A team of international tobacco control experts has found that use of e cigarettes can reduce overall smoking as well as potentially decrease the mortality rates particularly arising out of cigarette smoking.
The findings showed that e-cigarettes have the potential to counteract health risks and may do more benefit than harm.
Also, the evidence suggests a strong potential for e-cigarettes use to improve population health by reducing or displacing cigarette use in countries where cigarette prevalence is still high and smokers are interested in quitting.
“While e-cigarettes may act as a gateway to smoking, much of the evidence indicates that e-cigarette use encourages cessation from cigarettes by those people who would have otherwise smoked with or without e-cigarettes,” said lead researcher David Levy, professor at Georgetown University in the US.
However, the experts’ estimated that exclusive e-cigarette use is associated with about five percent of the mortality risks of smoking.
Research shows that cigarette smoking rates have fallen more in the last two years than they have in the previous four or five years in the US, Canada and England, and that this trend has coincided with the increase in e-cigarette use.
“We believe that the discussion to date has been slanted against e-cigarettes, which is unfortunate, because the big picture tells us that these products appear to be used mostly by people who already are or who are likely to become cigarette smokers,” Levy added.
In the study, published online in the journal Addiction, seven top international tobacco control experts have prompted regulators at the US Food and Drug Administration (FDA) to have a broad “open-minded” perspective when it comes to regulating vaporised nicotine products, especially e-cigarettes.
Taking a low-dose of aspirin may increase the chances of survival of cancer treatment patients by up to 20 per cent and help stop the disease from spreading, a new study suggests.
“There is a growing body of evidence that taking aspirin is of significant benefit in reducing some cancers,” said Peter Elwood from Cardiff University in the UK.
“Whilst we know a low-dose of aspirin has been shown to reduce the incidence of cancer, its role in the treatment of cancer remains uncertain. As a result, we set out to conduct a systematic search of all the scientific literature,” Elwood said.
“Our review, based on the available evidence, suggests that low-dose aspirin taken by patients with bowel, breast or prostate cancer, in addition to other treatments, is associated with a reduction in deaths of about 15-20 per cent, together with a reduction in the spread of the cancer,” he added.
For the study, researchers looked at all of the available data including five randomised trials and forty two observational studies of colorectal, breast and prostate cancers.
They found a significant reduction in mortality and cancer spread by patients who took a low-level dose of aspirin in addition to their cancer treatment.
“A mutation known as PIK3CA was present in about 20 per cent of patients, and appeared to explain much of the reduction in colon cancer mortality by aspirin,” said Elwood.
Information about Medical travel for patient with Cancer to Singapore
Irritable bowel syndrome (IBS) is a common disorder that affects the large intestine (colon). Irritable bowel syndrome commonly causes cramping, abdominal pain, bloating, gas, diarrhoea and constipation. IBS is a chronic condition that one needs to manage long term.Even though signs and symptoms are uncomfortable, IBS — unlike ulcerative colitis and Crohn’s disease, which are forms of inflammatory bowel disease — doesn’t cause changes in bowel tissue or increase the risk of colorectal cancer.Only a small number of people with irritable bowel syndrome have severe signs and symptoms. Some people can control their symptoms by managing diet, lifestyle and stress. Others need medication and counselling.
In the year 2014, American Gastroenterogical Association came out with guidelines on Pharmacological Treatment of Irritable Bowel Syndrome. The major recommendation of the guidelines ( in question and answer format ) are given as follows:-
More information about treatment about IBS - Medical travel and Medical tourism
Indo-UK Institute of Healthcare (IUIH) has come forward to set up 1,000-bed multi-speciality hospital here, it was announced.
A delegation from IUIH led by its chairman Mike Parker called on Telangana Chief Minister K. Chandrasekhar Rao, who assured all help from the government to set up the hospital, according to a statement from the chief minister’s office.
This will be one of the 11 institutes of health planned by IUIH, a consortium of Indian and British promoters.
Rao assured of allocating land near Outer Ring Road (ORR) for the facility. An MoU for the project will be signed after identifying the land.
The hospital will be set up with foreign direct investment and it will have the world-class infrastructure.
The delegation included UIH CEO Ajay Ranjan and British Deputy High Commissioner in India, Mike Nithavriankais.
Last year, Healthcare UK, a joint initiative of the Department of Health (DH), UK Trade and Investment (UKTI) and NHS England, had announced supporting Indo-UK Healthcare, a consortium of UK and India-based promoters to develop a chain of 11 Indo-UK Institutes of Health across India.
This was announced during Prime Minister Narendra Modi’s visit to Britain in November last year. An agreement was also signed on the occasion to set up first institute in New Chandigarh.
These institutes are expected to bring 1 billion pounds investment into India’s healthcare system, accompanied by strategic clinical and training partnerships with Britain’s finest NHS organisation, universities and private sector companies.
Hyderabad Hospital in collaboration with UK in India
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION
REVISION PETITION NO. 3812 OF 2011
(Against the Order dated 20/07/2011 in Appeal No. 81/2009 of the State Commission Himachal Pradesh)
1. MADAN LAL & ORS.
S/o Late Sh Shankar Chand, R/o Village Daka PO Palera, Tehsil and
2. Maste Shareshtha Bharati Nonir SOn,
Village Dhaka, PO. palera
3. Kumari Nanshee Wala Minor D/o madan Lal Son of Shankar Chand
Village Dhaka, PO. palera
1. DR. R.K. CHAUDHARY & ANR.
RK Nursing Home, VPO Bitra, Tehsil
2. Dr. Smt. Veena Choudhary
R.K Nursing Home, VPO Birta , Tehsil and
3. THE NEW INDIA ASSURANCE CO. LTD.
HON'BLE MR. JUSTICE J.M. MALIK, PRESIDING MEMBER
HON'BLE DR. S.M. KANTIKAR, MEMBER
For the Petitioner :Mr. Shaurya Sahay, Advocate
For the Respondent :For the Respondent Nos. 1 & 2 : Mr. K.G. Sharma, Advocate
For the Respondent No. 3 : Mr. Amit Kumar Singh, Advocate
Dated : 01 Apr 2016
O R D E R
DR. S. M. KANTIKAR, MEMBER
2. That in U/S scanning the normal (homogenous) and all normal (heterogeneous) tissue is differentiated and diagnosed as diseased one. Any lesion of the dimensions of two centimetres or less with inadequate heterogenicity is likely to be missed and more so when it is present in posterior wall of the uterus. As rightly said and taught and medical text “Images (i.e. Scan films) are good servants (guide) but bad masters “the repost of it is always to be correlated by the Specialist concerned with his/her clinical findings of the particular patient and so it is mentioned to correlate clinically. Also at times the report of different doctors may differ for the same patient and hence it is utmost essential to correlate the same with the clinical findings of the doctor concerned (Specialist asking for the U/S scanning).
1. Fibroid uterus with ovarian cyst which had been a sole indication for surgery is not supported by clinical findings as well as investigation. Available USG report does not confirm the above diagnosis.
2. Pre-operative & post-operative care given to the patient was a routine care which was modified according to the complaints of the patient.
3. On 15.07.2003 i.e. the 8th post-operative day the condition of the patient deteriorated for which no cause or diagnosis has been mentioned in the record and no relevant investigations to determine the cause of deterioration are mentioned in the record.
4. According to the death report issued by the Govt. Medical College, Chandigarh the cause of death was post-operative Pancreatitis with sepsis with Cardiorespiratory Arrest. No relevant record supporting the cause of death is available. Hence, opinion regarding cause of death and its co-relation with the deteriorating symptomatology of the victim on 8thpost-operative day may be sought from the doctor who examined and treated the patient after admission to Govt. Medical College Chandigarh.
“a) The report of the Ultrasound provided to us from the police department does not show any abnormality such as fibroids in the uterus or ovarian cyst. Also we do not know the clinical symptoms of this patient, we cannot say for sure whether the decision of the operating doctor to operate was right or wrong. There is no mention of the symptoms of menorrhagia. Also, we as internal medicine specialists cannot say about the indications of surgery in menorrhagia.
b) We also cannot say that any negligence has occurred especially as the cause of death has not been established. A post-mortem should have been done for a definite diagnosis of death.”
Will the ovaries be removed or left in place?The ovaries generally are not removed when a hysterectomy is performed for uterine fibroids. Removing the uterus alone will cure the bleeding and the size-related symptoms caused by the fibroids. Removing the ovaries is thus not required in treating fibroids as it is for other diseases like endometriosis or gynecologic cancers.
Many physicians were taught that at a set age (which varies between 35 and 50) women should be told that removal of the ovaries is recommended as part of the surgery, in the mode of “while we are there, we may as well.” The general teaching had been that ovaries don’t have any function after menopause and the risk of ovarian cancer increases with increasing age, so removing the ovaries near the time of menopause was a no-lose proposition. This was especially true if hormone replacement therapy could be used to help younger women transition to the time when they would naturally go through menopause.
In the instant case, the patient was 37 years of age. We do not find any justification to the act of OP, who performed TAH with removal of one ovary.
It further observerd that,
In the instant case the OPs failed on all counts.
ABORTION TRAVEL TO INDIA
Patient from Middle East travel to India as a legal safe and confidential destination for Medical and Surgical abortion.
A surgical abortion ends a pregnancy by surgically removing the contents of the uterus. Different procedures are used for surgical abortion, depending on how many weeks of pregnancy have passed.
Care before and after a surgical abortion includes a physical exam and lab tests, education about what to expect, self-care instructions, symptoms that mean you should call your doctor, and birth control planning.
Surgical methods in the first trimester (5 to 12 weeks)
Manual vacuum aspiration (MVA) or machine vacuum aspiration uses suction through a small tube to empty the uterus of all tissue.
Surgical method in the second trimester
Dilation and evacuation (D&E) are typically done when an abortion occurs in the second 12 weeks (second trimester) of pregnancy. It usually includes a combination of vacuum aspiration, dilation and curettage (D&C), and the use of surgical instruments (such as forceps) to clear the uterus of fetal and placental tissue.
A D&E is most commonly used during the second trimester because it has a lower complication risk than induction abortion.
Nonsurgical method in the second trimester
Induction abortion ends a second-trimester pregnancy by using medicines to start (induce) contractions, which expel (push) the fetus from the uterus. If the fetus has severe medical problems, a woman may choose to have an induction abortion.
More information about Medical and Surgical Abortion in India
UK visa applicants can complete the entire visa application process and enrol biometric data from their homes or offices through ‘On Demand Mobile Visa’ services. UK Visas and Immigration has launched this ‘on demand’ service that can be delivered on request at the applicant’s residence, office, or any location of choice (subject to risk assessment), in partnership with VFS Global. The service will be convenient and economical for large groups of people traveling to the UK, such as group corporate employees, college campuses, or film production unit members. The service is available by appointment only on a day of choice (including weekends) and charged separately. Another exclusive service, Home to Home (H2H) service, which provides chauffeur services and end-to-end assistance with form-filling and submission has been introduced for out-of-town applicants who may have to travel to certain cities for their UK visa applications. The H2H service offers pick-up and drop from airport/train station; access to premium lounge; personalized VFS assistance; longer working hours and is available at Ahmedabad, Bangalore, Chennai, Hyderabad, Gurgaon, Mumbai, and New Delhi. Speaking about the new services, Nick Crouch, UKVI Regional Director for South and Southeast Asia, said, “This is yet another example of UKVI and VFS working in partnership to offer visa applicants the service that they want. It is in direct result to client feedback and we are confident that these services will prove popular. We will continue to work together to improve our services even further.”
Air Ambulance International
US Congress and Government Help for Air Ambulance
It is but in the interest of Air Ambulance companies to take help from the Government.
What is often lost in mainstream media coverage of the U.S. air medical industry is the fact that the industry has more than one operating model. While many for-profit, community-based air medical operators are locked in battle with patients and insurance carriers, other providers simply are not. Boston MedFlight chief financial officer Maura Hughes said the service has a “great” relationship with insurance companies. “They know our patients are sick,” she explained. “We don’t have claims denied based on medical necessity.”
Boston MedFlight is a unique example of an air medical transport service: a nonprofit program funded by a consortium of otherwise competitive medical centers. For 30 years, Boston MedFlight has operated with the mission to “provide the right vehicle to the right patient at the right time, and transport them to the right facility.” Often, the right vehicle is a ground ambulance; the service reserves transports in its S-76 and Airbus Helicopters EC145s for those patients who would benefit from them the most.
“Our acuity is among the highest in the country,” observed CEO and medical director Suzanne Wedel. “We’re not doing transports that other services — for example, ground ALS — could do just to add to our numbers.” By contrast, a 2009 review by the Arizona Department of Health Services found a significant amount of inappropriate utilization among trauma patients transported by air ambulance in that state: 43 percent were discharged to home from the emergency department within 24 hours, and 88 percent had non-life-threatening injuries (as defined by a probability of survival greater than 90 percent).
While Boston MedFlight has adhered to the highest clinical and aviation standards and maintained positive relationships with its payors, it’s also true that the service loses money each year — as do many hospital-based and nonprofit programs around the country. The hospitals in the consortium continue to support Boston MedFlight because they see it not as a profit center, but as a cost center that serves a valuable role in the longitudinal continuum of a patient’s treatment. “Would we like to be paid more? Of course; we’re a high clinical acuity service, with significant investment in our aviation technology and training,” said Wedel. “But if you’re just focusing on the transport piece, you’re missing a lot of the patient experience and the cost of delivering care.”
The narrow focus on transport reimbursement is why many nonprofit and hospital-based air medical providers are skeptical of House Bill H.R. 822 and Senate Bill S. 1149 — twin bills, championed by AAMS, that are now under consideration by Congress. The bills would require air medical providers to report cost data, which would eventually be used to set Medicare reimbursement rates that accurately reflect the cost of providing air medical transports. In the meantime, the bills would increase Medicare reimbursement rates by 20 percent immediately, and by five percent each subsequent year until the new, cost-based guidelines are adopted. The House bill would provide a rate boost beginning in 2016; the Senate version would commence rate hikes in 2017, and would require the increased expenditures to be budget-neutral.
“Today’s reality is for every 10 patients flown, two may pay nothing at all (uninsured) and five are on government insurance like Medicare and Medicaid, neither of which pay close to the cost of an average transport (underinsured),” AAMS’ Blair Beggan wrote in an email to Vertical. “Our efforts on Medicare are solely focused on ensuring the Medicare pays a fair price for the cost of the services provided.”
It’s true that Medicare reimbursement rates, which since 2002 have only been adjusted by inflationary updates averaging 2.2 percent a year, no longer come close to covering the current costs of most air medical transports. Moreover, the increases proposed by H.R. 822 and S. 1149 would benefit all providers, including nonprofit services like Boston MedFlight. However, the biggest beneficiaries would be those for-profit, community-based providers who benefited the most from the original changes to Medicare reimbursement. And the legislation doesn’t consider the relationship between the cost per transport and volume of transports — which could encourage providers to pump even more helicopters into an already crowded market. “If this is such a bad business, then why do we have more and more suppliers?” observed LifeFlight of Maine’s Tom Judge. “The industry has created all of its own cost problems.”
Beggan countered that AAMS does not expect to see significant further growth in the number of helicopter air ambulances, but does anticipate growth in their number of flight hours. “It is readily apparent that the need for air medical transport will only increase over time,” she explained. “Air medical transport continues to fill a growing gap in the healthcare system in the U.S. As trauma centers and rural hospitals continue to close their doors, EMS helicopters are the means to move critically ill and injured patients to the medical facility best suited to treat their condition in a timeframe that can make a significant difference in their clinical outcomes.”
Beggan said that AAMS is optimistic about the prospects for H.R. 822 and S. 1149, citing “a number of productive conversations with the committees and our congressional supporters who serve on those committees.” When he’s speaking on the record to Air Methods investors, Aaron Todd is also optimistic about the proposed legislation (which hasn’t stopped Air Methods from recently diversifying into aerial tourism).
But the legislation faces some fundamental hurdles. As Boston MedFlight’s Maura Hughes observed, “Everyone knows we’re spending too much money on healthcare in this country.” Air Methods had over $1 billion in revenue last year, and AAMS’ supporters in Congress will have to make a plausible case for why the company and its competitors deserve even more.
A Legal Workaround?
States have long been told by the U.S. Department of Transportation (DOT) and various court rulings that they are prohibited from regulating air ambulance companies by the ADA, which explicitly prohibits states from enacting or enforcing any law related to “a price, route, or service of an air carrier.” When the ADA was passed in 1978, it was with the belief that deregulation would promote “efficiency, innovation, and low prices” among commercial airlines, and its intended beneficiaries were American consumers, not air medical stockholders. However, courts have consistently upheld that air ambulance providers qualify as air carriers for purposes of the ADA, and the DOT maintains that “state requirements with a ‘significant impact’ on an air carrier’s prices, routes, or services are preempted.”
But the level to which prices have risen has led many states to look for workarounds, and some believe they have found one in the McCarran-Ferguson Act of 1945. This act of Congress explicitly reserves the regulation of insurance to the states, except in cases where federal law specifically relates to “the business of insurance” — which the ADA does not.
When North Dakota passed its landmark air ambulance legislation in April of this year, it was careful to tie the provisions of that legislation to the business of insurance. The new law created service response zones for helicopter air ambulances “which are based on response times and patient health and safety,” and established primary and secondary call lists of air ambulance providers operating in the state. To qualify for the primary call list, a provider must be in network with health insurance carriers representing at least 75 percent of the health insurance coverage in North Dakota. Now, when a call for a request comes in, the recipient of the request must first reach out to the providers on the primary call list within the response zone. Only if none of them are willing and able to respond to the call may the dispatcher proceed to contact the providers on the zone’s secondary call list.
The North Dakota law also addresses the lack of transparency that has helped sustain air ambulance price increases. The ADA assumes the existence of informed consumers making free choices, which most of us are, when we compare airline ticket prices and book a flight on Southwest. However, most critically ill or injured patients have no control over which air ambulance is called for them, and are not told the price of the transport before the flight (which is why air ambulance providers concentrate their marketing efforts on the EMS organizations and hospitals doing the referring, not the patients themselves). The North Dakota law requires air ambulance companies to disclose their fee information, which is made available to referring agencies in advance. It also requires hospitals to make a reasonable effort to provide patients or their legal guardians with this fee information for the purpose of allowing them “to make an informed decision on choosing an air ambulance service provider,” unless a delay in transport might jeopardize their health or safety.
Air ambulance companies aren’t taking this without a fight. Valley Med Flight has filed suit against North Dakota in U.S. District Court, claiming that the law, H.B. 1255, is preempted by the ADA as well as by the Emergency Medical Treatment and Active Labor Act, which vests the treating physician with decision-making authority for emergency transport services. “By virtue of H.B. 1255, the dominant insurance carriers in the state, such as BCBS [Blue Cross Blue Shield], will effectively be setting the prices for air ambulance services,” Valley Med Flight observes in its complaint. The company states it has already been compelled to sign an agreement with BCBS “at rates that are substantially below the market rates charged by an air ambulance operator,” and that if it is unable to set the rates it needs to sustain its operations, it “will likely be forced to cease its critical life-saving operations in rural communities in North Dakota, with such cessation at the expense of the life and health of citizens in rural communities.”
Meanwhile, on Sept. 8, 2015, Texas Administrative Law Judge Craig R. Bennett issued a significant ruling in a dispute involving PHI Air Medical and insurance carriers in numerous workers’ compensation cases. According to a recent article by attorney James Loughlin, who represented insurance carriers in the dispute, air ambulance providers for many years accepted payment under the Texas Division of Workers’ Compensation’s medical fee guideline, which since 2002 has been set at 125 percent of the Medicare rate. Beginning in 2012, however, air medical companies began arguing that they were entitled to their full billed charges, which led to an explosion in the number of active medical fee disputes at the division, and the number appealed to the State Office of Administrative Hearings (SOAH).
In November 2013, SOAH’s Judge Bennett found that, due to the McCarran-Ferguson Act, the ADA does not preempt Texas guidelines for air ambulance reimbursement. He remanded a number of cases back to the Division of Workers’ Compensation, which, in a departure from previous decisions, began finding that air ambulance providers’ billed charges were “fair and reasonable” and ordered payment accordingly. Insurance carriers appealed, and 33 cases involving PHI were joined for hearing under the lead docket. After considering the evidence, Bennett ruled that neither PHI’s billed charges nor 125 percent of Medicare represented “fair and reasonable” reimbursement. Instead, he found the fair and reasonable amount to be 149 percent of the Medicare rate — which “reflects the per-transport amount of revenue that allows PHI to recover its costs and earn a reasonable profit,” and “neither unfairly subsidizes other patient populations nor requires subsidization by other populations.”
Neither Loughlin nor PHI responded to requests for comment on the case, but at press time, industry observers expected both PHI and the insurance carriers to appeal the ruling. While the ruling directly pertains to only a small number of air ambulance transports, its reference to the McCarran-Ferguson Act sets a precedent that other states and insurance companies will likely seize upon in their attempts to limit reimbursement. When Vertical asked AAMS for its opinion on the case, director of communications Blair Beggan stated, “The recent decision in Texas is under review, but it’s too early in the review process for AAMS to be able to comment.”
Air Ambulance facts and Cost factor
Helicopter Ambulance cost - Is it rising.
When Todd addressed the “inefficiency of competition” in the market, he referenced the statistic that the doubling of the U.S. air medical fleet over the past 10 years has helped an estimated 80 million Americans who can access Level 1 or Level 2 trauma centers within an hour only through the use of air medical helicopters. That’s significant, but the expansion of coverage hasn’t been evenly distributed. As the ADAMS maps show (see Figure 1), new bases have clustered in areas where reimbursement rates and payer mixes are most favorable, leaving large areas of the country with close to the same coverage they had a decade ago.
“A helicopter in a rural area improves access to care, but three helicopters in the same rural area do not actually increase access to care, they only increase costs,” observed Tom Judge, executive director of LifeFlight of Maine and a former president of AAMS. “The 2010 study by the GAO showed a 35 percent increase in the number of patients served between 1999 and 2008, but an 88 percent increase in the number of helicopters.”
When the number of helicopters in an area goes up, the number of patient transports per helicopter goes down — which leads to dramatic increases in the cost per transport. That’s because most of the costs associated with running an air ambulance service are fixed costs, which include, according to AAMS, “aircraft and associated maintenance costs; the costs of maintaining highly trained, properly licensed, and experienced flight and medical teams; and the significant costs of necessary safety equipment to ensure patients are cared for in the safest operational environment possible.”
Various industry sources consulted for this article estimated the fixed costs of an air ambulance base with one single-engine helicopter at around $225,000 per month; for a more medically sophisticated program flying twin-engine aircraft, the fixed costs can easily be twice that. The variable costs are relatively small by comparison: for example, Conklin & de Decker estimates the operating cost of an Airbus Helicopters AS350 B3 at around $750 per flight hour, and that of a Sikorsky S-76C+ at about $1,850 per hour. (The cost of medical supplies used during a transport is often factored into fixed costs.)
It’s not hard to do the math. Suppose a base with a single AS350 B3 performs 50 transports per month, with an average transport time of one hour. Then its total costs are its fixed costs ($225,000) plus its variable costs ($750 x 50 = $37,500), or $262,500. Dividing by the number of transports yields $5,250 per transport — which is close to the Medicare reimbursement rate. If that base performs only 35 transports per month, however, then its cost per transport rises to around $7,200, which is well above what Medicare reimburses. (Coincidentally, $7,100 to $7,200 was the average cost per transport for Life Star of Kansas in 2014, according to executive director Greg Hildenbrand. The nonprofit air medical program operates two AS350 B2s and an AgustaWestland AW119 Koala.)
Declining volumes have forced all air ambulance providers, even the nonprofit ones, to raise their rates. As Hildenbrand put it, “I’m blown away by our charges, and we’re charging a fraction of what other providers are charging.” Of course, for-profit providers are looking to do more than break even; they’re striving to continually grow their profits, year after year. So for-profit, community-based providers have raised their prices to compensate for declining volumes and ordinary inflation, then raised them again — and again, and again — to satisfy investors and pay fat executive salaries.
The extent to which they have been able to do so has been remarkable. As Voce Capital observed in its September public letter, “Because its prices are unregulated and demand is relatively inelastic, Air Methods has been able to take price routinely.” But Voce also noted that this is a “controversial practice” that is increasingly difficult for Air Methods to sustain as a public company.
Hospitals (and, by extension, hospital-based air ambulance providers) generally avoid aggressive collection practices because of the associated bad publicity; as Cato’s Michael Cannon pointed out, such negative press “is one of the market’s ways of disciplining providers.” Because community-based air medical providers typically have a lower public profile than hospitals, they haven’t taken the same precautions, but the market’s discipline may finally be catching up with them.
For many years, the air medical industry’s alarming safety record was the subject of critical media coverage. Now, such stories have given way to disturbing accounts of ordinary, insured Americans being driven into bankruptcy by air ambulance bills they can’t afford to pay. These horror stories have helped scare many people into buying “memberships” with community-based air medical providers, augmenting what is for some providers a substantial source of revenue. However, since memberships only protect individuals from balance billing, they haven’t won over insurers, who are still charged sky-high rates for members’ transports — and are finally starting to push back.
As of September 2014, there were 1,020 public and private helicopter air ambulances in the U.S., according to the Association of Air Medical Services (AAMS) and its Atlas and Database of Air Medical Services (ADAMS). If you think that sounds like a lot, you’re not alone. In Air Methods’ first quarter 2015 earnings conference call, CEO Aaron Todd remarked, “If you ask me personally, do we need 900 air medical helicopters to serve the country, I’d say probably not, maybe 500, 600 could do as well, but it’s an open market . . . and so, therefore, there’s going to be the inefficiency of competition.” (Air Methods, along with PHI Air Medical and AMGH, did not respond to repeated requests for comment for this article; AMRG failed to respond after initially indicating it would do so.)
The U.S. civilian air ambulance industry has grown steadily since the first programs were established in the 1970s, but the industry underwent significant change in 2002. That’s when the Centers for Medicare and Medicaid Services began phasing in a national fee schedule for air ambulance providers, part of a series of Medicare payment reforms mandated by the Balanced Budget Act of 1997.
As described in a 2010 report by the Government Accountability Office, prior to 2002, Medicare reimbursement differed depending on the air ambulance provider’s business model: hospital-based providers were reimbursed based on reasonable costs (and generally received higher reimbursement), while independent, community-based providers were reimbursed based on reasonable charges (and received less). The new fee schedule established a single rate for helicopter transports regardless of the business model followed; although it provided for higher reimbursement for transports in rural areas, it did not make provisions for the type of aircraft used, or the level of medical or safety equipment on board.
The new fee schedule incentivized the expansion of community-based providers flying smaller, cheaper helicopters, and that is exactly what happened. According to ADAMS, in 2003, there were 545 helicopter air ambulances in the U.S.; today, there’s almost twice that number. Meanwhile, the composition of the fleet has shifted from 41 percent single-engine and 59 percent twin-engine in 2004, to 51 percent single-engine and 49 percent twin-engine in 2014.
Helicopter Ambulance in the United states
Rising cost of Air Ambulance in the United States
In December 2009, NBCNews.com reported on high prices in the air medical industry in an article titled “Air ambulances leave some with sky-high bills.” The story opened with the case of Charlie Taylor, a then 49-year-old man from Lyons, N.Y., who was flown to the hospital by helicopter after a four-wheeler overturned on his chest, breaking seven ribs. Like many air ambulance patients, Taylor appreciated the care he received, but was stunned when he saw the bill for the flight.
Earlier this year, the New York Times published a similar article: “Air ambulances offer a lifeline, then a sky-high bill.” This story highlighted the case of Clarence W. Kendall, an Arizona rancher who was transported by air ambulance after he fell eight feet from a haystack and struck his head on the corner of a truck. The circumstances of the case were similar to Taylor’s, but the details underscored how much has changed in the past five-and-a-half years. Taylor’s bill — which “took his breath away” — was for $8,700, and was covered by his health insurance. Kendall’s bill — which “nearly gave him a heart attack” — was for $47,182 and was not covered by his insurance, leading the provider, Air Methods, to sue him to collect.
The provision of helicopter emergency medical services has always been an expensive undertaking — helicopters aren’t cheap, and neither is the advanced critical care that has come to be associated with rotary-wing air ambulances. But dramatic recent increases in billed charges by for-profit air medical providers are changing the public profile of the industry in the United States. With growing frequency, these providers are in the news not for saving their patients’ lives, but for presenting them with bills in the tens of thousands of dollars, then “resorting to hard edged legal tactics to get paid” (as the Times put it).
The bad press has been so significant that Air Methods shareholder Voce Capital referred to it explicitly in September of this year, when it issued a press release and public letter to the board of Air Methods arguing for the sale of the company to private investors. According to this activist hedge fund, the popular press now “depicts Air Methods as a villain that victimizes the very patients whose lives it saves, allegedly gouging them with rapacious pricing and then targeting them with aggressive collection efforts when they fail to pay.” Voce contends that Air Methods’ disclosures as a publicly traded company — including its “candor regarding its pricing strategy, and disclosures about its collections and the aging of its receivables” — have made it a prime target for negative attention and contributed to its falling stock price, which as of the date of the letter was down 37 percent over 12 months.
Whatever the actual motivations behind Voce’s letter (which triggered a sizable but temporary bump in the stock price), it is correct in observing that “the granular availability” of Air Methods’ data is unique in the air medical industry. Thanks to its financial disclosures, we know that Air Methods has increased its billed charges from an average of $13,198 in 2007 to $40,766 in 2014, according to data compiled by Jon Hanlon of the independent research firm Research 360. Likewise, we know that this tripling of its prices has contributed to a tripling of its net income, which has grown from $27.5 million to $99.4 million over the same time period.
But Air Methods is not alone in its pricing strategy. PHI Air Medical, a division of the publicly traded company PHI Inc., saw a 26 percent increase in profits from 2013 to 2014 alone, which was also helped by rate hikes. According to Research 360, PHI’s average charge per transport for privately insured individuals now exceeds $40,000 in some states, up from around $28,000 just three years ago. Lawsuits and consumer complaints across the U.S. reveal similar figures for companies in the privately held Air Medical Group Holdings (AMGH) and Air Medical Resource Group (AMRG), which do not disclose their financial data. According to a list of North Dakota Insurance Department air ambulance complaints, in 2014, the AMGH company Med-Trans charged $35,923.47 for a helicopter transport of less than 100 miles. Meanwhile, in 2013 an AMRG company, Guardian Flight, charged $50,062.17 for a transport of less than 20 miles.
According to Michael Cannon, director of health policy studies at the Cato Institute, “sticker shock” isn’t unusual in the healthcare industry — hospitals and other providers often set high “list prices,” from which they negotiate discounts for payers based on the payer’s negotiating power, and the return the provider expects to see from taking a tough negotiating stance. Typically, he said, insurance companies who negotiate and pay on behalf of large numbers of subscribers will get substantial discounts (while even larger discounts may go to patients who pay cash). This familiar dynamic is at work for many hospital-based air ambulance programs, which are generally “in network” with major insurance companies, and may be willing to accept as little as half, or less, of their billed charges as payment.
However, the community-based programs that have raised their prices the most have deliberately remained out of network — charging, essentially, whatever they want. Like hospital-based programs, community-based providers will accept very low set reimbursement rates for Medicare and Medicaid patients, and will receive little to no reimbursement for uninsured patients who lack the means to pay. The remaining, privately insured patients are consequently their major source of revenue, and many community-based programs, after accepting an initial payment from a patient’s insurer, will balance bill the patient for the rest.
As Air Methods CEO Aaron Todd noted in a recent earnings call, the company actually collects “very little” from individuals. But the individuals in question don’t necessarily know that. When an air ambulance company threatens a patient with a lawsuit and a lien or the specter of bankruptcy, the patient tends to lean on his or her insurer or employer to cover a larger share of the charges — often resulting in several more payments from the insurance company before the account is closed. (Todd explained in the earnings call, “When we get to the point where we know that we are just working with the patient, we will work very quickly to get the account wrapped up.”)
For many years, insurers have gone along with these price increases, supporting continued growth in what Todd described to Vertical in 2010 as an already saturated market. Now, however, the tide appears to be turning. While the size of insurers’ first payments to Air Methods continues to grow, the rate of growth has decelerated significantly. Meanwhile, workers’ compensation insurance carriers in Texas have mounted a successful challenge to PHI’s high charges, with an administrative law judge finding that the Airline Deregulation Act (ADA) of 1978 does not preempt states’ rights to regulate the business of insurance. North Dakota earlier this year passed legislation that would force air ambulance providers to negotiate with insurers to be placed on a priority call list, and several other states are also considering legislation that would limit what air ambulance providers can charge.
To be sure, protracted legal battles lie ahead on all of these fronts, and the ADA has served the air medical industry well in the past. The industry is also pinning its hopes on proposed legislation in Congress that would raise Medicare reimbursement rates by an immediate 20 percent, giving a significant boost to providers’ bottom lines. Nevertheless, the challenges being faced by the industry are real. In pushing prices ever higher, has the for-profit air medical industry finally reached a limit?
Air Ambulance International
Over the last 20+ years, the air ambulance industry has experienced some turbulence. In 1990, there was only one air ambulance accident in the U.S. with a fatality. Throughout the 90s, the number of air ambulance crashes, mostly involving helicopters, began to climb. The number of accidents peaked in 2004, when there were 19 accidents and 29 fatalities. Accidents have leveled off since then, but it’s still very much an issue the industry struggles with.
Fast-forward to the present, the air ambulance industry has seen rapid growth. In 2003, according to the Association of Air Medical Services (AAMS), there were 545 helicopter air ambulances in the U.S.1 Today there’s almost twice that number. TechNavio estimates that the industry will experience a compound annual growth rate (CAGR) of 9.57% over the period of 2014 to 2019, with an increasing number of vendors and a growing number of people in need.2
As we move into 2016, one of the biggest challenges facing the air ambulance industry is adequate safety, and one of the most promising prospects is the development of patient transport drones combined with remote-controlled telemedicine.
The military has experienced several incidents in which soldiers were in need of medevac services, but were unable to receive these critical services due to their location in hot zones deemed too high-risk for standard helicopter medevac response. In an attempt to find a solution, the U.S. Army sponsored a Small Business Innovative Research grant asking for concepts of an autonomous vertical, takeoff and landing, unmanned aircraft system for medical missions such as critical item resupply and casualty evacuation.
With the increase in air medical helicopters and airplanes deployed, there's a greater probability of accidents, simply because it’s hazardous work. When rescuing patients from remote areas in bad weather, unfamiliar landing zones or from military hot zones, both the civilian and military markets can benefit from the type of innovation sought by the research grant.
In 2007, United Medevac Solutions was fortunate to participate on this futuristic project with a collaborative team organized by the Aerospace Engineering Department at Georgia Tech University.
The concept was for the unmanned flying ambulance to arrive remotely piloted and once the ground medic loads the patient onto a specially designed stretcher platform, vital signs are monitored, IV fluids and medications can be administered and other life-saving procedures can be performed via remote control telemedicine.
In the years since, multiple companies have continued the development of these drone platforms, and in 2015 an Israeli company, Urban Aeronautics, actually built a working prototype of an unmanned aerial medevac aircraft for military use.3
Once this is proven as a military product, the same concept will have immediate applications in the civilian air medical industry. Sending drones instead of piloted ambulances into hostile weather and obscure environments will save air medical crew members' lives. Often, air medical crews feel compelled to respond to emergencies when they shouldn’t because of the human factor—a desire to help even when conditions aren’t safe. Unmanned flying ambulances could rescue patients injured by natural disasters, lost in dangerous territory or unexpectedly suffering from a medical emergency. These drones could also deliver food and supplies to isolated populations or inaccessible areas.
The air ambulance industry has always been dangerous. Sweeping technological progress is helping to change that, and we are seeing much progress in 2016. As we move further into the 21st century, a combination of drones and telemedicine will provide timely service, reduce flight crew risk/expenses and save lives.
Air Ambulance in Europe - www.airambulancespain.com
Inquest records misadventure in tragic cruise death
A coroner has recorded the verdict of misadventure in an inquest into the death of a cruise passenger while she was trying to board Cunard's Queen Elizabeth after an excursion.
Mary Atherton, aged 75, from Lancashire, was attempting to step from a tender on to a pontoon when an unexpected wave came.
Crew members jumped in to try to rescue her but she was crushed between the tender boat and the pontoon.
She was returning to the ship after an excursion in Sihanoukville, Cambodia.
During the inquest, her family had criticised Cunard saying crew should have been told about her mobility problems, which had been shared with the cruise line.
But coroner Dr James Adeley said it was impractical to expect the crew to have known.
He also dismissed evidence by an independent marine expert who said boarding should have been stopped because of the conditions, saying the evidence was ambiguous and was affected by hindsight.
Since the tragic accident last April, Cunard parent Carnival UK has brought in new safety procedures and has designed a new-style gangway for use in tender embarkation and disembarkation.
Women with a specific gene mutation that is known to increase the breast cancer risk may also have fewer eggs in their ovaries, finds significant research.
Women who carry the faulty versions of genes called BRCA1 and BRCA2 are also at an increased risk of developing breast, ovarian and fallopian tube cancers, the team said, suggesting that women carrying BRCA1 mutation should not delay pregnancy till their late 30s or 40s as fertility may be reduced because of their age.
“This means that women in their mid-30s, who carry the BRCA1 mutation have, on average, ovarian reserves similar to those of non-carriers who are two years older,” said lead researcher Kelly-Anne Phillips, professor and oncologist at the Peter MacCallum Cancer Centre in Melbourne, Australia.
The study analysed the levels of anti-Mullerian hormone (AMH), an indicator of egg counts, in women with either the BRCA1 or BRCA2 mutation.
The team found that women with BRCA1 mutations had 25 percent lower AMH concentrations than non-carriers on average, which is equivalent of a two-year age increase for a non-carrier woman in her 30s.
Also, BRCA1 mutation was found to damage DNA. The team said the BRCA1 mutation might stop DNA being properly repaired, which increases the risk of both cancer and infertility.
The findings also raise the hypothesis that BRCA1 mutations carriers may have a higher than average risk of chemotherapy-induced menopause.
For the results, the team analysed 693 women aged 25 to 45 who had no personal history of cancer.
A total of 172 women were carriers and 216 women non-carriers from families carrying the BRCA1 mutations, and 147 carriers and 158 non-carriers were from families with the BRCA2 mutations.
A new analysis of 204 studies involving more than 1.4 million people suggests that metformin, the most frequently prescribed stand-alone drug for type 2 diabetes, reduces the relative risk of a patient dying from heart disease by about 30 to 40 percent compared to its closest competitor drug, sulfonylurea.
The study, designed to assess the comparative not absolute or individual benefits and risks of more than a dozen FDA approved drugs for lowering blood sugar in type 2 diabetes, is described in the April 19 issue of the Annals of Internal Medicine. Diabetes now affects almost 10 percent of the U.S. population and poses a growing public health threat, and most people will eventually need drug treatment, the researchers say.
“Metformin looks like a clear winner,” says Nisa Maruthur, M.D., M.H.S., assistant professor of medicine at the Johns Hopkins University School of Medicine. “This is likely the biggest bit of evidence to guide treatment of type 2 diabetes for the next two to three years.”
Maruthur, the lead author on the meta-analysis, notes that cardiovascular fatalities heart attacks and strokes are major risks for people with uncontrolled blood sugar, but it has never been clear if one diabetes drug is better than another at lowering these fatalities. Other diabetes-related complications include blindness, kidney failure and limb amputations.
This review, Maruthur says, provides a much-needed update to two previous analyses, the last one published in 2011. Since then, researchers have published more than 100 new studies comparing the effectiveness of various blood sugar-lowering drugs, and several new drugs have also come on the market since the last report.
Of the total 204 studies analyzed, 50 spanned several continents, while others were conducted across Europe, Asia and the United States. Most of the studies were short term, with only 22 mostly observational studies lasting more than two years. Participants in the studies were generally overweight with uncontrolled blood sugar levels. Many studies excluded the elderly and those with significant health problems. Just shy of half of the studies made no mention of race or ethnicity. When researchers did report that information, only 10 to 30 percent of participants were nonwhite.
Maruthur says the new analysis not only looked at cardiovascular disease but also other drug effects, including glucose control, and common side effects, such as weight gain, hypoglycemia and gastrointestinal problems. Because the majority of patients with type 2 diabetes end up using multiple blood sugar-lowering drugs, Maruthur and her team also evaluated how the drugs performed when used alone or in combination. While some of the various studies’ participants were on insulin, this injectable drug was only evaluated when used in combination with other drugs.
Among other findings, the new review revealed that DPP-4 inhibitors, a class of anti-diabetic drugs that were very new at the time of the 2011 review, were clearly less effective at lowering blood sugar levels compared to metformin and sulfonylureas.
In terms of side effects, a new class of drugs known as SGLT-2 inhibitors, which work by shuttling excess glucose out of the body through urine, caused yeast infections in 10 percent of users, a side effect unique to this drug, Maruthur says. However, SGLT-2 inhibitors, along with another drug class known as GLP-1 receptor agonists, helped patients lose weight. Sulfonylureas, on the other hand, caused weight gain and resulted in the highest rates of hypoglycemia, or too-low blood sugar, among the oral medications.
Cautioning that such meta-analyses can be limited because of differences in research protocols and measurements across studies, Maruthur and her colleagues took steps to ensure that only studies using similar methods were combined. Also, they excluded from their analysis any studies that included patients taking additional, nonstudy diabetes drugs.
Overall, Maruthur says, the results indicate that metformin, which has been around since the late 1990s, works just as well, if not better, than sulfonylureas, which have been on the market since the late 1950s/1960s, and diabetes drugs that have appeared on the market more recently. She says the new findings are in line with the current recommendation that metformin be used as a first-line therapy. The real question arises, Maruthur says, when patients and doctors must choose a second drug to be used in combination with the metformin.
“The medications all have different benefits and side effects, so the choice of second-line medications must be based on an individual patient’s preferences,” Maruthur says.
Maruthur and her team’s work will be published alongside the report they wrote for the Agency for Healthcare Research and Quality, the funding agency for the study, detailing the hundreds of studies included in Maruthur’s analysis and an exhaustive summary. Both the American College of Physicians and the Department of Veterans Affairs plan to use these publications to update their guidelines.
The cost of diabetes drugs is a major consideration when prescribing. While metformin is available as a relatively cheap generic, many newer drugs carry a hefty price tag. In 2014, per-person spending was higher for diabetes drugs for any other class of traditional drugs, in part because over half the prescriptions filled for diabetes were for nongenerics.
Other researchers involved in the study include Eva Tseng, Susan Hutfless, Lisa M. Wilson, Catalina Suarez-Cuervo, Zackary Berger, Yue Chu, Emmanuel Iyoha and Jodi B. Segal, all of Johns Hopkins. Shari Bolen of Case Western Reserve University in Cleveland, Ohio, led the 2011 review while at Johns Hopkins and served as a co-primary investigator with Maruthur on this recent work.
Chennai: In a complex procedure that reflected its commitment to technological advancement with its path breaking work, Fortis Malar took a leap forward by using Extracorporeal cardiopulmonary resuscitation (ECPR) to revive a man nearly 45 minutes after his heart had stopped beating. A team of cardiac experts at the centre of excellence for advanced cardiac care Fortis Malar, Chennai, led by Dr. K R Balakrishnan, Director Cardiac Sciences performed the lifesaving procedure on a 38 year old patient. This therapy involves supporting patient with a portable heart and lung machine and cooling the temperature of the patient down to protect the brain during cardiac arrest.
38-year-old Jaysukhbhai Thaker from Gujarat was suffering from dilated cardiomyopathy leading to end-stage heart failure. He was airlifted from Porbandar and admitted to Fortis Malar Hospital for a possible heart transplant. After being stabilised with medications, he was shifted to a ward.
While awaiting a donor heart, the patient suffered a sudden cardiac arrest and was unresponsive. Cardiopulmonary resuscitation was immediately started and despite attempts for over 45 minutes, there was no cardiac contraction and he was, for all practical purposes, dead. A decision was taken to use ECPR and he was put on a portable cardiopulmonary bypass machine called ECMO (extracorporeal membrane oxygenator) while the CPR was being carried out. Doctors persisted with the treatment and his heart finally started beating after 45 minutes, he remained unconscious for 10 days, after which he woke up. Since ECMO cannot be continued indefinitely, an artificial heart pump or Left ventricular assist device (LVAD) called Centrimag was inserted to support him in the interim. When a suitable donor heart became available, he underwent a successful heart transplant. The patient has now recovered completely and is ready to go home.
Dr. K R Balakrishnan, Director, Cardiac Sciences, Fortis Centre for Heart Failure and Transplant, at Fortis Malar, said, “The patient made a steady recovery post the surgery and is now leading a normal life. While mechanical CPR was performed on the patient, ECMO was introduced to revive his heartbeat. This is a perfect example of the success of combining extracorporeal membrane oxygenation (ECMO) with cardiopulmonary resuscitation (CPR) in saving patients during cardiac arrest. Though the procedure was technically difficult and challenging, it is a promising new technology in situations deemed to be uniformly fatal. We have increasingly started using ECPR for “in hospital” cardiac arrest with very good outcomes and are exploring the possibility of extending it to other locations , including outside the hospital, as is done in a few places around the world, like Japan, San Diego and Taiwan.”
“We can increase the chances of survival considerably by using ECPR in a cardiac arrest situation. The miniaturized heart lung machine has enabled us to institute ECPR at any location. With a wide ranging experience in handling cardiac patients, we continue to explore new frontiers and extend the limits of Cardiac Care as we establish Fortis Malar as one of the biggest Cardiac institutions in the world.” said Dr. Suresh Rao K. G, Chief of Cardiac Anesthesia and Critical Care at Fortis Malar.
Dr Ravikumar, Interventional Cardiologist noted “From a Cardiologist’s point of view ECPR is a wonderful life saving procedure, but under utilized in the cathlabs and coronary care units due to various logistic problems. Fortis Malar has now taken a lead in this very critically useful area and is the first hospital to start this in a formal manner for cardiac arrest patients”
Cardiac care at Fortis Malar is well established and ranked amongst the finest in the country. Our team of highly accomplished doctors led by Dr Balakrishnan and Dr Rao along with an experienced team of leading cardiac experts have been doing pioneering work in the field. Thanks to their efforts, Fortis Malar regarded as a landmark institution for cardiac care that is recognized far beyond Indian shores. We look forward to more remarkable milestones in the future”, said Mr Raghunath, Facility Director of Fortis Malar.
Today Mr. Thaker is a happy man and is grateful to God that he was lucky. “I feel I have got a new lease of life,” he said.
The World Health Organisation aims to reduce to zero by 2020 the number of children diagnosed with leprosy and related deformities.
The decision is part of a new strategy launched against leprosy by the global health body, which also called for stronger commitments and accelerated efforts to stop disease transmission and end associated discrimination and stigma, to achieve a world free of leprosy.
“The new global strategy is guided by the principles of initiating action, ensuring accountability and promoting inclusivity. These principles must be embedded in all aspects of leprosy control efforts,” Poonam Khetrapal, regional director for the World Health Organisation’s South-East Asia Region, said at the launch of the global strategy for 2016-2020 “Accelerating towards a leprosy-free world” here.
The new strategy also aims to reduce the rate of newly-diagnosed leprosy patients with visible deformities to less than one per million; and ensure that all legislation that allows for discrimination on the basis of leprosy is overturned.
“The key interventions needed to achieve the targets include detecting cases early before visible disabilities occur, with a special focus on children as a way to reduce disabilities and reduce transmission, targeting detection among higher risk groups through campaigns in highly endemic areas or communities, and improving health care coverage and access for marginalised population,” said Khetrapal.
She said screening all close contacts of leprosy affected people, promoting a shorter and uniform treatment regime, and incorporating specific interventions against stigma and discrimination are the other strategic interventions that endemic countries need to include in their national plans to meet the new targets.
“The new strategy builds on the success of previous leprosy control strategies.
It has been developed in consultation with national leprosy programs, technical agencies and NGOs, as well as patients and communities affected by leprosy,” she said.
The strategy focuses on equity and universal health coverage which will contribute to reaching Sustainable Development Goals on health.
According to the health data, the main and continuing challenges to leprosy control have been the delay in detection of new patients and persisting discrimination against people affected by leprosy which has ensured continued transmission of the disease.
India, Brazil and Indonesia account for 81 percent of the newly diagnosed and reported cases globally.
Leprosy was eliminated globally in the year 2000 with the disease prevalence rate dropping to below one per 10,000 population.
Though all countries have achieved this rate at the national level, at the sub-national level, it remains an unfinished agenda.
Leprosy continues to afflict the vulnerable, causing life-long disabilities in many patients, subjecting them to discrimination, stigma and a life marred with social and economic hardships.
Leprosy in India - Communicable disease in India
The incident goes back to yesterday, when Pediatrician Dr Sunil Kumar Singh was attending to a child patient, while being on OPD duty at Jashpur Government Hospital in Uttarakhand’s Udham Singh Nagar district. At this time, around 10.30 am in the morning, two motor cycle borne assailants, reported to be their mid 20s approached the Hospital. One of the assailants went inside and shot the doctor in the chest from point blank range.
With the gunshot, chaos broke at the hospital and it is reported that the assailants escaped taking advantage of the commotion. The staff of the hospital, rushed the injured doctor to a private hospital in Kashipur, but unfortunately, Dr Singh died on the way.
Additional superintendent of police, Kashipur, Kamlesh Upadhyay informed TOI, “The initial findings hint at a personal rivalry but it is still early to arrive at any conclusion.” The police official further said that the two sons of Dr Singh were in Delhi and his wife was at Gaya at the time of crime. “Therefore, with family members not in Jaspur, not many facts related to the doctor have yet come to the fore,” the SP added.
Dr Singh, who hails from Gaya district in Bihar, had been posted in the district for last 15 years. The doctor, along with his wife and two sons, resided in his allotted residence inside the CHC premises.
Following the incident, the entire hospital had been shut down. As the news of the incident travelled, doctors of the Kumaon district demanded immediate arrest of the culprits, and showed their agitation by remaining off duty from work. The solidarity has been shown by both government doctors and private doctors alike who have come out openly condemning the incident and demanding justice
Provincial Medical Health Services (PMHS), an association of government doctors of Uttarakhand had declared that all government hospitals across the state will remain shut on Thursday, only emergency and post-mortem unit will be open. If the administration fails to catch the cuplits, doctors will even shut down the emergency as well. Similar reaction has come out from IMA Uttarakhand Branch, who are going to join the Statewide strike from tomorrow.
Speaking to Medical dialogues team, Dr DD Choudhary, General Secretary, IMA Uttarakhand Branch said,” Since Today IMA branches in the kumaon ragion have been on strike, along with the government doctors. Given the president’s rule in the state, we are going to meet the Governor tomorrow to demand justice for Dr Sunil Kumar Singh. If the culprits are not identified and caught at the earliest, all doctors across the state will go on a strike.”
Pediatrician in India shot dead in hospital
Polytrauma patient was evacuated from Dammam KSA to Kochi India in a safe and economical manner on a Commercial flight today.
Damiana Leaf Extract
"Damiani Tea has immensely improved the quality of life. It makes me feel so full of energy. It has improved my performance." says Lisa who is recovering from a long-term illness.
"I had major depression. My sex life was zero. Damiana helped me relax and overcome anxiety and get back the zing on the bed with my new partner. I Love it" says Mary.
Damiana leaves have been used as an aphrodisiac and to boost sexual potency by the native peoples of Mexico, including the Mayan Indians. The two species used in herbal healing are Turnera aphrodisiaca and Turnera diffusa.
Damiani is a known aphrodisiac and known since centuries to increase the sex life. Especially women find it highly enhancing at night. It is considered as 'the Queen of all Vitality Products'.
The product is extracted from the leaf and stem of a wild shrub which grows in Mexico, Central America and the West Indies.
Besides a potent vitality product - it is also useful for the treatment of depression, bed-wetting, anxiety, stomach upsets, constipation and it maintains and boosts general mental and physical stamina.
In Women, it is supposed to improve sexual satisfaction, increase orgasm frequency, and reduce vaginal dryness and has significantly enhanced their sex lives.
Damiana is safe to be taken by mouth in amounts commonly found in food or prescribed as medications by a qualified practitioner.
High doses of Damiana can rarely cause convulsions.
Avoid use during pregnancy and breastfeeding for there are not many studies to support the use of Damiana during the pregnancy and breastfeeding.
Damiana is supposed to decreased blood glucose in Diabetics so it is important to monitor your blood glucose when taking Damiana.
It is advisable to stop Damiana at least two weeks before any planned surgery since it can affect the blood glucose levels.
Damiana is said to interact with Diabetic medications like medications used for diabetes include glimepiride (Amaryl), glyburide (DiaBeta, Glynase PresTab, Micronase), insulin, pioglitazone (Actos), rosiglitazone (Avandia), chlorpropamide (Diabinese), glipizide (Glucotrol), tolbutamide (Orinase), and others.
HER ROAD TO SUCCESS!
"There was a certain standard of living I always dreamed of at home.
Training as a nurse and learning English help me to achieve the same." says Barbara.
She had completed training as a nurse and was planning to move to the UK to be a trained nurse.
She understood the misconception that nurses in the UK do not earn well.
She knew a mentor who was a Nursing Director in England earning about 95000 Pounds a year. The starting pay for nurses was 22000 Pounds a year. If you work in London, the pay could be 20% more than working in the interiors.
She knew that she could achieve all this lifestyle by learning to speak English. So she took the first step by joining a good English speaking training institute. That paved her way to her dream lifestyle.
Today her routine involves taking rounds with a senior nursing staff in the morning, administering medications to the patients, taking their vital parameters, doing the dressing for the post-operative patients.
Another work involves preparing for patient admissions, organizing discharges, taking hospital appointments, GP and specialist visits, reviewing care plans and arranging meetings for patients to see their relatives and friends. All this involves speaking in English.
With her absolute command over English, she enjoys being the main communicator with the patient relatives.
This means speaking to relatives in person, such as at regular Doctor-Patient meetings, over the phone and email. She has patients whose relatives are far away as America for instance, who appreciate updates about their loved ones. She is very good at it.
Her work is appreciated by her bosses as well as her patients.
Her plans are to join the Air Ambulance services the coming year.
The best thing about Nursing: it opens up doors you’ve never even thought of. I love being able to try out new things and discover what I like best. The potential is endless.
Thanks to her English speaking ability - she has achieved her dream!
Besides work, she enjoys being the wife to an English speaking gentleman whom she met in one of the meetings in the hospital, and she has two children, who are 5 and 3 years old. She enjoys swimming and music lessons. She does some social services in the community every weekend and enjoys interacting with people. She loves to travel and takes a holiday during Christmas time every year to go back to Poland.
A truly enviable lifestyle achieved by a Polish girl.
Her message to her fellow colleagues in Poland is the Road to her success started with the small English training course she took back home, and she remembers her teacher who played an important role in her training to become a successful Nurse in England.
Polish Nurse travel to UK for better opportunity. Flying Nurse opportunity in Air Ambulance.
Neurological patient transfer from India to United states
Brain in our Body
Most people does not understand what Dr.Jill says about "we can choose", since they know, they can't choose. They doesn't know that the choice is to choose between to be an opened system or a closed system, separated from the whole and closing the doors to evolution. We know that we can't spend choosing to run the deep inner-peace circuitry of our right hemispheres, But, evolutionary history is suggesting that yes, we can choose, or better, our ancestors made this choice before, and they chosen the left side, the field of closed systems. But we can fix this mistake.
Our brain has a systemic circuity that begins at the hippocampus, goes to the left side by clockwise direction and arrives to the superior cortex at the high top of the brain, drawing a half-moon. So, each thought that we have, runs inside this circuit and it works like a living thing. In a natural perfect system, when the flow arrives to the high top, it is divided into two flows ( you can see the picture of such system at my website). One flow continues normally drawing the another right half-moon till arriving back at the hippocampus. The second flow goes straight down towards the hippocampus, drawing a meridian in the brain, which generates the corpus callosum. This flow is responsible for the reproduction, self-recycling of the system, creating the perpetuation of systems' species, or connecting 'living' thoughts, creating the continuous thought that is the serial state of consciousnesses.
So, our ancestors choose to 'kill' the right flow. Our thoughts does not go beyond the left side of the cortex, they go back to its birth, or source, where they are self-recycled or they die.This was a "evolution-stop" of our brain's sensors also. But, which ancestors and why they did it... this wrong choice... A perfect closed natural system is a kind of paradise for the identity of that system living in it. Its body is its paradise. If you see the picture of this body
Doctor perspective in Mumbai India.
An article in Marathi
मग पहिले खूपखूप अभ्यास करून (टीव्ही खेळ छंद टाईमपास सगळं बाजूला ठेऊन) CET टॉप करा,
मग MBBS ला ऍडमिशन मिळवा,
साडेचार वर्षे पुन्हा पंचवीसेक विषयांचा अभ्यास करा,
(पहिले सहा महिने तर सगळं डोक्यावरूनच् जातं)..
रोज क्लास, क्लिनिक्स, केसेस,
एकाच विषयाची पाचसहा पुस्तके,
शेकडो रेफरन्स बुक्स,
सारख्या सारख्या परीक्षा, Viva सारखा टॉक्सिक प्रकार..
सारखी झापझापी... (ते पण एन्जॉय करायची सवय लागते आपोआप!!)
मेसचं जेवण.. आमटीच्या नावाखाली सजा-ए-कालापाणी..
महिनाभर चालणाऱ्या फायनल्स.. सतत जागरणं.. ऍसिडीटी..
सगळं करून पण पासिंग पुरतेच मार्क्स..!!
एवढं सगळं झाल्यावर एक वर्षे इंटर्नशीप, त्यातली काही महिने खेड्यात..
पुन्हा PG CET चा अभ्यास (वय 24 वर्षे)..
पुन्हा साडेचार वर्षांची सगळी पुस्तके एकाच वर्षात वाचायची.. आणि लक्षात पण ठेवायची..
आणि 15000 डॉक्टर विद्यार्थ्यांमधून पहिल्या 1500 PG मिळवायची..
पुन्हा PG ची तीन वर्षे.. संपूर्ण आयुष्यातला सगळ्यात भयानक काळ.. अक्षरशः सक्तमजुरी..
पुन्हा पेशंट्स, जागरणं, इमर्जन्सीज् , काम, काम आणि काम.. त्यातून वेळ मिळाला तर झोप अन् जेवण.. अंघोळ सतत ऑप्शनला..!
आणि अजूनच् अडचणीत पडायचं असेल तर लग्नाचा विचार.. (वय वर्षे 27-28)
PG संपली.. चला, आता 'सरकारी बॉण्ड' कंप्लिट करा.. का? तर सरकारने तुमच्या शिक्षणावर पैसे खर्च केलेत..!
मग IIT IIM किंवा इतर कोणत्याही क्षेत्रात सरकारचं हे बंधन नाही..
(मी म्हणतो, काय हरकत आहे, IIT च्या इंजिनिअर्सच्या बुद्धीचा उपयोग पण दोन वर्षासाठी सरकारच्या विविध योजना बांधकामे कंपन्यांमध्ये करून घेतला तर..!)
असो.. बाहेर पडलात..? स्पेशालिस्ट डॉक्टर झालात..! वा.. वा.. वा.. (वय वर्षे 30 च्या आसपास)..
आता तुमचे खरे दुर्दैव चालू...
कुठंतरी जॉईन व्हायचं? की हॉस्पिटल टाकायचं? की लग्न करायचं? कि सगळंच करायचं? ..काही कळत नाही.. आणि घरच्यांना तर वाटत असतं, आता हा भाराभर पैसे कमावणार बरंका.. पण कसचं काय, अन् कसचं काय!! ओम फुस्स...
हॉस्पिटलसाठीच्या जागेच्या किमती..
बांधकामाचा खर्च.. त्यासाठीच्या सरकारी परवानग्या..
हॉस्पिटलमध्ये लागणाऱ्या मशिनरींच्या किमती..
हॉस्पिटलमध्ये असणाऱ्या सोयींच्या किमती..
हॉस्पिटल चालू करण्यासाठी लागणाऱ्या 46 प्रकारच्या परवानग्या..
(खाली लिस्ट दिली आहे)
हॉस्पिटल चालू झाल्यावर त्याची मॅनेजमेंट..
हाऊसमन, नर्सिंग स्टाफ, त्यांची भांडणं, त्यांच्या सुट्ट्या.. अटेंडन्ट, वार्डबॉय, गेटकीपर, सेक्युरिटी, फायर कंट्रोल, पोल्युशन कंट्रोल, बायोमेडिकल वेस्ट.. इ इ..
तुम्ही डॉक्टर कमी आणि मॅनेजरच् जास्त असता..
डाॅक्टरांसाठी सरकारी करात कोणतीही सवलत नाही, औषधे महाग, मशिनरींच्या किंमती लाखोंच्या घरात, सगळ्या मशीनरी घ्याव्याच् हे सरकारी नियमांचं बंधन, आणि उपचार मात्र कमी खर्चात हवेत..!! हे कसं जुळणार..?
पण हे गणित जुळवायचंच्, नाहीतर समाज तुम्हाला लुटारू म्हणणार..
हाॅस्पिटलसाठी असलेल्या सरकारच्या नियमांप्रमाणे हाॅस्पिटल अद्ययावत करायचे असेल तर उपचारांचा खर्च खुपच वाढतो... (कमी खर्चात उपचार करणा-या हाॅस्पिटलमधे सुविधा पण अल्पच असतात).. रुग्णास काही झाले तर दुस-या हाॅस्पिटलला शिफ्ट करावे लागते..
आणि खूप प्रयत्न करूनपण पेशंटचं काही बरंवाईट झालं तर नातेवाईकांचा मार पण खायचा..
तोडफोड सहन करायची..
पेपर मधून बदनामी सहन करायची..
नाहीतर पत्रकारांना हप्ते द्यायचे, टिनपाट नगरसेवक खुश करायचे किंवा गावगुंड पोसायचे..
उत्सवांच्या जयंती-पुण्यतिथीच्या वर्गण्या गपगुमान द्यायच्याच्..
निवडणुकीसाठी खंडणी (त्याला 'मदत' म्हणतात) द्यायची.. त्यांच्या एका फोनवर पेशंट्स ची बिलं कमी करायची, नाहीतर काही खरं नाही..!
"हे डॉक्टर आहेत" म्हणून कोणत्याही वस्तूवर डिस्काऊंट मिळत नाही.. (उलट समोरचा डॉक्टर आहे कळलं की समाज दोन पैसे जास्तच उकळतो!)
शाळा, मॉल, थिएटर किंवा ट्रेन प्लेन इथे कुठेही सवलत नाही.. किंवा कोणता दुधवाला, सुतार, प्लम्बर, इलेक्ट्रिशियन तुम्ही डॉक्टर आहे म्हणून सवलत देत नाही.. पण डॉक्टरने मात्र समाजाला उपचारात (सेवेत) सवलत द्यायची..
(याला 'वैद्यकीय सेवा' म्हणायचं)..
हा असा एकमेव 'व्यवसाय' आहे ज्यात तुम्ही तुमची "जाहिरात" पण करू शकत नाही.. म्हणजे सेवा क्षेत्राचे benefits पण नाहीत, CPA मधून सुटका पण नाही, आणि 'व्यवसाय' असल्यासारखी समाजाची मान्यता पण नाही..
सगळ्या 'सेवा' क्षेत्रापेक्षा हे क्षेत्र वेगळं.. चांगलं झालं तर डॉक्टर 'देव' असतो, काही कमीजास्त झालं तर 'दानव' असतो, आणि बील भरायच्या वेळी 'लुटारू' असतो..
सर्वांच्याच हातात पैसे ओढायचा खोऱ्या नसतो.. कोणत्याही गावात किंवा शहरात भरपूर प्रॅक्टिस असलेले(खोऱ्या असलेले) मोजकेच 5-10% डॉक्टर्स असतात.. समाजाच्या डोळ्यावर तेच येतात.. आणि मग 'सगळे डॉक्टर लोकं खूप कमावतात' असं generalized statement करतो समाज...
हॉस्पिटल टाकण्यासाठी होत असलेला प्रचंड खर्च,
सरकारी परवानग्या व अटी,
इन्श्युरन्स कंपन्यांचे Eligibility criteria,
ग्राहक सुरक्षा कायद्याचा (CPA चा) जाच,
समाजाकडून वाढत असलेली असुरक्षा, मारहाण,
रुग्णाच्या नातेवाईकांचा intolerance,
पुढाऱ्यांचा अन् गावगुंडांचा उपद्रव..
..... अशा अनेक गोष्टींमुळे नवीन डॉक्टरांचे स्वतःचे एकट्याचे हॉस्पिटल टाकणे कमी कमी होत चालले आहे.. त्या पेक्षा मोठ्या हॉस्पिटलला attach होणे पसंत करतात बरेच जण...
पण यामुळे 'फॅमिली डॉक्टर' हा कन्सेप्ट जाऊन "कॉर्पोरेट हॉस्पिटल्स"चा जमाना येणार हे निश्चित..
खूप संघर्ष करून डॉक्टर व्हायचं.. पण नंतर कळतं की खरा संघर्ष तर डॉक्टर झाल्यावरच करावा लागतोय..
- डॉ सचिन लांडगे.
हॉस्पिटलसाठी च्या परवानग्या आणि कागदपत्र..
Please find below the list of all statutory requirements:
1 Registration with the local municipality (health department) Directorate of Health Services
2 Import export license Ministry of Commerce, Office of Jt Director General of Foreign Trade, for certain machines.
3 License from the fire brigade department for establishing boiler for laundry, keeping oxygen cylinder etc. No objection certificate from the Chief Fire Officer.
4 License under PNDT in order to purchase the ultrasound machine. PNDT Act, 1996. Local municipality (Health department)
5 License from BARC for establishing the x-ray setup, they approve the layout Bhabha Atomic Research Centre
6 Registration with the PF department. Employees provident fund Act, 1952. Employees provident fund Office
7 License for acquiring spirit, alcohol etc. for hospital use local municipality (health department)
8 Registration under the local hospital and nursing home regulatory body (for e.g. under the BNHRA in Maharashtra ) State Health Authorities
9 Registration for opening a drug store in the hospital (both outdoor and indoor pharmacy. Drugs and cosmetics Act, 1940. Pharmacy Act, 1948. Drug control department
10 Registration for opening canteen in the hospital premises Local municipality (health department)
11 License under Bio-medical Management and handling Rules, 1998. DPCC
12 Registration with a third party for bio medical waste management eg Synergy
13 Registration for opening and running a blood bank Local FDA
14 Registration with ESIC for employees ESIC Department
15 Narcotics and Psychotropic substances license and Act. Local FDA
16 Consumer protection Act, 1986.
17 Dentist regulations, 1976.
18 Fatal accidents Act, 1955.
19 Indian medical council Act and code of medical ethics, 1956.
20 Indian nursing council Act, 1947.
21 Maternity benefit Act, 1961.
22 License to perform Medical Termination of Pregnancy, MTP Act, 1971. Chief Medical Officer
23 Persons with disability Act, 1995.
24 Protection of human rights Act, 1993.
25 Registration of births and deaths Act, 1969.
26 Tax deducted at source Act.
27 License for Lift & escalators etc…. Govt. of Delhi and Mumbai( As it is applicable to these two places)
28 Approval of Building Plan Local Govt. Authority like HUDA etc.
29 Certificate of Building Completion Local Govt. Authority like HUDA etc.
30 Permission for Electrical Installations Electrical Inspectorate
31 Form C for Sewage & Water Connection Local Govt. Authority/Water Supply and Sewerage Board
32 Permission to dig Tube Well, Registration of Tube Wells State Ground Water Authorities/
33 Reg. Under Prenatal Diagnostic Techniques Directorate of Family Welfare
34 Registration of Echo Machines Directorate of Family Welfare,
35 License for Bulk Storage of HSD/Fuel Oil Chief Controller of Explosives (Nagpur)
36 License for storage of Compressed Gas Cylinders Chief Controller of Explosives
37 License for Liquid Oxygen Chief Controller of Explosives
38 License for Storage, use and disposal of Radioactive Materials BARC Mumbai Atomic Energy Regulatory Board
39 Clearance to run generators Pollution Control Board/Electricity Board/
40 Registration Under Labour Act, License for Contract Labor for Contractors Labour Dept. of Local State Govt.,
41 PAN No. Income Tax Dept.
42 TAN No. Income Tax Dept.
43 TIN No. Sales Tax Dept./VAT
44 Service Tax No. Service Tax Department
45 Certificate of Exemption under 80-G Income Tax Dept.
46 Certificate of Tax Exemption for Patient Income Tax Dept.
Doctor in Mumbai India - A view on career as a Doctor
Here are the 10 latest developments:
Air Ambulance India