30 April 2013


The report, just out, shows extraordinary rates of unnecessary hospital admissions and ED visits in 13 low-income New Jersey cities and communities. The lack of good primary care results in this revolving door hospital care that often is uncoordinated and episodic — not to mention expensive. The report for the first time shows that some communities are far worse than others.

For instance, the study found the rate of unnecessary hospitalizations per 100,000 population in Camden was 3,754. It was 3,207 in Atlantic City and 3,098 in Newark. In New Brunswick the number was 1,658.

Clearly, the State’s Medicaid program is not looking at the “big picture” in terms of care delivery in these communities. They are failing patients. The Medicaid program is called upon to help people cope with chronic illness without regular trips in and out of the hospital. They must help people with underlying mental illness and substance abuse problems. They are not merely financial transfer agents of reimbursement.

The take-away from the report is clear: We cannot continue to hand over taxpayer dollars and then not track how that care is delivered. We cannot just stand back and hope that managed care organizations and care providers are working to keep people well and out of the hospital. We need accountability and clear benchmarks.

Hundreds of millions of health care dollars could be saved if the worst communities could do as well as the communities that are not necessarily good, but just not as bad. More important, people would receive better care. Do we help a patient get access to daily asthma medicine or just have the ER “treat ’em and street ’em,” as they say, every time the person has a serious attack? Do we help people manage their diabetes, or wait until crises send them to the hospital?

New Jersey has passed legislation to create Accountable Care Organizations in these low-income communities that would reward the ACOs for keeping people well and out of the hospital. The word here is “accountable.” It’s a word we need to start using more. Whatever the management vehicle — managed care, ACOs — we should develop clear measures to determine if these organizations are doing their jobs or just standing by as patients with poor primary care go in and out of the hospital.

Here’s the link to the report by the Rutgers Center for State Health Policy: http://www.cshp.rutgers.edu/Downloads/9810.pdf

So what is wrong with this picture? A hospital makes more money when it provides inferior care that requires a patient to stay in the hospital longer. A hospital makes more money when it provides additional treatment for surgical complications that could have been prevented.

A recent study in the Journal of the American Medical Association examined hospital records of thousands of surgical patients. The study found that insurers paid hospitals about $30,000 more for each case that involved a patient with a complication, such as an infection, blood clot or pneumonia. So where is the financial incentive for hospitals to work to prevent these complications?

The study illustrates the need for re-thinking our fee-for-service payment system — an overhaul the Qualty Institute has long endorsed. Our current system does not work. Instead, we must reward hospitals and doctors for keeping patients well and for providing quality care. I do not believe that a hospital would deliberately cause complications to improve its bottomline. But right now the hospitals that work diligently and successfully to reduce surgical complications get paid less than those that do not.

The perverse system rewards the hospitals that make the most mistakes.

The Quality Institute has been supporting other models of care, such as the system used by Accountable Care Organizations. We sponsor the Affiliated Accountable Care Organizations, which facilitates the growth of new regional coalitions committed to becoming Safety Net Medicaid ACOs.

Under this care model, ACOs that keep people well and OUT of the hospital will be rewarded financially. These ACOs right now are being developed in urban areas with large populations of poor patientss. But the model holds promise beyond cities and is the kind of payment system we need to explore. We need to reward good quality instead of poor quality.

Here’s a link to an article about the study: http://nyti.ms/ZlUn0M


17 April 2013


Not long ago, it didn’t matter much where you were treated for a stroke. There was an intravenous clot buster that provided somedrvez benefit for some patients and not much else.

But today the hospital you are taken to after a stroke or other neurologic emergency can make an enormous difference — perhaps the difference between returning to your old life or spending the rest of your days severely disabled. Or maybe even between life and death.

The technology advances in emergency stroke care even in the past year have been profound. I bring this up because today the Capital Institute for Neurosciences begins a three-day conference in Atlantic City to advance the care of stroke and other neurologic emergencies, as well as to address additional topics in the field of neurology. An estimated 500 health care providers are expected to attend.

Capital Health has made enormous efforts to improve neurologic emergency care in New Jersey, most notably by creating the nation’s first ER for brain emergencies. It’s in Trenton. The institute has shaken up referral patterns and ruffled some feathers in the hospital world — all in the name of improving neurologic care.

I have a vested interest here. The institute is a member of our leadership council, and I know and respect Dr. Erol Veznedaroglu, director of the institute. And I personally know how high the stakes can be for a person suffering a stroke. I suffered a stroke while traveling in 2006 and I received expert care at Yale University Medical Center. I was lucky.

But Dr. Vez, as he is known, believes that good care should not be about luck. The best care should come from proper protocols and high standards as well as from highly trained staff supported with the appropriate technology. We should all welcome the 5th Capital Institute for Neurosciences Conference and the effort to make sure that we are not a state of haves and have-nots when it comes to the best neurologic emergency medicine.

Here’s a link to the conference:


15 April 2013


I recently met with Leslie Brody, a New Jersey reporter and author of The Last Kiss, a memoir about Leslie’s marriage to The Last Kiss Front CoverElliot Pinsley and his death from pancreatic cancer. Elliot, also a journalist, died at age 57.

I found myself thoroughly engrossed in Leslie’s story. I was right there with her at the Sloan-Kettering hospital room. Right there in the kitchen with Elliot making pancakes. Right there at Shea Stadium as the die-hard Mets fan and his wife squeezed every bit of love and happiness they could from life.

Leslie’s story is valuable for several reasons. First, The Last Kiss is a wonderful story of love and strength and courage. But Leslie and Elliot’s story also touches on important health care issues involving death and dying. And because Leslie never stops being a reporter we get a fact-based, accurate and unflinching look at the reality of health care at the end of life.

I wrote earlier about Leslie’s experience trying to find marijuana —at the suggestion of Elliot’s doctors — to relieve his nausea and help him regain his appetite. It is funny and poignant and reminds me exactly why we need to legalize medical marijuana in New Jersey.

But Leslie’s story also documents a sad and troubling failure in end-of-life care. Hospice failed Elliot and his family. The hospice program the couple employed was disorganized, inattentive and sometimes downright uncaring. Instead of sending one nurse to develop a relationship with the patient and his family there was a revolving door of caregivers, including one who arrived reeking of cigarettes.

Leslie’s pleas on the phone as Elliot exhibited more and more pain were dismissed. Hospice workers who said they would check on a possible medication interaction never called back. At the end, Leslie knew Elliot was in pain but her pleas for additional medication were dismissed until she screamed and shouted: “Your ONLY job is to make him comfortable. Can you people do that ONE thing right?”

Anyone who knows me knows that I am a great supporter of hospice care. Yet Leslie’s story must be part of the conversation if we want to improve health care at the end of life. The promise of hospice — that we can help people die as comfortably and as pain-free as possible — is a promise hospice must keep. Anyone who believes in providing the best hospice care possible should not dismiss Leslie as a grieving widow, but instead look squarely at the facts and failures she describes and find out how we can — and must — do better.

For more information on The Last Kiss, see www.lesliebrody.com.


By Tauya English, WHYY
April 3, 2013

Camden, N.J., has serious health problems, with too many people going to local emergency rooms unnecessarily. But progress is being made, albeit slowly.

John Pike, 53, is a Camden resident who used to be a frequent flier at the ER.

Pike has a smoker’s cough, and when that cough or pain in his bad hip flared up, he’d go to the ER — maybe eight or nine times a year. But when he did, ER staffers didn’t really remember him or his medical history.

“You get the feeling you are irritating them,” he says. “It would be a simple problem. I’m wasting their time, where they could be dealing with a real emergency.”

Once, he says, an ER nurse pulled him aside and said, “This is something your doctor can deal with.”

“Not much I could say, because she was telling the truth,” he says.

But Pike didn’t have a primary care doctor until a community group called the Camden Coalition of Health Care Providers opened a doctor’s office right inside Pike’s apartment building.

Ken Gross, director of research and evaluation for the coalition, says the idea was to get “super users” like Pike to stop going to the hospital so frequently.

Gross says the group saw ER overuse in Camden as “a sign for us, from the data, that you don’t have a source of primary care, or you have a loose relationship with primary care, or you can’t get an appointment with your primary care because of your work hours.”

Gross leads a team of health-data detectives at the coalition. For several years, they gathered hospital billing information from across Camden. Then they mapped the data block by block.

It turns out that Pike’s building is marked as a bright-red “hot spot” on the map. Pike and his neighbors at the Northgate II building had racked up more than $1 million a year in hospital admissions and trips to the emergency room over about a decade.

These days, Pike rides an elevator to the doctor, just six floors down from his apartment. The space is bare bones, with just two exam rooms and a tiny file office, but Pike has his own doctor now — Dr. Madhumathi Gunasekaran.

“I feel comfortable with her. I can talk to her; she doesn’t shove you off like some doctors,” Pike says.

Dr. Jon Regis is a longtime member of the Camden coalition. His company, the Reliance Medical Group, operates 21 offices across New Jersey, including the practice at Northgate II. The subsidized housing there is home to many low-income seniors and people with disabilities. Many people who live in Northgate II now see Gunasekaran for checkups and other medical issues. But Regis says it took longer than he had hoped to win over residents — almost two years.

“We thought that since they were having such a difficult time, we could just open up the door and they would come down,” he says. “That wasn’t the case.”

Regis says some residents told him they didn’t want their neighbors to know they’re going to the doctor. But Regis was persistent in trying to get residents to use Gunasekaran instead of the ER.

“We had to do a number of different things, like health fairs and meet-and-greets. We had to engender a sense of trust in the residents before they would come down to see us,” he says. “I think that was somewhat surprising. But we’re starting to get past that now.”

About a year ago, only about 80 people got their primary care at the office. That number has grown to nearly 130, or about 19 percent of the building’s residents. It was a slow start, but Regis says he is pleased with the progress.

Reliance uses revenue from private pay and private insurance patients at other office locations to help finance the clinic at Northgate II. This way, he says, “We don’t have to turn anybody away, and we’ve been able to make this work.”

This story is part of a partnership with NPR, WHYY and Kaiser Health News

By Emily Brill / Times of Trenton
April 2, 2013

TRENTON — Five city health clinics will soon begin screening patients for drug and alcohol problems thanks to a $5.2 million state grant received by the Trenton Health Team, the organization announced today.

“If you go to a substance abuse center, you’re often labeled a drug addict,” said Dr. Kemi Alli, medical director of the Henry J. Austin Health Center, in a press release. “But by incorporating screening into the very fabric of how we treat our patients, it becomes not very different than treating diabetes and hypertension.”

The Screening, Brief Intervention and Referral to Treatment or SBIRT program is expected to screen 8,750 people in its first year, Alli said. It will be implemented at Henry J. Austin’s three locations and at the city’s Capital Health and St. Francis clinics.

Patients who identified as being at risk for substance abuse will be referred to a healthcare educator who will conduct an intervention described as a 15-minute motivational conversation about treatment options, the release said.

The program has been used in cities in Colorado, Massachusetts, Florida and other states.

The five-year, $5.2 million grant from the New Jersey Division of Mental Health and Addiction Services will train clinic employees to screen and counsel patients, Trenton Health Team president Robert Remstein said.

“The idea is, when patients come into primary care, screen them for signs of substance abuse, drug abuse and do a brief intervention and get them into treatment,” Remstein said in the release.

The Trenton Health Team is an alliance of the Henry J. Austin Health Center, Capital Health, St. Francis Medical Center and Trenton’s Department of Health and Human Services.

Contact Emily Brill at ebrill@njtimes.com or (609) 989-5731.

By Michael Mancuso, The Times
April 2, 2013

Editorial Rutgers study on ER treatment costs in urban areas shows value of Trenton Health Team


(Photo: From left, Derrick Branch, of Trenton, New Jersey, has his blood pressure checked by nurse practitioner Peg Nucero at St. Francis Medical Center with health team members Debbie Farmer, nurse case manager, Suzanne Shenk, DO and Fran Herman, nurse practitioner in the room.)

Your grandmother might have reminded you that an ounce of prevention is worth a pound of cure.

In Trenton, as well as other urban areas, the stakes are considerably higher. A recent Rutgers study found that in Trenton alone, avoidable emergency room visits and hospitalizations cost $40 million over two years.

That’s a staggering amount in a city of such want. When added to the dozen other urban areas the Rutgers researchers studied, it works out to a statewide loss of $284 million in just 2010.

The scenario is distressingly familiar. Those lacking insurance or a doctor ignore a minor health concern or decide to tough out a chronic condition — until they become critical and warrant emergency attention.

Click here to read the full article