DC Medical Malpractice & Patient Safety Blog

As the health-care landscape continues to be reconfigured through legislative reform, greater consumer awareness, technological advances and evolving provider business models, an entrepreneurial niche has been carved out to help patients find the best, most efficient care. It’s called patient advocacy, and although the business is in its infancy, already there are a couple hundred members of the National Association of Healthcare Advocacy Consultants (NAHAC), as reported on Marketplace.

The organization’s self-described purpose is “to improve the way people interact with and experience the health care system by supporting public education to foster effective self-advocacy.”

We have repeatedly described the role of a patient advocate and explained why every patient who is hospitalized and all patients unable to fully inform themselves and act in their own interests should have a patient advocate.

The Marketplace story describes this function as a profession. It told the story of William Roach, who was diagnosed with brain cancer and faced multiple important decisions. He needed help. "It's not hard to find people who are sympathetic," Roach told Marketplace. "It is hard to find people that are both sympathetic and can provide information that can actually be helpful."

It’s sort of like asking your sister-in-law, who is good at math, to help with your financial portfolio. When you win the lottery, however, you need professional advice about what to do with all that money.

Roach contacted Elisabeth Schuler Russell, president of NAHAC and a private health-care consultant. Her line of work is so new, she said, sometimes doctors don’t understand her role. "They’re a little skeptical at first," she told Marketplace. "Because you’re not a family member, so why are you here? But once we explain to them that we’re there to help manage all the moving parts and to benefit the patient, they’re usually fine with that."

Her fees are $125 an hour. That’s a lot, but, according to her, most people need only a few hours of her time to help patients locate the right providers and supply them with relevant research so that they can “become their own best advocate."

Obviously, for some people this service isn’t affordable. And it shouldn’t be necessary if high-quality, cost-effective medical care routinely were delivered efficiently. We all know that doesn’t always happen.

Health-care consultant James Unland believes Baby Boomers will juice the patient advocate market for help choosing doctors, treatments, medications and dealing with billing, which is a whole other branch of the business.

But Les Funtleyder, author of "Health Care Investing: Profiting from the New World of Pharma, Biotech, and Health Care Services,” raises a warning flag. Because patient advocates so far aren’t licensed, accredited or otherwise certified, anyone can call himself a patient advocate even if he lacks qualifications. "You see this at the beginning of almost any new industry," Funtleyder told Marketplace. "There are always good ones and bad ones, and hopefully the bad ones get weeded out."

Roach apparently got the flower and not the weed. He said the $2,500 he spent on a patient advocate saved him money because it helped him spend fewer hours under a specialist’s care. And he’s fortunate that his screening tests lately have all been clear and he hasn’t required follow up.

The Deloitte Center for Health Solutions, a research arm of the business consulting firm Deloitte LLP, recently surveyed consumers, physicians and employers about the U.S. health-care system. Although these groups often have competing interests and agendas, they shared a low opinion about health care in America.

As reported on MedCity News, 63 percent of consumers, 65 percent of physicians and 65 percent of employers gave the U.S. health-care system a grade of C or lower. The poor grades, the thinking goes, is due to the perception that the system is wasteful and lacks value—only 1 in 4 respondents to an earlier consumer survey said they got the best value for their money.

There were differences, however, among the survey groups. When asked if they agreed that health-care reform (commonly referred to as “Obamacare”) was a step in the right direction, 44 in 100 physicians said yes, 38 in 100 consumers did and 30 in 100 employers. Only 4 in 10 mid-sized and large companies said they were “well prepared” to implement the Affordable Care Act reforms of 2014.

Asked who was to blame as the single largest contributor to health-care costs, 8 in 10 employers and nearly 6 in 10 consumers said “hospital costs;” 7 in 10 physicians said “consumer behavior.” There's a credibility gap that needs exploring. Because physicians are the ones writing the orders for drugs, tests and procedures, it's a little hard to swallow the idea that insistent consumers are browbeating doctors into wasting money on unnecessary medical stuff.

The advent of Medicare’s Part D drug plan introduced everyone to the concept of the “donut hole.” That’s the point at which prescription drug coverage ceases for a period during which the plan member pays full price. The gap closes when the patient has spent a set amount for drugs, and subsidies resume. As reported by Reuters Health, research has shown that this gap prompts seniors to stop taking medications for heart problems, diabetes and, now, depression.

According to the researchers of a new study published in the Archives of General Psychiatry, when these patients stop taking antidepressants, their risk of relapse increases. Such behavior, they said, “poses a serious risk.”

Once beneficiaries pay a deductible of a few hundred dollars, Part D drug plans usually cover 75 percent of drug costs until the threshold figure is reached. This year, for standard coverage, that amount is nearly $3,000. Then patients must shell out another $3,700 (amounts vary according to plan) before coverage resumes.

If the Affordable Care Act survives the current political upheaval, the donut hole will expire in 2020, when the legislation mandates that drug coverage be constant. But that’s a long time away, especially if you’re a senior citizen.

We’ve discussed how the insurance coverage options available to supplement Medicare are so confusing that seniors are less likely to enroll for additional coverage. But the study makes clear, however, that they are less likely to forgo their drugs if they have it.

The study involved more than 22,000 Medicare beneficiaries who had been diagnosed with depression and were prescribed antidepressants. Data was collected starting in 2007, the year after the Part D plan was initiated. Nearly 3,000 study subjects had supplemental insurance that filled the gap for generic drugs. Another 11,500 had complete coverage from other sources, including low-income subsidies. But more than 7,500 were stuck paying the gap amount.
Nearly 7 in 100 people who had generic drug gap coverage ceased taking their antidepressant meds, but more than 12 in 100 with no coverage did.

As the study notes, depression affects 13 in 100 Medicare beneficiaries 65 years or older. Many have additional chronic physical conditions. Treating and maintaining treatment of late-life depression with antidepressants prevents recurrent episodes of major depression. Caregivers generally recommend these patients take antidepressants for two years.

It’s a bad idea to stop taking these drugs cold turkey. As the lead researcher wrote, "If patients discontinue their appropriate medication therapy abruptly, they could be placing themselves at risk for medication withdrawal effects [including include dizziness, gastrointestinal distress, disturbing dreams, fatigue and irritability] and for (depression) relapse or recurrence."

Although the study didn’t find that rates of hospitalization were higher for the no-gap coverage group than the others in the study, the depressed elderly population remains vulnerable to the Part D donut hole.

If you or a loved one is in this situation, help is available. Contact the manufacturer of the relevant drug—they often have coupons or rebate/subsidy programs for the financially pinched. That link also includes contact information for other prescription assistance organizations, as well as general resources for seniors. For general information about Medicare’s prescription drug coverage, link here.

One component of the changing U.S. medical industrial complex is a greater awareness on the part of physicians that superior health care isn’t only about science and practice management. It’s also about the efficient and fair delivery of medical care.

There is, perhaps, no better example of this awareness than a recent report that issued from an annual meeting of the American Medical Association (AMA). As the largest medical professional organization, and publisher of the Journal of the American Medical Association (JAMA) and its several specialty publications, the AMA’s pronouncements carry heft not only for members, but for anyone interested in medicine.

Last month, the AMA’s principle policy-making body, the House of Delegates, declared that the provision of effective medical care includes an “obligation” to manage health-care resources well (p. 180). As reported on MedPage Today, the statement reinforced the notion that physicians are obliged primarily to serve the interest of individuals, and that too often, caregivers make decisions that don’t consider the welfare of the patient.

That includes recognition of the cost of care.

In our monthly newsletter, we’ve discussed the idea of transparency in health care, of how medical consumers usually have little idea of what treatment costs because its purchase is clouded in bureaucracy and a sliding standard, depending on whether insurance underwrites care, and if so, to what extent. It’s refreshing to see the organization that represents so many practitioners calling for the same clarity of cost.

The report cited several cost pressures under which caregivers work, some of which are beyond their control—drug prices, for one example. “Other cost drivers, however, such as extensive use of new technologies and high intensity of services provided at each patient encounter, are influenced by physician choices,” the report read.

Doctors must refrain, the report said, from ordering medically unnecessary tests, and to provide treatments of clear patient benefit. “Wise stewardship,” the report says, is what should shape decisions about care. “More intensive and/or costlier services do not necessarily lead to better health outcomes.” Readers of this blog have heard that before.

Some doctors practice defensive medicine—that is, they overtreat because they’re afraid of getting sued for malpractice if they don’t order many tests and something goes wrong. Unfortunately, however, instead of acknowledging that bogus premise and that good care and the immediate acknowledgment of responsibility in the event of an error have been proved to thwart lawsuits, the AMA statement said only that doctors should work harder for medical liability reform in order to fully implement its vision of “wise stewardship.”

Although some doctors were concerned that cost-consciousness would make patient well-being a secondary consideration, most were in favor of what the report specifically recommended:

• Base medical recommendations on patients' medical needs using scientifically grounded evidence.


• Help patients and their families form realistic expectations about whether a particular intervention is likely to achieve its goals.


• Choose the course of action that demand fewer resources if alternatives offer similar prospective outcome and anticipated benefit compared with anticipated harm.


• Be transparent about the medical alternatives, including disclosing when a constraint on resources played a role in decision-making.


• Try to resolve disagreement if a patient feels a costly intervention is worthwhile. This could include consulting other professionals.

The report also advised that “Medicine as a profession must … make it feasible for individual physicians to be prudent stewards by:”

• encouraging health-care administrators and organizations to make cost data transparent;


• ensuring that physicians have the training they need to be informed about health-care costs
  and how their decisions affect overall health-care spending.

As MedPage Today reported, Tamaan Osbourn Roberts, a family physician, told the House of Delegates at the AMA meeting, “Stewardship is not antithetical to care of a patient. As physicians, we make decisions on resources every day. If not us, who?"

The next time you’re annoyed by someone with impaired hearing who constantly asks you to repeat what you’ve said, try to restrain the urge to ask,“Why don’t you get a hearing aid?”

Because for many such folks, the answer might be that they can’t afford it. As reported by KaiserHealthNews.org (KHN), a hearing aid typically costs a few thousand dollars, sometimes more, and most insurance plans don’t cover the cost. Even Medicare, whose older patient demographic is prime for hearing loss, generally keeps the purse strings closed.

Only 1 in 4 of the 35 million adults in the U.S. who would benefit from having a hearing aid actually gets one, according to KHN.

As disappointing as it is to know that hearing loss isn’t considered worthy of coverage, the situation isn’t as bad as it used to be. A survey of people who bought hearing aids in 2008 showed that nearly 4 in 10 received an insurance contribution, which was somewhat more generous than four years earlier.

Insurance plans usually cover tests (or some of them) to evaluate hearing. But if the loss is sufficient for the care provider to prescribe a hearing aid, insurance generally amounts to only $500 to $1,000 for the device once every two to five years. They need to be replaced, on average, every four to six years.

One woman whose story was told in the KHN report began to lose her hearing as a young woman. She got her first hearing aid at 35, and by the time she was 40 had one in each ear. She estimates that she bought 11 hearing aids over the following two decades that cost approximately $25,000, all of which she paid as a customer of the individual health insurance market.

Still, there is cause for hope. A program introduced this year by UnitedHealthcare called hi Health Innovations is intended to make affordable hearing aids—ranging in cost from $749 to $949—available to both its members and the general public. The discounts of 30 to 50 percent are available because the company buys in bulk. Plan members might get an even better deal.

Patients can take a hearing test online, submit it for evaluation and choose among the four HI hearing aids. The selection is programmed to the patients’ specifications and mailed to them. The online operation also offers help with service issues, and there’s a toll-free customer service line at (855) 523-9355.

HI audiologists and hearing aid dispensers (who are also licensed, but with less training than audiologists) are located in major cities around the country. Email the company for information at hicustomerservice@hihealthinnovations.com

The program is too new to assess success, but advocacy groups are hopeful it can address the gaping hole in treatment for hearing loss. As Lise Hamlin of the Hearing Loss Association of America said, "We think getting hearing aids into people's hands is hugely important. But the test may be wrong or the hearing aids may not work for most people. So we're taking a wait-and-see attitude."

Some hearing loss is so profound a hearing aid is not the solution. Surgery might be. In that case, insurance coverage, including Medicare, generally is available. The procedure involves a small electronic device called a cochlear implant that stimulates the auditory nerve.

For more information about hearing loss and how to treat it, visit the Hearing Loss Association of America website.

As the Supreme Court begins to grapple with the Constitutional challenges to the Obama administration’s health-care reform legislation known as the Patient Safety and Affordable Care Act (ACA), Republicans in the House of Representatives continue to object.

In the words of Fiscal Times correspondent Merrill Goozner, writing on his GoozNews blog, the GOP “took another swipe at the alleged rationing in Obamacare” when they voted to disband the Independent Payment Advisory Board (IPAB). Its purpose is to examine Medicare spending when it grows substantially faster than the economy, and to offer Congress options of how to rein it in. Congress may exercise its suggestions, or enact its own cost-control measures.

That’s a reasonable oversight responsibility for a panel of 15 experts designed to resist political pressure. But Republicans have used fear and loathing to mischaracterize it and, by extension, the rest of health-care reform. They called the IPAB a “death panel,” accusing it of rationing care for the elderly.

Neither party can claim success in moderating Medicare spending, and Goozner indicts the tone of the House debate over the IPAB as the “perennial obsession with the next election, not the next generation.”

The House vote is insignificant because the Senate won’t confirm eliminating the advisory panel, but, Goozner notes, there’s irony in the fact that the vote occurred only a day after a different advisory panel at the Centers for Medicare and Medicaid Services (CMS) convened to discuss coverage issues. That meeting illustrated how wise rationing could save both patients and the government billions of dollars a year without jeopardizing care.

We’ve addressed the issue of cost-effective, appropriate care, by no less a vested interest than the American College of Physicians. The CMS panel, Goozner reports, considered whether there was sufficient scientific evidence to support a Medicare decision to subsidize drug treatments for diabetic macular edema. Caused by diabetes, the disorder compromises vision and can cause blindness.

An expensive drug made by Roche/Genentech called Lucentis is under consideration by the FDA. It costs $1,624 for a monthly shot which diabetics would require for the rest of their lives. Another drug, also made by Roche/Genentech, called Avastin, is equally effective. It’s essentially the same drug, but it’s compounded in larger doses than the newer, pricier version, and was approved by the FDA as a cancer, not diabetes, treatment.

Eye doctors, as Goozner explains, understand that dividing Avastin into smaller doses appropriate for injection into the eye pencils out to $43 per treatment.

If Avastin sounds familiar, that’s because of its recent notoriety over serious side effects, and problems experienced when eye injections are performed improperly.

But that’s not Goozner’s focus here. He’s concerned that the 325,000 Medicare beneficiaries who have diabetic macular edema and might qualify for the treatments must pay 20 percent of the cost as a co-pay. That’s $324.80, every month, for Lucentis, versus $8.60 for Avastin. The seniors get burned, and so do taxpayers.

“If everyone on Medicare who is eligible for the treatment receives Lucentis, it will cost the government $6.3 billion a year,” Goozner says, according to a report submitted to the panel. “If they receive Avastin, the government will pay only $167.7 million.”

The CMS committee, by law, may not consider cost when evaluating whether or not to pay for a treatment. The reform law that Republicans are trying to repeal says comparative effectiveness research paid for by the government—research such as the assessment on diabetic macular edema—cannot be used in making payment decisions.

So the committee’s vote reflected only science, not cost. It decided that both drugs worked about the same.

Currently, both are being used “off-label,” that is, for a purpose other than what they were approved for by the FDA. Still, Medicare contractors in about half the states, Goozner reports, pay for them. Once the FDA approves Lucentis for diabetic macular edema, Roche/Genentech won’t submit an application for Avastin as a treatment because they’re concerned about profit, not price. By law, Medicare must pay for an FDA-approved drug. And doctors, who get a small piece of the price of drugs they use in their offices, will have an incentive to use the more expensive, approved drug.

So, explain to us, again, why the ACA’s Independent Payment Advisory Board should be eliminated?

If you wish to register your opinions on rational rationing or irrational non-rationing and their effect on the public and individual bottom line, contact your Congressional representatives. You can find them here, as well as Congressional leadership.

In medicine, a culture shift may be underway in venture capital, which subsidizes the cutting-edge technology that keeps a culture moving forward.

As reported by Kaiser Health News (KHN) in conjunction with NPR and KQED, for venture capitalists, the bloom is fading from expensive medical gee-whizzery. These days, such deep-pocketed supporters are more in favor of improving medical efficiency than in staking a claim to such glitzy endeavors as robotic surgery, whose questionable benefits we recently covered.

Hospitals love boasting about their amazing new machines and surgeons love using them. Insurance companies don’t love paying for them, so their enormous costs are passed along to employers and patients.

As the recession took hold, however, and the Affordable Care Act (ACA) was passed, the financial engine behind high-tech R&D began to reassess where to put its fuel. As one Silicon Valley venture capitalist told KHN, “If you come in with [a device] that’s 10 percent better and twice as expensive, it’s hard to get anyone to care.”

Venture capitalists look for opportunity wherever it occurs, and these days it’s in areas such as helping hospitals figure out how to reduce readmissions. It’s expensive when a recently released hospital patient must be readmitted because of complications, and under the ACA, readmissions carry financial penalties.

Because the ACA will increase the number of people who are covered by high-deductible insurance plans, venture capital is funding a technology company that helps them choose the least expensive care. Another less-than-glamorous funding recipient, but one with an enormous impact, addresses the often torturous process of health-care billing.

“There’s a half a person per hospital bed on average that sits in the hospital doing coding and collections and trying to get paid,” according to one venture capitalist. His solution is to replace the labor-intensive manual coding with software that can understand repetitive charges and devise efficiencies that minimize repetitious functions.

That doesn’t mean new medical developments are all about process instead of product, but the products are simpler. Infections, notoriously borne by the widespread use of catheters, are being controlled better through the venture-capital development of a plastic device that kills microbes. The DualCap catheter costs less than a dollar.

Sometimes, the most thoughtful investment isn’t about the sexiest new surgical tool that helps 10 rich people find a place in medical history; it’s about helping millions of average patients gain access to competent, affordable care for the long run.

If it takes a village to raise a child, it takes a whole culture to ensure adequate health care for all. One Idaho obstetrician recently explained to his state’s legislators how he thinks it can be done.

Dr. Loel Fenwick, as reported by the Idaho Reporter, said in order to curb the rising cost of health care and address the U.S. propensity to overtreat, consumers must become more involved in health-care decisions. These aren’t new ideas, and readers of this blog will recognize the echoing refrain. The point is not only to lower costs, but improve outcomes.

Instead of the standard, but now diminishing, group health coverage by employers, Fenwick supports the idea of health savings accounts (HSAs) for private sector employees. HSAs are insurance plans with two basic elements:

• a tax-preferred savings account where money is set aside by the consumer (employers may also contribute) to pay for medical expenses and prescription drugs;


• a high-deductible health insurance plan.

According to Kaiser Health News, any adult with a high-deductible health plan and no other form of health care coverage may establish one of these accounts.

Fenwick’s idea is for the state to develop these accounts for private sector employees, and for insurance carriers to house the policies. Employers would deposit insurance premiums into the accounts, which could be tapped only for health-care expenditures.

Like all HSAs, the cash accounts are coupled with high-deductible insurance coverage for things beyond relatively modest procedures and treatments, such as vaccinations, and check-ups.

Fenwick’s plan would require doctors and hospitals to list the cost of treatments and procedures so that consumers could be informed about what stuff actually costs, instead of knowing only what is their share of an otherwise unknowable cost. Comparison shopping for medical needs! What a concept! This idea is gaining traction, and we wrote about one such program a few months ago.

Fenwick says Idaho would save as much as $1,350 per year, per resident in otherwise state-subsidized care.

One legislator expressed support for Fenwick’s idea, noting that the current health-care mind-set is to secure as many medical services—diagnosis, testing, treatment—as one’s insurance policy will permit, rather than to think about them as a commodity with resources that must be shared. “When something is free, people will take more than they need,” he said. “When you don’t have any skin in the game, you don’t care what it costs.”

To encourage participants to be careful medical consumers, the cash accounts permit withdrawals of a certain percentage of the funds each year. If you think there’s a financial reward for not using medical services you might not need, the thinking goes, chances are better that you won’t.

Fenwick’s plan isn’t a panacea for all the ills that render health care in the U.S. less than robust. But at least somebody on the front lines is proffering an alternative that people without high-maintenance and/or chronic health problems should be considering.

What is the essential core of a health insurance policy that every insurer should have to offer its customers? The federal government is struggling to come up with a definition, but it's proving to be not so easy.

Most people know that the Affordable Care Act (ACA), the health reform plan that was passed in 2010 and remains under political attack, imposes a series of requirements on health insurers. But most people also remain confused about what’s required of the companies that insure them.

Kaiser Health News helps interpret a recent document released by the Department of Health and Human Services previewing what most health plans must offer by way of insurance-covered services beginning in 2014.

Individual states have some latitude in defining “essential benefits” that must be part of coverage for individuals or small businesses, but the law is clear that 10 benefit categories must be included. States can decide, for example, how many doctor visits are allowed.

The HHS released a list of insurance plans names and network types that states may follow, but the feds’ document doesn’t include the benefits covered by those plans. And it doesn’t express a preference for what it would like to see covered.

Consumer advocates, of course, find that rather wanting.

As quoted by Kaiser Health News, Stephen Finan of the American Cancer Society-Cancer Action Network said that without the complete package, “we remain completely in the dark.” Late last year, consumer groups including the Cancer Society were signatories to a letter to HHS seeking advice about which health plans states could choose as benchmarks.

The list offered last week by the department isn’t exactly what they had in mind.

“We know a little more than we knew yesterday, but we still do not have basic documents to see if the plans are good or not so good for cancer patients, or any other kind of patient,” Finan told Kaiser Health News.

HHS lists the insurance plans in each state with the largest enrollments in the small group market. It also lists the three nationally available health plans with the largest enrollments open to federal employees. The document reads, “Under the state’s intended approach, states would have the flexibility to select an existing health plan to set the ‘benchmark’ for the items and services included.” If the selected plan doesn’t include benefits in the federally defined categories, the state must supplement the benchmark.

States may select a benchmark from four types of plans, but if you don’t know what’s in the plan, how do you make an informed decision? It’s like ordering a full course dinner from a brand name restaurant without looking at the menu.

If you’d like to make your feelings known, contact The U.S. Department of Health and Human Services at 200 Independence Avenue, S.W., Washington, D.C. 20201. The phone number is (877) 696-6775.

Knowledge, they say, is power. It’s also a necessary tool for crafting cost-effective medical practices and protecting patient safety.

Medicare has an enormous claims database from which valuable knowledge can be mined. Finally, within about one year, employers, insurance companies and consumer groups will be able to unearth its information to produce “report cards” on doctors and hospitals.

This blog has championed this access to information, and the subject also figures mightily in “The Life You Save: Nine Steps to Finding the Best Medical Care and Avoiding the Worst,” my book about patient advocacy and medical mistakes.

As described in an Associated Press story, researching a health-care provider’s history in the Medicare database has not been possible before, thanks to a decades-old court decision. Releasing such information, the ruling read, violates the privacy of doctors. The medical establishment was vigorous and vocal in not wanting the people who pay for and receive its ministrations to know how its members rate.

Congress and the executive branch disagreed. For once, both parties were unified on this issue, and federal law has been revised to authorize access to the Medicare database.

What does this mean to the average patient? Suppose you need a knee replacement. Wouldn’t it be nice to compare potential surgeons by how many such procedures they’ve performed, if there were preventable complications and how many?

Experts who analyze Medicare’s billing records glean critical information that not only promotes quality care, it reduces cost and waste by promoting practitioners who are skilled and responsive. The delivery of health care is more efficient and outcomes improve when complications, readmissions and legal adventures are kept to a minimum.

"This is a giant step forward in making our health care system more transparent," said Marilyn Tavenner, Medicare's acting administrator of the newly accessible Medicare mother lode.

Performance reports could be available to consumers by the end of next year. Although individual doctors will be identified in the files, patient names and personal information will not.

Companies are keen to identify the economies of scale that will emerge from analyzing Medicare’s data as it applies to their insurance coverage. But some employer groups also want their workers to know how well their health-care providers are doing their jobs. An executive with the Business Roundtable, which represents CEOs of major corporations, told AP, "We want to make it understandable and usable by our employees. That has always been the goal."

The American Medical Association, which represents doctors, claimed that this data could be misleading or misunderstood by the average consumer. A surgeon with many patients who develop complications, for example, actually might be a top practitioner. He or she just might be willing to accept difficult cases others reject.

There are accommodations to the medical community—providers have the right to see their information before it is released publicly, and they will have 60 days to challenge it.

And Medicare promises to screen the analytical methods of groups requesting access to the data, which isn’t free—access to the files comes at a cost.

The price for transparency is worth it.

First published on Technorati as Finally, Accurate Report Cards on Doctors' Safety and Quality of Care.

Patients’ rights advocates lost a valuable team member this month.

Dr. Donald Berwick resigned as administrator of the Centers for Medicare and Medicaid Services (CMS) for reasons wholly political. The respected, forward-thinking medical professional opted to leave rather than continue in the role for which President Obama sought Congressional approval, but resorted to a so-called “pocket” appointment when Senate Republicans blocked his nomination last year.

The appointment, which Obama made when the Senate was in recess, was in effect until the end of this year. Berwick, a pediatrician, has served 17 months and is leaving, as opposition among Republicans remains strong. They claim Berwick is a fellow traveler with Obama’s health-care reform movement—the Affordable Care Act, or ACA—and all too willing to ration health care.

They’re not completely wrong, but they’re not right.

As recounted on Medscape.com, when Obama nominated Berwick in April last year, he had headed the Institute for Healthcare Improvement, and various organizations supported the move, including the American College of Physicians, AARP, Walmart and Consumers Union.

In his temporary tenure at CMS, Berwick helped implement several elements of the ACA pertaining to the Medicare and Medicaid programs. Among them were regulations for accountable care organizations (ACOs). Those groups of health-care providers improve outcomes and reduce costs by coordinating the care of Medicare patients and, as a reward, get a cut of the money saved.

Berwick also shepherded a pilot program to effect essentially the same change—and benefits—for physicians, rewarding them for providing better quality versus higher quantity of care for the quality as opposed to the quantity of their services. Known as the Comprehensive Primary Care Initiative, the program assists primary care doctors in:

• helping patients with serious or chronic diseases follow personalized care plans;


• giving patients 24-hour access to care and health information;


• delivering preventive care;


• engaging patients and their families in their own care; and


• working together with other doctors, including specialists, to provide better coordinated care.

Dr. Glen Stream, president of the American Academy of Family Physicians, described Berwick for Medscape as someone "with an impeccable background in quality improvement and a willingness to evaluate healthcare from top to bottom." Stream doesn’t know if the initiatives Berwick supports will succeed in improving the quality of and lowering its cost, but like many of his professional colleagues, he give him props for addressing thorny medical-industrial issues others won’t.

Among them are the president and chief executive officer of the American Medical Group Association and the chief executive officer of the American College of Cardiology. The latter, Dr. Jack Lewin, applauds Dr. Berwick for listening to physicians while trying to reform the health-care system. As Medscape notes, when organized medicine initially gave a thumbs-down to the ACO rules, Berwick "went back and changed them significantly," Lewin said.

"CMS is trying to do its job as a regulatory agency, but facilitate innovation at the same time," Lewin said. "They're partnering with us. That's clearly part of Don's legacy."

"It's been a great era. It's too bad we don't have a few more years of it."

Because of his willingness to accept the limitations of modern health-care delivery, Berwick was scorned in Congress and all over the conservative blogosphere as "Dr. Death Panel," referring to his past statements supporting Britain’s National Health Service and accepting that rationing of healthcare is inevitable.

"The decision is not whether or not we will ration care — the decision is whether we will ration with our eyes open," Berwick is quoted as saying in Biotechnology Healthcare magazine in 2009. "And right now, we are doing it blindly."

For people more concerned about the quality, accessibility and cost of health care more than who wins political points making it happen, Lewin summarized Berwick’s situation for Medscape: "Unfortunately, he's been a scapegoat for Republicans who are mad about the ACA."

Here's an interesting interview with Dr. Berwick in the New York Times, where he gets off some parting shots about what's wrong with the politics of our health care system.

A primary consumer benefit of free enterprise is competition. Not happy with the service/quality/price of something you want to purchase? Compare one merchant’s offer with that of another, and take your business where it makes most sense to you.

A few months ago, we wrote about a Florida law requiring urgent care clinics to post prices. Unfortunately, knowing the cost of a medical service in advance generally isn’t possible in the health-care market. As noted by Merrill Goozner on his GoozNews blog,

“

For all the talk about consumer driven medicine …, why doesn’t anyone talk about pricing transparency in health care? Did you ever walk into a doctor’s office where the prices of various services were posted? A hospital? At the drug store’s pharmacy counter?”

But enabling medical consumers to contrast and compare isn’t as easy as, say, simply legislating that prices be posted wherever people are buying health-care products and services. Goozner says that although that’s a place to start, it’s inherently confusing because the U.S. system of health care is so fragmented. It’s not like buying a pair of jeans, where the only differences might be cost and whether or not you get free shipping.

When you’re buying treatment for a heart attack, as Goozner so deftly describes one hypothetical hospital emergency room patient, “You look up on the wall to learn that Insurance Company A pays $30,000 for angioplasty. Insurance Company B pays $28,000. Medicare pays $26,000. Medicaid pays $24,000. And (for) you, the customer right in off the street without coverage, the charge is $32,000. Don’t want to pay our rack rate? You might want to try down the street at Mother Mercy of the Poor. We understand their rack rate is $26,000, the same as Medicare.”

You still need to compare apples with apples. How many providers are involved in each of these options, what are their credentials, what’s the record for each hospital in terms of infection control and readmission rates? Every price listing begs another question.

Holy sliding scale!

“Pricing transparency” helps medical consumers understand the high cost of medical care, and the inefficiencies and inequities of a multipayer system of financing it, as Goozner notes, and that’s critical to effecting any meaningful change. But unless and until U.S. medical care is priced the same for everybody receiving the same service or product, he says, it won’t address the problem of why Americans pay more for medical care than residents of other countries.

Jason Shafrin, writing on the Healthcare Economist blog, is also a believer in pricing transparency. He promotes a tool consumers can use to help them shop for care. The Healthcare Blue Book, which is recommended by Consumer Reports, estimates costs for specific medical problems.

Armed with pricing information, consumers—especially the uninsured—are then empowered to negotiate, to ask for charges comparable to others they can quantify.

As stated on the Blue Book website, the resource “is a free consumer guide to help you determine fair prices in your area for healthcare services. If you pay for your own healthcare, have a high deductible or need a service your insurance does not fully cover, we can help. The Blue Book will help you find fair prices for surgery, hospital stays, doctor visits, medical tests and much more.”

Shafrin looked into how the Blue Book sourced its pricing information. Using claims and billing data, it averages prices paid by insurance companies to providers in a given market.

If you’re faced with a medical expense, either in full or as a contribution to what your insurance pays, inform yourself if the cost seems reasonable. If not, speak out. When it comes to fair health care costs, ignorance is not your friend.

It’s a widely, if grumpily, accepted fact that primary care physicians spend less time with patients than either would like. There are only so many minutes in the day, and there’s always more paperwork than time to address it.

No medical practitioner is more overburdened than a primary care physician, because in many health plans, he or she is the so-called “gatekeeper” to specialized care. Patients must see one in order to warrant a referral to someone else – a dermatologist, a cardiologist, a psychiatrist, a surgeon.

So no wonder that the American Medical Association recently asked the Centers for Medicare & Medicaid Services (CMS) to reimburse network physicians in fee-for-services health plans for phone calls, counseling and other efforts they expend to coordinate care for chronically ill patients.

No question that the labyrinthian nature of the U.S. health-care system demands much of people obliged to navigate it on behalf of others, and these professionals deserve to be compensated, according to independent health-care journalist Merrill Goozner.

But with shrinking coverage, strained budgets and the inexorable increase in the cost of health care, how will these merit pay raises be funded? How about, Goozner suggests, by the medical establishment reassessing and realigning its priorities? How about by embracing a rational sense of proportion?

There’s an ocean of difference in what providers are paid. Specialists often receive two or three times the fees paid to a primary care doc. Goozner says it’s difficult to justify that the “relative value” of back surgery or angioplasty is so much more than other kinds of treatment involved in gate-keeping. These two specialties, he says, are exemplary of “the most expensive and overused procedures in medicine, incentivized by the extraordinarily high fees earned by the surgeons who do them.”

Whether or not you agree with the politically driven Congressional mandate that any new spending must be offset by federal budget cuts – known as the “pay-for” rule – maybe Medicare should adopt the same policy. If Congressional Republicans find it acceptable to charge emergency flood relief with a pay-for, if President Obama is OK with sending the bill for his jobs package to the nation’s millionaires, maybe medicine should cover the coordination of care pay-for with a reduction in the inflated fees for specialist care.

“Congress needs to come up with nearly $300 billion over the next decade simply to hold physician salaries where they are,” Goozner writes. “The permanent fix would set a cap for total physician pay; and allow it to rise over time for inflation. But why not require that CMS adjust payments to the various specialties to meet that cap? Otherwise, in a few years we’ll be right back where we are today: a permanent fix that wasn’t permanent at all, with new services inflating the total tab beyond the cap.”

Last week, Steve Grossman, an advocate for greater FDA funding, voiced an argument on his blog, FDA Matters, that not only should the government’s food and drug watchdog consider the safety and effectiveness of drugs, therapies and medical devices in its approval process, but also their cost.

In the past, Grossman has supported a split in medical treatment responsibility -- the feds conduct risk-benefit analysis, and insurers, physicians and pharmacists make decisions about cost-benefit. It’s hard enough to determine safety and efficacy without loading cost factor into the equation.

But, he writes, “Two events [recently] have left me wondering whether there are certain limited circumstances when FDA should be able to take product cost into consideration.”

The September publication in the British medical journal Lancet of a report called “Delivering Affordable Cancer Care in High-Income Countries” concluded that as cancer care becomes increasingly expensive, affordability, accessibility and value must factor into treatment.

Grossman knows that Medicare, Medicaid and private insurers will look to the report for insight into cost containment and support for tough decisions they make in the near future about who gets what treatment.

Thanks to problematic realities such as drug shortages in the U.S. – which disproportinately affect cancer drugs – Grossman says the FDA should have a voice in this conversation. “Patients suffer, research is delayed and more expensive drugs are often substituted (or patients do without),” he writes.

Apart from shortages and manufacturing problems, economics are helping to steer this issue into the danger zone. If it’s not sufficiently profitable for manufacturers to make older cancer drugs (because patent protection has expired), the FDA can’t address the shortage situation without considering cost. It might have to find ways to favor less effective or riskier products, Grossman suggests, only because they can be made available at a market-driven price.

The second event that prompted Grossman to reconsider the separation of medical treatment responsibility relates to the FDA’s unintentional role in exacerbating the crisis in affordable cancer care. Numerous new cancer products have joined the market in the last few years, more are coming, and they’re expensive -- about $100,000 per cycle. Some patients need multiple cycles or multiple expensive drugs.

So when asked what would the FDA do if a drug was only 90% as good as the safest and most effective therapy on the market (a metric that defines "standard of care") but would be available for only 10% of the cost, Grossman gave the stock answer: The FDA approves only therapies that are as good as or better than the existing standard of care. The cost aspect is not part of the decision.

Eureka! In light of the Lancet study, wouldn’t patients benefit if the feds had some room to consider standards of care, risk-benefit and comparative cost?

“It scares me to write this,” Grossman admitted. “the whole notion of FDA putting cost on the table seems like an abandonment of principles, as well as fraught with potential misuse.”

The FDA is not permitted to approve a drug, biologic or device that is not quite as effective or safe as predecessors solely because it will make care more affordable and accessible. “I am not yet an advocate for this,” Grossman states, “but I think it is one of the possibilities that we need to be discussing.”

It’s a pretty radical idea. But how often does significant, positive change occur on a grand scale without a radical element pushing the envelope?

Kathleen Sharp tells a good, if scary, story. In “Blood Feud: The Man Who Blew the Whistle on One of the Deadliest Prescription Drugs Ever,” she describes how two Big Pharma companies conspired to develop and market an anti-anemia drug despite evidence of devastating side effects.

In a recent op-ed in the New York Times, she argues that scarily rampant fraud in health care is partly the fault of the feds.

The Obama administration announced plans to cut $320 billion over 10 years from the projected growth of Medicare and Medicaid by raising premiums and deductibles, lowering payments to providers and requiring recipients of home health care to make co-payments.

But, Sharp asks, what if instead of charging consumers more and eliminating services, the focus was on diminishing the estimated $100 billion that’s lost every year from these programs in the form of fraud? And the additional 150 billion fraudulent dollars collected in the rest of the health-care industry?

Here’s how taxpayers are defrauded:

• hospital chains buy drugs at steep discounts, then bill Medicare the retail cost;


• doctors bill for procedures never performed and drugs they receive free from pharmaceutical companies;


• pharmaceutical companies promote drugs for uses not approved by the FDA;


• laboratories pay kickbacks and/or offer discounts to doctors and hospitals that refer patients.

Individual cases of fraud would have more muscle, Sharp says, if the Justice Department moved front and center, rather than allowing individual state attorneys general to prosecute them. Although chronically understaffed, the department had more than 1,300 whistle-blower cases under investigation in the beginning of 2011; can anyone but the most dogged reporter track their progress? Two years ago, an additional $198 million was appropriated to fight health-care fraud, and where did that go?

“The only way to tell if taxpayers are getting their money’s worth of farud-fughting,” Sharp writes, “is for the Department of Justice to routinely publish, among other statistics on corporate fraud, a breakdown of the number of cases it opens and the number originating from whistle-blowers.”

So how would a more actuarial accounting of federal investigations boost successful prosecutions and fight fraud? The $2.5 million recovered in health-care fraud cases in 2010 is peanuts, Sharp says, because even if cases are settled, Big Pharma writes it off as a cost of doing business: If it costs $1 million to sell $10 million in drugs, that’s a good return.

The scourge of cervical cancer -- a leading cancer killer of women in the third world without access to Pap smears and HPV vaccinations -- is being whipped with an unlikely low-tech, low-cost preventive treatment: Ordinary vinegar plus freezing of the cervical warts before they turn cancerous.

The vinegar is brushed on the cervix by a nurse and any areas of abnormality turn white. It's not perfectly accurate -- sometimes spots turn white and they are totally benign. But the treatment of the white spots is low-pain and cheap -- and highly effective: freezing of the white spots with a metal rod dipped in liquid carbon dioxide (available from the nearest Coca Cola plant).

Read more about this public health innovation that was co-invented by American and Indian doctors, and spread in Thailand, in this New York Times article.

Like real estate, rating the quality of long-term care is about location, location, location.

A new report from AARP, The Commonweath Fund and The Scan Foundation found a wide disparity of services and accessibility in the U.S. for the elderly and disabled and their caregivers on a state-by-state basis.
As summarized by WebMD, the study looked at:

• affordability and access;


• patient choice of both provider and setting;


• quality of life and care; and


• support for family caregivers.

Overall, the five highest-scoring states are:
1. Minnesota
2. Washington
3. Oregon
4. Hawaii
5. Wisconsin

The lowest scores go to:
1. Mississippi
2. Alabama
3. West Virginia
4. Oklahoma
5. Indiana

The top five states cover nearly two-thirds of their low- to moderate-income population that requires long-term care. The worst states cover only one-fifth. The nationwide average is about one-third.

But everything is relative, and the authors are careful to note that even states with high scores need to improve the services they provide, and that low-ranked states performed well in at least some categories.

The authors said that if all states performed as well as Minnesota, more than 120,000 hospitalizations would be avoided at a savings of $1.3 billion. If all states had public safety nets as effective Maine’s, more than 667,000 people would be covered by Medicaid or other publicly funded programs.

To view the full study and how every state ranks, go to www.longtermscorecard.org.

At a time when the cost of health care represents nearly one-fifth of the U.S. gross domestic product, it is reasonable and necessary to discuss the notion of “appropriate care.” But a fair and conscientious examination of what measures, personnel and technologies should be employed to diagnose and treat medical problems must get past such inflammatory terms as “death panel,” “rationed care” and “tort reform” (that is, malpractice lawsuits). That kind of language does not advance or inform the discussion.

A recent commentary in the New England Journal of Medicine grappled with the topic, and the breadth of comments by its readers indicated how all of us – providers and consumers – must drive meaningful health-care reform.

Victor R. Fuchs, Ph.D., is an economist affiliated with Stanford University and an expert on health policy. His commentary, “The Doctor’s Dilemma – What Is ‘Appropriate’ Care?”, discusses the difference between what is “ethical” and what is “appropriate.”

“How can a commitment to cost-effective care be reconciled with a fundamental principle of primacy of patient welfare?” he asks.

We are a nation that celebrates the individual and enables development of expensive drugs, devices and procedures. Our default position is that if something is new! and improved! it should be widely used. But, Fuchs notes, “[T]echnologies that may provide high value for carefully selected patients are often used indiscriminately for a much larger cohort of patients.”

Nine in 10 medical bills are paid by health insurance (public or private), not by the patient. That distances individuals from the reality that even the newest (and often hideously expensive) procedure or gizmo isn’t always the best prescription. For example, U.S. patients average almost three times as many magnetic resonance imaging scans as Canadians. But there are no significant differences in our respective health outcomes.

Fuchs argues that if we didn’t have widespread insurance coverage, fewer physicians would order expensive procedures unless the chance of substantial benefit was demonstrable; that is, unless it was cost-effective. U.S.-style insurance is cost-insensitive, and that can undermine “appropriate.”

The insured patient, he says, usually wants any and all care that might possibly help, regardless of cost. And although the physician might know that it’s probably not going to help in certain cases, that it isn’t cost-effective, might recommend it anyway because he or she:

• wants to keep the goodwill of the patient;


• believes he or she is protecting against a malpractice claim;


• assumes that denial is “inappropriate” and “unethical.”

No one here – not patient, not provider – is ill-intentioned or looking for anything other than a solution to a medical problem. We aren’t the problem, Fuchs says, our system is.

The solution isn’t forcing patients to put “more skin in the game” – that is, subsidizing more costs of their care. The need for an annual cap on patients’ payments, above which insurance pays, is widely accepted. But today, 5 out of 100 patients account for 50% of annual health-care costs. That means the most expensive procedures go to patients whose costs have exceeded the cap.

Nor is the answer eliminating so-called “unnecessary” care, which is desirable, but which Fuchs says accounts for smaller potential savings than is usually claimed. If some procedures turn out to be useless or even harmful for some patients, that’s because the diverse nature of patient populations make it difficult or impossible to determine in advance who will benefit by a procedure and who won’t.

If a physician is paid on a fee-for-service basis and the patient has open-ended insurance, the default is more likely to fall to the “possible” than the “cost-effective” side of care. If so, the benefit other patients might get from the resources saved with cost-effective medicine isn’t necessarily clear.

Physicians who are paid on an annual fee-per-enrollee basis in a defined population are more likely to practice cost-effective medicine. The resources saved in those practices are used for the benefit of the defined population, which includes the physician’s patient.

Per capita health-care spending in Canada is nearly half what it in the U.S. Canadians have universal care, a defined budget and a default for the prudent expenditure of resources.

“In short,” Fuchs summarizes, “when physicians are collectively caring for a defined population within a fixed annual budget, it is easier for the individual physician to resolve the dilemma in favor of cost-effective medicine. That becomes ‘appropriate’ care. And it is an ethical choice … because if all physicians act the same way, all patients benefit.”

But we don’t have a Canadian-style health-care system, and as one physician pointed out in the online comments to Fuchs’ article, for people who are uninsured, there is no context for “appropriate.”

Another physician commented that by cultivating superior clinical skills, remaining current on medical developments and establishing honest rapport with patients, physicians can bypass the scorched-earth approach to treatment, resulting in lower costs.

A particularly articulate physician said, “Americans have come to expect unlimited health care resources while assuming little to no individual responsibility for paying for it. … The differences between American health care and other systems have been identified for years by Dr. Fuchs and others…. There is no system, not the market, not single payer, that can bridge the gap between this expectation and a diminishing ability of society to meet it. The hope for political compromise and develop a rational means to modifying our system so as to maximize benefit and minimize harm is unlikely until we come to accept this fact as a people.”

Ouch. But, he’s right – you can’t treat the festering sore until you yank off the bandage and examine, without political agenda, the problems that created it.

Another clarion call to simplify a program so critical to the welfare of so many Americans was sounded earlier this month in a report published online by Health Affairs. It concluded that when faced with numerous Medicare Advantage plans, older Americans were less likely to enroll than if their choice of plans was more limited. It also found that seniors whose mental faculties were impaired were less likely to enroll than others when the Advantage plans offered more generous benefits.

Medicare Advantage plans, a form of supplemental insurance administered by private companies, pay providers more for treating Medicare beneficiaries. They frequently offer more generous drug benefits than those that are available in Medicare Part D plans.

The findings suggest that many Medicare beneficiaries are unable to access or process information, so if they’re faced with numerous, complicated insurance plans, they make enrollment decisions that aren’t in their best interests.

The three-year study looked at 21,815 enrollment decisions made by 6,672 participants. In comparing enrollment decisions among participants with different mental capabilities and plan offerings, if 15 or fewer plans were available, there was usually an increase in Medicare Advantage enrollment. When the number of options surpassed 30, as it did in one-quarter of U.S. counties, enrollment in the program decreased.

The news that health insurers will be required to cover contraception and related counseling, courtesy of the Affordable Care Act (ACA) passed last year, received a lot of media attention and political blowback.

Because some people find that provision of preventive care for women objectionable, it overshadowed other elements of the new guidelines, which pertain to insurance policies whose plan years begin on or after Aug. 1, 2012. Such policies are referred to as “nongrandfathered” because they represent only new plans; a health plan in effect now cannot be “grandfathered” into this coverage, although some might include it anyway.

As defined by the U.S. Department of Health and Human Services, the mission of the ACA is to promote prevention of health problems in the hope of reducing the need to treat them. It also aims to make care affordable and accessible for everybody by requiring health plans to cover preventive services and eliminating cost sharing.

Although “preventive services” covers a lot of territory that can include marginally appropriate, cost-inflating measures, those required by HHS demonstrate strong scientific evidence of their health benefits, per research conducted by the Institute of Medicine (IOM). Not only must plans cover them, they may not charge a copayment, coinsurance or deductible if the services are delivered by a network provider.

In addition to the birth control measures, from which plans are exempt for certain religious employers, the following preventive services for women are mandatory and must be provided by insurers without cost sharing to policyholders for policies beginning on or after Aug. 1, 2012:

• well-woman visits;


• screening for gestational high blood sugar;


• human papilloma virus (HPV) DNA testing for women 30 and older;


• sexually transmitted disease counseling;


• human immunodeficiency virus (HIV) screening and counseling;


• breastfeeding support, supplies and counseling; and


• family violence screening and counseling.

If your health insurance plan or insurance policy began on or after Sept. 23, 2010, it is also subject to mandatory preventive services for which you are not supposed to be charged a copayment or coinsurance, or for which you must meet your deductible if services are delivered by a network provider. To find out what’s on the list, link here.

It's impossible to be a conscientious consumer of medical services if you don't know how much a procedure, an office visit or a lab test will cost. If you live in Florida, however, and are in need of urgent care, the mystery about costs is about to lift.

As reported on the St. Petersburg Times' Tampa Bay.com, a new health care transparency law requires urgent care clinics to post prices on their 50 most frequently provided services. The price of failure to do so? $1,000 per day until they comply.

As patients pay an ever greater share of their health costs, budgeting--or even self-rationing, in some cases--becomes a reality. But doctors opposed to posting prices say that health care pricing is too complex for such simple translation. Myriad insurance company billing codes and several ways to pay (cash, private insurance, government programs) will lead to information, they say, that's more misleading than informative.

The new law says posted prices apply only to patients who use credit cards or pay cash for services, not those with insurance. And it applies to urgent-care clinics, but not facilities such as hospital emergency rooms. Individual primary care physicians aren't required to post prices, but if they do so voluntarily, they are excused from paying license fees and fulfill continuing medical education requirements for a certain period.

Consumer and business groups including Florida Public Interest Research Group and Associated Industries of Florida support the legislation.

Doctors ... not so much. They're unclear about the requirements and which types of practices must comply. Apart from urgent care centers, what about clinics that accept walk-in patients? They're not wild about the cash/credit-only provision, because most patients at many clinics have some insurance coverage, and posted prices might drive away people who really need care. The continuing education enticement isn't particularly alluring, they say, because many physicians must meet course requirements to remain board certified.

But in an industry long overdue for transparency, this is a step in the right direction.

If you wanted to lobby for a law that wipes out the rights of patients to hold hospitals, drug manufacturers and doctors accountable when they hurt people by carelessness and wrongful conduct, what would you call your group?

"Protect Patients Now!" It has a nice ring, doesn't it?

However, the people behind this campaign, which was launched in Washington to advocate for the H.R. 5 "tort reform" bill in Congress, are anything but patient advocates.

The campaign comes from a group called the Health Coalition on Liability and Access. A list of the coalition's members can be found on its website, and includes:

* Major medical malpractice insurance carriers (Pro Assurance, The Doctors' Company, Medical Protective);

* Doctors' lobbying organizations, especially those who have been active in political efforts to curb lawsuits (the AMA, plus neurosurgeons' and orthopedic surgeons' societies and others);

* Long-time "players" in the legal "reform" space, particularly the American Tort Reform Association, which got much of its seed money from the tobacco industry.

The coalition calls itself a "grassroots advocacy organization" but conspicuously absent from its membership are any of the consumer groups — Consumers Union and Public Citizen, to name two — who have been pushing the medical industry to make health care safer (and thereby solve its lawsuit problem).

H.R. 5 was sent to the floor of the U.S. House of Representatives this week by a party line vote of the House Judiciary Committee. The bill gives special breaks in the form of damage "caps" and other special treatment not only to all physicians, nurses and other individual caregivers, but also to drug manufacturers, nursing homes and hospitals.

The idea of H.R. 5 is that by making the medical industry less legally accountable for the harms it causes, Congress will free up the industry to become safer and provide cheaper care to more Americans.

I did not make that up.

The American Association for Justice (of which I am a member) has an online petition for concerned consumers to send a message to their Member of Congress about this bill.

Article first published as George Orwell Comes to Washington: The "Protect Patients Now" Lobbying Group on Technorati.

Patient safety advocates like me have long dreamed of cracking open for the public the vast trove of data the government collects on doctors, so patients could figure out who gets the best outcomes and guide their doctor choices accordingly. Medicare was supposed to start down that path with its new "Physician Compare" website, but alas, it has a long way to go.

One critic says the new site "is confusing and unfriendly to consumers, painfully slow and, worst of all, factually unreliable. Put bluntly, the agency ... has produced a consumer tool that practically shouts, 'We couldn't care less whether any consumer ever uses this.'"

The quotation is from Michael L. Millenson, President of Health Quality Advisors LLC, writing on the Kaiser Health News website.

The Medicare site has basic information about doctors, like their practice address, but misses out on many tidbits that consumers want to know:

* Hospitals they practice at

* Malpractice history

* Where they trained

* Board certification.

Those kinds of things can be found at commercial sites like healthgrades.com for a small fee. Or you can search one of the sites that lists doctors' board certifications, like
the American Board of Internal Medicine, which certifies internists.

The quality information that consumers really crave, such as surgeons' complication rates or incidence of wound infections, lies off in the future somewhere. Medicare says it will begin adding quality data to the site in 2012, with a formal launch date in 2013. Don't hold your breath.

Meantime one surgical specialty group, the Society of Thoracic Surgeons, has collaborated with Consumers Reports to publish quality data on heart and chest surgeons. Read our blog entry on this here.

Quick triage of patients who arrive at the Emergency Department isn't just important for patient safety. It makes hospitals a lot more popular with their consumers, as one hospital has found.

The emergency department at Texas Health Presbyterian Hospital in Plano launched a policy called the 30-Minute Promise in October 2009, pledging to treat patients within a half-hour of arrival. The result: the hospital’s patient satisfaction scores in the Emergency Department rising above the 90th percentile of hospitals nationwide.

Last month, the Texas State Board of Nursing highlighted the service in its monthly newsletter as a best practice in patient safety.

According to Michael Webb, RN, BSN, performance improvement project manager at Texas Health Plano, “the process we have implemented for rapid triage and bedside registration allows patients to be brought back into the emergency room where they can receive the care they need from clinical staff. The radiology and lab team members interrupt nursing staff in patient rooms if needed to expedite critical testing.”

In addition,Webb writes, “team-based care defined by zones in the ED increases communication among staff members, physicians and, most importantly, patients.”

The hospital also opened the “back door” of the ED by tracking and trending the discharge order times of their physicians with the highest in-patient volume to increase internal capacity. In-patient nursing staff are responsible to ensure that discharge planning is initiated early in the hospitalization and the patient is discharged in a timely manner when clinical criteria are met.

Source: Texas Board of Nursing newsletter, page 4

Delays in the emergency room cause some patients to forgo treatment, according to a study by the University of South Florida. The study found that when ER patients have to wait to be admitted to hospital, the waiting time for other ER patients becomes longer, and the more likely it is that some of them will leave the ER and not get the treatment they need.

The problem is referred to as “boarding.” About 30% of ER patients need to be admitted to the hospital for further treatment, but often, they have to wait for inpatient beds to become free. As a result, waiting times for others in the ER increase.

The intent of the study, which monitored the ER at the USF-affiliated Tampa General Hospital, was to determine the number of ER patients that might walk out in frustration. The study determined that the longer those patients wait to be admitted, the more likely it is that other patients waiting behind them will leave the ER.

The research results have already been used to improve patient flow at TGH, which has implemented changes to the way patients are treated and admitted. However, study co-author David Wein, MD, says similar problems to those documented at TGH occur at hospitals across the country.

In 2007, almost 117 million people went to American hospital emergency rooms for medical attention, according to the National Hospital Ambulatory Medical Care Survey. In 2008, the number of visits increased to over 123 million.

Wein notes that the increased demand on emergency departments will be a problem if delays getting patients out of already busy emergency departments are not addressed.

Source: The Tampa Tribune

A new report comparing the United States to other industrialized countries has a depressing list of all the ways that America outstrips other countries in money spent but lags behind in health quality results. For example:

* Per person, the U.S. spends twice as much on health care as on food, and much more than the average Chinese person spends on EVERYTHING. (See slide #1 of the interactive graphic of the McKinsey Global Institute report here.)

* "Branded" prescription drugs are 77 percent more expensive in the U.S., and because we use a more expensive mix of drugs than other countries (being quicker to adopt new and expensive drugs), the average spending on drugs per person is more than double other industrialized countries. (Slide #8.)

* We lag behind 22 other advanced countries in life expectancy but spend around $650 billion more per year than our population's mix of health conditions would predict. (Slide #4)

* Administration costs -- paperwork, claims processing, etc. -- are on average five times more expensive in the United States. (Slide #9.)

* The care in the U.S. is much more intense than elsewhere -- more expensive surgical procedures, more diagnostic tests, but we spend less on prevention than elsewhere.

* We also are shifting more to outpatient care instead of care with overnight stays in hospitals, but that has not cut costs. The outpatient care is much more profitable for providers than inpatient care, and it tends to be more intense.

The New York Times did some arresting graphics on the McKinsey report. Click here to see them. Note that the U.S. appears as a red dot, "peer" European economies like Germany and the UK are yellow dots, and other industrialized countries are gray dots.

The red dot never wins on these graphs -- except on expense.

The best measure for understanding what Americans spend on health care is the health care share of GDP (Gross Domestic Production). When that share crossed the 10 percent thershold in the early 1980s, plenty of economists sounded the alarm that ruin was ahead if we couldn't somehow make that share stable, so the rise in health care spending kept pace with the economy but didn't take a bigger and bigger piece of the pie.

So how are we doing? Health care's share of the economic pie went up to 17.3 percent of GDP in 2009, according to a new report in the respected journal Health Affairs. It's the biggest single-year increase since 1960.

The Wall Street Journal's Health Blog crunched some numbers and reported:

The U.S. spent $2.472 trillion on health care last year, according to a paper out today in the journal Health Affairs. That’s $282 million an hour.

Health spending as a percent of GDP — a key metric that shows how much of all U.S. spending goes to health care — rose from 16.2% in 2008 to 17.3% in 2009, far higher than any other industrialized country. That’s the largest one-year increase since 1960, when the feds started closely tracking national health expenditures.

The figure went up so much because health spending continued to rise, even as the overall economy shrank. The aging population accounted for a small part of this rise, but two other factors were more important: rising prices and increasing use. Health-care prices rose by 3.2% in 2009, according to the Health Affairs paper, significantly faster than prices rose for the overall economy. Utilization, which includes both volume and intensity of health-care services, rose by 1.5%.

The share of health-care spending paid for by the government (through programs such as Medicare and Medicaid) is also rising, and is projected to cross the 50% threshold soon.

The share of the economy for health care will be close to 20 percent within the next 10 years, according to government forecasters.

These sobering numbers show the urgency of "bending the cost curve down," as the pundits like to say. Unfortunately the urgency of reforming the safety and quality of health care has taken a far back seat to the money discussion. They actually are compatible goals. One thing we've learned in the health care reform debate is the huge overspending in health care caused by widespread use of new technologies before their benefit is proven, driven in part by conflicts of interest by those pushing the new technologies.

Far more infants die in their first year of life in the United States than in most of the developed world, and new data from the Centers for Disease Control suggests one of the main reasons is premature births, and that could be helped by better access to prenatal care for mothers.

Infant mortality is a standard measure of a nation's health. The most recent numbers show that seven in 1,000 babies die before their first birthday in the United States, compared to about two in 1,000 in Singapore, the best in the world. Twenty-nine countries rank better than the U.S. -- nearly all of Europe, plus Australia, Canada, Hong Kong, Israel, Japan, New Zealand and Singapore.

A new CDC study says the U.S. has a much higher rate of premature births (before the 38th week of pregnancy), and prematurity goes hand in hand with higher death rates, not to mention long-term disabilities.

Twelve in one hundred babies are born prematurely in the U.S., compared to five in one hundred in Ireland. The CDC study says that if the prematurity rate could be cut substantially, much of the gap between the U.S. and the rest of the Western world could be eliminated.

But not all. Even among babies born at full term, the U.S. still has a higher death rate than most of the West, because of a higher risk of dying in the U.S. from sudden infant death syndrome, accidents, assaults and homicides, according to the CDC.

An article in the New York Times quotes Dr. Alan R. Fleischman, medical director for the March of Dimes, as saying

the new report was “an indictment of the U.S. health care system” and the poor job it had done in taking care of women and children. The report, Dr. Fleischman added, “puts together two very important issues, both of which we knew about but hadn’t linked tightly.”

Dr. Fleischman said the smallest, earliest and most fragile babies were often born to poor and minority women who lacked health care and social support. The highest rates of infant mortality occur in non-Hispanic black, American Indian, Alaska Native and Puerto Rican women. But other minorities have some of the lowest infant mortality rates in the United States: Asian and Pacific Islanders, Central and South Americans, Mexicans and Cubans.

The lead author of the CDC study, Marian F. MacDorman, a statistician at the National Center for Health Statistics, said American doctors also increasingly deliver babies at "late pre-term," between 34 and 37 weeks, for conditions like high blood pressure and diabetes that in earlier times they would have waited out. These late pre-term babies also have a higher risk of dying than full-term babies, but not as much as the severely pre-term babies.

Most doctors have to take regular continuing education courses to maintain their medical licenses. But what if the courses have a hidden agenda -- promoting the drugs of a sponsoring manufacturer?

That hidden influence has occurred far too often for the comfort of patient safety advocates, who want prescribing doctors to receive fair, balanced and neutral advice in the important subject of what prescriptions to write for sick patients.

Now the group that gives the official seal of approval for continuing education courses is taking tentative steps to curb the drug industry's influence on these courses. The group is called the Accreditation Council for Continuing Medical Education (ACCME). Its approval is necessary for a doctor to get official credit for any course taken. The head of the ACCME, Dr. Murray Kopelow, told the New York Times he will:

First, make public in the next few weeks a list of the classes and educational companies that have already been found to have broken the rules against commercial bias. This list was previously secret. Apparently there are less than a dozen names on the list as of now.

Second, consider further steps such as requiring the sponsor of a course found to be biased to send out corrective material to the doctors who took the course.

A doctor who is pushing for these and stronger reforms is Dr. Bernard Carroll, who filed a lengthy complaint about an online course on treatment of major depression, which he said was strongly biased by hiding bad information about the drugs of the sponsor, AstraZeneca.

The Times reported:

Dr. Carroll faulted the accrediting council for taking nine months to resolve the complaint, allowing the program to rerun and failing to notify doctors who had taken it. “They’re more interested in protecting the providers than watching what gets put out there as education,” Dr. Carroll said in an interview.

Here is Dr. Carroll's own blog posting on the subject.

The steps taken so far by the accrediting body are modest, but go in the right direction. Let's keep watching. As another industry critic, Dr. Bernard Lo, said, it's okay for the drug industry to support medical education. What's not okay is to create commercial bias in favor of one or another company's products.

"Amenable mortality" is a body count of unnecessary deaths due to lack of preventive health care. The latest measure is not flattering to the American health care system.

Researchers count these deaths by looking at premature deaths in areas like these:

* Adults who die from breast or colon cancer before age 75, indicating lack of timely mammograms or colon screens or care. * Children who die before age 14 from vaccine-preventable or easily treatable illnesses such as coughs, measles, asthma, and other respiratory problems. * Diabetics who die before age 50 from complications that could easily have been prevented with proper medical management. * People who die from infections or hypertension before age 75, a symptom of lack of preventative and appropriate care, including blood pressure control.

In the mid-1990s, the U.S. ranked 15th out of 19 industrialized nations in its death rate from "amenable mortality." Now the figures have been updated, and America is in last place -- 19th out of the same 19.

France, Japan and Australia do the best in this ranking. The United Kingdom used to be worse than the U.S. but has gotten a lot better.

Consumer Reports has a chart of the latest data here.

Many elderly patients suffer protracted, and expensive, deaths as health care providers pummel them with technological fixes for bodies that have already worn out. The dilemma is that while no doctor wants to give futile care that tortures more than it heals, no one also wants to be guilty of euthanasia or abandoning their patient.

A group of Roman Catholic nuns at a convent near Rochester, New York, has a new/old answer to this dilemma: Involve the patient in a warm and loving community where the patient's wishes are always paramount, but death is faced with realism, and care goals are clarified long before any final crisis. As Jane Gross reported in a beautiful article in the New York Times:

A convent is a world apart, unduplicable. But the Sisters of St. Joseph, a congregation in this Rochester suburb, animate many factors that studies say contribute to successful aging and a gentle death — none of which require this special setting. These include a large social network, intellectual stimulation, continued engagement in life and spiritual beliefs, as well as health care guided by the less-is-more principles of palliative and hospice care — trends that are moving from the fringes to the mainstream.

For the elderly and infirm Roman Catholic sisters here, all of this takes place in a Mother House designed like a secular retirement community for a congregation that is literally dying off, like so many religious orders. On average, one sister dies each month, right here, not in the hospital, because few choose aggressive medical intervention at the end of life, although they are welcome to it if they want.

“We approach our living and our dying in the same way, with discernment,” said Sister Mary Lou Mitchell, the congregation president. “Maybe this is one of the messages we can send to society, by modeling it.”

I recommend reading the entire article, which is one more example of a spirit that I have tried to imbue in my book, “The Life You Save: Nine Steps to Finding the Best Medical Care — and Avoiding the Worst.” When patients become actively involved in understanding their own health care, they can make decisions that best fit their own values.

Having an ally to help you negotiate the health care maze can be absolutely critical to obtaining the best medical care, especially if you are sick enough that you're not thinking as clearly as usual. A patient advocate does not need any special training in medicine or nursing -- just an inquisitive mind and persistence in asking questions and getting answers.

As this blog has previously reported, patients in some parts of the country now can find professional patient advocates to help them. People who have tried it say these advocates are lifesavers who are worth every penny of their fee.

A group that does this for free with volunteers is called Bedside Advocates in the Boston area, founded by retired physician Jonathan Fine. The group was featured in a recent story by NPR health reporter Richard Knox. The problem is that volunteers working part-time can only help a limited number of patients, and the need is vast.

Nurse Dianne Savastano has set up a professional patient advocacy service, also in the Boston area. The NPR story quotes one of her clients, Barbara Porter, who hired Ms. Savastano to help manage the complex care needs of her elderly father, for which she pays Ms. Savastano $15,000 a year. Says Ms. Porter: "I tell him, 'Dad, you got resurrected.' He literally did get resurrected. He would either be dead or in a nursing home right now if it wasn't for Dianne."

Patrick Malone's new book, "The Life You Save," gives a list of pointers for how family members can become effective advocates for their elderly relatives who cannot manage their own care. If you live in an area with professional patient advocates, that should be an option you should consider. None of us can go it alone in this complex health care system.

More and more doctors and patients are recognizing the link between affordability of medical care and safety. One problem that plagues fee-for-service medicine is that doctors are rewarded financially for ordering excessive tests and treatments, which are both dangerous and wasteful.

Geoff Berg, an internist in Rhode Island, put it this way in a letter to the editor in the New York Times:

"The problem with fee-for-service is not merely that it pays providers to provide service; it pays them to create service as well. It is this almost limitless ability of doctors to create service that makes our per capita health care costs twice that of any other developed country. If physicians were salaried employees with modest incentives for productivity and outcomes, we could, in very short order, have affordable health care for all."

Electronic medical records, if properly used to communicate key information among doctors and with the patient, also could help cut wasteful and pain-inflicting treatments, as letter writer Margie Parko wrote in the Times about her mother-in-law's experiences in the last 18 months of her life.

A New Yorker article by Dr. Atul Gawande, a surgeon, focused on why McAllen, Texas has higher medical costs than just about anywhere in the country. Dr. Gawande concluded that much of the problem could be traced to the very aggressive, intervention-oriented style of medicine practiced there -- all stemming from the fee-for-service payment system that rewards the doctors who practice intensive, high-cost care. His article achieved new prominence this week when President Obama told White House aides and members of Congress that after reading the article, he decided "This is what we've got to fix."

The President was quoted on that by Senator Ron Wyden in an article in the New York Times by Robert Pear.

Aggressive, high-cost medicine has never been proven to make anyone healthier or live longer. Why do the McAllen doctors order so many tests and procedures? Because they make more money from our fee-for-service system. The answer is to reorganize care so that doctor don't have a built-in conflict of interest where they prosper economically the more stuff they order. But that reorganization is easier said than done. Dr. Gawande rightly looks to models like the Mayo Clinic, where doctors are on salary. Read more about this on Dr. Bob Wachter's health care blog.

One interesting sidelight to Dr. Gawande's article is that he nails the old bug-a-boo of the medical industry: so-called "defensive medicine" in which doctors supposedly order lots and lots of tests not out of any perceived medical necessity but out of fear of being sued for malpractice. A group of McAllen surgeons tried this explanation out on Gawande, but he rightly pointed out to them that Texas has some of the strongest tort reform in the country, so he was skeptical.

He didn't mention, but might have, that other states like California, which in the 1970s made it almost impossible to sue for malpractice except for the most egregious cases, have enjoyed no medical cost savings that anyone has been able to count. Health care economists have proven that what explains disparities in medical costs is high numbers of specialists in a community and correspondingly low numbers of primary care doctors.

That Congress is just now discovering the realities of medical economics, which have been published in study after study over the last three decades, is itself pretty scary.

It sounds like every patient's medical fantasy: Easy access to your doctor 24/7, same-day appointments, thorough and unrushed examinations, little to no time in the waiting room. The only downside is expense: To get this kind of personalized care from a primary doctor, you have to pay an annual fee, and forget about insurance covering it. And you will still need insurance to cover hospital stays and specialists.

Is this ultra-personalized health care, which is called "concierge medical practice," worth it? Many patients think so. Even those squeezed by the recession are often finding room in their budgets for the annual fee for a concierge doctor, even as they cut down on restaurant dinners and other non-essentials.

According to a report by Kevin Sack in the New York Times, leaders in the field of concierge care say they see no impact of the recession in the steady growth of their practices. Dropout rates from the practices are holding steady.

It's estimated there are about 5,000 concierge doctors in the United States, a small fraction of the 240,000 internal medicine doctors in the country. One of the largest groups is called MDVIP, which started in Florida and now has 300-plus physicians in its network. Each MDVIP doctor is limited to 600 patients, who have to pay an annual fee of $1,500 to $1,800. The limit on the number of patients lets the doctors see far fewer patients in a typical day.

The advantage for patients is having a medical expert on hand who knows your body intimately and can sometimes detect subtle danger signs before a full-blown crisis develops.

In his new book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, finding a top primary care doctor is one of Patrick Malone's key "steps" to finding the best medical care. If it takes extra money to get that relationship, and you can afford it, signing up with a concierge medical practice can be money well spent.

Nobody wants to go home from the hospital only to be readmitted within a few weeks. But that revolving door is very common in conditions like heart failure, where the patient's heart muscle doesn't pump effectively after it has been weakened by heart attack or other heart disease.

The open secret of the hospital industry is that the financial incentives of Medicare and private insurers are tilted toward keeping that revolving door going. Hospitals that actually invest money in following patients after they leave the hospital to try to keep them healthy find that they lose money on this follow-up care. Reed Abelson of the New York Times wrote a report describing how progressive hospitals that have tried to keep their patients from readmission have lost millions of dollars in the process. Those include the Park Nicollet Health Services in Minnesota and Catholic Healthcare Partners in Cincinnati.

One lesson from this story is that patients don't have to wait for medical payment reform to get better care and avoid the revolving door. If you or someone in your family has heart failure, here are the early warning signs that symptoms may be worsening and a doctor or nurse should be called:

* Weight gain. Patients need to weigh themselves every day. Sudden weight gain often means a buildup of fluids caused by the heart not pumping effectively.

* Shortness of breath. Fluid buildup often is most apparent in the lungs and is signaled by being out of breath.

* Ankle swelling. Another place where fluid buildup can be spotted early.

A phone call to the nurse can result in an adjustment of medication that may ease the problem. If that doesn't work, a visit to the doctor's office might be in order. The goal is to intervene before a crisis develops and you have to be rushed to the hospital in an ambulance.

If your doctor already has a system in place that helps you monitor yourself at home, that means you have a top-quality doctor. If you have a hard time getting such a monitoring system going with your doctor, then it might be time to switch to someone who is more responsive.

Patrick Malone discusses how to find a top primary care doctor in his new book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst

Strokes cause more disability than just about any other disease, but they don't have to. Effective treatments are known for the most common type of stroke; delivering them to the right patients has proven to be difficult. Now a group of researchers is proposing some changes in how stroke care is organized, with the hope of matching reality to the promise and greatly improving stroke outcomes.

In 1995, a landmark study was published showing that the impact of stroke on the human brain could be greatly diminished by using clot-busting drugs to dissolve the clots that kill brain cells in ischemic stroke. (Ischemic stroke is responsible for about four of five strokes. In ischemic stroke, brain tissue dies because blood clots or narrowed blood vessels block flow of oxygen-rich blood to brain tissue. In hemorrhagic stroke, which affects about one in five stroke patients, brain tissue dies because a burst blood vessel causes bleeding in the tissue.)

Today, though, it is estimated that fewer than one in ten victims of ischemic stroke are treated with either intravenous tPA, the main clot-dissolving drug, or other effective treatments, such as breaking up the clot with a mechanical device inserted inside the blood vessel.

The accepted convention is that tPA does not work unless the i.v. is started within three hours of the onset of stroke symptoms. Most patients don't get to the hospital that quickly, and even when they do, time is eaten up by the necessity to give everyone a CT scan to make sure they are not having a bleeding stroke, for which use of the clot-dissolving drugs could be a disaster.

A new article by Drs. Reza Hakimelahi and R. Gilberto González, "Neuroimaging of Ischemic Stroke With CT and MRI: Advancing Towards Physiology-Based Diagnosis and Therapy," advocates these changes to help deliver more of these proven treatments to more patients:

* Doctors need to recognize that the three-hour window for treatment sometimes is much longer in patients who have blockages of smaller vessels in the brain with some temporary compensation through "collateral" vessels. Better imaging studies can identify these patients who have an "ischemic penumbra" that would benefit from clot-dissolving drugs.

* Many patients can benefit, even after the three hours has expired, by direct intervention with mechanical devices to break up clots from the inside of the vessels. Because this requires expertise in interventional neuroradiology, a field with only a few hundred practitioners in the United States, the authors recommend cross-training for doctors in related fields who know how to use tiny tubes inside blood vessels to deliver treatments. These include interventional cardiologists.

* Hospitals that are recognized as expert in care of acute strokes could be divided between advanced and general levels of expertise. On the general level, any such hospital needs to have 24-hour CT scanning and the ability to give clot-busting drugs in the emergency department. To qualify as an advanced stroke center, the hospital would have to have the ability to do interventional treatments inside blood vessels ("endovascular therapy"), a neuro-intensive care unit, and a team of doctors from multiple specialties that work together to decide the best treatment for each patient.

(NOTE: To read this article, you have to sign up for a free membership at Medscape.com.)

As these ideas are debated in the medical industry, the best strategy for patients is to have some advance knowledge and basic planning. Knowing how common strokes are, and how urgent the timeline is ("Time Is Brain" in stroke treatment) once stroke symptoms start, here is what I advocate:

* Know the basic symptoms of stroke, and don't rationalize your way out of a trip to the hospital if the symptoms seem mild or go away after a few minutes. Here is a basic list from the American Stroke Association:
* Sudden numbness or weakness of the face, arm or leg, especially on one side of the body
* Sudden confusion, trouble speaking or understanding
* Sudden trouble seeing in one or both eyes
* Sudden trouble walking, dizziness, loss of balance or coordination
* Sudden, severe headache with no known cause

* Know which hospital in your area has advanced stroke treatment staff and machines. Ask if they have a multi-disciplinary team. (It should include both neurosurgeons and endovascular therapists.) Ask if they have a neuro-intensive care unit (an ICU that treats only patients with brain or spinal cord problems).

* If a loved one suffers stroke symptoms, do not let the rescue squad take them to the nearest emergency room UNLESS the same hospital has advanced stroke treatment abilities.

* A multi-disciplinary team is important because conflicts of interest can drive doctors to advocate for therapy they can do when a safer, more effective treatment might be available from a doctor with different training. Having doctors work together to help the patient and family decide treatment is the best approach.

In his new book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, Patrick Malone discusses one tragic case in which a patient needed a teamwork approach to her neurological problem but didn't get it because the hospital had no effective team in place. The book discusses the questions to ask to make sure your doctors are working together and not as competitors for your health care business.

In a newly released Thomson Reuters survey, one in five respondents say they have delayed medical care, and one in four of those who did listed financial cost as the primary reason, reports Maggie Fox of Reuters. The survey also predicted that in the next three months, one in every five adults in America will have difficulty paying for health insurance or health care.

The data show a significantly higher number of Americans putting off healthcare than in 2006, when the same question was asked in a survey. Leaders of the study associate this increase with growing number of Americans losing employer-sponsored health insurance.

The study leader Gary Pickens predicted that America’s “collective well-being” will be hurt if people continue to delay necessary treatments.

If you find yourself unable to afford healthcare or health insurance, check with your state and local agencies to see if you are eligible for Medicaid or other forms of financial assistance. Pharmaceutical companies often have programs for uninsured patients. Additional resources may be available: Walgreens, for example, recently announced that its Take Care program will offer free routine clinic services for the uninsured and unemployed.

The Toledo Blade has a good article with stories from patients whose crucial treatments, ordered by doctors, have been denied or delayed by insurance companies.

It begins with the harrowing story of Randy Steele, who died after the kidney-liver transplant that could have saved his life was stalled by his insurer.

Even if patients do not die as a result of these repeated denials and delays, they often end up unable to follow their doctors' instructions and their health suffers seriously as a result.

The Blade conducted interviews with 100 physicians and did a survey of 920, which you can read more about by clicking the above link. The results of both the interviews and the survey show that doctors believe that insurers countermanding or stalling their orders is creating a crisis in health care. Of the survey's 920 respondents, more than 99 percent said that insurers had interfered in their medical decision-making.

Clearly doctors are more qualified to make medical decisions than insurance companies. Any health care system that allows a bureaucrat working for an insurance company to make these calls will inevitably end up creating the tragedies that this article describes.

It is instructive and interesting to read about Senator Edward Kennedy's treatment for his brain tumor.

The linked article describes the change in direction between May 20th of this year, when Kennedy's brain cancer was first disclosed and surgery was not discussed as a possible treatment, and two weeks later, when neurosurgeons performed a "successful" surgery on his brain.

Why the change? From the article:

Precisely why Mr. Kennedy’s treatment course changed is not known; he and his doctors are not talking to reporters.

What is known is that a few days after Mr. Kennedy learned he had a malignant brain tumor in the left parietal lobe, he invited a group of national experts to discuss his case.

The meeting on May 30 was extraordinary in at least two ways.

One was the ability of a powerful patient — in this case, a scion of a legendary political family and the chairman of the Senate’s health committee — to summon noted consultants to learn about the latest therapy and research findings.

The second was his efficiency in quickly convening more than a dozen experts from at least six academic centers. Some flew to Boston. Others participated by telephone after receiving pertinent test results and other medical records.

As the article notes, Senator Kennedy called similar conferences of experts when one of his children was diagnosed with bone cancer and the other with lung cancer. He has been known to advise his colleagues in the Senate to use this method when dealing with an illness in the family.

Obviously, powerful senators can do things the rest of us cannot. Again, from the article:

Mr. Kennedy can tap leading doctors for answers in a way few patients could. His celebrity status aside, he has spent a career promoting insurance and other ways to improve the health of Americans. And he has had a track record of being thorough and diligent in researching medical options when relatives or friends have fallen ill.

Nevertheless, despite Kennedy's power and influence, there are ways in which the average person can imitate his example and seek second and third opinions on their medical care:

Several doctors not connected with Mr. Kennedy’s case said in interviews that they admired his resourcefulness in getting more opinions simultaneously. At the same time, these doctors said many average patients gained competent advice, without a command performance, by sending pertinent records to experts for their opinions.

Many patients search the Internet for medical information and ask that their scans and other data be sent electronically or by overnight services.

Then such patients visit, call or write the consultant.

The potential negative consequence of all this opinion-shopping is that people may focus on what they want to hear and disregard everything else. This is partly why the doctors quoted in the article strongly recommend actually meeting physicians whose advise you intend to take (rather than just sending records and receiving written responses). That way the physician can make sure your expectations are realistic and address your specific concerns.

Unsurprisingly, there are wide global disparities in survival rates of cancer patients. This is partly because of the relative wealth of different countries. However, there are huge disparities within the United States as well:

In the United States, the lowest survival rates are in New York City, except for rectal cancer in women, where Wyoming scores worse. The best survival rate for cancer in the United States is in Hawaii, the researchers found.

Idaho also has a high survival rate for rectal cancer, and Seattle has the highest survival rate for prostate cancer.

But, there's a big disparity in cancer survival rates between whites and blacks in the United States, and it favors whites. The differences range from 7 percent for prostate cancer to 14 percent for breast cancer. This disparity is most likely due to differences in the stage of cancer when it is diagnosed, the researchers said.

We have discussed the impact of race and region on health care quality before on this blog. Unfortunately, not everyone can count on getting the appropriate kind of service from their health care providers depending on their circumstances, as this new study re-affirms.

Researchers at Dartmouth University have found striking regional differences in quality of health care. In addition, within any given region, black people are less likely to receive the appropriate health care than white people.

But region was the strongest factor that affected quality of health care. From the article:

For instance, the widest racial gaps in mammogram rates within a state were in California and Illinois, with a difference of 12 percentage points between the white rate and the black rate. But the country’s lowest rate for blacks — 48 percent in California — was 24 percentage points below the highest rate — 72 percent in Massachusetts. The statistics were for women ages 65 to 69 who received screening in 2004 or 2005.

In all but two states, black diabetics were less likely than whites to receive annual hemoglobin testing. But blacks in Colorado (66 percent) were far less likely to be screened than those in Massachusetts (88 percent).

What causes these differences? The researchers suggest that multiple factors are at work:

Such variations may be partly explained by regional differences in education and poverty levels, but researchers increasingly believe that variations in medical practice and spending also are factors.

The most extreme disparities, as the article notes, concern some important and even life-altering procedures. For instance, people in Louisiana, Mississippi and South Carolina are much more likely to have their legs amputated (usually as a result of diabetes or vascular disease) than those in Colorado or Nevada, and black people in those regions are much more likely to undergo amputation than whites. Also, access to mammograms sharply varies according to region.

Rocky Delgadillo, the Los Angeles City Attorney, is suing the insurance company Health Net. Delgadillo accuses the company of using misleading forms to get customers to make errors or admissions that could then be used as an excuse for canceling their insurance policies when they need expensive treatments. From the article:

The suit states that the Woodland Hills-based insurer used untrained salespeople to collect people's medical histories, used purposefully misleading forms and did not review the information until after they filed claims....The city attorney says Health Net went as far as to create a secret unit in its organization to cancel policies, and that it provided benchmarks -- including goals for numbers of rescissions per year and dollars in claims denied -- and bonus payments to employees for reaching company goals.

Interestingly, Delgadillo is pursuing a criminal investigation of individuals involved in these cancellations, in addition to filing a civil suit. If his allegations are substantiated, this is a very good thing. There should be strong disincentives against such dishonesty on the part of insurers.

The ScienceDaily pointed out recently that illiterate patients are at a serious disadvantage when it comes to getting proper healthcare, even to the point of having a higher mortality rate than literate patients. Another good discussion of the topic can be found in a July 24th, 2007 essay in the New York Times Health Section on illiteracy and the healthcare system by a Dr. Erin Marcus. As the ScienceDaily article and Dr. Marcus make clear, lliterate and semiliterate patients face many grave problems when confronted with the healthcare bureaucracy.

Dr. Marcus points out that health educators recommend that patients be given materials at an eighth-grade reading level or lower—but most consent forms and HIPAA forms and other such documents are at a much higher reading level. This has obvious, and negative, consequences for patients and can be a reason for patient “noncompliance” with doctors’ recommendations.

Patients with low literacy levels should, if possible, seek out doctors they trust to explain these materials to them and should not hesitate to ask for clarification.

The people with the real power to change this, however, are not the patients. Rather, it is the healthcare administrators who can arrange for patients to be given accessible information in accordance with the advice of health educators.