Hospital maneuvers: UW Medicine soon could include Valley Medical Center

King County’s major medical centers continue jockeying for position in the emerging new health-care world.

U.W. Medicine and Valley Medical Center proposed this week what they call a “strategic alliance.” Valley wants to retain its name, although the news release says Valley would become “part of U.W. Medicine.”

Earlier this year, U.W. Medicine took over running Northwest Hospital (in north Seattle), without actually owning the hospital.

As Dean Radford writes in the Renton Reporter:

Public Hospital District No. 1, which owns [Valley] medical center and neighborhood clinics, would still exist. Its five commissioners would sit on a larger board that would oversee management of Valley Medical. The Valley board would continue to oversee the hospital district itself.

In essence Valley Medical Center would become part of the UW Medicine system, which owns and operates Harborview Medical Center and the University of Washington Medical Center. UW Medicine also shares ownership and governance of Seattle Cancer Care Alliance, Children’s Hospital and Medical Center and Fred Hutchinson Cancer Research Center.

The bigger picture: U.W. Medicine and Swedish Medical Center are competing to be top-dog in the greater Seattle area. All the other hospitals are nervously watching, trying to decide if they can survive independently, or if they need to affiliate. I alluded to this in an article last spring, as the same pressures are reflected in the mad scramble to build new Emergency Departments all over King County.

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Gunshot wound might have killed Clemmons anyway

You might have been wondering, How could Maurice Clemmons have survived so long with a gunshot wound right in the belly?

He managed to last nearly two days  – after one of the Lakewood police officers (Greg Richards) shot him during the coffee shop ambush on Sunday.  Clemmons was hit just above the belly button, said Pierce County Sheriff spokesman Ed Troyer.  He later died in Seattle after another officer shot him two or more times on a city street.  Clemmons was found with duct-tape and cotton gauze covering the wound.

Police handgun, similar to the one used in battle at a coffee-shop near Lakewood, Wash. (photo by Clyde Armory)

We may never know why he lasted.  The King County Medical Examiner says autopsy reports are not public documents.  The autopsy is considered “protected health information.”  In other words, it’s private, and the next of kin must consent to any public release.  The public report will only confirm the cause of death.

I asked the chief trauma surgeon at Seattle’s Harborview Medical Center for some speculation.  Harborview is the hospital where nearly all gunshot victims end up in the Seattle area.

Dr. Jerry Jurkovich says most gunshot wounds to that region would be fatal without surgery, since “it would almost certainly have injured some segment of the intestine.”  But, it might take several days for the infection to get bad enough to kill.  Bleeding to death is unlikely (and would happen very quickly).

It’s possible the bullet hit Clemmons from a sideways angle and did not penetrate major organs.

Does it matter? Not really, except as it sheds light on how much the “assistance” from his friends and family kept Clemmons alive.

MORE INFO [12/16/09] — Here’s some speculation.  Okay, it’s from unnamed sources, but credible enough to share, with caveats.  A friend of mine was discussing the case with a buddy in the FBI.  They came up with this:  One reason Clemmons might have survived that initial gunshot wound was if he was shot by one of his own guns, instead of the officer’s gun.  His .38 caliber revolver packs a smaller impact than the .40 caliber Glock (pictured above).

If so, that also reveals a little about how the events might have unfolded.  After the other three officers had been shot, Ofc. Richards was struggling with Clemmons, who still could have had a revolver in each hand.  Perhaps, one went off and hit Clemmons in the belly, but Clemmons might have used the other hand to shoot Richards in the head.  In this scenario, Richards’ gun was never pulled.  Clemmons would have taken it off his body before he ran.

Vaccines and autism on trial

For anyone who still thinks vaccines are causing an epidemic of autism, please take a deep breath and open up to the possibility that such a theory might be completely wrong.

The latest verdict comes from a special tribunal.   A 3-judge panel has ruled against plaintiffs who were seeking damages, claiming their children had developed autism because of preservatives in the measles-mumps-rubella (MMR) vaccine.  We have a brief version of the story on our website.

This isn’t quite as dramatic as the Darwin trial in Dover, PA.  There was no jury, no courtroom theatrics.  Instead, it’s a court that exists only to hear complaints under the National Vaccine Injury Compensation Program.  But, the judges, who are not part of the public health infrastructure, reviewed thousands of pages of studies and other documents.  It sounds like they ruled pretty conclusively.  No link between autism and the vaccine.

This is not a surprise.  Every time an independent group has taken a look at this issue, they’ve come to the same conclusion.  And earlier this week, one of the British authors of a study that has fueled the anti-vaccine movement was revealed to have  faked some of his data (thanks to dogged reporting by The Times of London).

Opponents of vaccines have evolved their theory over the years.  Many now say, it isn’t just one vaccine, it’s the fact that so many are given at such a young age.  (Moving target?)   Still, I haven’t seen any credible evidence to suspect the vaccines.

Vaccine subsidies may end

My story on KPLU about a proposal to end state subsidies of childhood vaccines only brushed over the impact on pediatricians and family doctors.  It was a short story, written for a newscast.  This is not the most important budget cut pending in Olympia, or the one that will impact the most people.  But, it’s an example of a good program that probably is in trouble in this economy.

I traded messages with the president of the Washington chapter of the American Academy of Pediatricians.  Dr. Neil Kaneshiro wrote an eloquent explanation of what it might mean:

The burden on the pediatrician depends on how they respond to the change. As you have found out, it is a dramatic shift in policy. In the “old days” before Universal Purchase, pediatricians used to see kids for their checkups and then send them to the health dept for their vaccines. Not a very good system as some of those parents didn’t bother or weren’t able to take the kids in to a separate facility on a different day possibly missing work again just to get their vaccines. Now the vast majority of immunizations for kids are delivered in the pediatrician/family practitioner office because the immunization program makes it a seamless process. The benefits for kids were easy to see. No hassles and no barriers to immunizations. Immunization rates improved. (Many will say that Universal Purchase does not correlate with high immunization rates. That is true, but it definitely helps the rate by removing all financial barriers to immunizations so that any parent who wants one for their child can get it. The problem with immunization rates in Washington State is primarily with the strong anti-immunization sentiment fueled by celebrities like Jenny McCarthy. We have the highest proportion of families who opt out of school mandated vaccines in the nation.)

There are significant costs associated with provision of immunization services. Ordering, inventory, refrigeration/freezer capacity, needles, syringes, nurse/medical assistant time, physician counseling of patients.
Those are the costs with the current Universal Purchase program. When that is taken away, several other things come into play.
1. Acquisition cost. I estimate we have $150,000-200,000 worth of vaccine in our refrigerator and go through that monthly.
2. We would need vigilant monitoring of insurance reimbursement because doctors in other parts of the country have lost significant amounts of money because insurers were not reimbursing less than the actual cost of vaccine.
3. We would need to set up an entirely separate ordering and inventory system and institute failsafe measures to prevent vaccine from moving from VFC stock to Commercial stock and vice versa. Lots of potential fraud issues arise if VFC vaccine is used for someone with Blue Cross insurance. And potential bankruptcy issues arise if purchased vaccine is given to Medicaid kids.

Medicaid reimburses essentially nothing for the above services. Commercial insurance reimburses for the administration, but sometimes not the ordering, inventory refrigeration, insurance/overhead costs. The unspoken deal with the state was that physicians would move immunization services for Medicaid into the medical home since they were providing vaccines for everyone. In turn the state would be able to reduce the immunization infrastructure in the public health system as the primary care providers were taking care of it.

Depending on individual pediatricians vaccine purchasing power and negotiating position with insurers, buying and selling vaccine could be either profitable or not. Pediatricians are unfortunately not known for their business savvy and this will cause some practices to go under or stop doing immunizations.

I think that since pediatricians lose money every time they give a vaccine to a Medicaid child, it is possible that the financial strain will force some to revert back to the old system of referring kids to the health department for immunization services. Unfortunately much of that public health infrastructure has been dismantled and is unlikely to be rebuilt under the current budget situation.

The bottom line is that this will introduce barriers to immunization for kids that are not there now and our immunization rates will fall.

Smart dummies, spreading

Simulation is becoming a trendy buzzword in medicine.  Technology has advanced to the point where a lot of medical procedures can be practiced on high-tech mannequins, or via computer simulations.  A few studies have shown better outcomes for doctors who trained first on simulators, although the evidence is still somewhat preliminary. I have a story airing tomorrow (Thursday) on KPLU about the mannequins.  (Update 1/15 – story now posted here.)

I didn’t have room to mention in the story some of the expansion that’s in the works locally.  The University of Washington’s main simulation center, called ISIS, is not only in new digs at the surgery pavilion.  They’re getting ready to add a much bigger simulation center at Harborview hospital, possibly by the end of 2009, and another one after that at Seattle Children’s Hospital.  Then, there are plans to offer continuing medical education courses using the U.W. simulators.

That should keep the U.W. as one of the national leaders in medical simulation (the top spot is generally considered to be Stanford’s sim center).

The U.W. will be competing locally with Swedish Medical Center, which just opened its own simulation center, and expects to rent it out to train teams from other local hospitals.

The mannequins have come a long way from the old Resusci-Annie, used for CPR training.  They are still clearly dolls, so, as hospitals around the country start buying into simulation, expect to see a lot more innovations.  (Good news for the Norwegian company Laerdal, which invented the Resusci-Annie, and still makes the most popular mannequins.)

Laerdal's SimNewB

Laerdal's SimNewB

Also, for a nice overview of the use of simulation to make better medical teams, see Tom Paulson’s recent story in the P-I.

Flunk that report card

Do Washington state residents have some of the worst access to emergency medical care in all of America? That’s what a reputable organization would have you believe. The American College of Emergency Physicians issued what they call a “report card” on the 50 states. They rank Washington at the very bottom when it comes to availability of hospital beds and psychiatric beds, and near the bottom in the availability of registered nurses.

But, the state Department of Health has no evidence of such a severe shortage. Spokesman Donn Moyer asked the various data-crunchers within the agency, and they concluded, “This isn’t how we would quantify access to care.” He says they can’t understand why the Emergency Physicians would measure hospital beds “per capita,” because that’s not a method that’s typically used in the world of public health.

What does this mean?

(a) there’s a hidden crisis brewing in Washington, unseen by our officials, with people getting turned away in growing numbers as they seek hospital care

(b) having fewer hospital beds in your state does not automatically translate into lack of access to care by people who live in that state

(c) an interest group has created a report that – surprise – serves the interest of its members (by advocating for more spending on hospitals and medical staff)

I would go with both (b) and (c). To believe (a), you’d have to think everyone at hospitals and in the emergency medical system is keeping quiet about a major problem, which is worse here than the rest of the country. And, they only decide to speak up when ACEP releases its bi-annual report.

Do “diversions” happen, when an Emergency Room is full, and a patient is sent to an E.R. that’s not necessarily the closest? Yes, but that also might be a sign that we’re using the medical system efficiently. What do you think?

“Assisted lethal medication”

We’re having a lively discussion in the KPLU newsroom about the language surrounding the recently passed Initiative-1000. It’s called the “death with dignity” law by supporters, and “physician-assisted suicide” by opponents.   A judge ruled last spring that the ballot title would not include a reference to assisted suicide, preferring instead more neutral language. Last summer, the Associated Press decided to call it “assisted suicide” – and that is the source of copy for many stories we read over the air on KPLU.

Here’s the challenge for radio and TV broadcasters: It doesn’t always work to say aloud a phrase like, “the measure that allows terminally ill competent adults to obtain lethal prescriptions.” We need a shorthand phrase. That’s one reason why the AP went with assisted suicide.

The other reason is, we prefer to be clear and descriptive, and to avoid speaking euphemistically. The phrase “assisted suicide” seems to summarize what the law allows. In the past, it was illegal for a doctor to prescribe medication that would enable someone to end their life. Now, the initiative makes it legal to provide such assistance. Taking your life is called suicide. What could be more clear?

In the medical community, it looks like “physician-assisted suicide” has been used for some time to describe Oregon’s law. And the Washington State Medical Association on its homepage says, “Washington has become the second state to legalize physician-assisted suicide.”  (But, the WSMA also opposed the initiative.)

I asked Colin Fogarty how he handles this issue. He covered Oregon’s lethal prescription initiative for many years for Oregon Public Broadcasting and National Public Radio. (He now edits stories heard on several public radio stations, via the Northwest News Network.) He says they had frequent newsroom debates, but came down on the side of “assisted suicide,” because it seemed the most clear and accurate.

Those who campaigned for the initiative say the word “suicide” has negative connotations. And they say the people authorized to take the lethal prescriptions are already diagnosed as being in the process of dying. So, the medication is hastening their death, not exactly causing it.

I’m sympathetic to this argument. If I’m dying of cancer, and I speed up the process by a month or two, you still might say I died of cancer. Under the law, my death certificate must list the underlying terminal disease. But, you’re also leaving out part of the story, so it doesn’t feel completely transparent.

The news business is a little different from the legal business.  Our credibility depends on being transparent and straightforward. So, for now, we’re sticking with “physician-assisted suicide,” but we’ll do our best to also include phrases such as, “the Death with Dignity Act,” or “aid in dying.”


Medical clinics where you shop

Last week, I wrote a story about the mini-clinics inside grocery and drug stores. It included this paragraph:

“Most treatments are priced at 59 dollars. You’d be billed twice or three times as much at a traditional urgent-care clinic. MultiCare accepts insurance and Medicaid, so most people end up with just a co-payment either way. To break even, the mini-clinic needs to see at least 25 patients a day. That covers rent and the salary for the Nurse Practitioner who staffs it. The one-person staff keeps costs down – along with treating only minor ailments. Is this the next big trend? Not yet, despite hype from some chains. It’s been moderately successful in other parts of the country – but not a revolution.”

For Tacoma’s MultiCare health system, the key is integrating the retail clinic with their larger system. Many of the patients (including the two that I interviewed in the drugstore) were referred from MultiCare’s traditional urgent-care clinic, which was overcrowded.

The question I did not address, but hinted at, in the story is this: Are these retail clinics a good indicator of how much you pay for inefficient overhead during your basic medical appointment? We’ve been hearing for years how wasteful the medical system is, and how paperwork eats up a big share of every dollar. But this seems to be a graphic illustration, at least for all those visits that didn’t need fancy MRI machines and surgical suites nearby.

Medicine and shopping

I’ve been watching the trend of drugstores (and supermarkets) adding mini-medical clinics inside their stores. It’s an interesting idea, sort of an end-run around all the hassle of trying to get an appointment with your doctor and be seen in a timely manner. Instead, just walk into the nearest drugstore and have your minor ailment checked out. And, it’s supposed to provide an option for people without insurance.This started on the East Coast, and Bartell Drugs first tested it here in Washington a couple years ago, by contracting with a chain called Minute Clinics. Apparently, that didn’t work out so well.

Now, Rite Aid is trying a new angle, at two of its stores in Tacoma. It’s teaming up with a local health-care provider, in this case MultiCare Health System. MultiCare is huge in Tacoma, the dominant medical provider, with four hospitals, and a network of primary care and Urgent Care clinics. MultiCare is staffing the mini-clinics (with ARNP’s — Nurse Practitioners) as one more branch of its network.

According to a story in the Puget Sound Business Journal, these clinics do better (financially) when there’s a shortage of primary care providers — so, outside major cities. In Houston, they’re converting the mini-clinics to telemedicine clinics, because it was too expensive to pay a nurse to sit there all day.

Will this ever be an important trend in medical care? Is it helpful to have a service like this? Or does it just seem like a new type of marketing?