The New Yorker had an incredible article by Dr. Atul Gawande explaining why health care costs are so high in different parts of the country.  I strongly encourage everyone to read the entire article but below are some excerpts and thoughts.

The article discusses McAllen, Texas. McAllen is in Hidalgo County, which has the lowest household income in the country.  In 1992, in the McAllen market, the average cost per Medicare enrollee was $4,891, almost exactly the national average. But since then, McAllen’s health costs have grown faster than any other market in the country, ultimately soaring by more than ten thousand dollars per person.  Now McAllen is one of the most expensive health-care markets in the country. Only Miami—which has much higher labor and living costs—spends more per person on health care. In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns.  McAllen, with its high poverty rate, has an incidence of heavy drinking sixty per cent higher than the national average. And the Tex-Mex diet has contributed to a thirty-eight-per-cent obesity rate.

There’s no evidence that the treatments and technologies available at McAllen are better than those found elsewhere in the country. The annual reports that hospitals file with Medicare show that those in McAllen and El Paso offer comparable technologies—neonatal intensive-care units, advanced cardiac services, PET scans, and so on. Public statistics show no difference in the supply of doctors. Hidalgo County actually has fewer specialists than the national average.

Medicare ranks hospitals on twenty-five metrics of care. On all but two of these, McAllen’s five largest hospitals performed worse, on average, than El Paso’s. McAllen costs Medicare seven thousand dollars more per person each year than does the average city in America. But not, so far as one can tell, because it’s delivering better health care.

Of course, many people will blame lawyers.  However, several years ago, Texas passed a tough malpractice law that limited pain-and-suffering awards at two hundred and fifty thousand dollars.  Since then, there haven’t been any lawsuits.  Something fundamental had changed since the days when health-care costs in McAllen were the same as those in El Paso and elsewhere. Yes, they had more technology but the real problem is doctors overusing technology.  Compared with patients in El Paso and nationwide, patients in McAllen got more of pretty much everything—more diagnostic testing, more hospital treatment, more surgery, more home care.

Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits. The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.

A 2003 study examined the treatment received by a million elderly Americans diagnosed with colon or rectal cancer, a hip fracture, or a heart attack. They found that patients in higher-spending regions received sixty per cent more care than elsewhere. They got more frequent tests and procedures, more visits with specialists, and more frequent admission to hospitals. Yet they did no better than other patients, whether this was measured in terms of survival, their ability to function, or satisfaction with the care they received. If anything, they seemed to do worse.

Complications can arise from hospital stays, medications, procedures, and tests, and when these things are of marginal value the harm can be greater than the benefits. In recent years, we doctors have markedly increased the number of operations we do, for instance. In 2006, doctors performed at least sixty million surgical procedures, one for every five Americans. No other country does anything like as many operations on its citizens. Some hundred thousand people die each year from complications of surgery—far more than die in car crashes.

Our country’s health care is by far the most expensive in the world.  Spending on doctors, hospitals, drugs, and the like now consumes more than one of every six dollars we earn. The financial burden has damaged the global competitiveness of American businesses and bankrupted millions of families, even those with insurance.

 If we brought the cost curve in the expensive places down to their level, Medicare’s problems (indeed, almost all the federal government’s budget problems for the next fifty years) would be solved. The difficulty is how to go about it. Physicians in places like McAllen behave differently from others.

Renaissance is the newest hospital in the area. It is physician-owned. And it has a reputation for aggressively recruiting high-volume physicians to become investors and send patients there. Physicians who do so receive not only their fee for whatever service they provide but also a percentage of the hospital’s profits from the tests, surgery, or other care patients are given. (In 2007, its profits totalled thirty-four million dollars.) This gives physicians an unholy temptation to overorder.

Some doctors own strip malls, orange groves, apartment complexes—or imaging centers, surgery centers, or another part of the hospital they directed patients to. They had “entrepreneurial spirit." They were innovative and aggressive in finding ways to increase revenues from patient care. Financial considerations drive the decisions doctors made for patients—the tests they ordered, the doctors and hospitals they recommended—and it bothered him. Several doctors who were unhappy about the direction medicine had taken in McAllen told me the same thing. “It’s a machine, my friend,” one surgeon explained.

No one teaches you how to think about money in medical school or residency. Yet, from the moment you start practicing, you must think about it. You must consider what is covered for a patient and what is not. You must pay attention to insurance rejections and government-reimbursement rules. You must think about having enough money for the secretary and the nurse and the rent and the malpractice insurance.

Many physicians see their practice primarily as a revenue stream. They instruct their secretary to have patients who call with follow-up questions schedule an appointment, because insurers don’t pay for phone calls, only office visits. They consider providing Botox injections for cash. They take a Doppler ultrasound course, buy a machine, and start doing their patients’ scans themselves, so that the insurance payments go to them rather than to the hospital. They figure out ways to increase their high-margin work and decrease their low-margin work. This is a business, after all.

As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future.


The Northwest Herald had an article about a lawsuit involving the neglect of a resident that led to a fall that caused her death.  The wrongful death lawsuit against a Chicago nursing home, Sacred Heart Home, states that the nursing home failed to prevent the fall that led to the resident’s death.

Kathleen Koch, died after suffering from a broken back, head injuries and paralysis after she fell in a stairwell at the nursing home. The fall happened Dec. 21, and she died eight months later at 61 years old.

The case alleges that staff should have better supervised Koch because they knew she had been diagnosed with bipolar disorder and schizophrenia and was at high risk for wandering and falls.  However, her room was not near a nurse’s station, and Koch was able to go into the stairwell unsupervised.

She was the type of resident that needs to be closely monitored and supervised which clearly was not done.  I am sure the nursing home will blame the resident and claim it was all her fault.


The L.A. Times reported that State officials have fined two nursing homes in Orange County for providing care so inadequate that it caused the deaths of two patients.

In one case, a woman died from dehydration.  This is clearly a preventable death.  The nursing home failed to give a resident sufficient fluids, causing her to suffer dehydration and acute kidney failure.   A doctor ordered that the patient’s fluid intake and urine output be monitored during every shift.  A review of the patient’s intake and output of fluids was blank or illegible.  The woman’s condition had deteriorated so much that she was transferred to a hospital, where she was diagnosed with a urinary tract infection, dehydration and an "altered mental status."  

The patient died six days later, on Christmas Day.  Alamitos West Health Care Center in Los Alamitos was fined $100,000

 In the other, staff failed to provide CPR to a man suffering a heart attack because they mistakenly believed he was under orders not to be resuscitated.  A registered nurse supervisor did not call 911 as a patient was dying "because she thought the patient had orders" not to be resuscitated. In fact, the patient’s medical record included an advance directive form from a family member on which was marked the option, "I DO WANT C.P.R." in an emergency situation.  A licensed vocational nurse called to inform a family member that the patient had died. The nurse told the family member that the patient was dead and that paramedics were not called because the facility had orders not to resuscitate the patient.  The family member told the nurse to hang up and call 911.  By the time paramedics arrived, they found the patient in bed with no heartbeat. He was covered with a sheet with no signs that CPR had been initiated.

State officials levied an $80,000 fine on the Huntington Valley Healthcare Center in Huntington Beach.


McKnight’s had an article discussing the recent National Nursing Home Survey: 2004 Overview is the seventh in a series of periodic nursing home surveys conducted by the Centers for Disease Control and Prevention’s National Center for Health Statistics, Division of Healthcare Statistics. The full study is available at here.

The number of both nursing home beds and nursing home residents in the United States declined between 1999 and 2004.   The number of nursing home beds dropped by more than 10% from 1.9 million in 1999 to 1.7 million in 2004. Meanwhile, the number of nursing home residents fell by 6% from 1.6 million to 1.5 million according to the study.

Here are other study findings:

More facilities were both Medicare and Medicaid certified in 2004 (87.6%) than in 1999 (81.8%).

Of the 936,000 persons providing nursing home care in 2004, the vast majority (roughly 600,800) were certified nursing assistants (CNAs).

Slightly more than 88% of the residents of the nation’s 16,100 skilled nursing facilities are over the age of 65, 45.2% are over the age of 85, and 71.2% are female.

Only 1.6% of the entire nursing home population received no assistance with activities of daily living (ADLs) while a slight majority—51.1%—required assistance in all five ADL categories.


The Journal Times had an article about a recent settlement between a nursing home and an abused resident.  The Racine County Board passed a resolutions which settled the case for $25,000.

Arthur Woiteshek, a resident at Ridgewood Care Center, sued the county because of abusive treatment by the nursing home’s certified nursing assistants.   Woiteshek, who had been diagnosed with Alzheimer’s disease, was living at the center.  CNA Amelia Clay twisted his ear so violently that it caused three cuts on one of Woiteshek’s ears, two of about one-half inch and the other of slightly more than 2 inches. Doctors used 19 stitches to close the wounds.

The $25,000 settlement will be made with Woiteshek’s estate. He died at Ridgewood on May 17 at the age of 88.  Clay was fired from her job at Ridgewood but filed a grievance which is now in arbitration. The incident also resulted in additional training and the reinforcement of training at Ridgewood, said Geoff Greiveldinger, the county’s chief of staff.


There is a bill that was introduced in Ohio that would require nursing homes to notify residents and their families when a sex offender moves into the facility.   This seems like a no-brainer. 
Under current law, not only is notification not required, but nursing homes are not allowed to turn away applicants for being sex offenders.

Senate Bill 130 would require licensed nursing care facilities to notify residents and their families that a Tier 3 sex offender is living there.   Notification would also be required if a person was imprisoned for a felony any time during the 12-month period of their application for admission.

Nursing home operators worry that notification will put them in a difficult legal position.

"What is the answer when (family members) come to the facility and say, ‘Well, we don’t want this person living next door to our loved one? What are you going to do about it?’ " said Peter Van Runkle of the Ohio Health Care Association, which represents nursing home. "We are not legally allowed to refuse to admit someone that we have the ability to take care of because of their past offenses."

Here is the link to the story.

I ran across the Nursing Home Complaint Center website which seems to be an advocacy group to prevent neglect, abuse, and Medicaid/Medicare fraud.   Their website states that Americas Watchdog created the National Nursing Home Complaint Center because there really is no government or private organization that will act as advocates for senior citizens and their families with one simple phone call.

If a loved one has concerns about the treatment a family member is receiving in a nursing home in any state, they can call the Nursing Home Complaint Center anytime at 866-714-6466.

Aside from patient advocacy, the Nursing Home Complaint Center is also an advocate for the taxpayers, dedicated to the idea that the patient only has to pay for the treatment they receive. The group estimates on an annual basis US nursing homes over bill US taxpayers billions for services billed to Medicare & Medicaid, that were never performed. The Nursing home Complaint Center thus has a dual purpose; patient advocacy, and taxpayer protection.

Hopefully, this group will do a good job advocating for nursing home residents since we know regulatory agencies and politicians are certainly not doing a very good job.

Tulsa World had an article about a nursing home employee who reported neglect and abuse at a nursing home, and was subsequently fired from her job despite her affirmative duty to report such incidents.  This is outrageous.  This employee did exactly what she was supposed to do and the nursing home fired her for it.  She is now suing Cimarron Pointe Care Center and one of its contractors for wrongful termination.  Is it any wonder why many nurses look the other way when residents are abused and neglected?

In the lawsuit, Harris said she worked as a housekeeper at the facility. She was paid by Health Care Services Group, a Tulsa company contracted by the home to provide cleaning services, and supervised by nursing home staff.   During her employment, she observed numerous instances of improper care of the home’s residents.

"Mrs. Harris observed a male resident who had been left in his own waste for so many hours that he had feces caked on to his leg from his hip to below his knee, and had wet himself at least one time."   She saw the man sitting in his waste and reported it to her supervisor, the head nurse and two nurse’s aides. Her supervisor sprayed deodorant in the man’s room to cover the smell. The aides said they would leave him for the next shift.

"Two and a half hours later, he was still sitting in his own waste," Harris said. "He couldn’t say nothing. I would always talk to him. He would just light up when I went to clean his room. It’s heartbreaking when you see a resident not being taken care of."

Also, an elderly woman paralyzed from the waist down was left in her own waste, Harris said. She rolled out of the bed and into the hallway to get someone to change her soiled garments and the nurses "just laughed at her," Harris said.

"On another occasion, Ms. Harris brought the needs of another female resident to the attention of the nursing staff. The resident’s needs were ignored, prompting the resident to write a letter to her family saying goodbye, in anticipation of death from neglect," the petition states.

Another female resident, who was unable to sit up alone, was left on a bench in the shower. She fell and hurt herself, the petition said.

Harris reported each instance of neglect or abuse to the facility’s staff.  The home’s administrator and a supervisor from Health Care Services Group of Tulsa, the contractor that paid Harris, fired her.   Of course, Cimarron Pointe Care Center denies any improper care of its residents. It also states that Harris was employed by Health Care Services Group, so the nursing home isn’t responsible for her termination.   However, Ms. Harris was told that the only basis for her termination was her reporting of the abuse.  Ms. Harris had not done anything else to merit termination, and no other basis for termination were discussed or even suggested."


The Palm Beach Post had an article about  nursing home neglect that really pissed me off.  The nursing home resident that was neglected was a bilateral amputee with bed sores on his stumps and buttocks.  When a state inspector saw him, he was sleeping unattended in a wheelchair on the front walkway of the Azalea Court nursing home in West Palm Beach.  She noticed a lit cigarette smoldering on a towel covering the resident’s left stump. A 1-inch hole had burned into the towel and the edges of the fabric were glowing red. “Smoke was actively rising from the towel,” according to the inspection report. The man had been labeled a “safe smoker.”  The patient had been found asleep with a lighted cigarette on prior occasions. Two weeks earlier, a nurse found the man sitting outside the facility, sleeping with a lit cigarette in his mouth.

The incidents reflect the nursing home’s “intentional or negligent failure to provide adequate and appropriate health care,” state officials said in a complaint that called for a $31,000 fine against Azalea Court. As part of a settlement agreement, the fine was lowered this year to $11,000.

Azalea Court was also fined $5,000 this year when after state inspectors last year found maggots crawling out of the leg cast of a resident. That fine was initially $10,000. Azalea Court has appealed both fines to an administrative law judge.

The Florida Agency for Health Care Administration also has cited Azalea staff last year for failing to respond to an alarm connected to the front door of the facility that signals if people are leaving the facility.  In addition inspectors interviewed six residents who said they were scared to voice grievances with the facility for fear of retribution.  This is a common complaint in most nursing homes.  Residents are scared that the care will get worse if they complain or get a nurse in trouble.

Kristi Nelson at had an article about the nursing home employee who was caught taking nude pictures and videos of residents and sharing them with others.  This is a violation of the residents’ privacy and dignitiy.   The unauthorized cell-phone photos and videos resulted in a state penalty for Pigeon Forge Care and Rehabilitation Center, a ban on staff members using cell phones in resident areas, and, according to state surveyors, multiple violations of at least a dozen residents’ privacy and dignity.

The photos and videos were found when a cell phone was left at a local restaurant.   A restaurant worker turned on the phone in an attempt to identify its owner, recognized one of the photos of a resident and gave the phone to a family member employed at the nursing home.   That person gave the phone to the director of nursing, who turned it over to the facility’s administrator after seeing the photos and videos.  Administrator Jon Bowers gave the phone to the Tennessee Bureau of Investigation and immediately fired the certified nursing assistant to whom the phone belonged. A second certified nursing assistant who appeared in some photos was later fired, and two others believed to be involved had earlier left the facility’s employ.

The Tennessee Department of Health conducted an investigation at the nursing home.   In its report, the state determined Pigeon Forge Care and Rehabilitation Center failed to protect the residents from having unauthorized photos and videos taken – compromising their dignity, privacy and safety from abuse – and suspended admissions to the nursing home for a week.

Twelve residents appeared in 47 pictures and 27 videos, taken between July 2007 and March 2009, found on the phone. They included:

— A photo of a male resident sitting on a shower chair, nude, with a string of beads around his neck.

— A photo of a female resident sitting on a bed wearing only a brief and a hat, with one breast fully exposed.

— Photos of a female resident wearing, at various times, a bib, a feathered mask, strawberry-shaped sunglasses and a wicker basket on her head.

— A photo of a male resident lying nude on the floor.

— Photos of a resident being fed, "wearing a bib and food running down (his) chin and neck."

— Videos of residents being fed or attempting to feed themselves.

— A video of a resident eating a cookie without dentures.

— A video of a resident lying in bed with one hand down his pants.

— A video of a resident in a wheelchair, using a broom in a motion similar to rowing a boat.

— A video of a moaning resident in a bed being shaken by two certified nursing assistants, in an apparent attempt to get him to make a certain noise.

— A video of the certified nursing assistant repeatedly telling a resident "I love you" and coaxing the resident to say it back.

The report states that the worker showed the photos to fellow employees.  Meanwhile, the resident council president told state investigators that residents had first complained about staff cell phone use in October 2007.