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March 4, 2015   Download print version

The next Ebola zone: Report finds 28 high-risk countries

Norovirus sickens nearly 3 dozen at Phoenix VA

Officials urge testing as Portland, Oregon sees rise in syphilis cases

The ACA’s hospital tax-exemption rules and the practice of medicine

New York City rats carry fleas known to transmit plague

Do heart surgery patients get too many blood tests?

What are the best hospitals? Rankings disagree

Florida ponders life sans subsidies

 
 

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March 2015

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The next Ebola zone: Report finds 28 high-risk countries

Where else could an epidemic of Ebola or some other disease come? Try Somalia, Chad, Nigeria, Afghanistan, Haiti, Ethiopia, Central Africa Republic, Guinea, Niger, and then Mali. They all have weaker healthcare systems than Sierra Leone, Save the Children warns. The group, which has been fighting the epidemic ravaging Sierra Leone, Guinea and Liberia, says 28 countries have near-nonexistent health systems.  

Public health experts agree that poor health systems helped Ebola turn from a series of outbreaks into a full-fledged epidemic. It's infected nearly 24,000 people and killed around 10,000 by official count. People carried the virus to the U.S., to Europe and to neighboring countries.

"A robust health system could have helped get Ebola under control much sooner, saving thousands of children's lives and billions of dollars," Save the Children says. And many other countries are just as vulnerable, if not more so. The group devised an index of the public health systems of the world's poorest countries based on the number of health workers, government spending on health and mortality rates.

Somalia ranked worst, with the index finding there is one health worker for every 6,711 people compared to one health worker for every 88 people in Britain. Chad has one health worker for every 4,444 people and Niger one per 6,410 people. In Afghanistan, which was fourth-lowest, public spending on health is $10.71 per person a year compared to more than $3,000 in Britain and $4,000 in the United States. In Guinea, it's $9 a person.                  

"Without trained health workers and a functioning health system in place, it's more likely that an epidemic could spread across international borders with catastrophic effects," said Carolyn Miles, president and CEO of Save the Children USA. "The world woke up to Ebola but now people need to wake up to the scandal of weak health systems, which not only risk new diseases spreading, but also contribute to the deaths of 17,000 children each day from preventable causes like pneumonia and malaria."                

Building better public health systems would be cheaper than fighting epidemics, the report argues. It says the cost of dealing with this Ebola outbreak has been nearly three times the annual cost of investing in building a universal health service in all three affected countries.

The World Bank projected that fighting this Ebola epidemic could cost $30 billion. The U.S. spent $1 million to treat just two of its 10 Ebola patients. Visit NBC News for the article.

 

 

Norovirus sickens nearly 3 dozen at Phoenix VA

Norovirus has sickened nearly three dozen patients and staff members at the Phoenix VA Health Care System, prompting the hospital to halt admission of new patients to two mental-health units contaminated with the highly contagious virus.

Phoenix VA officials said that laboratory-confirmed norovirus has infected 16 patients and 19 staff members. All have recovered except three people who are being treated in a medical unit, VA officials said. The Carl T. Hayden Veterans Affairs Medical Center stopped taking new patients at two mental-health units with 48 beds on the hospital's fifth floor. Veterans who need mental-healthcare will be evaluated at the hospital's emergency department or outpatient clinics, according to VA officials. Those who need inpatient care will be sent to other VA units or to mental-health providers in metro Phoenix.

VA officials have embarked on a cleaning regimen to rid the hospital of the virus. Some steps include limiting staff members who are allowed to access the affected floors and using paper trays to deliver food, according to Phoenix VA Health Care spokeswoman Jean M. Schaefer. The VA also has informed staff and patients about steps they can take to prevent the spread of germs. Visit AZ Central for the story.

 

 

Officials urge testing as Portland, Oregon sees rise in syphilis cases

A spike in syphilis cases in Portland in the past three years has prompted concerned public health officials to urge more sexually active adults to get tested regularly for the treatable bacterial infection. The Portland metro area has seen about 240 new cases of the disease on average each year since 2012, many times more than the 10 to 30 cases that were detected annually before that.

Across the country, incidences of syphilis are on the rise. The Centers for Disease Control and Prevention said last year the number of infections in the United States climbed by more than 10 percent in 2013 to 17,535 cases, compared with the previous year.

"Nationally there's been an increase in syphilis diagnoses but our increase has exceeded the national average," Kim Toevs, a senior manager with the Multnomah County Health Department, said on Tuesday. Health officials in Oregon's biggest city asked the CDC for help last year, she said, and it enlisted social and behavioral scientists, as well as public health physicians, to study what caused the increase.

Syphilis can be cured with penicillin but if left untreated can cause blindness, hearing loss, neurological damage and birth defects in children born to affected mothers. Half of the men with syphilis nationwide also are infected with HIV, according to the CDC. Visit Reuters for the report.

 

 

The ACA’s hospital tax-exemption rules and the practice of medicine

The Affordable Care Act (ACA) and related regulations include obligations for nonprofit (and some government) hospitals to provide benefits, such as free care, to their communities. On their face, these new obligations seem a valuable response to longstanding concerns of some legislators, litigators, and scholars that some nonprofit hospitals are really ‘for-profits in disguise’ and to the related calls to eliminate tax-deductions for gifts to nonprofit hospitals. Moreover, the requirements have been lauded for their potential to improve public health, particularly in leading to better consultation and collaboration with local public health officials.

The ACA, through new Internal Revenue Code §501(r), creates additional conditions for charitable hospitals to qualify for federal income tax exemption and related benefits. To maintain such status, nonprofit hospitals must 1) establish financial assistance and emergency medical care policies, 2) limit charges to patients eligible for assistance under those policies, and 3) make reasonable efforts to identify eligible patients before engaging in extraordinary collection actions against them.

Hospitals must also conduct community health needs assessments and adopt implementation strategies to meet those needs at least once every three years. Although final regulations (released December 31, 2014) offer hospitals slightly more flexibility in defining the relevant community and its health needs than the proposed rules, they still place poverty relief as an important, probably central, consideration.

Hospitals that do not report on and comply with the requirements risk financial penalties in the form of excise taxes ($50,000 on each hospital that fails to meet the new requirements). Hospitals that do not comply with the new regulations also risk losing their tax exemptions altogether.

Many in Congress saw this provision as a way of fostering accountability by nonprofit institutions. In addition, Congress likely intended this section of the law to improve access to care for needy patients. This is a laudable goal, as even after the full implementation of the ACA, the Congressional Budget Office has estimated that approximately 30 million people will remain uninsured. Others will have difficulty making co-payments.

Many advocates suggest that nonprofit hospitals should provide free care equal to the value of their federal tax exemptions. The U.S. Government Accountability Office (GAO) has estimated that tax-exempt status saved hospitals $12.6 billion in federal, state, and local taxes in 2002 ($16.1 billion in 2012 dollars). Other estimates peg the value from $8.5 to $21 billion.

It is estimated that all hospitals combined spend a total of $25.4 billion on uncompensated care, which corresponds to about $16 billion at nonprofits. Including other community benefits such as outreach and education, researchers have estimated that the total accounts for 7.5 percent of operating expenses at nonprofit hospitals. Thus, existing spending might fulfill the new requirements in total. However, spending on uncompensated care is not uniform across hospitals. Some hospitals will have to devote more.

If not from profits or existing uncompensated care programs, where will hospitals get the resources to meet their new obligation? Some of the response could involve converting bad debt (payments that a hospital anticipated but did not receive) into charitable uncompensated care (care for which a hospital never expected to be reimbursed).

Another approach would be for hospitals to add more profitable services, such as diagnostic imaging or invasive cardiac services, to raise revenue to fund the new requirements. There may well be room for growth in provision of these profitable services given that nonprofit hospitals are less likely than for-profit hospitals to provide them. However, many analysts worry that these services are already over provided. This strategy thus raises the risk of overuse of services.

In other cases, nonprofit hospitals may find resources to pay for new requirements through selectively reducing the provision of services that are unprofitable for hospitals, such as psychiatric emergency or trauma care. Since nonprofit hospitals are more likely than comparable for-profits to provide low- or negative-margin services, there will be room to cut here. The losses saved in these areas can then be used to offset the requirement to provide more indigent care in other areas — for example, providing more free services in domains of care that are otherwise profitable to staff. Visit Health Affairs for the report.

 

 

New York City rats carry fleas known to transmit plague

Rats in New York City are brimming with fleas and other parasites that can carry a number of diseases, including the plague, a new study reports. Researchers analyzed 6,500 specimens of five well-known species of fleas, lice and mites found on over 130 rats from around the city.

The samples included Oriental rat fleas, a type of flea that can transmit bubonic plague, also called the Black Death. However, it's important to note that while the researchers found fleas capable of transmitting plague, they didn't find the bacteria that causes the plague in the fleas or rats.

"If these rats carry fleas that could transmit the plague to people, then the pathogen itself is the only piece missing from the transmission cycle," study author Matthew Frye, an urban entomologist at Cornell University in Ithaca, NY, said in a university news release.

In the United States, the plague is found among ground squirrels, prairie dogs and the fleas they carry. About 10 people are infected each year, according to the researchers. However, they said plague is more common in some other parts of the world.

The researchers did find that Oriental rat fleas in New York City carry several species of Bartonella bacteria. This bacteria can cause a wide range of health problems, some of them severe, according to study co-author Cadhla Firth, a research scientist at Columbia University's Center for Infection and Immunity in New York City.

The study is the first of its kind since the 1920s, according to the researchers. Findings from the study were published March 2 in the Journal of Medical Entomology.

The research suggests that public health officials need to closely monitor city rats and the fleas they carry, Frye said. He also urged everyone to take steps to control rat populations. (HealthDay) Visit NIH for the study.

 

 

Do heart surgery patients get too many blood tests?

The high number of blood tests done before and after heart surgery can sometimes lead to excessive blood loss, possibly causing anemia and the need for a blood transfusion, new research suggests.

The study included almost 1,900 patients who had heart surgery at the Cleveland Clinic between January 2012 and June 2012. From the time they first met their heart surgeons until they left the hospital, the patients collectively had more than 221,000 blood tests. That works out to 116 tests per patient, according to the study. The total median amount of blood gathered during an entire hospital stay was about 15 ounces (454 milliliters) per patient, the researchers found.

"We were astonished by the amount of blood taken from our patients for laboratory testing. Total phlebotomy volumes approached 1 to 2 units of red blood cells, which is roughly equivalent to one to two cans of soda," study leader Dr. Colleen Koch of the Cleveland Clinic said. The highest amounts of blood loss occurred among patients undergoing the most complex heart surgeries.

The greater the number of lab tests and the longer patients stayed in the hospital, the more likely they were to require transfusions.

"Prior research shows that patients who receive blood transfusions during heart surgery have more infections after surgery, spend more time on the ventilator, and die more frequently -- even after adjusting for how sick they were prior to surgery," Koch said. "They should inquire whether smaller-volume test tubes could be used for the tests that are deemed necessary. Every attempt should be made to conserve the patient's own blood -- every drop of blood counts," Koch concluded. (HealthDay) Visit US News for the story.

 

 

What are the best hospitals? Rankings disagree

What makes a top hospital? Four services that publish hospital ratings for consumers strongly disagree, according to a study in the journal Health Affairs. No single hospital received high marks from all four services—U.S. News & World Report, Consumer Reports, the Leapfrog Group and Healthgrades—and only 10% of the 844 hospitals that were rated highly by one service received top marks from another, the study published Monday found. The measures were so divergent that 27 hospitals were simultaneously rated among the nation’s best by one service and among the worst by another.

The Health Affairs study didn’t name individual hospitals, but UCLA’s Ronald Reagan Medical Center in Los Angeles was among U.S. News’ top 18 hospitals in the nation in 2013, while receiving a ‘D’ safety rating from Leapfrog that year. Demand for such data is surging, the authors wrote, as consumers increasingly comparison shop for medical services and efforts accelerate to tie payment to the quality of care. But they warned that widely varying definitions of quality could create more confusion than clarity—and make it difficult for hospitals to know where to focus improvements.

“You can go into most towns in America and the local hospital is on somebody’s list of top somethings,” the study’s senior author, Peter Pronovost, said in an interview. “The public deserves much more transparency about what these quality measures mean so it isn’t just a beauty pageant,” added Dr. Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine in Baltimore.

All four services use different rating methodologies, eligibility criteria and data sources and describe their results differently. Consumer Reports calculates a safety score for hospitals from 0 to 100, based on rates of infection, readmissions and other measures. Leapfrog’s Hospital Safety Score assigns hospitals letter grades from A to F, reflecting how well they keep patients from “preventable harm and medical errors.”

Healthgrades calculates an annual list of the country’s 50 and 100 best hospitals, based on mortality and complication rates for a variety of conditions. U.S. News focuses on care for serious conditions and scores hospitals from 1 to 100 in 16 specialties, as well as ranking them nationally and regionally. To compare them, the study authors defined “high performing” as a score of 65 or higher from Consumer Reports; an A from Leapfrog; being listed in Healthgrades’ top 100 and being included in the U.S. News Honor Roll of hospitals with high scores in at least six specialties.

Low performers were those with a score of 30 or lower from Consumer Reports, a D or F from Leapfrog or a score of 10 or lower in at least one specialty from U.S. News. Healthgrades doesn’t list low-performing hospitals.

Officials from each of the services defended their approach and said they publish more detailed information on their websites. Visit the Wall Street Journal for the story.

 

 

Florida ponders life sans subsidies

The Supreme Court will hear arguments in a case, King v. Burwell, that challenges the legality of the subsidies in more than 30 states, including Florida. The case, developed by conservative legal scholars, argues that only people using state-run marketplaces are entitled to subsidies.

If the court agrees -- a decision is expected in June -- subsidies will disappear in states that do not have their own online marketplaces, almost all of which have Republican-led governments that oppose the law and have resisted creating state exchanges.

No state would be more affected than Florida, where more than 1.6 million people have insurance plans under the Affordable Care Act, the most in the nation, and almost all of them receive subsidies. Yet there is little talk of a Plan B here, such as creating a state-run exchange where subsidies would still be available, if the Supreme Court strikes down the subsidy program. Asked about the case last month at the American Action Forum, a conservative advocacy group, Gov. Rick Scott, a Republican, said, "This is not my program." He added, "It's a federal problem."

The issue is particularly significant in southern Florida: All 10 of the ZIP codes with the highest enrollments in the nation are in the Miami and Fort Lauderdale region.

Administration officials, as well as many Democrats in Congress, have also been unwilling to discuss how they would handle a ruling that ended subsidies in most states, preferring to focus attention on Republican opposition to the law. After deflecting questions for weeks about whether the administration had a contingency plan, Sylvia Mathews Burwell, the secretary of health and human services, wrote in a letter to members of Congress on Tuesday that it did not.

Still, some Republican leaders are showing signs that they are worried about the party's liability on the issue. Rep. Paul Ryan of Wisconsin, chairman of the House Ways and Means Committee, and Sen. Orrin Hatch of Utah, chairman of the Senate Finance Committee, have announced that they are working on ways to help people who might lose subsidies. And last week, former Sen. Phil Gramm of Texas warned his fellow Republicans in an opinion article in The Wall Street Journal that they would face "enormous" political pressure to address the loss of subsidies if the court ruled against the administration.

In Florida, insurance agents and health advocacy groups have worked tenaciously to enroll people in coverage, with colorful marketing and outreach campaigns. Partly as a result, healthcare experts say, Florida's rate of uninsured residents -- among the nation's highest in 2013, at 22.1 percent -- dropped to 18.3 percent last year, according to the Gallup-Healthways Well-Being Index. Should the subsidies be blocked, elected officials may also come under pressure from insurers, 14 of which sell plans through the federal marketplace in Florida, and providers.

Brian E. Keeley, the president and chief executive of Baptist Health South Florida, which has seven hospitals around the region, said he found it maddening that neither political party had offered a workaround. (New York Times) Visit the Herald Tribune for the article.