While healthcare coupons may offer discounts on items and services reimbursable by the federal healthcare program, there are a lot of stipulations that have to be taken into consideration.

To help keep providers and facilities safe so they don’t break any laws, like those of the Federal anti-kickback statute, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) has issued an advisory opinion (No. 12-02) with the following guidelines:

• Coupons may only offer discount services, not free services. And providers must give the same discount to any third-party payor or insurance carrier that the provider offers to the patient. For example, a provider may not offer a 20% discount directed only at the patient’s cost-sharing amount. The website must include information explaining that the coupons apply to the entire service, and the coupons themselves must include similar language.
• The website offering the coupon can’t be that of a provider. It would have to be a third-party marketer that charges providers a flat fee to host the coupons. Any marketing done by a healthcare provider of any type would be subject to extra scrutiny. Reason: The OIG says “healthcare providers and suppliers are in a position of trust and may exert undue influence when recommending healthcare-related items or services.”
• Coupon use can’t be relied on by providers. The OIG states that providers and advertisers would pay a set fee, consistent with fair market value to purchase the space for posting their coupons on the website. And the fee wouldn’t take into account the volume or value of any business garnered by the coupon. For example, providers would be able to see statistics regarding how many times their profile was viewed and how many times customers downloaded their coupon, but the fee charged wouldn’t vary based on these statistics.
• Personal information about the coupon purchaser can’t be shared with the provider. In other words, an account can’t be a requirement to download the coupon, and any personal information provided, such as an email address, can’t be shared with the provider.
• The coupon has to be structured like the ones people get through snail mail. To decrease the risk of violating the anti-kickback statute, the customer can’t pay anything up-front for the coupon. Prepayment of a coupon increases the likelihood of service over-utilization. The example the OIG gave was, if a person bought a prepaid coupon for service x, when that person walks into the offering provider’s office requesting service x — having already paid for service x — the offering provider might feel pressure to render it even if it isn’t medically necessary.
• Providers must comply with the discount safe harbor. Under the arrangement, providers would be the “sellers” and the customers would be the “buyers” for purposes of the discount safe harbor.  To qualify for protection under the discount safe harbor, buyers and sellers have certain reporting obligations to ensure that any discounts are shared with federal healthcare programs.

What do you think about providers offering service coupons — good idea or just too risky? Share your thoughts below.

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Thanks to the skilled medical professionals who perform these surgeries, along with advanced medical technologies, mortality rates and complications have been significantly reduced. But despite ongoing medical advancements, there are still procedures that present high risk for complications during the procedure or recovery period.

Here’s a list of the 10 riskiest medical procedures:

10. Bariatric surgeries/Gastric yypass

As with many other major surgeries, there are risks that patients take when electing to undergo them, but these patients’ excessive weight poses even more threats. Surgeons have a harder time operating and must use special instruments because internal organs are often hard to separate and have may layers of slippery fat surrounding them. These patients also have an increased risk for complications with anesthesia, because it’s often difficult to insert the tube into their airways, and drugs or anesthetic gases may need to be given in higher dosages because they are easily absorbed by fat. Breathing must also be closely monitored before, during and after the surgery, as these patients have a higher risk of developing of pneumonia.

9. Septal Myotomy

This surgical procedure is performed to reduce the thickening of the heart muscles, a symptom of patients diagnosed with advanced stages of a complex type of heart disease called hypertrophic cardiomyopathy (HCM). This is a complicated procedure because it requires the patient to be placed on cardiopulminary bypass, or the “heart-lung machine”, so that the surgeon can work on a still heart. In total, this surgery can last anywhere from 3 to 6 hours, and the recovery period requires a stay in the Intensive Care Unit.

8. Pancreatectomy

This procedure comes along with a fairly high risk of complications. In fact, a Johns Hopkins study documented complications in 41% of pancreatectomy cases. These include serious problems like post-operative bleeding, delayed gastric emptying — a condition in which food and liquids are slow to leave the stomach — internal anastomatic leaking. The good news is that in recent years, the mortality rate for this procedure has decreased to a range of 5-10%.

7. Thoracic Aortic Dissection Repair

Aortic dissection, or a tear in the innermost layer of the heart, can trigger a number of high-risk complications like heart failure, stroke or even a rupture of the aorta, making its repair vital to the survival of the patient. Immediate treatment is required and this often results in the surgeon removing the area of dissected aorta and rebuilding the blood vessel with a synthetic graft.

6. Esophagectomy

This is a major surgery which carries a lot of risk because of the reconstruction of the area between the stomach and the healthy part of the esophagus. Three different methods of this surgery can be performed depending on the patient’s condition, but they all carry with them serious risks, such as a leakage of the fluid from the stomach or esophagus where the new connection was made. Despite the risks, most patients recover well and have few complications.

5. Bladder Cystectomy

This procedure is most often performed to remove a part of, or the entire urinary bladder, in patients diagnosed with bladder cancer. The major risks for this procedure are the highest for an infection of the intestine which can lead to peritonitis or the inflammation of the membrane lining the abdomen. For procedures that remove only a part of the bladder, there is a high risk for urine leakage from the bladder incision site, which can cause a number of other internal problems.

4. Coronary Revascularization

Also known as coronary artery bypass grafting (CABG), this procedure reroutes the blood around one or more clogged coronary arteries to help improve blood flow to the heart. New connections are made using arteries or vein grafts taken from another part of the patient’s body. For some patients whose ventricular function is failing too quickly, this surgery may not be an option because the risks are too high.

3. Spinal Osteomyelitis Surgery

There are a number of treatments that patients may undergo before requiring surgery to correct this spinal infection, but for those with spinal instability, significant deformity and/or neurological deficit, a paravertebral abscess causing sepsis, or any sized epidural abscess, emergency surgery is often needed. Infections of the spine are extremely destructive, and any surgical procedures performed on this area comes with a lot of risk, such as complete or partial paralysis, or other serious infections.

2. Surgical Ventricular Restoration

This procedure is done to treat congestive heart failure as a result of a heart attack in order to improve its function by restoring it to its normal size and shape. This, like any other heart-related surgery, is very risky because the patient is put on the heart-lung machine and major repairs are done to a very sensitive part of the body. Improvements in techniques have been made and the hospital readmission rate for a SVR is only 8.8%.

1. Craniectomy

Any type of brain surgery presents a high risk to the patient because the brain controls every function in the body. But a craniectomy presents even more risks. This procedure requires that the piece of skull removed to access the brain is not replaced after the surgery is complete, leaving fully recovered patients the risk of brain damage after the surgery if they do not properly protect their head. Depending on the area of the brain where this procedure will be performed, other serious risks like changes or loss in the functions of vision, mobility, speech, memory, coordination, and more can be permanent. Excessive build up of fluid in the brain, stroke, seizures, spinal fluid leakage, swelling of the brain, and more can also occur after the procedure, making this one of the highest risk surgeries.

Sources: surgery.com
mayoclinic.com
clevelandclinic.org
hopkinsmedicine.org

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A new study, which was done in two pediatric ERs, suggests that having professional translators – not a patient’s family member – in the ER may lower medical errors by limiting miscommunications.

When the translator was an amateur (family  member or a hospital employee) the amount of translation slips – omitting or adding certain words or phrases –that had potential health risks was 20% to 22%.

When a professional translator was available to Spanish-speaking families, 12% of translation slips could have had medical consequences, such as giving a wrong medication dose.

And when translators had 100 hours of training or more the translation slips dropped to only 2% having the potential for doing harm.

Approximately 25 million Americans have limited English proficiency, and the law requires U.S. hospitals that receive federal funds to offer some type of translation help for these patients. That can be a heavy financial burden for hospitals with already limited budgets.

However, other studies have already shown that having a translator may improve care and actually cut costs. Getting the proper treatment, medication and guidance for home care lowers the risk of unnecessary tests or patients having to return to the ER.

This study shows the added benefits of having a “professional” translator – avoiding potentially dangerous doctor/patient miscommunications.

Unfortunately, while federal law requires hospitals to provide an interpreter, it doesn’t require government or private insurance to pay for them, leaving hospitals and the taxpayers to cover the costs.

However, some hospitals in California are proving that the cost doesn’t have to be significant. The facilities have joined together to offer translators by phone and audioconference, which only costs $25 per patient.

Does your facility offer translators for your non-English-speaking patients? If so, what kind (in-person, audioconference or phone)? Share your experiences in the box below.

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Anna Brown had gone to three hospitals in the course of a week seeking treatment for a sprained ankle that had gotten increasingly painful — to the point that she was using a wheelchair to get around.Within hours of being kicked out of the last ER as a “drug-seeker,” she was found dead on the floor of her jail cell. Cause of death: blood clots that had traveled from her legs to her lungs.

Now her family would like to know just what went wrong.

Here first hospital visit, to St. Louis University Hospital, began last September 13. She stayed for two days for additional testing, but hospital officials said there was no indication at that point that she had a blood clot in her leg.

Four days after she was discharged, she arrived on crutches for what would turn out to be her final visit with her children, ages 11 and 2.

On Sept. 20, she went back to SLU Hospital complaining of knee and ankle pain. Doctors there said X-rays were negative and she was given painkillers — but she refused to leave the hospital, claiming that they hadn’t sufficiently treated her. After police arrived, she wheeled herself to a nearby pediatric hospital. Doctors there found she had significant tenderness in both legs. Eventually she was taken by ambulance to St. Mary’s Hospital in Richmond Heights, Missouri.

Doctors there said that ultrasounds of both legs were negative for blood clots. A social worker at the hospital gave her a list of local shelters and a number to call for transportation. Brown left, but returned within a few hours, complaining of continued pain. The hospital discharged her at 7 a.m., but Brown refused to sign the papers.

Shortly after, the hospital called police to have her arrested for trespassing. Brown complained repeatedly that she was in severe pain, could not stand and needed further medical care. Instead, a doctor at the hospital issued a “Fit for Confinement” report, indicating that Brown was well enough to be arrested.

Police had to literally pull Brown from the patrol car and into jail. Notes in her booking report listed “suspected drug use” and “unknown leg pain.” Brown was carried into a cell and left on her back on the floor of the cell.

An officer monitoring the cell by camera noted that she was moaning and moving slightly — until she stopped moving around 2 p.m. The officer thought she had fallen asleep. Fifteen minutes later, she was found unresponsive and attempts to revive her failed. She was taken back to St. Mary’s where she was declared dead.

Autopsy results showed no drugs in her system.

Brown had gone through a rough patch in life in the year leading up to her death: One home was destroyed by a tornado, she lost her job and then her second home was condemned. She was left homeless, and unable to care for her two children who were taken in by her mother.(State child protective services were supervising the children, and wouldn’t allow Brown to live in the home with them).

Brown passed required drug tests, but results of a screen for mental or behavioral illnesses was inconclusive. She resisted a court-ordered psychological evaluation because, according to her caseworker, she didn’t understand how it differed from the other tests she had undergone.

It’s debatable if Brown, homeless and seemingly mentally unstable was simply pigeon-holed as yet another drug-seeking scam artist in the ER. For it’s part, St. Mary’s says a review of her medical records indicates that it did everything correctly in terms of trying to diagnose and treat her and that is simply a case of a missed diagnosis.

Brown’s family is less certain. They’ve hired a lawyer to investigate the matter, but as of yet have not filed suit. The family feels strongly that Brown’s complaints were not taken seriously by at least some of the health care professionals who treated her. Her sister, Krystle Brown said in a statement to the local media: “My sister is not here today because people passed judgment.”

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As it turns out, it’s the result of several unrelated issues — none of them easily fixed.

While multiple sites, such as RateMDs and HealthGrades, have been set up to collect patient reviews of doctors, they tend to have relatively little data for individual doctors. It’s not uncommon to find a doctor who has treated hundreds of patients but only has two or three reviews on any given site.

And anyone who has used Web-based reviews knows that just one or two outliers can severely skew the results of the company (or doctor) being reviewed to the point that the reviews are no longer useful to anyone shopping around for a new provider.

In its coverage of this issue, the New York Times uncovered several issues:

• Those in professional fields, such as doctors and lawyers, are far more likely to threaten, and sometimes take, legal action against negative reviewers and the sites that host the information.
• The personal nature of the doctor/patient relationship may make some patients hesitant to share information about the doctor or the treatment they received, and
• Some patients put their doctors on such a high pedestal that they’re simply unable or unwilling to publicly share even relatively benign, constructive criticism (such as the need to work on reducing wait times).

Those issues are understandable, but they don’t change the fact that the lack of effective review sites leaves patients short of a useful tool to help choose a new provider.

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HCA, one of the largest for-profit hospital chains, has adopted such a policy. The outcome? More than 80,000 ER “patients” left the hospitals without being treated. How many left because of a lack of funds or from the realization that the visit wasn’t worth the $150 charge is impossible to say.

But HCA hospitals aren’t the only ones requiring cash before patients get treated. Fees can run as high as $350 a pop for the uninsured at some hospitals. And while it’s hard to argue that emergency medical care can’t be more efficient in general, not everyone agrees that this is a good way to handle patients.

Some ER docs and patient advocates say it hurts some patients, with little benefit to the hospitals. For example, patients with less serious illnesses are usually processed relatively quickly and without expensive tests or taking up needed beds.

What it does do is scare off the most indigent of the uninsured, who may have little other recourse for basic medical care. (Non-urgent patients with insurance would only have to pay their usual co-pay and whatever fees are associated with the treatment they eventually get.) Without timely treatment, uninsured patients may well end up back in the emergency department — this time with the type of urgent illness that allows them to bypass the “admission” fee.

Is it just plain good business to charge up-front fees for non-urgent care? Or is it just one more example of how the health system allows some people to fall through the cracks? Sound off in the comments.

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Two new studies, just published in the New England Journal of Medicine, found that established weight-loss surgeries were significantly more effective than other conventional treatments for Type 2 diabetes.

Patients who had the weight-loss surgeries experienced a complete remission of their diabetes, or failing that, needed less medicine than their counterparts who stuck with traditional medical treatments along with diet and exercise. Many of the surgical patients also experienced lower cholesterol levels and blood pressure.

The results were startling: In the first, at the Catholic University in Rome, after two years, two groups of surgical patients had complete remission rates of 75% and 95%. None of the medically controlled patients went into remission.

A second study at the Cleveland Clinic looked at similar groups of patients. Overall, these groups had lower remission rates (partly due to a stricter definition of “remission”). But one year after surgery the two surgical groups had remission rates of 42% and 37%. Only 12% of patients receiving medical treatment went into remission. (Note: Neither study included so-called “lap band” surgery as one of the treatments, because it does not alter the shape of the stomach.)

The studies are the first to scientifically examine the effect — long noticed by doctors working with bariatric surgery patients.

According to the researchers, even though obesity is a known factor in the onset of Type 2 diabetes, the surgeries didn’t control the disease simply by helping patient lose weight. Instead, it seems the anatomical changes to the organs actually changes the levels of various hormones that control how the body metabolizes fat and sugar.

While more effective treatments for diabetes are a godsend for many patients, many experts caution that bariatric surgery comes with its own risks, and isn’t necessarily a good choice for many patients.

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The woman (who was not named by local reporters) said she was in intense pain when she went to the hospital. But she claims doctors there belittled her, making jokes about why she hadn’t used birth control. They said she was pregnant and having a panic attack and sent her home.

After taking two pregnancy tests which came back negative, she returned to the hospital and insisted on a more thorough exam.

An ultrasound revealed the truth of the matter, and the patient is now receiving chemotherapy.

Score another point for patients who are willing to advocate for themselves when their complaints aren’t taken seriously.

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Orthopedic surgeons, plastic surgeons and neurosurgeons are the specialists whose bills are most likely to generate surprises for their patients. In fact, 50% of mega-bills insurers receive from out-of-network doctors come from one of those three types of doctors.

Those are the findings of a new report by the New York Department of Financial Services. According to the report, too many patients are left holding the bag for surprisingly large bills because of how little coverage insurers offer for services provided by out-of-network doctors.

The report also looked at more than 2,000 consumer complaints regarding large bills for non-emergency, pre-approved treatments. Because medical providers don’t have to disclose whether or not they’re in-network before they provide the treatment, patients may not understand that they could be facing much larger out-of-pocket costs. For example, in one of the complaints a patient went to an in-network hospital for routine gallbladder surgery with an in-network surgeon. But the anesthesiologist was out-of-network, which left the patient on the hook for an unexpected $1,800 bill.

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A number of widely used statins, including Lipitor, Crestor and Zocor are getting new warning labels courtesy of the FDA. The new labels will warn that the drugs may increase blood sugar levels and could cause memory loss.

Statins are a go-to drug for patients at risk of coronary disease — and still worth taking for the majority of those patients, according to most doctors — and the FDA isn’t recommending that fewer patients take the drugs.

But the new labels will highlight that the drugs also come with significant side effects and risks that patients need to be aware of.

The new warnings come about based on more recent research that shows patients on statins face a slightly elevated risk of increased blood sugar as well as developing Type 2 diabetes. In addition, adverse event reports indicate some patients experience memory loss while on statins. There isn’t yet any proof that statins are the cause of the problem, but the FDA wanted to alert patients to the possibility.

One warning is actually being eased though: The suggestion that patients receive ongoing monitoring of liver enzymes is being dropped since related liver disease has been found to be rare.

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