Is response time the best way to judge ambulance services?

Tom Kimball, described as a Boston-area paramedic who will be  attending medical school this fall posed that question in a Boston Globe opinion piece this weekend. ambulances

Many cities and towns in Massachusetts still judge the performance of their ambulance services using metrics like response times, which can miss the point. An additional two minutes waiting for an ambulance will rarely make a difference for a trauma patient facing emergency surgery that may take hours.

Patient outcome is a more valuable measure of whether a medical service is doing right by people. In many areas of health care these days, it is the gold standard, a key factor in determining how much insurance companies pay service providers. Changing the terms of ambulance companies’ contracts to make good patient outcomes the goal could greatly improve the quality of medical care across the state — and save lives.

ProPublica: Yelp, #Health and #Privacy


Stung by Yelp Reviews, Health Providers Spill Patient Secrets

by Charles Ornstein ProPublica, May 27, 2016, 11 a.m.

CaptureBurned by negative reviews, some health providers are casting their patients’ privacy aside and sharing intimate details online as they try to rebut criticism.

In the course of these arguments 2014 which have spilled out publicly on ratings sites like Yelp 2014 doctors, dentists, chiropractors and massage therapists, among others, have divulged details of patients’ diagnoses, treatments and idiosyncrasies.

One Washington state dentist turned the tables on a patient who blamed him for the loss of a molar: “Due to your clenching and grinding habit, this is not the first molar tooth you have lost due to a fractured root,” he wrote. “This tooth is no different.”

In California, a chiropractor pushed back against a mother’s claims that he misdiagnosed her daughter with scoliosis. “You brought your daughter in for the exam in early March 2014,” he wrote. “The exam identified one or more of the signs I mentioned above for scoliosis. I absolutely recommended an x-ray to determine if this condition existed; this x-ray was at no additional cost to you.”

And a California dentist scolded a patient who accused him of misdiagnosing her. “I looked very closely at your radiographs and it was obvious that you have cavities and gum disease that your other dentist has overlooked. 2026 You can live in a world of denial and simply believe what you want to hear from your other dentist or make an educated and informed decision.”

Health professionals are adapting to a harsh reality in which consumers rate them on sites like Yelp, Vitals and RateMDs much as they do restaurants, hotels and spas. The vast majority of reviews are positive. But in trying to respond to negative ones, some providers appear to be violating the Health Insurance Portability and Accountability Act, the federal patient privacy law known as HIPAA. The law forbids them from disclosing any patient health information without permission.

Yelp has given ProPublica unprecedented access to its trove of public reviews 2014 more than 1.7 million in all 2014 allowing us to search them by keyword. Using a tool developed by the Department of Computer Science and Engineering at the NYU Tandon School of Engineering, we identified more than 3,500 one-star reviews (the lowest) in which patients mention privacy or HIPAA. In dozens of instances, responses to complaints about medical care turned into disputes over patient privacy.

The patients affected say they’ve been doubly injured 2014 first by poor service or care and then by the disclosure of information they considered private.

The shock of exposure can be effective, prompting patients to back off.

“I posted a negative review” on Yelp, a client of a California dentist wrote in 2013. “After that, she posted a response with details that included my personal dental information. 2026 I removed my review to protect my medical privacy.”

The consumer complained to the Office for Civil Rights within the U.S. Department of Health and Human Services, which enforces HIPAA. The office warned the dentist about posting personal information in response to Yelp reviews. It is currently investigating a New York dentist for divulging personal information about a patient who complained about her care, according to a letter reviewed by ProPublica.

The office couldn’t say how many complaints it has received in this area because it doesn’t track complaints this way. ProPublica has previously reported about the agency’s historic inability to analyze its complaints and identify repeat HIPAA violators.

Deven McGraw, the office’s deputy director of health information privacy, said health professionals responding to online reviews can speak generally about the way they treat patients but must have permission to discuss individual cases. Just because patients have rated their health provider publicly doesn’t give their health provider permission to rate them in return.

“If the complaint is about poor patient care, they can come back and say, 2018I provide all of my patients with good patient care’ and 2018I’ve been reviewed in other contexts and have good reviews,’ ” McGraw said. But they can’t “take those accusations on individually by the patient.”

McGraw pointed to a 2013 case out of California in which a hospital was fined $275,000 for disclosing information about a patient to the media without permission, allegedly in retaliation for the patient complaining to the media about the hospital.

Yelp’s senior director of litigation, Aaron Schur, said most reviews of doctors and dentists aren’t about the actual health care delivered but rather their office wait, the front office staff, billing procedures or bedside manner. Many health providers are careful and appropriate in responding to online reviews, encouraging patients to contact them offline or apologizing for any perceived slights. Some don’t respond at all.

“There’s certainly ways to respond to reviews that don’t implicate HIPAA,” Schur said.

In 2012, University of Utah Health Care in Salt Lake City was the first hospital system in the country to post patient reviews and comments online. The system, which had to overcome doctors’ resistance to being rated, found positive comments far outnumbered negative ones.

“If you whitewash comments, if you only put those that are highly positive, the public is very savvy and will consider that to be only advertising,” said Thomas Miller, chief medical officer for the University of Utah Hospitals and Clinics.

Unlike Yelp, the University of Utah does not allow comments about a doctor’s medical competency and it does not allow physicians to respond to comments.

In discussing their battles over online reviews, patients said they’d turned to ratings sites for closure and in the hope that their experiences would help others seeking care. Their providers’ responses, however, left them with a lingering sense of lost trust.

Angela Grijalva brought her then 12-year-old daughter to Maximize Chiropractic in Sacramento, Calif., a couple years ago for an exam. In a one-star review on Yelp, Grijalva alleged that chiropractor Tim Nicholl led her daughter to “believe she had scoliosis and urgently needed x-rays, which could be performed at her next appointment. 2026 My daughter cried all night and had a tough time concentrating at school.”

But it turned out her daughter did not have scoliosis, Grijalva wrote. She encouraged parents to stay away from the office.

Nicholl replied on Yelp, acknowledging that Grijalva’s daughter was a patient (a disclosure that is not allowed under HIPAA) and discussing the procedures he performed on her and her condition, though he said he could not disclose specifics of the diagnosis “due to privacy and patient confidentiality.”

“The next day you brought your daughter back in for a verbal review of the x-rays and I informed you that the x-rays had identified some issues, but the good news was that your daughter did not have scoliosis, great news!” he recounted. “I proceeded to adjust your daughter and the adjustment went very well, as did the entire appointment; you made no mention of a 2018misdiagnosis’ or any other concern.”

In an interview, Grijalva said Nicholl’s response “violated my daughter and her privacy.”

“I wouldn’t want another parent, another child to go through what my daughter went through: the panic, the stress, the fear,” she added.

Nicholl declined a request for comment. “It just doesn’t seem like this is worth my time,” he said. His practice has mixed reviews on Yelp, but more positive than negative.

A few years ago, Marisa Speed posted a review of North Valley Plastic Surgery in Phoenix after her then20133-year-old son received stitches there for a gash on his chin. “Half-way through the procedure, the doctor seemed flustered with my crying child. 2026,” she wrote. “At this point the doctor was more upset and he ended up throwing the instruments to the floor. I understand that dealing with kids requires extra effort, but if you don’t like to do it, don’t even welcome them.”

An employee named Chase replied on the business’s behalf: “This patient presented in an agitated and uncontrollable state. Despite our best efforts, this patient was screaming, crying, inconsolable, and a danger to both himself and to our staff. As any parent that has raised a young boy knows, they have the strength to cause harm.”

Speed and her husband complained to the Office for Civil Rights. “You may wish to remove any specific information about current or former patients from your Web-blog,” the Office for Civil Rights wrote in an October 2013 letter to the surgery center.

In an email, a representative of the surgery center declined to comment. “Everyone that was directly involved in the incident no longer works here. The nurse on this case left a year ago, the surgeon in the case retired last month, and the administrator left a few years ago,” he wrote.

Reviews of North Valley Plastic Surgery are mixed on Yelp.

Health providers have tried a host of ways to try to combat negative reviews. Some have sued their patients, attracting a torrent of attention but scoring few, if any, legal successes. Others have begged patients to remove their complaints.

Jeffrey Segal, a onetime critic of review sites, now says doctors need to embrace them. Beginning in 2007, Segal’s company, Medical Justice, crafted contracts that health providers could give to patients asking them to sign over the copyright to any reviews, which allowed providers to demand that negative ones be removed. But after a lawsuit, Medical Justice stopped recommending the contracts in 2011.

Segal said he has come to believe reviews are valuable and that providers should encourage patients who are satisfied to post positive reviews and should respond 2014 carefully 2014 to negative ones.

“For doctors who get bent out of shape to get rid of negative reviews, it’s a denominator problem,” he said. “If they only have three reviews and two are negative, the denominator is the problem. 2026 If you can figure out a way to cultivate reviews from hundreds of patients rather than a few patients, the problem is solved.”

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Under #ACA and #IRS rules, hospitals to play larger role in public health #NEU

Gary Young, director of the Northeastern University Center for Hstate houseealth Policy and Healthcare Research in Boston spoke to me for my quality column in Health Leaders Media this week.  The column looked at the role social services play in promoting health.

He said the Accountable Care Act’s  Community Health Needs Assessment requirement is intended to integrate hospitals more tightly into the public health Infrastructure. They’re already required to  demonstrate “community benefit” spending to the IRS.  Compliance with that requirement is spotty.

As it is, Young’s research team recently reported wide variation in community benefit spending by hospitals. 

“Hospitals have always been focused on treatment and not prevention and promotion,” Young says. “That’s what they’ve been paid to do. From a cultural standpoint, that’s the orientation of hospitals. “

They do not have the infrastructure—intellectual or material—to deal with community health, he says. However, they are facing a paradigm shift.  

The Health Wonk Review: HIT, LGBT and ACA

No sorting this edition of the Health Wonk Review into categories. They cover the range:  insurance, HIT, report cards, LGBT health and cancer. Along with this collection of health policy blog posts, we offer a little color from the former home of the Hospital de la Santa Creu i Sant Pau in Barcelona.

Find a Twitter list of contributors here.

barcelona backup 207112014 (35)

Sant Rafael Pavilion

At Workers’ Comp Insider, Tom Lynch talks about Oklahoma, fracking, earthquakes and Obamacare: In Oklahoma, The Times, They Are A’Changin’.

Are Bronze level plans on the chopping block? InsureBlog’s Henry Stern offers evidence that this may soon be the case.

Brookings & Ponemon on Privacy & Security: Meet the Experts: David Harlow shares some highlights from two recent research reports on the state of health data privacy and security, one qualitative and the other quantitative. In all, about 200 covered entities and business associates were surveyed, and with the promise of anonymity offered some candid observations, suggestions and rants.



Sant Rafael Pavillion, old and updated view

From Charles Gaba at ACA Signups: Presenting the ACA Signups 2017 Requested Rate Hike Challenge. Last year I spent gobs of time tracking down the requested 2016 individual market rate hike requests and compiling them into statewide and nationwide weighted averages…This year I’m doing it again, but with some crowdsourcing added.


Roy Poses at Health Care Renewal asks: Who Benefits? – Hospital Profits and Quality May Fall, But Hospital Executives’ Compensation Keeps Rising Here is the latest roundup of cases in which non-profit hospitals’ top executives compensation continued to rise despite their institutions’ financial or clinical setbacks.  As usual, the executives, their boards of trustees, and/or their hired spokespeople defended their ever increasing riches with familiar talking points. 

From Brad Flansbaum of The Hospital Leader: Why he punts on hospital report cards.

Peggy Salvatore at Health System Ed offers: Prompted by an excellent blog last time by Anthony Wright at Health Access on the political realities of implementing single payer, we had a little bit of a discussion last week on the HWR podcast. This week an article by some Harvard physicians keeps the topic alive. 


Images projected on tunnel walls

In a post entitled Obamacare’s anti-discrimination protections fortified, Amy Lynn Smith at explains how the HHS-issued final rule on Section 1557 of the Affordable Care Act has removed one more roadblock to full healthcare equity for the LGBT community. 

Is High Prescription Drug Spending Becoming Our New Normal? On Health Affairs Blog, Leigh Purvis and Crystal Kuntz examine the rise of specialty drugs, the lack of meaningful price competition for biologics, and the current research pipeline and market and suggest next steps for addressing these trends.  

David Williams at the Health Business Blog offers: Due diligence in middle market healthcare investing  I share my perspective on the special case of commercial due diligence of mid-sized healthcare firms, where the issues can be complex and information is hard to come by.

Hospital visitor

Sant Jordi Pavilion

Jason Shafrin at The Healthcare Economist provides an overview of 5 different approaches for designing a cancer value framework in the latest issue of JAMA.

Colorado Health Insurance Insider offers: Simple Choice plans in the federally facilitated exchange.  Louise Norris wonders about the “Simple choice plansfrom a CMS blog post and how they differ from what has been finalized about Standardized plans in February in the 2017 Benefit and Payment Parameters.

Joe Paduda offers a quick review of Sec. Clinton’s proposed health care reforms = Medicare for some, consumer cost caps, and more Medicaid.

Finally, while still blogging here, find my most recent work at Health Leaders Media, where I write a weekly column on quality of care.

Photos © Tinker Ready


Boston surgeons can help patients get a new penis, or lose the old one

CaptureNot at the same place. Both the Globe and WBUR report today on Boston Medical Center’s new male-to-female gender reassignment surgery program. News comes just after MGH’s announcement of the first penis transplant.

From the Globe

Boston Medical Center plans to become the first hospital in Massachusetts — and one of a few in the country —to offer gender reassignment surgery, responding to a growing and unmet demand for treatment in the transgender community.

The hospital said more than 100 patients have already signed on to a waiting list to be evaluated for surgery — even before it has widely publicized the program. Boston Medical Center has long provided primary care, mental health services, and hormone therapy for transgender men and women, and most of the patients considering surgery are from the Boston area. Capture2Across the country, many hospitals have been reluctant to offer male-to-female and female-to-male genital surgeries, but health care providers said that is slowly changing as insurance coverage expands and public acceptance of transgender people grows.


Do we need to learn to live with sponsored health care content?

I was going to scan in the front page of today’s Globe, which features a story on Partners staff complaining about how hard it is to learn the new $1.3 billion HIT system. There was a teaser nestled up to it for a story on the first penis transplant. That juxtaposition made me wonder how a slip of the finger on keyboard might impact the noted surgery. But, I decided to be a grown up.

Instead, I’ll let someone else rag on the Globe, or in this case the sort of Globe. That would be the part of the Globe Media Co. that is hiring new staff, not the newspaper itself, which is offering staff buy-outs.

Over at Health News Review, Trudy Lieberman complains about a “serious and rapidly emerging dilemma for consumers of health news. What’s real journalism and what’s “content” masquerading as journalism as we know it?  Examining stories on The Guardian’s Healthcare Network site and on STAT, the fledgling digital news service that’s making a name for itself with loads of daily content, I discovered a blending of traditional stories with advertising and promotion that simply fools the reader.

She goes on: When I first caught on to what STAT was doing, I felt deceived like I was when I read The Guardian’s breakthrough piece. The pooh-bahs at STAT are making it easy for me to read something I don’t want to read and confusing me with look-alike content prepared by some of the biggest names in the healthcare business— Cigna, CVS Health, Johnson & Johnson, Baxalta, a new biopharmaceutical company, and PhRMA whose contributions to Morning Rounds have included “America’s biopharmaceutical researchers and scientists are tireless in the fight against disease” and “Imagine “smart bombs” that fight cancer and reduce side effects.”

First, my conflicts. I was involved in a major sponsored content project once. And I have a family member who works at the Globe.  And while I’m not a big fan of native advertising, I am a big fan of good journalism and we need to pay for it somehow. Or, the folks at STAT will be getting those buy-out offers.

Plus, it looks pretty well-Capturemarked to me with all that orange.  Also, I’m not sure the idea is so much to hide PR in news-sheep’s clothing. My understanding it that the idea is to get this stuff out on social media where the orange banners and disclosures don’t show up — social marketing. That concerns me, along with all these university and hospital publication that look and sound like news but are PR and marketing. Many will argue — we report these stories just like journalist. The difference is — who do they answer to? Who is the customer? That would be the marketing staff at institution or the hospitals, not the reader. But, that stuff gets tweeted out and no one knows the difference. My journalism students don’t know the difference.

Honestly, I hate this stuff as much as Lieberman does. I want to keep that wall between advertising and editorial up. Are native advertising and social marketing, by nature, deceiving the reader?  You could make that argument.  But, I see the dilemma. Here’s hoping we find a better way to support good journalism.



Docs reject Harvard jobs because of conflict of interest policy?

Well, that’harvard meds  what Dr. Peter Slavin, president of Massachusetts General Hospital, told STAT news in a story about Harvard’s revised conflict of interest policy:

Slavin said the change may help with a recruitment problem: “Some faculty don’t come because they perceive that Harvard Medical School has rules that are much too restrictive.”

Or they leave, according to Gretchen Brodnicki, dean for faculty and research integrity.

 Brodnicki said she has heard anecdotes of faculty leaving, or being unable to conduct specific studies, because of the rule, though she said the impact is hard to measure.

Here’s the new rule:

First, the school is raising the thresholds: Faculty will have to receive at least $25,000 in income (up from $10,000), or hold $50,000 in equity of a publicly traded company (up from $30,000) to trigger the prohibition on clinical research. Faculty still cannot hold any equity in a privately held company if they want to do clinical trials on that company’s product.

Second, the school will now allow faculty to petition for an exemption if they’re over those thresholds and still want to do the research.



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