowledge that this policy is a starting point in dialogue and will require more fine-tuning as physicians and patients navigate the online terrain.


Posted: November 23, 2011 by Doc in Uncategorized

Viewpoint: Midlevel Providers Aren’t the Solution to the EP Workforce Shortage

Ginde, Adit A. MD, MPH; Camargo, Carlos A. Jr. MD, DrPH

 from EM News
Emergency Medicine News:
July 2010 – Volume 32 – Issue 7 – p 3, 23

There will not be enough emergency medicine residency trained physicians to cover our nation’s emergency departments for many years. (Acad Emerg Med 2008;15[12]:1317.) This shortage is even more pronounced in smaller and rural EDs and in the face of continually increasing demand for emergency care.

So who covers these EDs? In 2008, 31 percent of physicians practicing in EDs — more than 12,000 physicians — were not emergency medicine residency trained or emergency medicine board certified. (Ann Emerg Med 2009;54[3]:349.) They are family physicians, internists, surgeons, and pediatricians who provide emergency care when an emergency medicine-trained physician is not available. This emergency medicine workforce shortage was a major topic of the 2009 Future of Emergency Medicine Summit, which brought together representatives of the leading emergency medicine organizations. (Schneider SM, et al. The future of emergency medicine. Ann Emerg Med 2010; in press.) Numerous potential solutions were discussed, including increasing emergency medicine residency slots, loan repayment for emergency physicians, joint emergency medicine-family medicine training, and using scribes to improve efficiency. One recommendation that has become increasing popular is the use of midlevel providers such as physician assistants and nurse practitioners.

Indeed, the introduction of midlevel providers to emergency care is already occurring in great numbers. In 2005, 13 percent of all U.S. ED visits were covered by a midlevel provider, up from only four percent in 1993. (Am J Emerg Med 2010;28[1]:90.) At first glance, this may seem like a win-win scenario. Midlevel providers help expand the efficiency of emergency physicians, and cover some of the workforce gap. Their cost to the hospital is lower than a physician’s, and at least for minor presentations, patient satisfaction appears to be high. (Am J Emerg Med 2000;18[6]:661.) An increasing scope of practice and level of autonomy, however, calls into question whether midlevel providers are collaborating with emergency physicians or actually replacingthem.

We fully support emergency medicine residency training, and believe that emergency medicine board certified physicians are the gold standard for providers in the ED. When emergency medicine-trained physicians are unavailable or unwilling to cover some EDs, such as smaller and rural EDs, however, many non-emergency medicine-trained providers, both physicians and midlevel providers, continue to fill the void. While physicians attract a greater amount of criticism and scrutiny, midlevel providers, who do not have formal emergency medicine training and fewer overall years of medical training than physicians, are often embraced as a solution to the workforce shortage.

While NPs are licensed to practice independently in some states, PAs must collaborate with physicians. The scope of practice and degree of autonomy for both groups is state-dependent. Neither group has developed accredited emergency medicine training programs for specialization in emergency care. Yet independent practice is becoming increasingly common. (See figure.) In paging through ED job announcements, we have encountered postings that state, “We are currently seeking a PA who is comfortable working autonomously in our ED.” In 2005, five percent of all ED visits nationwide were seen by midlevel providers without onsite physician involvement, up from one percent in 1993. (Am J Emerg Med 2010;28[1]:90.)

But indirect physician supervision of PAs and their independent practice is legal, isn’t it? Supervision and scope of practice for midlevel providers are defined at the state level. Most states allow provision of emergency care and define supervision as the availability of a physician, but participation in care or even physical presence in the facility is often not required. Physician supervision by co-signing charts or prescriptions days to weeks after the ED visit is occurring throughout the country, although it is unknown how widespread this practice is. How much oversight is truly being provided for these patients?


Image Tools

But isn’t this is only an issue for rural EDs, where any provider is better than no provider? Not really. National data show that 86 percent of midlevel provider visits without physician involvement are in urban EDs. (Am J Emerg Med 2010;28[1]:90.) While the number of these visits has remained stable in rural EDs, they have markedly increased in urban EDs over the past decade. Emergency physician workforce shortages are probably not driving this as much as practical and financial considerations; ED administrators may hire less expensive midlevel providers instead of emergency physicians. With emergency medicine residency graduates having difficulty obtaining jobs in some desirable urban markets, it’s possible midlevel providers may actually be taking jobs away from emergency medicine residents rather than solving the emergency medicine workforce shortage and maldistribution.

What about acuity? Midlevel providers don’t really need a physician to directly supervise the care of patients with obvious ankle sprains and minor lacerations. This may be true, and data support the quality of care by independent midlevel provider care for minor ED presentations. (Lancet 1999;354 [9187]:1321.) Of ED patients seen in 2005 by midlevel providers without direct physician supervision, however, six percent arrived by ambulance, 37 percent had urgent/emergent acuity, and three percent were admitted to the hospital. (Am J Emerg Med2010;28[1]:90.) While these acuity data are lower than those for physicians in the ED, the role of midlevel providers, who may practice without on-site physician involvement, has clearly extended beyond minor presentations.

Limited data address the quality and patient safety of midlevel provider care of higher acuity ED patients. A recent study of 4,029 visits for acute asthma in 63 U.S. EDs found that unsupervised midlevel providers had a significantly lower quality of ED asthma care, compared with physician-supervised midlevel providers and with physicians alone. (Am J Emerg Med 2010;28[4]:485.)

The latter groups, in which physicians were directly involved, provided care of similar quality. While this is a single study of one condition, acute asthma care has well-defined treatment pathways and evidence-based national guidelines that should create more uniform care than other acute conditions. These data support a view that midlevel providers should collaborate with, rather than replace, emergency physicians, especially for higher acuity patients.

Midlevel providers have a major role in U.S. emergency care, and we support efforts to develop emergency medicine training, accreditation, and continuing medical education for PAs and NPs. Indeed, there are now several post-graduate emergency medicine training programs for PAs and NPs. Before moving forward with a midlevel provider-based “solution” to the emergency physician workforce shortage, we encourage more thoughtful discussion about training, scope of practice, and supervision. The growing acceptance of non-emergency medicine-trained midlevel providers practicing independently in EDs is difficult to reconcile with the often heated and absolute opposition to non-emergency medicine residency trained physicians. The ultimate goal of most emergency physicians and midlevel providers, regardless of their emergency medicine training and accreditation, is to provide effective and safe care for our patients. This should stay at the forefront of the emergency medicine workforce debate.

© 2010 Lippincott Williams & Wilkins, Inc.

March 21, 2010

Obama Hails Vote on Health Care as Answering ‘the Call of History’


WASHINGTON — House Democrats approved a far-reaching overhaul of the nation’s health system on Sunday, voting over unanimous Republican opposition to provide medical coverage to tens of millions of uninsured Americans after an epic political battle that could define the differences between the parties for years.

With the 219-to-212 vote, the House gave final approval to legislation passed by the Senate on Christmas Eve. Thirty-four Democrats joined Republicans in voting against the bill. The vote sent the measure to President Obama, whose yearlong push for the legislation has been the centerpiece of his agenda and a test of his political power.

After approving the bill, the House adopted a package of changes to it by a vote of 220 to 211. That package — agreed to in negotiations among House and Senate Democrats and the White House — now goes to the Senate for action as soon as this week. It would be the final step in a bitter legislative fight that has highlighted the nation’s deep partisan and ideological divisions.

On a sun-splashed day outside the Capitol, protesters, urged on by House Republicans, chanted “Kill the bill” and waved yellow flags declaring “Don’t Tread on Me.” They carried signs saying “Doctors, Not Dictators.”

Inside, Democrats hailed the votes as a historic advance in social justice, comparable to the establishment of Medicare and Social Security. They said the bill would also put pressure on rising health care costs and rein in federal budget deficits.

“This is the Civil Rights Act of the 21st century,” said Representative James E. Clyburn of South Carolina, the No. 3 Democrat in the House.

Mr. Obama celebrated the House action in remarks at the White House.

“We pushed back on the undue influence of special interests,” Mr. Obama said. “We didn’t give in to mistrust or to cynicism or to fear. Instead, we proved that we are still a people capable of doing big things.”

“This isn’t radical reform,” he added, “but it is major reform.”

After a year of combat and weeks of legislative brinksmanship, House Democrats and the White House clinched their victory only hours before the voting started on Sunday. They agreed to a deal with opponents of abortion rights within their party to reiterate in an executive order that federal money provided by the bill could not be used for abortions, securing for Democrats the final handful of votes they needed to assure passage.

Winding up the debate, Speaker Nancy Pelosi said: “After a year of debate and hearing the calls of millions of Americans, we have come to this historic moment. Today we have the opportunity to complete the great unfinished business of our society and pass health insurance reform for all Americans that is a right and not a privilege.”

The House Republican leader, Representative John A. Boehner of Ohio, said lawmakers were defying the wishes of their constituents. “The American people are angry,” Mr. Boehner said. “This body moves forward against their will. Shame on us.”

Republicans said the plan would saddle the nation with unaffordable levels of debt, leave states with expensive new obligations, weaken Medicare and give the government a huge new role in the health care system.

The debate on the legislation set up a bitter midterm campaign season, with Republicans promising an effort to repeal the legislation, challenge its constitutionality or block its provisions in the states.

Representative Paul D. Ryan, Republican of Wisconsin, denounced the bill as “a fiscal Frankenstein.” Representative Lincoln Diaz-Balart, Republican of Florida, called it “a decisive step in the weakening of the United States.” Representative Virginia Foxx, Republican of North Carolina, said it was “one of the most offensive pieces of social engineering legislation in the history of the United States.”

But Representative Marcy Kaptur, Democrat of Ohio, said the bill heralded “a new day in America.” Representative Doris Matsui, Democrat of California, said it would “improve the quality of life for millions of American families.”

The health care bill would require most Americans to have health insurance, would add 16 million people to the Medicaid rolls and would subsidize private coverage for low- and middle-income people, at a cost to the government of $938 billion over 10 years, the Congressional Budget Office said.

The bill would require many employers to offer coverage to employees or pay a penalty. Each state would set up a marketplace, or exchange, where consumers without such coverage could shop for insurance meeting federal standards.

The budget office estimates that the bill would provide coverage to 32 million uninsured people, but still leave 23 million uninsured in 2019. One-third of those remaining uninsured would be illegal immigrants.

The new costs, according to the budget office, would be more than offset by savings in Medicare and by new taxes and fees, including a tax on high-cost employer-sponsored health plans and a tax on the investment income of the most affluent Americans.

Cost estimates by the budget office, showing that the bill would reduce federal budget deficits by $143 billion in the next 10 years, persuaded some fiscally conservative Democrats to vote for the bill.

Democrats said Americans would embrace the bill when they saw its benefits, including some provisions that take effect later this year.

Health insurers, for example, could not deny coverage to children with medical problems or suddenly drop coverage for people who become ill. Insurers must allow children to stay on their parents’ policies until they turn 26. Small businesses could obtain tax credits to help them buy insurance.

The Democratic effort to secure the 216 votes needed for passage of the legislation came together only after last-minute negotiations involving the White House, the House leadership and a group of Democratic opponents of abortion rights, led by Representative Bart Stupak of Michigan. On Sunday afternoon, members of the group announced that they would support the legislation after Mr. Obama promised to issue an executive order to “ensure that federal funds are not used for abortion services.”

Mr. Stupak described the order as a significant guarantee that would “protect the sanctity of life in health care reform.” But supporters of abortion rights — and some opponents — said the order merely reaffirmed what was in the bill.

The vote to pass the Senate version of the bill means that it will become the law of the land as soon as Mr. Obama signs it, regardless of when — or even whether — the Senate acts on the package of changes the House also passed.

The Senate majority leader, Harry Reid of Nevada, has promised to take up the package of changes in short order, and he has said he has the votes to pass it. The Senate will consider it under a parliamentary maneuver that will allow the Democrats to pass it with a simple majority, averting the threat of a Republican filibuster.

Indeed, Senate Republicans were quickly faced with a need to recalibrate their message from one aimed at stopping the legislation to one focused on winning back a sufficient number of seats in Congress to repeal it.

Mr. Obama, in his remarks shortly before midnight in the East Room, urged the Senate to complete the final pieces of the legislation. “Some have predicted another siege of parliamentary maneuvering in order to delay it,” he said. “I hope that’s not the case.”

He continued, “It’s time to bring this debate to a close and begin the hard work of implementing this reform properly on behalf of the American people.”

Mr. Obama watched the roll call with Vice President Joseph R. Biden Jr. in the Roosevelt Room in the White House.

The House galleries were full, and the floor was unusually crowded, for the historic debate on health care.

Working together, Mr. Obama and Ms. Pelosi revived the legislation when it appeared dead after Democrats lost their 60th vote in the Senate and with it their ability to shut off Republican filibusters.

Republicans said they would use the outcome to bludgeon Democrats in this year’s Congressional elections. The White House is planning an intensive effort to convince people of the bill’s benefits. But if Democrats suffer substantial losses in November, Mr. Obama could be stymied on other issues.

The campaign for a health care overhaul began as a way to help the uninsured. But it gained momentum when middle-class families with health insurance flooded Congress with their grievances. They complained of soaring premiums. They said their insurance had been canceled when they got sick.

“It’s not just the uninsured,” said Representative Jim McGovern, Democrat of Massachusetts. “We also have to worry about people with insurance who find, for crazy reasons, that they are somehow going to be denied coverage.”

In the end, groups like the United States Chamber of Commerce and the National Federation of Independent Business tried to stop the bill, saying it would increase the cost of doing business. But other groups, including the American Medical Association and AARP, backed it, as did the pharmaceutical industry.

Lawmakers agreed that Sunday’s debate was historic, but they were poles apart in assessing the legislation.

Representative Rodney Alexander, Republican of Louisiana, said, “You cannot expect to expand coverage to millions of individuals and to curb costs at the same time.”

Republicans said the picture painted by the budget office was too rosy, because the new taxes and fees would start immediately, while the major costs would not show up for four years.

Moreover, Republicans said Democrats would pay a price for defying public opinion on the bill.

“Are you so arrogant that you know what’s best for the American people?” Representative Paul Broun, Republican of Georgia, asked the Democrats. “Are you so ignorant to be oblivious to the wishes of the American people?”

Lawmakers spoke with deep conviction in explaining their votes.

“Health care is not only a civil right, it’s a moral issue,” said Representative Patrick J. Kennedy, Democrat of Rhode Island, who invoked the memory of his father, Senator Edward M. Kennedy, a Massachusetts Democrat and a lifelong champion of health care for all.

After the legislation passed, Mr. Obama sought to place the day in perspective.

“In the end what this day represents is another stone firmly laid in the foundation of the American dream,” the president said. “Tonight, we answered the call of history as so many generations of Americans have before us. When faced with crisis, we did not shrink from our challenges. We overcame them. We did not avoid our responsibilities, we embraced it. We did not fear our future, we shaped it.”


For a quick summary of what is in the bill scheduled to be voted on this Sunday, take a look at the Washington Post‘s chart. The New York Times offers a copy of the House reconciliation bill itself, which runs some 150 pages in length.

“What’s in the Senate health care bill?” Washington Post

New York Times link (PDF)

The Decline of St. Vincent’s Hospital

Posted: February 4, 2010 by Doc in Uncategorized

Published: February 2, 2010
For more than 150 years, St. Vincent’s Hospital Manhattan has been a beacon in Greenwich Village, serving poets, writers, artists, winos, the poor and the working-class, and gay people.

It has treated victims of calamities: the cholera epidemic of 1849, the sinking of the Titanic in 1912, the 9/11 attack and, just last year, the Hudson River landing of US Airways Flight 1549. The poet Edna St. Vincent Millay got her middle name from the hospital, where her uncle’s life was saved in 1892 after he was accidentally locked in the hold of a ship for several days without food or water.

But today the hospital is struggling, and last week, in what could mean the death knell of the last Roman Catholic general hospital in New York City, a chain of hospitals proposed to take over St. Vincent’s, shut down its inpatient beds and most of its emergency room services, and convert it into an outpatient center tied to hospitals uptown and on the East Side.

Gov. David A. Paterson’s office said on Tuesday the state was extending a $6 million emergency loan to help St. Vincent’s meet its payroll, an indication of how dire its finances had become.

How St. Vincent’s went from a cherished neighborhood institution to one threatened with extinction is a chronicle of increasingly troubled management whose problems were made worse by the economics of the health care industry, changes in the fabric of a historic neighborhood and the low profit potential in religious work.

It was once part of the Roman Catholic Church’s social and political network in New York City, a cradle-to-grave embrace of parishioners who were born in Catholic hospitals, educated in parochial schools, married in the church and given last rites by a priest.

Last week, a day after the announcement of the proposed takeover, members of the Sisters of Charity, the Catholic order of nuns that founded the hospital in 1849, gathered for a noon Mass at St. Vincent’s second-floor chapel and vowed to fight. “We are not going away,” said Sister Jane Iannucelli, vice chairwoman of the hospital board, standing in the light of stained glass windows.

“One of the things that’s so crucial to the Sisters of Charity is serving the poor,” she said.

It was that very calling, some industry executives suggested, that may have helped make the hospital obsolete.

“Helping the poor is indeed the mission and the cause célèbre,” said Kenneth E. Raske, president of the Greater New York Hospitals Association, a trade group. “Therein lies the dilemma.”

Other hospitals emphasize high-tech care and rush to invest in the fancy equipment and celebrity doctors that attract patients with the means to pay for them; St. Vincent’s sticks to its motto of “compassionate care,” rooted in its origins as a place that trained nurses and that was under the auspices of nuns.

As the Village changed, becoming home to more middle-class families, by many accounts St. Vincent’s failed to change with it. In 2007, several years after an ill-fated merger with other Catholic hospitals, St. Vincent’s management proposed selling off its maze of outdated buildings around Seventh Avenue and 12th Street to build a state-of-the-art high-rise building across the street, to be designed by Pei Cobb Freed & Partners Architects, famous for cutting-edge projects like the glass pyramid expansion of the Louvre museum in Paris and the John Hancock Tower in Boston.

But some said it was too late. In an indication of how St. Vincent’s reputation had fallen in the neighborhood, during a fierce debate over whether to demolish a low-rise Modernist building to make way for the new hospital, the actors Susan Sarandon and Tim Robbins suggested that St. Vincent’s no longer served the neighborhood well.

“I would not want to bring my children there,” Ms. Sarandon declared at a landmarks preservation hearing.

At the height of the AIDS epidemic in the 1980s, St. Vincent’s ministered to those affected, and was bursting at the seams. But by the 1990s, drugs and public awareness helped bring AIDS under control, and the Village’s wealthy newcomers were choosing other hospitals.

From 1996 to 2007, the most recent year for which figures are available, the number of patients the hospital admitted went down by 10 percent, while the rate for hospitals citywide was flat, state records show.

And its emergency room volume has been growing faster than the citywide rate, suggesting that it has the worst of both worlds — more emergency room patients and fewer inpatient admissions, which are where the money is.

St. Vincent’s is a major city contractor for homeless services, and hospital administrators said that homeless people from all over the city find their way there for treatment.

In short, many of the patients who frequent St. Vincent’s are part of the old Village rather than the new Village, as was clear from a tour of the emergency room last week. It was electric with activity, every bed filled. Many of the patients were elderly, from Chinatown, or grizzled remnants of the Village’s old working class. Nuns from Mother Theresa’s order hovered about.

The room, like other parts of the hospital, had a homey feeling, more like a place television’s kindly Dr. Marcus Welby would have taken his patients rather than the overly caffeinated environment of “House.”

“There’s a sense we’re here for the mission, and it truly permeates,” said Dr. Eric Legome, the chairman of emergency medicine.

Despite 62,000 emergency visits, nearly 1,800 births, almost 22,000 hospital admissions and 263,000 outpatient visits a year, according to St. Vincent’s officials, the hospital is bleeding red ink, and has been for years.

Hospital officials, who asked not to be named because of the sensitivity of negotiations with Continuum Health Partners, the chain that has offered to take over the hospital, said the hospital was close to having to declare bankruptcy for the second time since 2005. It is about $700 million in debt.

Officials blamed a high rate of poor and uninsured patients as well as cuts in Medicare and Medicaid and the hospital’s inability to negotiate favorable contracts with health insurance companies, claiming their fees were 30 percent below the market rate.

continued on

Under prompt appeal is this automatic decision by the lower court in New York, which takes deference to ” rational basis” analysis to another level. AAPS argued that New York State cannot have a website that lists physicians as board certified in Emergency Medicine and explains that that means they were residency trained in Emergency Medicine, when in fact some of those physicians were grandfathered into Emergency Medicine and did not do a residency in Emergency Medicine.
New York State maintained that the reason for having the site is so that consumers can be informed about who is in fact treating them in Emergency Rooms. While most non lawyers might not understand how the court arrived at their superficial conclusion, an explanation is in order.
New York’s actions discriminate against equally situated physicians, namely (1) ER physicians who belong to AAPS who did not do a residency in Emergency Medicine and (2) ABEM certified physicians who grandfathered in to Emergency Medicine who also did not do a residency in Emergency Medicine. AAPS argued the obvious. Since there is no difference essentially between the two groups of physicians, why are the ABEM physicians listed on the website and the AAPS physicians, not listed?
This is logic so simple a caveman could get it. However, enter rational basis analysis. Challenges to New York’s action is analysed by the court under a rational basis theory. Under “rational basis”, New York need only have a rational basis, meaning any basis you can think of, even a not so rational, rational basis. The lower court held that New York was rational in listing physicians as they did because the ABEM grandfathered physicians were granddfathered in and basically New York could choose to ignore the obvious deficiency in residency training and that illogic was ok under rational basis legal analysis. Huh! come again.
AAPS pointed out the irrationality and of course the obvious fact that by finding for New York, the lower court perpetuating a fraud on the people of New York. So AAPS has appealed. It will be interesting to see what happens.

Click on the link below for the full decision.


AAPS-NYSDOH decision

NY Judge Decides AAPS Case Goes Forward

American Board of Physician Specialties (ABPS)
IOM Report Ignites New Debate on Who Should Practice Emergency Medicine
Disposable Doctors 2: ER Docs Fight Back in NY
Disposable Doctors 1
An ER Doc’s Top Ten List
United States Alliance of Emergency Medicine (USAEM)
“Tribal Thinking and the Ultimate Confounder”

The film MONEY-DRIVEN MEDICINE reveals how a profit-hungry medical-industrial complex has turned health care into a system that squanders millions of dollars on unnecessary tests, unproven and sometimes unwanted procedures and overpriced prescription drugs. Oscar-winning filmmaker Alex Gibney has teamed up with producers Peter Bull, Chris Matonti, and director Andy Fredericks to produce a film based on Maggie Mahar’s powerful book MONEY-DRIVEN MEDICINE.

After covering the health care industry for years as a financial journalist, Mahar wanted to write a book examining the system from the perspective of doctors and patients. The response from the doctors she contacted was overwhelming — five out of six called her back. The film brings their stories to the screen, portraying an industry where corporate profits often get in the way of care.



Bill Moyers’ Journal

Nightline: Health Care Sound and Fury

By Shawn Tully, editor at large

NEW YORK (Fortune) — In promoting his health-care agenda, President Obama has repeatedly reassured Americans that they can keep their existing health plans — and that the benefits and access they prize will be enhanced through reform.

A close reading of the two main bills, one backed by Democrats in the House and the other issued by Sen. Edward Kennedy’s Health committee, contradict the President’s assurances. To be sure, it isn’t easy to comb through their 2,000 pages of tortured legal language. But page by page, the bills reveal a web of restrictions, fines, and mandates that would radically change your health-care coverage.

If you prize choosing your own cardiologist or urologist under your company’s Preferred Provider Organization plan (PPO), if your employer rewards your non-smoking, healthy lifestyle with reduced premiums, if you love the bargain Health Savings Account (HSA) that insures you just for the essentials, or if you simply take comfort in the freedom to spend your own money for a policy that covers the newest drugs and diagnostic tests — you may be shocked to learn that you could lose all of those good things under the rules proposed in the two bills that herald a health-care revolution.

In short, the Obama platform would mandate extremely full, expensive, and highly subsidized coverage — including a lot of benefits people would never pay for with their own money — but deliver it through a highly restrictive, HMO-style plan that will determine what care and tests you can and can’t have. It’s a revolution, all right, but in the wrong direction.

Let’s explore the five freedoms that Americans would lose under Obamacare:

1. Freedom to choose what’s in your plan

The bills in both houses require that Americans purchase insurance through “qualified” plans offered by health-care “exchanges” that would be set up in each state. The rub is that the plans can’t really compete based on what they offer. The reason: The federal government will impose a minimum list of benefits that each plan is required to offer.

Today, many states require these “standard benefits packages” — and they’re a major cause for the rise in health-care costs. Every group, from chiropractors to alcohol-abuse counselors, do lobbying to get included. Connecticut, for example, requires reimbursement for hair transplants, hearing aids, and in vitro fertilization.

The Senate bill would require coverage for prescription drugs, mental-health benefits, and substance-abuse services. It also requires policies to insure “children” until the age of 26. That’s just the starting list. The bills would allow the Department of Health and Human Services to add to the list of required benefits, based on recommendations from a committee of experts. Americans, therefore, wouldn’t even know what’s in their plans and what they’re required to pay for, directly or indirectly, until after the bills become law.

2. Freedom to be rewarded for healthy living, or pay your real costs

As with the previous example, the Obama plan enshrines into federal law one of the worst features of state legislation: community rating. Eleven states, ranging from New York to Oregon, have some form of community rating. In its purest form, community rating requires that all patients pay the same rates for their level of coverage regardless of their age or medical condition.

Americans with pre-existing conditions need subsidies under any plan, but community rating is a dubious way to bring fairness to health care. The reason is twofold: First, it forces young people, who typically have lower incomes than older workers, to pay far more than their actual cost, and gives older workers, who can afford to pay more, a big discount. The state laws gouging the young are a major reason so many of them have joined the ranks of uninsured.

Under the Senate plan, insurers would be barred from charging any more than twice as much for one patient vs. any other patient with the same coverage. So if a 20-year-old who costs just $800 a year to insure is forced to pay $2,500, a 62-year-old who costs $7,500 would pay no more than $5,000.

Second, the bills would ban insurers from charging differing premiums based on the health of their customers. Again, that’s understandable for folks with diabetes or cancer. But the bills would bar rewarding people who pursue a healthy lifestyle of exercise or a cholesterol-conscious diet. That’s hardly a formula for lower costs. It’s as if car insurers had to charge the same rates to safe drivers as to chronic speeders with a history of accidents.

3. Freedom to choose high-deductible coverage

The bills threaten to eliminate the one part of the market truly driven by consumers spending their own money. That’s what makes a market, and health care needs more of it, not less.

Hundreds of companies now offer Health Savings Accounts to about 5 million employees. Those workers deposit tax-free money in the accounts and get a matching contribution from their employer. They can use the funds to buy a high-deductible plan — say for major medical costs over $12,000. Preventive care is reimbursed, but patients pay all other routine doctor visits and tests with their own money from the HSA account. As a result, HSA users are far more cost-conscious than customers who are reimbursed for the majority of their care.

The bills seriously endanger the trend toward consumer-driven care in general. By requiring minimum packages, they would prevent patients from choosing stripped-down plans that cover only major medical expenses. “The government could set extremely low deductibles that would eliminate HSAs,” says John Goodman of the National Center for Policy Analysis, a free-market research group. “And they could do it after the bills are passed.”

4. Freedom to keep your existing plan

This is the freedom that the President keeps emphasizing. Yet the bills appear to say otherwise. It’s worth diving into the weeds — the territory where most pundits and politicians don’t seem to have ventured.

The legislation divides the insured into two main groups, and those two groups are treated differently with respect to their current plans. The first are employees covered by the Employee Retirement Security Act of 1974. ERISA regulates companies that are self-insured, meaning they pay claims out of their cash flow, and don’t have real insurance. Those are the GEs (GE, Fortune 500) and Time Warners (TWX, Fortune 500) and most other big companies.

The House bill states that employees covered by ERISA plans are “grandfathered.” Under ERISA, the plans can do pretty much what they want — they’re exempt from standard packages and community rating and can reward employees for healthy lifestyles even in restrictive states.

But read on.

The bill gives ERISA employers a five-year grace period when they can keep offering plans free from the restrictions of the “qualified” policies offered on the exchanges. But after five years, they would have to offer only approved plans, with the myriad rules we’ve already discussed. So for Americans in large corporations, “keeping your own plan” has a strict deadline. In five years, like it or not, you’ll get dumped into the exchange. As we’ll see, it could happen a lot earlier.

The outlook is worse for the second group. It encompasses employees who aren’t under ERISA but get actual insurance either on their own or through small businesses. After the legislation passes, all insurers that offer a wide range of plans to these employees will be forced to offer only “qualified” plans to new customers, via the exchanges.

The employees who got their coverage before the law goes into effect can keep their plans, but once again, there’s a catch. If the plan changes in any way — by altering co-pays, deductibles, or even switching coverage for this or that drug — the employee must drop out and shop through the exchange. Since these plans generally change their policies every year, it’s likely that millions of employees will lose their plans in 12 months.

5. Freedom to choose your doctors

The Senate bill requires that Americans buying through the exchanges — and as we’ve seen, that will soon be most Americans — must get their care through something called “medical home.” Medical home is similar to an HMO. You’re assigned a primary care doctor, and the doctor controls your access to specialists. The primary care physicians will decide which services, like MRIs and other diagnostic scans, are best for you, and will decide when you really need to see a cardiologists or orthopedists.

Under the proposals, the gatekeepers would theoretically guide patients to tests and treatments that have proved most cost-effective. The danger is that doctors will be financially rewarded for denying care, as were HMO physicians more than a decade ago. It was consumer outrage over despotic gatekeepers that made the HMOs so unpopular, and killed what was billed as the solution to America’s health-care cost explosion.

The bills do not specifically rule out fee-for-service plans as options to be offered through the exchanges. But remember, those plans — if they exist — would be barred from charging sick or elderly patients more than young and healthy ones. So patients would be inclined to game the system, staying in the HMO while they’re healthy and switching to fee-for-service when they become seriously ill. “That would kill fee-for-service in a hurry,” says Goodman.

In reality, the flexible, employer-based plans that now dominate the landscape, and that Americans so cherish, could disappear far faster than the 5 year “grace period” that’s barely being discussed.

Companies would have the option of paying an 8% payroll tax into a fund that pays for coverage for Americans who aren’t covered by their employers. It won’t happen right away — large companies must wait a couple of years before they opt out. But it will happen, since it’s likely that the tax will rise a lot more slowly than corporate health-care costs, especially since they’ll be lobbying Washington to keep the tax under control in the righteous name of job creation.

The best solution is to move to a let-freedom-ring regime of high deductibles, no community rating, no standard benefits, and cross-state shopping for bargains (another market-based reform that’s strictly taboo in the bills). I’ll propose my own solution in another piece soon on For now, we suffer with a flawed health-care system, but we still have our Five Freedoms. Call them the Five Endangered Freedoms.