(A quick PubMed search did corroborate the disease’s rarity, revealing only 27 articles ever published on it. The most recent case report, from 2005, noted that only 67 cases have been reported world-wide.)
Yet, Health Net, the family’s managed care organization, has resisted four appeals to authorize payment to Dr. MacKenzie.
Chronicle columnist, C. W. Nevius, wrote, “HMOSs never want to hear about rare diseases.” He quoted a local health care advocate, “When you have to fly a patient out to the East Coast, it is a fundamental HMO no-no. It is the M.O. [modus operandi] of health care providers [presumably meaning HMOs] to deny access to expensive treatments. They give you the runaround and hope you go away.”
The HMO in question, Health Net, which initially failed to respond to Nevius’ requests for comments, apparently was not moved by a note from the patient’s primary care physician that “it is imperative” that he see the East Coast specialist. The Chief of Pediatric Orthopedics of University of California- San Francisco, Dr. Mohammad Diab, admited he had no experience with the necessary surgery, but suggested it be done fast, “the door is closing, if not closed.”
After the story appeared in the Chronicle, Health Net partially relented, according to Nevius’ next column, authorizing a consultation with the specialist, but no further treatment. David Olson, the Senior Vice President for Corporate Communications, dismissed the notion that the patient is in imminent danger, calling it a “typical lawyer ploy. There is nothing in the record to indicate that something has to happen right now.”
This sort of heavy-handed approach to cost-containment is what sparked the anti-managed care backlash in the 1990’s. As is usual for managed care, the emphasis seems to be on restricting access to care, rather than on bargaining down the costs of egregiously high-priced goods and services.
Moreover, focusing on restricting treatments for patients with rare diseases will almost never be truly evidence-based, because rare diseases will not be subject to studies of sufficient statistical power to demonstrate that particular treatments will not work. But focusing on such restrictions will not even save much money in the aggregate, since rare diseases are, well, rare.
So the main result of this approach will be to reinforce managed care’s reputation for heartlessness. In the case of Health Net, it seems particularly distinct from the preamble to the company’s statement about business conduct and ethics, “Health Net, Inc. is dedicated to helping people be healthy, secure and comfortable. To succeed in our mission, we must maintain our customers’ trust….”
Perhaps managed care would do better if it were lead by people who have some knowledge of the clinical context. In contrast, Mr. David Olson, the one Health Net official who has spoken publicly about this case, according to his his official biography seems to have no obvious direct health care experience. Mr. Olson is now responsible “for the company’s investor relations function and internal and external communications, and also oversees government relations and charitable contributions.” He previously served as “vice president, Investor and Public Relations, for Health Systems International, Inc. (HSI),” and ” vice president, Corporate Communications for National Medical Enterprises, Inc. (NME), having joined NME in 1989 as director of Shareholder Communications.” His only academic qualifications are “a BA in English from Washington and Lee University.” Maybe he needs to talk to a doctor.
Such cases, with their recitations of monetary amounts and repeated public relations talking points, can be rather dry. So this week we present another case which is a bit more colorful.
The Reliably High Pay of the CEO of Bronx-Lebanon Hospital
The CEO of the Bronx-Lebanon Hospital in New York City has long been criticized for receiving millions from a hospital which mainly serves the poor.
In 2009, the New York Post published an article entitled “Sickening Bonuses” about how
hospital presidents and CEOs … collect fat bonuses and ‘incentive payments,’ even as health-care systems cry poverty,…
In particular it noted that presumably pre the 2008 global financial crisis:
A $1.2 million bonus went to Miguel Fuentes Jr., CEO of the 958-bed Bronx-Lebanon Hospital. His $4.8 million package included $878,024 in salary and an $858,000 pre-retirement payout. He’s also set to get $1.8 million in retirement cash next year.
In 2013, after the great recession, the New York World reported on a measure proposed by New York Governor Andrew Cuomo to cap salaries at hospitals that receive significant amounts of money from Medicaid. It stated:
The hospitals that will be targeted by Cuomo’s salary cap sit in poorer neighborhoods and serve large volumes of patients who depend on Medicaid. They include Bronx-Lebanon Hospital Center,…
At that time it was known that Mr Fuentes still was making a lot of money, although less than before:
Bronx-Lebanon Hospital Center … President and CEO Miguel Fuentes made more than $1.7 million in 2011, according to tax records….
In 2014, Modern Healthcare published an article that questioned whether hospital CEO pay was justified by their or their hospitals’ performance. In particular, it quoted a JAMA Internal Medicine article that:
found no association between CEO pay and very important benchmarks, including a hospital’s ‘margins, liquidity, capitalization, occupancy rates, mortality rates, readmission rates, or measures of community benefit.’
Researchers found wide variation in what trustees chose to pay the CEOs of their not-for-profit hospitals.
It also noted
One community hospital is a perennial on the list [of those with highly paid executives]. Bronx-Lebanon Hospital Center’s Miguel Fuentes Jr. has spent decades at his institution, and arguably needs no retention pay. His $1.8 million package includes about $200,000 in a supplemental retirement plan payment.
So what does a CEO have to do to earn millions at a safety-net hospital? Hospital boards and public relations officials often justify high CEO with standard talking points: their CEOs are brilliant, and such brilliant people must be paid well to be recruited and retained (look here). However, I found no published record of any attempt to probe justifications for this particular CEO’s pay. Mr Fuentes does seem to have won an award from the local YMCA for “outstanding leadership” (look here). In a 2015 news release about an affiliation between the Mount Sinai Health System and Bronx-Lebanon, the hospital was described as
a remarkable institution that has shown leadership through its commitment to delivering high quality care to patients and the communities in the Bronx
But I could not find anything in public about the particulars of this outstanding leadership.
Allegations of Organized Crime Ties
On the other hand, in June, 2017, the New York Post published two articles suggesting that Mr Fuentes’ leadership might be a bit more dubious than advertised above.
The first article, published June 4, 2017, included allegations of shady dealings between the hospital and organized crime:
The mob turned taxpayer-backed Bronx-Lebanon Hospital expansion into its own piggy bank.
Construction expenses at the hospital’s new nine-story outpatient center ballooned by some $5 million — with cash allegedly ending up in the pockets of the Lucchese crime family and hospital executives, The Post has learned.
Lucchese underboss Steven ‘Wonder Boy‘ Crea Sr. and associate Joseph Venice were charged with wire and mail fraud in connection with the project at ‘a major New York City hospital,’ according to a federal indictment unsealed last week in a major mob takedown. But the document didn’t identify the hospital or reveal the scheme’s dirty details.
No Bronx-Lebanon executives were named in the indictment, but the federal probe, which began four years ago, is ongoing, and focused on hospital honchos whose palms may have been greased.
Crea, 69, had close ties to Sparrow Construction, the Bronx firm in charge of building the $42 million annex at Bronx-Lebanon. He was a regular visitor to the firm’s offices while the center was under construction, a source told The Post.
Crea worked for Sparrow before he was busted in a 2000 state racketeering case. At that time, he was considered the acting boss of the Luccheses.
Work began on the outpatient center in 2009 and was supposed to take 19 months. But the Health and Wellness Center wasn’t finished until 2014 and was plagued with cost overruns.
Sparrow was the general contractor and billed the hospital $26 million for only $21 million worth of work, sources told The Post.
The heating and ventilation system cost $2.3 million to install. Yet ‘the hospital still paid somebody $5 million’ for it, the source said.
The alleged scheme was carried out through falsified invoices and change orders, the source said.
‘The hospital didn’t question one change order,’ the source said.
The bulk of the project was paid for through the sale of $36 million in state Dormitory Authority bonds. The hospital is paying back the Dormitory Authority over 25 years.
At the end of the article we found that Mr Fuentes’ compensation has remained large, and stable.
Longtime CEO Miguel Fuentes’ total compensation came to $1.7 million in 2015, according to its latest tax filings.
But it added that he has had a lifestyle to match:
Fuentes lives a luxury lifestyle with a condominium on the Upper East Side and a Southampton retreat with a pool.
Allegations of Unethical Conduct to Enhance Revenue
A second article published June 24, 2017, raised further questions about Mr Fuentes’ management. First, it questioned his direct appointment of a chief of orthopedic surgery.
Hospital CEO Miguel Fuentes hired [Dr Ira] Kirschenbaum as a division chief without consulting Dr. John Cosgrove, who was then chief of surgery and would have overseen him, Cosgrove told The Post.
Cosgrove said he did not have a chance to vet Kirschenbaum.
The article suggested that Dr Kirschenbaum was hired to push “moneymaking surgeries such as hip and knee replacements.”
The hospital lavished six-figure bonuses to its chief of orthopedics, Dr. Ira Kirschenbaum, despite brass being told of four deaths after he arrived in 2008 and about others patients who suffered serious complications, according to sources.
Kirschenbaum received a $314,210 bonus in 2014 and a $180,940 bonus in 2015, according to Bronx-Lebanon’s tax filings. The extra pay came on top of his $851,000 salary.
Seven hospital employees, who identified themselves as doctors, nurses and technicians, sent The Post a copy of a letter they said they presented to a state medical disciplinary panel to complain about patients more recently injured under Kirschenbaum’s care — including one who allegedly lost a leg.
The letter was sent anonymously, and the state Health Department would not comment on any complaints to the Office of Professional Medical Conduct.
Furthermore, Dr Cosgrove, who appears to have become a whistleblower, alleged dodgy payments to hospital employed physicians at the behest of Mr Fuentes, apparently to increase patient volume.
Cosgrove also said he saw another troubling practice at the hospital: bonus payments of up to $60 paid to doctors for each visit made to the institution’s clinics — in order to tout that it treated 1 million patients annually. The hospital realized that number in 2012, according to the MD.
‘Seeing a patient in the clinic is your obligation as a hospital physician and that should not be incentivized,’ Cosgrove said. ‘Mr. Fuentes said at many meetings he wanted to hit a million-visit mark at their 55-or-so outpatient clinics.’
Doctors were already paid salaries by Bronx-Lebanon, and the clinic bounties came from the Medicaid reimbursements, according to Cosgrove.
Such an incentive system was ripe for abuse because it could entice doctors to schedule additional, and possibly unnecessary, visits, he said.
‘It’s really counter to what we as doctors stand for,’ said Cosgrove, who left the hospital in 2013 and is now chief of surgery at Eastern Long Island Hospital.
Finally,the article reiterated Mr Fuentes’ total compensation of $1.7 million in 2017, but added that
He has a car and a driver — and a source described a $20,000 glass-and-tile shower for his office bathroom. The shower was removed because of concerns over how such an amenity might appear, the source said.
Fred Miller, a hospital lawyer, said Bronx-Lebanon doctors were not paid clinic bonuses, only salaries, and that compensation was ‘consistent with Medicare/Medicaid principles.’
Miller acknowledged that a shower had been installed, but called it ‘modest’ and disputed its cost.
So the CEO of Bronx-Lebanon Hospital has been paid more than a million a year since at least 2008 (and much more than that in 2008 before the great recession), without any apparent public explanation for this pay, and particularly without any apparent attempts to justify it based on quality of care or clinical outcomes. Yet recently there have been allegations that the CEO was directly involved with efforts to increase revenue regardless of ethical or patient safety concerns. Worse, there have also been allegations that organized crime has been allowed to create a “piggy bank” out of the hospital, perhaps in ways also benefiting top executives, although none of this has been proven in a court of law.
Nonetheless, it seems that high executive pay in health care, particularly at non-profit institutions serving the poor, should be justified by more than lack of proof that the executives broke the law. In fact, how could anyone justify paying the CEO of a non-profit hospital that primarily serves the poor using government money unless that person had a sterling record of accomplishment promoting the quality of clinical care at his or her institution, accompanied by integrity and accountability?
Instead, we get questions of mob influence and $20,000 showers.
So here we go again….
We will not make any progress reducing current health care dysfunction
if we cannot have an honest conversation about what causes it and who
profits from it. True health care reform requires publicizing
who benefits most from the current dysfunction, and how and why. But it
is painfully obvious that the people who have gotten so rich from the
current status quo will use every tool at their disposal, paying for
them with the money they have extracted from patients and taxpayers, to
defend their position. It will take grit, persistence, and courage to
persevere in the cause of better health for patients and the public.
As a person ages, we notice that some seem frail early in life yet others continue as vital for decades. Is there a way to detect frailty onset or even potential lifespan? There may be with a simple gait test.
New research suggests that “gait speed” can predict survival. The test is simple. Have the person walk a four meter distance starting from a standing still position. Measure the time with a stop watch. Speeds of greater than 1.0m/sec closely associates with healthier aging. Below 0.6m/sec correlates with poor health and less functional capability. A breakpoint of about 0.8m/sec separates individuals who will survive for less than or more than the median. Over 1m/sec suggests better than average survival and over 1.2m/sec suggests an even greater survival advantage. These are from a Jan 5, 2011 publication by Dr. Stephanie Studenski and colleagues in the Journal of the American Medical Association.
Fragility may seem to be just a subjective observation but, as I posted previously, there is a real science to frailty measurement.
Those predicted to live another five to ten years or more might be given greater consideration for preventive measures that normally take years to achieve a benefit. On the other hand, those with high risk for a short life span might be considered further for what modifiable circumstances could be adjusted to the patient’s benefit.
The data for these analyses were from nine studies conducted from 1986 to 2000. Each study had over 400 older participants, each community dwelling, whose gait speed was recorded and then followed for survival for five plus years. The graphic will illustrate the findings.
These data help to differentiate the old (based on age) from the geriatric (based on biology). In an accompanying editorial, Dr. M. Cesari points out that not only is it useful to make this differentiation in older individuals but in other groups as well. For example in oncology practices, it is well known that performance status predicts outcome. Restated, those with low performance scores should normally not be treated with aggressive chemotherapy (the exception is in certain well defined situations) because the side effects are likely to outweigh the possible benefits. Surgeons, likewise, need to know who might be likely to encounter an adverse outcome. Gait speed might prove a useful way to select out who should likely not have chemotherapy or who should likely not have elective major surgery. Cesari points out that gait speed is not just a measure of leg function. It probably is a marker of a generalized physiologic function that correlates with health status.
Gait speed may become a marker to differentiate the chronologically old from the functionally geriatric. Check out your own rate.
The Board of Health has scheduled a public hearing for April 19, 2017 regarding adoption of the proposed changes. Details regarding that public hearing may be viewed at: https://www.colorado.gov/pacific/cdphe/draft-regulations
Laurie Schoder, 303-692-2832, firstname.lastname@example.org
Why? I have some theories.
The speed of developing the vaccine seems by many to have been rushed. Instead of being impressed that a novel influenza virus could be identified, sequenced, and subsequently developed into a vaccine seemed to escaped many. Does anyone remember the SARS / avian flu virus that caused problems in Asia a few years ago? No vaccine was developed as far as I know. When we watch and read about stories online and have no personal experience with the flu, then we become detached from the reality. It can’t happen to me mentality.
I suspect that when faced with a choice of possibly getting a pandemic virus verus the reality of getting a real novel vaccine now and whatever problems it may or may not have (and really the vaccine should be as safe as previous flu vaccines), people not surprisingly are uneasy about rolling up their sleeves for the latter.
I would also suggest that the same type of denial occurs with other preventive measures like screening for cancer and is why many people don’t get mammograms for breast cancer screening or flexible sigmoidoscopies / colonoscopies for colon cancer screening. People would rather wait until they have symptoms and then deal with the consequence, even if they are life threatening and when medical science often has no answers.
As for the H1N1 vaccine, clinical trials are already occurring in Australia which is in the middle of flu season. Safety data will come out eventually but probably not in time to allow people to truly have informed consent. It is expected that the H1N1 vaccine will be available in October.
Almost no one worried about the H1N1 uses the paralyzing condition – Guillian Barre as a reason for skipping the vaccine. Gullian Barre is a legitamate concern as a few hundred cases occurred in 1976 when a flu epidemic occurred at the Fort Dix military base. CDC found since then that the risk of Guillian Barre is small (about 1 in 1 million are potentially at risk), but there has been no strong link between flu vaccine and the condition.
Recommendations by CDC suggest that those who need H1N1 vaccination are individuals age 24 years old and younger down to 6 months old, caregivers watching children 6 months and younger, as well as those ages 25 to 65 years old who have chronic illnesses and pregnant women. Many of my older patients don’t wish to have the vaccine do so on altruistic grounds, which I find rather amazing in a society where the current generation seems more focused on “me” rather than “we”.
While it is true that people 65 years and older who are otherwise healthy don’t the H1N1 vaccine, patients don’t necessarily appear relieved when I tell them this. They seem more skeptical that the science shows they are at least risk.
I don’t blame them. For years we tell those who are vulnerable, typically those who are younger and those who are older, to get vaccinated. (Recall that when there was a flu vaccine shortage a few years ago due to a manufacturing problem that President George W. Bush was on television urging Americans who were otherwise healthy to skip the shot as he was). Now, we are saying “over 65 and healthy? Don’t need the H1N1 vaccine”. Though my patients don’t appeared to be swayed about allegations of “death panels” and rationing of medical care based on age which have appeared with the healthcare reform debate, one could understandably be suspicious about the H1N1 recommendations and the absence of including the elderly.
What to do?
At least get the typical seasonal flu vaccine which is available now (local grocery stores have it). The flu kills 36,000 Americans annually.
Think about getting the H1N1 vaccine if you are supposed to. The process of producing the vaccine is similar to that of prior vaccines. It has been more difficult to produce and as a result it requires two shots rather than one.
Still on the fence? Talk to your doctor. Check out the CDC’s website for the latest information.
The leading cause of death for male gorillas in zoos is heart disease. Sadly, animals that live in close contact with (and fed by) humans end up with human chronic diseases.
Gorillas are the largest of the primates, and they are one of the four species of great apes (great apes make up the Hominidae superfamily, which includes chimpanzees, bonobos, orangutans, and gorillas). Following chimpanzees, gorillas are the closest living relatives to humans, differing in only about 3% of our genetic makeup.
Gorillas are herbivores that live in the forests of central Africa, where they can eat up to 50 pounds of vegetation each day, mostly leaves and fruit. Although most gorillas have a preference for fruit, they also eat large amounts of leaves, plus herbs and bamboo, and occasionally insects. In the wild, gorillas spend most of their day foraging and eating.1 Read more…
Sleep has a definite purpose and that is why all mammals sleep. Lack of sleep apparently does not cause any physical harm. But anyone who gets less than his normal sleep experiences a decrease of efficiency and concentration.
In old age, sleep normally becomes fitful. It is good to regulate sleeping hours. One should go to bed at a fixed time. The human body maintains a 24-hour cycle. During this cycle, the body temperature rises and falls at fixed times. In the middle of the night, the body temperature comes down. In the afternoon, it reaches its maximum. It is comfortable to be sleeping when the body temperature is at its lowest. If someone is compelled to be awake by the circumstances at his time, he would not feel physically and mentally at his best.
The most common cause of insomnia is worry; the other is depression. Environmental disturbances also cause lack of sleep. Loss of sleep often results in fatigue and quickly impairs a person’s normal judgment. The higher centers of the brain are the first to show the effects of overwork and anxiety. Such a person may become depressed, losing all interest in life and burdened with a sense of impending death. Unreasonable fears now arise to the surface of his mind, causing all kinds of anxiety and distress, as well sensation of acute pain.
Sleeping pills should be avoided. Sleeping pills taken over a long period disturb the second phase of the normal sleep, the rapid eye movement phase and thus cause harm to the person consuming them. Moreover, the effect of the drugs may last beyond the normal time for waking up and thus cause a reduction in efficiency and concentration. Sleeping pills mixed with alcohol can even be fatal. Patient should practice some technique to relax. Yoga can help or listening to music
HOME REMEDIES FOR INSOMNIA
* It may be good, however, not to overload the stomach with food before going to sleep. A heavy meal disturbs sleep.
* A bath before going to bed is of positive help and so is exercise in the afternoon.
* In order to get good sleep taking a cup of hot milk before going to bed is a useful habit.
* Late nights affect health most adversely because, after 10:30 p.m., the body requires rest and sleep while a late dinner, social function or a musical evening running into morning hours disturb the sleep patterns which is most suitable to the human body.
* Stimulants brews like coffee or tea should be avoided in the late evening. Coffee after dinner has an adverse effect on sleep. Smoking of cigarettes also stimulates and thus keeps us awake.
* The sleeping environment should be as comfortable as possible, neither too hot nor too cold. Beds, which are too soft, are not conducive to sound sleep. The bed should be firm, hard and of a proper size.
* Drinking Kava kava a few hours before bedtime reduces stress, tension, anxiety and relaxes muscles. It helps to fall asleep deeper and to rest more.
* A very effective insomnia home remedy is – Prepare a mixture by adding1 tsp. chamomile flowers,1 tsp. Hops,1 tsp. valerian root and1 cup of boiling water. Steep for 45 minutes, strain and drink 1 hour before bedtime.
* Wake up at the same time everyday no matter when you got to sleep.
* Avoid high protein meals for dinner; instead try to take complex carbohydrates in the dinner.
* Drink a cup of warm milk with honey, nutmeg can also be added. The tryptophan in milk helps in sleeping.
* Thiamine or vitamin B is of special significance in the natural cure for insomnia.
* Lettuce is beneficial in the treatment of insomnia as it contains a sleep-inducing substance, called ‘lectucarium’. Boil one tablespoon of seeds in half a litre of water, till it is reduced by one-third. It is very useful in preventing insomnia.
* The patient should take plenty of curd and massage it on the head. This will induce sleep.
* The mixture of bottle gourd juice and sesame oil in 50:50 ratio acts as an effective medicine for insomnia.
* Prepare a tea by boiling about 375 ml of water in a vessel and adding a teaspoon of aniseed. The water should be covered with a lid and allowed to simmer for fifteen minutes. It should then be strained and drunk hot or warm. The tea may be sweetened with honey, and hot milk may also be added to it. This tea should be taken after meals or before going to bed. This is very effective home remedy for insomnia.
* Honey is also an effective remedy to induce sleep. Two teaspoonful of honey should be mixed in warm water and taken before going to bed.
* Take 1 tsp juice of celery leaves with stalks and 1 tsp of honey.
* Have raw onion salad in the dinner.
* Take 2 tsp of fenugreek leaves juice with 1 tsp of honey at bed times daily
* Prepare a mixture by adding two tablespoons of apple cider vinegar with one cup of honey and store this mixture in an airtight container. Take two spoonful of this mixture whenever necessary. This is also very effective home remedy for insomnia.
* Sleeping with your head pointing north can improve the quality of your sleep
Are the skinny jeans just seated within the back again of the closet? Learn techniquestechniques to . Uncover how you can increase metabolic processmetabolic rate although going on a diet and working outexercising. Choose the correct strategy for you personally and obtain back again into individualsthese skinny jeans, for existencelifestyle! Do not starve your self, diet plan wholesome.
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