Author: David Shubin

15 Mar 2019
Maritime Health Newsletters David Shubin 0 comment

SphereMD Now Open in Panama

Portland, OR U.S.A—In an ongoing effort to provide full service medical services to the worldwide shipping industry, SphereMD now has a network of medical professionals who provide routine as well as complex medical and dental care in Panama. SphereMD has compiled a summary of the unique aspects of Panama’s medical market, the Company’s service goals in Panama, and recommendations for ship owners, managers, and operators in the region.

Understanding Panama’s Medical Market

Compared to the U.S. medical market, Panama’s government does not provide oversight to control prices. However, Panama’s physicians are generally well trained. Additionally, many Panamanian hospitals are internationally certified and receive U.S. level hospital certification from bodies such as The Joint Commission on Accreditation of Hospitals (JCAH). However, the smaller hospitals may not meet the rigid standards of such certification. Panama’s medical market differs in key ways for hospital services, physician’s fees, commissions, and the use of medical brokers and intermediaries. Here’s a quick rundown:

  • Hospital services: Compared to U.S. hospital services, Panamanian hospital fee schedules and prices are generally lower. However, significant savings may result by managing hospital services by insisting on medical management with any hospitalized patient to decrease utilization.
  • Physicians’ fees: In the United States, laws require each doctor to charge all patients the same price, and doctors use standardized codes and medical notes to justify charges. In Panama and in most of Central and South America, there are no laws that require physicians use insurance codes or provide detailed medical records.
  • Commissions: Documented cases show medical brokers and intermediaries receive up to 20% or more of medical charges. This type of commission drives up costs for ship owners and may be a conflict of interest.
  • Third parties: Third parties in Panama may add additional costs to some of the issues mentioned. For instance, a third party may increase medical costs by receiving discounts from hospitals and doctors and then overcharging for those services.

As you can see, working with medical staff and facilities in Panama requires a slightly different approach than in the United States or Europe. Therefore, while markets differ from country to country, the key is to control medical costs before any care is rendered, and to start with your P&I Club or medical manager who knows the market firsthand.Meeting Service Goals in Panama

Based on firsthand experiences, SphereMD identified the following actionable goals for managing medical services in Panama. Ship owners can follow these goals, as well:

  • Keep routine care routine by using P&I Clubs and medical managers who have a network of trusted Panamanian
  • Avoid elective care in Panama to reduce medical services costs.
  • Opt for repatriation for treatment when medically appropriate.
  • Decrease the length of hospitalizations by insisting on medical management with any hospitalized patient.
  • Require providers to deliver clear legible records and reports in a timely manner.

By choosing SphereMD as a medical partner, you are choosing to use trusted physicians and certified hospitals, and to control costs while ensuring the best medical care while in Panama.

Taking Precautions

If a crew member needs medical services in Panama, you can help keep costs under control by being proactive:

  • Insist on a proof of payment settlement to the hospital before paying a hospital bill.
  • Insist on paying individual providers and hospitals directly—don’t pay third parties in Panama who provide doctor and hospital services on one invoice without first vetting the invoice with your P&I Club.
  • Contact your P&I Club or a trusted medical manager—don’t ask your agent to arrange for medical care because it could cause a conflict of interest.

Learning More

Like all medical markets, understanding the system is key. SphereMD has cultivated a strong understanding of medical markets through firsthand experiences, which we are happy to share. Contact us at operations@spheremd.com if you have any questions or would like more information, including summaries of real case experiences that support our findings.

SphereMD specializes in coordinating, managing, and reviewing medical cases in an ethical, transparent, and cost-effective manner. We yield tangible and significant financial benefits to our clients while ensuring that your crew members receive the highest quality of care possible, every day of the week, 24 hours a day, 365 days a year.

30 Mar 2018
Maritime Health Newsletters David Shubin 0 comment

Lessons from the Philippines

Having all the right information at the right time makes all the difference in the world. To make that vision a reality for maritime medical claims, we need to understand what’s actually happening in our world.

That was my mission on a recent trip to the Philippines. While in Manila, I met many talented and dedicated manning agents, doctors, claims managers, and correspondents. Each person I encountered plays a valuable role in managing illness and injury claims for crew members repatriated to the Philippines. I gained a great deal of valuable insight through our conversations. For instance, I now have a better understanding of issues related to post-repatriation claims concerning injuries and accidents that happen abroad, and a more thorough understanding of the pre-employment medication examination (PEME) process and clinics in the Philippines.

As far as the claims issues, one key takeaway I found is that claims professionals are looking for clear, sufficient, accurate information by which to fairly adjudicate claims. Currently, the information they receive ranges from non-existent to vague or unclear.

  • Vacuum of Information: Almost all claims handlers expressed concern over the poor information they receive from doctors in the United States and around the world. In some cases, no documentation is received whatsoever, especially for crew members treated in the United States. To compound matters, claims handlers said subsequent requests for documentation are often ignored, and privacy laws in many countries present a barrier to accessing medical records.
  • Inadequate Documentation: Another common concern is that when medical records are available, the documentation is often inadequate. Some records are illegible or incomplete, and others contain little information that can be used to accurately adjudicate a claim. In addition, vessels’ medical forms are often missing, and when included, they are also incomplete or illegible. Furthermore, language barriers can add an extra level of complication in understanding records, reports, and forms.
  • Poor History: Missing medical history information presents yet another challenge for claims handlers. Even in the presence of legible medical notes, insufficient information is often provided concerning the history of the illness, patient’s medical history, the prescriptions the patient was on pre-examination, and so forth. Most claims handlers I spoke with cited this as a primary concern. Without an accurate medical history, they cannot determine preexisting conditions.
  • Unclear Documentation: Universally, claims handlers said medical providers rarely sufficiently indicated if an illness or injury is a work-related illness or injury. Most claims professionals agree that this is a critical piece of information. Without this documentation, claims determination and adjudication are far more difficult than necessary. This issue may be rooted in perspective. From a medical provider’s perspective, at least in the United States, claims issues are not the concern. Instead, the medical issue is the main concern, and the documentation addresses patient wellness and serves to avoid medical legal liability. Claims handlers view the situation from an entirely different perspective.

While the claims complications can occasionally be individually identified, in many cases all factors are present to some degree. Understandably, this makes adjudicating claims excessively difficult. It doesn’t have to be this way. We can take steps to help claims handlers obtain the information they need from the outset.

The first step to creating a better process is awareness. Certainly, most medical providers have never been asked to provide documentation in a different way up front. Instead, medical providers respond to queries for clarification, questions about workplace illnesses and injuries, medical history, and more- information they often provide after the fact. Theoretically, medical providers could document these data points up front if they are aware of the need for the information. For people who provide and coordinate maritime care, we need to ensure that this awareness exists and create a process that meets the unique needs of claims handlers.

The challenge is making hundreds of individual providers aware of this need across the United States (and possibly thousands of providers around the world). This daunting thought is one reason many ship owners have Fit for Duty forms that attempt to answer medical questions of history, occupational cause or relation of injuries and illnesses, and so forth. But as noted earlier, these forms are rarely completed accurately, if at all.

While tackling awareness and response on a global basis will be a work-in-progress for many years, SphereMD has the awareness and capabilities to begin to collect this type of information with all our medical cases. In doing so, we will be able to provide complete, accurate, and clear information for a few thousand medical cases per year. While this is a relatively small number of cases compared to the tens of thousands of maritime illness and injury claims that occur every year, we feel this will make a difference.

After considering these issues, I have a final thought and a question. In managing maritime claims from a medical perspective, I firmly believe that claims and medical care can be managed with a greater deal of control and precision. I believe this because in the United States, insurance companies have been achieving this for decades. Better control is possible, and I wonder, would you, as a claims professional, doctor, correspondent, or P&I Club stakeholder, be interested in collaborating on a project with SphereMD to collect an idealized set of data to help claims managers effectively, fairly, and efficiently adjudicate medical claims? If so, we would love to collaborate with you. In a future article, I will share some of the perspectives I gathered concerning PEMEs performed in the Philippines.

If you are interested in collaboration, please contact David Shubin at shubin@spheremd.com.

 

01 Feb 2018
Maritime Health Newsletters David Shubin 0 comment

Quicker Return to Fit for Duty Status

crewman working

Quicker Return to Fit for Duty Status

Crew members spend more time than necessary dealing with shore side medical care. Many things can be done to improve the efficiency of shore side care. This article provides specific recommendations to expedite U.S. shore side care and quickly return a crewmember to fit for duty status.

Communicate While at Sea

Even before a ship arrives at its intended or nearest port-of-call, a key step can be taken to increase the likelihood that an injured or ill crew-member can return to fit for duty status relatively quickly. Specifically, it is important to seek medical advice via e-mail or radio with a medical provider – e.g. a physician or nurse. Medical providers will describe the best course of treatment that can be achieved while the crew-member is still at sea. Such treatment will typically be relatively easy to implement, such as crew-member immobilization, ice treatments, use of anti-inflammatory medications, and adequate rest.

Make Medical Appointments Prior to Arriving in Port

If, two days in advance of port arrival the crew-member is still being adversely impacted by their injuries, or still has illness symptoms, it is important to schedule a land-based medical appointment to take place as soon as possible. Such medical appointments can be made by making requests to a medical manager. With up-to-date information about the crew-member’s medical condition and the ship’s arrival schedule, the medical manager will schedule an appointment with the appropriate medical facility, physician, or medical specialist. Keep in mind that if the crew-member’s condition improves before the ship arrives in port, the medical appointment can be easily canceled.

Waiting until the vessel arrives to make medical arrangements can result in the use of hospital emergency rooms, which (as will be described below) are expensive and problematic for quick return to fit for duty status.

Share Work & Schedule Information with Physicians and Medical Managers

Before the crew-member’s medical examination and treatment, it is important to provide U.S. physicians with information about the crew-member’s responsibilities. In particular, such information should focus on flexibility in the crew-member’s work duties. The more that U.S. physicians understand about flexibility in crew-member’s duties, the more options they have in terms of granting fit for duty status. Examples of such flexibility include:

  • Indicating that the crew-member’s responsibilities allow for light duty restrictions or modifications (e.g. 2-hour work shifts with intermittent work breaks).
  • Explaining that the crew-member’s responsibilities mainly consist of bridge duty, for which remaining seated is acceptable.
  • Indicating if bedrest can be accommodated by vessel

Additionally, it is important to share the ship’s port-of-call schedule with U.S. physicians. As U.S. physicians typically do not have confidence in other countries’ medical infrastructures, it is beneficial to share with them any near-term visits to U.S. ports of call. With such information, U.S. physicians will gain confidence that adequate follow-up medical care can be provided, and will more likely approve fit for duty status. Even if the crew-member is not fit for duty, U.S. physicians may grant a “fit to sail” status. In this case the crewman is able to return to the ship, keeping it in compliance with its crewing certificate. Fit to sail status provides time for owners to locate and onboard replacement crew, often reducing costs surrounding immediate repatriation.

Points to Remember

SphereMD recommends sending the following information to your medical manager with every shore side crew member: job title, specific duties, next port, expected date of sign off, and accommodations available (examples above, such as light duty and modifications).

This information will assist your medical manager in working with U.S. physicians to ensure that the crew member’s and vessel’s needs and accommodation options are well-understood and taken into consideration. The end goal is to communicate the right information to provide the best care and an appropriate fitness determination.

Choose the Right Medical Provider

It is well accepted that emergency rooms are an expensive, inefficient venue to receive non-emergent care, and therefore should be avoided for routine cases. Further, emergency rooms in the U.S. tend to issue more restrictive fit for duty statuses, and require follow-up that doesn’t consider the movement of ship. Emergency rooms are often unwilling to complete ship medical paperwork, as they are not required by U.S. law to do so. Sometimes, emergency room physicians omit any mention of fit for duty status, which means that those physicians must be re-visited (requiring extra time, paperwork, and costs to request fit for duty status).

The best way to avoid emergency rooms and find the right medical provider in each port is to work with a medical manager. Medical managers will ensure that the crewmember is taken to the right physician (e.g. an eye doctor for an eye injury) or to a clinic if a specialist is not required. Not only can clinics cover the majority (90%) of emergent or non-urgent care, they also provide quick service and are willing to fill out ship medical paperwork. By being proactive with care and utilizing medical management services, you can have better control over crew member medical care in the U.S. You will decrease costs, protect vessel schedules, and enjoy more effective medical care.

 

20 Dec 2017
Maritime Health Newsletters David Shubin 0 comment

Mental Illness in a Shipboard Environment

At any moment, 500 million people worldwide struggle with some sort of mental illness. One in four people will experience psychiatric symptoms at some point in their lives. These symptoms can arise from emotional distress, imbalance in brain chemicals, disease, or physical damage to the brain.

Some symptoms of mental illness can include:

  • Feeling sad or down
  • Confused thinking or reduced ability to concentrate
  • Excessive fears or worries, or extreme feelings of guilt
  • Extreme mood changes of highs and lows
  • Significant tiredness, low energy, or problems sleeping
  • Inability to cope with daily problems or stress
  • Trouble understanding and relating to situations and to people
  • Excessive anger, hostility, or violence
  • Suicidal thinking

Most of the time, people can manage symptoms on their own- mental illness is not usually a barrier to a healthy, productive life. Healthy supports that can help people manage mild psychiatric illness include friends and family, medical care, and spiritual or religious communities. In most cases these are sufficient to help someone manage their symptoms.

Sometimes, however, it takes more effort to manage and overcome psychiatric symptoms, and they can become severe enough to require further professional help. Depending on the situation, medical treatment, mental health therapy, psychiatric intervention, or even temporary hospitalization may be required.

Psychosis is one example of the sort of severe symptom that can sometimes manifest with many different types of mental illness and brain injury. Psychosis can involve hallucinations (hearing, seeing, or otherwise sensing things that other people do not) or delusions (having irrational beliefs that are not based in reality). When mental or medical illness result in psychosis, it is referred to as a psychotic break- an event that can be extremely frightening and confusing for both the individual and those around him. The individual may feel that he is no longer in control of himself, and the people around him may fear for his safety or their own.

Often the symptoms of mental illness can be manageable under peaceful, comfortable conditions; but get worse during periods of stress. A shipboard environment provides a number of unique and stressful conditions that can dramatically increase the severity and nature of psychiatric symptoms, whether they are a result of mental illness or medical conditions.

Examples of these stressors include:

  • Isolation: spending long periods of time at sea with little social interaction
  • Separation from support system: no access to friends, family, or other comforts of home
  • Tight deadlines: the need to accomplish important tasks very quickly
  • Physical exhaustion: physically and mentally demanding work
  • Sameness: boredom, lack of stimulation, and repetitive tasks
  • Small, enclosed spaces: tight confines that can feel oppressive

In addition, the types of support resources that most often help relieve emotional distress- medical, emotional, and spiritual resources- are necessarily limited at sea. When everyone is focused on their missions, they are less able to observe one another for signs of emotional, mental, or medical distress. Under such stressful conditions, underlying mental illness or brain injury can become apparent, and existing symptoms can become worse.

Complicating matters is a reluctance of crewmembers to report any mental or emotional stress they are experiencing. As with other medical issues, crew may be afraid of losing their jobs if they report their symptoms. They may be afraid of becoming “blacklisted” due to their illness, especially if they have family who rely on their vessel income. Additionally, many people may fear appearing weak in front of their peers.

As a result, many symptoms of mental illness or emotional distress may go unreported for months or even years as the crewmember suffers in silence without seeking help.

If a crewmember seems to be exhibiting signs of emotional distress, mental illness, or psychosis, the first priority should be a medical examination. Since many symptoms can arise from medical issues, the crewmember should be assessed for injury or illness. However, only an experienced mental health professional can diagnose mental illness.

Treatment of severe mental health symptoms can take time. The duration of treatment is greatly lessened, and the treatment more successful, when the individual has access to the emotional and social supports he would normally have (while not at sea). Help from friends and family is one primary driver of recovery from psychiatric symptoms. Treatment is also faster and more effective when provided by mental health professionals from the individual’s own culture and in his native language. As a result, repatriation should always be considered for a crewmember experiencing a mental health crisis.

For severe symptoms, including psychosis, shipboard medical care may not be sufficient. In this case, medical staff should focus on de-escalation- keeping the crewmember calm and safe- until he can be repatriated to his home country for more directed treatment. This may involve temporary relief from work duties, providing a quiet and calm environment, or (in severe cases) temporary sedation.

Sometimes immediate hospitalization may be required in order to de-escalate and stabilize the crewmember.

While occasionally necessary for the safety of the crewmember, immediate hospitalization can present complications. Often a psychotic episode is brief and responds well to emergency treatment, but at times an underlying illness may mean a longer period of emergency supervision. In the United States (US), doctors have the authority to keep patients under observation if they consider the patient a risk to himself or others, or incapable of making rational decisions.

Particularly in psychiatric cases, US physicians are given full control of the patient’s care. This may mean a doctor or hospital could hold an ill crewmember for longer than stabilization and repatriation would normally require. This can result in greater distress to the crewmember, a longer time before he may be reunited with his support network and culturally appropriate care, and increased logistical difficulties when he is cleared to travel.

As a result, hospitalization in the US should be considered only for very short-term stabilization in the event the crewmember cannot be stabilized on board. The goal of mental health treatment should be the same as with any illness or injury: immediate safety and stabilization before returning to duties or repatriation. Repatriation and treatment in the crewmember’s home country will ultimately be more effective, safer, and less costly than an extended stay in a foreign hospital system.

Points to Remember

  • Contact your P&I Club. Your club will have resources to assist when you suspect mental health issues. Call your club before the crewman’s condition deteriorates.
  • Early intervention saves time and money. The earlier symptoms are noted and addressed, the more likely the crewmember is to make a swift and full recovery, and at considerably lower cost. A crewmember in a mental health crisis should be evaluated immediately by shipboard medical staff, who should focus on de-escalating the crewmember’s crisis and providing medical and emotional support.
  • Make repatriation a priority. If a crewmember shows signs of persistent or increasing mental illness, the initial cost of returning him to his home port is far outweighed by the potential costs of severe and disabling symptoms. Repatriating a crewmember for treatment in his own country before his symptoms become unmanageable will save money, time, and crewmember health.
  • Contact SphereMD. When symptoms are not manageable on board, and immediate psychiatric intervention is necessary, ship medical staff should work to keep the crewmember calm and be in contact with SphereMD to coordinate the least invasive and most effective care. If US hospitalization is absolutely necessary, SphereMD can ensure that the crewmember is stabilized quickly and effectively, and repatriated as soon as is medically appropriate.
27 Sep 2017
Maritime Health Newsletters David Shubin 0 comment

Hiring a Medical Escort

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
Maritime Health Newsletters David Shubin 0 comment

High Cost Warning: Freestanding ERs in Gulf

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
Maritime Health Newsletters David Shubin 0 comment

Illness to Fitness Determination

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
Maritime Health Newsletters David Shubin 0 comment

Tuberculosis

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
Maritime Health Newsletters David Shubin 0 comment

Gambling with Medical Costs

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.

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