April 20, 2014

Choosing Wisely Campaign Protects Its Own

We’ve been champions of the Choosing Wisely campaign, an initiative by several medical specialties to call out procedures they advise doctors and patients to view with skepticism. But now it looks like there's a big "Not in My Back Yard" problem with the program.

Last year, for example, our blog “Orthopedic Treatments You Should Reject” outlined five treatments the American Academy of Orthopaedic Surgeons said appeared to have little worth.

So it’s disappointing to realize, as a story by KaiserHealthNews and the Chicago Tribune recounted last week, that some of the largest medical associations participating in Choosing Wisely tabbed rare treatments or those performed by practitioners in other fields instead of those that are lucrative for them. "They were willing to throw someone else’s services into the arena, but not their own," said Dr. Nancy Morden, whose research into the societies’ advice was published in the New England Journal of Medicine.

The campaign was a welcome change in a medical profession that historically had been reluctant to spurn unnecessary treatments, often because they are money-makers for the practitioners. Of course, that also means they add costs for patients and insurers, aren’t proved to improve health and sometimes can cause harm.

Since 2012, 54 specialty societies in Choosing Wisely have recommended procedures to avoid, and the lists have been distributed to more than half a million doctors. Hospitals that use them report diminishing use of unnecessary procedures.

And Morden’s study did find that some specialty pointed the finger at their own indulgences — gastroenterologists, radiologists and clinical pathologists among them. For example, as our blog reported, the Society of General Internal Medicine advised against getting an annual physical exam.

Other medical specialties said they hadn’t included their own procedures if the concerns about them were about overuse, because in some cases, for some patients, they are appropriate, such as stents for heart patients and spine surgery, two procedures we have advised patients to scrutinize very closely before undergoing.

Those societies tended to focus on limiting testing that others do. Morden, a researcher at the Dartmouth Institute for Health Policy & Clinical Practice in New Hampshire, examined everything named on the first 26 Choosing Wisely lists. More than 8 in 10 targeted radiology, medications and cardiac and lab tests — not physician services.

The American College of Cardiology included the use of cardiac testing in four circumstances, but didn’t address what scientific evidence indicates is the most frequent type of overtreatment in the field — implanting stents, which are small tubes used to prop open arteries of patients who are not suffering heart attacks. More measured, and often more successful treatments for potential heart problems, are prescribing certain medicines and making changes in lifestyle.

KHN/Tribune refers to a study showing that as many as 1 in 8 stent procedures should not have been performed, and at hospitals where stenting was most overused, about 6 in 10 stents were deemed inappropriate.

But, as one cardiologist told KHN/Tribune, "Let's face it, angioplasty and stenting is a big business, it's highly profitable for hospitals, and it's highly remunerative for physicians. There's a tremendous impetus to not rock the boat and not to call attention to the fact that we do too many procedures in stable patients for whom outcomes would be the same if not even better if treated medically."

Orthopedics is another specialty whose Choosing Wisely recommendations protected its members’ interests but not necessarily those of patients and insurers. The American Academy of Orthopaedic Surgeons discouraged patients with joint pain from taking certain dietary supplements, from using custom shoe inserts or overusing wrist splints after carpal tunnel surgery and from a procedure some doctors use to bathe an aching knee in a saline wash.

Although the advice to spare yourself the cost of glucosamine supplements is good, the loss of that commerce doesn’t affect doctors. And the knee saline injections are seldom done anyway. When Morden reviewed 2011 Medicare billing records for the procedure, she found "zero claims."

"That's how pathetic that item is," she told KHN/Tribune.

One orthopedic surgeon nominated other, more significant procedures he told the reporters were overused but were not on the Choosing Wisely lists, including replacing hips and knees when the patient’s pain is minimal and can be managed with medicine, and surgically inserting metal plates into broken collarbones, rather than letting the injury heal with the help of a sling.

"The abuse of surgery is due to the overwhelming control of the profession by the implant manufacturing companies," he told KHN/Tribune.

Being a spine surgeon is a lucrative profession: According to one survey, the median compensation is more than $730,000 per year, so it might seem upstanding that the North American Spine Society included a procedure using bone growth material for neck fusion on its “avoid” list. But it’s not clear how many spine surgeons even perform it anymore. The FDA issued a safety alert against the procedure it in 2008 because it could cause the neck to swell, compress airways and make breathing and speaking difficult.

This group’s members didn’t mention spinal fusion, which more than doubled in frequency between 1998 and 2008, according to one study. Patients with back pain are more likely to be referred to another physician, probably for things like injections and surgery, instead of physical therapy, which usually should be the first line of treatment.

As the KHN/Tribune story notes, “where the lists have been actively embraced, the rate of those services has dropped. Last year, the Cedars-Sinai Health System in Los Angeles added 120 Choosing Wisely recommendations into its computerized patient records so that they would pop up on a screen whenever a clinician tried to authorize one.”

The use of benzodiazepines and other sedative-hypnotics to treat the elderly have decreased at Cedar-Sinai as a result of Choosing Wisely recommendations by the American Geriatrics Society. That’s good, because these drugs can cause elderly patients to fall.

At Anne Arundel Medical Center in Annapolis, "Choosing Wisely" lists are broadcast on hospital television screens, posters decorate the walls of doctors' offices and the lists are included in communications mailed to county residents. The lists also are embedded as links in electronic patient records so physicians can easily review them.

Those are all excellent measures as far as they go, but as the NEJM study suggests, they just don’t go far enough.

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April 17, 2014

Another Careless Promotion of C-Sections

No matter how hard medical experts and other promoters of good, safe health care try, it seems, there are always loud voices chiming in from the fringes of ignorance to offset their message.

A few weeks ago, in a blog about obstetricians recommending that women not be rushed into induced labor and also calling for fewer cesarean sections, we revisited the dangers of unnecessary C-sections, and noted that nearly 1 in 3 U.S. women give birth via C-section.

But when Dan Murphy, second baseman for the New York Mets, missed the first two days of the Major League Baseball season, he was berated, belittled and bullied by Mike Francesca and Boomer Esiason, two hosts on New York’s WFAN sports radio. Bad enough that these mic jocks called out Murphy because they believe it’s a higher priority to play a game than it is to attend the birth of your child and support its mother, but, worse, they promoted the idea of planning that birth — by cesarean — for the convenience of your schedule, not the baby’s.

As recounted on, among other news sites, NYDailyNews.com, Francesca mocked MLB players' collective bargaining agreement giving them three games off for paternity leave, calling it a "scam" and a "gimmick."

"One day I understand,” Francesca said. “And in the old days they didn’t do that. But one day, go see the baby be born and come back. You’re a Major League Baseball player. You can hire a nurse to take care of the baby if your wife needs help. ... What are you going to do? I mean you are going to sit there and look at your wife in a hospital bed for two days? Your wife doesn’t need your help the first couple of days; you know that you’re not doing much the first couple days with the baby that was just born.”

His colleague Esiason piled on the mindlessness, saying Murphy should have insisted his wife “have a C-section before the season starts. I need to be at Opening Day, I’m sorry.”

Sigh. If this was intended as a joke, it fell a bit flat.

Wiser minds have tried for years to prevent unnecessary C-sections, which often are performed purely for reasons of convenience. As we’ve noted in our C-section backgrounder, the risks include:

  • injury to the mother’s ureters (tubes that carry urine from the kidneys to the bladder), bowels or other pelvic organs;

  • a higher likelihood of uterine rupture in future pregnancies.

There are also risks to the baby, including:

  • breathing problems;

  • heart disorders;

  • anemia;

  • bleeding in the brain.

It’s disheartening when people blessed with a bully pulpit use it for misguided and dangerous purposes. But it’s also uplifting when others stands up. According to the Daily News story, Mets General Manager Sandy Alderson, said, “The paternity-leave policy was introduced not just for the players’ benefit, but recognition by clubs in contemporary times that this is an appropriate time for parents to be together. So I’ve got absolutely no problem whatsoever with Murph being away. I think the delivery was a little earlier than expected, but those things you don’t control."

And Murphy apparently told ESPN that he can handle the negative blowback from the Neanderthals among us. He’s fine with his decision, and his priorities. And no one should criticize his work ethic — he missed only one game during the entire season last year.

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April 16, 2014

Suggested Reading: Coming to Grips with End-of-Life Decisions

Sometimes, we read an article that’s important, moving and, we hope, illuminating, but too long to summarize fairly in a blog post. Last year, one such story, written by Charles Ornstein, a Pulitzer Prize-winning health journalist, was published by ProPublica.org, a nonprofit investigative news site.

It perfectly captures the emotional turmoil involved in making end-of-life decisions for someone else — in this case, his mother. Even though Ornstein is an expert consumer when it comes to health care, he wasn’t prepared for the complex reality of his family’s situation. You must be prepared, he says, but that only makes it easier to deal with a loved one’s death — it doesn’t make it easy. For the full story, link here.

To help prepare for end-of-life situations, see our newsletter, “Talking to Your Doctor When You Can’t Speak.”

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April 14, 2014

Miscommunicating the Science of Mammography

The more we discover about cancer screenings, it seems, the less clarity there is about who should have them, when and what to do about the results. Mammography is one of the more common footballs being kicked around in the best-practice screening arena, and we’ve regularly covered the news about this imaging test.

So has Gary Schwitzer on HealthNewsReview.org, whose recent post reviews the difficulty many media have in reporting results of mammography studies that are accurate, nuanced and provide the context people need to make informed decisions about what’s best for them.

This time, Schwitzer refers to a recent study in the Journal of the American Medical Association (JAMA) called “A Systematic Assessment of Benefits and Risks to Guide Breast Cancer Screening Decisions.” If that title doesn’t speak to the ongoing debate about who-when-why, nothing does. “It reached a conclusion,” Schwitzer writes, “that you might think few could disagree with — although on this topic one should never underestimate the potential for disagreement.”

The researchers concluded that although mammography screening appears to be associated with reduced breast cancer mortality, the harms of screening might outweigh the benefits for some people. They say that research priorities should be: better screening methods; better understanding of their harms; better strategies to identify the highest-risk patients; and tools to help them and their doctors make screening decisions.

An editorial accompanying the study addressed the challenge of teasing out all the factors that should be considered in mammography decisions. Drs. Joann Elmore and Barnett Kramer said that the “nuanced balance is not easily communicated.” They say that the federal government’s policy on insurance coverage of mammography doesn’t help this communication:

With the goal of improving access to preventive services and medical screening, the Affordable Care Act (ACA) offers free screening mammography to women. However, women often pay for the consequences of screening, even if the screening examination is free. Women bear not only financial charges but also important human costs. Screening mammography can trigger recalls for more testing, biopsies, mastectomies, radiation, systemic therapy, days off work, and debt related to health care costs. These byproducts of screening can lead to adverse financial consequences and personal harm. … Balanced messaging is essential to help each woman make her own individual decision regarding her participation in screening mammography.

“Nuanced balance,” Schwitzer says, is not what you’re generally going to find in the news.

  • A Washington Post headline: “Despite strong benefits, mammograms may have greater harms than previously realized, study says.”

    The story refers to “substantial” benefits, but the JAMA study doesn’t refer to “strong” or “substantial” benefits. The story quotes one study author that the results are “profoundly disappointing that mammography doesn’t quite live up to its promise. …it does not show as strong a benefit as is often suggested in the media.”

    Schwitzer’s legitimate gripe is that “strong and substantial” and “profoundly disappointing and not as strong as suggested in the media” appear in the same story without, apparently, awareness of the contradiction, or the need for interpretation.

  • An announcement on a TV station in Hawaii: “Mammogram benefits outweighs risks, new study says.” Except that it didn’t.
  • A Society of Breast Imaging (SBI) news release titled “JAMA Article Breast Cancer Screening Recommendations Potentially Deadly for Many Women.” Never mind, Schwitzer says, that the JAMA article only reviewed the evidence; it didn’t make any direct recommendations about screening, only that such decisions should be individualized based on patients’ risk profiles, preferences and an improved understanding of potential harms.

    The SBI, by the way, states that it “seeks to minimize the possibility and appearance of inappropriate influence from outside parties.” It paid to place an exhibit at a recent convention of health-care journalists.

“Nuanced balance?” Schwitzer concludes. “You be the judge.”

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April 13, 2014

Who Pays the High Costs of Medicines? Check This Out

In a fascinating set of letters to editor in the New York Times, responding to an article about six-figure prices for some drugs for those with chronic diseases like diabetics, this caught my eye, from reader Ed Schmith:

Last year, according to my calculations, these four [manufacturers], with a total of about $100 billion in sales, had nearly $22 billion in after-tax profits (21.9 percent). By comparison, in a highly competitive industry, Campbell Soup’s net profit was 8.4 percent, and we can choose whether or not to buy its products, a choice not available to those with Type 1 diabetes.

As outrageous as these numbers may seem, it’s really even worse in the United States. As the article points out, countries with universal health care systems are able to negotiate much lower prices with health care providers. As a result, Americans are shouldering not only much of the research and development costs but also the high health care company profits.

Why don't we negotiate with drug and device makers for lower prices? Because Congress banned Medicare from doing so, when it added prescription drug coverage to Medicare. Money talks in our nation's capital. And taxpayers pay the price.

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April 13, 2014

A Busy Week for Courts and Drug Company Complaints

Two legal actions last week are focusing attention, once again, on pharmaceutical companies motivated by financial gain without regard for patient safety.

As reported by the New York Times, a court in Louisiana has ordered Takeda Pharmaceutical, a Japanese company, and its American partner to pay a combined $9 billion in punitive damages over Actos, a diabetes drug linked to bladder cancer.

In Arkansas, as explained on AboutLawsuits.com, the attorney general has asked the state’s Supreme Court to reconsider its ruling from last month overturning a $1.2 billion judgment against Johnson & Johnson concerning its antipsychotic drug, Risperdal.

We’ve written about both of these cases, here and here.

The district court in Louisiana ordered Takeda to pay $6 billion in punitive damages after a jury found that the company had hidden the bladder cancer risks. The court also ordered Takeda’s U.S. partner, Eli Lilly, which marketed the drug in this country, to pay $3 billion. Takeda, of course, is planning to appeal.

In deliberating a lawsuit filed by a patient diagnosed with bladder cancer in 2011 after using Actos for seven years, the jury determined that Takeda became aware of links between Actos and bladder cancer more than a decade ago, but withheld that information from patients and doctors.

That was only one lawsuit of thousands filed against Takeda over Actos, which had been one of the company’s best-selling products, generating about $16 billion in U.S. sales since it was introduced in 1999.

Some European countries have banned Actos, and the FDA ordered that the drug’s labels include warnings about the increased risk of bladder cancer with long-term use of it.

J&J got into trouble over Risperdal for illegally marketing it. But in March, the Arkansas Supreme Court ruled that a state commission had incorrectly applied the Medical Fraud False Claims Act, and also that an FDA letter about the drug was improperly admitted as evidence at trial. So it overturned the judgment.

Now, the attorney general is requesting that the court reconsider because of breaches in legal procedure. He said the high court’s ruling was based on legal arguments that neither side had raised, and that one of the justices asked a key question during oral arguments. The court’s not allowed to raise an issue for the first time at that stage.

The procedural issues don’t absolve J&J, as indicated by the judgment of $1.2 billion in 2012 for marketing Risperdal for uses not approved by the FDA, and for minimizing the drug’s risks. Doctors may prescribe drugs for uses other than what the FDA approved, but the drug makers may not promote them for those “off-label” uses.

The illegal marketing led to the unwise use of Risperdal, for example, in nursing homes as chemical restraints. That’s not only abusive to residents, but can put dementia patients’ lives at risk.

As AboutLawsuits noted, the Risperdal damage award was only one of many state cases that resulted in verdicts of hundreds of millions of dollars against J&J over the drug.

Johnson & Johnson and its subsidiary, Janssen, have been sued in recent years because of other problems with the drug — namely, young males who were given the drug as children and who developed gynecomastia, which causes breast growth.

The complaints claim that the company did not warn consumers or practitioners about the risk of boys developing breasts, some of whom required breast removal surgery.

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April 10, 2014

Routinely Screening Elderly for Dementia Is a Waste of Time and Money

According to the U.S. Preventive Services Task Force (USPSTF), routine screening of all older individuals for cognitive impairment - or early warning signs of dementia - has no scientifically proven benefit.

The task force, which rigorously evaluates clinical research to assess the merits of preventive measures, such as screening tests and medications, analyzed evidence of benefits, harms and sensitivity of screening instruments for cognitive impairment in older adults. It concluded, as reported by MedPageToday.com, that a clear benefit for screening has not been established, relative to the potential for harm for people who are older than 65 and have no signs or symptoms of cognitive decline.

The panel reviewed 55 studies examining the accuracy of screening instruments, and more than 130 studies of interventions aimed at slowing or stopping cognitive decline in patients who tested positive for cognitive impairment. Its results were published in the Annals of Internal Medicine.

The report indicated that current drug treatments such as acetylcholinesterase inhibitors (drugs that impede certain enzymes from interfering with brain synapses) may have "a small effect on cognitive function measures in the short term for patients with mild to moderate dementia, but the magnitude of the clinically relevant benefit is uncertain."

It was the same for interventions other than drugs. The task force concluded that trials of cognitive stimulation resulted in "inconsistent evidence," and in trials showing some benefit, it was of only borderline clinical significance.

Bottom line: There’s insufficient evidence to draw a conclusion about the balance between benefits and risks of screening. And evidence for harms was lacking as well, but would certainly include drug side effects.

The USPSTF reviewed the issue in 2003, and more than 10 years later, its report is much the same. But the task force emphasized that the review covered only routine, universal screening for older patients without clear signs or symptoms of cognitive impairment.

According to MedPageToday, the Alzheimer's Association disagrees with the don’t-bother conclusion of the task force. Medicare covers cognitive screening, and the association recommends that Medicare enrollees take advantage of it. But the American Geriatrics Society takes no position on cognitive screening if the patient or his or her caregivers have no complaints. But the society does recommend certain assessment and treatments approaches for patients selected for screening.

As usual, screenings should be customized — there is no one-size-fits-all approach. "There doesn't seem to be, on a group basis, a clear way to decide whether there is sufficient benefit to justify screening,” one Alzheimer’s expert told MedPageToday, “but patients may think differently for themselves, and individual physicians may think differently."

He said screening might help patients adopt lifestyle changes, such as lowering cholesterol and exercising, to reduce their chance of their impairment progressing. He also said that although anxiety resulting from a positive screen has been cited as a potential harm of screening, a study examined that issue and found little risk of that sort.

We’re not ready to accept that conclusion, as anxiety can be truly debilitating — see our blog, “Blood Test for Alzheimer’s Raises Thorny Questions.” And, as the MedPage story points out, one study in 2006 involved 3,573 individuals who were offered screening. Nearly all accepted, but of 434 with positive screening results, 207 refused a more definitive follow-up assessment, presumably because they didn't really want a firm diagnosis.

Regarding drug therapy benefits, the USPSTF literature review from last year indicated improvements of 1.36 to 3.06 points in scores on the 70-point Alzheimer's' Disease Assessment Scale-Cognition (ADAS-Cog) test — a four-point improvement is the minimum for clinical relevance.

Regarding caregiver burden, interventions at the stage of mild impairment also appear to be of minimal benefit, according to the literature review. Data from two dozen studies of group, individual and telephone-based interventions showed statistical significance … but the clinical benefit was questionable.

Still, the panel offered some guidance for doctors who do choose to perform screening. It identified eight instruments that seem to be effective for identifying mild impairments in the primary care setting, which you can see by linking to the report; see the section labeled Screening Tests.

Our take-home message: The decision to test or not should be made on an individual basis after frank and clear discussions among the doctor, patient and caregivers.

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April 9, 2014

Make the Most of Your ACA Insurance Plan

Now that the initial enrollment period has ended for health insurance coverage under the Affordable Care Act (ACA, or “Obamacare”), many people have insurance who didn’t have it before. And for some people, the terms of their plans are different from what they might be used to. With the help of KaiserHealthNews.org (KHN) and USA Today, here’s how to make the most of your new plan, and how to avoid incurring unexpected costs.

As the news site explains, successfully enrolling in a government exchange plan is only the first step — now you have to understand it. Like anyone else covered by an individual or employer-provided plan that conforms with the ACA, the several million people (figures were unconfirmed at this writing) who have enrolled so far in state of federal exchange plans are all guaranteed certain preventive services with no out-of-pocket costs, such as routine immunizations and pap tests. There’s also a cap on out-of-pocket medical expenses, and no one can be denied coverage because of a pre-existing condition.

But to ensure you get the full benefit of ACA provisions, you must know the guidelines, and follow the rules. They are:

  • Carry your membership card everywhere.

    Make copies. You don’t want a hassle if you have an unexpected doctor or hospital visit.

  • Understand your plan's doctor and hospital network.

    Insurance companies negotiate participation and payment rates with a network of providers to control costs. Most exchange plan networks are smaller than what you might be used to; for an underwriter, the smaller the network, the more control it has over costs.

    Although it can be difficult, you should be able to consult a plan's directory of providers either with the insurer online or with documents you receive when you enroll. You can find out if specific physicians are part of your network, or call their offices to ask. You should know the hospitals and urgent care facilities to ensure you stay within the network whenever possible.

  • Stay in the network!

    You can’t be charged more than the out-of-pocket limit if you use only in-network providers. Whether you’re in an HMO that pays almost no out-of-network benefits or a PPO that covers some, the pocketbook protections don't apply if you see a doctor or go to a hospital outside of your network.
  • Try to stay in-network even for emergency care.

    Under the ACA, insurance plans do have to pay for non-network emergency visits — for example, if you're in a car crash far from home.

    But non-network hospitals often "balance-bill" the difference between what your plan pays and what they charge, which is often much more.

  • Avoid all emergency rooms unless it's really an emergency.

    Traditional health plans came with a modest copayment for an emergency visit — maybe $150.
    But many policies sold on the exchange, even those in the more expensive "gold" category, not only have ER copays of several hundred dollars but also subject ER charges to the overall deductible. (Copays are flat fees for specific services. Deductibles are what you pay out of pocket before the insurance kicks in.)

    So you could be billed for the full cost of an emergency visit, up to the out-of-pocket limit.
    “Broken leg?” asks KHN. “Head to the hospital. Sprained ankle? Maybe wait until the urgent care center or doctor's office opens.”

  • Pay monthly premiums on time and accurately.

    Officially, open enrollment for 2014 coverage ended March 31 (deadlines were stretched in some cases). Open enrollment for 2015 begins Nov. 15. If you fail to pay fully and promptly you could be dropped from the plan and not allowed to re-up until the next open enrollment season. That leaves you exposed to possibly high medical costs, and possibly vulnerable to a penalty for noncoverage.

    Underpaying the premium by a small amount gives an insurance company grounds to drop your coverage. There’s a brief grace period if you get behind, but don’t push it; coverage will be terminated for nonpayment.

  • Register online with your new insurance company.

    Insurance sites track claims and enable you to shop around for the best deals on nonemergency treatment. For example, you can compare the cost of an X-ray among all of the network image providers.
  • Save paperwork. Make sure you really owe what doctors and hospitals bill you for.

    If you suspect a bill is erroneous or too high, you need the documentation to question, challenge or file it with a state oversight agency.
  • If you don't get satisfaction from providers or insurers, try regulators.

    Check the insurer's explanation of benefits (EOB) detailing your claims. There should be contact information for a state consumer assistance program. In addition, link here for resources provided by the Centers for Medicare and Medicaid Services (CMS) that offer state-by-state information.

  • Read your plan's summary of benefits and coverage.

    It tells you how to file a claim, what you must pay to see a primary care doctor, what charges are imposed before or after the deductible is reached, how much it costs to go to the ER, etc.

    It’s not an exciting read, but it’s critical if you care about your health and your health-care expenditures.

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April 9, 2014

How Much Did Your Doctor Make from Medicare?

Now you can find out, by checking this huge database of names and dollars just released from Medicare. The New York Times made the data searchable by doctor's name, specialty and location.

The database shows total payouts by Medicare to individual doctors by name for 2012. It includes all Medicare "Part B" payments, which include not only the doctor's office visit fee, but charges for medicines and procedures administered in doctors' offices. Medicare payments to institutions like hospitals are not included.

Already news media have found some eyebrow-lifting numbers. One ophthalmologist in West Palm Beach, Florida, Salomon Melgen, received more than $20 million for 2012. His lawyer issued a statement cautioning that the vast bulk of the money went to pay drug companies for expensive drugs used in treatment.

Another high-dollar specialty is cardiology. By my count, in the one town of Ocala, Florida, seven of the 34 cardiologists in the database received seven-figure payments in 2012. One, Asad Qamar, got $18 million.

I checked my own internist's building in downtown Washington, D.C., and noticed that ten radiologists in the building all pulled down more than $300,000 in Medicare payments that year. (You can see for yourself by selecting "diagnostic radiology" and zip code 20036 in the database.)

The New York Times found that 2 percent of the 880,000 doctors paid by Medicare in 2012 received nearly a quarter of all the payments.

It will take a while to sort out the meaning of this vast trove of data, reportedly the largest ever released by Medicare.

Commenters on news sites are already drawing their own pre-fabbed conclusions, some arguing, for example, that this proves that all of government is vastly corrupt and inefficient, with others saying the data show the need for a single-payer medical system with doctors paid by salary.

Stay tuned for more on a story that is only starting to unfold.

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April 7, 2014

How to Reduce Your Chances of Getting Pneumonia While Hospitalized

After being ignored too long, the prevalence of hospital infections and how to prevent them has achieved transparency. Medical professionals and patients alike are aware that being in the hospital raises one’s chances of contracting an infection that wasn’t part of the reason for being there in the first place.

Insurance companies and Medicare have imposed financial penalties on facilities that don’t address or can’t control their rates of infection, but practitioners and patients also must be aware of how to minimize the chances of a health-care acquired infection (HAI). Not only do these infections impede your ability to recover, they’re expensive — see our recent blog, “The Costs of Catching an Infection in the Hospital.”

The Association of Professionals in Infection Control and Epidemiology (APIC) recently issued a consumer alert specifically about contracting pneumonia in a hospital setting. Although many different infections can be acquired in the hospital, pneumonia is common and relatively easier to avoid.

Pneumonia is an infection of the lungs that can be caused by bacteria, viruses and/or fungi. You’re more likely to catch it if you’re older than 65; younger than 5; have a chronic medical condition such as diabetes, heart disease or asthma; smoke cigarettes.

Being hospitalized puts you at a higher risk of developing pneumonia because certain situations disrupt normal breathing — for example, if you’re completely bedridden, take certain medications or if you need a ventilator and endotracheal tube. That machine aids breathing by supplying oxygen through a tube inserted into the patient’s mouth, nose or through a hole in the front of the neck.

But anybody is at risk, so here are nine ways to minimize it:

1. Wash your hands and make sure the patient’s health-care providers and visitors do so as well.

Clean your hands after using the bathroom; after sneezing, blowing your nose, or coughing; before eating; when visiting someone who is sick; or whenever your hands are dirty.

Doctors, nurses, technicians, orderlies … anybody who works with patients should clean their hands before and after contact with a patient who has a breathing tube, and before and after contact with any respiratory device a patient uses, whether or not they wear gloves. They should clean their hands before and after touching a patient, before a procedure, after being exposed to a patient’s fluids and after touching a patient’s surroundings, whether or not the patient has a breathing tube.

2. Ensure proper use of breathing tubes.

The patient or family member/advocate should ask what measures will be taken to reduce the chances of needing a breathing tube, or to reduce the time the patient needs one. If you’re having surgery, ask the anesthesiologist if it can be done with a regional or spinal anesthesia instead of through the mouth.

Family members/advocates should ask health-care providers to check on the patient’s ability to breathe on their own every day so that if there is a breathing tube, it can be removed as soon as possible.

3. Watch what you wear.

Caregivers should wear gowns, gloves, masks, or face shields when performing procedures such as suctioning the patient’s secretions and inserting a breathing tube. They should change them if they get soiled with respiratory secretions. Protective coverings keep germs from moving from provider to patient.

If you or the patient you’re looking out for is having such a procedure, ask the caregiver to don a clean protective covering first.

4. Take deep breaths and get moving.

If you have been prescribed breathing exercises using an “incentive spirometer” (a device you blow into that moves plastic balls in a tube), do the exercises as often as directed. If you’re urged you to get up and walk around, it’s not just your muscles providers are seeking to build, it's you’re your lung function. Taking deep breaths and moving around as much as you can also help reduce your chances of acquiring pneumonia.

5. Raise the head of the bed.

Ask the health-care providers if the head of the hospital bed should be elevated (to an angle of 30-45 degrees) to reduce the chances of breathing in secretions.

6. Take a break from sedating medications.

For patients who are sedated, family members or advocates should ask the health-care team if the drugs can be stopped to determine of the patient is alert enough to begin the process of removing the breathing tube.

7. Get vaccinated.

If you or your loved one is at high risk for pneumococcal disease, get vaccinated before your hospital stay. Pneumococcal disease is an infection caused by Streptococcus pneumoniae bacteria, sometimes referred to as pneumococcus. It can cause many illnesses, including pneumonia, blood infections, ear infections and meningitis.

The pneumococcal vaccine is recommended for all adults 65 and older and for anyone 2 and older who’s at high risk for disease. That includes smokers, people with chronic illnesses or conditions that weaken the immune system, or who live in a nursing home or other long-term care facility. Other vaccines that can help prevent diseases that cause pneumonia are Haemophilus influenzae type b vaccine (Hib), pertussis, varicella, measles and influenza.

8. Keep your mouth clean.

Good oral care is important in preventing pneumonia. Patients or family members/advocates should ask the caregivers how often they will clean the inside of the patient’s mouth. This should occur regularly with a toothbrush or antiseptic rinse.

9. Stop smoking.

Smoke is not lung-friendly. Smoking increases the risk of pneumonia and other health conditions. If you are a smoker, try to stop. And don’t expose yourself to someone else’s secondhand smoke, which also compromises lung function.

To learn more about HAIs, link to the CDC’s site with data and information here. To learn more generally about infections acquired in the hospital, link to our backgrounder.

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April 6, 2014

Another If/Then Review of Hospital Safety Ratings

Two hospital safety reports issued last month drew another confused picture of the inpatient experience.

The Centers for Disease Control and Prevention (CDC) concluded that the number of infections U.S. residents acquire during hospital stays has declined substantially over the last decade, for two notable reasons: Hospitals have tried to improve their practices, and nursing homes have admitted more patients for medical care.

Consumer Reports concluded that hospitals vary widely on safety measures and in how likely patients are to die of avoidable surgical complications. The organization said that patients are at higher risk in some hospitals of national renown than in some tiny facilities in rural areas.

The CDC report, as interpreted by the New York Times, shows that there were about 722,000 hospital infections in 2011; previous reports put that estimate at about 1.7 million a year. So in 2011, 1 in 25 patients contracted an infection while in the hospital, versus 1 in 20 previously.

Federal officials said that the old estimate, issued in 2007 using data from 2002, was less precise.

According to The Times, the new report, published in the New England Journal of Medicine, is the first nationally representative count of hospital infections. Its researchers randomly selected more than 10,000 patients at 183 hospitals.

Health officials say that the old and new estimates, despite not being precisely comparable, give an indication of the trajectory of hospital infections, which kill thousands of people every year.

Approximately 75,000 people with infections died in 2011 for a ratio of about 1 in 9, which CDC officials called “a trend toward improvement.” That’s a hedged description due to the fact that although hospitals were key to the declining numbers, other forces were at work, as noted by The Times: More than 6 in 10 operations are performed outside of hospitals in outpatient facilities such as orthopedic surgery centers, and much of the continuing care that used to be provided by hospitals is shifting to nursing homes. To put it bluntly, there are fewer opportunities for hospitals to mess up.

The CDC report counted only hospitals’ rate of infections, but the feds said they were working to expand data collection to include nursing homes and outpatient facilities.

The Consumer Reports story was the result of crunching the safety rating numbers of 2,591 hospitals.

In its coverage of the report, Reuters described the rate of U.S. hospital errors as “soaring.” It alluded to the 1999 Institute of Medicine (IOM) report that first shone a light on the problem of hospital errors, concluding that at least 98,000 people died annually from medical mistakes in hospitals. In 2010, the Department of Health and Human Services (HHS) said poor hospital care contributed to 180,000 deaths of Medicare patients every year. A 2013 study said at least 210,000 died and maybe as many as 440,000 every year. Last month, in “Hospital Errors Remain Too Common Because of Doctor Deficiencies,” we, too, revisited the apparently intractable problem.

Reuters said that if the high numbers in the 2013 study were accurate, poor hospital care would be the country's third leading cause of death, after heart disease and cancer.

Consumer Reports analyzed data on readmissions to hospitals within 30 days of discharge. Such quick turnarounds often signal poor initial care or follow-up; overuse of CT scans (which can cause cancer years later); hospital-acquired infections; miscommunication about things like discharge instructions; and mortality.

The mortality statistics concerned patients who had a heart attack, heart failure or pneumonia and died within 30 days of entering the hospital. They also accounted for surgery-related deaths, meaning patients who had treatable but ultimately fatal complications after an operation, such as blood clots, or cardiac arrest.

In past reports, some hospitals rightfully objected if their numbers were high because their patient populations were sicker when they were admitted. This time, according to Reuters, Consumer Reports adjusted for that.

See how Consumer Reports rates individual hospitals by linking here, but it requires a subscription to the magazine.

Patients who are hospitalized for pneumonia at low-scoring facilities were 67% more likely to die within 30 days of admission than pneumonia patients at top-scoring hospitals. Of 1,000 surgical patients who develop a serious surgical complication in top-rated hospitals, 87 or fewer die; more than 132 die in low-rated hospital.

According to Reuters, consumers might be frustrated if they research their local hospital on both Consumer Reports and Medicare's Hospital Compare because many kinds of data are missing from many hospitals.

And in some cases, the two raters flat-out disagree. Consumer Reports gave one hospital in Nyack, N.Y., a safety score of 25, tied for ninth worst. But Medicare rated its surgical complications at about average, as well as readmission and death rates for pneumonia, heart attack, and heart failure patients.

Ditto for higher-rated hospitals. One that got the highest safety rating by Consumer Reports had rates of surgical complications, infections, death from pneumonia and heart failure, and readmission of heart failure and pneumonia patients no different from the national average, according to Medicare. But it did very well in avoiding unnecessary imaging.

This is a consider-the-source issue. Medicare might deem a hospital's infection or mortality rate "average" if it’s only a few percentage points below the U.S. average, but Consumer Report sees it as below average.

We’ve covered the rocky terrain of hospital ratings many times — here and here, for example. The bottom line is that consumers should understand the biases of the raters, the demographics of the facilities and look for trends as much as single issues or categories of care.

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April 3, 2014

Suggested Reading — Willful Ignorance Has a High Social Cost

Too often, people make medical decisions based on fear, ignorance, convenience or a combination of them. We’ve often written (here and here) about the need to understand the basics about a health condition you might have, to understand proven practices to address it, and not just pop cultural attitudes about it.

Michael Hiltzik recently wrote a thoughtful column in the Los Angeles Times about the cost of people not knowing, and, often, not wanting to know, about the science of health.

Hiltzik’s piece shows how greed (brought to you primarily by the tobacco and pharmaceutical industries) promotes ignorance over truth, and what that costs: “When this sort of manipulation of information is done for profit,” Hiltzik wrote, “or to confound the development of beneficial public policy, it becomes a threat to health and to democratic society.”

“ ‘The myth of the "information society" is that we're drowning in knowledge,' " said one of Hiltzik’s sources who studies the phenomenon of anti-truth. “ ‘But it's easier to propagate ignorance.’ "

“Once allowed to take root,” Hiltzik said, “misinformation — whether cultural or manufactured — is very hard to dislodge.” The more enduring problem is that “ignorance interferes with the creation of intelligent policy.”

It’s a fascinating, and disturbing, read.

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