Health insurers are taking a new tack in a bid to improve patient safety and reduce health-care costs: refusing to pay -- or let their patients be billed -- for hospital errors.
Aetna Inc., WellPoint Inc. and other big insurers are moving to ban payments for care resulting from serious errors, including operating on the wrong limb or giving a patient incompatible blood.
The companies are following the lead of the federal Medicare program, which announced last summer that starting this October, it will no longer pay the extra cost of treating bed sores, falls and six other preventable injuries and infections that occur while a patient is in a hospital. The following year, it will add to the list hospital-acquired blood infections, blood clots in legs and lungs, and pneumonia contracted from a ventilator.
Private insurers are looking first at banning reimbursements for only the gravest mistakes. But health-insurance executives say it is only a matter of time before the industry also stops paying for some of the more common and less clear-cut problems that Medicare is tackling, such as hospital-acquired catheter infections or blood poisoning. "I'd rather have the cudgel in place first than push the list too far," says Aetna President Mark Bertolini.
Some hospitals and others are concerned that the new strategy could drive up medical costs in other ways as hospitals absorb or pass on the expense of introducing the safety and screening procedures needed to help avoid mistakes.
Ultimately, insurers say, the efforts will trigger safety improvements and savings for patients.
Aetna, the country's third-largest insurer by number of members, is beginning to stipulate in hospital contracts up for renewal that it will no longer pay nor let patients be billed for 28 different "never events." Compiled by the National Quality Forum, a coalition of physicians, employers and policy makers, these mistakes include leaving an instrument in a patient after surgery, the death of a mother in a low-risk pregnancy, allowing a patient to develop bedsores or using contaminated devices. Such errors are so egregious "there can't be any argument that they should ever happen," says Troy Brennan, Aetna's chief medical officer.
WellPoint, the largest insurer, is testing the same approach in Virginia with four errors from the forum's never-events list, including leaving a sponge or other object in a patient after a procedure and performing the wrong procedure. It plans to extend the policy soon to its plans in New England, New York and Georgia. UnitedHealth Group Inc. and Cigna Corp. say they're exploring policies similar to Medicare's. The Blue Cross Blue Shield Association says that its 39 member health plans are looking at approaches similar to Aetna's or working with hospitals on reducing errors.
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The National Quality Forum's so-called never events are rare enough that private insurers say they don't expect to see a big financial savings at first. In Minnesota, where hospitals are required by law to report such errors, 154 never events were reported last year out of nine million hospital admissions. Rather, the idea is to spur more attention to safety and public reporting of mistakes.
"It's not a matter of not paying for them. It's about getting them not to happen in the first place," says Thomas Granatir, director of policy and research at Humana Inc., which is working on a policy similar to Medicare's.
The more common errors offer the biggest potential for savings -- in both lives and money. The Centers for Disease Control and Prevention estimates that patients develop 1.7 million infections in hospitals a year, causing or contributing to as many as 99,000 deaths a year. On average, urinary-tract infections and hospital-acquired pneumonia -- which are on the Medicare list but not on the never-events list -- can add more than $10,000 to a patient's hospital bill. A more serious antibiotic-resistant bloodstream infection can result in more than $100,000 in extra costs. Such common errors total more than $4.5 billion in additional health spending a year, according to the CDC.
Despite growing evidence that hospitals can take steps to reduce infections drastically, until recently, infections typically have been considered an inevitable part of care and billed accordingly. "It's something that no one ever questions when you see it on the bill. But now that Medicare will, maybe that's going to change," says Nora Johnson, director of compliance and education at Medical Billing Advocates of America, a nationwide patient-advocacy network that deciphers hospital and insurance bills for consumers and advocates on behalf of uninsured patients.
As insurers roll out the policy across the country, they say they are structuring their contracts with hospitals so that the hospitals also won't be able to charge patients for care made necessary by medical errors. Given the high rate of medical billing errors, however, consumer advocates advise patients to examine their bills carefully, especially if they are aware of errors or problems that occurred during their stay. People with health insurance should check their bills against the explanation of benefits they receive from the health plan, or press their insurers to make sure they haven't been overcharged.
When it comes to medical errors, some hospitals say they forgive bills or adjust charges on a case-by-case basis. But the complex billing and payment arrangements between hospitals and insurers can make it hard to avoid paying for errors and for patients to know whether they're being charged.
Last January, when Arlene Whitfield, a Los Angeles elementary-school teacher, underwent a hip replacement at Centinela Hospital in Inglewood, Calif., she accidentally received B-positive blood, instead A-positive.
The mistake lengthened her recovery time by two days and she ended up staying in the hospital for a week, for which Centinela billed accordingly. That is because Medicare's hospital billing guidelines require hospitals to document and itemize all the care they provide to a patient, says Von Crockett, the hospital's president and chief executive. "That's different than what we expect to collect and get paid for it," he says. "It's a documentation of what happened to the patient." He says Ms. Whitfield's portion of the bill was forgiven.
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Her health plan, WellPoint's Blue Cross of California, ended up paying for only two days, not because it refused payment for the added stay because of the error, but because before the operation, WellPoint had only authorized a two-day stay and didn't receive a request for an extension. (The average length of a stay for Ms. Whitfield's procedure is 4.6 days.) The insurer says it noted nothing unusual about the claim filed by the hospital, although the bill did list the diagnosis code for an infusion of "mismatched blood."
Spurred by laws requiring more public reporting of errors, some hospitals have adopted their own policies on billing for medical errors. All hospitals in Minnesota and Massachusetts, for example, have pledged not to charge for all or some of the errors on the never-events list.
But others say broader policies, such as Medicare's, could punish hospitals unfairly and force them to absorb the costs of screening each patient for bedsores or infections at the time of admission.
Insurers are refusing to pay for care triggered by some complications they believe hospitals should prevent, including:
Object left in patient after surgery
Letting patient wander or disappear
Administering wrong blood type
Artificially inseminating wrong donor sperm or egg
Allowing patient to fall
Operating on wrong limb
Performing wrong procedure
Using contaminated drugs or devices
Discharging infant to wrong person
Mother's death or serious disability in low-risk delivery
Hospital-acquired bedsores
Patient abduction or sexual assault
Some in the industry worry that hospitals may find ways to turn away or divert patients at greatest risk of developing infections or bedsores. "The concept of not paying for complications that are often a biological inevitability, regardless of safe practice, is discriminatory and could be punitive to those patients at greatest risk," Michael Maves, executive vice president of the American Medical Association, wrote in a June letter to the federal Centers for Medicare and Medicaid Services.
Hospitals have an incentive to invest in reducing infection rates, health-safety advocates argue. Since health plans pick up only so much of the extra cost caused by infections, "hospitals are losing their shirts, too," says former New York Lt. Gov. Betsy McCaughey, who formed the Committee to Reduce Infection Deaths, a national, nonprofit campaign to push hospitals to lower infection rates.
To lower its rate of infection, one hospital, Pitt County Memorial Hospital in Greenville, N.C., in February expanded its screening for methicillin-resistant staph infections to all patients coming into the hospital. By identifying and isolating those with the strain early, it lowered the number of MRSA pneumonia cases related to ventilator use by 67% and MRSA urinary-tract infections by 60% within eight months. In all, the expanded screening has cost nearly $1 million, $800,000 picked up by private and public insurers.
Steve Lawler, the hospital's president, says it has more than recouped its $200,000 investment. Moreover, spending the money to make the hospital safer is a "better return on investment...than some billboard campaign," he says.
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Looking to build on the success of its iPod and iPhone devices, Apple Inc. introduced several new products including an ultra-thin laptop computer, dubbed the Macbook Air, and a much-anticipated online movie rental service.
The new Apple notebook computer's major attribute is its sleek profile: it's about three-quarters of an inch thick and weighs three pounds. The Macbook Air features a full-sized keyboard, a 13-inch screen, a built-in camera, and Wi-Fi and Bluetooth connectivity, all powered by an Intel Corp. dual core chip.
Appearing on stage at the company's Macworld expo, Apple Chief Executive Steve Jobs said the computer, which he called "world's thinnest notebook," will cost $1,799 and is scheduled to ship in about two weeks.
With the MacBook Air, Apple becomes the biggest name in two years to try to revive an industry it arguably began with the introduction of its Newton handheld computer 15 years ago.
Ultramobile notebooks represent about 6% of the 270 million notebooks expected to the sold this year. Sales have of the devices have languished, despite efforts from Lenovo Group, International Business Machines Corp., and two years ago by Microsoft Corp. with its "Origami" ultra mobile device.
Apple may benefit from good timing. Asustek Computer Inc.'s recently introduced Eee PC has topped sales charts at Amazon.com and is usually sold out at retail stores.
"Apple's Newton was ahead of its time,' said Shaw Wu, an analysts with American Technology Research. "The functionality wasn't quite there, battery life, screen technology. Now there are products out there proving there's a market for this."
Investors seemed to be unimpressed by the new products: Apple hares dropped more than 6% Tuesday on the Nasdaq Stock Market.
Apple's CEO also launched the computer maker's much-anticipated online movie rental service and unveiled an updated Apple TV device that will let viewers bypass their computers and rent movies directly from their widescreen TVs.
Apple's Macbook Air
Mr. Jobs said iTunes users can rent new-release movies to watch over their computers, iPods or iPhones for $3.99 for a 30 day period. Older titles will rent for $2.99 for the same time period.
The service has the support of all major Hollywood studios including Walt Disney Co., Time Warner Inc.'s Warner Bros., Paramount, Universal, Sony Pictures, Metro-Goldwyn-Mayer, News Corp.'s Fox, Lionsgate and New Line, Apple said.
Apple's push into the online video market comes after the original Apple TV device stumbled badly with its first effort last year. "We tried. Now were back," he said.
Apple sees the Internet video service as another key element in its effort to put its products at the center of the living room entertainment hub of the future, and at the same time, sell more of its hardware products. This tactic worked before, when the Cupertino, Calif., company created iTunes music store to drive iPod sales.
Mr. Jobs also disclosed Apple had sold more than four million iPhones worldwide in the 200 days since the company's trend-setting smartphone was launched. Mr. Jobs said the iPhone had sold 3.4 million units in the U.S., outstripping even the most optimistic analyst forecasts. Mr. Jobs said Apple now has a 19.5% share of the U.S. smartphone market, second only to Research in Motion Ltd.
Apple also introduced an iPhone software update, available Tuesday, that would include new features that allow users to send texts to multiple addresses, create bookmarks that show up as icons on the home screen. It will cost $20 for iPod Touch customers.
A highly drug-resistant superbug is gaining resistance to more drugs and burrowing deeply into the gay communities of San Francisco and Boston, researchers said.
Sexually active gay men are 13 times as likely to have this strain of the highly resistant bacterium, known as MRSA, or methicillin-resistant staphylococcus aureus.
More worrisome still, the new strain of MRSA called USA300 is growing resistant -- or unresponsive -- to three or even four classes of widely used antibiotics.
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MRSA causes deep and stubborn skin infections and has been called the most common cause of skin infections treated in the nation's emergency rooms. It also more rarely can cause lethal invasive infections such as pneumonia or sepsis (blood poisoning).
Several drug classes that have lost their punch against the worsening strain include families that contain: penicillin, erythromycin, clindamycin, tetracycline and fluoroquinolone drugs such as Cipro, said Binh Diep, researcher at the University of California at San Francisco and first author of the study in the Annals of Internal Medicine.
The toughest strain also now is resistant to mupirocin, a topical antibiotic drug used to clear MRSA from the skin surface and nostrils where the bug is known to colonize even people without an infection.
The study emerged from a retrospective review of charts from 183 patients treated for MRSA at the San Francisco General Hospital's Positive Health Program, an outpatient clinic used by people with HIV, the virus that causes AIDS. An additional 130 patients were studied at Boston's Fenway Community Health clinic.
The review of charts found gay men age 18-35 to be hardest-hit. ZIP Codes around San Francisco's Castro District, a largely gay neighborhood, were heavily affected. Previously, MRSA infections have been documented in sports teams, prison populations, gym-goers and the community at large.
Skin-to-skin contact, including sexual relations, are believed to be major ways the bug spreads from person to person. But Henry "Chip" Chambers, chief of infectious diseases at SF General and a study co-author, said heavy antibiotic use is "the most important factor" that the superbug's toughest strain resides among gay men.
Unlike resistant infections of the past, which thrived mainly in hospitals, MRSA runs rampant through the community and can crop up in people with no recent antibiotic use.
"It's more virulent than standard staph," said Shelley Gordon, an infectious-disease specialist in private practice at California Pacific Medical Center. To avoid using the wrong drug and fueling even more resistance, she urged testing for drug resistance, adding, "doctors in emergency settings have to be hip to this and do cultures."
Worry warts often believe they inherited their tendency to stew from their parents. Biology does play a role, research suggests, but there are things you can do to break the cycle of agonizing.
Researchers at Yale have identified a gene mutation for "rumination" -- the kind of chronic worry in which people obsess over negative thoughts. It's a variation of a gene known as BDNF that's active in the hippocampus, an area of the brain involved in thinking and memory. In a study of 200 mothers and daughters published in the journal Neuroscience Letters last month, the Yale scientists found that those who had been depressed in their youth were more likely to be ruminators and to have this particular variation of BDNF.
The discovery adds to a growing body of evidence that depression involves an inability to control negative thoughts, not just excess emotion, says psychologist Susan Nolen-Hoeksema, one of the Yale investigators. And just because rumination has genetic roots doesn't mean it's inescapable, she says. "People can learn to stop these thought processes and have better emotional health."
Some successful professionals find that worry works for them. Imagining everything that might go wrong, and preparing for it, is known as "defensive pessimism."
"I spend all day thinking of ways to gain an advantage over my adversaries, and I assume they're doing the same thing," says Victor Bushell, a partner at Bushell, Sovak, Ozer & Gulmi LLP. "If that was your job description, wouldn't you be worried?"
Other people use worry as a kind of magical shield -- if they worry that the plane will crash, it won't. It doesn't, ergo, they have to worry on every flight.
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Worrying also seems to be part of some people's personalities. "I've been furrowing my forehead forever -- you could pick me out in kindergarten," says Pam Abramson Grisman, who runs a custom-writing business in Mill Valley, Calif. "These days, I worry about my parenting. Prior to that, it was focused completely on the workplace. Prior to that, it was, 'Am I cool enough to live?' "
But worrying is wearying, she says: "It's like chronic pain, and ultimately it doesn't shield you anymore. It becomes a self-fulfilling prophecy. Then you have a heart attack."
Chronic worry can, in fact, lead to a variety of health issues, including headaches, gastrointestinal problems, high blood pressure, anxiety and depression, studies have shown. Rumination, which focuses more on past events than future what-ifs, has also been linked to binge eating, binge-drinking and self-harm. Ruminators may be subconsciously trying to stop their harmful thoughts, says Dr. Nolen-Hoeksema. "Disengaging is really, really hard -- you see that in their neural activity and in their behavior," she adds. But studies have shown that doing something distracting for just 10 minutes can break the cycle and help people tackle problems more effectively.
Techniques from cognitive-behavioral therapy can also help worriers stop the kind of thinking that just makes them miserable.
"It's all about finding the balance between productive and unproductive worrying," says psychologist Robert L. Leahy, director of the American Institute for Cognitive Therapy in New York City. "Say to yourself, 'Is this worry leading to a To Do list?' If it doesn't lead to some action on your part today, set it aside."
He suggests literally reserving 20 minutes a day to worry. If you can postpone worrying, you are exercising control over it, rather than letting it control you.
And learn to accept some risks. "Worriers feel a tremendous intolerance for uncertainty. They get the idea that worrying can eliminate it. But you can't prepare for everything," Dr. Leahy adds. He also suggests a simple "exposure" technique: Practice saying or writing whatever you fear most, such as, "the plane is going to crash" or "I'm going to lose my job." "Repeat it over and over again slowly, like a zombie, and the fear will begin to subside," he says. Eventually, "you'll just get bored with it."
Wall Street's scramble for foreign funds to shore up the big banks' books continues, with Merrill Lynch this morning announcing $6.6 billion in new investments and Citigroup $12.5 billion -- both relying heavily on cash from Asia and the Middle East.
Merrill said it is issuing convertible, preferred stock as a long-term investment to Korean Investment Corporation, Kuwait Investment Authority, and Mizuho Corporate Bank of Japan. "One of my main priorities over the last several weeks has been to ensure Merrill Lynch's balance sheet is strong, and these transactions make certain that Merrill Lynch is well-capitalized," said John Thain, the former New York Stock Exchange chief picked to lead Merrill last fall as the brokerage giant was reeling from bad bets on mortgage-backed securities. The financial breakdown among the three new investors wasn't immediately clear.
Citigroup's move to get back on what newly installed Chief Executive Vikram Pandit called "our 'front foot'" was bigger in scale and broader in action. Citi's new funds include $6.88 billion from the Government of Singapore Investment Corporation, and money from Capital Research Global Investors; Capital World Investors; the Kuwait Investment Authority; the New Jersey Division of Investment; Prince Alwaleed bin Talal of Saudi Arabia, who's already a big Citi stockholder; and former Citi Chairman and CEO Sanford Weill. After months of saying it wouldn't cut its quarterly dividend, Citi is also doing just that, to 32 cents a share from 54 cents. Citi's investment news came amid its release of quarterly financial results that Mr. Pandit called "clearly unacceptable." Citi posted a net loss of $9.83 billion, or $1.99 per share, on revenue of $7.22 billion -- results that reflected $18.1 billion in write-downs and higher credit costs blamed on Citi's exposure to investments derived from subprime-mortgages. Citi also said that burgeoning losses related to consumer loans had raised its credit costs in the U.S. by $4.1 billion.
A source notably missing from Citi's new list of benefactors was the China Development Bank, a state-owned institution previously expected to invest in Citi that was apparently pulled back by the government. It isn't clear why Beijing nixed the deal, but The Wall Street Journal notes how much political flak such investments by sovereign-wealth funds have been catching in the West, as well as uncertainty about how much bigger the U.S. banks' subprime-related losses can grow. In another announcement today with a much lower profile, the Dubai government-controlled investment firm Istithmar said the political backlash in the U.S. and Europe was too harsh for its tastes, and that it was considering investments in China.
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Talk about a tough spot. While the Fed may be contemplating another rate cut in response to recession worries, its sworn enemy inflation apparently is still stalking the land.
The price of gold, traditionally considered both a safe haven in times of trouble and an important inflation gauge, notched historical highs today, touching $914 an ounce overnight before easing a bit but staying above the $900 psychological barrier. Analysts proffered various rationales for the runup, citing concerns over inflation, the weakening dollar -- gold like oil is denominated using the venerable buck -- and worries that the U.S. economy may be entering recessionary times. Tensions between inflation and recession worries also twisted up the yield curve for bonds early today, with the short side of the curve sinking in response to the looming rate cut by the Federal Reserve. On the other hand, "the long end of the curve is rising [and] that is suggesting that that market is very concerned about inflation," said Lee Olver, fixed-income strategist for SMH Capital this morning.
Shortly after midday, the longer side of the yield curve eased somewhat, suggesting concerns over inflation may be relaxing. But the inflation warning signs this morning likely have many investors wondering what to make of them. Here's one takeaway: Right now, it's good to not to be Fed chief Ben Bernanke, who finds himself having to contend with a mix of price and economic growth data which -- in an a nightmare scenario -- could conceivably coalesce into a stagflationary environment. Still, few see Mr. Bernanke swiveling his white horse to confront the dragon of inflation with recession concerns at their current pitch. Perhaps his best bet for now is to wait for Wednesday's Consumer Price Index reading to filter out of the Labor Department and pray it doesn't fan inflation fears further.
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“That is hot ice, and wondrous strange snow!”
Midsummer Night’s Dream 5.1.59
Rather than in a primordial soup prepared in burning fire and bubbling cauldron, perhaps life originated in ice?
Small amounts of liquid water still exist at -60 degrees F (salt can help maintain liquid water down to -65 degrees F and, under more rare conditions, thin films of liquid water can exist at – 90 degrees F) in an ice field. There are at least one million liquid compartments –- test tubes -- in one cubic yard of sea ice. Sea ice accumulates “pollutants” (ammonia, cyanide, etc.) from the atmosphere and stores and concentrates them in the aforementioned liquid compartments.
The typical assumption is that as the temperature drops, the speed of chemical reactions slows. However, that general tendency does not necessarily apply when chemicals are frozen in ice; when frozen in ice, some reactions increase in speed, especially reactions where small molecules join together to form larger molecules, i.e., e.g., complex polymers. This seemingly counter-intuitive tendency is known as “eutectic freezing.”
Eutectic freezing involves the crystallization of water which necessarily remains unadulterated, i.e., the pollutants are excluded. As such, the pollutants become concentrated in the remaining liquid pockets which, in turn, causes certain pollutant molecules to collide more often which process more than offsets the other slowing effects of cold thus accelerating the reaction(s).
Even more, the structure of ice has a generally regular pattern of positive and negative charges which leads to strong bonding with the liquid water remaining in the compartments. Repeated experiments have established that these electric charges organize the pollutants into chains; further, those shorter chains develop into very long chains IF a single strand of RNA is placed into the compartment to act as a template. ,
Scientists believe cyanide was abundant on primordial Earth more than 2.5 billion years ago. Importantly, cyanide tends to self-assemble into larger molecules and does so efficiently under freezing conditions. Tellingly, cyanide evaporates more quickly than does water so it could only become concentrated in cold temperatures. Cold temperatures also preserve fragile molecules – such as nucleobases – dramatically extending the time they exist thus increasing the opportunity(ies) for further development. Frozen cyanide in the presence of ammonia can form adenine (a nucleotide base).
To state the obvious, the above reasoning has expanded the range of worlds on which to search for extraterrestrial life.
Reference List
Fox, D. (2008, February). Did life begin in ice? Discover. 52-60.
National Public Radio. (2000, March). Analysis: Scientists share results of 25-year experiment of freezing vials of liquid. Retrieved January 11, 2008 from the National Public Radio Home Page: http://www.npr.org/ .
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