When Your Hospital Doctor Doesn’t Work for the Hospital

Increasingly, for-profit companies are delivering clinical healthcare services, raising issues about goals, costs, and quality. Understanding the business decisions that ultimately affect patients is critical, and one major financial decision facing hospitals across the country is the decision to outsource clinical and non-clinical services. Outsourcing in healthcare is an issue I’ve been able to study and write about in “The High Stakes of Outsourcing in Healthcare” published in the November issue of Mayo Clinic Proceedings. To probe further beyond our paper, I interviewed a hospital CEO about his experience with outsourcing healthcare functions, asking him about when outsourcing is appropriate as well as its risks and benefits. Outsourcing in healthcare is a hot-button issue and such conversations can quickly spark controversy. To pave the way for total candor, the CEO and I agreed to keep his name anonymous. I’ll refer to him as “Chuck.”

Chuck has had significant experience in outsourcing hospital services, including cleaning, food, and physician services that include emergency medicine, radiology, and pathology. Our conversation began by discussing the outsourcing of patient-facing services, such as emergency room care. Most patients are unaware that half of ER doctors in the U.S. don’t actually work for the hospital, but rather they work for a contract management group that staffs the hospital’s emergency department. Chuck discussed how physician groups are often contracted for their expertise; however, patients don’t always benefit from these arrangements. Chuck said, “When you go to the ER, the hospital will charge you for your CT scan or your X-ray, but you’ll also get a bill from your ER doctor who works for a separate company. And, your scan was probably read by a radiologist, so you’ll get a radiology bill, too. Multiple groups billing the patient can lead to higher costs for the patient, particularly if one of the outside clinicians is out of the patient’s insurance network.” Hospitals tell physician group contractors to maintain insurance contracts with the hospital’s same group of insurers, but this doesn’t always happen, and resulting out-of-network bills contribute to the surprise medical billing we’ve seen across the country.

I asked Chuck about one of the findings in our research which was that although outsourcing companies may bring in “expertise,” they don’t always deliver on quality. He said that he hasn’t seen this as often with physician services as he does with non-patient facing services, such as hospital cleaning and food services. In our paper, my co-authors and I discuss a study showing that hospitals that outsource their cleaning services report significantly higher hospital acquired infection rates. When I asked for Chuck’s experience with outsourcing cleaning services, he echoed many of the findings in our research, saying, “When you talk about cleaning services, you have to ask: how does a third party profit off of this business when it’s not a business our hospital wants to be in? And that’s where you see inferior benefits for employees, you may see compression of wages… and with some of these service providers, I’ve seen relatively high turnover, in part because they may not have as rigorous pre-employee screening as we do. With all of this, you very well could be getting a lower-quality employee.”

Chuck’s discussion of the different outsourcing contract structures that hospitals enter into was fascinating. He explained the two most common, yet competing, outsourcing arrangements. The most commonly used contract is called a Profit & Loss Contract. That’s where the contractor says something like, “Let me sign a 5-year deal with your hospital to do all your housekeeping services. And I’m going to do that whole deal for $1 million.” Let’s say that $1 million contract breaks down as follows: $850,000 in wages, $50,000 in supplies, and $100,000 in management fees (profit). With such an agreement, Chuck says, “For the contractor to preserve its margin of $100,000, it will inevitably have to cut back on some other piece of the pie if costs are higher than expected (e.g. due to wage inflation over the 5-year period) or the contractor just wants to beef up their profit margin. And the way I’ve seen it most commonly play out is that as the contract progresses from year one to year five, you start to see suppression of the number of employees in order to cut back on wage spending. This is why at the beginning of the contract period, the contractor may provide 40 cleaning staff, but by the end of the contract period, there are only 32 staff. My hospital hasn’t changed in size over those 5 years, but now there are fewer cleaning staff… that’s where you start seeing quality issues. With Profit & Loss Contracts, there tends to be growing dissatisfaction with time.”

The second type of contract is the Management-Fee Contract (also known as a Cost-Plus Contract). In the same scenario, rather than signing a 5-year deal for a fixed amount of money, the contractor comes to the hospital and says, “I’m going to provide your hospital with 40 cleaning staff because that’s what I think it takes to provide high quality service. I’m going to take a management fee of $100,000, and I will bill your hospital for all the operating costs.” In this model, the supply and wage costs are passed down to the hospital. Chuck says that with this model, “as the contractor gives its staff wage increases, they don’t have to cut back on labor to preserve their profits because their profits are guaranteed and were made transparent through the stated management fee.” The hospital covers all of the costs of wages and other operating expenses. In this scenario, Chuck says that “the hospital may pay a little more each year compared to the Profit & Loss Contract, but the quality of service is maintained over time.” Chuck says that he likes the Management Fee structure, but it is the rarity and not the norm.

The decision to outsource hospital services is not one to be taken lightly, and when outsourcing is appropriate, hospitals should employ a contract arrangement that prioritizes patients over profit. Additionally, patients often don’t know of all the external financial relationships doctors have, and if you have to visit the ER, it may be worth asking if your work-up will involve doctors out of your network. Because the last thing we all want is a big bill and an unhappy surprise.

*I spoke with a hospital CEO about the risks of outsourcing in healthcare and how some patients can get an unaffordable, surprise bill from their hospital.*

Congress’s Overdue Baby is Named ‘Paid Family Leave’

Republicans and Democrats have found every way to disagree when it comes to health policy, and this has caused us to lag behind on enacting legislation that will move our country forward. One of those policies is paid family leave following childbirth. There are not many similarities between the United States and Papua New Guinea, but surprisingly our great nation and New Guinea are two of very few nations that do not provide paid family leave after childbirth. But, we are at the perfect time for change. While the Family and Medical Leave Act, which provides up to 12 weeks of unpaid and job-protected leave, was passed under Clinton, President Trump has been a leader in the Republican party by being the first Republican president to endorse paid family leave for mothers and fathers after a newborn or an adopted child.

The first months of life are the most critical for a child. Poor upbringing can negatively impact a child’s entire life, and right now, only 17% of private industry workers have access to paid family leave. In our fiercely capitalistic society, almost 80% of Americans live paycheck to paycheck, and this makes taking time off to care for a newborn more challenging than ever before, which is why 25% of mothers must return to work within 10 days of giving birth. Researchers using data from the U.S. National Survey of Family Growth found that mothers who have access to paid leave are more likely to begin breastfeeding their newborn and are twice as likely to continue breastfeeding at 6 months compared to mothers who do not have access to paid family leave. Without breastfeeding or adequate time for bonding, a child’s full potential may be hindered. Unfortunately, there are no long term studies on the effects of paid family leave; however, it could be argued that the severity of future issues for a child and the likelihood of the child to utilize social welfare during adulthood is reduced if proper care during infancy is provided. This system overwhelmingly negatively affects the poor, who are often kept in cycles of substandard academic performance, but legislation on the floor of Congress could break that cycle.

Women who receive paid family leave have a higher likelihood of returning to their job, which benefits the entire system involved—the employer benefits from not having to spend additional money on training a new employee and the US economy benefits from a higher and more dedicated labor force. However, the largest challenge to the enactment of paid family leave is the possibility that some employers will choose not to hire women who are likely to have a child. This notion is substantiated by empirical data from New Jersey, which implemented statewide paid family leave in 2009. A 2016 study in New Jersey found that employment rates for women aged 22 to 34 fell about 8%. However, data is limited and states such as California have found that 90% of employers felt positively or neutral about paid leave after it was enacted statewide in 2004.

Now, with all this said, what are the plans currently being debated on the floor of Congress? As with the majority of our politics today, all the paid family leave proposals in Congress can be represented by two main plans: a fiscally conservative plan, led by senators Marco Rubio and Mitt Romney, as well as a liberal plan, led by senator and democratic candidate Kirsten Gillibrand. The two significant plans are briefly described below, and the best path of action is highly debated… where do you stand?

Gillibrand’s FAMILY Act: A working parent can receive 12 weeks of paid leave at 66% of normal wage with a maximum benefit of $4000/month. This plan would be paid for with a 0.2-0.4% payroll tax on all working American employees and employers, depending on your employment status. This is how the system is paid for by states like New Jersey that have already implemented statewide paid parental leave. One of the main concerns with this plan is that it adds a new tax. Despite a great federal deficit, our current administration and Congress voted on and passed a significant tax cut in 2017. Because of this, it is very unlikely that a plan proposing to add a new tax to working Americans will be well received by Republican congressmen.

Rubio and Romney’s New Parents Act of 2019: Working employees and employers contribute to social security, and this bill allows parents to tap into their future social security benefits to finance their leave, which can be up to 12 weeks. You are essentially paying for your own leave with money you were going to receive. In exchange for using this money earlier, a parent may work for 3-6 months past retirement age and continue contributing to their social security during this time, or they may receive small reductions in their social security benefits upon retirement. Similar to the FAMILY Act, parents will receive about 66% of their normal wage until a maximum benefit is reached. Overall, this mitigates the cost burden on employers, employees, and companies as a whole.

A significant issue is that there is bipartisan agreement that something needs to be done; however, neither side has been willing to accept the other’s way of acting, and this has blocked the enactment of any substantial federal bill regarding this issue. Right now, Democrats may need to accept that a full-benefit bill (FAMILY act) may not pass because of the added new tax stipulation that is highly unfavored among Republicans, who currently control the Senate and the Presidency. It may be important to start slowly with a more moderate bill like the New Parents Act proposed by Republicans, which is a more practical and feasible solution in our current state of no federal mandate for paid family leave.

Sources:

Burtle, A., & Bezruchka, S. (2016, June 01). Population Health and Paid Parental Leave: What the United States Can Learn from Two Decades of Research.

Jou, J., Kozhimannil, K. B., Abraham, J. M., Blewett, L. A., & McGovern, P. M. (2017, November 02). Paid Maternity Leave in the United States: Associations with Maternal and Infant Health.

May, A. (2017, May 18). Paid family leave is an elite benefit in the U.S.

Mirkovic, K. R., Perrine, C. G., & Scanlon, K. S. (2016, March 17). Paid Maternity Leave and Breastfeeding Outcomes – Mirkovic – 2016 – Birth – Wiley Online Library.

O’Dea, C. (2019, February 11). Lawmakers Move to Improve Paid Family Leave Program in New Jersey.

Vesoulis, A. (2019, May 16). Americans Could Finally Get Paid Family Leave. But Who Pays?

Warner-Richter, M. (2017, October 27). Paid parental leave is rare, but good for kids.

Congressional Research Service: Paid Family Leave in the United States

National Partnership for Women & Families: The Family And Medical Insurance Leave (FAMILY) Act

S.463 – FAMILY Act 116th Congress (2019-2020)

S.920 – New Parents Act of 2019 116th Congress (2019-2020)

America is Bleeding, and Congress is Trying to Stop It

With 16 physicians in Congress, America has taken great steps toward putting healthcare providers in a position to address our nation’s most pressing healthcare issues. We have all heard about the most prevalent causes of death in America such as heart disease and cancer, but trauma is actually the leading cause of death for Americans aged 1-44. Whether it’s a car accident, a fall, or even gun violence, trauma kills over 200,000 people per year in the US alone. The figures abroad are in the millions. Every year, trauma-related injuries cost the US almost $700 million. Many of these deaths are caused by massive blood loss, and around 20% could be prevented. With millions of dollars and thousands of lives to be saved, Congressman and physician Dr. Brad Wenstrup (R-OH) and Congressman Alcee Hastings (D-FL) have introduced bipartisan legislation, the Prevent Blood Loss with Emergency Equipment Devices Act of 2019 (H.R.2550), also known as the Prevent BLEEDing Act, which would require blood loss equipment such as tourniquets (a device tightly wrapped around an arm or a leg to stop bleeding) and clotting bandages in public spaces like libraries, schools, and malls.

I sat down with the Chairman of National Stop the Bleed Month Andrew D. Fisher, a fellow Aggie, to talk about this bill and other ways we can improve trauma care in the United States. As a Major in the US Army, Andrew Fisher’s military and civilian experience is extensive. He has completed over 500 missions with a total of 30 months deployment in Iraq and Afghanistan as a physician assistant, and he is a recipient of the Purple Heart. Fisher’s military prowess led him to be named the 2018 U.S. Army Hero of Military Medicine. Now, at the age of 46, Fisher has over 40 publications in peer-reviewed medical journals and is in his last year of medical school at Texas A&M College of Medicine.

Many Americans know how to perform CPR, but Fisher points out that after receiving CPR, only around 10% of patients survive to the time of discharge. However, Fisher says that in the case of massive blood loss, the application of a tourniquet yields a higher survival rate. His previous unit in the US Army brought prehospital mortality from blood loss down to zero after proper blood loss training was given. So far, tens of thousands of people have been trained in bleeding control through National Stop the Bleed Month, and all the training has been completed for free and supported by the American College of Surgeons. Furthermore, traditional CPR/AED courses should add basics about bleeding control. A Texas study found that the mortality rate after a severe vascular injury to the arms or legs was 8% without the application of a tourniquet immediately after injury. However, the mortality rate drops down to 3% for patients who receive a tourniquet. Learning how to use a tourniquet could be vital in a deadly situation.

My own uncle passed away six years ago in a bus accident, and his life could have been saved through the use of a tourniquet. His arm was severely injured in the accident, and he was bleeding out. In a perfect situation, a tourniquet would have been available on the public bus. In this case, a bystander would have wrapped his arm above the site of bleeding, and the tourniquet could have stopped blood from leaving the major artery in his arm. Even where a tourniquet is not available, any type of band, scarf, or long piece of fabric can be used to tightly wrap the arm or leg above the site of bleeding.

When I asked Andrew Fisher about the Prevent BLEEDing Act, he said that he appreciates Congress’s efforts, but noted that the federal government is “a little late to the game.” Fisher pointed out that a few states, such as Georgia, have taken matters into their own hands by equipping every Georgia public school with bleeding control kits. Actions by the slow-footed federal government may not be the most desirable; however, the ratification of this bill would greatly advance bleeding-control education, provide a federal mandate for the availability of blood loss supplies in public spaces, and situate blood-loss prevention as a nationally recognized issue.

Mass shootings in public spaces, such as the Las Vegas Shooting in which 58 people were killed and 851 were injured, have become more common. Bullets can cause major bleeding in an extremity, and death can occur in minutes, which is why time is essential. After the horrific shooting at Sandy Hook Elementary School in which 20 children and 6 adults were killed, the Hartford Consensus was created to improve the response to mass casualty and active shooter events. The Hartford Consensus calls for bleeding control bags to be present in places such as schools. And although it’s debated whether or not teachers should be armed, there are no apparent downsides to having teachers learn basic bleeding control techniques in the case of an emergency.

Fisher emphasizes that one is unlikely to be a victim of a terrorist attack or a school shooting; however, the chance of being in a car accident is much greater. This is where the vitality of emergency medical technicians (EMTs) and paramedics comes into play. These emergency responders are the first experts to the scene, and their actions frequently determine the life and death of a patient. One of the most common injuries from a major car accident is internal bleeding, which cannot be stopped through the basic application of a tourniquet. However, a procedure called REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) can be done by inflating a balloon in the aorta to temporarily stop blood loss. Currently, only trauma-related physicians are able to perform this procedure. However, Fisher along with countless others in the field of pre-hospital medicine, are calling for the training of paramedics to perform the procedure in a life or death situation. Fisher, a former paramedic, says that it is a challenging skill, but it may save more lives after traumatic injury. In addition to REBOA, Fisher believes that all paramedics should be trained on the administration of ketamine as a pain-reliever. Trauma related injuries can cause excruciating pain that warrants care, which is why first responders must be trained to administer safe pain-relievers to severely injured patients. Only half of paramedics report learning about ketamine during their training; however, ketamine has been vetted through research and has been shown to be a powerful and safe tool for pain relief in the pre-hospital setting. Fisher also believes that EMT standards should drastically increase to broaden their understanding of anatomy and pathophysiology, noting that professional hairdressers have to complete over 1000 hours for their program while based on national averages, EMTs only have to complete a total of 120-160 hours. Overall, furthering the knowledge and clinical skills of our medical responders has the potential to better stabilize patients before they reach the hospital and ultimately save lives.

Thousands of bills flow through our legislative bodies, and the majority of the bills signed into law are sponsored by Republicans and Democrats. The Prevent BLEEDing Act, which would appropriate $10 million to making blood loss supplies more accessible in public spaces, has already gained bipartisan support, and this bill along with other improvements in emergency medicine would have a positive impact on trauma care in the United States.

*Major Fisher and I met to talk about trauma care and prehospital medicine*

Sources:

Buckland DM, Crowe RP, Cash RE, et al. Ketamine in the Prehospital Environment: A National Survey of Paramedics in the United States. Prehospital and Disaster Medicine. 2017;33(1):23-28. doi:10.1017/s1049023x17007142.

Civilian Prehospital Tourniquet Use is Associated with Improved Survival in Patients with Peripheral Vascular Injury. Teixeira, Pedro G.R.Vu, Megan et al.Journal of the American College of Surgeons, Volume 226, Issue 5, 769 – 776.e1

DiMaggio C, Ayoung-Chee P, Shinseki M, et al. Traumatic injury in the United States: In-patient epidemiology 2000-2011. Injury. 2016;47(7):1393–1403. doi:10.1016/j.injury.2016.04.002

Hastings and Wenstrup Introduce the Bipartisan Prevent BLEEDing Act of 2019. U.S. Congressman Alcee L. Hastings. https://alceehastings.house.gov

Hax SD, Davis K, Stone B, Bledsoe B, Hodnick R. Ketamine’s Versatility Makes it a Powerful Tool for EMS. Journal of Emergency Medical Services. https://www.jems.com/articles/print/volume-42/issue-2/features/ketamine-s-versatility-makes-it-a-powerful-tool-for-ems.html. Published February 1, 2017.

Stop the Bleed – Georgia – Georgia Trauma Foundation.

Zero Preventable Deaths After Injury. Washington (DC): National Academies Press (US); 2016 Sep 12. 1, Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK390332/

https://firstcareprovider.org/blog/tk-how-to

Giving Life Twice

Most mothers only give life to one child at a time, but about 800,000 women worldwide give life to two… and I’m not talking about twins. I’m talking about the donation of their umbilical cord blood, the blood that remains in the umbilical cord after childbirth. Most commonly, the umbilical cord and the placenta are thrown away after birth, but these organs contain precious stem cells that have the capacity to save lives… to give a second life to someone else.

Harvesting umbilical cord blood and utilizing it for treatment is a relatively new scientific advancement that started in the late 1980’s. Scientists and doctors have realized that umbilical cord blood is rich in stem cells, specifically multipotent hematopoietic stem cells. These are big words to describe a simple yet incredible cell. Multipotent hematopoietic stem cells are cells that can give rise to all the blood cells, which is why these cells are invaluable to someone suffering from a blood disease. So, how does all this work and what does it treat? Well, first of all, the procedure is painless for both the mother and the child, and it takes 2-5 minutes. To collect the umbilical cord blood after a baby is born, the physician first cuts the umbilical cord then simply puts a needle into the blood vessels of the umbilical cord before drawing out the blood. This blood is then stored and frozen at -196°C. Mothers who have donated this blood have described it by saying that they did not even know it was being collected until after the doctor told them that they were done. After this blood is tested and stored, it can be matched with a blessed patient somewhere around the world who needs a blood transplant. Umbilical cord blood can be used to treat patients with various types of common blood cancers and diseases, such as leukemia, lymphoma, as well as sickle cell anemia.

Numerous advantages exist for umbilical cord blood, including the following:

No/very little risk to donor
Easily stored
Cells collected are immunologically immature and have a high growth potential
Low incidence of Graft vs Host Disease, which is a disease where the grafted stem cells detect the normal cells as foreign, resulting in the stem cells attacking the healthy body cells
Blood type matching is easier with stem cells harvested from cord blood compared to the conventional stem cells harvested from bone marrow

Now, you may be wondering where all this blood is stored, and this is where the debate comes in. There are two options you can choose from for where your cord blood goes: public banks or private banks. Public banks are completely free, and this is where your cord blood goes into a world registry where a matching donor can be found and treated. However, private umbilical cord blood banks make up a several hundred-million-dollar industry. When the private bank option is chosen, the blood is collected and stored for the sole use of that family. These blood banks say that their service is “biological insurance” for your kid if anything goes wrong in the future, and this is simply misleading. Numerous marketing techniques are used on pregnant mothers to sell them a cord-blood bank plan, but the chance of the child ever actually using this cord blood is trivial. Some studies show the rate of private bank blood used being 0.09% while other studies show that public bank blood is 30 times more likely to be used than private. Furthermore, numerous studies have shown that the quality of cells and the number of stem cells are lower when kept by private cord banks versus public. As one study published in the journal Transfusion said, “Quality parameters of privately banked umbilical cord blood are inferior to those stored in public banks.”

Very few blood diseases can be treated with one’s own umbilical cord blood because if the disease is genetic, then the stored blood has the same genetic abnormality, thereby rendering it useless for the kid. Almost 90% of transplants are between unrelated people with the remaining 10% being between family members, which is another powerful benefit of umbilical cord blood. For example, if you have a kid who has been diagnosed with leukemia, and you also have another kid on the way, then the umbilical cord blood for the second child can be harvested and used for the baby’s brother. This can be done through public bank systems at little to no costs. I keep talking about how public banks do not cost you anything because of the striking difference between public and private banks. Private banks are very expensive! For example, let me tell you about one of the several well-known private cord blood banking companies. According to the company’s website, to store your cord blood, the company charges $1,575 for the collection of the blood and an annual storage fee of $175. That already sounds like a lot, but a greater opportunity cost exists here. At the time of your child’s birth, if you put $1,575 dollars into a mutual fund that grows at a conservative rate of 8%, and you contribute just $175 to that fund every year, here’s how much your kid will have after….

20 years: $15,000

40 years: $80,000

65 years (retirement): $560,000

Many people never attain more than half a million dollars in their entire life, and now your kid can have it just for them at the time of retirement. The sad reality is that while 800,000 women have publicly banked their blood, 5 million have used private banks. Umbilical cord blood is much better off in the hands of a public bank, and this notion is supported by the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and many more. As Dr. Paul Harker-Murray at UT Southwestern said, “Umbilical cord blood is an underutilized medical resource with immediate life-saving clinical applications,” which is why it is so important for pregnant women to strongly consider donating their umbilical cord blood to a public bank.

Sources:

Ballen KK, Verter F, Kurtzberg J. Umbilical cord blood donation: public or private? Bone Marrow Transplantation. 2015;50(10):1271-1278. doi:10.1038/bmt.2015.124.

Kurtzberg J. (2017). A History of Cord Blood Banking and Transplantation. Stem cells translational medicine, 6(5), 1309–1311. doi:10.1002/sctm.17-0075

Newcomb, J. D., Sanberg, P. R., Klasko, S. K., & Willing, A. E. (2007). Umbilical cord blood research: current and future perspectives. Cell transplantation, 16(2), 151–158.

Shenoy S. (2013). Umbilical cord blood: an evolving stem cell source for sickle cell disease transplants. Stem cells translational medicine, 2(5), 337–340. doi:10.5966/sctm.2012-0180

Sun, J., Allison, J., McLaughlin, C., Sledge, L., Waters-Pick, B., Wease, S., & Kurtzberg, J. (2010). Differences in quality between privately and publicly banked umbilical cord blood units: a pilot study of autologous cord blood infusion in children with acquired neurologic disorders. Transfusion, 50(9), 1980–1987. doi:10.1111/j.1537-2995.2010.02720.x

Waller-Wise R. (2011). Umbilical cord blood: information for childbirth educators. The Journal of perinatal education, 20(1), 54–60. doi:10.1891/1058-1243.20.1.54