Category: Maritime Health Newsletters

27 Sep 2017

Hiring a Medical Escort – Insurance & Clinical Practice Concerns

Selecting A Medical Escort for Repatriation of Crew

Recently, SphereMD was asked to assist with medical repatriation services in an area where we had no trusted assets available. We immediately began searching for a medical service provider who met our standards, and our pursuit proved to be eye-opening.

Typically, we use our own staff for repatriation services. When SphereMD staff are unavailable, we rely on trusted, pre-vetted partners. In fact, most of our partners have been heavily vetted for large, ongoing government and oil contracts. With our staff and trusted partners, we are confident our patients are in good hands.

This time, we faced the rare case of having to find a new partner.

With a few phone calls to colleagues and a couple of internet searches, we easily found over a dozen options. Each service was willing to accept the assignment of transporting a stroke patient from the North American West Coast to Bangladesh.

Expected Services Proved Easy to Find

On the surface, the providers seemed equally viable. They all offered the services you would expect:

  • Air travel coordination
  • Ground and air travel for the patient
  • Hospital discharge coordination
  • Collection of repatriation
  • Authorization documentation
  • Receiving facility coordination

We were satisfied with the basic services offered, but what about medical direction and insurance?

We dug deeper.

The Surprising Challenge—Medical Direction and Insurance

Medical repatriation services are far more complex than simply transporting a person from one country to another. To align with our in-house standards, we needed our new provider to also guarantee medical direction and proof of insurance.

Medical Direction
Medical directors play a critical role in medical repatriation services. A medical director can confirm when a patient’s medical condition is stable enough for travel, and can give orders for required care and emergency treatment. Any provider we partner with must have a qualified, in-house medical director.

At SphereMD, we require medical direction for all repatriation services provided by our staff and trusted partners. When we asked each company about their medical direction, we were surprised to find that it is not always required.

A few companies had in-house physicians who could approve and set orders for the repatriation staff. Other companies relied on repatriating nurses or EMTs. We found this concerning and removed all companies without medical directors from our list.

Our pool of candidates was thinning, and we still had more questions. Having explored the basic services and medical direction; we turned our attention to an important, but often overlooked, aspect of medical repatriation services and international travel—insurance.

Insurance
Insurance is rarely fun, almost always complicated, and too important to ignore. Therefore, we asked each company to provide proof of insurance and show us their insurance certificate. Results varied, including:

  • One provider’s insurance certificate showed a $1,000,000.00 policy attached to an EMT license. When we requested a copy of the corporate insurance, we were told corporate insurance was not required because the providing company did not own assets.
  • Several companies only provided proof of basic insurance policies attached to nursing or EMT licenses.
  • Many of the companies had no professional liability coverage (sometimes referred to as medical malpractice coverage). One company had a $1,000,000.00 general liability policy, but no professional liability.
  • None of the companies could certify that their coverage extended beyond the United States. This is critical when operating internationally as a policy written in the US is often limited to the US, its territories and possessions, and Canada.

While we are not insurance experts, SphereMD believes we have a duty to understand the types of insurance and extent of coverage services providers carry before we partner with them to transport patients under our care. A $1,000,000 general policy is inadequate (in our opinion).

At SphereMD, we carry the following and recommend that you require your providers to offer similar levels of insurance:

  • Professional (medical malpractice) liability that provides coverage for suits brought anywhere in the world. We look for limits of $2,000,000 per occurrence/$4,000,000 annual aggregate.
  • Workers’ compensation coverage with endorsement for coverage outside of the United States. This sometimes can be endorsed on to the existing workers’ comp policy, but many times it is picked up through an international policy.
  • General liability policy with limits of $1,000,000 per occurrence/$2,000,000 annual aggregate minimum that extends internationally.li>
  • Automobile liability with liability limit of $1,000,000, again extending internationally.
  • Excess liability (sometimes called umbrella) with a minimum limit of $1,000,000. This policy should provide excess liability for general liability, automobile liability, and workers’ compensation (employers’ liability) on a worldwide basis. Because professional liability is a separate “tower”, you will not typically find that this policy would extend above it.

Our goal is to protect everyone involved in repatriation. At SphereMD, we believe comprehensive coverage is a requirement and a responsibility.

Questions to Ask

When looking for a medical repatriation provider, ask about services, medical direction, and insurance. For example:

  • Do you have an in-house physician or qualified medical director who can approve and set orders for the repatriation staff?
  • Do you have insurance certificates to show proof of coverage for general liability, professional liability, auto liability, and workers’ compensation (employers liability)?
  • Does your insurance coverage extend on a worldwide basis?

Consider asking your existing providers these questions, as well. Do their services include medical direction and adequate insurance? If not, what can be done to improve the situation?
Asking these types of questions can help with both reducing risk and avoiding financial fiascos.

End Results

After extending our search and conducting extensive research, we finally found a partner who met our standards. We confidently partnered with the company for our mission and will employ their services again in the future.

Fortunately, we can avoid such extensive emergency research in most cases. SphereMD focuses on staying ahead of emergencies by preparing well and actively filling geographical gaps by pre-vetting providers before an emergency occurs. We rely on our highly qualified staff and heavily pre-vetted repatriation providers in nearly all cases. On rare occasions, we search for new providers in critical times. When we do search, we seek the best.

We’re Here for You

If you would like to learn more about what we found during our search and our vetting experiences, please contact us. Regardless of whether you contract our medical services, we would be happy to help you find the best medical repatriation providers for your needs.

28 Jul 2017

High Cost Warning

In today’s complex U.S. healthcare market, healthcare facilities regularly seek new ways to serve patients’ needs, meet insurers’ criteria, and follow legal requirements. The rise of primary care clinics, urgent care facilities, and hospital-owned satellite emergency facilities are noticeable and useful additions in communities around the country. They often offer cost savings, quicker service, and, in some cases, the only care in areas without immediate access to hospitals. Recently, a new twist has been added to the mix of “pop-up” medical facilities. Many medical care providers view these new facilities as “disruptors.” For patients, these new facilities can be confusing and, worse, can result in enormous bills. What are these new facilities called? Independent, non-hospital affiliated freestanding emergency rooms (FSERs).

After taking a close look as FSERs and assessing a few cases directly (two cases are described later in this article), SphereMD has some well-founded, fact-based reservations about independent freestanding ERs. SphereMD is sharing its research and findings so ship owners and crew members can avoid costly surprises later.

Rise of Independent Freestanding ERs

At the basic level, independent freestanding ERs are stand-alone facilities where people can receive emergency healthcare any time of day, in a nearby facility. FSERs were initially conceived as a way to offer emergency room services and emergency care access in areas where hospitals were nonexistent or miles away, such as in rural or low-income areas. Sadly, the facilities have not yet been deployed that way. Instead, they are most likely to be found in affluent areas where profits are more readily available, including Texas and other Gulf states.

FSERs began making a strong presence in healthcare in Texas after a 2009 law allowed the establishment of non-hospital affiliated emergency rooms. Since then, independent freestanding ERs have spread across Texas and through other states. In fact, according to a recent Washington Post article, in 2017, “across 32 states, more than 400 freestanding ERs provide quick and easy access to care.”

Increased access to healthcare without having to go to the hospital sounds like a positive development for mariners, but the Washington Post article goes on, the freestanding ERs “also are prompting complaints from a growing number of people who feel burned by ­hospital-size bills, like $6,856 for a cut that didn’t require a stitch or $4,025 for an antibiotic for a sinus infection.”

Over $6,000 to treat a cut? That’s not a typo. While the convenience of freestanding ERs is appealing, their costs are stirring up serious controversy.

The Controversy

To be fair, on the upside, the main draw of independent freestanding ERs is convenience. To patients, they look like the more-affordable urgent care centers but with the added benefit of offering limited emergency services. These facilities can even transfer critical patients to hospitals when needed. The urgent care appearance is misleading, though. As the Texas Association of Health Plans explains:

Though freestanding ERs tend to have the same look and feel of urgent care centers, many consumers are unaware that, unlike urgent care centers, these facilities are often out of network and can charge patients up to 10 times more for the same services.”
-TAHP  (http://tahp.org/advocacy/freestanding-ers)

Keep in mind, freestanding ERs are still emergency rooms, which means they charge emergency room prices. In addition, many independent freestanding ERs also charge a facility fee. Therefore, sending crew members to an independent freestanding emergency room is just like paying an extra fee to receive emergency room treatment. As most shipowners and crew members know, emergency rooms are already the most expensive and least efficient venues for non-emergency healthcare. Adding an extra fee on top of ER prices further compounds the problem.

In side by side comparisons, independent freestanding ERs are dramatically more expensive than typical urgent care facilities and medical clinics. For example, as mentioned, freestanding ERs charge higher base fees and usually present two separate bills—one for the facility and one for the emergency services. In non-emergency clinics, patients receive one bill for a medical service, without the added “facility fee” bill. In addition, like hospital emergency rooms, freestanding ERs tend to overuse services, which increases costs. In all emergency rooms, patients are more likely to receive more tests and services than they would in an urgent or primary care clinic.

To better understand the differences, SphereMD documented two real-life cases handled by independent freestanding ERs.

Case 1

Injury: Small puncture wound to the foot; no fractures or breaks.
Treatment: Bandage, no other treatment rendered

Independent Emergency Room Provider

Cost: $4,173.02

Cost Breakdown:

  • Physician Examination – $667.01
  • Pharmacy General – $257.25
  • Medical Supplies – $92.35
  • X-Ray Left Foot – $707.16
  • X-Ray Right Foot – $707.16
  • Emergency Room General – $1,721.40
  • Discharge Medication (Ciprofloxacin 500mg qty. 14) – $20.69

Estimated Urgent Care Facility

Cost: $220.69 – $645.69*

Cost Breakdown:

  • Examination – $125–$300
  • Pharmacy – $75
  • Medical supplies: – 0
  • X-Ray Left Foot – $125*
  • X-Ray Right Foot – $125*
  • Emergency Room General – 0 (included in the examination fee)
  • Discharge Medication (Ciprofloxacin 500mg qty. 14) – $20.69

Savings: Over $3,525


*Note: X-rays may not have been ordered in an urgent care facility as this decision would have been based on clinical discretion vs. protocol. Eliminating the x-rays would save an additional $250.

 

SphereMD asked the freestanding ER about the x-rays in this case. The ER responded that the x-rays are protocol for puncture wound cases. This approach is both medically aggressive and expensive. Treatments based on protocol vs. clinical judgement brings into question the necessity of much of the care provided. In SphereMD’s opinion, this practice leads to overuse of services. In general, emergency rooms, freestanding and in hospitals, are notorious for overusing services.

In comparison, the same care could have been provided in an urgent care facility or doctor’s office for a fraction of the cost, for a savings of over $3,525, as shown.

Case 2

Injury: Abdominal pain
Final diagnosis: Constipation

Independent Emergency Room Provider

Cost: $3,346.79

Cost Breakdown:

  • Initial Exam – $752.40
  • EKG – $296.27
  • X-Ray Abdomen, one view – $858.00
  • CBC – $231.00
  • CMP – $615.12
  • Troponin – $297.00

Estimated Urgent Care Facility

Cost: $711.50

Cost Breakdown:

  • Examination and blood draw – $430
  • EKG – $250
  • CBC – $31.50

Savings: $2,635.29

 

Like Case 1, Case 2 demonstrates another overuse of services by an ER. In this case, an urgent care facility most likely would not have ordered several of the lab tests run by the freestanding ER. Further, the blood test costs are outrageous. To compare, the lab SphereMD uses charges the following prices:

  • CBC – $31.50
  • CMP – $38.25
  • Troponin – $132.75
  • CK-CM – $137.50
  • CK-CM (Cardiac Enzymes) – $297.00

SphereMD’s total lab charges would be $340 vs. $1,440.12 charged by the ER. Remember, many of these tests would not have been ordered by an urgent care facility in the first place.

Based on SphereMD’s experience, if this patient had visited an urgent care facility instead of an independent freestanding ER, the patient would have received an examination with a blood draw, an EKG, a CBC, and no other services, for an estimated savings of $2,635.29, as shown.

As you can see, in both cases, patients were charged outrageous prices given the underlying medical issues. These typical examples are presented to caution shipowners and crews from using independent freestanding ERs, especially for non-emergency issues. This might sound like common sense, but without having this background information, it might not be clear how a medical issue is being handled.

Medical Assignment

A key back-end detail in both cases is that the independent freestanding ER assigned their billing rights to a third party who arranged for the patients to be taken to the FSER in the first place. Most likely, the third-party provider has an arrangement in place that would increase their profits by sending patients to the FSER instead of more appropriate facilities, such as urgent care centers. This arrangement may or may not be transparent to shipowners and crew members.

Vigilance Required

With such a wide variety of facilities available, medical services require vigilance. Facilities need to be vetted and medical issues need to be treated appropriately. In Texas and elsewhere, independent freestanding ERs are being used to treat mariners. SphereMD has reviewed several cases in addition to the two described here in which patients did not require emergency care. Instead, the cases could have been treated in less expensive venues, such as outpatient clinics or urgent care centers. As a medical manager, SphereMD can help shipowners and crews attain the best services at the most affordable prices. SphereMD keeps all records transparent and removes all concerns about patients possibly being directed to independent freestanding ERs or other facilities for kickbacks.

SphereMD Recommendations

To help manage medical situations, SphereMD, a respected and experienced medical management company, has a few recommendations on how to avoid the pitfalls of independent freestanding ERs:

  • SphereMD recommends that all shipowners and crew members know about the existence and practices of independent freestanding ERs. This knowledge keeps shipowners one step ahead of high costs.
  • SphereMD recommends contacting a P&I Club for even small medical matters in the United States, especially in the Gulf area.
  • Finally, to ensure the best medical treatments at the most affordable prices, SphereMD recommends having a medical manager handle both small and large cases, especially in the United States. Leaving medical choices to agents or other non-medically informed entities can result in dramatically higher costs and subpar care.

27 May 2017

Charting the Best Course

Advice on Quickly Obtaining Fit for Duty Status in the United States

Crew members sometimes need medical care. This surprises no one. Even with the best planning and practices in place, injuries and illnesses occur. Fortunately, ship owners and crew members need not resign themselves to hapless floundering when faced with medical adversity. SphereMD has identified concrete, practical steps that can be taken to minimize disruption when medical incidents take place. Based on extensive experience, SphereMD has identified the following four specific actions that can help streamline treatment and recovery. This practical advice benefits ship owners and crew members alike.

#1: Get Help While at Sea

As soon as a medical issue arises, communicate! Start the process of treatment and help before the ship arrives at its intended or nearest port of call. The sooner communication begins, the sooner the crew member may be returned to fit for duty status.

Specifically, seek medical advice via email or radio. Contact a medical provider, such as a physician’s assistant or nurse, to discuss the issue. This contact is proactive. Medical providers can describe the best way to care for a crew member while the ship is at sea. Treatments will typically be simple to implement, such as immobilizing the injured crew member, applying ice treatments, administering anti-inflammatory medication, enabling rest or relief, and so forth. These treatments can clear the way for an easier transition to a care facility as soon as the ship reaches port.

#2: Schedule Medical Appointments Two Days Prior to Port

When the ship is two days out from the next port, reassess the situation. If the crew member continues to
suffer from an injury or illness, a land-based medical appoint should be scheduled to take place as soon as possible after the ship docks. This is when a professional medical manager’s knowledge and contacts can be invaluable.

If a ship owner contracts with a medical manager, the medical manager can gather the most up-to-date information about the crew member’s medical condition along with the ship’s arrival schedule. Armed with this information, the medical manager can schedule an appointment with a prescreened
and appropriate medical facility, physician, or medical specialists.

Scheduling early ensures appropriate medical resources will be available when the ship arrives. If the crew member recovers before the ship reaches port, the medical manager can easily cancel the arrangements.

Warning: Waiting to make medical arrangements until after the ship arrives in port can result in unnecessary delays and expensive trips to hospital emergency rooms. Emergency room visits are especially problematic for a quick return to fit for duty status, as described in the sidebar.

Best Fit for Medical Services

Emergency rooms in the United States are expensive. Avoid them! Exorbitant costs aside, they also bring a host of complications regarding fit for duty status releases. Emergency rooms:

  • Tend to issue more restrictive fit for duty statuses.
  • May require follow-up appointments or treatments that fail to consider ship movements.
  • Are often unwilling to complete ship medical paperwork (U.S. law does not require emergency room physicians to complete fit for duty paperwork).
  • May omit mention of fit for duty status during the original visit, which means the physician must be revisited later (requiring extra time, paperwork, and costs) to acquire a fit for duty status.

To avoid emergency room pitfalls and access the best medical services in each port, work with a medical manager. A medical manager, like SphereMD, can ensure that each crew member in need visits the most appropriate physician (such as an eye doctor for an eye injury) and clinic or facility. Over 90% of medical treatments can be handled by clinics or non-urgent care facilities. This approach is cost effective, medically sound, and streamlined. As an added benefit, identified care providers are already familiar with completing medical paperwork for ships, including Fit for Duty forms.

#3: Share Requirements and Flexibility of Duties

Be prepared to provide information about a crew member’s roles, responsibilities, and duties. In other words, keep communicating! This information needs to be specific. A medical manager can help convey this information to medical care providers. As much as possible, physicians should understand ways the crew member may be able to modify tasks or receive flexibility in assigned duties.

The goal is to expand the medical provider’s options in terms of granting fit for duty status to the crew member. When a medical provider understands how a crew member’s duties may be adapted to allow continued healing, the possibility of granting fit for duty status increases.

A couple examples of communicating flexibility:

  • Suggest allowing light duty restrictions, such as two-hour work shifts with intermittent breaks, if possible and appropriate.
  • Explain that the crew member’s responsibilities mainly consist of bridge duty, which enables the crew member to stay seated.

#4: Share Port-of-Call Schedule

Among other information provided to physicians, the port-of-call schedule should be shared. This may seem unnecessary, but physicians, especially in the United States, want to be reassured that crew members will have access to quality care. Any near-term visits to other U.S. ports will indicate that adequate follow-up medical care will be accessible, as needed. With this reassurance, physicians are more likely to approve fit for duty status.

Further, if a crew member is not fully fit for duty, U.S. physicians will be more confident about granting a “fit to sail” status pending a near-term stop in another U.S. port. With a fit for sail status, the crew member can return to the ship in compliance with its crewing certificate. Fit to sail status can eliminate unnecessary repatriation costs.

As you can see in the actions described, SphereMD’s experience emphasizes the need for early and ongoing communication, including:

  • Early intervention
  • Efficient scheduling
  • Clear communication of duties and flexibility
  • Transparent ship schedule

Combined with insider knowledge of the best physicians and facilities in each port, a medical manager, like SphereMD, can facilitate top quality medical care with the quickest path to a return to fit for duty status.

29 Mar 2017

Care of Foreign Crewman Diagnosed with Tuberculosis in U.S. Ports

Recently, SphereMD has had several active Tuberculosis (TB) cases from mariners entering the U.S. In each case, the patient had advanced active disease with significant respiratory symptoms. These cases all required extended hospitalizations, high expense, and, in one circumstance, a very complicated repatriation.

TB History & Risk:

Life and work aboard a merchant ship is characterized by crowded, enclosed spaces. The crews of ships are often multinational, coming from countries identified by the CDC as having a “high burden” of TB. This list includes Bangladesh, India, Indonesia, Myanmar, Philippines, China, Brazil, and several other countries. This combination of sustained proximity and populations with increased incidence of TB is a serious potential health threat to mariners and a risk management issue for vessel owners.

TB is a bacterial infection transmitted by respiratory droplets from an infected individual. There are multiple risk factors for TB, including proximity and duration of exposure to an infected individual and the severity of the infected individual’s TB infection. Several factors have resulted in resistance to the drugs used to treat TB. Some strains of TB may also be multi-drug resistant or extensively drug resistant.

TB Infection:

TB infection has three stages: primary infection, latent or dormant infection, and active infection. The incubation period for infection of TB is 2-12 weeks, with the risk of developing active disease highest within the first two years of infection.

It is important to note that only 1 in 10 people who have latent TB will develop active TB.

Most patients with TB can be successfully treated. However, patients with some types of extensively drug-resistant TB have a mortality rate at or above 50%

Suspected TB in a Mariner:

Once TB infection is suspected in a mariner in the U.S., the mariner’s medical care becomes dictated by public health concern and U.S. law. Upon suspicion of TB, doctors will order that the patient be hospitalized and transferred to a negative flow isolation room under respiratory precautions. This means that regardless of the actual acuity or level of patient illness, the patient will be placed in a private room in a “high” care medical setting.

Post-isolation, the patient will undergo a battery of tests that may include X-ray, CT Scan, laboratory studies, and sputum cultures. The patient also may be preemptively started on antibiotics while test results are pending.

Before a patient with suspected TB is discharged from the hospital they must have three negative sputum cultures. Since sputum cultures generally take 72 hours to grow, minimum hospitalization time is generally seven days just to rule out the presence of TB.

Further, in some circumstances, physicians may keep patients in the hospital even in the absence of positive sputum cultures. The bottom line is that suspicion of TB by a U.S. physician usually means a minimum of one week hospitalization and associated expenses.

Treating TB in a Mariner:

Once TB is diagnosed by a sputum culture, the lab sends the culture out to determine which drugs the patient’s specific TB is “sensitive” to. Assuming the patient has nondrug-resistant TB, the conventional therapy is started to treat the infection. If the patient has drug-resistant TB, multiple sputum samples will be sent to the lab in search of drugs that are effective for the patient’s strain of TB.

U.S. law requires that the hospital inform the State Health Department of the patient’s infection in whichever state the patient is receiving care. The State Health Department is then responsible for informing the U.S. CDC of the infection in specific circumstances. Once the case is confirmed, the state and/or CDC must be consulted and approve both treatment and discharge from the hospital.

The length of treatment will vary depending on several factors including drug resistance, the patient’s overall health, and the degree of infection at admission. Practically speaking, patients can be discharged after three negative sputum cultures in as little as two weeks. For patients with extensive disease, or any form of drug-resistant TB, hospitalizations may last months.

SphereMD has had two cases in the last 90 days with hospitalizations lasting over 60 days. Of these cases, one patient had extensively drug-resistant TB and required a chartered jet to repatriate; the other had a non-drug-resistant TB with very concentrated disease in his lungs.

TB Treatment Differences forNon-Mariners:

Most non-drug-resistant TB patients who are U.S. residents would be discharged home after diagnosis and stabilization, usually within a couple of weeks. Precautions would be taken to protect the patient’s family members from acquiring TB. The patient would be ordered to avoid contact with people outside of the home. Treatment would be monitored by the State Health Department to assure compliance with the treatment regimen. Monitoring would include regular sputum cultures, examinations, and possibly home visits by a public health nurse.


Repatriation:

As previously mentioned, TB patients who are mariners are not usually allowed to leave isolated hospital rooms until they have produced three negative sputum cultures confirming that they are no longer infected with active TB. Once this has occurred, patients may fly aboard commercial flights without special precautions.

In certain circumstances, it is possible to repatriate a patient with active TB who is stable and for whom extended treatment is anticipated. Because such patients are public health risks, these repatriations become quite complicated. In the most extreme cases, these patients will require a repatriation plan that is approved by the State Health Department, the CDC, and the WHO. A qualified, approved physician must be found in the patient’s home country who will continue the patient’s care upon repatriation. Because of the public health risk, the patient will likely require repatriation by air ambulance. For patients with extensively drug-resistant TB, few air ambulance companies will transport these patients. Air ambulance costs for these patients are high. We have seen quotes ranging from $163,000.00 USD to $365,000.00; the latter amount was for an aircraft equipped to transport Ebola patients.

Follow Up for Crew Who Were Exposed:

It is vitally important that crewmembers who have been exposed to a patient with active TB be screened for TB. Upon determination that they were exposed to active TB, all crewmembers, including those who have signed off, should receive initial screening with a blood test called a QuantiFERON-TB Gold (QFT). Eight to ten weeks later, the exposed crewmembers will require a second QFT test. It should be noted that TB skin tests are not appropriate for non-U.S. born crewman. X-rays are not effective as they will not show latent TB and are only useful for ruling out active TB. It is also important to remember that with the multinational population of ship crews, it is likely that some of the crew will have a positive QFT. Crewmen with a positive QFT will require a chest X-Ray to rule out active TB.

The public health officer who is charged with the crewman’s care should be the individual charged with making screening recommendations for the patient’s contacts.

Screening:

Of the recent TB cases described above, all the patients had advanced symptomatic infection. While most manning companies require screening for TB, the advanced disease seen in these patients causes some concern about the effectiveness of this screening.

Examining the Costs of a U.S. TB case:

Costs shown below are from a simple TB case treated in 2015. The crewman was hospitalized for only 16 days.

table2

It is important to note that there were additional costs associated with this case that are not detailed above including legal fees, medical management, and any supplementary crew claims. Further, this patient had a 16-day hospitalization and responded to treatment quickly. Imagine the extensive costs with a 30-, 60-, or 90-day hospitalization.

Summary:

TB is a public health issue that poses a serious health and financial risk to ship owners and their crews. Pre-employment screening for TB in ship crews may be ineffective. Once TB is suspected by a U.S. physician, treatment will likely extend for a minimum of 10 days and may continue for many months. With the minimum cost of the simplest 10-day hospitalization being $10,000.00-$20,000.00 USD, TB treatment in the U.S. is a huge potential expense. Unlike other medical issues, most TB patients cannot be repatriated for treatment. Because TB is a serious public health issue, all crewmembers who have been in contact with the infected patient, including those who have signed off, must be screened at least twice for TB.

TB treatment in the U.S. may be confusing to ship owners for several reasons. First, the crewman is sometimes required to stay in the hospital for no other reason than to assure that they are compliant with the medication regimen and that they do not make contact with the U.S. population. Expensive guard service is often required even though the patient is hospitalized. There is also little predictability about how fast or effective treatment may be, so the length of the hospitalization is uncertain, and crew managers often feel an understandable lack of control. Further, requirements for screening all crewmembers who have had sustained contact with the infected patient is financially burdensome and logistically difficult. Finally, the U.S. health authorities tend to be inflexible about treatment regimens, citing public health concerns.

Recommendations:

  • SphereMD recommends that all companies evaluate their pre-employment TB screening programs for effectiveness.
  • Contact your P&I Club immediately should a diagnosis of TB be suspected or confirmed.
  • In the event of a TB exposure, quickly and effectively screen exposed crewmembers using the previously stated methods.
16 Feb 2017

Medical pricing in the United States is NOT regulated.

Ship owners and insurers can be overcharged in any port for any service. Without medical management, ship owners are at the mercy of inconsistent pricing.

Consider the pricing practices used by U.S. hospitals. Because prices are unregulated in the United States, they are artificially high in most hospitals. This is mainly because hospitals expect insurance companies—not individuals—to pay for medical costs. This results in exorbitant bills for people who are uninsured or from another country.

In most countries,

medical pricing is regulated.  Ship owners and insurers must understand that medical pricing in the United States is unregulated. Pricing can vary dramatically from one provider to the next. This is not a trivial matter.

Compounding matters, U.S. hospitals are entitled to collect 100% from mariners, regardless of nationality. Some new collection companies specifically focus on collecting payments for international medical bills. These companies typically resist discounting. Their policies state that arrangements must be in place before medical services are provided, leaving unprepared ship owners with no recourse.

To more clearly see how wildly medical costs can fluctuate in the United States, look at some prices identified by SphereMD in three locales—New Jersey, Houston, Texas, and Washington.

Which amount would you rather pay?

  • $450 or $12,000? In New Jersey, an abdominal computerized tomography (CT) scan can cost from $450 (out-patient) to $12,000 (hospital).
  • $18 or $650? In Houston, Texas, a complete blood count (CBC) test, which is a simple blood test, can cost $18 (clinic) to $650 (hospital).
  • $15 or $950? In Houston, a chem 7 blood text can cost $15 (clinic) to $950 (hospital).
  • $16,000 or $108,000? In New Jersey, an appendectomy can cost $108,000 (hospital) compared to $16,000 (hospital) in Washington state.

USMap2

Clearly, medical pricing is all over the map.

Ship owners and crewmembers have jobs to do—they don’t have time or resources to track down the best services and pricing for every medical need. Medical managers like SphereMD can help alleviate this unfair burden.

Ship owners can take advantage of SphereMD’s knowledge and expertise. With SphereMD, ship owners stop gambling with medical costs and confidently save hundreds, sometimes thousands, of dollars while still getting high quality medical care for their crews.

SphereMD knows...

where crewmembers should go to receive the best services at the fairest prices in every U.S. port.  Medical pricing is different in each facility in each city—finding the best services takes knowledge and expertise.

20 Dec 2016

Outrageous Medical Costs in U.S. Ports Are Even More Extreme in the U.S. Gulf Area (Texas, Alabama and Louisiana)

Gaining a quick understanding of maritime healthcare can save your company thousands of dollars. Here’s a quick rundown.

In the United States, maritime healthcare involves two main groups—healthcare providers and medical service companies. In addition, multiple roles exist within each group.

Healthcare Providers

Healthcare providers are medical facilities and medical professionals. Medical facilities are hospitals and clinics. Medical professionals are doctors, nurses, and other medical specialists who provide services to crew members.

Healthcare providers make money by charging a fee for each service they provide to a patient. United States laws prohibit healthcare providers from paying commissions to people or companies who refer patients to them.

Medical Service Companies

Medical service companies coordinate medical care for crewmembers and ship owners. The United States maritime healthcare market generally consists of two types of medical service companies, which you can classify as—medical managers and medical brokers.

Why Agents Should Not Be Tasked with Providing Healthcare Services

In the United States, ship agents may be able to send crew members directly to healthcare providers, but they shouldn’t. Working with providers can be challenging for already overworked agents. When agents add medical services to their already long list of duties, expensive and often unnecessary emergency room visits frequently occur, because going to the emergency room is the most expedient action an agent can take on short notice.

Medical Managers

Medical managers like SphereMD are medical service companies with doctors and nurses on staff. They manage medical care on behalf of agents, P&I clubs, correspondents, ship owners, and ship managers. Medical managers generally charge hourly rates and fees based on a set percentage of medical bill savings achieved.

Medical managers NEVER pay commissions to other organizations.

Medical Brokers

Medical brokers are medical service companies that contract with specific healthcare providers for discounted rates, and they provide medical services at the request of agents and transportation providers. When given a choice, many P&I clubs and correspondents avoid the use of medical brokers.

Medical brokers seldom have doctors on staff. Instead, they focus on setting up arrangements with providers to send patients to specific facilities and medical professionals for a substantially discounted rate, sometimes up to 65%, which ultimately benefits the brokers.
Here’s how it works. Medical brokers forward full-cost medical bills from providers to agents, for payment-in-full by ship owners or P&I clubs. Medical brokers make money by keeping the difference between each medical bill’s full amount and the prearranged provider discounted rate. Some medical brokers may pay commissions to transportation providers and other companies who send medical cases their way.

The tables show an example of a hypothetical medical broker’s cost breakdown for a crew member’s six-day hospitalization.
chart1
Even if the $59,000.00 profit is reduced by a 20% discount offered to the P&I club for the initial gross bill for services, the profit for the broker would still be $41,200. The question remains, does the broker’s involvement warrant such a high commission? In addition, the calculations might be even more complicated and less transparent if the broker also paid a commission to a referring party.

Again, these examples are hypothetical but based on real world cases. Are you, as a ship owner or P&I club, okay with the bottom line economics of these cases?

Medical brokers can use this business model because by tend to avoid transparency. In other words, medical brokers usually avoid disclosing the discount relationship they have with providers or the actual costs they are paying for medical services.

Are you okay with a broker making more than the hospital?

The Transparency Test

Telling the difference between medical brokers and medical managers can be tricky. To help you understand your medical service provider and avoid paying excessive medical costs in the United States, SphereMD recommends asking the following five “transparency” questions for all major medical cases*:

1.) Ask the medical service company: Can you provide evidence of payment in full to the provider?
Before paying medical bills, request evidence of payment in full to the hospital from the medical service company. This information can reveal if any hidden discounts were accepted. Medical managers will gladly provide such evidence; however, medical brokers may resist or outright refuse to provide this information.

2.) Ask the medical service company: How much profit is the medical service company making on the billing?
Request information about how much profit the medical service company is making on the billing. The cost of using a medical service company should be transparent, reasonable, and predictable, such as based on a predetermined hourly rate or percentage of savings. A medical manager will share this information, but medical brokers may resist or refuse this request.

3.) Ask the medical service company: Would you be willing to stand down and no longer be involved with a case, if necessary?
Ask the medical service company if it would be willing to stand down and no longer be involved with a case. A willingness to step down shows flexibility, fair dealing, and the desire to work on behalf of the ship owner or P&I club. A company that refuses to step down implies a forced relationship and poses a barrier to transparency. Medical managers will happily comply with this request, but medical brokers may resist or refuse to step down.

4.) Ask the healthcare provider: How much was the bill settled for after the fact?
Find out from the provider facility (the hospital, clinic, or other facility) how much the bill was settled for after the fact. You can then use that number to cross-reference with the medical service company’s invoice. A medical manager’s invoice will transparently show the settled amount. A medical broker’s invoice will not show the settled amount.

5.) Ask the healthcare provider and medical service company: What were the detailed charges?
Request to see a detailed account of all provider charges. Such details are necessary to understand how much providers have discounted their fees for the medical service company. Medical managers will provide the details, but medical brokers may resist or refuse this request to avoid transparency.

 

Proactive Steps

Armed with this information about medical providers and medical service companies, ship owners and P&I clubs can better control their costs. SphereMD believes that the best practice is to work with agents to define the steps to be taken for any crew medical care before the need arises. We also recommend that your P&I club is contacted as soon as any non-routine injury or illness occurs. Finally, ship owners may consider hiring a medical manager to represent all U.S.-based medical needs to ensure transparency, every step of the way.

Injury Care Done Right

At SphereMD, we have handled serious injury situations many times, and helped thousands of vessels and crews avoid unnecessary delays. We know what we’re doing, and we’re ready to go when tragedy strikes.

When a crewmember was pinned to a vessel by the gangway, we made sure he was immediately taken to the hospital for treatment. Then, we dispatched a technician to get a sample from the patient within 1 hour of his arrival at the hospital. As soon as we had the sample, we got it in for testing that same day and had results before the patient returned to the vessel. Compare our expedited process to the other real event described in the sidebar, when the 2nd Engineer cut off the tip of his finger.

Nobody wants to think about accidents and serious injuries, but failing to report or waiting until the USCG requests testing can keep your ship stuck for 3-5 days. At an estimated $20,000.00 per day, a little planning saves big.

Two Strikes and You Are Out!

SphereMD recommends a “Two Strikes and You Are Out” policy with major medical cases*. We know that’s one less strike than usual, but medical care is too costly to wait for a third mishap. We recommend that you avoid any medical service company that resists or refuses to respond to any of the transparency questions twice. Once a company strikes out, instruct your agents to avoid the medical service company by NAME in your voyage instructions.

 

 

*We define major medical cases as having an average bill of more than $5,000. Reviewing small, expediently run cases tends to be more expensive to review than the amount of savings that could be realized.

29 Sep 2016

USCG Drug Testing: Delays, Dollars, and Sense-Costs of Not Reporting

Imagine getting one of these calls:

“Your captain slipped off a ladder and landed headfirst! The captain is being treated at a medical  facility, and a replacement captain is already onboard. Unfortunately, the USCG won’t let your vessel leave. They want to see the drug and alcohol test results, but tests were never taken…”

 “A cadet on your vessel injured his finger. He was treated in port and repatriated after being found unfit for duty. Your vessel’s ready to go as soon as the drug test results are in. For now, everyone’s just waiting around.”

These scenarios are based on true accounts of onboard injuries. Injuries occur, and when they do, they can cause extended delays and devastating losses, well beyond the initial tragedy. With proper training and planning, some of your losses can be mitigated when an injury occurs on your vessel.

Did You Know?

In the United States, medical pricing is unregulated. A CT scan can cost $350 in one port or facility, and $11,000 in another.

Reminder: Always contact your P&I Club when an injury or illness requires more than basic first aid onboard the vessel.

When an injury occurs that requires more than first aid, captains, crewmembers, and shipping agents should immediately think about drug and alcohol testing. Train and remind your crew that drug and alcohol testing must be conducted as soon as possible after an injury. This helps your vessel avoid delays, and it’s a federal regulation. By law, everyone directly involved in an incident must be chemically tested as soon as possible:

  • Drug testing is mandatory within 32 hours following a serious marine incident
  • Alcohol testing is mandatory within 2 hours following a serious marine incident

If alcohol testing cannot be conducted within 2 hours due to safety concerns directly related to the incident, testing must be done as soon as possible but no later than 8 hours following the injury. All inspected vessels certificated for unrestricted ocean routes must have an alcohol breath-testing device on board.

Testing Specifics

Directly Involved

You may have noticed that directly involved is mentioned in the federal regulations. A directly involved person is anyone whose order, action, or failure to act may have contributed to an injury. In addition, a law enforcement officer, such as a Coast Guard officer or a state or local police officer, may decide whether a person was directly involved in an injury. Once a person is identified as possibly being directly involved, the required alcohol and drug testing must be completed.

Coast Gaurd Forms

Along with testing, two Coast Guard forms must be submitted to the appropriate Officer in Charge, Marine Inspection following a serious injury:

  • CG-2692, Report of Marine Accident, Injury or Death
  • CG-2692B, Report of Required Chemical Drug and Alcohol Testing Following a Serious Marine Incident

As you might suspect, drug test results are not always available when the forms are submitted. In those cases, the marine employer must report the results—positive or negative—as soon as the results are available.

The Timeline

The testing and analysis process involves a number of agencies and takes time. This can be seen in our simplified timeline diagram to the right.

At a minimum, the process takes several days. Every delay in the initial sample collection slows down the entire process. This can quickly grow into an enormous problem because vessels often cannot operate or are held by USCG until negative results are confirmed. When you preemptively train your crew and plan for emergencies, you gain some control over your vessel’s delays.

Injury Costs

Recently, a 2nd Engineer was working on a motor. Everything was humming along until he cut off the tip of his right index finger. Immediately, an ambulance rushed him to the hospital. The vessel was due to depart for Japan in three days. At this point, the path to recovery could go two ways—what actually happened and what could’ve happened.

What Actually Happened—Days of Delays

Here’s what happened in the real situation. Try not to cringe as you feel the days slip by:

  1. The patient was treated at the hospital and returned to the vessel.
  2. The marine inspector reported that he required drug and alcohol testing results.
  3. The testing was performed on the patient two days after the initial report of injury.
  4. The test was mailed to the lab.
  5. The lab sent the results to the Medical Review Officer (MRO).
  6. The MRO confirmed the results and sent them back.

As you might imagine, those six steps took several days—but that’s not the end of it!

  1. After receiving the initial test results, the USCG reported that they also needed drug and alcohol test results from two other crewmembers, who were “involved” in the accident but were not yet tested…

What Could’ve Happened—A Quicker Way

If the vessel owner had been prepared, days could have been saved. While the patient was being treated, required actions could have begun immediately and looked something like this:

  1. The injury was reported correctly and drug testing was performed immediately on everyone involved in the accident.
  2. The tests were mailed to the lab.
  3. The lab sent the results to the MRO.
  4. The MRO confirmed the results for everyone involved in the accident and sent them back.
  5. The engineer was back onboard, crewmembers were cleared, and the vessel sailed with minimal delay.

In the real situation, the USCG would not authorize the vessel to sail until they received test results for all crewmembers involved in the accident. Vessels need people in certain positions who hold specific certifications. Leaving the crewmembers was not an option. Ultimately, the vessel was delayed two additional days, which cost a minimum of $20,000.00 per day.

Preemptive Planning

Preparation

Be prepared—by far, that’s your best plan. The USCG inconsistently enforces drug testing. Some ports are stricter than others. Instead of hoping for the best, you need an action plan that’s ready to go when you need it. In our experience, we’ve found that you can avoid vessel movement delays and reduce costs after an injury if you:

  • Make testing arrangements
  • Have shore-side support for all potential drug-testing needs—get someone to the ship to get samples taken as quickly as possible.
  • Report, report, report! Report all injuries requiring more than first aid to the marine inspector.
  • Teach and remind your captain, crew, and shipping agents to think “drug testing” as soon as a serious injury occurs.

Injury Care Done Right

At SphereMD, we have handled serious injury situations many times, and helped thousands of vessels and crews avoid unnecessary delays. We know what we’re doing, and we’re ready to go when tragedy strikes.

When a crewmember was pinned to a vessel by the gangway, we made sure he was immediately taken to the hospital for treatment. Then, we dispatched a technician to get a sample from the patient within 1 hour of his arrival at the hospital. As soon as we had the sample, we got it in for testing that same day and had results before the patient returned to the vessel. Compare our expedited process to the other real event described in the sidebar, when the 2nd Engineer cut off the tip of his finger.

Nobody wants to think about accidents and serious injuries, but failing to report or waiting until the USCG requests testing can keep your ship stuck for 3-5 days. At an estimated $20,000.00 per day, a little planning saves big.

Beware...

Some doctors along the eastern seaboard may be overcharging. This month, we are calling attention to independent east coast providers who, based on our experience, have rates that are sky high compared to typical rates.

Example physician charges:

  • $600-$750 to see a patient

(typical rate: $200–$400)

  • $2,000 x-ray fees

(typical fees: $200–$400)

To avoid run-ins with unnecessary costs, we recommend contacting your P&I Club for port specific medical advice.

We also recommend that all Owners and Operators hire a medical management company to handle ALL medical requests for US ports of call.

SphereMD facilitates the best medical care for you and your employees,
efficiently and affordably in all U.S. ports and Panama.

Japan