Dr. Zoe Maher has never been busier. In addition to being a trauma surgeon and a new mom, she’s spent the last year and a half talking to hospital patients and community groups across Philadelphia about a study she’s confident will save more adult gunshot and stab wound victims.
On a recent Saturday morning, Maher stood before a dozen members of a North Philadelphia neighborhood association to walk them through the specifics of the Philadelphia Immediate Transport in Penetrating Trauma Trial. At the heart of the study is a simple but counterintuitive idea. For patients who are potentially bleeding to death, Maher and her colleagues say, basic, stabilizing care is better than more advanced care until they reach the hospital.
To test this, patients in the study would get different medical attention based on the dispatch number city paramedics receive — what’s called a randomized study.
“It’s like the flip of a coin if patients are getting advanced or basic,” said Maher, who works at Temple University Hospital.
People with odd dispatch numbers will get what’s called advanced care, which is what the majority of patients transported by paramedics get now. It includes procedures like inserting a breathing tube or supplying intravenous fluids.This story is part of a partnership that includes WHYY, NPR and Kaiser Health News. It can be republished for free. (details)
Even numbers will get what’s known as basic care, which can include hemorrhage control, breathing assistance with a bag-valve mask, dressing wounds and aligning bones. They would then be immediately transported to the hospital.
But the idea of assigning types of care randomly got mixed reviews at the community meeting in North Philadelphia.
Joanne Taylor was wary, but, like nearly everyone in the room, she has first-hand experience with gun violence. She said she is mourning a husband, son, grandson and cousin, so she’s willing to support anything that may save more lives.
“It shakes me up a little bit, but I know something has to be done somewhere,” said a teary-eyed Taylor afterwards.
Others had more trepidation.
“In the interim, you’re still sacrificing people, somebody,” said Charles Lanier.
Yanitza Gonzalez, a staffer with City Councilwoman Maria Quiñones-Sánchez, nodded from across the room.
“It almost seems like we’ll be gambling with people’s lives,” said Gonzalez.
Community buy-in is key for Maher. She wants to tell as many people about the study before patients are enrolled, potentially this fall, and she told them residents can opt out.
Maher has heard the gambling response before, but she’s convinced that her study is closer to a sure thing. She said previous research has proven as much, and that her trial is just about confirming those results.
The study would look only at use of IV fluids and breathing tubes, explained Maher.
That’s because if someone is shot or stabbed and bleeding to death, the body instinctively tries save itself by constricting blood vessels and forming clots. For those clots to stick, the body needs to maintain a lower-than-normal blood pressure. IV fluids can raise a patient’s blood pressure and potentially cause more internal bleeding.
Maher said a breathing tube could also be problematic and cardiopulmonary resuscitation or CPR is a better option because it keeps more blood moving from the heart to the rest of the body.
On average, about 30 percent of patients who would qualify for this study die. If basic care becomes the norm for paramedics in Philadelphia, Maher says the rate could get down to roughly 20 percent. In a city that routinely records 250-plus murders each year, that could mean a lot of lives being saved.
Dr. Brent Myers, president-elect of the National Association of EMS Physicians, said the study is a big deal for medical professionals, especially paramedics.
“This has been one of the great questions: How much advanced life support is beneficial for victims of penetrating trauma?” Myers said. “You could probably go to any paramedic in any city in the United States and engage in a debate, because we just don’t have the appropriate evidence to guide the decision.”
It’s part of why Myers said he wouldn’t expect a lot of grousing from paramedics, even though it will effectively dictate what they do in the field.
Dr. Amy McGuire, a medical ethicist at Baylor University in Texas, said while the study does carry some risk for patients, there’s nothing inherently unethical it.
“The only way to really know whether this is better or not is to do a randomized trial and to compare it to what is currently the standard of care,” McGuire said.
Where she does see some moral gray area is in the community outreach piece of the trial. It’s impossible for everyone in the city to know about the study before it gets underway.
“They’ll be enrolled in the study, and they may not have wanted to have participated,” said McGuire.
Every resident in Philadelphia is a potential enrollee in the study, all 1.5 million people. But residents can choose to not participate. They would get a wristband that they’d have to wear for the duration of the study, which is expected to last five years, maybe more.
Researchers hope to enroll roughly 1,000 patients, half of whom would get advanced care, half would get basic care. Anyone who is under 18, pregnant or a prisoner will be excluded.
Maher said the study would end early if it’s clear that one kind of care is doing more harm than good.
“All of the evidence points to us being right, but if we are wrong, we will not complete the study,” said Maher. “We surely don’t want to hurt anyone.”
Every trauma center in the city is participating. That includes: Temple University Hospital, Hospital of the University of Pennsylvania, Hahnemann University Hospital, Thomas Jefferson University Hospital, Einstein Medical Center, Aria Health Torresdale, and City of Philadelphia Fire Rescue.
MADISON, WIS.— Something astonishing has happened in the past year to outpatient treatment at the Veterans Affairs hospital here.
Vets regularly get next-day and even same-day appointments for primary care now, no longer waiting a month or more to see a doctor as many once did.
The reason is they don’t all see doctors. Clinical pharmacists — whose special training permits them to prescribe drugs, order lab tests, make referrals to specialists and do physical examinations — are handling more patients’ chronic care needs. That frees physicians to concentrate on new patients and others with complex needs.This KHN story also ran in USA Today. It can be republished for free (details).
A quarter of primary care appointments at the Madison hospital are now handled by clinical pharmacists since they were integrated in patient care teams in 2015. Several VA hospitals — in El Paso, Texas, and Kansas City, Mo., among them — have followed Madison’s approach and more than 36 others are considering it, according to hospital officials.
“It’s made a tremendous positive impact in improving access,” said Dr. Jean Montgomery, chief of primary care services at the Madison hospital.
That’s critical for the VA, the focus of a national scandal in 2014 after news reports revealed the Phoenix VA hospital had booked primary care appointments months in advance, schedulers falsified wait times to make them look shorter and dozens had died awaiting care. Further investigations uncovered similar problems at other VA facilities. More than two years later, tens of thousands of vets are still waiting a month or two for an appointment, according to the latest data from the VA.
The Obama administration has allowed some veterans to seek care in the private sector if they choose, but VA wait times remain long and more action is needed, the General Accountability Office reported in April.
Expanding clinical pharmacists’ role is a solution.
They receive two more years of education than regular pharmacists and they can handle many primary care needs for patients, particularly after physicians have diagnosed their conditions.
The VA has had them for more than 20 years, but their growing involvement in patient care is more recent. This year it employs 3,185 clinical pharmacists with authority to prescribe medications, order lab tests and perform physical assessments — nearly a 50 percent increase since 2011.
“It’s having a significant impact on reducing wait times and our office is trying to expand more of them nationally to increase access,” said Heather Ourth, national clinical program manager for VA Pharmacy Benefits Management Services.
In 2015, VA clinical pharmacists wrote 1.9 million prescriptions for chronic diseases, according to a report co-authored by Ourth and published in September in the American Journal of Health-System Pharmacy.
A goal is to increase the use of clinical pharmacists to help patients with mental health needs and pain management.
“This helps open up appointment slots for physicians to meet patients with acute care needs,” Ourth said.
Clinical pharmacists’ authority is determined at each VA hospital based on their training and knowledge.
The Madison VA allowed clinical pharmacists to take over management of patients with chronic diseases such as diabetes and high blood pressure, participate in weekly meetings with doctors and other members of patients’ care teams and handle patients’ calls about medications.
They typically see five patients in their office each day, usually for 30 minutes each, and they talk to another 10 by telephone, said Ellina Seckel, the clinical pharmacist who led the changes at the hospital.
Many issues involve adjusting medication dosages such as insulin, which do not require a face-to-face visit. When Seckel sees patients, she often helps them lower the number of drugs they take because they may cause unnecessary complications.
Expanding clinical pharmacists’ role in primary care has cut readmission rates and helped more patients keep their diabetes under control, Seckel said.
VA hospital officials in both Madison and El Paso said they faced challenges initially in persuading doctors to delegate some duties to qualified pharmacists.
“Some physicians feel like it’s a turf war and don’t want to refer their patients because they feel the clinical pharmacist is trying to practice medicine,” said Lanre’ Obisesan, a clinical pharmacist and assistant chief of pharmacy at the El Paso VA.
Even so, the El Paso VA’s average wait time fell from two months to two weeks, he said, after it added several clinical pharmacists and gave them independence to help patients. About 30 percent of the VA patients in El Paso have used clinical pharmacists, Obisesan said.
That share will rise. The hospital now has one clinical pharmacist for every six physicians, but it aims to add more pharmacists to reduce the ratio to 1 to 3.
The Madison VA is close to that ratio now after adding four clinical pharmacist positions in the past year.
Patients there can choose whether to see a doctor or a pharmacist. With approval from primary care physicians, pharmacists took over 27 percent of the follow-up appointments for patients with chronic illnesses, Seckel said.
That shift yields benefits for both doctors and patients, said Montgomery, the head of primary care services at the Madison VA.
Many VA doctors only have time to deal with patients’ acute care issues, such as knee or back pain, with little time to focus on a patient’s multiple chronic illnesses and often a dozen or more medications they may be taking for them.
“The more we can have members of the team to do routine things that do not require a physician’s time the better the quality of the visit and the better patient outcomes,” he said.
Patients seem to like what the hospital is doing.
Stephen Howard Foster saw a clinical pharmacist recently who told him he could stop taking one heartburn medication and switched him to another medicine to reduce side effects. He said he was comfortable with the pharmacist advising him without first consulting his physician and he saved time.
“This is a good idea rather than put up with normal delays,” said Foster, 51.
Another Madison VA patient, Mike Fonger, 71, saw clinical pharmacist Anita Kashyap recently to get a blood pressure check, lab test results, a review of his medications and to change an ointment he was taking for back and shoulder pain. Kashyap also helped him ease the side effects from the cholesterol-lowering drug he takes by cutting his dosage in half.
“I like the extra attention I get here,” Fonger said.
Aging can take a toll on teeth, and for many seniors paying for dental services is a serious concern because they can’t rely on their Medicare coverage.
Low-income seniors, in particular, are struggling. More than a third with incomes below 200 percent of the federal poverty level (about $23,000 annually) had untreated tooth decay between 2011 and 2014, according to an analysis of federal data by the American Dental Association.
“What ends up happening is that almost everybody, when they get to be 65, is sort of on their own and they have to pay for dental care out of pocket,” said Dr. Michael Helgeson, chief executive officer of Apple Tree Dental. Apple Tree is a Minneapolis-based nonprofit organization operating eight clinics in Minnesota and California that target underserved seniors, as well as mobile units that provide on-site dental care at nursing homes and other facilities.Insuring Your Health
KHN contributing columnist Michelle Andrews writes the series Insuring Your Health, which explores health care coverage and costs.
To contact Michelle with a question or comment, click here.
This KHN story can be republished for free (details).
Traditional Medicare doesn’t usually cover dental care unless it’s related to services received in a hospital. Medicare Advantage managed care plans generally provide some dental care, but the coverage can vary, and often is minimal, dental advocates say. The plans often are “a loss leader,” said Dr. Judith Jones, a professor of dentistry at Boston University. “It’s meant to attract people. It gets people in but the coverage is really limited.”
In a way, older people are victims of dentistry’s success. Regular visits to the dentist, along with daily tooth brushing and water fluoridation, have all contributed to improvements in oral health. In the first half of the 20th century, by the time people reached their 30s or 40s many had already lost all their teeth, Helgeson said, while today more than 60 percent of people in nursing homes still have at least one tooth.
But teeth need tending. Without regular dental care, tooth problems can cause pain and limit how much and what type of food people are able to eat. Similarly, gum disease can loosen teeth and allow bacteria to enter the body. A growing body of research has linked treating periodontal disease with lower medical costs for diabetes and heart disease, among other conditions.
People’s lives are affected in other ways by their oral health. “You use your mouth to eat and kiss and smile and interact socially,” said Jones. “It’s a source of great embarrassment and suffering for many adults without access to care.”
With limited income and no insurance, seniors may skip visiting the dentist regularly, even though many report that their mouths are dry and painful, and they have difficulty biting and chewing, not to mention avoiding smiling and social interaction if they have missing or damaged teeth.
Medicaid, the state-federal program for lower income people, covers dental care for children in every state, but coverage for adults is much spottier. Most states cover emergency dental care, but eight states offer no adult dental benefits at all, according to a study by Oral Health America, an advocacy group.
Even trying to purchase private dental insurance, which typically covers a few thousand dollars worth of dental care, may not provide good value, said Marko Vujicic, vice president of the American Dental Association’s Health Policy Institute. “When you add up the premiums and copays, for the vast majority of adults it’s not worthwhile to have dental insurance,” he said.
Seniors with traditional Medicare spent $737 on average out-of-pocket on dental care in 2012, said Tricia Neuman, director of the Program on Medicare Policy at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)
But the figures may be much higher for people who need major restorative work.
“I know people who are spending sometimes more than $10,000 on what they consider essential dental care, like implants, none of which is covered,” Neuman said.
Seniors with limited means have few options for help affording dental care. Federally qualified health centers may provide geriatric dental services on a sliding-fee scale, and clinics like Apple Tree help a limited number of seniors who live in their service area. But they’re a band-aid, said Jones.
She and other advocates want Medicare to add a dental benefit to Medicare Part B. Their proposal would provide a basic bundle of diagnostic and preventive services through a premium increase, and seniors would only be responsible for copayments if they need pricey restorative work like crowns and bridges.
“Over the years, there has been some interest in expanding Medicare to include dental coverage,” Neuman said. But a dental benefit has faced stiff competition from other priorities, including adding a prescription drug benefit in 2006 and preventive coverage under the health law in 2010.
But some people think this time might be different. “There are 250,000 people every month who are turning 65, and 30 percent of dentists say they could use more business,” said Beth Truett, president and CEO of Oral Health America, which supports the proposal. “It’s a perfect storm.”
KHN’s coverage of aging and long-term care issues is supported by The SCAN Foundation.
Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.
Provider directories for private Medicare Advantage plans are riddled with errors, according to the government’s first in-depth review.
The results made public Monday, arriving amid the annual enrollment period through Dec. 7, validate gripes long made by seniors and consumer advocates. The level of errors still surprised regulators, said officials from the Centers for Medicare & Medicaid Services who disclosed their findings at an industry conference in Washington.
Incorrect information was found for almost half of the 5,832 doctors listed in directories for 54 Medicare Advantage plans checked last fall, they said. Only online directories were examined.
The government hopes that a new rule this year will help raise that bar because it requires Medicare Advantage plans to contact doctors and other providers every three months and update their online directories in “real time.”
CMS did not identify the names of insurers that were surveyed.Use Our Content This KHN story can be republished for free (details).
CMS’ survey found the most error-prone listings involved doctors with multiple offices that did not serve health plan members at each location, said Christine Reinhard, a health insurance specialist in the CMS Division of Surveillance, Compliance and Marketing.
Explanations could be that the doctor was retired, worked at a different location or never worked at the address. Or maybe the doctor never had a contract with the Medicare health plan — a less likely possibility, according to officials.
The review also uncovered:
- Wrong phone numbers for 521 doctors’ offices.
- Wrong addresses for 633 doctors’ offices.
- Error rates that exceeded 60 percent of the doctors surveyed for five Medicare Advantage plans.
CMS has not issued any fines but that could still occur, said Jeremy Willard, also a health insurance specialist in the CMS surveillance division. Inaccuracies found in the Medicare Advantage directories could lead to penalties up to $25,000 a day per beneficiary or bans on new enrollment and marketing.
Senior citizens rely on provider directories when choosing a health plan to identify in-network doctors. They also use them when seeking referrals to specialists.
“Errors jeopardize the beneficiary’s ability to be connected with a needed provider,” Willard said.
CMS carried out the survey by randomly calling 108 doctors representing primary care, cardiology, ophthalmology and oncology for the Medicare Advantage companies. The highest error rates involved primary care physicians and cardiologists.
America’s Health Insurance Plans, the industry trade group, said its companies work hard to make provider directories accurate and keep them up-to-date.
“That’s what consumers need — and that’s what we’re committed to improving,” said spokesman David Merritt, acknowledging that plans needed to do better.
More than 17 million Americans, or nearly a third of Medicare beneficiaries, get coverage through Medicare Advantage plans.
Medicare Advantage plans and most exchange plans restrict coverage to a network of doctors, hospitals and other health care providers that can change during the year.
CMS is also surveying Medicare Advantage companies this fall, and officials hope to survey every company by 2018 when the three-year review will be completed.
The widespread drop in state support for schools over the past decade — which we’ve documented in our new report — reflects outside factors, such as weak revenues and rising costs, as well as state policy choices, such as relying on spending cuts to close budget shortfalls and cutting taxes.
While reviewing a truck of materials, I found three items with the following bookplate:Since I had run across this bookplate before and admired it, I thought it would be a great visual to share in a blog post. This bookplate was specifically designed for the Yudin Collection. The Library of Congress acquired the Yudin Collection from the Siberian collector and bibliophile Gennadii Yudin (1840-1912) in 1906. It is the foundation of the Library’s Russian collections. When the volumes arrived at the Library in 1907, they were housed with the Slavic collection for a time, and then the volumes were sent to the relevant custodial divisions. Splitting the collection was a lucky break for the Law Library, which benefits from holding a number of Russian law volumes in our rare and special collections. The photo you see here is from one of our Yudin volumes.
According to Harry Leich, the Russian area specialist who has published articles about the collection, the plate was probably designed by Yudin himself. It’s also possible Yudin told Librarian of Congress Herbert Putnam and/or Alexis Babine, the Russian literature specialist who brought the material back from Russia, what design he wanted on the bookplate. On the left of the plate is a portrait of Yudin; in the center a drawing of St. Basil’s Cathedral in Moscow, and on the right a drawing of Yudin’s library building in Tarakanovo. There are two versions of the bookplate, the second one printed by the former U.S. Government Printing Office (GPO) in 1928 after the Library ran out of the bookplates it had printed for the arrival of the collection in 1907. When GPO printed a run in 1928, it printed the agency’s name across the bottom to credit their printing job– but not the design.
The law materials from the Yudin Collection are just some of the materials you can find here in our Law Library collections on the shelf.