Friday, October 28, 2005
At one time, it was believed that proton therapy was the holy grail of Radiation Therapy. But with the advent and introduction of new technologies in Radiation Therapy such as IMRT (Intensity Modulated Radiation Therapy) it may no longer be considered such. Proton Therapy deposits its dose in the planning tumor volume without exposing surrounding healthy tissues to high doses. IMRT, implemented in most areas of the country 4 years ago, accomplishes the same effect at a MUCH lower cost. There are no comparative randomized studies comparing the two technologies. But, the name of the game in cancer care today is differentiation from your competitors. You're always looking for that edge that will gain marketshare by offering a service your competition doesn't have. MD Anderson, the cancer center above all cancer centers, is taking this concept to a new level. It's occuring in our area with CyberKnife, GammaKnife, and MammoSite albeit on a much smaller scale.
The second issue is also becoming an increasing trend in cancer care today; joint ventures. Most often these ventures are between a health system and physicians but, in this case it is between MD Anderson and many outside investors. MD Anderson stands to make a seven figure benefit if the investors make enough money. Part of the agreement states MD Anderson has to promote this type of therapy. This type of arrangement causes many concerns. One of which is will this incentive consciously or inconsciously cause patients to be steered toward Proton therapy rather than the cheaper and more efficient IMRT? You would hope that the Hippocratic oath and strong ethics would come into play here but, after experiencing similar situations myself, I know better. Just like in everything else, its ALL about the money. I report, you decide.
Wednesday, September 28, 2005
The Director described several instances in the last year of individuals presenting to the ER for medical care and using stolen insurance cards. The more I thought about it the more I surmised that this would be harder to catch than trying to nab people using stolen credit cards.
Think about it. You go to the ER or your physician's office and give them your insurance card which, they copy and give back to you. You receive your service, make your co-pay, and you're out the door. Weeks later you receive your EOB of which you review, well, some of you review. Therein lies the problem. You won't even discover that someone has stolen your medical identity until weeks later and they're long gone. In the mean time, while you attempt to straighten this out, the medical providers turn you over to a collection agency and now you have issues not only with your medical records but your finances as well. Think its far-fetched? This poor soul didn't even have his insurance card stole and he still became a victim on an ID alone.
There are even more versions of medical identity theft. You could be laid up in the ICU and someone takes your identity and runs with it. Criminals are also purchasing medical supplies and equipment with health insurance info and then fencing them on the gray market to support their other dubious endeavors. This widow reports on the FTC website that she avoided possible tragedy when someone admitted herself into the hospital in her name with a different blood type than hers. Had she not checked when she needed an infusion she could have possibly received the wrong blood type.
In a recent article, the University of Connecticut notes that it has experienced this problem to the tune of $76,000 for one patient alone and is taking aim at correcting it by requiring picture ID's for all services. They have already experienced positive results of their new policy. Several people have presented for care and have stated they left their ID in the car only to never return after going to retrieve it.
How can you help protect yourself? Carolyn Pennington of UCONN states in her article that the State of Connecticut recommends the following:
The state insurance department offers tips for protecting yourself:
- Never give out health insurance information over the phone.
- If you lose your card, call your insurance company right away.
- Keep your health insurance information private, even from family members.
Thursday, September 15, 2005
I had to chuckle, for a couple of reasons. One because it reminded me of the old Eddie Murphy Delirious stand up comedy routine where he describes the situation where a wife sees her husband exiting a motel room with another girl. When she confronts him about it he continually denies it was him saying, "wasn't me." She tells him that she saw him with her own two eyes and he continues to state it wasn't him. After a few minutes, she begins to question herself and says "Maybe it wasn't you?" The second reason was I said to myself, "I just thought I had heard it all."
So I go and review our records and just like I thought we have signature proof and detailed records demonstrating that he was indeed here on the disputed date. It is amazing the things people will do to avoid paying the bill. In my next post, I'll discuss a related issue that came up when trying to resolve this one. Something I hadn't even thought about or knew existed but, when I was told about it, it didn't surprise me in the least.
In my hiatus, several topics I would like to discuss have come on the horizon so I hope to get them out of my head and onto the blogosphere. So look for some new posts from here on out.
Monday, August 01, 2005
I'm a little more nervous for this inspection since I won't be here for it. I scheduled vacation thinking the inspection would come later. Guess, what? It didn't. Oh well, they always say evidence of a good administrator is how well his staff performs while he is away. I guess I'll be finding out.
Email me any pointers or questions you've been asked in any recent inspections.
Saturday, July 30, 2005
I always find it interesting that we're required to submit proposals for the next capital budget year in June. Number one, its hard to get quotes for equipment/software that will last until the new year. Secondly, for those in Radiation Oncology, ASTRO isn't until mid-October so you have to try to budget for equipment that will not be released or seen until after your budget is submitted.
I find capital budgeting interesting. Basically, in our system, you're competing with other service lines for a limited amount of dollars. For us, our main competition is imaging. Since the dollars are limited, thorough proposals where the high tech lingo is explained in layman's terms for executive management teams with proformas that demonstrate revenue and income usually win out. You would be amazed at some of the shoddy proposals I've seen submitted.
To top things off, our system heads right into operational budget prep after capital is submitted. Operational wouldn't be that bad if there were only one cost center. Even that isn't that bad but what is the real kicker that has came on the scene in the last few years is productivity monitoring.
Percentiles, targets, yada, yada, yada. I think its all a bunch of hocus pocus in our field. I see where these type programs might work for service lines such as nursing that have large numbers of employees and can flex with volumes. But Rad Onc?, I can't see it. Number one you need a basic number of staff whether you treat 1 patient or 40. Number two, I haven't a center that accurately reflects the number of procedures they perform. They either under report due to incompetentcy or they over report to make themselves look better. Either way, in Rad Onc it is extremely hard to compare apples to apples. Thus, if your comparisons are flawed from the "get-go" the whole production is shot. I could go on but, that's another post another day.
Saturday, June 11, 2005
So since we have a tax on everything else it doesn't surprise me that someone is now proposing a tax on food. Now, I'm all for battling cancer but taxing Big Macs, Whoppers, and fries isn't the method to take. It will control people's desires for fast food about as much as it does for beer and cigarettes.
I believe education about diet and making those choices available or two of the main keys to a better diet. If you don't know what to eat then obviously eating a healthy diet will be a little challenging to say the least. Recent changes to the food pyramid, the low carb craze, and other methods of the day have only confused people to what is a healthy diet. Secondly, if you know what to eat but those choices are not available then eating healthy is a mute point. What we need are some decent healthy fast food choices. One can only eat so much Subway. The message is getting there but a fruit bowl isn't enough for me.
Thursday, May 26, 2005
What is the deal anyway with the new trend of not only having one color, but two? My brunette wife came home a few weeks with not ony auburn highlights but blonde as well. Of course you still have your single dye people such as the girl serving my mocha blast from Baskin Robbins last night. She had just a section of purple in her silky black locks which, kind of matched some of the flavors. To each his own I guess.
Tuesday, May 10, 2005
According to Mr. Swan, the ellagic acid in single malt whiskey acts as a "free radical scavenger" that "absorbs" or "eats up" free radicals produced from eating. "The free radicals can break down the DNA structure of our existing cells, which then leads to the risk of the body making replacement rogue cancer cells," he said. While it may be true that antioxidants may help ward off free radicals, what he forgets to mention is that alcohol use can lead to liver damage, esophageal cancer and a myriad of other diseases. Not to mention the addictive habits that illicit many of today's social ills such as drunk driving and mental or physical abuse.
Let's take a look at Mr. Swan's profile from the EuroMedLab Glasgow 2005 News March issue. Mr. Swan "assists the quality aims of blue chip brewers, wine makers, and spirits distillers as well as small producers in 5 continents...He is a member of the scotch malt whiskey society taste panel...(here's the kicker) His particular love is the quality and varied flavours of single malt scotch whiskies." Yea, I bet it is. Can you say "Major Conflict of Interest" here. I knew you could. Sounds like to me his particular love is lining the insides of his pockets with pounds, euros or whatever they're using over there now by espousing half truths that ordinary people will take as fact.
Statements like this is just outright irresponsible. I found no more than 28 articles touting this supposedly great news! What Mr. Swan here is doing is taking a small part out of the whole picture and using it solely for the benefit of his clients. Most of these articles make small mention of the damaging effects of alcohol use.
What is disappointing about irresponsible statements like this is that it sets back the healthcare industry's efforts to educate the public about true preventative measures for cancer. Yesterday, I was reviewing news articles of when our cancer clinic was first opened in 1937. Guess what one of the major challenges cited to the success of the program was? Education of the public to the truths about cancer prevention and treatment. Overcoming the belief that cancer was a communicable disease was a monumental challenge in that day. At least then they didn't have news articles stating that it was.
Tuesday, May 03, 2005
Of course, we hear the "We're not going to send any patients from here there." Uhhhh, yea. If you build it, they will come (especially if you own a significant stake). We first noticed a drop in CT scans then we heard from a mutual patient that they had a scan at this new facility. We didn't even know it existed. While the state I'm in is a Certificate of Need state, it doesn't cover CT scanners under a certain price range if I'm correct. Needless to say we were a little surprised.
Upon further investigation you would expect that we would find that they had purchased a new 32 or 64 multi-slice CT scanner. Only the best for their patients, right? Not a chance. What did they purchase and install? A refurbished Siemens unit. Let's say that it is not exactly top of the line.
Soon, we start having patients ask our receptionist why they have to travel 20 minutes to have a CT scan when they can have one right here without leaving the building. Hmmmmm....... We have a very astute receptionist who questioned what reason the Medical Oncologist gave for sending them away. They stated that he said "we like the techs better down there." Yea, right. While the patient is thinking technologists we all know they were thinking "technical charges!" This was a patient that lives a half a mile away from our facility. This has been repeated several times. We even had a patient that lives in another state that presented for treatment and they sent them 20 minutes away to the new center. These are cancer patients for pete's sake. They would like to be home resting and not driving all over town.
In the May 2 Wall Street Journal, Donald Ryan of CareCore National Inc. a firm that analyzes imaging claims to help control costs for insurers, states that "Utilization goes through the roof" when physicians have a financial investment in a center that provides diagnostic imaging scans. Talk about a major conflict of interest. And not to mention the ethical issues this presents. But, it appears this is the wave of the future. I can go to my PCP and he'll attempt to send me to his group's Imaging Center 25 minutes away when we have the equipment downstairs.
Guess what's next? A PET/CT Scanner. Rad Onc will be next to follow. Physicians are continually siphoning off the profitable business from hospitals and leaving the non-profitable non-insured patients for the hospital to provide care. To boot, they're doing it on inferior equipment and its usually non-PACS meaning it can't be visualized on multiple PC's. Hospital's better get a better lobby or there are going to be quite a few of them heading for closure.
Monday, May 02, 2005
Speaking of the Relay, while it was a huge fundraising success, the event left much to live for. As usual, we were deluged with heavy storms while setting up. Something about setting up a tent while it was beginning to thunder and storm just didn't seem very wise. I was beginning to wonder if the hospital would still cover my salary for the day if I got struck by lightening. Thankfully, the rain stopped before the event begin and didn't return until about 5 the next morning when it begin to fall from the sky like the day's of Noah. Needless to say they called the whole event around 5:30. Of course, there were only about 10 people left at the whole event so I'd say that had something to do with it.
The American Cancer Society (ACS) has killed this event in our city by splitting it into 5 separate events according to what region of the county you live. There just aren't enough teams to carry the event throughout the night. A good majority of the teams pack it up after the luminary ceremony and that just leaves a few of the hard core campers. Without enough teams, there isn't even enough people to hold the events scheduled throughout the night. In addition, the poor planning and organizational skills of the ACS committee only added to the demise of this year's event. But, I digress...
Tuesday, April 19, 2005
We've held a couple of fundraisers for our team. One of them was a media sale where we sell used books, cd's, dvd's, vhs tapes, and software, that our system's employees donate, for a $1. We sold over 400 items in one day.
Our biggest fundraiser is a system wide "theme" basket sale. We challenge different departments in our system to create different theme baskets. Some of them this year were "Dinner & a Movie", "Fun in the Sun", "Baby Boy", I think you get the point. We set them out for a whole week and seek a$1 donation for a ticket to win the basket. Last year, one department used a wheelbarrow for a basket. This year coolers seemed to be the "basket" of choice. We had over 30 baskets this year and we broke last year's record by raising almost $7000 in donations for the baskets. Believe it or not, one lady won three baskets! I asked her if she wanted to go buy some lottery tickets after work.
Despite all the extra work, it has been fun working for such a great cause. Some of the best people you can meet are ones that volunteer their time for events such as the Relay. I'm planning on spending the whole night this year so wish me luck. Please share any favorable experiences you've had with Relay.
Friday, April 08, 2005
In the typical fashion of releasing bad news when most people are not focusing on the news, on Friday, April 2 H. Lee Moffitt Cancer Center & Research Institute released information that 77 patients received 50% higher radiation doses than prescribed. Whoa!
This is what we would call a major misadministration and the one thing that every Radiation Oncology professional fears. Boy, I can imagine the puckering sounds resonating in the executive and legal offices of that center. I'd say it is probably safe to say that there will be a few lawsuits filed in this case.
The technique used for these misadministrations is referred to as Stereotactic Radiosurgery. Basically this is a procedure that allows us to give higher doses of radiation by utilizing stereotactic techniques that minimize radiation doses to surrounding healthy tissues while delivering a therapeutic dose to the defined tumor volume. This is usually done in 1 to 5 fractions (treatments) instead of the normal 33 fractions for conventional Radiation Therapy. There are varying stereotactic techniques of which some require a frame screwed into the skull while others just require a thermoplastic mask that is molded into the shape of the patients head along with some type of bite block inserted into the mouth.
In most cases where a misadministration occurs, it is limited to a few patients. But in this case, it affected 77 patients from May '04 until last month. Not all of these were cancer patients. 21 of the patients were treated for benign processes such as AVM (arteriovenous malformation) or Acoustic Neuroma. Unlike most brain cancer patients, these individuals are expected to continue to live long healthy lives after their procedures are completed.
It was stated in the article that 12 patients have already died but didn't show any side effects of the overdose before passing. I would guess that these were most likely metastatic patients who were probably some of the first patients treated. Usually when initiating high risk procedures like this, you select patients that are going to die regardless of the results of the procedure. I know that probably sounds morbid but, the number one rule in medicine is to cause no more harm to a patient's condition than already exists. And in something like this, you sure want to have all possible problems eliminated before you perform the procedure on a curative or benign condition patient.
What is really sad about this unfortunate incident is that the effects of these misadministrations will not be realized for months or years in these patients. Radiation has a latent effect which means injury will not appear until a later time.
How did this happen? Good question. A place like Moffitt has at least 2 Medical Physicists and one Medical Dosimetrist. Probably more than that. That being said, if this staff was experienced, one would think that they would have questioned the higher than normal monitor units for the doses given. Monitor units are a measurement unit that we use to give the radiation doses on a linear accelerator.
Scuttlebutt in the field is stating that during the commissioning process of the new equipment there was data was converted to an MS Excel file and the cells were not protected. One of unprotected cells was then accidentally changed without anyone's knowledge. All subsequent QA was based on this incorrect data resulting in the dose errors.
There was an incident similar to this that occurred in a Nashville hospital in the early 90's. In that case a Medical Physicist inadvertently inserted a calibration factor twice. Luckily, this mistake was corrected early but still not until several patients had received large overdoses. A physician I knew saw one of these patients for a consultation to review the damage and it was not pretty.
Thank God for the RPC (Radiological
In the end, this will end up an expensive mistake that will cost the hospital lots of money, probably some people their jobs but most of all cost many patients their well being. One can only hope that the physicians were kind and caring physicians. Studies have shown that patients are least apt to sue if they fill that physician is caring and just made an honest mistake.
Wednesday, April 06, 2005
This will obviously bring lung cancer to the forefront of cancer discussions. We are seeing better success with lung cancer treatments but no where to the level you would like to see 5 year survival rates.
If you've ever seen a smoker's lung compared to a normal healthy lung you would be amazed. Lung cancer would be greatly reduced if people gave up the cancer sticks.
Occasionally there are still those cases where people who don't smoke but still develop lung cancer. We currently have a 33 yo female non smoker with a large upper lobe cancer that grew over 50% on two different chemo regimens. Luckily, with combined chemo (Gemzar)/radiation treatment the tumor regressed and was able to be resected. Amazingly enough, when the tumor was removed there was no evidence of disease. I put this one in the divine intervention category.
Tuesday, April 05, 2005
Currently, there aren't any indicators for performance in the area of Oncology but I would be safe to say they're coming. The current indicators have to do with Cardiology and Respiratory results in the hospital environment. I was really intrigued by the results when I compared local hospitals in my region. You should definitely give it a try in your area.
What will really be groundbreaking is if they can develop a physician comparison database. Although, I think that will be a long time in coming. It would definitely be welcomed by the public. Can you imagine comparing the physician you've been scheduled to see to other like physicians? If his/her results aren't favorable than you might decide to cancel and schedule with the one that has favorable results. This would turn the healthcare marketplace on its ear and would help break the barrier to make "pay for performance" a reality.
There are many roadblocks to implementing such a database. One would be issues with tracking and reporting data which would only add to the cost of private practice. In the face of decreasing reimbursements, the physician lobby would prevent this from ever being mandated by the government. But we can dream!
Monday, April 04, 2005
Have you noticed an increase in blurred spots on your TV screen as of late? In the latest "don't give any ad time for free" craze, TV stations and networks across the country have been blurring out anything from t-shirts and car logos to restaurant signs to the sides of soda cans.
First it started with t-shirts with less than proper usage of the English language but now it has escalated to anything that hasn't paid a fee to be cameoed on the show. Half the time I think there is something wrong with my TV. How would you like to have that job? I guess you would watch the show with your blur mouse and follow around the illegal ad as it moved throughout the show whether it is a hat, shirt, shoe, tattoo, door, chair, wall, sign, building, pizza, I digress.
I guess it is all stemming from the state of advertising today. If there is a place to put an ad its there. The only place I hadn't seen one yet is on the underside of a toilet seat. Don't tell anyone or it will be sure to appear. I can see it now, "Use Tidy Bowl for ..., " you get the point.
Tuesday, March 29, 2005
The following link details a patient's initial experience with a brain tumor and the subsequent treatments which are followed by their last days in hospice. The wife of the patient saved all of her email concerning her husband's battle with Glioblastoma and decided to create an online diary to help others with a similar fate. I think it also serves us well in remembering the plight of our patients when in our care.
Diary of a Brain Tumor Patient's Wife
Wednesday, March 09, 2005
Combining PET and CT scans leads to more accurate radiation therapy for lung cancer patients
Monday, March 07, 2005
It is totally amazing the one time issues that occur day to day in an Oncology department. From software glitches to physician disappearances they all suck up the hours. I'm starting to think I'm an issue juggler. I''m constantly throwing one issue up and catching another. Sometimes I throw one up high, another even higher in hopes it takes a while for them to come down. Right now I have policies and procedures way up there, even higher is new Information System HIPPA standards, new procedure coding, staffing issues, coding issues, construction, Relay for Life event, and the list goes on and on.
Am I complaining? The more I read this the more I think why would anyone else read this? I bet most would be thinking why would anyone want to do this? I'll save that one for another day.
Thursday, March 03, 2005
Most satisfaction surveys have scales from 1 to 5. With 1 being poor and 5 being excellent. When results are tabulated, the majority of institutions consider a 3 or above as a successfully satisfied customer. What is interesting about Disney's model is how they report the results of their surveys. Their surveys list responses basically on a scale of 1 to 5 like most others. But where they differ is that they only consider a response of 5 as a success. When their results are reported it may read that only 70% of their customers replied with a rating of 5. Why track only 5's and not 4's (very good) you may ask? Because to quote Fred Lee, "they are not measuring customer satisfaction; they are measuring customer loyalty." Interesting, huh?
To receive a 5 a customer must have an experience, a story. Without an experience or story a customer may be just merely satisfied because their expectations were met. But if their expectations where exceeded then there is an experience or story behind it and because of that you've likely gained a loyal customer. I could delve much further but, you can begin to see the premise of the book. That Disney's success stems from customer loyalty and believe it or not the same principles can be applied to the healthcare field.
On a side note, although I'm not a Disney fan, I had a 5 level experience with our stay at one of their resorts a couple of years ago. We stayed at the Wilderness Lodge and it was well worth it. But what definitely assisted in making the trip a success was this website, Tour Guide Mike. If your planning a trip to Disney this is the ticket. I highly recommend it.
Back to building a good satisfaction survey. Below are some of the top 10 drivers of patient satisfaction according to Press, Ganey (August 03) and Gallup (1999).
1. How well staff worked together to care for you
2. Overall cheerfulness of the hospital
3. Response to concerns/complaints made during your stay/procedure
4. Amount of attention paid to your personal and special needs
5. Staff responded with care and compassion
6. Staff advised you there were going to be delays
What's interesting to note is none of these speak to the offerings of the latest technology or procedures. Lee's rationale for this is that patients expect hospitals to offer the same technology, procedures, and services. What they are most concerned about is their experience while they are there.
The most interesting one I find above is number 6. How many times have you sit in a doctor's office for an hour without one iota of why you're having to wait. In our centers we make it a practice to inform the patient of the actual reason for the delay. We've found that if informed the patients are very appreciative and much more patient.
Needless to say, after consulting this reference and others my own ideas for survey questions paled in comparison. I'm going to try a few of these questions and await the results. And by the way, we're only going to report 5's.
Tuesday, March 01, 2005
Part of the problem is Medicare (CMS) can't call an ace an ace and a spade a spade. They hire fiscal intermediaries (FI), usually insurance companies, who develop there own local medical review policy (lmrp) for a region of the country. For the most part, the individuals that develop these policies have no clue about the procedures they're making decisions on, especially in Radiation Oncology.
So for one part of the country you can charge for this procedure but, maybe not in another part of the country. I've contacted our FI for guidance on procedures and they don't even have an LMRP for the procedures I was inquiring! Let alone what we can charge for it and what we can't.
Its so bad a cottage industry has sprouted to just try to interpret the rules for us. For a small fee no doubt. What happens then is that this consultant says you can charge for this, another says no, and chaos abounds in the world of cancer coding. In addition, if you do charge for a procedure the documentation required to prove you did indeed do the charges associated with it is ludicrous. Our charts and have doubled in size in the last five years. Thus, increasing our paper, charts, and storage costs.
Adding insult to injury, there are these insane code edits( regulations)that if you perform x on this day you cannot charge y or z unless it is on another day. Even if the charges are totally unrelated. Huh?
Thus it is easy to see that it is a very grey area on what can be charged and what cannot. What I've described here is only the tip of the iceberg. If only Medicare could state in black and white you can charge x,y, & z but not n for this procedure the costs of healthcare would instantly decrease. And my productivity would inversely increase. Not to mention the positive effects on my frustration levels
Monday, February 28, 2005
An avid reader, I've been engrossed in the recent swell of medical blogs. From The Cheerful Oncologist to A Chance to Cut is a Chance to Cure I've found it interesting to get the inside viewpoint of the different disciplines in the medical field.
Thus, I decided to embark on my own medical viewpoint blog but from a little different aspect. Most medical blogs I've read are from a physician's viewpoint. This fills a definite need but there is a gap out there I would like to begin to fill - the view from an Oncology hospital administrator/director. The often misunderstood or disliked discipline that has the unfortunate challenge of attempting to manage a business with a mission while assuring that both physicians and staff are satisfied. A truly thankless job.
I manage two cancer centers in a large healthcare system in the Southeastern United States. My background has roots in the Radiation Oncology field more specifically Medical Dosimetry as a Certified Medical Dosimetrist. What's that? Click Here for an explanation. I also have a degree in Education of which I use sparingly outside my day job.
So I ask you to join me in my discussion of the frustrations and rewards of the life of an Oncology Administrator. In addition, I hope to give you insight to the sometimes encouraging, sometimes discouraging world of Oncology.