AcuteCare Telemedicine Blog

Daniel H. Bauer Joins AcuteCare Telemedicine Advisory Board

AcuteCare Telemedicine (ACT) announces the addition of Daniel H. Bauer as a member for the ACT Board of Advisors. Bauer’s extensive C-level experience as a CFO with a diverse portfolio of companies and status as a Certified Public Accountant will guide the business with sound advice.

Bauer, a graduate of the University of Tennessee and Emory University, is presently serving as Chief Financial Officer of CardioMEMS, a medical device company that has developed and is commercializing a proprietary wireless sensing and communication technology for the human body.

After beginning his career in public accounting at Price Waterhouse, Bauer also previously served as the Chief Financial Officer for Industriaplex, Granite City Food and Brewery (NASDAQ: GCFB), and Church’s Chicken, the largest division of AFC Enterprises (NASDAQ: AFCE), which was acquired by Arcapita.

Bauer is currently a board member of the Association for Corporate Growth and a member of the advisory board of Emerge Scholarships. He was a recipient of a Delaney Consulting 2011 excellence in Finance and Accounting Award and a finalist for the Atlanta Business Chronicle CFO of the year in 2010.

“Mr. Bauer’s track record is indicative of his knowledge and commitment to building strong businesses,” says Matthews Gwynn M.D., Partner, ACT. “We are fortunate to have the luxury of Mr. Bauer’s perspective when weighing important decisions. The scope of his experience will be invaluable to keeping AcuteCare Telemedicine on track as we continue to grow the business in 2012.”

The Times, They Are A-Changin’

Health care reform must not add to our deficits over the next 10 years — it must be at least deficit neutral and put America on a path to reducing its deficit over time. To fulfill this promise, I have set aside $635 billion in a health reserve fund as a down payment on reform. This reserve fund includes a number of proposals to cut spending by $309 billion over 10 years –reducing overpayments to Medicare Advantage private insurers; strengthening Medicare and Medicaid payment accuracy by cutting waste, fraud and abuse; improving care for Medicare patients after hospitalizations; and encouraging physicians to form “accountable care organizations” to improve the quality of care for Medicare patients.

            President Barack Obama

June 3, 2009

By the end of this decade, medical care will be delivered as never imagined by more than a few. No longer will you pay a doctor for his services. Instead, you will belong to one of thousands of Accountable Care Organizations (an ACO).

Your money will be paid to an entity whose job it will be to provide medical services to you and thousands of others from cradle to grave. You will pay a fixed fee that will be pooled and distributed as determined by the ACO to providers such as neurologists and other physicians. If they meet certain criteria, like fewer hospitalizations and lower medication costs, they will get bonuses. If not, they will simply be fired.

You will likely be tied to a long-term contract in order to control your behavior so that you get healthier and the ACO can show benefit to regulators. Otherwise the lengths that the ACO will go to in order make you healthier -like education or fitness programs-will show up on some other ACO’s achievement table. There are a few entities that approximate this type of program, such as Kaiser Permanente and the Harvard Pilgrim Plan, but unlike with future ACOs, participants float in and out, which is a disincentive for investing money in patients.

How will this affect the delivery of neurological care? According to the American Academy of Neurology, only about 7000 neurologists actually practice in the US, about 25 per million people. More and more are dropping out of hospital work because of high medical liability risk, poor reimbursements and the high demand in office practices because of the shortage. Consequently, neurologist availability will be a challenge for ACOs as Americans develop stroke and other diseases of the elderly in ever greater numbers. Not all ACOs, will be able to employ them, especially in smaller towns and rural areas.

Because nearly all of neurology relies heavily on patient history and observational exams (what the neurologist sees rather than touching or listening to the organs) and because treatments rely almost solely on medications rather than operations or procedures requiring proximity, telemedicine offers an excellent solution.

With salary, benefits, and other expenses, the cost of recruiting and retaining a neurologist is extremely high. If the neurologist is paid based on membership figures, a smaller ACO may not be able to support even one neurologist to handle the clinic, let alone cover hospitals for emergencies.

Alternatively, the services of a company like AcuteCare Telemedicine can be obtained for a small fraction of the cost, and can cover a larger number of patients in many different regions of the country sequentially or even simultaneously. Telemedicine specialists would only be called when needed, and because many ACOs would be employing the group on a fractional basis, the cost to each one would be far lower than that of hiring even one neurologist full time. Furthermore, studies show that patient satisfaction and stroke outcomes are as high as in-person consultations in urgent care situations.s

Teleneurology and the development of ACOs will have a mutually beneficial relationship in the coming years. Practitioners of this field will find a welcome home in these organizations and will help solve the coming shortage of neurologists in a new era of medicine.

The Brain’s Glorious Complexity

The brain is the most complex organ in the human body. In fact, the thinking part of our brains can be thought of as two symmetrical hemi-brains connected by a large bundle of nerves. Unfortunately, this complexity can mean increased susceptibility to diseases.

In the 90% of us that are right handed, the left half of the brain is called dominant and the right half of the brain is called nondominant. Damage to the left brain often leads to language disorders called aphasia and damage to the right brain often leads to loss of awareness called agnosia. A recent patient encounter highlights how knowledge of the brain’s organization can explain abnormal behavior:

A 72 year old man had trouble logging on to his computer to play word games on Saturday. Normally, he has no problem with this, but he had to get his wife to help him three times that day. The next day, he was restless and slept more than usual. On Monday, he was agitated, could not say what was wrong and had to be led to the car. At the hospital, the emergency room doctor could find no evidence of a stroke or intoxication, so depression or psychosis were suspected. The stroke neurologist identified that he was not confused, depressed, or psychotic; he was aphasic and brain imaging confirmed a small recent stroke on the left side of his brain. This man had Wernicke aphasia due to damage to his dominant hemisphere in the area described by Dr. Wernicke in the late 1800s.

Study of patients with brain damage has led to a great deal of understanding about how the normal brain works. For example, the right brain’s abilities lie in its subconscious attention to the details of recognizing faces, objects, sounds, shapes, and smells. These are critical for human survival – imagine the survival disadvantage if you could not rapidly distinguish foe from friend!

For a stunningly lucid overview of current brain knowledge, check out Charlie Rose’s recent Brain Series which explores “the most exciting scientific journey of our time: understanding the brain.”

Advances in Telemedicine and Technology Call for Changes in Standardization

Rudimentary forms of health care standardization in the United States can be traced back more than a century. The Joint Commission, for example, began its evolution with an elementary inception in 1910, when Dr. Ernest Codman proposed the “end result system of hospital standardization”. This system was designed to track patient care and outcomes to determine whether treatment was effective. In cases where treatment was unsuccessful, attempts were made to improve patient care. Three years later, the American College of Surgeons (ACS) was formed to promote this standards system, and in 1917, it developed the Minimum Standard for Hospitals. The following, year the ACS began on site hospital inspections, and of the 692 hospitals surveyed, only 89 met the standards set forth by the one page document. After the introduction of an 18 page manual in 1918, hospitals had increased incentive to meet these standards, and by 1950 standard of care had improved tremendously, with more than 3,200 hospitals approved by the ACS.

Needless to say, over the next 60 years, with countless advances in medicine and technology, there have been many changes to the ACA and its manual. The committee now known as The Joint Commission has expanded and upgraded standards in an effort to ensure that health care organizations are providing quality patient care. Although the Joint Commission is one of the most recognized and sought after accreditation programs, several other organizations such as Leapfrog, HealthGrades and Get With The Guidelines have also been formed in an attempt to foster improvement in quality of care throughout health care systems. The decision to seek accreditation by The Joint Commission or any other organization has always been voluntary, but because of its link to Medicare and Medicaid, Joint Commission accreditation has essentially become a default requirement. Because reputation, reimbursement and, most importantly, patient care may at minimum be presumed to be compromised without certification, a health care organization’s failure to achieve accreditation by the Joint Commission may be adversely perceived.

In 2003 The Joint Commission, in collaboration with the American Stroke Association, developed a Primary Stroke Center (PSC) Certification Program. This program was developed to recognize health care centers “that make exceptional efforts to foster better outcomes for stroke care”.  According to The Joint Commission, a PSC “is the best signal to your community that the quality care you provide is effectively managed to meet the unique and specialized care of stroke patients.” Demonstrating compliance with these national standards may help a facility obtain contracts from employers and purchasers concerned with controlling costs and improving productivity. Becoming a PSC has been shown, in one published study, to have increased the administration of IV- TPA to eligible patients 7 fold.

Unfortunately for many hospitals, this level of achievement in stroke care is not possible due to lack of availability of 24/7 neurology coverage. The reality is particularly challenging for smaller, rural hospitals. However, in 2011, the Brain Attack Coalition updated recommendations for PSCs, acknowledging the use of telemedicine as a means to provide remote diagnosis of acute stroke in facilities where this capability would otherwise be unavailable. Hospitals that do not have current PSC certification could use telemedicine services along with physicians that provide 24/7 expert care in acute stroke to become PSC certified or either transfer eligible patients to the closest PSC for IV- TPA administration. The Brain Attack Coalition has also recommended that EMS transport acute stroke patients to the nearest PSC facility, thereby potentially improving patient outcomes and increasing revenue at certified hospitals.

In 1997, The Joint Commission launched “ORYX: The Next Evolution in Accreditation” which incorporated the use of performance measures into the accreditation process. Under this initiative, hospitals had the flexibility to choose which performance measures they would submit for accreditation. This system posed problems in that there were no standard measurements across health care organizations. The Joint Commission has since put in place core measurement sets for which specific, standard accountability measures must be met in order to obtain and maintain accreditation. The initial core measurement sets were designated in 2003 and included Acute MI, Heart Failure and Community Acquired Pneumonia. As of 2011, Stroke has been added to the core measurement sets, giving facilities even more incentive to become Primary Stroke Centers.

Undoubtedly, the standards that have been initiated by the Joint Commission and other accreditation programs have lead to changes and improvement in health care outcomes for all specialties of medicine. Reaching a perfect level of standardization will always be a work in progress, particularly with the rapid advances in technology that have helped medicine evolve more quickly in recent years. As the landscape of medicine and technology continues to change and expand in the future, particularly regarding the management of acute stroke care, it is our expectation that hospitals will continue to strive to adapt to these changes in order to achieve the highest quality of patient care.

A Sharper Mind, Middle Age and Beyond

Though many studies have found that college graduates earn more money, it looks like there may be an even better reason to dig in deep for the sheepskin. According to the Midlife in the United States, or ‘Midus study,’ a very large study involving more than 7000 people over the course of many years, a college degree appears to slow the brain’s aging process by up to a decade. The findings appear to be true regardless of other factors such as differences in income, parental achievement, gender, physical activity, and age.

According to an article in the New York Times, the effect seems, perhaps surprisingly, to be truer for ‘fluid intelligence,’ described as “the abilities that produce solutions not based on experience, like pattern recognition, working memory and abstract thinking, but rather the kind of intelligence tested on I.Q. examinations.” ‘Crystallized intelligence,’ by contrast, “generally refers to skills that are acquired through experience and education, like verbal ability, inductive reasoning and judgment.” The interesting finding of this study is the fact that the ‘fluid’ intelligence that appears to benefit more from schooling, is often considered largely a product of genetics, and ‘crystallized’ intelligence would seemingly be far more dependent on influences, including “personality, motivation, opportunity and culture.”

All other conditions being equal, the more years of schooling a subject had, the better he or she performed on every mental test. Up to age 75, the studies showed, “people with college degrees performed on complex tasks like less-educated individuals who were 10 years younger.” If the overall health of the brain can be improved with continued education, perhaps it’s time to consider going back to school!