Only solicitors with proved expertise in medical negligence cases will get legal aid funding for such claims in the future, under plans unveiled by Britain’s lord chancellor last week.

The UK government believes it is wasting millions of pounds a year on non-specialist lawyers who fail to deliver an optimum service in this complex area of practice. From August 1999, only law firms with a clinical negligence franchise from the Legal Aid Board will be funded by taxpayers for malpractice claims. Solicitors who are members of specialist panels run by the Law Society and Action for Victims of Medical Accidents and who prove specialist competence, will be eligible for a franchise.

Only 185 solicitors in a total of 131 firms in the United Kingdom belong to the specialist panels, raising fears that some parts of the country will have insufficient expertise. But the lord chancellor, Lord Irvine, said that specialist solicitors would be expected to travel to see clients if necessary, as many already do.

Medical negligence cases have a notoriously low success rate compared with other types of case. Nearly half of the cases in 1996-7 ended inconclusively, with no trial or settlement, but costing the taxpayer 14m [pounds sterling] ($22.4m) in legal aid fees, more than half the total 27m [pounds sterling] net cost of clinical negligence cases to the board. Only two of every five cases that went to trial or were settled out of court resulted in compensation for claimants.

The board believes that one reason for the high failure rate is lawyers’ lack of expertise. The move to specialisation is likely to mean more successful claims, bigger awards, and higher legal costs for the NHS. But this could be offset to some extent by plans to limit aid to applicants whose cases have a 75% predicted chance of success.

Bent over and barely able to walk, Dale Gowan turned to Deaconess Medical Center’s emergency room for relief from the pain shooting down from his lower back and into his legs.

“We’re not in the pain management business,” Dale said the ER doctor told him before writing a prescription.

With his long hair and thin frame, Dale’s appearance apparently fit the profile of a drug user looking for a fix. At least, that’s the way Dale believes the doctor treated him - not as a man with a chronic back injury in need of attention.

A spokeswoman for Deaconess denies this was the case, which makes it the word of a health care professional against that of someone on Medicaid. But it would not be the first time Dale, 38, who came to Spokane in search of work with his wife, Rebecca, and their three children, has suffered the indignity of poverty. The family lived in an old school bus before entering a homeless shelter in January.

In March, soon after moving into the Salvation Army’s reduced- rent transitional housing apartments, Dale lost his job as a drywall hanger. His employer had read about Dale’s back problems in The Spokesman-Review.

More than 20 years of drywalling have damaged the vertebrae in Dale’s back, making it dangerous for him to continue the only work he knows.

In health care matters, the United States is still pretty much a country where you get what you pay for. By that standard, the Gowans are fortunate to have the care they are receiving at the Community Health Association of Spokane’s Maple Clinic.

CHAS, a nonprofit system of federally qualified community clinics, provides medical and dental care to patients regardless of insurance status. In 2003, the clinics treated more than 24,000 people, 18 percent of whom were homeless.

Nearly five months after his first visit to the Maple Clinic, Dale, who was diagnosed a year ago in Boise with a bulging vertebra, has yet to see a neurosurgeon or even get an MRI. Though primary care is available to the poor at clinics such as those run by CHAS, specialized care is still hard to come by for an estimated 45 million uninsured and an untold number of underinsured Americans.

Spokane is no exception.

“We haven’t as a community gone to the next step of getting people who have extreme needs that special attention,” said Becky Swanson, vice president for marketing and communications at Empire Health Services, which runs Deaconess.

Lernout & Hauspie Speech Products NV is paying up to 5.8m pounds ($9.3m) to acquire a company that established the coding standard for medical records in the UK. Its purchase of Computer Aided Medical Systems Ltd (CAMS) gives L&H a pivotal position in the medical market in the UK with the potential for growth in Europe.

CAMS is responsible for Read Codes, a standard method of classifying clinical terms in the UK that can be shared between medical professionals and enable medical records to be more easily analyzed. While L&H has seen the medical sector as one of the key vertical markets, particularly for its dictation products, the CAMS acquisition takes it into the coding market and an opportunity to create a comprehensive medical reporting package.

The development of IT systems in the UK’s state-run National Health Service has never been short of controversy and Read Codes, named after developer Dr James Read, have been criticized as being less comprehensive than international standards in certain specialist areas. However, supporters of the system have hopes that they could eventually be adopted as the standard for the European Community which would dramatically widen the market.

L&H plans to voice-enable the ReadEngine software and develop a version that would automatically identify and code medical terminology in text, eliminating a task now done by coding specialists. L&H is paying 3.8m pounds ($6.1m) for CAMS with an earn-out of 2m pounds ($3.2m) and says the acquisition will be accretive in 2000.

Dr. Alex Valadka has taken emergency room call in the nation’s fourth largest city, Houston, for 12 years. But only since last July did the 43 year-old neurosurgeon get paid for it.

One of two institutions where he practices. The Methodist Hospital, doles out $500 for each day he agrees to come in to treat emergency patients for cervical spine fractures, cerebral hemorrhages and more.

“Doctors brought it up. The hospital administration said, ‘no,’” Valadka, says. “Eventually they realized it was a trend.”

All Methodist community physicians are compensated now for covering the ER, whether or not they are called. Samplings of daily rates include $100 for pediatricians, $250 for general surgeons, topping off at $500 for cardiologists. “The stipend does not cover losses from being in your office and seeing patients, but it’s better than nothing,” Valadka says.

About 30 percent of the nation’s hospitals report they pay some specialists for ER call, according to a 2004 American Hospital Association survey of hospital leaders. About 2 percent of that number pays all specialists.

Most began the practice within the last two years. “It is becoming more common to pay physicians for on call ER coverage,” says Caroline Steinberg, vice president, trends analysis, AHA, Washington, D.C. Medical defense coverage and reimbursements for the poor are sometimes additional.

Stipends were little known only a decade ago. A confluence of changes in medicine altered what doctors provided voluntarily as a social imperative, as a means to build young practices and as a way to sustain old ones. A tide of uninsured patients, rising medical liability insurance rates and physician lifestyle issues converged to make ER call exceedingly undesirable. Doctors are demanding compensation.

“Historically, hospitals provided work shops for physicians in exchange for physicians having a responsibility to the community at large,” AHA’s Steinberg says. That workshop environment changed considerably when hospitalists started relieving primary care doctors of admissions in the 1990s.

At the same time, the growth of alternative practice venues, combined with technological and scientific advances that made outpatient surgeries possible, encouraged some surgical specialists, once dependent on hospitals, to reduce or drop their privileges.

My grandfather was a damage-control chief in the Navy. My dad never really joined the military, but he kind of stuck around in a military town [Norfolk]. My uncle on my mom’s side owns a marina, so I knew that I definitely wanted to do something on the water. I guess it flows in my veins. I bought my first boat when I was 18, a 26-foot little sailboat.

I had it narrowed down at one time to Marines, Navy and Coast Guard, but I ended up picking the Coast Guard mostly to try to do search-and-rescue type stuff. That was what I did in Key West. Coming here has been something completely different.

We were sent over to Africa basically to fulfill a mission that the Navy could not: teach these foreign navies the mission that we do in the Coast Guard of lifesaving, search and rescue, and guarding the coast against pirates and drug runners.

Basically, Fm in charge with making sure that onboard [the Bear], we receive message traffic and can communicate properly with the guys on land. We have lots of different equipment and lots of different ways to contact people, but just to try to find a method that gets through reliably on a consistent basis is probably one of the most difficult things.

This is definitely one of the more tight-knit, team-playing units that I’ve ever worked at. Our captain wanted to make sure, for example, that we came home a day early. And as petty as that sounds, we were just ready to come home. And when the command tries to take care of us, then we try and do our job a little better. And that, in turn, makes him look better.

I hope to be the kind of leader who can sit back and have guys who are well-trained and well-equipped enough that they can do their jobs well and come to me if they have problems, but let them get their own recognition for it.

I’ve got at least another three years to go. I really am kind of in limbo. I’m definitely making a headlong run at getting myself trained and prepped and ready for making it a career.

I’m currently going to an EMT (Emergency Medical Technician) school. I also go to school to learn how to use our ion scan machine, which is the machine that we use to scan for drugs, because that’s the mission on our next ship.

I don’t know about going to the top. I had actually hoped to achieve chief. I’ve already made E-5 in three years. It’s definitely achievable, maybe not within six years, but definitely within 10.

Discover the wide array of benefits and cost savings that accrued when a Charlotte, N.C. cardiology clinic implemented electronic medical records.

If you don’t think electronic medical records can save money and improve performance for your practice, talk to Stephen McAdams, MD.

McAdams, CEO of Mid-Carolina Cardiology in Charlotte, N.C., convinced all 25 physicians in the practice to use electronic medical records (EMR) and says the results are impressive. EMR raised revenue, lowered overhead costs and improved quality and patient satisfaction.

He had previous experience with an EMR and when he interviewed for the CEO position in 1999, he wound up giving a PowerPoint presentation to every doctor saying, “This is where your practice is. This is what I think I can do for you.”

The first year of EMR, “we raised revenue by 35 percent. Our overhead went from 62 percent to 46 percent because the practice became more efficient in every aspect from checking in patients to seating them in the rooms,” McAdams says.

The EMR system, developed by Gateway Electronic Medical Management Systems, tracks all the patients’ movements: when they check in, how long they sit in the waiting room, when they go into the exam room, how long they are with the doctor, the total time of the visit. Mid-Carolina sees about 45,000 office patients each year.

“When physicians see how their data compares with others, it inspires all of them to be more efficient,’ McAdams says. The system is integrated with the billing system, scheduling, prescription writing, doctor visits and hospital encounters.

Benefits of EMR

McAdams says EMR brings many benefits to his group including:

Proper billing

With EMR, the doctors don’t have to remember all the ICD9 codes to do the billing, he says. They use a pointer to click on terms they know–atrial fibrillationchronic, angina-stable, hyperlipidemia–and that links automatically with the ICD9 codes so the bill is generated and the level of service is actually suggested by the computer.

“The screen says, ‘It looks like you did a level 3. If you think you did a level 4, you better go back and find out what you missed,”‘ McAdams explains. “It is always calculating where you are in the medical decision-making process. When the doc is done and the patient is escorted out to the front, the super bill is in the computer.”

In recent years, the physician-patient relationship has transformed from one of paternalism into an egalitarian and participatory partnership in which patients and physicians work together to make healthcare decisions (Committee on Bioethics, 1995). Today there is general societal acceptance that “patients have a right to know about their health, to know about available diagnostic and treatment options and then” risks and probable benefits, and to choose among the alternatives” (Committee on Bioethics, 1995, p. 315). Informed consent is an essential part of the communication process between physicians and patients. The information provided by physicians about illness and treatment options is vital to patients’ decision-making and influences their psychological well-being (Rushforth, 1999).

Although adults receive considerable encouragement to become active participants in healthcare decisions, children and adolescents often have little voice in decisions about their medical treatment (Kunin, 1997; Lidz et al., 1984). As minors, adolescents often are unable legally to provide informed consent and are granted limited access to confidential medical care. Confusion and mixed messages abound about the abilities and rights of adolescents. The present review examines the developmental literature on children and adolescents’ capacities to make medical decisions that are informed, voluntary, and rational.

In its simplest form, informed consent is the treatment authorization given by a patient to a physician. Legally, it is an intentional authorization in that it must be given knowingly, rationally, with volition, and without coercion (Grisso & Vierling, 1978; King & Cross, 1989; Scott, 1992). By informed, it is meant that the decision must be based on knowledge of the situation and potential consequences. Consent must be voluntary; it must be volitional and not reflect mere acquiescence. Consent also must be rational, implying that it is rendered by an intellectually competent and mature individual.

Hospital rankings and report cards are growing in number and importance, but a new University of Michigan study suggests these measures may be inaccurate if they don’t take into account the high number of very sick patients that large hospitals receive as transfers from other hospitals.

This study, which focused on medical intensive care unit (MICU) patients, was as much about benchmarking as it was about the MICU, says Andrew L. Rosenberg, MD, assistant professor of anesthesiology and internal medicine at the University of Michigan Health System (UMHS) in Ann Arbor, and lead author of the study.

“The idea of this study was to try to quantify something that most physicians intuitively know: Transfer patients are sicker,” says Rosenberg. “However, this is difficult to quantify because the type of precise data needed are often lacking; they are expensive and hard to get at. In fact, much of [the quality rating] benchmarking deals with administrative databases, not clinical databases.”

The UMHS study results were published in the June 3, 2003, issue of the Annals of Internal Medicine, in an article titled, “Accepting critically ill transfer patients: Adverse effect on a referral center’s outcome and benchmark measures.”

“We used a very detailed clinical database [APACHE III for Acute Physiology and Chronic Health Evaluation],” Rosenberg notes.

The study examined 4,579 consecutive admissions for 4,208 patients from Jan. 1, 1994, to April 1, 1998. A full 25% were transfer patients. Its measurements were MICU length of stay, hospital length of stay, MICU readmission, and hospital mortality rates. “We reasoned, why not study the place [MICU] where the most valid benchmarking tools are used?” says Rosenberg. “If we still can’t adjust for the ICU, how can we possibly do it at another level?”

After many years as a provider to primarily uninsured and underinsured patients, Truman Medical Centers in Kansas City, Mo., was confronting critical financial issues. With federal, state, and local sources of revenue drying up, the organization underwent physical and operational changes aimed at advancing its position in the marketplace and capturing the elusive healthcare dollar.

Truman placed a strong emphasis on managed care in the areas of contracting, operations, revenue, and most importantly, revenue recovery. The health system’s efforts were aimed at supporting its mission to provide health care to the city’s uninsured and underinsured while pursuing an evolving role as a viable partner with commercial payers in the Kansas City community.

Truman more than tripled the number of its managed care contracts over two years and soon realized that a monitoring function was needed to manage its growth effectively. To this end, Truman conceived its managed care revenue recovery program. In the early stages, Truman estimated that by improving processes and adding revenue recovery to its efforts, 10 percent of its gross managed care revenue could be returned to the organization’s bottom line.

Truman dedicated staff from its managed care division to recovering revenue owed because of underpayments from payers. The organization added a revenue recovery specialist to the division and hired a former insurance company staff member who had worked in provider relations to oversee the revenue recovery program.

Initially, the revenue recovery process was performed manually, using reports from the hospital’s information systems. Accounts were examined individually to identify errors in payments. Although this initial revenue recovery process was time-consuming and narrow in focus, Truman achieved its first success shortly after the start of the recovery program with a $500,000 recovery from a single payer.

Broadening the Scope

As additional significant recoveries were realized, Truman evaluated automated products that would enable the organization to broaden its reach by having the ability to monitor all contracts and payments simultaneously rather than conducting audits manually for one payer at a time. This integrated approach allowed

Truman to compare, track, and trend underpayments that are identified. After a careful selection process, Truman found its answer in contract management software.

A recent randomized, controlled trial conducted in Italy sheds new light on the use of spinal manipulation in the treatment of acute back pain and sciatica with disc protrusion. Results of the study, published in a recent issue of The Spine Journal, indicate that active spinal manipulation relieves pain more effectively than a sham simulation, leading to fewer days of localized pain and fewer days of radiating pain, and with no side-effects.

The study population consisted of 102 adults seen in two medical rehabilitation centers in Rome. All of the patients demonstrated the following characteristics: moderate to severe low back pain, moderate to severe radiating pain in one leg, and MRI evidence of disc protrusion in the spinal segments believed to be associated with the pain. Obese patients with acute LBP were excluded, as were patients with chronic LBP, disc protrusion with a ruptured annulus, and those who had already received spinal manipulation.

Upon admission to the study, each patient was interviewed and given a complete physical examination. During the interview, researchers collected detailed information on low back pain and leg pain (using a pair of visual analog scores), including the location of pain and the patient’s overall quality of life with the pain.

Participants were randomized into two types of manipulation groups active and simulated. Individuals in the active manipulation group received a maximum of 20 sessions over a 30-day period, with each session lasting five minutes. Active manipulation consisted of examining the range of motion in the patient’s back, followed by soft-tissue manipulation and “brisk rotational thrusting away from the greatest restriction.” The purpose of manipulation was to restore movement to the “physiological motor unit” (with each motor unit consisting of two vertebrae, disc and surrounding structures). Subjects in the simulated manipulation group received soft muscle pressing that was similar to manipulation, but did not follow any specific patterns or involve rapid thrusts. All manipulations were performed by two experienced chiropractors with similar formal training from a U.S. chiropractic college.