Inpatient Practice

What Kind Of Mask Should You Wear?

It has now been 3 years since the SARS-CoV-2 virus first infected humans in Wuhong, China in December 2019. By now, most Americans have either had a COVID-19 infection or have been vaccinated against COVID. So, what type of mask should we be wearing in the hospital and in public places?

Our two most powerful weapons against COVID are vaccination and mask-wearing but mandates for both have been been unpopular in the United States. Since the peak of the pandemic, most mask mandates in public areas have been relaxed. However, mask mandates are still in place in many hospitals. Furthermore, as of the writing of this post, there are 25,380 patients with COVID infection currently admitted in U.S. hospitals. Consequently, healthcare workers continue to have regular exposure to infected persons. So, what kind of mask should our healthcare workers wear?

Mask-wearing is not new. Surgeons and other operating room personnel have worn masks during surgeries for more than a century. However, the purpose of wearing masks in the OR is to prevent the surgeon’s respiratory secretions from infecting the patient’s incision and not to prevent the patient’s incision from infecting the surgeon. A simple surgical mask is very effective in catching respiratory droplets if the surgeon sneezes, coughs, or talks during an operation.

Before COVID, there were situations when healthcare workers did wear masks to prevent getting infected by patients, for example, when caring for patients infected with influenza (where transmission is usually by respiratory secretion droplets). A regular surgical mask is effective in preventing infection from respiratory secretion droplets but for smaller particles, an N95 mask is necessary. For 35 years, I wore N95 masks whenever I was caring for patients infected with tuberculosis or when doing bronchoscopy on patients suspected of having TB. It only takes inhaling  one tuberculosis bacteria to become infected with TB. A respiratory secretion droplet is about 5-10 μm in size whereas a tuberculosis bacteria is about 2 μm in size. A regular surgical mask will usually stop the droplets but will not stop a TB bacteria, whereas an N95 mask will.

For an N95 mask to be effective, it must have a tight seal to the face so that air cannot get between the edges of the mask and the skin. Everyone’s face is shaped a little differently and not all brands of N95 masks fit all faces equally well. Healthcare workers are normally required to be “fit-tested” to determine which N95 mask provides an acceptable seal against the face. Passing the fit test meant that all of the inhaled air went through the mask material and did not leak between the mask and the skin. At our hospital, we required healthcare workers who worked with patients with suspected tuberculosis to be fit tested every year. A number of years ago, the Occupational Safety and Health Administration (OSHA) put out a requirement stating “The employer shall not permit respirators with tight-fitting facepieces to be worn by employees who have facial hair that comes between the sealing surface of the facepiece and the face…“. In other words, men with beards were not supposed to use N95 masks.

Like influenza, the COVID virus is usually transmitted by respiratory secretion droplets. So, in theory, a surgical mask should be sufficient. However, there are certain situations when an infected patient’s respiratory secretion droplets can be broken down into smaller particles, in which case, a surgical mask could be insufficient and an N95 mask may be more effective. Such situations include performing endotracheal intubation and bronchoscopy. Having had a beard for 40 years, I had repeatedly passed my annual N95 fit tests despite having a beard but when COVID hit, I shaved it in order to be in compliance.

We now have several studies performed over the past 3 years of the pandemic to give us better guidance of what type of mask is most effective in preventing healthcare workers from becoming infected. Unfortunately, each of these studies have potential limitations and the studies have given mixed results.

A word about KN95 masks. An N95 mask is a NIOSH-approved mask that filters out at least 95% of particles that are 0.3 micons in size. In reality, a well-fitting N95 mask actually filters out 99.8% of particles that are 0.1 micons in size, which is also the size of a COVID virus particle. A KN95 mask is a mask approved by the Chinese government (and not NIOSH). A study of KN95 masks found that 70% of them did not meet the NIOSH standard for effectiveness. For hospital purposes, a KN95 mask can be considered as effective as a surgical mask but not as effective as an N95 mask

One of the earliest studies comparing surgical to N95 masks was published in JAMA in 2009 and randomized 446 nurses caring for patients with acute febrile respiratory illnesses to wear either surgical masks or N95 masks during patient care. An equal percentage of the nurses were diagnosed with influenza during the study and the conclusion was that the type of mask worn did not make a difference. Another study published 10 years later in JAMA in 2019 also found that among 1,993 healthcare workers randomized to wearing surgical or N95 masks, there was no difference in the incidence of influenza or other respiratory infections.

There have been several studies comparing masks to prevent COVID infection. A 2021 study examining the effectiveness of N95 versus surgical masks based on analysis of droplet size characteristics concluded that a surgical mask was theoretically sufficient to prevent COVID infection in low-virus environments but N95 masks would be theoretically more effective in virus-rich environments. A 2021 study comparing the fit of cloth, surgical, KN95, and N95 masks found that N95 masks had better fit factor scores than the other masks and that KN95 masks had similar fit factor scores as surgical masks. The study also concluded that fit is critical to the level of protection offered by masks. A 2021 meta-analysis of 8 studies involving N95 versus surgical masks found that N95 masks were more effective than surgical masks in preventing healthcare workers from becoming infected with a variety of respiratory viruses, including COVID. A 2022 study of 3,259 healthcare workers who were randomly assigned to use filtering facepiece class 2 masks (analogous to N95 masks) versus surgical masks found no overall effect on the incidence of COVID infection; however, those healthcare workers with > 20 contacts with COVID patients did have fewer COVID infections if they were wearing the filtering face piece class 2 masks. A 2022 MMWR report involved a retrospective review of 1,528 COVID-infected persons and 1,511 case controls and found that people who reported wearing N95 masks in public were less likely to become infected than those who wore surgical masks in public places. However, a major limitation of this study is presumably those wearing N95 masks were also more likely to take other precautions to avoid COVID than those who chose to wear a regular surgical mask.

The most recent study was published this week in Annals of Internal Medicine. 1,009 healthcare workers in Canada, Israel, Egypt, and Pakistan were randomized to use N95 or surgical masks during patient care for 10 weeks. Overall, there was no difference in the incidence of COVID infection between the two groups but it is notable that most of the subjects (71%) were in Pakistan or Egypt with only 29% in Canada or Israel. In Pakistan and Egypt, 82% of subjects had previously been infected by COVID before the study whereas in Canada and Israel, only 3% of subjects had a previous COVID infection. There was a trend for N95 masks to be more effective than surgical masks in Canada and Israel; however, because of the low number of subjects in those countries, the results did not reach statistical significance. Because past COVID infection confers some immunity to reinfection, it is possible that the failure of N95 masks to have superior protection over surgical masks was due to the very high percentage of healthcare workers with immunity from previous infection in Pakistan and Egypt.

The bottom line: What mask should you wear?

Medicine is a very dynamic science and recommendations change as new clinical studies are published. As a result, today’s medical dogma is tomorrow’s medical malpractice. Based on the available information a few general recommendations can be made:

  1. In hospital areas where the prevalence of COVID infection is low, wearing regular surgical masks is sufficient to prevent healthcare workers from becoming infected. This means parts of the hospital that provide care for non-COVID patients, such as general medical and surgical floors, cafeterias, public areas, and offices.
  2. In hospital areas where there is likely to be a high number of viral particles in the air breathed by a healthcare worker, N95 masks are preferable. This would include areas where the viruses are likely to be aerosolized, such as during intubation or bronchoscopy, particularly in rooms with stagnant airflow, such as those lacking sufficient number of air exchanges per hour. In locations where the virus is in respiratory droplets (as opposed to being aerosolized), surgical masks may be sufficient. Because several studies have shown that the viral loads are similar among symptomatic versus asymptomatic patients with COVID infection, the decision of whether to wear an N95 mask should not be based on the severity of the patient’s infection.
  3. Wearing surgical masks by healthcare workers is sufficient to prevent workers with asymptomatic COVID infection from infecting patients. This has been a concern for the care of patients at high risk of severe COVID infection, such as those patients who are immunocompromised, obese, diabetic, or elderly. These patient are at particular risk if in contact with a maskless infected healthcare worker. Because daily testing of all healthcare workers caring for these patients is impractical, preventative mask-wearing is prudent.
  4. Because viral loads are just as high in asymptomatic patients as in symptomatic patients, hospital visitors should wear surgical masks inside of the hospital as long as the prevalence of COVID infection in the community remains substantial or high. What constitutes “high” is a matter of opinion but the CDC defines “low” as up to 10 cases/100,000 population, “moderate” as between 10-50/100,000, “substantial” as 50-100/100,000 population, and “high” as greater than 100/100,000 population. Currently, the U.S. as a whole has a case rate of 91/100,000 population. However, hospitals are not like the country as a whole – currently 5.6% of all Ohio inpatients have COVID infections for an inpatient rate of 5,600/100,000. Because inpatients with COVID infection are more likely to have family and friends who are also infected (from home and workplace transmission), the probability of encountering a hospital visitor with a COVID infection is a lot higher than encountering a waiter in a restaurant with a COVID infection.
  5. Healthcare workers who prefer to wear an N95 mask (but are not required) should be permitted to do so. Because of non-statistically significant trends in some studies suggesting a slight benefit of N95 over surgical masks, those healthcare workers who perceive greater safety with the N95 masks should be allowed to wear them if desired and if supplies permit.
  6. Healthcare workers who are required to wear N95 masks should be fit-tested annually. Because ill-fitting N95 masks lose most of their protective benefit, there needs to be assurance that the N95 mask that the worker wears actually does what it has the potential to do. It is reasonable for hospitals to also require fit-testing for those employees who want to wear an N95 mask but are not required to wear an N95 mask, especially if the hospital is paying for the masks.
  7. KN95 masks are an acceptable alternative to wearing a surgical mask but should not be used in clinical situations when N95 masks are required. Given the reduced effectiveness of KN95 masks compared to N95 masks, a KN95 mask cannot be viewed as equivalent to an N95 mask. It may, however, be better than a surgical mask.

What about outside of the hospital? At the grocery store or airport, I generally see only 5-10% of people wearing masks. At athletic events, that percentage is even lower. The risk of becoming infected in a public place is dependent on how likely you are to come in contact with someone’s exhaled viruses. That in turn depends on the prevalence of COVID infection in the community, the number of people in an enclosed space, the size of the enclosed space, the duration of time that you are in that space, the amount of singing or shouting in the space, and the ventilation of the space. Based on viral load studies, it does not matter whether an infected person in the space is symptomatic or asymptomatic. In situations when those variables indicate a higher risk of COVID, wearing a surgical mask is prudent. Those people who feel more secure wearing a KN95 mask or an N95 mask should do so.

As for me, N95 masks kept me from getting TB despite caring for patients with tuberculosis for decades. They also kept me from getting COVID infection despite intubating and performing bronchoscopy on COVID patients in our intensive care unit. My fit-tested N95 mask is sort of like a security blanket for me. So, I think I’ll keep wearing it in public areas for now. When the case rate gets below 50/100,000 population, I’ll reconsider. And when the case rate gets below 10/100,000, I’ll feel safe without any kind of mask in public.

December 2, 2022

Academic Medicine Medical Education

Results Of The 2022 Internal Medicine And Pediatric Subspecialty Fellowship Match

Yesterday, on November 30, 2022, the results of this year’s fellowship match for internal medicine and pediatric subspecialties was released. This is for fellowship positions that will begin in July 2023. Every specialty has its own fellowship match and the dates of the match results vary from as early as May the year before the start of fellowship (vascular surgery, thoracic surgery, pediatric surgery) to January the year of the start of fellowship (sports medicine, psychiatry). The internal medicine and pediatric match results are released at the end of November.

The results of all of the fellowship match results are made available in a report published by the National Resident Matching Program in March every year. Last year’s match showed that more physicians are subspecializing, fewer foreign medical graduates applied, certain subspecialties were very competitive (surgical and OB/GYN subspecialties) and certain subspecialties were less popular (most internal medicine and pediatric subspecialties).  Although we will not know the complete results of all subspecialty fellowship matches for several months, internal medicine and pediatrics represent the largest number of fellowship positions and so we can draw preliminary conclusions for yesterday’s match results in those subspecialties.

The terminology used in physician specialization can be confusing. As an example, internal medicine is a specialty and cardiology is a subspecialty within internal  medicine. This means that a cardiologist must first complete an internal medicine residency and then do further training in a cardiology fellowship. This post will focus on the recent subspecialty fellowship match results for the specialties of internal medicine and pediatrics.

Internal Medicine

Overall, there were 2,042 different programs participating in this year’s internal medicine subspecialty fellowship match and these programs offered a total of 5,779 fellowship positions. 82.1% of programs filled all of their positions and 89.5% of all positions in the country filled. These results are similar to last year. Of the physicians who did match, 46.8% were U.S. MD graduates, 13.5% were U.S. DO graduates, 12.8% were U.S. citizens who attended foreign medical schools, and 26.7% were foreign medical graduates. This is a slight decrease in the percent filled by U.S. MD graduates and a slight increase in foreign medical graduates compared to last year.

As in the past, certain internal medicine specialties were more competitive than others. Competitive programs are those that had a higher percentage of their total positions filled. The most competitive subspecialties were cardiology and interventional pulmonary that both filled 100% of their positions, followed by gastroenterology (99.8%) and hematology/oncology (99.7%). Three subspecialties filled fewer than 65% of positions: adult congenital heart disease (63.6%), transplant cardiology & heart failure (55.9%), and geriatrics (45.4%).

Two other subspecialties had relatively low fill percentages: infectious disease (74.4%) and nephrology (72.8%). These two subspecialties are concerning because their total number of fellowship positions is considerably higher than other low-performing subspecialties. There were 441 infectious disease fellowships offered and 493 nephrology fellowship positions offered compared to adult congenital heart disease (22 fellowship positions offered) and transplant cardiology & heart failure (127 positions offered). The implication of these results is that our country will face a much larger shortfall in the number of internal medicine infectious disease specialists and nephrologists in the future compared to other subspecialties.

A second way of determining the competitiveness of a subspecialty is by the percentage of positions filled by U.S. medical school graduates (MD). In general, most subspecialty fellowships are affiliated with medical schools offering MD degrees (as opposed to DO, or osteopathic, degrees). Historically, U.S. MD graduates tend to have an advantage over U.S. DO graduates, U.S. citizens graduating from foreign medical schools, or foreign medical school graduates who are not U.S. citizens. Subspecialties with the highest percentage of U.S. MD graduates filling available fellowship positions were adult congenital heart disease, gastroenterology, hematology & oncology, and interventional pulmonary. Pulmonary medicine had a very low filling percentage by U.S. MD graduates but there were only 27 total positions offered in 2022 since most physicians instead choose to do a combined pulmonary & critical care medicine fellowship (748 positions offered).

Graduates of U.S. osteopathic (DO) schools were most likely to fill pulmonary medicine-only fellowships or critical care medicine-only fellowships. But again, these fellowships offer very few available positions since most available positions are in combined pulmonary & critical care medicine fellowships. Geriatrics, infectious disease, and nephrology all had high percentages of U.S. osteopathic graduates.

U.S. citizens attending foreign medical schools account for nearly as many filled subspecialty fellowship positions as U.S. osteopathic graduates and followed a similar trend with a high percentage in pulmonary-only and critical care medicine-only fellowships followed by nephrology, interventional pulmonary, geriatrics, and endocrinology.

The final group of physicians filling positions in the 2022 internal medicine subspecialty fellowship match was non-U.S. citizens who graduated from foreign medicine schools (foreign medical graduates). Subspecialties with the highest percentage of positions filled by foreign medical graduates were endocrinology, pulmonary-only, and nephrology.


Overall, there were 919 different pediatric subspecialty fellowship programs that together offered 1,814 fellowship positions in the 2022 match for fellowships to start in July 2023. 74.9% of the programs filled and 84.7% of all positions were filled. Pediatric subspecialty fellowship positions were most likely to be filled by U.S. MD graduates (61.6%) followed by foreign medical graduates (14.8%), U.S. DO graduates (14.7%), and U.S. citizen graduates of foreign medical schools (8.8%). These percentages were unchanged compared to the previous year’s match. Compared with internal medicine, more pediatric subspecialty fellowship positions fill with U.S. MD graduates.

The most competitive pediatric subspecialty fellowships were gastroenterology, emergency medicine, and cardiology which all filled more than 97% of available fellowship positions. Similar to internal medicine, the least competitive subspecialties were infectious disease (49%) and nephrology (54%), as well as endocrinology (61%).

The pediatric subspecialties most likely to fill with graduates of U.S. medical schools were adolescent medicine, hospital medicine, and infectious disease – all of which filled 73% of positions with U.S. MD graduates. The least likely were transplant hepatology and endocrinology, each of which filled 50% of available positions with U.S. MD graduates.

Subspecialties with the highest percentages of graduates of U.S. osteopathic schools were child abuse (31%), gastroenterology (19%), and hospital medicine (19%). Subspecialties with the lowest percentage of U.S. DO graduates were infectious disease (5%) and rheumatology (4%).

There were only 135 U.S. citizen graduates of foreign medical schools who matched into pediatric subspecialty fellowships with the highest percentages in developmental-behavioral medicine (16%) and endocrinology (14%).

Foreign medical graduates had the highest representation in rheumatology (30%) and transplant hepatology (33%). They had the lowest representation in hospital medicine (1%).

Implications of the match

The overall trends of the 2022 match (for fellowships to begin in July 2023) are similar to the 2021 match. For both internal medicine and pediatrics, two subspecialties continue to be unpopular and had a high percentage of unfilled positions:  nephrology and infectious disease. In both pediatrics and in internal medicine, physicians in these two subspecialties have lower annual incomes than other subspecialties due to the current U.S. physician billing and reimbursement model. For internal medicine, these 2 subspecialties are also those with the highest percentages of foreign medical graduates filling fellowship positions.

The results of the match suggest that the United States will see an increasing shortage of both adult and pediatric nephrologists and infectious disease specialists. Pediatric endocrinology and adult geriatrics will also face physician shortages In order to attract these subspecialists, hospitals will need to subsidize their salaries as they are not able to generate competitive incomes by professional revenues alone. As these shortages become more severe, the clinical services provided by these subspecialists will need to increasingly be provided by primary care physicians and advance practice providers.

December 1, 2022

Physician Finances Physician Retirement Planning

End Of The Year 11-Point Financial Health Checklist

The end of the calendar year is the time to do a check-up of your personal finances and investments. As we enter December, there are a few important things to do in order to ensure that you are taking advantage of tax breaks, performing needed investment portfolio maintenance, and adapting your personal finances for inflation. Here is a short list of eleven tasks for your financial health to do before the end of the year.

Eleven point financial checklist

1. Do a “backdoor” Roth IRA.

I believe that everyone should have a Roth IRA as part of a diversified retirement portfolio. Unlike a traditional IRA, 401k, or 403b, once you put money into a Roth IRA, you never have to pay any taxes when you withdraw money from it. This allows you to withdraw money in retirement from different types of investments in order to take maximal advantage of your income tax situation in any given year of retirement. If your income is less than $129,000 (or $204,000 if filing a joint income tax return), then you can directly contribute to a Roth IRA using post-tax income. If your income exceeds these amounts, then you cannot directly contribute to a Roth IRA but you can do a “backdoor” Roth by first contributing post-tax income into a traditional IRA and then promptly doing an IRA conversion by transferring that money from the traditional IRA into a Roth IRA. For 2022, you can contribute $6,000 to an IRA if you are under age 50 and $7,000 if you are older than age 50.

The best time to do a backdoor Roth is when the stock market has fallen. Stocks inevitably go up and down – your goal is to buy stocks when the market falls so that you can make the most money when you sell those stocks in the future. Stocks have taken a real beating this year… and that is good for the long-term investor since this creates a buying opportunity. For example, the S&P 500 index has fallen 17% since January 1, 2022. By contributing to a backdoor Roth today, when the stock market eventually recovers to its January 2022 value, you will have made a 17% return!

In 2021, Congress proposed eliminating the backdoor Roth in the Build Back Better Act but the legislation died in the Senate leaving backdoor Roths alone for now. With the U.S. House of Representatives and the U.S. Senate now controlled by different political parties, the resultant gridlock makes backdoor Roth elimination in the next 2 years unlikely. However, predicting Congressional legislation is difficult so anything is possible. Nevertheless, now is the best time to do a backdoor Roth – when they are still legal and when the stock market is down.

2. Do a Roth IRA conversion.

If you already have money in a traditional IRA, then you can convert some (or all) of that money into a Roth IRA without doing a backdoor Roth conversion. There are 2 ways that you can contribute to a traditional IRA, with pre-tax income or with post-tax income. If your current annual income is less than $129,000 (or $204,000 if filing a joint income tax return), then you can contribute pre-tax income into the traditional IRA and then when you withdraw money from that traditional IRA in retirement, you pay regular income tax on the entire amount. If your current annual income is higher than these values, then you cannot contribute pre-tax income into the traditional IRA but you can contribute post-tax income into a traditional IRA. In this latter situation, your tax on withdrawals in retirement gets complicated – you do not pay income tax on the amount of money that you originally invested but you do pay income tax on the accrued value of the investment. This requires you to keep careful record of the amount of your contributions over the years and then do some mathematical gymnastics to calculate the percentage of any given year’s withdrawals that are taxed and not taxed.

I see no reason why anyone should put post-tax income into a traditional IRA and leave it there since you would have to pay income tax on the accrued value when you take withdrawals in retirement. If you had instead converted that post-tax money in the traditional IRA into a Roth shortly after making the original contributions to that traditional IRA (i.e., a backdoor Roth), you would never have to pay taxes on the withdrawals in retirement. So, if your traditional IRA is composed fully (or mostly) of post-tax contributions, convert that traditional IRA into a Roth now in order to minimize your taxes.

Traditional IRAs composed of pre-tax income are different and the decision of whether or not to convert these traditional IRAs into a Roth IRA requires some strategic financial analysis. Your overall goal is to pay the least amount in income taxes. When your traditional IRA is funded by pre-tax income, then when you convert money from that traditional IRA into a Roth IRA, you have to pay income tax the year that you do the conversion. In other words, that conversion to a Roth IRA counts as a withdrawal from the traditional IRA for income tax purposes. There are 2 situations when it is advantageous to do convert money from a pre-tax traditional IRA into a Roth IRA:

  1. When your income tax rate today is lower than your income tax rate in retirement. This is difficult to know with certainty since no one can predict what the income tax rates will be 30 years from now – tax rates go up and go down, depending on how much money the federal and state governments need to keep running. As a general rule, your income tax rate is likely to be lower when you are early in your career and higher after you have been working for 20-30 years. Therefore, doing a Roth conversion in your early working years is generally preferable to doing a Roth conversion later in your career.
  2. When the stock market is down. Since you pay regular income tax on any withdrawals from a traditional IRA that was originally funded with pre-tax income, you will pay less tax if you do a Roth conversion when the stock market has fallen and the overall value of the traditional IRA is lower. Then, when the stock market recovers, all of the accrued value will be in your Roth IRA and you will not have to pay income tax on it when you take withdrawals in retirement. Conventional wisdom is that when it comes to stocks, you should sell when the value of a stock is high. In order to minimize taxes when doing a Roth conversion it is just the opposite: sell (convert) when the value of the traditional IRA is low. Since the stock market is currently down 17% compared to January 1, 2022, now is a great time to do a traditional IRA to Roth IRA conversion in order to minimize the total amount of income tax that you will pay over the course of your lifetime. However, don’t forget that the amount of the conversion will add to your adjusted gross income for the year of the conversion and will result in an increase in your income tax rate that year. You will need to weigh the cost of the increased income tax rate against the benefit of the IRA conversion.

3. Contribute to a 529 plan.

The 529 college savings plans allow you to invest money today and then never have to pay any taxes when you withdraw money for college expenses in the future. Think of 529 plans as Roth IRAs for college savings. That tax-free feature of 529 plans make them an unbeatable tool to save for college and you can use the money to pay for college for yourself, your spouse, your children, or your grandchildren. There are several reasons to consider contributing to a 529 plan in December.

  1. Get a tax deduction. Each state has its own 529 plan and they all vary considerably with respect to their state income tax advantages. For example, here in Ohio, residents of the state can deduct the first $4,000 of annual contributions to an Ohio 529 plan. That tax deduction applies to each child’s account you hold so if you have 3 children, you can deduct $4,000 of annual contributions from each child’s account for a total of $12,000 state tax income deduction!
  2. The best time to contribute is when the market is down. The 529 plans are designed to be long-term investments. When you open an account at the birth of a child, that money will not be withdrawn for at least 18 years. The U.S. bond market is down 13% this year and the U.S. stock market is down 17%. This means that stocks and bonds are the cheapest that they have been in 2 years. Now is a time when you can “buy low”.
  3. They make great Christmas presents. I have a granddaughter who lives in a different state. Last year, I opened an Ohio 529 plan in her name when she was born. This year, we’ll contribute to her 529 plan for her Christmas present. Older children usually expect tangible stuff for Christmas but for toddler grandchildren, a 529 plan contribution is perfect. A Lego set will hold a kid’s attention for a couple of weeks but an education lasts a lifetime.

4. Maximize your deferred income retirement contributions.

In 2022, the maximum amount that you are permitted to contribute to a 401k, 403b, or 457 plan is $20,500 if you are younger than 50 years old and $27,000 if you are over 50. Some people (such as employees of state universities) can contribute to both a 403b and a 457. This can bring your annual contribution up to $41,000 ($54,000 if you are over age 50). If you have not yet contributed the maximum allowed amount this year, you still have time to do a one-time contribution in December to bring you up to the annual contribution limit.

In addition, this is also the time to change your monthly 401k, 403b, or 457 plan contributions. In 2023, the contribution limit to these plans will increase to $22,500 for people younger than 50 and $30,000 for people older than age 50. Be sure to get the contribution forms submitted to your human resources department now so that your monthly contributions increase in January.

5. Consider tax loss harvesting.

Tax loss harvesting is when you sell an investment that has lost value (capital loss) on in order to offset a profit that you make selling another investment that increased in value (capital gain). The amount of capital gains tax that you pay is the total of all of your capital gains minus all of your capital losses for that year. If you have more losses than gains, then you can take up to $3,000 of the excess losses and apply them as a tax deduction to your regular income tax. December is normally the best time to decide if selling an investment for tax loss harvesting makes sense and to determine how much of that investment should be sold to optimize your taxes. Because the stock market has fallen so low this year, many people have lost money on investments making tax loss harvesting a viable financial option for more people than in previous years.

There are a couple of important caveats to tax loss harvesting. First, the losses only apply when the selling price is lower than the purchase price. For example, the S&P 500 has fallen in value by 17% in 2022 but it increased in value by 27% in 2021. Therefore, if you bought an average stock on January 1, 2022, you would have a capital loss. But if you bought that same stock on January 1, 2021, you would have a capital gain if you sold the stock today, even though that stock lost value in 2022.

Second, tax loss harvesting is more of a capital gains tax-deferral strategy than a capital gains tax-reduction strategy. If you sell a losing stock today to take advantage of tax loss harvesting and then turn around and invest the proceeds of that stock sale into a second similar stock that has also lost value recently, then when that second stock eventually increases in value in the future, you’ll pay more capital gains taxes on the sale of the second stock because your capital gains will be higher. For example, say Ford and GM shares are always the same price. You buy shares of Ford in 2021 at $100 per share and then today, Ford has fallen to $80 per share. You then sell your shares of Ford for tax-loss harvesting purposes and turn around and buy shares of GM at $80 per share. In 2024, you sell your shares of GM at $120 per share. If you had held onto Ford until 2024, then you would have $20 per share in capital gains when you sold it in 2024. Instead, you would have $40 in capital gains when you sell the GM stock in 2024. In other words, tax-loss harvesting just postpones when you pay capital gains tax if you re-invest the proceeds of your investment sale.

Tax-loss harvesting can be to your benefit if you take the capital losses as an income tax deduction since most people’s federal income tax rate is higher than their capital gains tax rate. However, this can be tricky since you have to be able to estimate what your 2022 income tax rate will be in order to ensure that it is less than your capital gains tax rate. Also, many people forget that their mutual funds will usually have capital gains each year since the fund managers are constantly buying and selling the component stocks within that fund so even if you do not sell any of your shares of that mutual fund this year, you may still have capital gains from that mutual fund. You have to calculate what all of those mutual fund capital gains will be this year in order to be sure that your capital losses from tax-loss harvesting exceed those mutual fund capital gains so that you can apply those capital losses as an income tax deduction. And remember, the maximum income tax reduction from tax-loss harvesting is $3,000.

6. Optimize schedule A deductions.

The Tax Cuts and Jobs Act of 2017 increased the standard income tax deduction from $12,700 in 2017 to $24,000 in 2018 (married filing jointly). This reduced the amount of income tax that most Americans paid but it also eliminated itemized deductions for most Americans. The standard deduction for 2022 is $25,900 (married filing jointly). Therefore, you cannot make any itemized deductions unless those itemized deductions total more than $25,900. Itemized deductions can include charitable donations, mortgage interest & points, medical & dental expenses, and taxes paid (property, state, and local). However, the maximum amount of property and other taxes that you can apply to itemization is $10,000.

December is the time to estimate the amount of your itemized deductions. If those itemized deductions are close to your standard deduction amount ($25,900 if married filing jointly), then you may be able to increase your itemized deductions now so that those itemized deductions exceed the standard deduction amount. For example, you could make extra charitable contributions now rather than in 2023. Or, you could pay your next property taxes early, before December 30th. Or, you could buy the new eye glasses now that you had planned to wait until next summer to buy.

7. Contribute to an SEP.

An SEP (simplified employee pension plan) is a deferred income retirement account for self-employed people. Even if you have a regular employer but have a side gig doing consulting, getting honoraria, or selling artwork, you can open an SEP for the income that you earn from that side gig. The SEP allows you to invest pre-tax income and then pay taxes on the the withdrawals from the SEP when you are in retirement. In that sense, the SEP is functionally similar to a 401k, 403b, 457, or traditional IRA. Although you have until April 2023 to make contributions to an SEP for your income earned in 2022, it may be better to contribute to an SEP now, since the stock market has lost so much value recently – in other words, contribute to an SEP now, while stocks are “on sale”. You can contribute up to 25% of your total self-employment income and up to a maximum contribution amount of $61,000. December is a time that you should be able to reasonably estimate your total self-employment income for the past year and then calculate the amount that you can contribute to an SEP.

8. Review your beneficiaries. 

Every investment account should have a designated primary beneficiary and secondary beneficiaries in the event of your death. If you are married, the primary beneficiary will probably be your spouse. If you have children, they will probably be your secondary beneficiaries. By specifying beneficiaries on those investment accounts, you can make it faster for your family to access those funds in event of your death. Also, your heirs can avoid costly legal fees that would be incurred if no beneficiaries were listed and the accounts need to go through probate court. For most investment companies, you can do this quickly and easily online.

9. Rebalance your portfolio.

This has been a wild year for investors. The bond market is down, the stock market is down more, and real estate is down even more. Meanwhile, inflation is reducing the value of fixed income pensions and increasing the interest rates on certificates of deposit. The net result is that the relative percentages of stocks, bonds, real estate, and cash in most people’s investment portfolios has changed significantly since January.

Now is the time to rebalance those portfolios to ensure that the percentage of each type of investment is at its desired amount. For example, since real estate investments have fallen more than stocks, you may need to sell some shares of your stock mutual fund and buy some shares of a real estate investment trust (REIT) fund to rebalance. Since stocks have fallen in value more than bonds, you may need to sell some shares of your bond mutual fund and buy some shares of a stock mutual fund. Rebalancing not only ensures that your portfolio has a healthy diversification but it also results in you “selling high and buying low” in order to maximize your overall returns.

10. Increase disability and life insurance policy amounts.

The U.S. inflation rate has risen with the result that the consumer price index has increased 13% over the past two years. In other words, you need 13% more money today to buy the same amount of stuff you bought in 2020. However, most disability insurance policies and life insurance policies have not changed their values. The $100,000 life insurance policy that you bought in 2020 would only be effectively worth $87,000 in today’s money. December is a good time to critically evaluate those policies to see if the payout amounts are still appropriate – in many cases, you may need to increase those amounts to ensure that should you become disabled, you will still have enough money to live on. Or, should you die, your family will still have enough money to live on.

11. Update next year’s budget.

Inflation does not affect everything you buy equally. For example, for the 12 months ending in October 2022, the price of food was up 10.9%, gasoline was up 17.9%, new cars were up 8.4%, and clothes were up 4.1%. This means that the amount that you budgeted for all of these items a year ago has changed. Each family’s inflation is a little different. So, although housing costs nationwide are up 11%, if you bought your house a year ago and have a fixed monthly mortgage, then your housing costs may not have gone up at all. Similarly, if you heat your house with electricity, your energy costs went up 14.1% in the past year but if you heat your house with fuel oil, your costs went up 68.5% in the past year.

To prepare next year’s budget, start with your credit card statements. Most credit card companies will divide each of your purchases into different categories, for example, groceries, transportation, housing, utilities, etc. You can often do the same with your checking account. This will give you a reasonable idea of where you spent your money over the past year. You can then use the Bureau of Labor Statistics Consumer Price Report to estimate how much each of those categories will need to be increased for your next year’s budget. Keeping to that budget ensures that you will have enough cash to pay off your credit cards and loans each month without dipping into your cash emergency fund.

Your annual financial checkup should be in December

The end of the year is the best time to do your annual financial checkup. By December, you should have a good idea of your total 2022 income and know whether you are likely to get a raise next year. Retirement account contribution limits usually change in January giving you the opportunity to change your monthly contributions. Also, you should be able to estimate how much you can spend  this year on charitable contributions, 529 account contributions, IRAs, and SEPs. The best way to start the new year is to finish the old year on solid financial ground.

November 30, 2022

Emergency Department Intensive Care Unit

A Better Way to Defibrillate Patients In Cardiac Arrest?

I have taken the American Heart Association’s Advanced Cardiac Life Support (ACLS) certification/recertification course every 2 years since 1983. That’s 20 times since medical school. The resuscitation algorithms have changed dramatically over the past 39 years and based on a new study, it may be time to change them once again.

Summary Points:

  • Currently, defibrillation is performed using 2 electrode pads located in the upper right chest and lateral left chest.
  • Vector-change defibrillation is performed using 2 electrode pads located in the left anterior chest and left posterior chest. In a recent study, vector-change defibrillation was superior to standard defibrillation in patients in refractory ventricular fibrillation.
  • Double-sequential external defibrillation is performed using 2 defibrillators, each attached to 2 electrode pads located on different parts of the chest. Double-sequential external defibrillation was superior to either standard defibrillation or vector-change defibrillation in patients with refractory ventricular fibrillation


In 1984, every patient in ventricular ventricular fibrillation got lidocaine and sodium bicarbonate as first line medications. The second line antiarrhythmics were quinidine, procainamide, and bretylium. Amiodarone was not yet in use. The current ACLS algorithm for ventricular fibrillation is much simpler. In addition to CPR, patients receive electrical defibrillation every 2 minutes, epinephrine every 3-5 minutes, and amiodarone if sinus rhythm is not restored within the first 6 minutes.

For decades, defibrillation has consisted of placing 2 electrode pads on the patient’s chest – one just below the right clavicle and the other just below and lateral to the left nipple. Then, a single shock of 300 or 360 joules is delivered followed by resumption of chest compressions. A new Canadian study published in the New England Journal of Medicine suggests that there may be a better way to do electrical defibrillation. In the study, 405 patients with out-of-hospital cardiac arrest with refractory ventricular fibrillation were randomly assigned to receive one of three different defibrillation techniques. All patients had an initial three defibrillation attempts using standard defibrillation technique with each attempt occurring 2 minutes after the previous attempt. Patients remaining in ventricular fibrillation were considered to have refractory ventricular fibrillation and were eligible for inclusion in the study. The three salvage defibrillation techniques consisted of (1) standard defibrillation, (2) vector-change defibrillation, or (3) double-sequential external defibrillation.

  1. For standard defibrillation, the electrode pads are located in the traditional locations: one pad below the right clavicle and the other pad on the lateral part of the left chest, just below the left nipple. After the initial 3 defibrillation attempts, all additional attempts occurred with with the pads located in their original position.
  2. For vector-change defibrillation, the pads were re-located with one pad on the anterior chest just below the left nipple and the other pad on the posterior chest, just below the scapula and just left of the spine.
  3. For double-sequential external defibrillation, the two standard pads are left in place and two additional pads are placed with one pad on the anterior chest between the sternum and the left nipple and the other pad on the posterior chest, just below the scapula and left of the spine. With this technique, 2 shocks are delivered within 1 second of each other with the first shock via the anterior/lateral pads (in red on the adjacent figure) and the second shock via the anterior posterior pads (in blue on the adjacent figure).

The primary outcome of the study was survival to hospital discharge and the findings were statistically significant. For patients receiving salvage defibrillation via the standard technique, only 13.3% survived to hospital discharge. For those receiving salvage defibrillations via the vector-change technique, 21.7% survived to hospital discharge. And for those receiving salvage defibrillations via the double-sequential external defibrillation technique, 30.4% survived to hospital discharge. The double-sequential external defibrillation was also superior to the other techniques in terminating defibrillation, achieving return-of-spontaneous-circulation, and modified Rankin scale score (a measure of neurologic disability).

As with all clinical trials, there are limitations to the study. It included only out-of-hospital cardiac arrest patients so it is not clear whether similar results would be achieved in patients arresting in the hospital. It was not a blinded study so it is possible that the EMS personnel could have had unconscious bias in their resuscitation efforts. The number of patients was relatively small so it is possible that larger studies may not achieve the same results. The post-arrest care received in the hospitals was not protocoled so there may be differences in targeted-temperature management, cardiac catheterization management, sedation, mechanical ventilation, etc. Because all patients had 3 initial attempts at standard defibrillation before randomization, it is unclear whether either vector-change defibrillation or double-sequential external defibrillation is superior to standard defibrillation as an initial defibrillation technique. Lastly, it is unclear whether the results can be extrapolated to other tachyarrhythmias such as ventricular tachycardia, atrial fibrillation, or supraventricular tachycardia.

Implication for hospital care

So, what does this mean for physicians responding to cardiac arrests in the emergency department, intensive care unit, and hospital nursing units? It is unlikely that the American Heart Association will change the ACLS algorithm for ventricular fibrillation management in the immediate future. However, the study does at least indicate that when patients do not respond to initial defibrillation efforts, we have two other options that we can try.

Vector-change defibrillation is the easiest technique to implement since it simply requires moving the existing defibrillator pads to different locations. Double-sequential external defibrillation may be more challenging for hospitals to implement since it requires the use of a second defibrillator. In addition, although vector-change defibrillation can be performed using an automated external defibrillator (AED), double-sequential external defibrillation cannot be performed using an AED.

When a patient is in refractory cardiac arrest and is not responding to usual advanced cardiac life support measures, physicians may find themselves in a position of having nothing to lose by trying alternative defibrillation techniques. In this situation, vector-change defibrillation or double-sequential external defibrillation may be worth a try.

November 28, 2022

Hospital Finances

How Do Hospitals Make New Equipment Purchases?

New technology is constantly improving healthcare delivery to patients. But new technology is expensive, whether it is a new MRI machine, a new surgical robot, or a new hip replacement implant. The processes that hospitals use to choose new equipment, supplies, and technology are complicated and hospitals can seem impenetrable to manufacturers new to the market.

Each hospital is different but in general, the more expensive an item, the more layers of approval are required. At the highest level of approval is the hospital board of trustees (or board of directors). These boards are largely comprised of non-physicians who bring outside expertise in business, finance, law, and community engagement. Decisions about new property purchases, new building construction, and major renovation will be made at the board level. These are decisions that involve long-term strategic planning for the hospital.

The next highest level of approval is the hospital CEO who generally makes decisions about major capital purchases, clinical program expansion, and moderate-sized renovation. Although the items approved by the CEO often require approval by the hospital board, most of the time, the board approval is merely a formality and the board generally accepts the recommendation of the CEO.

The next level of approval is the hospital administrative director. For medical centers with multiple hospital facilities, there may be separate administrative directors for each hospital, all reporting to the CEO. For smaller hospitals, the administrative director and the CEO are the same person. At this level, decisions are made about minor equipment purchases, minor renovation, and supply vendors.

The lowest level of approval is the individual unit managers. This can be the nurse manager of a patient care ward, the operating room manager, the emergency department manager, radiology manager, pharmacy manager, etc. These managers will typically make decisions about hiring and termination of individual staff and can make decisions about minor supply and equipment purchases, although such purchase decisions may require final approval by the hospital administrative director.

Academic hospitals can be even more complicated with the dean of the medical school and the department chairs having variable influence in the purchase decisions of the hospital. Some hospitals or medical centers will have a chief operating officer and/or a chief administrative officer in addition to a chief executive officer. Many hospitals will have a chief technology officer who can also influence purchase decisions. This variability in organizational structure from one hospital to another can result in vendors (and often the hospital’s physicians) being unsure who is ultimately making decisions.

Hospital medical directors generally do not have final approval authority for major purchases but they do have a great deal of influence in those purchases. Frequently, the clinical need for a new renovation, a new piece of equipment, or a new line of supplies will be initially identified by the physicians who then express those needs to the medical director who in turn makes recommendations to the administrative directors or to the CEO.

Understand the budget cycle

Every new purchase must fit somewhere into the hospital’s budget. Once again, every hospital is a bit different but budgeted purchases generally fall into one of three categories: major capital purchases, minor capital purchases, and annual discretionary spending. Each of these categories will appear on the hospital’s annual budget. Academic hospitals run on a budget calendar that is aligned with its university’s academic calendar, usually July through June. Non-academic hospitals more commonly run on a January through December business calendar.

For every hospital, there is an aspirational budget timeline and a reality budget timeline. Hospitals will aspire to start the budget process on the first day of the new business year and aspire to have final approval of the budget by the board of trustees or board of directors several months before the start of the next business year. The reality is that this rarely happens and the budgets often do not get final board approval until the last minute, and sometimes not until after the start of the next business year. A realistic budget timeline is as follows:

6-months before the start of the business year. The budget process generally begins about 6-months prior to the start of a new business year. For academic hospitals, this is January and for non-academic hospitals, this is July. At this time, the hospital will ask for budget item requests for the next year. Requests can come from a variety of people including unit managers, the medical director, or individual physicians. The requests will include the estimated cost of each item. Simultaneously, the hospital will begin estimating the amount of revenue that it anticipates in the next business year based on projected patient volumes.

4-months before the start of the business year. After all of the requests for new personnel positions, new equipment purchases, and space renovation have been received, the hospital administrative director must prioritize these requests. In some hospitals, the administrative director has unilateral prioritization power but more commonly, there will be a core group of hospital leaders who will prioritize the requests by consensus. Again, all hospitals are different but the core group may consist of the medical director, nursing director, hospital chief financial officer, assistant administrative director, etc.

3-months before the start of the business year. Once requests have been prioritized, the request list then goes to the hospital CEO. In larger health systems and medical centers with multiple hospital facilities, there may be multiple request lists submitted from each of the hospital locations. The CEO must then create a master prioritization list comprised of budget item requests from all of the various medical center locations. This is generally done by having a group of high-level leaders vote on each of the budget items. This group may consist of individual hospital administrative directors, the health system’s CEO & CFO, the health system’s chief administrative officer, the health system’s chief medical officer, and the health system’s chief nursing officer. It is generally the CEO’s and CFO’s responsibility to determine how much money can be allocated for capital purchases for the upcoming year. Once that amount is determined, the prioritized items are approved by their rank until the total budgeted amount for all capital purchases is reached.

2-months prior to the start of the business year. Once the proposed budget is created by the CEO and CFO, it is then submitted to the hospital board for final approval. Once approved, the hospital administrative directors and unit managers are empowered to proceed with purchasing contracts, utilizing the hospital’s purchasing department and supply chain department.

The hospital administrative directors are also given an amount that they can use for discretionary purchases during the upcoming business year. In general, the hospital board will not want to be bogged down having to approve every new colonoscope for the endoscopy suite and every new instrument tray for the operating room. Therefore, hospitals will create a “threshold amount” above which requires approval by the board on the annual budget and below which is left to the discretion of the hospital administrative directors and the unit managers. It is up to them to decide the prioritization for these items that are below the threshold amount. The value of the threshold can vary from hospital to hospital and from year to year. Some amount is always held out for emergency purposes, for example to replace a broken ultrasound machine in mid-year.

Vetting new equipment and technology

Every item on the hospital’s capital budget has to be justified. “Because I want one” is not reason enough to buy a new surgical robot for a surgeon or to buy a new gamma knife machine for a radiation oncologist. For some items, the vetting process takes place at a committee level. For example, the decision about whether to stock a new drug for inpatients is commonly made by the pharmacy and therapeutics committee. The decision about whether to change to a different brand of suture is commonly made by the operating room committee. Many hospitals will have a “new technology committee” or similar committee to weigh the cost and benefits of new equipment prior to proposing that item of equipment on the next year’s budget. The biomedical engineering department usually needs to sign-off on proposed purchases to be sure that the item is compatible with the infrastructure of the hospital. There are several factors that are considered in this vetting process.

  1. Does it do what they say it will do? One of the catch phrases in healthcare is “evidence-based medicine”. This generally means having publications in medical journals proving that a piece of equipment is safe and effective – preferably from a randomized, double-blind study.
  2. Does it improve patient care? Hospitals are in the business of improving the health of patients. Does the new equipment provide a more effective cure for disease? Reduce the risk of a patient dying? Relieve patient suffering?
  3. Will it save money? For example, if a new chemistry analyzer uses less reagents and requires less manpower to operate, it can reduce the clinical lab’s costs to perform chemistry tests. If the analyzer costs $600,000 but will lower operating expenses to perform tests by $700,000 every year, then it saves money.
  4. Will it bring in new income? For example, by purchasing a hyperbaric oxygen chamber, the hospital’s wound center would be able to begin billing for hyperbaric wound treatments. This represents a new billing opportunity for the hospital.
  5. Has a fair market analysis been performed? Radiation therapy machines are not reviewed by Consumer Reports or Wire-Cutter. It can be difficult for hospitals to know whether the price they are being quoted is fair. Sometimes, it takes calling leaders at other hospitals to find out what they paid for similar equipment.
  6. What is the cost of consumables? For example, does a new laboratory analyzer require that the lab switch to more expensive reagents? Or, does a new surgical robot require the robotic instrument arms to be replaced  with new arms after a certain number of uses? What about the cost of cleaning and storage? These are all hidden costs that can make a seemingly inexpensive piece of equipment be quite expensive in the long run.
  7. Does it improve patient safety. For example, a new point-of-care ultrasound in the intensive care unit may not bring any new revenue to the hospital but by using it, the physicians can perform central venous catheterizations with fewer complications. This can translate to better metrics on publicly reported safety measures and reduced costs of treating those complications.
  8. Does it improve patient experience? For example, if a program to purchase hand-held tablets for inpatients to use to access their medical record and to view health instruction videos improves patient satisfaction, that can result in higher scores on the HCAHPS survey.
  9. Does it improve staff satisfaction/safety? For example, if new security cameras in the parking lot make staff feel safer going to and from their cars at night, this can create greater satisfaction and improve the hospitals workplace-of-choice ratings. As a result, it can be easier for the hospital to attract new employees.
  10. Does it integrate with the hospital’s IT system? For example, a point-of-care ultrasound device that can directly upload ultrasound images into the hospital’s electronic medical record has greater value than one that requires images to be printed and then scanned into the EMR.
  11. Does it allow the hospital to provide a unique service? For example, if a no other hospital in the area has a surgical robot, then by purchasing one, the hospital can promote its robotic surgery program as an example of its use of cutting edge technology to differentiate it from other the other hospitals in advertising campaigns.
  12. Does it reduce length of stay? For example, if a new model of a mechanical ventilator allows patients with respiratory failure to be extubated 1 day faster than the previous ventilators, then patients will have a lower ICU length of stay, thus reducing the hospital’s cost to care for those patients.
  13. Does it improve operational efficiency? For example, purchasing “workstations on wheels” that nurses can take into different patient rooms to do charting (rather than charting at desktop workstations in a central charting area) can improve nursing efficiency.
  14. Does it replace personnel? For example, if a central video monitoring system eliminates the need for individual one-on-one sitters for confused or suicidal patients, then one staff member can do the work of several, thus reducing personnel costs.
  15. Does it avoid a disruption in patient care? For example, when remodeling our cardiac catheterization lab, we leased a mobile catheterization lab housed in a trailer that we placed in the hospital parking lot. This allowed us to continue to do cardiac catheterizations on inpatients during the months that the regular cath lab was closed down.
  16. Is the vendor reliable? For example, in the past, as the manufacturer provided good customer service? Timely installation? Prompt repairs?
  17. Are there additional downstream costs? For example, if a new cardiac MRI machine requires the hospital to recruit and hire a new technician trained in using the machine and hire a new cardiologist who has done a cardiology MRI fellowship, there can be considerable costs over and above the machine itself.
  18. What are the environmental specifications? For example, do the temperature and humidity thresholds require modifications of the HVAC systems in the area that the equipment will be located in? New alarm sensors? New electrical wiring? Higher water pressure? This is where the hospital’s clinical engineering department can be helpful.
  19. Is the manufacturer willing/able to guarantee profitability? For example, if a new software program for patient bed placement advertises that it can reduce waiting times in the emergency department for patients being admitted, is the company willing to reduce the price of the software if the promised waiting time goals are not met?
  20. Who pays for maintenance and repair? For example, colonoscopes frequently break and need to be repaired – will the manufacturer cover these repairs or does the hospital have to purchase a separate, expensive repair contract? Does the manufacturer supply loaner colonoscopes when a colonoscope is out for repairs?
  21. Does the manufacturer provide staff training? For example, a surgical robot requires not only specialized physician training but also specialized training for surgical assistants. A manufacturer that provides free training and certification courses or on-site training can save the hospital money in the long run.

In a disaster, the purchasing rules change

Budgets are fine when the future goes as planned but when the unexpected happens, the normal purchasing process is too laborious. Fires, floods, tornados, pandemics, and other natural or man-made disasters require immediate acquisition of equipment, supplies, and other resources. For example, when the COVID pandemic hit, our hospital had to acquire a mobile outdoor drive-up testing unit that was made from a converted transportation container and we also had to purchase new lab analyzers to perform hundreds of COVID tests each day. When a broken water pipe flooded our kitchen, we had to lease a mobile kitchen trailer that we parked by the loading dock to prepare inpatient meals. These were purchases that needed to be completed and installed within hours or days and that could not wait until the next month’s board of trustees meeting. Sometimes these expenses are eventually covered by insurance but frequently the hospital has to draw from its “days cash on hand” funds to cover costs. These funds are held as emergency resources to cover expenses that cannot be covered by the much smaller amount budgeted for more minor emergency expenses on the annual budget.

Decisions about these emergency purchases are generally made by the hospital executive director, CEO, or CFO. With no time to go through the usual channels, the decision is often based on recommendations from individual physicians or staff members. Frequently, hospitals will have a “disaster team” to manage the hospital’s response to a disaster. Equipment and technology purchase recommendations will often be channeled through the disaster team to the administrative leader who is authorized to make those purchases.

The Joint Commission requires hospitals to perform at least 2 emergency response exercises (disaster drills) every year. I have participated in dozens of of these exercises over the past 3 decades. Each disaster drill simulates a different scenario. We have had a simulated plane crash at the Columbus airport, a simulated bombing at the state fairgrounds, simulated  terrorist mass shootings, a simulated tornado striking downtown, and simulated communicable disease outbreaks. In an ironic twist of fate, we had a simulated “super-flu” outbreak for an emergency response exercise 2 years before the COVID pandemic – it is eery just how closely the simulation foreshadowed the actual pandemic. During these simulations, the disaster teams ask themselves questions such as: what would we do if we needed… a portable morgue, 30 additional mechanical ventilators, 50 additional ICU rooms, or 5 more operating rooms? From these disaster drills, hospitals compose lists of equipment and vendors so that in the event of a true disaster situation, the hospital already knows who to call.

What can the hospital do when it cannot afford to purchase a new item?

Advances in medicine and technology happen at break-neck speed. Just like personal computers, automobiles, and cell phones, next year’s medical device models promise that they can do more and do better than last year’s models, whether that device is a CT scanner, a bronchoscope, a surgical robot, or a telemetry monitor. When the hospital decides it really needs one of these items but cannot fit it into next year’s budget, there are options.

  1. Negotiate a better price. Member-based supply chain analytic organizations can provide data on equipment pricing and can allow for group purchasing. For example, Vizient, Inc. is an organization whose members include 97% of academic medical centers and more than half of all U.S. acute care hospitals. Vizient member hospitals can benefit by purchasing equipment and supplies from vendors using Vizient-negotiated prices.
  2. Rent it. There are a number of ways to acquire the use of equipment without buying it outright. There are lease-by-month/year contracts, lease-to-own contracts, and pay-per-use contracts. An advantage of these options is that the annual cost of the equipment will then often fall below the annual budget “threshold amount” and thus give the hospital administrative director latitude to acquire the equipment without having to go through higher authorities.
  3. Buy used. Many times refurbished used equipment can adequately fill the clinical needs of the hospital. This can be especially true if the equipment will be only intermittently used.
  4. Buy last year’s model. When the next year’s cars come out, car dealers discount the previous year’s models to clear their lots. Medical equipment manufacturers do the same thing. Frequently, the new model of a piece of equipment will have features that are not essential to the clinical needs of the  hospital and the previous year’s model will suffice at a lower cost.
  5. Depreciate accurately. Knowing the life expectancy of a piece of equipment is essential in determining its true cost. For example, a CT scanner that costs $1.2 million that can be depreciated over 10 years is less expensive in the long run than  CT scanner that costs $1 million but is depreciated over 5 years.
  6. Get a demonstration unit. As a medical director, I was frequently asked by a physician to buy a particular piece of equipment. If that physician is particularly eloquent, particularly vocal, or particularly influential, then I was not always sure if the hospital really needed that piece of equipment. That concern can often be settled by arranging for the equipment to be brought in for a demonstration period by the vendor to determine if the equipment would really be used as much as was said. This can avoid making costly purchases of devices that go unused. Several years ago, one of the physician groups at our hospital insisted that they HAD TO HAVE a $500,000 piece of equipment in order to provide standard of care services. They gave me projections on the annual number of procedures that they would use it for and how many years it would take the hospital to recoup the investment. I successfully lobbied senior leadership and the hospital purchased the equipment. Four years later, that physician group had not used the equipment a single time and I’ve regretted that purchase ever since.

Hospital purchases are unique

Major equipment purchases made by hospitals are different from purchases made by other organizations, companies, or individuals. The value of a piece of equipment is judged differently than in any other industry. Benefits in patient length of stay, hospital throughput, and patient satisfaction from equipment or technology can often be just as valuable as increased revenue from equipment or technology. Moreover, physicians have considerably more clout than rank and file employees in other organizations or companies. Knowing how to define the true value of equipment or technology is the key to making wise and informed purchases.

November 11, 2022


Am I Weird If I Still Wear A Mask?

I am in an increasingly small minority of Americans who still wear face masks in public indoor areas. And I feel increasingly self-conscious when I’m the only person wearing a mask. But should I feel that way?

I realized that something had changed when I attended the annual American College of Chest Physicians meeting in Nashville last week. When I preregistered a few months ago, I had to attest online that I agreed to wear a mask at all times while attending convention events. When got to the meeting last week, the instructions had changed to “masks are recommended”. In the meeting rooms, I kept track – overall, only 5% of attendees wore a mask. I’m used to this percentage of mask-wearers at the grocery store but at the meeting were hundreds of the country’s pulmonary and critical care physicians who are more intimately familiar with the danger and transmissibility of COVID-19 than any other segment of the U.S. population. Except while delivering a lecture, I wore an N-95 mask the entire time but could not help to think “Does everyone think I’m weird?“.

During the first year of the pandemic, I spend endless hours caring for critically ill COVID patients in our ICU. I intubated them, performed bronchoscopy on them, and pronounced them dead. Back then, everyone wore a mask – in the hospital, in the grocery store, in the airport. And masks worked. Unlike the majority of Americans, I have made it this far through the pandemic without getting infected. I was even part of a CDC prospective study of high-risk healthcare workers and had to get serial blood antibody tests to determine if I got infected caring for COVID patients. All of the tests were negative. When vaccines became available in December 2020, I got my first vaccination at 7:00 AM the first day they were available. And I’ve gotten all 3 booster vaccinations in the first week that they were offered. Other than being 64-years-old, I have no risk factors for severe COVID. So, you’d think I’d be ready to go back to life as it used to be, without face masks.

The thing is, I just don’t want to get COVID.

Yes, I realize that the chances of me dying if I get infected are pretty slim. But they are not zero and besides, there are a lot of other unpleasant complications of COVID that I’d just as soon avoid.

Just because you’re vaccinated doesn’t mean COVID can’t kill you

The COVID vaccines we now have are great. But like most vaccines, they are not perfect. Data from the CDC shows that in August 2022, people who had the primary vaccine series plus 2 or more boosters were 12-times less likely to die of COVID than unvaccinated people. But still, 1 out of every 200,000 Americans died of COVID that month despite being fully vaccinated and boosted. To put that in perspective, if you are vaccinated, you are still 1,500-times more likely to die of COVID than to win the Powerball lottery.

A relative commented to me recently that “COVID is no worse than the flu“. Unfortunately, it is actually worse… much worse. In a typical season, about 25,000 Americans die from influenza. In 2021, 463,000 Americans died from COVID. In other words, Americans were 18-times more likely to die of COVID than die of influenza. And that was despite strict social distancing, masking, school closures, and work-from-home initiatives in 2021. This graph shows the annual deaths from influenza (blue) compared to deaths from COVID (gold).

COVID causes assorted badness other than death

Last month, I was surf fishing in North Carolina. I got to talking to a fellow fisherman who as a chiropractor in his late 60’s who had a bout of COVID shortly after returning from a trip to Ireland. He was fully vaccinated and boosted but still felt wiped out for several days. Weeks later, he still could not taste or smell anything. Personally, I like to taste and smell. I like to be able to tell the difference between a pice of unseasoned tofu and a medium-rare lamb chop. I enjoy a Mendocino pinot noir a lot more than a bottle of Two-Buck Chuck. I don’t want to give those things up. A study from JAMA this summer found that 56% of people infected with COVID have some loss of taste and smell at the time of initial infection. Of those affected, 12% still had loss of taste and smell 2 years after infection. Although the newer variants of COVID are less likely to affect taste or smell than the original COVID, 44% of those infected with Delta and 17% of those infected with Omicron had loss of taste and smell.

Patients experiencing long COVID symptoms have now become common in primary care practices. A study from this month’s JAMA looked at 1.2 million people infected with COVID and found that 6.2% of people have long COVID symptoms – persistent fatigue in 3.2%, persistent respiratory symptoms in 3.7%, and cognitive dysfunction in 2.2%. The average duration of long COVID symptoms was 9 months in those who required hospitalization for their COVID infection and 4 months for those who did not require hospitalization. However, 15% of people with long COVID had symptoms lasting more than 1 year. It seems to me that wearing a mask is a small price to pay in order to avoid fatigue, shortness of breath, and brain fog.

Although vaccination greatly reduces the chance of severe COVID requiring hospitalization or ICU care, breakthrough infections are common in vaccinated people as well as those with immunity from previous infection. A study in the New England Journal of Medicine found that breakthrough infections in vaccinated people typically caused fever, muscle aches, loss of taste/smell, and cough. These symptoms lasted more than 14 days in 31% of people and 23% of people had to take off more than 10 days of work due to symptoms. In short, it is no fun to have a breakthrough COVID infection even though you will probably survive it.

The CDC’s COVID dashboard indicates that the number of COVID cases in the U.S. is falling – only 260,000 new infections were reported last week – down from 5.6 million new cases nine months ago during the third week of January 2022. However, the current prevalence numbers underestimate the true number of new covid infections because many people either choose to not be tested or test themselves using over-the-counter COVID home tests. Either way, these cases do not get reported to local public health departments and are thus not included in the CDC’s data. The bottom line is that tens of thousands of Americans are still getting COVID infections every day.

The social pressures to wear masks

The psychology of masking and unmasking is complex and was nicely described in an essay by blogger JTO, PhD. The various psychological concepts that contribute to people disliking masked people when they themselves are not wearing masks include cognitive dissonance, confirmation bias, psychological reactance, and hostile attribution bias. The net effect of these is strong peer pressure to conform when those around you are not wearing masks.

Social psychologist Dr. Wendy Treynor has proposed a theory of peer pressure called “identity shift effect”. According to this hypothesis, a person’s internal harmony is disrupted a person fails to conform to a group standard resulting in a threat of social rejection. In order to eliminate this threat, the person changes their behavior to conform to the group but in doing so, causes internal conflict because that person has now violated their own code of conduct. To eliminate this internal conflict, the person undergoes an “identity shift” and adopts the group’s standards as their own, thereby eliminating internal conflict and restoring internal harmony. The net result is that the person adopts a new attitude.

For example, if you go to a restaurant wearing jeans because you don’t like getting dressed up and everyone else in restaurant is wearing an evening dress or a suit, you will experience a great deal of psychologic disharmony. The next time you go to the restaurant, you wear a dress or a suit in order to avoid the disharmonious feelings, even though in the past, you didn’t like wearing formal attire.

As human beings, we strive to be accepted by groups of other people. Even non-conformists are often trying to conform to the behavior of other non-conformists to prove that they are just as much of a non-conformist as the other non-conformists.

When you wear a face mask in a store full of unmasked customers or in a church full of unmasked parishioners, you start thinking: “Do they think I’m weak?” or “Do they think I’m a coward?” or “Do they think I’m the one who is contagious?” Fortunately, wearing a mask is not as much of a violation of social norms as wearing a MAGA hat to an ACLU convention or wearing a Cincinnati Bengals jersey in a Pittsburgh sports bar. But nevertheless, there is increasing peer pressure to take one’s mask off.

The advantage of being old

One of the wonderful things that happens when you retire is that you now have the luxury of doing what you want to do rather than what everyone else is doing. Even so, I find myself sometimes apologizing for wearing a mask when no one else is. I’ll sometimes offer up excuses such as “Sorry, I worry too much because I’m a senior citizen” or “I’m going to visit my pregnant daughter and don’t want to risk exposing her“. Most people who I pass in a store or airport just think I’m weird. But I can live with that because I plan to enjoy a healthy life for many more years. Life is just too short to waste days or weeks of it being sick. So, I’m OK with being weird.

October 28, 2022


Is Natural Immunity Better Than Vaccination Immunity Against COVID?

There are two ways to become immune to COVID-19: either from previous infection (natural immunity) or from vaccination. But is one better than the other? Many people believe that anything “natural” is better than “artificial” and consequently some pundits, influencers, and bloggers advocate for for natural immunity over vaccination immunity. The COVID Nationwide Antibody Surveillance Survey reported that by February 2022, 58% of Americans had been infected with COVID-19 and thus have some degree of natural immunity. The most recent CDC vaccination data shows that 80% of Americans have received at least 1 dose of a COVID vaccine and 68% have received 2 doses with resultant vaccination immunity. Therefore, most Americans have some degree of immunity one way or the other. Employers and governments are now grappling with whether to mandate vaccination or proof of previous infection as workers return to in-person workplaces.

Summary Points:

  • Viral infection and vaccination stimulate the immune system differently.
  • Either type of immunity is better than no immunity.
  • People with natural immunity from past infection can improve their immunity by getting vaccinated


Immunology 101

At the risk of oversimplification, there are two main components of our immune systems – cellular and humoral. Cellular immunity involves T-lymphocyte cells that help fight infection. Humoral immunity involves immunoglobulins (antibodies) that help fight and prevent infection; immunoglobulins are produced by B-lymphocytes. There are five types of immunoglobulins but the three types that are most important for preventing viral infection are IgG, IgM, and IgA. All three of these types of antibodies can be found in the bloodstream but mostly IgA is found on the surface of respiratory cells, such as in the mucus that lines the airways and nasal passages.

When a person gets infected with a virus, the virus uses special molecules on its surface that can bind to cells and then slip inside those cells. These surface molecules are like keys that open the cells allowing the virus to get in. Once inside of a cell, the virus takes over the cell and causes the cell to start to manufacture thousands of copies of the virus (its like what happened to people in the movie Alien). The cell then dies and releases all of the newly manufactured viruses that can then infect more cells.
CNX OpenStax, CC BY 4.0 <>, via Wikimedia Commons

Once infected with a virus, the body’s immunologic response is to create antibodies to pieces of the virus. Antibodies first start to be produced by B-lymphocytes 5-7 days after an infection with the first antibodies being IgM. Within days to weeks, some of the B-lymphocytes switch to making IgG plus IgM antibodies and the levels of IgM antibodies quickly fall. Over time, the quantity of IgG antibodies in the bloodstream also gradually falls but when the body is re-infected with the same virus, memory B-lymphocytes that had previously been “taught” to make specific antibodies against that virus can ramp up production very quickly resulting in high IgG levels in 1-2 days.

Antibodies fight viral infections in three ways. First, they bind to molecules on the surface of viruses that attach to cells. This is like covering up the “key” so that the virus cannot attach to and get inside of cells. Second, when antibody-coated viruses do get inside of a cell, that cell uses the antibodies as a signal to the rest of the immune system that it is infected, causing other immune cells to attack and kill the cell before it can produce new viruses. Third, when viruses are coated with antibodies, immune cells called macrophages recognize them and “eat” the viruses. The macrophages then digest the viruses and destroy them.

Respiratory viruses, like COVID-19, are first inhaled into the nose and respiratory tract where they get stuck in the mucus that lines those passages. The viruses then infect airway cells and eventually get into the bloodstream where they are carried throughout the body and can infect cells in the heart, liver, brain, muscles, etc. IgA in the mucus of the airways (mucosal immunity) is the first line of defense when a person inhales COVID-19 viruses. IgG in the bloodstream (systemic immunity) is the next line of defense once the COVID-19 virus gets past the airway cells and invades the body.

Olgamatveeva, CC BY-SA 4.0 <>, via Wikimedia Commons

Antibodies do not always prevent viruses from getting into the body, they just prevent viruses from getting out of control. Since the memory B-cells take 1-2 days to ramp up antibody production, the virus will have a 1-2 day head start to begin to infect cells and reproduce. However, in those first 1-2 days of infection, there are not too many viruses in the body and so a person usually has no symptoms early on (this is the incubation period). Thus neither natural nor vaccination immunity necessarily prevents viruses from getting into the body, they primarily prevent the infection from becoming severe and hopefully prevent you from dying of the infection. In this sense, a viral infection is similar to a mouse infestation in your house – mouse traps in your kitchen can stop the mice from reproducing and eating all of the food in your house but they won’t prevent the mice from getting into the house in the first place.

Because antibodies do not usually prevent viruses from getting into the body and starting to initially reproduce, people with either natural or vaccination immunity can still be contagious to others in those first few days after a virus gets into their body, even though they have no symptoms. The good news is that the number of viruses in the air that they exhale is low and the lower the number of viruses in the air, the less likely it is that someone else breathing that air will become infected.

When a person is infected with COVID, B-lymphocytes in the airways are stimulated to produce anti-COVID IgA antibodies that is released into the airway mucus. Once the COVID virus gets into the bloodstream, blood B-lymphocytes are stimulated to make anti-COVID IgA, IgM and IgG antibodies that are released into the blood. These antibodies recognize different molecules on the surface of the virus and because there are lots of different surface molecules, there are lots of different types of IgA, IgM, and IgG antibodies produced. In other words, COVID-19 infection results in many different types of IgG antibodies. This is different than vaccination immunity.

When a person is vaccinated against COVID, the vaccine is injected into the muscles and then the vaccine gets into the bloodstream. As a result, most of the B-lymphocytes that get stimulated are bloodstream lymphocytes and not airway lymphocytes. These are the lymphocytes are mainly responsible for producing IgM and IgG. B-lymphocytes in the blood also produce some IgA that stays in the blood but since the airway B-lymphocytes are not stimulated, very little airway mucus IgA gets made. Vaccination immunity to COVID also differs from natural immunity because of the types of IgG that are produced. The original Anti-COVID vaccines only produce antibodies against one part of the “spike protein” which is a the molecule on the surface of the virus that the virus uses to attach to cells. If the virus mutates and the spike protein molecule changes shape (as happened with the Omicron variant), then the antibodies produced from vaccination immunity may not recognize this new shape and may be less effective. The new booster COVID vaccines are bivalent and produce antibodies against a part of the spike protein on the original COVID virus and also against a part of the spike protein on the newer Omicron variant.

Natural COVID immunity

Natural immunity to COVID refers to immunity caused by previous infection by COVID. Some people (for example, quarterback Aaron Rodgers) falsely claim “natural immunity” from homeopathic treatments but this is NOT natural immunity. The only ways to develop immunity to COVID is to either have previously been infected by COVID or be vaccinated against it. Because of the different ways that natural immunity and vaccination immunity affect the body’s immune system, both forms of immunity have advantages and disadvantages.

Advantages of natural immunity:

  1. Bloodstream IgG production. Human B-lymphocytes have been making IgG in response to infection by various viruses for hundreds of thousands of years and our B-lymphocytes have gotten very good at it.
  2. More types of IgG antibodies. Because infection with COVID results in many different types of antibodies against many different parts of the surface molecules of the virus, there is a better chance that some of those antibodies will still work against the virus if a new variant arises with a different shape to just one of the surface molecules. A January 2022 study in the MMWR found that prior to the emergence of the Delta variant, people who were vaccinated were less likely to become infected than people who had previously had a COVID infection but after Delta emerged, those with a previous COVID infection were better protected against future infection than those who were vaccinated. Similarly, a study published two months ago found that previously vaccinated people were 13-times more likely to have a breakthrough infection with the Delta variant than previously infected but unvaccinated people.
  3. More mucosal IgA antibodies. Because the COVID virus first stimulates airway B-lymphocytes, those lymphocytes can “learn” to make anti-COVID IgA that gets into the mucus of the nose and airways. Since mucus IgA is the first line of defense, if a person gets re-infected with COVID at a later time, that mucosal IgA can kill off the viruses before they can get into the bloodstream.

Disadvantages of natural immunity:

  1. Lower levels of IgG antibodies. Our immune systems are like muscles, they work best when they continue to train. The more you repstimulate the humoral immune system, the stronger it gets. A COVID-19 infection results in a one-time stimulation to the immune system and this can result in lower antibody levels than in a person whose immune system is stimulated by 2 doses of a vaccine followed by booster doses. Some people produce little or no antibodies after infection. A study from September 2021 found that only 64% of people with severe COVID infections causing ARDS had detectable IgG or IgA antibodies after they recovered from infection.
  2. You only get natural immunity if you survive the infection. More than 1 million Americans have died of COVID infection. These people’s immune systems never got a chance to make antibodies for long-term protection. Even for those who survived the initial infection, the results of the infection are usually feeling really, really bad for a few days and often having long-term loss of taste and smell. Furthermore, long-COVID symptoms occur in one out of every five people infected. Thus, the cost of natural infection is very high.

Vaccination immunity

Because of the different way that COVID infection and COVID vaccination affect the immune system, there are different advantages and disadvantages with vaccination immunity.

Advantages of vaccination immunity:

  1. Bloodstream IgG production. All vaccines work by teaching the body’s immune system to make antibodies and the COVID vaccines are no different.
  2. High levels of IgG antibodies. The initial vaccination consists of 2 dose of the vaccine, given 3 weeks apart. This results in the humoral immune system being stimulated twice, as opposed to actual infection with COVID which only stimulates the immune system once. Getting booster vaccinations results in a third, fourth, and fifth time that the immune system gets stimulated. This “trains” the immune system to get very good at producing anti-COVID antibodies. A study from July 2022 found that antibody levels after mRNA vaccine administration were higher and lasted longer than antibody levels after COVID infection.
  3. Better protection if variants do not occur. A study from August 2021 found that prior to the emergence of the Delta variant, people who had been infected with COVID but not vaccinated (natural immunity) were 2.3-times more likely to become reinfected than people who were vaccinated but never previously infected (vaccination immunity).
  4. You don’t have to get sick to become immune. Although it is true that COVID vaccines can cause side effects, scientific studies as well as my own personal experience show that the side effects of vaccination are way, way, way less than the symptoms of a COVID infection. I have now had 5 different COVID vaccinations and I would take the side effects of all of them combined over even a mild case of COVID infection any day.
  5. The vaccines won’t kill you. The vaccines are safe. A study of 11 million people vaccinated with the Pfizer or Moderna vaccines found that there was no increased risk of mortality by getting vaccinated. On the other hand, about one out of every 100 people who get a COVID infection die from the infection. Even those people who survive the initial COVID infection are 233% more likely to die in the year after infection than people who do not get infected based on a study published last December. To put the mortality numbers in perspective, you are 3 million times more likely to die from a COVID infection than to have a winning Powerball ticket.
  6. Vaccination after a COVID infection improves immunity. A study from July 2022 found that the effectiveness of infection was 46%, the effectiveness of three doses of a vaccine was 52% but the effectiveness of infection plus three doses of a vaccine was 77%. This is sometimes called “hybrid immunity”.

Disadvantages of vaccination immunity:

  1. Single type of IgG antibody. Since the original vaccines resulted in IgG against a specific part of the COVID spike protein, if there is a change in that protein, then the antibodies may not work as well. This was a particular problem with the Omicron variant that caused infection in many people who had been vaccinated earlier. However, even though the vaccines do not work as well if the virus mutates, they do still work and as a result, vaccinated people who get a COVID infection will have milder cases of the infection than unvaccinated people. The newer booster vaccines are bivalent and result in production of two types of antibodies which improves the effectiveness against variants.
  2. Lower mucosal IgA levels. Because the airway B-lymphocytes are not strongly stimulated by vaccination, there is lower anti-COVID IgA in the mucus of vaccinated persons compared to those who have previously had a COVID infection. Thus vaccinated persons may not have as strong of a first-line defense against infection. A study from 2021 found that vaccination causes high levels of IgA and IgG in the bloodstream but little to no IgA in the saliva. A study from July 2022 found that infection with the Omicron variant of COVID resulted in 10-times more IgA in respiratory secretions (bronchoalveolar lavage fluid) than vaccination. A second study from October 2022 also found that people previously infected with COVID had higher mucosal IgA levels than vaccinated but not previously infected people.

What does all of this mean?

So, is natural immunity better than vaccination immunity? Well, it depends… We can draw several conclusions from all of the above findings:

  • If variants do not emerge, vaccination immunity is better than natural immunity.
  • The more boosters a person gets, the better their protection.
  • If variants emerge, natural immunity may be stronger than vaccination immunity until new vaccines are developed against those variants.
  • Natural immunity plus vaccination immunity (hybrid immunity) gives the strongest protection.
  • Although early studies are promising, it is too early to tell if the new boosters that cover Omicron will be better than natural immunity.

For employers trying to decide about whether to mandate vaccination for employees, it is hard to defend a position that vaccination is superior to natural immunity in every case. For example, a person who received 2 shots of the original mRNA vaccines in 2021 may have less immunity than a person who survived an Omicron infection in 2022. Instead of vaccination mandates, a better approach would be immunity mandates by having employees either provide documentation of vaccination or documentation of past infection. However, Americans as a society dislike mandates of any kind and so rather than mandates, it may be better to link immunity documentation to health insurance premium prices, life insurance premium prices, or other employment fringe benefits.

My recommendation is that everyone should get vaccinated and then get as many boosters as you can, including the newest booster that covers Omicron. In theory, immunity from these new boosters should be better than having natural immunity alone. If you have previously had a COVID infection (and are still alive), then get vaccinated and also get the new booster… you can relax with the knowledge that you will then probably have the best immunity against COVID on the planet. We have come to a point in the pandemic where having no immunity (neither natural nor vaccination immunity) is socially irresponsible and only prolongs the pandemic for the rest of us.

October 20, 2022

Medical Economics Physician Finances

Inflation Is Like A Disease – Here Is The Cure

As a physician, I have spent decades diagnosing diseases and then prescribing treatments. For many diseases, there is more than one single cause and there are more than one possible treatment. Sometimes the treatment is easy but sometimes the treatment is worse than the disease. Inflation is no different. Here is how to fix inflation from a physician’s vantage point, when we look at inflation the way we look at a disease.

What causes inflation?

In 1976, my college macroeconomics professor said that understanding inflation at its basic level is simple – it is too many dollars chasing too few goods and services. 46 years later, that central tenet is still true: inflation occurs when demand exceeds supply. In this sense, inflation is similar to a medical condition like respiratory failure. In respiratory failure, the patient gets short of breath when the body’s demand for oxygen exceeds the supply of oxygen that the lungs can deliver. The treatment of respiratory failure is to either increase the supply of oxygen being delivered to the body’s tissues or reduce the demand for oxygen by the body’s tissues. Preferably, you do both.

Like respiratory failure, there is usually not just one simple cause of inflation but instead there are several alterations in the things that cause demand for goods and services as well as the things that affect the supply of goods and services. Although demand can be affected by changes in what consumers want to purchase, it is more often caused by the amount of money consumers have in their hands to make purchases. In our nation’s current bout of inflation, there are contributions from both the supply side and the demand side. In addition, there is an effect of the national psychology attendant to inflation expectations.

  1. Alterations in demand for goods and services:

    1. Increased disposable income from COVID relief programs. When COVID surged, the U.S. unemployment rate spiked and the government response was to inject money into the economy in the form of COVID relief checks. This resulted in many Americans having cash on hand and no place to spend it during the COVID isolation period. In 2021 and 2022, when isolation restrictions eased up, many Americans started to spend these built up cash reserves and we all started to buy stuff.
    2. Exceptionally low interest rates to borrow money since 2010. Borrowing money has never been less expensive in the U.S. as it has been for the past 12 years. Low interest rates result in more people buying houses and cars. Low interest also result in companies borrowing more money to expand their business operations. As more people borrow money, there is more money circulating in the economy and that results in more money available to spend on goods and services.
    3. Historically low federal income tax rates enacted by the 2018 income tax cuts. The current U.S. income tax rates are among the lowest Americans have had in generations. This graph shows the effective income tax rates for all incomes in 2016 (before the 2018 tax cuts) and in 2020 (after the 2018 tax cuts). As a result of these tax cuts, all Americans had more money to spend on goods and services over the past year.
    4. Federal student loan forgiveness programs. In August 2022, President Biden authorized $10,000 per person federal student loan forgiveness ($20,000 for those with Pell grants). This week, former students can start to apply for those funds. The economic effect of this will not be felt until individuals get their forgiveness applications approved but many affected Americans have already changed their spending habits based on the expectation that they will have $10,000 or $20,000 more to spend on goods and services than they had budgeted for earlier this year.
    5. Increasing federal deficit spending since 2002. The U.S. government has a long habit of spending more money than it takes in each year. In fact, the only years that the government ran an annual surplus in recent memory were in 1998 – 2001 due to combined efforts by Democratic president Bill Clinton and Republican House Budgetary Chairman John Kasich. When the government spends money, it primarily goes to purchasing goods and services and puts more money in the hands of Americans that produce those goods and services.
  2. Alterations in supply of goods and services:

    1. COVID brought supply chain disruptions. These disruptions made it difficult to get foreign-produced products into the United States. These supply chain disruptions also made it difficult to get raw materials and production components into the U.S. resulting in decreased domestic production. As a result, products such as appliances made abroad and U.S.-manufactured cars that depend on foreign-made computer chips became suddenly scarce.
    2. Changes in consumer buying patterns during COVID. As a result of the pandemic, Americans wanted computers in order to work from home and wanted new suburban homes to work and live in. This resulted in heightened demand for houses and computers. There were also transient demand spikes for toilet paper and subscription video streaming services, like Netflix. During the pandemic, consumers could not spend money on services (like travel, restaurants, and concerts) and shifted their spending patterns to goods, like appliances, TVs, and furniture. Quite rapidly, the demand for these goods exceeded the supply of these goods.
    3. COVID rebound spending. As isolation practices eased, Americans started to act on their pent-up consumption appetite. We started eating out at restaurants again. We began planning vacations involving air travel and car rental. We started buying new clothes to wear as we returned to the office. But restaurants had just recently laid off staff, airlines had stopped replacing retired pilots, and car rental companies had sold off their rental car stocks. As a result, these industries were unable to meet the rebounded demand for their goods and services.
    4. War in Ukraine. The global disruption in gas and oil supply resulting from global sanctions on Russia after its invasion of Ukraine has been felt in most Western nations, including the United States. As a result, the worldwide supply of gasoline exceeded the supply and the price per gallon spiked.
    5. Foreign import tariffs. A tariff is a tax on imported goods. By making these goods more expensive, the demand for those goods drops and is replaced by demand for more expensive domestically-produced goods. In addition, tariffs can cause foreign manufacturers to redirect their sales to other countries that do not have tariffs in order to maximize their profits. As a result, the amount of foreign-produced goods falls and U.S. consumers pay more for a given item. Tariffs introduced by President Donald Trump resulted in a drop in supply of many foreign-produced goods.
    6. Low unemployment rates. The supply of services is often reflected in the unemployment rate. When the unemployment rate rises, there are too many workers competing for too few jobs and when the unemployment rate falls, there are too many jobs for too few workers causing employers to increase wages to attract workers. The pandemic resulted in many workers retiring early and also restricted the flow of immigrants and seasonal foreign workers into the United States thus shrinking the labor pool. Consequently, we now have too many job openings for too few workers, particularly for low wage jobs and farm workers.
  3. Alterations in the expectation of inflation:

    1. Worker expectations. When workers think inflation is getting worse, they proactively demand increased wages. This was evidenced recently but the increase in unionization over the past year with the assumption that by unionizing, they could use collective bargaining to get pay raises.
    2. Manufacturer and employer expectations. Forecasts of inflation also affects the costs of goods and services – when companies forecast inflation in the near future, they increase the price of their goods and services in anticipation of increased costs to produce those goods and services in the future.
    3. Consumer expectations. The psychology of inflation is often discussed in terms of worker and employer expectations but consumer psychology is just as important. When consumers hear that inflation is going up, they come to believe that they should be paying more for goods and services. This can result in a mentality of: “Well, normally I’d never pay $25 for a pizza but inflation is happening so I guess it is OK to spend that much”.

How do we cure inflation?

With disease, we often focus too often on treating the symptoms rather than treating the underlying cause. Symptom-based treatments can provide transient relief but do not cure the underlying disease. You can give a patient with sepsis Tylenol and make his fever go away but he’ll still die of sepsis. Similarly, a disease with multiple causes requires treating all of the underlying causes and not just one. When a trauma patient is bleeding from 5 different gunshot wounds and you only suture one of them up, the patient will still bleed to death. Treating inflation is no different – you have to treat the underlying causes. Some of these treatments are relatively easy but others can be too politically painful to realistically implement.

Treating alterations in demand for goods and services:

  1. Eliminate COVID relief spending. Much of this has already occurred but many state and local governments still have unspent federal COVID relief funds and they are looking for things to spend that money on. Unspent funds should be returned to the Federal government to prevent further cash injection into the economy.
  2. Increase interest rates. The Federal Reserve is already addressing this by progressively increasing the federal fund rate. The downstream effect is rising mortgage rates and car loan rates that in turn reduce demand for new house construction and automobiles.
  3. Raise income taxes. This is probably the single most effective way for the federal government to cool off inflation. It takes money out of worker’s pockets and thus reduces their demand for goods and services. However, increased taxes is viewed as a politically nuclear option and no elected official wants to go on record for voting for higher taxes. Even politicians who lean to the left usually only want to increase taxes on the wealthy. However, selectively increasing taxes on the wealthy can increase federal government revenues but has less effect on inflation. The wealthy tend to spend their extra income on investments and luxury goods but to really cool off inflation, one must decrease the demand for everyday goods. For that reason, for tax increases to be effective in reducing inflation, everyone would have to pay higher taxes, not just the wealthy.
  4. Eliminate loan forgiveness programs. Unfortunately, once you promise people money, it is exceptionally difficult to then take it away – it would be political suicide. Nevertheless, even lowering the income threshold for loan forgiveness eligibility would effectively take cash out of the economy.
  5. Decrease federal spending. Much of the huge spike in federal spending from 2020 – 2022 was on COVID programs such as vaccines, medications, and testing. The public health advocate in me wants to continue free access to vaccines and tests but to reduce inflation, it is better to start asking Americans to pay for these goods and services themselves. Belt-tightening inside the Washington Beltway is never popular but to fight inflation, federal spending should be limited to only those programs and federal departments that are vital to keep the country running safely.

Treating alterations in supply of goods and services:

  1. Improve supply chain disruptions. Many of the COVID supply chain issues have been resolving over the past year as the country has gotten back to work. However, transportation bottlenecks still exist in some areas and union strikes could cause additional transportation disruptions in the near future.
  2. Re-set consumer buying patterns. The free market is already doing this to an extent. Computer sales are falling as people return to the office after working from home. Netflix subscriptions are falling. Home sales are decreasing due to a combination of people no longer fleeing to the safety of the suburbs to avoid COVID, no longer needing more space to work from home, and no longer being able to buy houses with rock-bottom mortgage rates.
  3. Temper COVID rebound spending. The government can’t just tell people to stop buying stuff. But fortunately, the combination of a year of high inflation plus a year of spending down COVID-related household cash reserves has already tempered America’s recent buying spree.
  4. End the war in Ukraine. This one is not under the United States’ control but until the war ends, normalization of trade relations with Russia as well as resumption of Ukrainian agricultural and manufactured goods exports will continue to cause international inflationary pressure. In addition, Western countries, including the U.S., are spending much cash on military items with the downstream effect of that cash going into military production worker wages.
  5. Lift foreign import tariffs. There are compelling political reasons to continue some tariffs but from an economic standpoint, the more inexpensive goods we get into the country, the better from an inflation standpoint. First, increased imports reduce the cash supply by getting U.S. cash out of the country and thus out of circulation in the U.S. economy. Second, increased imports keep the cost of American-made goods lower by increasing competition.
  6. Increase the unemployment rate. It would be politically poisonous to simply eliminate jobs but if the unemployment rate increases, circulating cash is taken out of the economy as the supply of workers drops. In addition, employers would no longer have to keep increasing wages to attract workers. However, an alternative strategy could be more palatable, namely, increase the number of workers by increasing foreign immigration. We currently have too many foreigners trying to get into our country illegally in order to find employment and escape unsafe living conditions. By legalizing the presence of many of these undocumented foreigners, we can increase our workforce, particularly for lower wage jobs and farm work jobs. Our immigration problem and our low unemployment problem are the solutions to each other.

Treating alterations in inflation expectation:

  1. Politicians as psychologists. Changing the psychology of an entire country is hard, but not impossible. This is where the charisma of individual leaders can have an impact. Another ways by having agreement between the political parties. Getting Republicans and Democrats to come together on  anything is hard anytime but even more so in an election year. During election years, it is far too easy for both parties to point the blame for inflation on each other. It is far to easy for a political party to say “Elect us because the other guys are going to make inflation worse”. Nevertheless, consensus on legislation portrayed as being inflation-reducing can send a powerful psychological signal that can help Americans of both parties.
  2. Just do something. In medicine, doctors often prescribe antibiotics for bronchitis and sinusitis even though they know that the infection is most likely viral and the antibiotics won’t do anything. But it is the patients’ expectation that something is being done to cure their disease. If Americans see no-one doing anything to reduce inflation, their expectation will be that it is just going to keep on going until someone does something. Thus far, the public face on inflation control has been the Federal Reserve and to give the Fed credit, they have made aggressive interest rate increases. But ideally, there should also be executive branch action and legislative branch action to fight inflation so that our country’s perception is that war is being fought and will soon be won.

It really is like a disease

Admittedly, I am neither an economist nor a politician. But as a doctor, I see so many similarities between inflation and disease. In fact, inflation can be seen as a disease of the country’s economy. And just like most diseases, you can’t just treat the symptoms and hope that it goes away on its own, you have to treat the causes of the disease, preferably all of the causes.

October 19, 2022

Medical Economics

What Is The Difference Between Medicare Parts A, B, C, & D?

If you want to understand Medicare, don’t ask your doctor. Medicare details are not taught in medical school and with most physicians now being employed by either hospitals or large group practices, physicians do not need to understand the intricacies of Medicare in order to run their medical practice. I am a physician who was formerly the treasurer of a $1.5 million physician group practice and formerly the medical director of a 200-bed hospital but it was not until I turned 64 and started to plan for Medicare that I realized how little I knew about it. As the annual Medicare open enrollment period begins, seniors are getting inundated with advertisements to join commercial insurance Medicare Advantage plans. But what are these plans and are they right for you or your patients?

Summary Points:

  • Medicare and Medicare-related insurance plans are incredibly complex.
  • Most Americans and most physicians do not fully understand the nuances of Medicare-related health insurance options for people over age 65.
  • Cheaper Part C and Part D plans are sometimes the most expensive option in the long run.


What is Medicare?

In simplest terms, Medicare is nationalized healthcare for Americans who are either over age 65 or who are disabled. There are additionally two medical conditions that qualify a person to be eligible for Medicare: kidney disease requiring dialysis and amyotrophic lateral sclerosis (ALS). Medicare is primarily funded in two ways: (1) federal payroll (FICA) taxes deducted from paychecks when Americans are employed and (2) Medicare monthly premiums after Americans turn age 65. The payroll taxes cover Medicare Part A and the monthly premiums pay for Medicare Parts B & D.

Medicaid is a different but related program that pays for healthcare for low-income individuals, low-income families, and disabled citizens. Unlike Medicare that is entirely funded through the federal government, Medicaid is funded by both the federal government and state governments. As a result, each state makes its own rules about Medicaid resulting in Medicaid eligibility and services varying widely from one state to another.

Medicare (Parts A & B) and Medicaid were created in 1965 by Title XVIII of the Social Security Act. Prior to that time, 40% of American seniors had no health insurance and had no way of paying for healthcare. Since 1965, Congress has passed additional laws expanding or clarifying Medicare coverage including the creation of Medicare Part C in 1997 and Medicare Part D in 2006.

Currently, according to the most recent CMS data, 18.4% of Americans are covered by Medicare and 17.8% are covered by Medicaid. However, because most healthcare costs occur in elderly people, Medicare accounts for a disproportionately higher percentage of total U.S. healthcare expenditures at 21.1%. Although not shown in the graph below, the percentage of healthcare costs paid by Medicare fell in 2020 because of federal COVID programs that are included in the “Other Third Party Payers and Programs” (maroon line).

The components of Medicare include Parts A, B, C, and D. In addition, there are Medigap plans that can supplement Parts A & B.

Medicare Part A

Medicare Parts A and B are often called “traditional Medicare” or “original Medicare” since these were the components when Medicare was originally created in 1965. Medicare Part A covers hospital charges for inpatient admissions and also covers skilled nursing facility charges. Once a person turns age 65, Medicare Part A is free if that person (or their spouse) has been employed and paid payroll taxes for at least 10 years. You do not get Medicare Part A automatically, you must sign up for it, preferably 3 months before your 65th birthday. If a person (or their spouse) has not been previously employed and paid payroll taxes for 10 years, then they can purchase Medicare Part A at a cost of either $274 or $499 each month, depending on the total number of years that person or their spouse did pay payroll taxes.

Medicare Part A does not cover all hospital charges, however. There is an annual $1,556 deductible that the individual must first pay. After paying the deductible, the portion of hospital charges that Medicare Part A covers depends on the duration of hospitalization:

  • Days 1-60: $0 after the Part A deductible.
  • Days 61-90: $389 copayment each day.
  • Days 91-150: $778 copayment each day while using the 60 lifetime reserve days
  • After day 150: all hospital charges paid by the individual

There is a similar payment scale for skilled nursing facilities with Medicare Part A covering all costs for the first 20 days. For days 21-100, there is a  $194.50 co-payment per day. After 100 days, the individual is responsible for all daily charges.

Medicare Part B

Medicare Part B covers physician charges (both inpatient and outpatient) as well as office visits, outpatient hospital charges, chemotherapy, and many intravenous drugs administered in a physician office. Unlike Medicare Part A, a person must pay monthly premiums in order to receive Medicare Part B, starting at age 65. It is important to sign up within 3 months of turning 65 because failure to sign up in time will result in a 10% monthly penalty (in addition to the monthly premium). The monthly premium depends on the person’s annual income. This is based on the modified adjusted gross income (MAGI) reported to the IRS two years ago (thus, your 2022 Medicare Part B premiums are based on your 2020 income tax forms. The MAGI includes income such as employment wages, pensions, 401(k)/403(b)/457 withdrawals, interest, dividends, and social security payments.

Medicare Part B has an annual $233 deductible and a 20% co-pay for most charges. Notably, “observation status” admissions to the hospital are considered outpatient visits and are thus covered by Medicare Part B and not Part A. Part A only covers “inpatient status” admissions which generally require a patient to have a hospital stay of greater than 2 midnights. Overall, about 20% of hospitalizations are considered to be observation status but for some hospitals, that number can be as high as 50%. As a result, many patients face unexpected 20% co-pays for hospitalizations.

Medigap. These are health insurance policies that can cover Part A deductibles, Parts A & B co-pays, and foreign travel health costs. There are 10 different Medigap plans, 8 of which are open to new enrollees. Each plan has different degrees of extended coverage. They are sold by commercial insurance companies and the monthly premiums vary but average about $155 per month. There are a number of rules pertaining to Medigap plans:

  1. You must have Medicare Parts A & B
  2. You cannot have a Medicare Advantage Plan
  3. Medigap plans do not cover medications
  4. If you sign up for a Medigap plan more than 3 months after turning 65, you will pay a penalty and insurance companies can refuse to sell you a Medigap plan

Medicare with other group insurance. Many people over age 65 receive health insurance through their employer, their union, or their retirement system. In this case, healthcare coverage is provided by both Medicare and the commercial group health insurance. There are rules that dictate whether Medicare pays first or the group health insurance pays first. These are sometimes called primary and secondary payers. In general, the group health insurance will provide the same types of coverage that a Medigap plan and a Part D prescription drug plan covers and thus these individuals should not sign up for a Medigap or Part D plan. These group health plans are often more expensive than Medicare Advantage Plans but usually have more comprehensive coverage with lower deductibles and co-pays.

Medicare Part C

Medicare Part C (also known as Medicare Advantage Plans) can best be thought of as privatized versions of Medicare Parts A & B combined with a Medigap policy and a Part D prescription drug plan. Under these plans, commercial health insurance companies are paid each month by Medicare to outsource your healthcare coverage. In return, the commercial insurance companies pay the services normally covered by Medicare Parts A & B. Medicare Advantage plans also pay for charges that would otherwise be covered by a Medigap policy and usually cover prescription drug costs as well. These plans sometimes provide additional services not covered by traditional Medicare Parts A & B such as fitness programs, dental insurance, and vision insurance. Overall, 45% of new Medicare enrollees chose to enroll in Medicare Part C rather than traditional Medicare.

To enroll in a Medicare Advantage Plan, a person must first be enrolled in Medicare Parts A & B. New Medicare enrollees can sign up for a Medicare Advantage Plan at the time of enrollment in Medicare (age 65). People currently on traditional Medicare Parts A & B can also change to a Medicare Advantage Plan during the regular open enrollment period: October 15 – December 7. People currently on a Medicare Advantage Plan can switch to a different Medicare Advantage Plan either during the regular open enrollment period or during the Medicare Advantage Plan open enrollment period: January 1 – March 31.

When a person enrolls in a Medicare Advantage Plan, he/she continues to pay regular monthly Medicare Part B premiums to Medicare and additionally pays the Medicare Advantage Plan monthly premiums to the commercial insurance company. These latter premiums can vary widely from as little as $0 to more than $200 per month. A recent study found that 69% of Medicare Advantage Plans in 2022 had no additional premium and the average Medicare Advantage Plan premium that includes prescription drug coverage is $58 per month. On the surface, the Medicare Advantage Plans appear to be a great deal – for the same price or just a few dollars more than Medicare Part B, you can also get prescription drug coverage, lower co-pays, lower deductible limits, dental care, and vision care. However, like most things in life, you get what you pay for and there are features of Medicare Advantage Plans that can make them less desirable than traditional Medicare to some people:

  1. Restrictions in which physicians you can see. With traditional Medicare, you can see any physician in the country who accepts Medicare; only 1% of non-pediatric physicians have opted out of Medicare which means that a person with traditional Medicare can see any of 99% of U.S. physicians who treat adults. With Medicare Advantage plans, enrollees are limited to only those physicians who in network for that particular commercial insurance plan. A Kaiser Family Foundation study found that the average Medicare Advantage  Plan only covers care by 46% of physicians in any given county. Medicare Advantage Plans generally fall into one of two categories: (1) HMOs that restrict enrollees to seeing only physicians who are members of that HMO and (2) PPOs that have a lower cost for in-network physicians and a higher cost for out-of-network physicians. These restrictions work fine for most healthy people but those requiring specialized care for chronic diseases or those who need elective surgeries can find themselves unable to be treated by specialists of their choice. For example, I specialized in interstitial lung diseases and for many years was the only pulmonologist in Columbus who specialized in these diseases. Patients belonging to a Medicare Advantage Plan sponsored by one of the other health systems in Columbus were not able to see me unless they paid for their office visits themselves, out of pocket.
  2. Restrictions on which skilled nursing facilities you can use. Each Medicare Advantage Plan will also have a group of in-network skilled nursing facilities. A study published last month found that enrollees in traditional medicare had access to more of the top-rated skilled nursing facilities than enrollees in Medicare Advantage Plans.
  3. Prior authorization requirements. Medicare Advantage Plans almost always require prior authorization before a patient can see a specialist or undergo a procedure. Prior authorization is quite laborious for physicians and office staff and frequently, physicians will just not order a consult or a test because it takes too much time. As an example, many Medicare Advantage Plans require prior authorization when a physician orders a CT scan. The chest CT scan is a standard part of the work-up of every patient with interstitial lung disease. My office staff would typically complete the initial prior authorization forms but after the insurance company does its preliminary review, it would frequently require a “peer-to-peer” review that would require me to speak directly to another physician who works for the insurance company. This would require me to first call the insurance company myself to schedule a day and time for their physician to call me back. Then the physician would call me and almost always approve the CT scan. I would then need to contact the radiology department with the approval number. Not only would this require a minimum of 4 phone calls but I would often be put on hold when calling myself – once I was kept on hold for 45 minutes just to get a routine chest CT approved! As a result of prior authorization, many patients are either unable to get a recommended specialist consult, procedure, or test or there is a delay in getting the consult, procedure, or test.
  4. Long hospitalizations are more expensive. A recent study found that the average Medicare Advantage plan has lower out-of-pocket costs to enrollees for hospitalizations of 6 days or shorter than traditional Medicare. However, for hospital stays longer than 6 days, the out-of-pocket costs are higher for the average Medicare Advantage Plan than for traditional Medicare.
  5. Variable deductibles and co-pays. The degree that each Medicare Advantage Plan covers deductibles and co-pays varies considerably and many of the low cost plans can be more expensive than traditional Medicare in the long run. It is essential that seniors look at the fine print of each Medicare Advantage Plan that they are considering enrolling in.
  6. Variable prescription drug coverage. Each Medicare Advantage Plan covers prescription drugs differently and just because a plan advertises prescription drug coverage does not necessarily mean that the enrollee will save money on the drugs that they take. Plans often restrict enrollees to purchase medications from a specific pharmacy. Co-pays and deductibles for prescribed medications can vary considerably from plan to plan. And perhaps most importantly, each plan will have a different drug formulary listing which drugs the plan will actually cover. There are only 2 drugs approved to treat idiopathic pulmonary fibrosis and each cost about $100,000 per year. Many of my patients who switched to lower cost Medicare Advantage Plans found that these drugs were not on the new plan’s formulary or had co-pays of as much as $40,000 per year. These patients had to either pay out of pocket or stop taking the medication.

Because it would seem that the Medicare Advantage Plans offered by commercial insurance companies provide much more comprehensive medical care at a lower cost than traditional Medicare plus a Medigap policy, many pundits have suggested that all of Medicare should be privatized. However, there is a dark side of the Medicare Advantage Plans. First, they bill Medicare for each senior that they enroll. However, they get paid by Medicare based on how sick each enrollee is. For that reason, the plans have gone to great lengths to document every medical condition that each enrollee has and in many cases, they have exaggerated these conditions by inflating enrollees’ “risk scores”. A report by the Kaiser Family Foundation found that Medicare Advantage Plans overcharged the federal government by $106 billion between 2010-2019. The problem seems to be accelerating as $34 billion of these overcharges were in 2018-2019 alone. There is a bright side to this, however. Because insurance companies are incentivized to document every medical condition that each enrollee has in order to increase patients’ risk scores, the insurance companies are incentivized to get their enrollees screened for as many diseases as possible. This resultant emphasis on screening has led to many Medicare Advantage Plans out-performing traditional Medicare when it comes to disease screening and routine wellness visits.

A second dark side of the Medicare Advantage Plans is that they use prior authorization denial and payment denial in order to avoid paying for costly procedures and tests. An April 2022 report by the U.S. Office of the Inspector General found that 13% of prior authorizations that were denied by Medicare Advantage Plans actually met regular Medicare approval criteria. Furthermore, the OIG found that of services that were performed but that Medicare Advantage Plans later denied payment for, 18% of denials met Medicare criteria and should have been paid. These denials are a strategy used to increase the profits of Medicare Advantage Plans and is potentially dangerous for patients.

A third dark side of the Medicare Advantage Plans is that although they are great for people when they are reasonably healthy, they often limit coverage for people once they become ill. The U.S. Office of the Inspector General found that sicker people who are in Medicare Advantage Plans were more likely to disenroll and return to traditional Medicare than healthy people. This is especially true for seniors who develop cancer and find that cancer specialists or cancer hospitals that they want to utilize are not in the Medicare Advantage Plan’s network.

Medicare Part D

A Medicare Part D plan is a prescription drug insurance policy sold by a commercial insurance company approved by Medicare. It is required that enrollees have Medicare Part A and/or Part B. Having a Medigap plan is permitted but not required. Seniors can enroll in a Part D plan either when they turn 65 and enroll in Medicare Parts A & B or during the open enrollment period between October 15 – December 7 each year. However, if you do not enroll in a Part D plan when you are first eligible to enroll in Medicare, then you will have to pay a 12% annual penalty if you enroll in a Part D plan at a later date. If you are enrolled in a Medicare Advantage Plan (Medicare Part C), you cannot enroll in a Medicare Part D plan.

The cost of Medicare Part D depends on both the cost of the specific Part D plan and the modified gross annual income of the enrollee. Each Part D plan has different costs, depending on drug coverage. The average Part D base premium is $33.37. Similar to Medicare Part B, there is an additional add-on cost to the base premium for those people with higher modified annual gross income:

Part D plan costs do not stop with monthly premiums, however. In addition, there is an annual deductible that can vary from $0 to more than $480, depending on the individual Part D plan. There are also co-pays on each drug each month. The co-pay amount varies from plan to plan and can vary depending on specific drugs within a plan. A person’s costs also change during the coverage gap (also known as the “donut hole”). Each year, the coverage gap begins when a person has spent $4,430 in out-of-pocket expenses in their Part D plan (for deductible and co-pay amounts). When in the coverage gap, there is a limit that Part D will cover for drugs and the enrollee pays up to 25% of the cost of a drug out-of-pocket. Once a person’s annual out-of-pocket drug expenses reach $7,050, the coverage gap ends and “catastrophic coverage” begins resulting in the individual only having to pay a 5% co-pay for prescribed drugs for the rest of the year.

As with Medicare Advantage plans, each Medicare Part D plan has its own formulary of covered drugs and the drugs on the formulary can change each year. For this reason, it is important that seniors considering a Part D plan look carefully at the plan’s formulary to confirm that their current prescription drugs will actually be covered.

Sign-up recommendations

In my opinion, there are really only three realistic options: (1) Sign up for a Medicare Advantage Plan. (2) Sign up for a combination of traditional Medicare + a Medigap plan + a Part D plan. (3) Sign up for Medicare Parts A & B and continue your group health insurance plan through your employer, union, or retirement system. Relying on traditional Medicare alone is risky because Medicare Parts A & B deductibles and co-pays can be financially devastating if you do not have a Medigap policy. Prescription drug costs can be financially devastating without a Part D plan.

Part A. If you or your spouse has previously worked for at least 10 years, Medicare Part A is free – never turn down free healthcare. Sign up 3 months before you turn 65. You sign up through Social Security (on-line or in person).

Part B. Sign up the same time you sign up for Medicare Part A. If you continue to work past age 65 and get comprehensive health insurance through your employer, then sign up when you retire (although some employers will require you to sign up for Medicare Parts A & B at age 65 even if you are continuing to receive employer-provided group health insurance). You sign up through Social Security (on-line or in person).

Medigap. Sign up at the same time you sign up for Medicare Parts A & B. You should only buy a Medigap policy if you are enrolling in traditional Medicare (Parts A & B) and you should not buy a Medigap policy if you intend to sign up for a Medicare Part C Advantage Plan. If you have group health insurance through your employer, union, or retirement system, you do not need a Medigap policy. You sign up through a commercial insurance company.

Part C (Medicare Advantage Plans). Sign up as soon as you have signed up for Medicare Parts A & B and have your Medicare number. Medicare Advantage Plans are usually preferable to traditional Medicare + a Medigap policy + a Part D plan for people who are relatively healthy. People with serious diseases, such as cancer, need to be careful when signing up for a Medicare Advantage Plan since traditional Medicare + a Medigap policy + a Part D plan may be less expensive in the log run and may allow more choices in physician specialists and specialty hospitals. If you have group health insurance through your employer, union, or retirement system, you do not need a Part C plan. You sign up through a commercial insurance company.

Part D. Sign up as soon as you have signed up for Medicare Parts A & B. Only sign-up for a Part D plan if you intend to enroll in traditional Medicare and not in a Medicare Advantage Plan. If you have group health insurance through your employer, union, or retirement system, you do not need a Part D plan. You sign up through a commercial insurance company.

This all seems really, really complicated

When first enacted, the U.S. Federal income tax system was very simple. Since that time, there have been dozens of new tax laws passed that have resulted in the tax code becoming extraordinarily complicated. The same thing has happened with Medicare – when first enacted, it was simple. But since then, numerous pieces of legislation have added, modified, or deleted parts of Medicare coverage resulting in Medicare now becoming so complex that most people need help navigating all of the decisions they must make when signing up for Medicare. It is important to carefully consider factors such as in-network providers, deductibles, co-pays, and medication formularies when selecting among Medicare options. Like most things in life, when it comes to Medicare options, you get what you pay for and often the cheapest option in the short-run can end up being the most expensive option in the long-run.

October 17, 2022

Intensive Care Unit Procedure Areas

Credentialling For Common Bedside Procedures

In the past, nearly all internal medicine residents were required to perform common bedside procedures during residency. However, currently, bedside procedure competency is no longer required during residency and the result is that hospitals are often challenged to have credentialed hospitalists available to perform them. These procedures include central venous catheter placement, arterial line placement, thoracentesis, paracentesis, lumbar puncture, endotracheal intubation, arthrocentesis, and bone marrow aspiration/biopsy. In order to ensure that the hospital has coverage for these different procedures requires innovative provider coverage models and careful wording of credentialing requirement documents.

Summary Points:

  • Fewer internal medicine residents learn to perform common bedside procedures during residency than in the past.
  • Hospitalists are less likely to be able to perform these procedures than in the past.
  • Hospitals require innovative tactics to ensure that credentialed healthcare providers are available 24-hours a day to competently perform common bedside procedures.


Residency & fellowship training program requirements

There are two organizations that dictate residency and fellowship training requirements, the Accreditation Council for Graduate Medical Education (ACGME) and the specialty board. In the case of internal medicine, the specialty board is the American Board of Internal Medicine (ABIM). The ACGME determines what the training programs have to teach and the ABIM determines what competencies trainees must have in order to become board certified. For internal medicine residents, the ACGME program requirements document states: “Residents are expected to demonstrate the ability to manage patients by demonstrating competence in the performance of procedures as appropriate to their career paths“. The ACGME document further states: “Experience must include opportunities to demonstrate competence in the performance of procedures listed by the ABIM as requiring only knowledge and interpretation“. In other words, the ACGME defers to the ABIM to dictate what procedures are required. The ABIM procedure for certification document states: “Not all residents need to perform all procedures. Program directors must attest to general competence in procedures at end of training. Residents must have the opportunity to develop competence in procedures which will further their development as fellows in their chosen subspecialty or as independent practitioners in their intended fields if entering practice after residency“. In other words, the ABIM leaves it up to the resident to decide what procedures he/she wants to do and leaves it up to the residency program director to determine if the resident is competent to perform the procedure.

The ABIM also dictates competency requirements for subspecialties. As relevant to bedside procedures, the ABIM requires the following:

Notably absent are the procedures of lumbar puncture and paracentesis that are not required by any ABIM subspecialty for board certification.

The ACGME has different requirements for what procedures subspecialty fellows need to be competent to perform during their fellowship training. In many cases, the ACGME subspecialty requirements differ from the ABIM subspecialty board requirements. Notably, paracentesis is required for gastroenterology, pulmonary, and critical care fellowship training. Also, lumbar puncture is required for pulmonary and critical care training. The ACGME has the following requirements for subspecialty fellows:

Although most hospitalists do internal medicine residencies, some hospitalists do family medicine residencies. Neither the ACGME nor the American Board of Family Medicine have specific procedure requirements.

In some hospitals, emergency medicine physicians perform many bedside procedures for hospital inpatients when there is no other provider available to perform those procedures. The ACGME training requirements for emergency medicine includes competency (with required numbers of procedures) in endotracheal intubation (35), central lines (20), lumbar puncture (15), sedation (15), and chest tubes (10).

The bottom line from the ACGME and ABIM is that hospitalists come out of residency training with variable procedural skills. Increasingly, many of them are not proficient to perform any bedside procedures. Over time, it can even become difficult for those residents who do want to be trained in bedside procedures to get that experience. Residents can only perform a procedure under the supervision of an attending physician who is credentialed for that procedure. As fewer of their internal medicine attendings perform these procedures, it can become difficult for the residents to get experience doing procedures during their training. This can result in a patchwork of consultation for procedures: anesthesia for endotracheal intubation, pulmonary for thoracentesis, rheumatology for arthrocentesis, interventional radiology for lumbar puncture & paracentesis, and surgery for central lines. In the middle of the night, it often falls to the emergency medicine physician on-duty to perform any bedside procedure.

Hospital credentialing

The ACGME and ABIM only determine what procedures are necessary to be taught during training or to become board-certified. Decisions about whether or not a physician is permitted to perform a procedure lies with the hospital’s credentials committee to set criteria for hospital privileges. There are two types of privileges: core privileges and optional privileges.

Core privileges are those that any physician credentialed in a given specialty can perform, without additional requirements. It can be easy to select a procedure to include in core privileges when either the ACGME dictates that competency in that procedure is required to complete residency/fellowship training or the ABIM dictates that competency is required to become board certified in that specialty. For example, the ACGME requires cardiology fellows read at least 3,500 EKGs during fellowship training and the ABIM requires pulmonologists be proficient in conscious sedation to become board certified. But credentials committees can also add additional procedures into core privileges that are not required by either the ABIM or the ACGME. These are typically procedures that are commonly performed by residents or fellows in their training even though they may not be specifically required by the ACGME or ABIM. In this case, the procedures are usually listed in the hospital privilege application with the option for the applicant to either request or opt out of each individual procedure privilege. It is then up to the department chair to attest whether or not the applicant is competent to perform that particular procedure. Including lumbar puncture in core privileges for hospitalists is an example.

Optional privileges are those for procedures that some physicians in a given specialty perform but others do not. These are generally not procedures that either the ACGME or ABIM specifies in their requirements and are procedures that require a relatively high level of skill or high level of risk. Often, the credentials committee will require documentation of successful completion of a certain number of these procedures under supervision. Including endotracheal intubation as an optional privilege for a hospitalist is an example.

When a physician get his/her initial appointment to a hospital’s medical staff, it is usually for a short probationary period – typically 6-months. At the end of the probationary period, if the new physician has not had any major quality issues, that physician then moves from a probationary appointment to a regular, full medical staff appointment. The probationary period is an opportune time for physicians who lack adequate training in a procedure to learn how to do that procedure and generate sufficient procedure numbers to qualify for hospital privileges for that procedure when they move from a probationary appointment to a regular appointment to the medical staff.

Hospital privileges usually last for 2 years at which time the physician must apply for re-credentialing. For core privileges, this usually just requires the physician to request those privileges without additional documentation (other than approval by the department chairman). Optional privileges will usually require documentation of on-going competency, such as a patient procedure log documenting the number of that particular procedure the physician has performed in the past 2 years. It is important that the credentials committee is careful and realistic in choosing which procedures require a specific number every 2 years to retain privileges for that procedure. For example, if the hospital has 18 hospitalists and there are a total of only 25 lumbar punctures performed in the hospital every 2 years, then if the credentials committee requires every hospitalist to perform 10 lumbar punctures every 2 years to retain lumbar puncture privileges, none of the hospitalists will realistically be able to do enough lumbar punctures to meet the privilege requirement. That hospital will soon find itself with no hospitalists credentialed to perform lumbar puncture.

Some practical solutions

It is the credentials committee’s obligation to ensure that anyone performing a procedure in the hospital is competent to do that procedure. It is the medical director’s obligation to ensure that when a patient needs a particular procedure, there is a person with hospital privileges available to do it. In order to meet both of these obligations, there are some specific tactics that the hospital can take.

  1. Include procedures that are already in ACGME or ABIM requirements in core privileges. In this case, there is no need to “recreate the wheel” by requiring procedure logs and it only results in applicants keeping unnecessary duplicate records. For example, since the ABIM requires that cardiology fellowship directors attest that a cardiology fellowship graduate is competent to perform cardioversion and since the ACGME requires cardiology fellows to document doing at least 10 cardioversions to graduate from fellowship, there is no need for a new cardiologist to have to provide procedure logs in order to become privileged to perform cardioversion as a member of the medical staff.
  2. Strategically include other low-risk procedures in core privileges. Since most hospitalists are general internists and neither the ACGME nor the ABIM have requirements for any procedures, this will apply to just about any procedure included in hospitalist core privileges. These should include those procedures that are commonly performed during residency and are relatively low risk. Examples are skin punch biopsies, arthrocentesis, and lumbar puncture. Giving the applicant the ability to opt-in or opt-out for individual procedures on the hospital privilege applications allows those hospitalists who have not been trained in these procedures to opt-out. The responsibility of confirming that the hospitalist is competent to perform these procedures thus lies with the division director or department chair who has to sign-off on the application before it goes to the credentials committee. This overcomes the problem of performing a specific number of a rarely performed procedure every two years, especially for procedures that pose relatively low risk of complications, such as a skin biopsy or lumbar puncture.
  3. Include optional privileges for any conceivable bedside procedure that a hospitalist might perform. This is particularly useful for procedures such as central venous catheters and endotracheal intubation. Some internal medicine residents perform many of these during residencies and become quite proficient with them. If a medical staff applicant can produce a procedure log documenting 20 successful proctored endotracheal intubations during internal medicine residency (which is the same number of intubations required by the ACGME for emergency medicine), then that internal medicine hospitalist should be eligible for intubation privileges.
  4. Develop training opportunities for optional procedures. If the hospitalists are the only physicians in the hospital at night, then hospitalists need to be credentialed to perform endotracheal intubation and central venous catheterization. If they were not adequately trained to do these procedures during residency, then the hospital needs to provide that training. At our hospital, we had new hospitalists without prior intubation training spend a couple of mornings in the operating room with our anesthesiologists to get a minimum number of proctored intubations. We additionally required then to perform a specific number of emergency intubations in the ICU and during code blues that were observed by one of the senior hospitalists. We also required them to attend an airway course in our simulation lab in order to get additional experience using different laryngoscopes, bougies, and end-tidal CO2 monitors.
  5. Don’t forget about ultrasound. Bedside ultrasound is routinely used during thoracentesis, paracentesis, arterial lines, and central venous catheters – it makes performing these procedures safer and reduces complications. In fact, many residents and fellows have never performed these procedures without using bedside ultrasound. Residents and fellows typically go through a formal ultrasound training course in a simulation lab. Completion of such a course is often required for bedside ultrasound privileges. We found that many of our older physicians learned how to use bedside ultrasound during their regular clinical practice and never attended an ultrasound course. When documentation of attending a course was required for hospital privileges, these physicians had to stop using ultrasound. The hospital has to be careful with ultrasound privileges – by being too strict, it can force physicians to do procedures such as central line placement without ultrasound guidance with the unintended result that patients are being made less safe. The reality is that today’s bedside ultrasounds are simple to use – it took me longer to learn how to use my fish finder sonar than the hospital ultrasound device. As ultrasound becomes increasingly ubiquitous during residency training, separate credentialing to use ultrasound for venous access guidance makes about as much sense as requiring separate credentialing to use a stethoscope.
  6. Utilize simulation labs. Particularly when credentialing or re-credentialing a physician for an infrequently performed procedure, a simulation lab can be invaluable. Performing a procedure is a skill and like every skill, the more you practice, the better you get. A simulation lab can allow a physician to do many practice procedures and can provide an opportunity for a more skilled proceduralist to give technique pointers and feedback. Although intubating a manikin is a lot different than intubating a live patient during CPR, practice in a simulation lab can at least allow a reduction in the number of live patient procedures required for re-credentialing every 2 years.
  7. Allow non-physician staff to work at the top of their license. Once again, endotracheal intubation is a great example. Respiratory therapists are trained in performing intubation during respiratory therapy school and most states allow respiratory therapists to perform intubations. When our hospital replaced our previous hospitalist group with a new hospitalist group, the new group did not perform intubations (and did not want to). We permitted our respiratory therapists to be credentialed to perform intubations at night (when hospitalists were the only physicians physically in the hospital). We used the same process of anesthesia proctored intubations in the OR, attendance at a simulation lab airway lab, and a specific number of emergency intubations observed by a previously credentialed provider.
  8. Utilize advance practice providers. Nurse practitioners and physician assistants do not have any specific procedure experience required during initial training. There are some advance practice provider fellowships (for example, our medical center has a 1-year critical care nurse practitioner fellowship) and these fellowships often include procedural training. Our critical care NPs and PAs can be credentialed to perform intubation, central venous line placement, and arterial line placement in the ICU.
  9. Consider procedure teams. These are particularly useful in large hospitals that have a reliably large number of regularly performed bedside procedures. These are sometimes lead by a physician credentialed in common procedures but are often staffed by advanced practice providers (NPs and PAs). Elective and semi-elective procedures that lend themselves for NP/PA procedure teams include central lines, lumbar puncture, thoracentesis, paracentesis, and bone marrow biopsy.
  10. Do not over-rely on surgeons and anesthesiologists. Some hospitals are large enough to have a designated in-house anesthesiologist (or CRNA) available to perform emergency intubations outside of the operating room. But small and medium-sized hospitals usually have all of their anesthesiologists assigned to operating rooms during the day and may not have an in-house anesthesiologist at night. Anesthesiologists and surgeons need to be in the operating room and usually cannot just pause a surgical procedure to run out to the ICU to place a central line or intubate a patient. Reserve using anesthesiologists for intubating only difficult airways and using surgeons for only difficult venous access situations.
  11. Have a back-up plan. Emergency medicine physicians are credentialed for most bedside procedures. However, ER doctors really need to remain physically in the ER whenever possible. They can be an important back-up at night in situations when the provider covering the ICU or covering code blue calls is unable to successfully intubate a patient or place a central venous catheter. Anesthesiologists often can play this same back-up role for intubations and surgeons can often play the same back-up role for central lines. But they should generally only be called as a last resort when the first line provider is unsuccessful.
  12. Promote a hospital culture of mutual assistance. As a pulmonary/critical care physician, I had hospital privileges for all common bedside procedures as well as deep sedation. As the hospital medical director, I was usually present in the hospital when not seeing outpatients in the clinic building. I frequently had the cardiologists (who were credentialed for moderate sedation but not deep sedation) schedule cardioversions between my hospital meetings and would pop in to push intravenous propofol and fentanyl for deep sedation. I also frequently performed lumbar punctures and endotracheal intubations when there was not a credentialed provider present. Not every medical director is credentialed for bedside procedures or has the time during the day to perform bedside procedures. But there is frequently other experienced physicians present in the hospital at any given time who can assist a hospitalist or other physician who is not experienced in performing a given procedure. The medical director can promote a culture of mutual assistance

It’s a new era

In bygone times, teaching hospitals were run by internal medicine and surgical residents. They were in the hospital 24-hours a day and did any and all bedside procedures by the time they were senior residents. The training process consisted of “see one, do one, teach one”. And the volume of procedures was so great that there were plenty of them for all residents to become proficient.

But things have changed. Antiseptic catheter coatings eliminated the need to place fresh central lines and arterial lines every 3 days. Ultrasonography reduced the need for pulmonary artery balloon catheters. PICC lines eliminated the need for many central lines. Better imaging reduced the need for lumbar punctures, thoracenteses, and paracenteses. In addition, quality initiatives increased the training requirements to demonstrate procedure competency. The ACGME and the ABIM reduced and in come cases eliminated the requirements for procedure proficiency for residency/fellowship completion or board certification.

As a consequence, internal medicine trainees now perform fewer procedures during residency/fellowship and hospitalists are frequently not prepared to perform those procedures when they join the medical staff. Hospitals must develop innovative new strategies so that all patients and get the procedures they need anytime of the day and night. The best solution for one hospital may not be the best solution for another hospital. But it is clear that hospitals can no long rely on the training and credentialing processes that were used 20 years ago.

September 26, 2022