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Letting go when people let go of their lives Print E-mail
Written by John Dodson, MD | KevinMD   
Tuesday, 05 November 2019 18:46

My 83-year-old patient had outlived peoples' expectations on several occasions. Faced with a critical illness three years ago, she underwent emergency surgery and spent several months in the hospital with a series of complications, including septic shock, renal failure, and hospital-acquired pneumonia. I'd seen her in the office for a new visit soon after she was discharged. It took nearly 20 minutes to go through her history before walking into the exam room. Notes from several doctors during that hospitalization said that she might never become well enough to be discharged home. When I finally walked into the room, I expected to see someone frail, debilitated, with a caregiver answering most of my inquiries. Instead, she appeared robust, completely alert, and cheerfully answered my questions herself. "You look better than your chart," I told her, truthfully. Given the extent of her recent workup, we agreed to keep further testing and medication changes to a minimum. I established that we'd touch base in the office every three to four months - a typical interval at her age.

Last Updated on Friday, 20 December 2019 17:39
What does cable news do to your brain? A neurosurgeon explains Print E-mail
Written by FHI's Week in Review   
Monday, 28 October 2019 12:35

Marc Arginteanu, MD writes in a KevinMD post on 10.25.19:
The availability of up to the minute information, presented 24/7/365, could assist a democratic society in making the best choices in determining its future. That was the promise of cable news. Unfortunately, cable news has fallen short of its potential and has led to the further polarization of America. More than that, it has changed the way your brain works. Not for the better...Brain science supports the notion that intellectual bubbles, such as those created by cable news, are bad for society. Citizens are intellectually impoverished by the absence of input from those with different life experiences and different perspectives. 

Read more in the current issue of Week in Review>>
The irrational exuberance of early cancer detection Print E-mail
Written by H. Gilbert Welch, MD | KevinMD   
Tuesday, 15 October 2019 17:34

Here's some good news for a change about cancer: Cancer mortality - the rate of death from cancer - has fallen substantially over the last four decades. There is also, however, some not-so-good news: Cancer incidence - the rate of cancer diagnoses - has been rising. This doesn't reflect increasing dangers in our environment, but a danger in our medical system. In the New England Journal of Medicine, two colleagues and I examined the last four decades of cancer statistics in the United States. The decline in cancer mortality is a good sign. Everyone, including the National Cancer Institute, agrees that a declining cancer death rate is the best measure of progress against cancer.
Florida’s Health Care System Could Lose Nearly Half of Its Nurses Print E-mail
Written by FHInews   
Thursday, 10 October 2019 07:52

In 2018, 45% of all nurses who became licensed in Florida graduated from career schools, according to data provided by the Florida Center for Nursing. Yet most of these schools are being shut down by the Florida Board of Nursing due to a controversial law that brought owners of small nursing schools together for a forum on Saturday, September 28, 2019, with Florida Representatives Nicholas Duran (DEM District 112) and Ana Maria Rodriguez (REP District 105), who both sit on the health care committees that consider laws involving nursing practice in Florida.

The Floridians most likely to be excluded from nursing careers are low-income Floridians who seek a second chance in life by enrolling in career schools. Carolyn Sutton, proprietor of Ruby’s Academy of Health Occupations in Lauderhill, explained that “the average applicant at our school has an annual income of less than $12,000 a year.” Sutton’s student population is similar to that of most career schools. The applicants are nontraditional college students, often from the lower ranks of their high school graduating classes. Some have only a GED. Almost none would qualify for admission at most public nursing schools in Florida. Yet they are capable of learning the material and getting jobs with starting pay that averages over $50,000, according to

On August 7, 2019, the Board of Nursing shut down 30 nursing programs including some with job placement rates of 80% or higher.  The terminations were based on a provision in the Florida Nurse Practice Act that terminates RN programs if they fail to become accredited within 5 years. No exceptions. Among the terminated programs was Orlando-based Gwinnett Institute’s RN program. Campus President, William Atkinson, objected to the termination because he said Gwinnett placed 79 of 96 graduates in nursing jobs in Florida last year. That’s 82% when the placement rate required by most accreditors is 70% to 80%. Atkinson told the Board, “We’re doing our job,” but the Board voted to close the program anyway, blaming the Legislature.

Attorney Shavon Jones of RegulatorGuards, a company that represents small businesses in disputes with the government, hosted the forum. Jones points out that while the statute provides only five years to obtain nursing accreditation, the accreditation process actually takes six to seven years to complete. This is because nursing accreditation is a multi-step process. First, a school must have two years of operating history. Only then can they school apply for general accreditation called “institutional accreditation,” which takes 18 to 24 months, followed by nursing accreditation which takes an additional 2 to 3 years to complete. That explains the controversy–the reason that so many programs are being shut down is because the law did not provide enough time to begin with. Plus, many of the programs did not have even the full five years that the statute provides, because shortly after they finished Step 2 (institutional accreditation) their institutional accreditor was shut down by the federal government only to be reinstated two years later when the U.S. president changed. “These schools are like a political football,” said Jones.

The school owners believe that the Florida legislature is not fully aware of the accreditation process or the impact of this law. “The Legislature was intending to eliminate bad schools that are not getting their graduates licensed. But the law they passed is too broad and is eliminating good programs that are needed to provide adequate educational opportunities to Florida residents who want to become nurses,” said Jones.

Representatives Duran and Rodriguez came prepared, having researched the issue. They listened attentively, and they provided information and guidance on how the program owners can seek relief in the next legislative session, which begins January 14, 2020. The lawmakers’ willingness to listen provides hope that the unintended consequences of the law can be addressed before permanent harm is done to our communities.

Last Updated on Thursday, 10 October 2019 07:54
The Invasion of Private Equity into Healthcare- Are we experiencing a new era of efficiency or a 1990s disaster sequel? Print E-mail
Written by David H. Fater   
Saturday, 05 October 2019 13:17

There is a marked invasion of private equity into healthcare (again) and a day does not go by without reading about another physician practice acquisition or some other combination of healthcare providers being ushered along with private equity dollars and financial backing. There were 181 private equity deals for all types of physician practices last year and this year there will be even more.  In dermatology alone, there have been 200 practices acquired by private equity groups over the past six years. Orthopedists, along with gastroenterologists and urologists are among the newest targets in the current gold rush. The attraction with these types of groups are the rich revenue that can be generated from ancillary services such as ambulatory surgery centers, lab, imaging and other such services. This rapid proliferation of private equity deals has raised alarms about whether investor ownership of physician practices will negatively affect healthcare costs and quality. The other $64,000 question is whether this rash of deals will implode, crash and burn much like they did in the late 1990s.

Three Card Monte or the Shell Game

The big potential payday for both the doctors and the private equity groups comes three to seven years down the road when the private equity group sells the “expanded” business to another private equity group, insurer, hospital system or another physician company. In some respects, it is like a large chain letter and hopefully you are not the one that is left holding the bag. Of course, the song the private equity groups sing is “We are simply focused on growing the business and consolidating the market in orthopedic surgery [dermatology or whatever the specialty is] in the best interests of our patients”. Sure, and the moon is made of green cheese if you think there is not a real profit motive here. And when there is a profit motive, someone has to come up with the short end of the stick.

Despite the experience of the 1990s and many of the deals of this decade, physicians are still running into the arms of private equity groups because they see this route as their only and best alternative to ownership by hospital systems or insurers and that they will be able to preserve their professional autonomy. Because of the prohibitions in many states against the corporate practice of medicine, the practice itself is not “acquired” but a Management Services Organization (“MSO”) is formed that takes over the administrative non-clinical functions freeing up the physicians to focus on medicine and patient care.

Typically, the shareholder physicians receive a large cash payment upfront (this is particularly attractive to the older physicians near retirement) with the golden carrot being the bonanza that will be realized when the private equity firm sells to another buyer. The initial payment is calculated with rocket science and differential calculus and is based on a multiple of the practice’s EBITDA (Earnings Before Interest, Taxes, Depreciation and Amortization). The multiple can be as high as 12; HOWEVER, since the EBITDA of a typical practice is 0 because the physicians pay all that out to themselves, the physicians have to take as much as a 30% decrease in compensation. This plus any valuable practice assets turned over to the Private Equity Group “pays” for the physician ownership in the MSO. Naturally a year later, the physicians forget about that and just start grousing about how their personal income has gone down.This could lead to inevitable friction that will ultimately lead to a meltdown of the entity leaving everyone unhappy.

The Pot of Gold at the End of the Rainbow

Advocates contend that private equity groups can help physician groups grow and improve their efficiency and quality of care through investments in management and technology as well as facilitate the transition to value-based payment models which are being mandated by the Centers for Medicare and Medicaid Services (“CMS”). The transition to one-stop shops for all needed services helps speed the shift to lower-cost outpatient settings. Additionally, the improved quality, larger size and expanded services and locations enables the group to negotiate better deals with payers.  This fact is often kept quiet to avoid attracting the attention of the antitrust regulators.

Not all is rosy, however, and there are naysayers besides the unhappy physicians. Those that develop health policy are concerned that private equity firms are not focused on making healthcare better. The belief is that they are rather focused on hunting out narrow slivers of the healthcare system where they can make significant amounts of money by exploiting loopholes. Two examples, determined by a study at Yale University, found that two large hospital-based medical groups (Team Health and EmCare) owned by private equity groups aggressively used out-of-network billing tactics to boost revenue. In fact, insurers have pointed to private equity ownership as a factor in the current battle over legislation to end surprise out-of-network medical bills.

Is the Business Model Sustainable?

A looming question is whether the private equity business model is sustainable for medical practices, particularly after the first buyer cashes out. Who is going to be the ultimate buyer? If there is no ultimate buyer, then things don’t turn out so pretty. Today’s buyers and sellers say they are acutely aware of the disastrous experience with the wave of investor- owned physician management companies in the 1990s. (And I was one who lived through those wars from the beginning in 1992 through the meltdown in 1999). Several of those companies, along with the physician practices they acquired, went bankrupt and have been called Ponzi schemes.

Today’s buyers seem to have learned that putting physicians on salary is not productive or beneficial. Physicians are intelligent, self-select and are autonomous in nature. So smart private equity firms now structure deals to allow physicians to be “partners” with strong financial incentives to boost productivity and revenue.  Unfortunately, some investors continue to see this trend as a pure financial play spurred on to acquire, acquire and grow. The caveat is that if you don’t integrate what you buy, you have a mess on your hands.

So Who Really Benefits from Private Equity Buyouts?

One could argue that if the policymakers really want to expand value-based care, then someone needs to hit the pause button and take a closer look at this private equity buyout activity. The trend that may have started with dermatology, ophthalmology and dentistry (which is interesting because each of these have an element of retail plus healthcare) are spreading to the costliest areas of medicine-orthopedics, gastroenterology and urology. As stated above most of the balance billing surprises from being “out-of-network" arise from the large emergency departments who are staffed by physicians that work for private equity owned firms.

This business model in healthcare parallels other industries by using highly leveraged private capital to roll up small companies into a larger one with the private equity firm providing the management. They charge hefty fees for arranging the deal and a 20% annual return on its investment after paying the interest on the debt related to the transaction. After three to seven years, the private equity firm and the physicians earn a windfall with the first flip and by this time, the private equity firm has taken all its money off the table. If things don’t go as planned, there is always a bankruptcy which cuts the private equity firm loose with no loss. As to how to achieve the financial targets, there can either be sharp cost reductions or ways to increase revenue. Since those specialty physicians took a pay cut to play the game, they have a powerful incentive to ignore cost controls or value-based treatment.  While we give lip service to value-based payments, the majority of revenue (which pays those physician salaries) still comes from fee-for-service medicine. It’s hard to see how this cycle is going to help the United States achieve a less-costly and higher-quality healthcare system. And let’s not even go near “Medicare for All”. We need to make sure that physician practices are allowed/mandated to practice medicine and still achieve the Triple Aims of High Quality, Low Cost and Patient Satisfaction.


David Fater is CEO at ALDA and Associates International in Boca Raton.

Last Updated on Monday, 07 October 2019 13:20
Want to Reduce Suicides? Follow the Data - To Medical Offices, Motels and Even Animal Shelters Print E-mail
Written by Maureen O'Hagan | KHN   
Tuesday, 24 September 2019 17:43

HILLSBORO, Ore. - On Kimberly Repp's office wall is a sign in Latin: Hic locus est ubi mors gaudet succurrere vitae. This is a place where the dead delight in helping the living. For medical examiners, it's a mission. Their job is to investigate deaths and learn from them, for the benefit of us all. Repp, however, isn't a medical examiner; she's a PhD. microbiologist. And as the Washington County epidemiologist, she was most accustomed to studying infectious diseases like flu or norovirus outbreaks among the living. But in 2012 she was asked by county officials to look at suicide. The request led her into the world of death investigations, and also appears to have led to something remarkable: In this suburban county of 600,000 just west of Portland, the suicide rate now is going down. It's remarkable because national suicide rates have risen despite decades-long efforts to reverse the deadly trend.

Last Updated on Tuesday, 05 November 2019 18:45
A family's cry: a life-changing case for the ER staff Print E-mail
Written by Storytellerdoc, MD | KevinMD   
Tuesday, 17 September 2019 18:07

"The death of a child is the single most traumatic event in medicine. To lose a child is to lose a piece of yourself."

I walked into work yesterday morning, and it only took seconds to appreciate the immense sorrow and sadness that permeated the air. My beautiful work family was despondent and deflated. Shoulders were slumped, feet were shuffling, faces wore defeat. Something terrible had occurred during the night shift. Damn it. I felt my heart clench with the fear of anticipating the news that would cause such palpable pain to my coworkers. Walking toward the first nurses' station, "Central" as we know it, I said brief good mornings to several nurses and techs as well as our unit coordinator, Amy. Most of them were either sitting or standing, leaning into the counter. Under the fluorescent lights, their eyes were dull. A profound fog of nothingness seemed to envelop each of them. 

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