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Is My Cancer in the Wrong Body Part?

Mar 4, 2012• 2

By Elaine Waples

Recently, our city hosted the fifth annual national marathon to fight breast cancer. This is not part of the Komen “race for the cure” but rather a grassroots effort that mushroomed from its inception five years ago into the impressive event it is today. Thousands of people participate as runners, volunteers, and cheerleaders clad in the signature color. I must admit, seeing some grown men run twenty six miles wearing pink tu-tus is both awe inspiring and a testament to dedication over self-image.

Its supporters include corporate sponsors, vendors, and exhibitors, and (no surprise) pharmaceutical companies. Its originators are a local TV celebrity breast cancer survivor and a cancer physician at Mayo clinic. It promises to donate 100% of the money to breast cancer research or care. To date, the event has raised millions of dollars and has met its contribution promise. It’s all very worthy, noble and heartwarming.

So why do I get an embarrassingly annoyed feeling when the pink parade makes its way through my neighborhood? After all, isn’t it a victory that so many people today recognize the need for education and awareness about a terrible disease that kills 40,000 women a year? Of course it is. And I have met many women breast cancer survivors who have become warm wonderful friends and I am thrilled for the overwhelming support they have.

The frustration seems even more puzzling in light of the fact that I am a cancer survivor myself. I was diagnosed in 2010 with advanced primary peritoneal ovarian cancer, the most lethal of all gynecological cancers with an alarmingly small overall survival rate. So for the past two years of chemotherapy and difficult treatment, I have struggled to suppress what feels like a petty sentiment about all the pink attention. If I just own up to it, I feel left out and I really want a parade with everyone wearing teal in support of ovarian research and care. My cancer! My body part! A cure for me!
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Contraception Conundrum

Feb 27, 2012• 13

By J.D. Kleinke

What makes the contraception coverage debate currently raging in Washington unusually problematic is that both sides are exactly right. Female employees who receive part of their cash compensation in the form of health benefits have the right to benefits that include FDA-approved birth control methods. Employers defined by their religious values—not just churches, synagogues, and mosques, but also thousands of hospitals, universities, and charities—should not have to compromise those values with their own money, and the government has no right to trample the First Amendment by compelling them to do so. The Obama administration’s “accommodation” —shifting the new federal requirement to the insurers who administer those organizations’ health plans—is a cynical shell game that ignores the most basic tenets of business accounting.

As the problem is no more complicated than two sets of equally valid rights in direct opposition, neither is the solution all that complicated, at least in principle: employment and health insurance should have nothing to do with each other.

Unfortunately, this arrangement—a relic of the World War II civilian wage freeze and enshrined in the tax code as soon as workers got a taste of this new-fangled “fringe benefit” of employment—is now an enduring part of the U.S. healthcare system. The entanglement of our health insurance with our employment goes a long way toward explaining not just today’s conundrum over the birth control coverage mandate, but myriad other economic distortions, market dysfunctions, and cultural conflicts that define much of what is wrong with the U.S. healthcare system.

The Obama administration’s ‘accommodation’ last week is a cynical shell game that ignores the most basic tenets of business accounting.

Is a New Federal Patient Safety Effort Doing Enough to Curb Medical Errors?

Feb 23, 2012• 1

By Michael Millenson

The Medicare program is betting on a new course of action to curb what one medical journal has dubbed an “epidemic” of uncontrolled patient harm.

The effort is pegged to the success of a little-known entity called a “hospital engagement network” (HEN). In December, the government selected 26 HENs and charged them with preventing more than 60,000 deaths and 1.8 million injuries from so-called “hospital-acquired conditions” over the next three years. That would be the equivalent of eliminating all deaths from HIV/AIDS or homicide over the same period.

Despite those big numbers, and an initial price tag of $218 million, it’s unclear whether the HENs are adequately ambitious or still only pecking away at the patient safety problem. While this is by far the most comprehensive public or private patient safety effort ever attempted in this country, it still aims to eliminate less than half the documented, preventable patient harm.

The inspiration for these networks comes from similar collaborative projects run by the Institute for Healthcare Improvement and other groups. Dr. Donald Berwick, IHI’s founder and president, headed up the Centers for Medicare & Medicaid Services for two years and launched a larger Partnership for Patients that includes the HENs.

In December, the government chose a mix of national and local groups — primarily health systems and hospital organizations — to run individual HENs. Each HEN is charged with spreading safety-improvement innovations that have been proven to work in leading hospitals to others through intensive training programs and technical assistance. Although the program lasts three years, initial HEN contracts are for two years, with an “option year” dependent upon performance.

So Much For “Everyone Can Get Care In An Emergency Room”

Feb 22, 2012• 4

By Aaron Carroll

We’ve long argued this meme isn’t true. But now it’s explicitly false:

Last year, about 80,000 emergency-room patients at hospitals owned by HCA, the nation’s largest for-profit hospital chain, left without treatment after being told they would have to first pay $150 because they did not have a true emergency.

Led by the Nashville-based HCA, a growing number of hospitals have implemented the pay-first policy in an effort to divert patients with routine illnesses from the ER after they undergo a federally required screening. At least half of all hospitals nationwide now charge upfront ER fees, said Rick Gundling, vice president of the Healthcare Financial Management Association, which represents health-care finance executives.

So sure you can get non-emergent care in an ED – if you pay for it out of pocket. Please understand I’m not saying that all care should be free. I’m saying that the emergency department is no different than a physician’s office. If you have insurance, or can pay for care yourself, you get it. Otherwise, you don’t. No matter where you are.

Why is this happening?
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Is North Carolina Medicaid the Healthcare Industry’s Solyndra?

Feb 21, 2012• 31

By Al Lewis

North Carolina Medicaid recently reported, for the third time, using a third consulting firm, the achievement of massive savings through its patient-centered medical home (PCMH) program, now called Community Care of North Carolina (CCNC). Among other things, CCNC pays the physicians more money in order to encourage and compensate behaviors and processes, including enhanced access to care and case management, to hopefully reduce the need for emergency and inpatient services. (A brief summary of this and past consulting reports appear in the current issue of Modern Health Care. http://www.modernhealthcare.com/article/20120218/MAGAZINE/302189938/1140)

However, the third time is not a charm. Notwithstanding these consultants’ reports — which paradoxically support my contrary conclusions by choosing to ignore the overwhelming data contradicting their own claims – the program is a total failure as far as reductions in cost and inpatient utilization are concerned.

Fact #1: According to the Medicaid and CHIP Payment and Access Commission (MACPAC) report to Congress http://www.macpac.gov/reports, North Carolina is by a significant margin the highest-cost state per capita in its region for adult and for child Medicaid spending. These are the two categories in which the PCMH has been in place the longest. In the “aged” category, in which PCMH had barely been started when the MACPAC data was compiled (and would not affect medical costs noticeably because the state is a “secondary payer” following Medicare, and most Medicaid “aged” spending is custodial anyway), North Carolina is the lowest cost state in the region.
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A New Grassroots Movement By Doctors

Feb 21, 2012• 6

By Ron Gutman

There’s a new movement in healthcare – and it’s growing from a surprising place. Instead of emerging from government or industry, it’s budding from the grassroots –from everyday physicians. The movement is democratizing health information and giving birth to a new landscape: Interactive Health.

Interactive Health is transitioning clinical care from real-world, costly encounters to virtual, inexpensive, cloud-based care. And the view from the cloud is better. This transformation is starting with the most fundamental interaction in healthcare: patient question, physician answer.

In late April of 2011, HealthTap decided to help facilitate this movement by bringing together physicians to engage online and create a roadmap for “care in the cloud.” Nine months later, the growth of physician engagement on HealthTap and beyond proves that Interactive Health is here to stay.

Politics in the Exam Room

Feb 20, 2012• 1

By David M Sack MD

An ancient maxim of dinner party etiquette, which I believe has been proffered from more than one source, is “never discuss politics, religion or sex in polite company”. In some ways, for me as a physician, entering the exam room with a patient seems to require some similar degree of discretion. But the consequences of straying outside the bounds of polite discussion in the doctor’s exam room are quite different from any awkwardness that might ensue after a social misadventure.

Dr. Henry Lee, the well-known Connecticut State forensic medicine expert likes to relate a tale of his own introduction to dinner party etiquette, which I will try to relay somewhat faithfully. His English was poor when he arrived in the U.S. and, invited to a party in which guests were seated in the traditional “boy-girl-boy-girl” arrangement, he knew he would be pressed to make conversation with the women on each side of him. A friend reassured him, “You’ll have no problem if you can just get the woman talking about herself and then all you have to do is listen politely. Simply ask ‘Are you married?’ and then ask “Do you have any children?’. This should get things going just fine.” Armed with this strategem, Dr. Lee was seated and turned to an attractive young woman on his left and asked if she was married. She replied “No”. So of course, he went on to the next question, “Do you have any children?”. He was surprised when she reacted with a look of indignation and quickly turned her attention to the guest on her other side. Puzzled at her reaction, he surmised that he must have gotten the sequence out of order. Trying out the other way around, he turned to an older woman on his right and asked confidently if she had any children. “Three!”, she replied happily. Delighted with his progress, he then inquired if she was married. Dr. Lee says he spent the dinner conversing with his soup and salad.

I have also had exam room encounters come to grief because of sex, politics and religion, but nothing has caused me more regret than politics. I will explain.

Where Have All the Liberals Gone?

Feb 17, 2012• 20

By John Goodman

There are two conservatives for every liberal in America. That’s the message of a recent David Brooks column as well as a Gallup survey. I think the imbalance is much starker. I would guess there are four conservatives for every liberal. Maybe even more.

Here’s a test I invite you to take. Watch C-Span’s morning call-in show and listen to what people who phone in on the “Democrat” or “liberal” line have to say. When is the last time you heard a caller say, “We should all pay higher taxes so that the government can provide us with universal day care”? Or how about, “We should all pay higher taxes so the government can provide us with universal long term care”? I bet you can’t remember ever hearing that.

Here is what I suspect you will hear: Teachers complaining that teachers aren’t paid enough. Union members complaining about competition from workers overseas. Senior citizens whining about the meagerness of Social Security or Medicare benefits. Minority callers advocating more affirmative action. What is the common denominator of these comments? Self-interest.

Yes, I know. Special interests are in both parties. Why wouldn’t they be? Yet as I wrote in my analysis of “progressivism,” the left in America has elevated special interest privilege to an art form.

Here’s the point: people wanting more, more, more are just people pursuing their own self interest in politics. They are not in principle different from any other special interest group. Importantly, they have nothing in common with what we normally have in mind by the term “liberalism.”

Paving the Regulatory Road

Feb 17, 2012• 1

By Deven McGraw

The poor quality and high cost of health care in the U.S. is well documented. The widespread adoption of electronic medical records—for purposes of improving quality and reducing costs—is key to reversing these trends.[1] But federal privacy regulations do not set clear and consistent rules for access to health information to improve health care quality. Consequently, the regulations serve as a disincentive to robust analysis of information in medical records and may interfere with efforts to accelerate quality improvements. This essay further explains this disincentive and suggests a potential regulatory path forward.

The U.S. has dedicated approximately 47 billion dollars to improve individual and population health through the use of electronic medical records by health care providers and patients.[2] Much of the funding for this initiative, enacted by Congress as part of the Health Information Technology for Economic and Clinical Health Act of 2009, will be used to reimburse physicians and hospitals for the costs of purchasing and implementing electronic medical record systems. The legislation also includes funding to establish infrastructure to enable health care providers to share a patient’s personal health information for treatment and care coordination purposes and for reporting to public health authorities.

Federal policymakers also intend for electronic medical records to be actively used as tools of health system reform. The legislation directs the U.S. Department of Health and Human Services to develop a “nationwide health information technology infrastructure” that improves health care quality, reduces medical errors and disparities, and reduces health care costs from inappropriate or duplicative care.[3]The 2011-2015 Federal Health Information Technology Strategic Plan identifies improving population health, reduction of health care costs, and “achiev[ing] rapid learning” as key goals of federal health information technology initiatives.[4]

The Unfortunate Side Effect of Death

Feb 16, 2012

By Andrew Schutzbank

Peggy was in her early 70s and suffered from a terrible lung disease known as pulmonary hypertension. Her case was so bad that she had a pump infusing a medicine under her skin 24 hours a day to keep the blood supply to her lungs open. Once started, this medicine, treprostinil, was known to improve life in those with pulmonary hypertension. Unfortunately, like all continuous infusion medicines of this type, it has the unfortunate side effect of sudden death if stopped for more than 4 hours. Starting it was a difficult choice for Peggy and her expert team of physicians, but her disease had progressed to a point where it was the right decision. As you can imagine, this drug was mighty expensive. We would only find out how expensive later.

On the day that I met Peggy, she was being admitted to the Intensive Care Unit (ICU) not for her pulmonary hypertension, but because she had a bleed in her stomach, which caused her to swallow blood/stomach contents into her already damaged lungs. Once stabilized, our first challenge was to ensure that she continued on the treprostinil. It took a little magic from pharmacy and the drug’s manufacturer, but we were able to get everything together and Peggy was no worse for the wear.

A few days later Peggy was improving, breathing tube out and awake and back to herself. Due to the special nursing needs with treprostinil, Peggy was required to be in the Cardiac Care Unit (CCU), a special type of (ICU), despite her progress. Even though Peggy managed this medicine at home by herself, hospital policy prevented her from transitioning out of the ICU to the general medical floor, at a fraction of the cost. Conceding that point, the decision was made to try and transition Peggy directly to Rehab. But her progress was stalled for one simple reason: treprostinil.
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