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The military concept of “honor” as reflected in how it treats the troops

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C. J. Chivers has a somewhat depressing article in the NY Times today. It’s a lengthy article, but it’s definitely worth reading.

Daniel Mould’s sense of abandonment was profound.

An Air Force staff sergeant wounded in a chemical weapon accident in 2004, he willingly helped the military study his wounds. From his bed in a Philadelphia burn ward, as blisters from sulfur-mustard agent erupted on his skin, he signed a waiver allowing doctors to gather his body fluids to experiment with new laboratory methods for confirming chemical exposure.

Over the next 18 months, as the military gave him attentive care and doctors prepared peer-reviewed journal articles about his case, another branch of the service, the Army, concluded that it needed to be exhaustive in tracking troops exposed to chemical warfare agents: Citing Sergeant Mould’s burns, it called for monitoring victims for life.

The case seemed a welcome example of the military’s working closely with a patient to improve understanding of a rare battlefield risk and to develop practices to learn from patients’ medical experiences. Then came the shift.

When Sergeant Mould accepted medical retirement in 2006, he was suffering a cascade of health problems, but he said he had been assured of long-term monitoring. Instead, he said, “the Air Force never contacted me again. I’ve never been tracked.”

In October, reacting to an investigation by The New York Times, the Army surgeon general’s office announced that it would begin monitoring the long-term health of all veterans exposed to nerve or blister agents during the American occupation of Iraq. The victims had been kept secret as long as a decade, and the Army’s treatment guidelines had not been followed.

For Mr. Mould, 45, who had never spoken publicly about the accident, the irony of the Army’s announcement was startling. Even the person whose wounds spurred one branch of the military to call for tracking exposed veterans had not been enrolled in long-term monitoring — by either the Pentagon or the Department of Veterans Affairs.

The origins of his case span almost a century of American chemical-warfare policies, and like the experience of Iraq — where troops were wounded by abandoned chemical weapons — his example speaks to the persistent dangers presented by discarded or forgotten munitions.

Almost all of the military’s previous chemical-exposure victims had been World War I veterans or human subjects in classified military tests during World War II and the Cold War. The latter group, tens of thousands of enlisted men, were systematically exposed to nerve and blister agents in gas-chamber tests, field exercises or other efforts to evaluate protective equipment and human reactions to chemical-warfare agents.

Often the human subjects were sworn to silence. The Pentagon denied their existence for decades, until victims came forward with medical claims, prompting a 1993 review of the military’s conduct by the National Academies’ Institute of Medicine, which noted “a well-ingrained pattern of abuse and neglect” of the human subjects, some of whom had been duped into consent.

That review also found enduring negligence: “No formal long-term follow-up medical care or monitoring was provided” for exposure victims, even though follow-up, the authors said, “could have provided a wealth of information on the effects of these war gases.”

Tracking exposure victims is important, military and health officials say, because blister and nerve agents can carry long-term effects. Sulfur mustard, for example, can cause lingering respiratory difficulties and is carcinogenic, although precise risks have proved hard to measure in the limited studies to date.

That legacy of squandered opportunities appeared to change by 2004, when Sergeant Mould was burned.

His wounding was like a case study in the long-lasting dangers of modern weapons. In 1917 and 1918, the United States brewed chemical agents for use on Europe’s front lines, only to find it had little storage capacity for thousands of tons of chemical artillery shells that had not been fired before the armistice in 1918.

The Army found a solution: Dump them off the East Coast. “War Gas Dumped Far Out At Sea,” read the headline on a New York Times article in 1919, which noted that one vessel dropped 200,000 shells overboard between 60 and 100 miles out.

Little is known of the locations of many shells, which were scattered by multiple ships. But out of sight did not mean out of reach. One shell intersected with Sergeant Mould more than eight decades later, after the police found a rusted artillery projectile at a chicken farm in Delaware in the summer of 2004.

The projectile had been brought ashore by a fishing vessel and delivered to the farm with a load of crushed clamshells to be used as roadway fill.

Sergeant Mould, at the time assigned to an explosive ordnance disposal team on Dover Air Force Base, was dispatched to pick up the shell and bring it back the base. There, he said, he and a more senior noncommissioned officer misidentified it as a conventional, high-explosive 75-millimeter round.

The next day, Sergeant Mould’s team was assigned to destroy the shell. The plan was to breach it with a small shaped charge, causing its suspected contents to burn out and minimizing the risk of a larger blast or fragmentation.

After the team detonated the shaped charge, Mr. Mould recalled later, something was clearly wrong: The shell was leaking a “liquid about the consistency of vegetable oil and black as the ace of spades.” The liquid, he said, smelled like hot asphalt.

Continue reading.

See also this collection of reports. The blurb:

For nearly a decade, the United States government kept secret that troops were being injured as they stumbled across aged chemical weapons that Saddam Hussein had built for his war with Iran. Explore the original Times investigation, eyewitness accounts from victims and the developments that led to the Pentagon’s response, policy changes and follow-up care.

Written by LeisureGuy

31 December 2014 at 11:06 am

The downside of the profit motive: Degrading service to make money in the hospice industry

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We’ve already seen how the single supreme goal of making profits in a free-enterprise world can readily create rather than solve problems—the example in an earlier post today is how airline companies work to make economy-class service worse and worse so that people will purchase upgrades. That’s how the free market works: do whatever it takes to increase profits.

And we’ve repeatedly seen how hospitals run under a for-profit, free-enterprise model are more expensive and provide lower-quality care. Cutting costs and increasing profits are the focus, not quality of care and support of the medical and nursing staff.

While some charter schools run by private corporations may be good (at least temporarily), the drive to increase profits seems to turn some into little more than scams to bilk taxpayers of education dollars while helping students little.

Now the hospice industry is being milked of cash by for-profit corporations: Peter Whoriskey and Dan Keating report in the Washington Post:

The influx of for-profit companies into the hospice field has benefited patients, advocates say, because the commercial companies made big investments in technology, focused on efficiency and made care more accessible.

But a Washington Post analysis of hundreds of thousands of U.S. hospice records indicates that, as those companies transformed a movement once dominated by community and religious organizations into a $17 billion industry, patient care suffered along the way.

On several key measures, for-profit hospices as a group fall short of those run by nonprofit organizations.

The typical for-profit hospice:

●Spends less on nursing per patient.

●Is less likely to have sent a nurse to a patient’s home in the last days of life.

●Is less likely to provide more intense levels of care for patients undergoing a crisis in their symptoms.

●Has a higher percentage of patients who drop out of hospice care before dying. High rates of dropout are often viewed as a sign that patients were pushed out of hospice when their care grew expensive, left dissatisfied or were enrolled for hospice even though they were not close to death.

The quality of individual hospices varies widely. In some cases, for-profit hospices provide service at levels comparable to nonprofits, according to the review. But the data analysis, based on hundreds of thousands of Medicare patient and hospice records from 2013, shows that the gap between the for-profits as a whole and nonprofits is striking and consistent, regardless of hospice size.

“Unfortunately, a lot of people have come into the business for the wrong reasons,” said Michael Girard, who with his wife Deb owns the Circle of Life for-profit hospice in Reno, Nev. “A lot of the problems we have in hospice today have happened with the entry of what I call the ‘vulture capitalists.’ ”

About half of Americans of retirement age will employ a hospice service before death, but public information about the agencies is meager, and many consumers are unaware whether a hospice operates as a nonprofit or for-profit. . .

Continue reading. The article includes an interesting graphic.

The free market does not necessarily solve problems nor deliver good services. What it does deliver is profits to the owners: that is its sole goal.

 

Written by LeisureGuy

27 December 2014 at 8:36 am

Best healthcare system in the world: Hounding the poor edition

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Some hospitals have outrageous policies. At ProPublica Paul Kiel describes how publicly supported non-profit hospitals work down in Alabama:

More than a century ago, Alabama enshrined a basic protection in the state’s constitution shielding its poorest citizens from being forced to pay debts they couldn’t afford.

But a public hospital in the mostly rural southeast corner of the state has found a way around the law. Before patients can receive treatment at Southeast Alabama Medical Center, they must sign a form waiving that legal protection, clearing the way for the facility to seize funds from their pay or bank accounts to cover medical debts.

ProPublica and NPR reported last week that nonprofit hospitals, which are legally required to offer discounted care to the poor, often sue low-income patients and garnish hefty portions of their pay.

But ProPublica found similar tactics are wielded by public facilities that often serve as hospitals of last resort.

About a fifth of U.S. hospitals are public, operating under a patchwork of local and state authorities and balancing two potentially competing mandates: They must provide care to those who can’t get it anywhere else while spending as little public money as possible.

Southeast Alabama Medical Center (SAMC), the only public hospital in the small city of Dothan, meets the first mandate by having a generous financial assistance policy. But it also ranks among the area’s most aggressive debt collectors, relentlessly pursuing payment even from patients who would have been eligible for reduced or free care had they applied for it.

Over the past three years, SAMC has filed more than 4,000 suits against its patients. And those who tumble through the hospital’s safety net often are stuck not only with care billed at full price, but with interest and legal fees from the court action.

Other public hospitals in Alabama and other states use similar tactics. In Missouri, two of the three hospitals that file the most debt-collection suits are public.

Chi Chi Wu, an attorney with the National Consumer Law Center, said it is “outrageous” for a public entity to take “this kind of heavy-handed action” against poor people already grappling with unavoidable health care emergencies. . .

Continue reading.

Written by LeisureGuy

23 December 2014 at 9:58 am

How organizations fight change and punish whistleblowers: Military hospitals

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Sharon LaFraniere reports in the NY Times:

Beyond conducting their periodic evaluation of Womack Army Medical Center, one of the military’s busiest hospitals, the inspectors who came here to Fort Bragg last March had a special task. A medical technologist had complained of dangerous lapses in the prevention of infections. The inspectors planned to follow up.

But Teresa Gilbert, the technologist, said supervisors excluded her from meetings with the inspectors from the Joint Commission, an independent agency that accredits hospitals. “I was told my opinions were not necessary, nor were they warranted,” said Mrs. Gilbert, an infection-control specialist.

The review ended disastrously for Womack, one of 54 domestic and overseas military hospitals that serve more than three million active-duty service members, retirees and family members. The inspectors faulted infection prevention and many other aspects of care, putting the hospital’s accreditation under a cloud for months.

It was disastrous for Mrs. Gilbert, too. She said she was reprimanded for being an obstructionist, reduced to part-time hours, investigated for what she called trumped-up charges and transferred to a clerk’s job.

The message to Womack workers, she said, was clear: “You don’t go against us. If you do, we will get you.”

At any hospital, patient safety and quality of care depend on the willingness of medical workers to identify problems. The goal is for medical workers to be free to speak bluntly to — and about — higher-ups without being ignored or, worse, punished.

In interviews and email exchanges, many doctors, nurses and other medical workers said military hospitals fall short of that objective.

During an examination of military hospitals this year, The New York Times asked readers to recount their experiences via a private electronic portal. Among more than 1,200 comments were dozens from medical workers about how the system thwarted efforts to deliver superior care.

Physicians and nurses described in follow-up interviews how they were brushed off, transferred, investigated, passed over for promotion or fired after they pointed out problems with care.

Senior military health officials said they were working aggressively to instill a culture where complaints are welcomed and addressed.

“We want people to come forward,” Lt. Gen. Patricia Horoho, the Army surgeon general, wrote in a statement. “We are committed to patient safety, we are committed to transparency, and there will be NO COMPROMISE.”

But hospital workers, both military and civilian, described compromise as routine. The nature of military medicine, they say, muddles the emphasis on patient safety and quality of care.

Military hospitals must train a combat-ready medical corps while treating fevers and delivering babies. The staffs are top-heavy with novices, and active-duty medical workers are constantly rotated. Experts say some hospitals are dangerously small.

The command structure is so rigid that a nurse can oversee a doctor because the nurse holds a higher military rank. Promotions often reward administrative deeds over medical performance. Legal accountability is diminished: Active-duty service members cannot sue for malpractice, and other patients can sue only the government, not individual doctors or nurses.

Military supervisors wield more power than civilian ones; they are authorized to enforce rules that govern even the size of earrings a doctor can wear. Stepping out of line can be perilous for subordinates: One former Army radiologist said her supervisor threatened to transfer her to an outpost so remote that the only housing was in trailers.

“In the military you are not taught to question; you are taught to obey. And that’s great on the battlefield,” said Bill Benham, until recently first sergeant of the hospital at Fort Knox in Kentucky. “But health care is another beast.”

Risk in Raising Concerns

An analysis of military hospital data by The Times this year foundpreventable errors are chronic and rates of complications, when measured, are high in two cornerstones of treatment, maternity care and surgery. The Times also found that hospitals routinely failed to investigate after patients died unexpectedly or suffered permanent harm.

Continue reading.

One sidebar to the story:

Accreditation Trouble

In March, the Joint Commission found Womack Army Medical Center failed to comply with a long list of hospital standards. Inspectors cited continuing problems in two follow-up visits. A final inspection last month found no violations.

In the initial report, Womack was found to be out of compliance with 19 standards including the following:

  • Staff are competent to perform their responsibilities
  • The hospital effectively manages its programs, services, sites, or departments.
  • The hospital has an infection prevention and control plan.
  • The hospital plans the patient’s care
  • The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
  • The hospital uses data and information to guide decisions and to understand variation in the performance of processes supporting safety and quality.

Written by LeisureGuy

21 December 2014 at 6:16 am

Best healthcare system in the world: How Nonprofit Hospitals Are Seizing Patients’ Wages

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Paul Kiel (ProPublica) and Chris Arnold (NPR) have an interesting story on how bad the US healthcare system is, compared to healthcare in most Western countries:

On the eastern edge of St. Joseph, Missouri, lies the small city’s only hospital, a landmark of brick and glass. Music from a player piano greets visitors at the main entrance, and inside, the bright hallways seem endless. Long known as Heartland Regional Medical Center, the nonprofit hospital and its system of clinics recently rebranded. Now they’re called Mosaic Life Care, because, their promotional materials say: “We offer much more than health care. We offer life care.”

Two miles away, at the rear of a low-slung building is a key piece of Mosaic—Heartland’s very own for-profit debt collection agency.

When patients receive care at Heartland and don’t or can’t pay, their bills often end up here at Northwest Financial Services. And if those patients don’t meet Northwest’s demands, their debts can make another, final stop: the Buchanan County Courthouse.

From 2009 through 2013, Northwest filed more than 11,000 lawsuits.  When it secured a judgment, as it typically did, Northwest was entitled to seize a hefty portion of a debtor’s paycheck. During those years, the company garnished the pay of about 6,000 people and seized at least $12 million—an average of about $2,000 each, according to a ProPublica analysis of state court data.

Many were uninsured Heartland patients who were eligible for financial aid that would have eliminated or drastically cut their bills. Instead, they were charged full price for their care, without the deep discounts negotiated by insurers, according to court records, interviews and data provided by Heartland. No other Missouri hospital sued more of its patients.

Blue collar workers, Walmart cashiers, nursing home aides, clerical staffers—these types of patients have long been the most vulnerable to unexpected debt. They can’t afford insurance, yet they’re not poor enough for Medicaid. Even after the 2010 Affordable Care Act, about 30 million Americans remain uninsured, in part because some states, like Missouri, have not expanded Medicaid to cover more of the poor.

Earlier this year, ProPublica and NPR reported that the wages of millions of U.S. workers are diverted to pay off a variety of consumer debts. Most states, like Missouri, allow creditors to take a quarter of after-tax wages—an amount that government surveys show is unaffordable for lower-income families.

Consumer advocates say the laws governing wage garnishment are outdated and overly punitive, regardless of the debt’s source. But the consequences are especially dire when garnishment is used to collect unavoidable health care bills—with interest and legal fees piled on.

No one tracks how many hospitals sue their patients and how frequently, but . . .

Continue reading. And do read the whole thing: it’s an in-depth article.

The US could fix this if it wanted, but it’s easier just to screw over poor people.

Written by LeisureGuy

19 December 2014 at 1:23 pm

A Copper Bedrail Could Cut Back On Infections For Hospital Patients

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Hannah Block reports for NPR:

Checking into a hospital can boost your chances of infection. That’s a disturbing paradox of modern medical care.

And it doesn’t matter where in the world you’re hospitalized. From the finest to the most rudimentary medical facilities, patients are vulnerable to new infections that have nothing to do with their original medical problem. These are referred to as healthcare-acquired infections, healthcare-associated infections or hospital-acquired infections. Many of them, like pneumonia or methicillin-resistantStaphylococcus aureus (MRSA), can be deadly.

The World Health Organization estimates that “each year, hundreds of millions of patients around the world are affected” by healthcare-acquired infections. In the United States, the Office of Disease Prevention and Health Promotion in the Health and Human Services Department estimates that 1 in 25 inpatients has a hospital-related infection. In developing countries, estimates run higher.

Hospital bed safety railings are a major source of these infections. That’s what Constanza Correa, 33, and her colleagues have found in their research in Santiago, Chile. They’ve taken on the problem by replacing them, since 2013, with railings made of copper, an anti-microbial element.

Copper definitely wipes out microbes. “Bacteria, yeasts and viruses are rapidly killed on metallic copper surfaces, and the term “contact killing” has been coined for this process,” wrote the authors of an article on copper in Applied and Environmental Microbiology. That knowledge has been around a very long time. The journal article cites an Egyptian medical text, written around 2600-2000 B.C., that cites the use of copper to sterilize chest wounds and drinking water.

Correa’s startup, Copper BioHealth, has not yet assessed the railings’ impact in Chilean hospitals. But a study of the effects of copper-alloy surfaces in U.S. hospitals’ intensive care units, published last year in Infection Control and Hospital Epidemiology, showed promising results: Their presence reduced the number of healthcare-acquired infections from 8.1 percent in regular rooms to 3.4 percent in the copper rooms.

Correa spoke with Goats and Soda a few hours before she presented her work at a Latin America innovation conference earlier this month, hosted by the Inter-American Development Bank in Washington, D.C.

You have a simple strategy to combat hospital-associated infections. Tell me what it involves. . .

Continue reading.

Written by LeisureGuy

17 December 2014 at 10:37 am

Best medical system in the world: Echocardiogram edition

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Via Kevin Drum, Elisabeth Rosenthal writes in the NY Times:

Len Charlap, a retired math professor, has had two outpatient echocardiograms in the past three years that scanned the valves of his heart. The first, performed by a technician at a community hospital near his home here in central New Jersey, lasted less than 30 minutes. The next, at a premier academic medical center in Boston, took three times as long and involved a cardiologist.

And yet, when he saw the charges, the numbers seemed backward: The community hospital had charged about $5,500, while the Harvard teaching hospital had billed $1,400 for the much more elaborate test. “Why would that be?” Mr. Charlap asked. “It really bothered me.”

Testing has become to the United States’ medical system what liquor is to the hospitality industry: a profit center with large and often arbitrary markups. From a medical perspective, blood work, tests and scans are tools to help physicians diagnose and monitor disease. But from a business perspective, they are opportunities to bring in revenue — especially because the equipment to perform them has generally become far cheaper, smaller and more highly mechanized in the past two decades.

And echocardiograms, ultrasound pictures of the heart, are enticing because they are painless and have no side effects — unlike CT scans, blood draws,colonoscopies or magnetic resonance imaging tests, where concerns about issues like radiation and discomfort may be limiting. Though the machines that perform them were revolutionary and expensive when they first came into practice in the 1970s, the costs have dropped considerably. Now, there are even pocket-size devices that sell for as little as $5,000 and suffice for some types of examinations.

“Old technology should be like old TVs: The price should go down,” said Dr. Naoki Ikegami, a health systems expert at Keio University School of Medicine in Tokyo, who is also affiliated with the University of Pennsylvania’s business school. “One of the things about the U.S. health care system is that it defies the laws of economics, and of gravity. Once the price is high, it just stays there.” . . .

Continue reading.

Kevin Drum quotes from the article with emphasis added:

The five hospitals within a 15-mile radius of Mr. Charlap’s home here charge an average of about $5,200 for an echocardiogram, according to an analysis of Medicare’s database. The seven teaching hospitals in Boston, affiliated with Harvard, Tufts and Boston University, charge an average of about $1,300 for the same test. There are even wide variations within cities: In Philadelphia, prices range from $700 to $12,000.

….In other countries, regulators set what are deemed fair charges, which include built-in profit. In Belgium, the allowable charge for an echocardiogram is $80, and in Germany, it is $115. In Japan, the price ranges from $50 for an older version to $88 for the newest, Dr. Ikegami said.

Because Mr. Charlap, 76, is on Medicare, which is aggressive in setting rates, he paid only about $80 toward the approximately $500 fee Medicare allows. But many private insurers continue to reimburse generously for echocardiograms billed at thousands of dollars, said Dr. Seth I. Stein, a New York physician who researches data on radiology. Hospitals pursue patients who are uninsured or underinsured for those payments, he added.

blog_portable_echo

Best medical system in the world, eh?

Written by LeisureGuy

16 December 2014 at 10:52 am

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