July 2, 2015

Suggested Reading: When It Comes to Heart Attack, Speed Heals

In the 10-year period between 2003 and 2013, the U.S. death rate from coronary heart disease fell about 38%. In a long, anecdote-filled story that was part of its series on heart disease, the New York Times detailed how the decline reflects not only that we’re giving up cigarettes and controlling our cholesterol and blood pressure better, but that emergency departments are treating heart attack patients significantly faster.

“With no new medical discoveries, no new technologies, no payment incentives — and little public notice,” according to The Times, “hospitals in recent years have slashed the time it takes to clear a blockage in a patient’s arteries and get blood flowing again to the heart.”

A heart attack occurs when a blocked artery prevents blood from reaching heart muscle. The longer a heart goes without sufficient blood flow, the greater the damage. So, the best outcome after a heart attack, like a stroke, follows fast treatment. Not that long ago, it commonly took hospitals more than two hours to get blood flowing to a patient’s heart. Now, the story explained, “nearly all hospitals treat at least half their patients in 61 minutes or less, according to the most recent data from the American College of Cardiology.”

That such a significant improvement has been notched in such a short time, The Times reported, is the result of a detailed analysis of treatment delays and a campaign by the college (a professional society for specialists in heart disease) and the American Heart Association.

And unlike a lot of medical benefits that are realized only by people wealthy enough to pay for them, or lucky enough to live near elite medical centers, the good heart news also is happening to people treated at local hospitals in financially struggling regions.

MedPageToday.com lauded The Times’ series on heart disease, but made an important observation about the value of quick medical response and the best outcomes: “A short treatment time in the hospital won't mean much if the patient waits several hours before calling 911 or showing up at the door. “

Read here how medicine figured out how to fix what ailed heart attack care, and several of the stories about patients who benefited from it.

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July 1, 2015

U.S. Chamber of Commerce Shakes Hands with Death and Evil

I can sort of get why the U.S. Chamber of Commerce would attack the whole concept that ordinary people should be able to sue corporations when said corporations inflict injury and death on the citizenry. After all, lawsuits to enforce corporate accountability are none too popular in boardrooms across America. And so the endless claims of "frivolous lawsuits" by the Chamber's various front groups like the Institute for Legal Reform make sense in the "you've gotta look out for your own people" category.

But now the Chamber has descended to a new circle of Hell in whose interests it decides to promote. The international tobacco industry, responsible for more preventable deaths and more hideous disease than all the other corporate enterprises in the world combined (yes, including weapons makers, poisoners, polluters and all such), turns out to be a favorite darling of the Chamber's lobbying efforts. Not just here in the USofA, but everywhere.

The Chamber of Commerce has mounted a global campaign to protect the interests of tobacco from all manner of efforts by the world's governments to discourage their peoples from smoking.

And this is an outfit on whose board sits representatives of various big hospitals and health insurers!

I turn the floor over to the New York Times:

From Ukraine to Uruguay, Moldova to the Philippines, the U.S. Chamber of Commerce and its foreign affiliates have become the hammer for the tobacco industry, engaging in a worldwide effort to fight antismoking laws of all kinds, according to interviews with government ministers, lobbyists, lawmakers and public health groups in Asia, Europe, Latin America and the United States.

And what is one of the big tactics the Chamber uses around the world in its campaign to promote death by smoke inhalation? Why, lawsuits, naturally. Again from the New York Times:

The tobacco industry has increasingly turned to international courts to challenge antismoking laws that countries have enacted after the passage of the W.H.O. treaty. Early this year, Michael R. Bloomberg and Bill Gates set up an international fund to fight such suits. Matthew L. Myers, president of the Campaign for Tobacco-Free Kids, an advocacy group that administers the fund, called the chamber “the tobacco industry’s most formidable front group,” adding, “it pops up everywhere.”

What's the Chamber of Commerce doing in the current back room negotiations about the Trans Pacific Partnership treaty? You guessed it: Preserving the "rights" of tobacco companies to sue to block regulations intended to wean the world's smoking habits.

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July 1, 2015

Waiting List for Vets Seeking Health Care Grows

Last year the country was shocked to learn the extent of the systemic problems the Department of Veterans Affairs had in delivering adequate health care generally, and, specifically, the grossly long periods vets had to wait to get an appointment.

It’s not getting better.

Department officials told the New York Times that the number of vets on waiting lists of at least one month is 50% higher than it was during the height of last year’s problems.

Because the VA has a budget shortfall of nearly $3 billion, the outlook continues to look bleak.

Despite last year’s reports of insufficient medical staffing, the VA might put people on furlough, freeze hiring and take other personnel-reduction steps to address its financial problems. In addition, according to The Times, it might ration some expensive medical costs, which invites all sorts of unpleasantness about who deserves what.

Is this any way to treat people who have served their country? Is this any way to treat anybody?

Sloan D. Gibson, deputy secretary of the VA, told The Times, “Something has to give. We can’t leave this as the status quo. We are not meeting the needs of veterans, and veterans are signaling that to us by coming in for additional care, and we can’t deliver it as timely as we want to.”

In addition to the waiting-list scandal that broke last year, the VA has come under fire for several breaches of ethical and/or medical standards. Even if they’re not directly related to the shortage of caregivers for this needy population, you have to believe lack of money and clinical staff compromise care on all levels.

Since last year’s news broke, the VA did respond to the need for faster access to health care, handling 2.7 million more appointments than in any previous year. It also authorized 900,000 more patients to see physicians outside of the VA system via a program called Choice Card that permits veterans in rural areas who languish on waiting lists to seek care from private doctors outside the department’s health system.

Agency officials told The Times that they have increased capacity by more than 7 million patient visits per year, double what they originally thought they needed.

So why have the waiting lists continued to grow?

It appears that the need expanded to surpass the supply — the department didn’t expect the demand to soar so much beyond the ability of physicians to handle the workload over the last year.

The Times got VA budget information showing that physician workloads grew by 21% at hospitals and clinics in parts of the South, for example, and by 20% in the Southern California and southern Nevada. The taxpayer-funded physician care provided outside of the department grew by 50% in Pennsylvania, and by 36% in some parts of the Midwest.

Those numbers reflect multiple appointments by individual patients, and patients often schedule more appointments than they used to. Still, the number of people being treated has jumped significantly in many areas, and the VA was stunned by the number of new patients seeking treatment.

The boom in patients seeking appointments is not the only factor driving the VA’s inability to keep up with demand, nor is it responsible for all the excess costs. The increasing need for prosthetic limbs and the outrageous price for new drugs to treat hepatitis C (approaching $100,000 for a single patient) are huge contributors.

The more things change at the VA, it seems, the more they remain the same.

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June 30, 2015

Q&A on Medicare’s End-of-Life Care

End-of-life medical care has come under sharp review recently as policymakers grapple with whether health-care professionals should be reimbursed for talking to patients about their treatment options.

Planning for such care is fraught with difficulty. No one wants to discuss death and the infirmity that often surrounds it, but such discussions with doctors and families are critical to ensuring people receive the treatment they prefer if they are unable to communicate their wishes when the time comes. (See Patrick’s newsletter, “Dying in America: A Necessary Conversation.”)

About 3 in 4 of the 2.5 million people in the U.S. who die every year are 65 and older, making Medicare the largest insurer of health care provided during the last year of life. About 25% of what Medicare spends for health care is on services during beneficiaries’ last year of life. The cost is so high because many elderly people several serious and complex conditions.

Other considerations besides cost factor into end-of-life planning and determining public policy for it. About 9 in 10 adults, according to Kaiser Family Foundation (KFF), a nonprofit health research and policy outfit, say they would prefer to receive end-of-life care in their home if they were terminally ill, but data show that only about 1 in 3 Medicare beneficiaries dies at home.

KFF, which is not affiliated with the provider/insurer Kaiser Permanente, has compiled a Q&A about Medicare’s current role in end-of-life care and advance care planning. Here are some excerpts:

Q: What is “end-of-life care” and does Medicare cover it?

A: End-of-life care encompasses all health care provided to someone in the days or years before death, whether the cause of death is sudden or a result of a long-term illness. For people older than 65, the most common causes of death include cancer, cardiovascular disease and chronic respiratory diseases.

Medicare covers health-care services beneficiaries may receive until they die, including care in hospitals and other facilities, home health care, physician services, diagnostic tests and prescription drug coverage through a separate Medicare benefit.

Many of these services may be for curative or palliative (symptom relief) purposes, or both. Beneficiaries with a terminal illness are eligible for the Medicare hospice benefit not included under traditional Medicare (more about hospice services below).

Q: What is “advance care planning” and does Medicare cover it?

A: Advance care planning involves multiple steps designed to help individuals: understand the health-care options available for end-of-life care; determine which types of care best fit their wishes; share their wishes with family, friends and their physicians.

In some cases, patients who have already considered their options might need only one advance care planning conversation with their physician. But some beneficiaries might require several conversations with their physician or other health professionals to clearly understand and define their end-of-life wishes.

Medicare covers advance care planning only under limited circumstances. Neither physicians nor beneficiaries are reimbursed by Medicare for advance care planning if it’s the sole purpose of the doctor visit. To be covered under Medicare, such discussions must occur either as part of appointments made for other reasons (such as illness or injury) or during the one-time “Welcome to Medicare” visit that may occur within a beneficiary’s first 12 months of Medicare enrollment.

The agency that runs Medicare (the Centers for Medicare and Medicaid Services, or CMS) included advance care planning as a voluntary service when the Affordable Care Act (ACA, or Obamacare) established annual wellness visits. But the provision was retracted before it could take effect in 2011 because the CMS said it did not have sufficient “opportunity to consider prior to the issuance of the final rule the wide range of views on this subject held by a broad range of stakeholders.”

Q: Are policymakers, such as CMS or Congress, considering changes in Medicare’s coverage of advance care planning?

A: Yes. Last year CMS said it will consider the possibility of allowing physicians to bill Medicare separately for advance care planning in the future. CMS highlighted billing codes submitted by the American Medical Association to acknowledge advance care planning services as of 2015, but did not approve their use for Medicare reimbursement. CMS said it will consider whether to pay for these services in 2016, after it “has had the opportunity to go through notice and comment rulemaking.” This discussion is anticipated in August.

Before passage of the ACA, bogus claims were made during the 2008 election that including advance care planning in Medicare coverage beneficiaries would result in government “death panels,” or people making end-of-life decisions for Medicare beneficiaries. That nonsense persisted even after the ACA passed.

Now, two bills have been introduced in Congress pertaining to advance directives and end-of-life care. One would provide coverage under Medicare for advanced illness planning and care coordination services, including discussions about treatment options and patient preferences, to Medicare beneficiaries who have a serious progressive or life-threatening illness. The other would establish Medicare and Medicaid coverage for advance care planning consultations between patients and doctors or other health-care professionals.

Q: What’s an advance directive?

A: An advance directive is written instructions that reflect a patient’s wishes for health care to guide medical decision-making in the event he or she is unable to speak for himself or herself. Generally, it’s the result of advance care planning and often involves a living will, which defines the medical treatment that patients prefer if they are incapacitated, or designation of a certain person as a medical power of attorney. Advance directives fall under state regulation, and the required forms for formal advance directives vary from state to state.

About 4 in 10 Americans 65 and older do not have advance directives or have not written down their own wishes for end-of-life medical treatment.

Q: Are health-care facilities, such as hospitals or skilled nursing facilities, required to keep records of Medicare patients’ advance directives?

A: The Patient Self-Determination Act, which took effect in 1991 requires hospitals and skilled nursing facilities to ask each patient on admission if he or she has an advance directive and record its existence in the patient’s file. Facilities may not require a patient to create an advance directive before providing treatment or care, and Medicare patients are not required to have one before they receive care.

Recent surveys show that among long-term care patients, those receiving care in a facility (such as a nursing home or hospice facility) are more likely to have advance directives.

Q: Does Medicare cover hospice care? How many Medicare beneficiaries use hospice?

A: Yes. For terminally ill Medicare beneficiaries who choose palliative over curative treatment, Medicare covers an array of services, including nursing care, counseling, palliative medications and some respite care to assist family caregivers. Most often, hospice care is provided in patients’ homes.

Medicare patients covered by the hospice benefit have little to no cost-sharing liabilities for most hospice services.

To qualify for hospice coverage under Medicare, a physician must confirm that the patient is expected to die within six months if the illness runs a normal course. If the Medicare patient lives longer than six months, hospice coverage may continue if the physician and the hospice team re-certify the eligibility criteria.

In 2013 nearly half of all Medicare beneficiaries who died used hospice. Hospice care accounts for about 10% of traditional Medicare spending in beneficiaries’ last year of life.

Medicare Advantage plans do not cover hospice care, so if a Medicare Advantage enrollee receives hospice care, it’s covered under traditional Medicare (Parts A and B).

Although the benefits of hospice care in providing appropriate end-of-life care are clear, questions have been raised about the growth in for-profit hospice agencies, citing differences in the average care needs of the patients they serve compared with those served by nonprofit agencies.

Q: What is “palliative care” and does Medicare cover it?

A: Palliative care focuses on managing symptoms and providing comfort to patients and their families, no matter how old a patient is or what kind of coverage he or she has; it’s not restricted to people with terminal illnesses, but commonly used among people living with serious, complex and chronic illnesses, such as cancer, heart disease, general pain or depression.

Nearly half of all Medicare beneficiaries have four or more chronic conditions for which palliative care services might be appropriate, either in combination with or instead of curative treatment.

Q: Has the Institute of Medicine (IOM) made any recommendations regarding advance care planning and end-of-life care?

A: The IOM recently released a comprehensive report, “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life,” that included five recommendations to increase the quality of end-of-life care and improve the ability for patients to choose their own treatment plan.

Briefly, they are:

  • coverage of comprehensive care for patients with advanced serious illnesses who are nearing the end of life by both government and private health insurers;

  • development of standards and ways to measure clinician-patient communication and advanced care planning, with insurance reimbursement tied to performance of the standards;

  • strengthening clinical training and licensing/credentialing requirements in palliative care;

  • regulations to establish financial incentives for integrating medical and social services for people nearing the end of life, including electronic health records that incorporate advanced care planning; and

  • widespread efforts to inform the public about the benefits of advance care planning and the ability of individuals to choose their own course of treatment.

For additional information about Medicare, see Patrick’s newsletter, “Welcome to Medicare.”

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June 28, 2015

A Move Toward Eliminating Medical Bill Surprises

It probably has happened to you or someone you know: A patient chooses the doctor and the facility where the procedure occurs mindful of his or her insurance plan’s network, then later receives a surprise bill showing, sometimes, thousands of dollars owed for out-of-network care. The services were provided, but the patient never knew about them and/or that they weren’t in-network.

The New York Times described this situation in stark terms in its series “Paying Till It Hurts.” (See our blog.) And a recent survey by Consumers Union further quantified it, showing that almost 1 in 3 Americans with private insurance got a big surprise on a medical bill in the last two years when their insurance covered less than expected. Almost 1 in 4 of those surprises got billed by a doctor from whom they did not expect a bill. Fewer than 3 in 10 people were satisfied with the ultimate outcome of the issue.

As described by Modern Healthcare, “Consumers get especially upset when they go to an in-network hospital for an emergency and later get a bill from an emergency physician who was not in their plan's network.” It mentioned a report last year from Texas, where more than half the in-network hospitals for one major underwriter had no in-network emergency physicians; another major insurance carrier offered in-network ER docs barely half the time, and another major player averaged an in-network ER provider about 1 in 5 times.

This game of “gotcha,” the magazine said, infuriates patients because often there’s no way for them to know that their providers were out of network at the time the care was delivered, so they’re deprived of making an informed choices. “You can't shop around for a network emergency doc,” the story said, “when you have crushing chest pain. “

California made a move earlier this month to rectify part of the problem. As reported by Los Angeles Times columnist Michael Hiltzik, the state Assembly passed a measure prohibiting ancillary providers, such as pathologists (who examine bodily fluid and tissue samples to interpret and diagnose the changes caused by disease), anesthesiologists and radiologists (who interpret imaging scans) from charging patients more than the in-network rate for their specialty, if they delivered the service at an in-network hospital.

The bill moves to the state Senate for consideration, but its progress is opposed by the formidably powerful California Medical Association and other provider groups, which is not a surprise (unlike some patient bills).

The gotcha game is fairly new, Hiltzik explained, because doctors in the key specialties often responsible for billing surprises largely used to be hospital employees. So if your hospital was in your insurer's network, so were those providers. But today, those services mostly are provided by independent doctor groups, which might or might not be in the same network as the hospitals where they perform them. If not … surprise!

Hiltzik pointed out that the problem can be worse in other states (Texas, are you listening?). A California Supreme Court ruling in 2009 banned emergency room physicians from “balance billing” — that’s when patients are charged more than an insurance reimbursement. But that ruling doesn't apply to pathology, anesthesiology and radiology, and most other states, according to Hiltzik, don't have California’s ER protection, although 13 do have restrictions on out-of-network balance billing. But they apply mostly to managed care (HMO) plans, not preferred provider organizations (PPOs).

But networks are shrinking, especially among plans offered by the state and federal exchanges of the Affordable Care Act (“Obamacare”). But the problem certainly isn’t limited to them. In addition to fewer provider choices, the gap between what the plan covers for in-network versus out-of-network care (which, for the latter, often is nothing) is growing wider. Some out-of-network charges aren’t just gouging; they can cause a family to lose its house.

“The injustice of course,” Hiltzik wrote, “is that patients typically have no control over the choice of their pathologist, anesthesiologist or X-ray or CT scan provider; sometimes they don't even know they're being treated by one. It's unreasonable to expect them to vet every such doctor, even after they've taken all the proper steps to schedule a procedure at a network hospital.”

With the increasing popularity of high-deductible health plans, Modern Healthcare noted, consumers are paying more for health care before the insurance subsidies kick in, making them increasingly sensitive to unexpected bills. “[M]any plans have no out-of-pocket limit for out-of-network charges,” the story said. “A recent New York Times/CBS poll found that nearly half of respondents described paying for health-care as a hardship, up 10 points from a year earlier.”

Because the California legislation limits charges to whatever the in-network charge would have been, medical providers are nervous about who will be responsible for the excess. The medical association wants an amendment to "require an efficient, equitable dispute resolution mechanism that guides parties towards a reasonable rate for services," according to an Assembly staff analysis. The association supports a 2014 New York law requiring arbitration between providers and insurers, which excuses patients from the tussle.

That’s good news for consumers, but are we too cynical to wonder if disputes between the other interests can only add to the cost of insurance and medical coverage in the long run?

Modern Healthcare didn’t go there, and offered a more optimistic scenario: If more states established regulations like New York (and maybe California), insurers and providers would know that patients can’t shoulder unexpected bills, and the likely outcome of out-of-network payment disputes will nudge them toward signing network contracts.

Consumers Union, it reported, intends to raise the issue with the U.S. Labor Department, which is authorized to impose rules against surprise bills in self-insured plans that are not subject to state regulation.

“But insurers and providers should take action on their own to head off surprise bills,” the magazine advised. “If they don't, the public and elected officials may decide that limited networks are not such a good idea after all. Then industry players and policymakers would have to dream up a new model for making private markets work in health care.”

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June 26, 2015

A Reliable Online Library of Safety Stuff You Want to Know

The Agency for Healthcare Research and Quality is part of the U.S. Department of Health and Human Services. Its Patient Safety Primers are topical resources for people seeking information on everything from Adverse Events After Hospital Discharge to Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery

Because it’s a government compilation replete with acronyms and abbreviations, and because each explanation is evidence-based, it’s rather wonky reading. As the introduction says, “Patient Safety Primers guide you through key concepts in patient safety. Each primer defines a topic, offers background information on its epidemiology and context, and highlights relevant content from both AHRQ PSNet and AHRQ WebM&M.”

But each topic is explained clearly enough to get your arms around without Too Much Information, and if you want to pursue a topic further, the site offers links to additional resources.

Among the topics we find especially relevant:

  • Diagnostic Errors
    Thousands of patients die every year due to diagnostic errors. While clinicians’ cognitive biases play a role in many diagnostic errors, underlying health care system problems also contribute to missed and delayed diagnoses.

  • Error Disclosure
    Many victims of medical errors never learn of the mistake, because the error is simply not disclosed. Physicians have traditionally shied away from discussing errors with patients, due to fear of precipitating a malpractice lawsuit and embarrassment and discomfort with the disclosure process.

  • Health Care–Associated Infections
    Although long accepted by clinicians as an inevitable hazard of hospitalization, recent efforts demonstrate that relatively simple measures can prevent the majority of health care–associated infections. As a result, hospitals are under intense pressure to reduce the burden of these infections.

  • Medication Errors
    Adverse drug events are likely the most common source of preventable harm in both hospitalized and ambulatory patients, and preventing ADEs is a major priority for accrediting bodies and regulatory agencies. Medication errors can occur at any stage of the medication use pathway, and a growing evidence base supports specific strategies to prevent ADEs.

  • Never Events
    The list of never events has expanded over time to include adverse events that are unambiguous, serious and usually preventable. While most are rare, when never events occur, they are devastating to patients and indicate serious underlying organizational safety problems.

  • Patient Safety in Ambulatory Care
    The vast majority of health care takes place in the outpatient, or ambulatory, setting, and a growing body of research has identified and characterized factors that influence safety in office practice, the types of errors commonly encountered in ambulatory care and potential strategies for improving ambulatory safety.

  • Radiation Safety
    Greater availability of advanced diagnostic imaging techniques has resulted in tremendous benefits to patients. However, the increased use of diagnostic imaging poses significant harm to patients through excessive exposure to ionizing radiation.

  • Voluntary Patient Safety Event Reporting (Incident Reporting)
    Patient safety event reporting systems are ubiquitous in hospitals and are a mainstay of efforts to detect safety and quality problems. However, while event reports may highlight specific safety concerns, they do not provide insights into the epidemiology of safety problems.

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June 26, 2015

When Malpractice Starts with a Doctor’s Mouth

A northern Virginia man successfully sued a doctor for defamation and medical malpractice, earlier this month receiving a judgment of $500,000 for the serious — and, frankly, weird — ethical and medical harm he suffered during a colonoscopy.

The case is weird because “defamation” is something plaintiffs who are medically harmed don’t often claim, and also because the proof of both the defamation and the malpractice was recorded by the man’s phone. During the procedure, he was under general anesthetic and dressed only in the standard hospital gown.

As the Washington Post explained,

“Because he was going to be fully anesthetized, the man decided to turn on his cellphone’s audio recorder before the procedure so it would capture the doctor’s post-operation instructions, the suit states. But the man’s phone, in his pants, was placed beneath him under the operating table and inadvertently recorded the audio of the entire procedure, court records show. The doctors’ attorneys argued that the recording was illegal, but the man’s attorneys noted that Virginia is a ‘one-party consent’ state, meaning that only one person involved in a conversation need agree to the recording.”

It was clear that the gastroenterologist, Soloman Shah, who was dismissed from the suit, and the anesthesiologist, Tiffany M. Ingham, mocked and insulted the man while he was incapacitated. Ingham made fun of his stated aversion to needles and made several other disparaging remarks about his character, stating her personal dislike of his manner. She defamed him, the jury decided, by warning a medical assistant not to touch a rash on his genitals because she might get “some syphilis on your arm or something,” and added, “It’s probably tuberculosis in the penis, so you’ll be all right.”

She was guilty of malpractice, the jury determined, by falsifying his chart with the notation that he had hemorrhoids. He did not, but Ingham was recorded as saying, “I’m going to mark ‘hemorrhoids’ even though we don’t see them and probably won’t...”

She and Shah also suggested “misleading and avoiding” the plaintiff after his procedure. Ingham was recorded as saying Shah should pretend to receive an urgent “fake page” and said, “I’ve done the fake page before,” according to the complaint. “Round and round we go. Wheel of annoying patients we go. Where it’ll land, nobody knows.”

Rarely is such disrespect for the people you’re supposed to help so clearly expressed and captured. No surprise that the jury, composed of human beings with the requisite compassion the medical “professionals” lacked, found in favor of the patient.

One of the jurors told The Post that the plaintiff had asked for $1.75 million and that the $500,000 judgment was a compromise between one juror who thought the man deserved nothing and at least one who thought he deserved more.

“We finally came to a conclusion,” the juror said, “that we have to give him something, just to make sure that this doesn’t happen again.”

Ingham seems to have disappeared from the northern Virginia area since the case came to light. Listening to her trash talk on the inadvertently recorded audio is a strange experience. One or two little black humor jokes is one thing. But as the audio rolls on and on, you realize this is one doctor who is alienated from the whole concept of the awe necessary when an anesthesia doctor beholds that a helpless patient's life is entirely in his or her hands.

You wonder how many doctors are so unhappy with their profession as to take it out on their unconscious patients. Hopefully the number is few, and maybe it's time for Ingham to think about a different career, when the people she's talking to may get a chance to talk back.

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June 25, 2015

Why Hospitals Perform Procedures They’re Not Equipped to Do

Hospitals love new technology and new treatment initiatives because using them can result in better outcomes for patients. But hospitals also like them because they can charge more for an expensive or complicated surgical tool or protocol, and leverage that use for promotional purposes.

Unfortunately, as we’ve often pointed out, new and complicated treatments sometimes don’t work right. Sometimes they’re used by people insufficiently trained. Sometimes they cause grievous harm to patients and qualify as malpractice. So, many policy experts are calling for hospitals to prove they’re capable before they engage in certain surgical practices.

“As the U.S. health-care landscape advances toward rewarding quality rather than quantity, just buying a new high-tech surgical tool or hiring skilled surgeons may not be enough to support offering the new service,” according to a recent story in Modern Healthcare. “Facilities should more frequently be asked to prove not only the ability to achieve good clinical outcomes, but that there is a community demand for the service in the first place, [health quality and policy leaders] say.”

Implementing new surgical programs sometimes is the result of misguided priorities (see our blog about proton beam technology). Devon Herrick, senior fellow at the National Center for Health Policy Analysis, told Modern Healthcare, “They don't establish [such programs] because they have a competitive advantage or are especially skilled in the area. [They do so] because there are patients who have insurance that will reimburse for these lucrative services.”

He also said that if hospitals don't compete on price, they probably don't compete on quality either.

According to the Centers for Disease Control, congenital heart defects affect about 1 in 100 (about 40,000) births per year in the U.S. About 1 in 4 of those babies are sick enough to require surgery. One medical center that performed them for four years suspended elective pediatric congenital heart surgeries earlier this month because of too many poor outcomes.

In those four years, St. Mary’s Medical Center in West Palm Beach, Fla., performed only 132 separate heart procedures on a total of 90 patients after receiving approval by Florida's Agency for Healthcare Administration in 2011. Florida, Modern Healthcare explained, requires a Certificate of Need (CON) before a facility may expand, offer a new service or purchase certain kinds of equipment.

When St. Mary’s got the approval, it made sure people knew: “No other hospital in Florida has received such approval in more than 15 years,” it announced, claiming that congenital heart defects are fairly common and that local folks could now access the “unique minimally invasive treatment option right here in the local community.”

But given the CDC data, was there ever a demand for this service in this community? As we’ve noted, the more often a provider performs a certain procedure, the likelier it is that its patients will get the best outcomes. “Families and insurers could have sent patients to already established facilities that have specialized pediatric cardiovascular care teams and in some cases average more than 800 of the procedures each year,” Modern Healthcare noted.

“Ask a parent if they would prefer a place that does that many, or one that does one every other week. I don't think it takes a genius to figure that out,” Dr. Edward Bove told Modern Healthcare. He’s head of the divisions of pediatric and adult cardiac surgery at the University of Michigan Health System, and collaborates with Joe DiMaggio Children's Hospital, where a few patients from St. Mary's had been transferred for additional care.

St. Mary’s wanted the cachet and the revenue from pediatric heart surgery, but it appears that it didn’t have the chops, regardless of what the state decided.

In places where hospitals must receive a CON before a new service can be offered, some industry experts believe they should be required to prove that they have the resources to establish a program as well as a sufficiently high volume of such cases in order to remain proficient.

It’s not as if St. Mary’s was surprised that its reach exceeded its grasp. Concerns over its suitability to perform pediatric heart surgeries were raised during public hearings for its CON process. At the time, reported Modern Healthcare, the hospital’s open heart surgery program was expected to generate 64 cases in the first year and 66 cases in the second, both of which are low numbers. Still, the hospital managed only 46 and 44 respectively in those years.

Cardiac surgeons told Modern Healthcare that hospitals doing these procedures must provide specialized cardiac teams around the clock. “You really need an entire city of people, it's an enormous technical undertaking,” Bove said. “You don't just go out and hire a surgeon.”

It’s not clear whether St. Mary's had that expertise. Documents in support of its CON said its on-call policies would enable the rapid mobilization of surgical and medical support for emergency cases, and that the hospital would recruit staff with appropriate experience and training in pediatric open heart surgery.

Legal claims filed last year by at least four families whose infants underwent cardiac care at St. Mary's accused the hospital of not being able to quickly recognize and treat the complications during and after their surgeries. They alluded to “systematic failures.”

According to Modern Healthcare, The Joint Commission, the nonprofit that accredits U.S. hospitals and conducts unannounced onsite surveys, said the situation at St. Mary's is something it “will likely take a look at.”

Conventional wisdom would deem that sort of review necessary before a facility performs the surgery. The view from hindsight is much more likely to reveal collateral damage that never should have been inflicted in the first place.

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June 24, 2015

Smoking-Related Cancers Aren’t Limited to the Lungs

According to JAMA Internal Medicine, half of the 346,000 people 35 and older who died from cancer in 2011 had a history of smoking cigarettes. But what’s truly remarkable about the new research is that this is the first study to identify deaths from 11 kinds of cancer besides lung cancer that were associated with cigarette use.

As described by KaiserHealthNews.org, the researchers referred to the 2014 U.S. Surgeon General’s Report as fundamental to their study, which estimated the annual number of smoking-related deaths from cancer generally and from lung cancer specifically between 2005 and 2009.

The study traced how smoking behavior and its association with cancer have changed over time. Between 2000 and 2012, the number of people who smoked decreased from 23 in 100 to 18 in 100, and the number of deaths for most types of cancer tied to smoking also declined.

That’s good news, but for people who smoke, the risk of developing cancer might increase over time. Even though smoking in the U.S. has declined over 50 years, that behavior still causes nearly 170,000 deaths from cancer every year, the researchers concluded.

The researchers wanted to define the magnitude of risk for different types of cancer. They analyzed 12 cancers in relation to cigarette smoking, and — no surprise — lung and bronchial (air passages) cancers were the most closely associated with smoking. But half of the deaths from oral cavity (mouth, tongue, gums), esophagus and bladder cancers were attributed to smoking as well.

Reducing the rates of smoking-related cancer, the scientists concluded, requires more extensive control of tobacco.

The study was led by Rebecca L. Siegel of the Intramural Research Department at the American Cancer Society. In a story on the American Cancer Society (ACS) website, she said “People who are poor have double the rate of smoking as people who are not. Gay and lesbian people are almost twice as likely to smoke as straight people.”

She also pointed out how smoking rates vary depending on where you live. “Cigarette taxes in tobacco-producing states are about one-third the rate of nontobacco-producing states,” she said. “Georgia’s tax is about 37 cents compared to $4.35 in New York.”

In addition to cancer, smoking raises your risk of long-term lung diseases including emphysema and chronic bronchitis, as well as heart attack, stroke, blood vessel diseases and eye diseases such as macular degeneration. Half of all smokers who keep smoking, according to the ACS, eventually will die from a smoking-related illness.

For help in saying goodbye to cigarettes, see the ACS’ Guide to Quitting Smoking, or call the organization at (800) 227-2345.

For more information about lung cancer, see our blogs on the topic, and to read about myths associated with tobacco use, link here.

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June 22, 2015

FDA Bans Trans Fat ... in Three Years

By the early 1990s, scientific evidence was overwhelming that the artificial fat known as “trans” fat was a huge risk factor for heart disease, and in 2006, the FDA required food manufacturers to include the trans fat content on product labels. U.S. consumers have reduced their intake of the artery-hardening substance, but it’s still such a health threat that last week the feds decreed that it be eliminated altogether from processed foods.

Food companies have three years to comply, but from where we sit, that’s a pretty generous interval. According to the Center for Science in the Public Interest (CSPI), the food industry has known since at least 1999 that artificial
trans fat was dangerous and should be eliminated.

As pointed out by Michael Jacobson, executive director of the CSPI, “Labeling alone stimulated many to eliminate trans fat. After lawsuits against companies such as Kraft, McDonald's, KFC and Burger King, additional trans fat was taken out of the food supply.”

Jacobson called the removal of trans fat from the food supply a “landmark public health victory that is saving tens of thousands of lives per year.” So why wait three years to do what’s pretty clearly doable a lot sooner?

Trans fat is produced industrially as partially hydrogenated oils. That means hydrogen is added to vegetable oil, enabling it to remain solid at room temperature. “Partially hydrogenated” oil is useful in the commercial food industry because it gives food a longer shelf life; the oil doesn’t spoil as quickly.

But what’s good for business isn’t good for your heart.

An NPR story explained that trans fats increase the risk for heart attacks and strokes, and no longer are referred to as “GRAS” — “generally recognized as safe" for use in food.

Dr. Dariush Mozaffarian, a cardiologist, epidemiologist and dean of the nutrition policy and science school at Tufts University, told NPR, "There's really not any other fat that has this constellation of harmful effects"; trans fat raises bad cholesterol, lowers good cholesterol and increases inflammation, all of which harm blood vessels.

Last week, the journal PLoS One published a study of adults showing an association between a higher consumption of trans fat and a diminished ability to recall words. So in addition to clear threats to your cardiovascular system, eating a lot of trans fat might compromise some neurological functions, like memory.

The popularity of trans fats grew as replacements for more natural but heart-unhealthy ingredients like lard, which, as in the form of Crisco, commonly were used to make baked goods like pie crusts flakey. Trans fats could replicate most of the “mouthfeel” lard afforded, and was thought to be better for you.

Other foods that often contain trans fats are margarine, microwave popcorn and fried dishes at restaurants.

Even before the FDA imposed the labeling requirement, according to NPR, many food companies eliminated trans fats in anticipation of a ban. The Grocery Manufacturers Association said the food industry has reduced its use of it by more than 86 percent, and now even Crisco is made without partially hydrogenated oils.

Still, we eat too much, and trans fat content can be deceptive on food labels. Products are allowed to claim zero grams of trans fat on the label even if they contain as much as 0.5 grams of it. Products with higher levels are featured on CSPI’s Trans Fat Wall of Shame Pinterest board; you should refrain from eating them if you care about your heart’s health.

For more information about dietary fat, see Patrick’s newsletter, “Saturated Fat: The Good, the Bad and the In-Between.”

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June 21, 2015

Want Fewer Medical Malpractice Claims? Then Deliver Better Care

The verdict is in. Again. Yet another study proves that medical malpractice claims diminish not by limiting consumers’ rights to file them, but by delivering better medical care.

PopTort, an initiative of the Center for Justice & Democracy at New York Law School, commented earlier this month on a new study published in the American Journal of Medical Quality that showed how one state reduced malpractice claims by improving the quality of its hospital care.

“Turns out you can reduce claims and lawsuits not only by stripping patients of their legal rights after they’ve already been hurt (as in Texas),” PopTort observed. “You can accomplish the same thing by stopping the injuries and deaths in the first place, which they found examining a hospital system in Louisiana.”

The recent research study depicted how the drop in malpractice claims in that state corresponded with an increase in hospitals' quality scores based on 22 factors Medicare uses to measure hospital performance.

The study’s co-author, Dr. Khaled J. Saleh, who is chief of Division of Orthopedic Surgery at Southern Illinois University School of Medicine, said the findings suggest that hospitals can reduce liability claims with or without tort reform.

That term describes efforts to limit plaintiff judgments on medical malpractice and other restrictions that effectively stack the deck against people who have been harmed through medical misadventure.

“Clearly,” Saleh told HealthLeaders Media.com, “the evidence shows that if you do high-quality care, it is well received by patients and decreases your medicolegal costs."

Then there’s Texas. Its “success” at tort reform, PopTort reminded, has made its laws “so Draconian that legitimate claims can no longer be brought.” The extent of its decline in civil justice is explored in a new book, “Tort Reform: Plaintiffs' Lawyers, and Access to Justice,” by Stephen Daniels of the American Bar Foundation and Joanne Martin at the American Bar Endowment.

By reducing lawyers' ability to use contingency fees as compensation, as tort reform has done in Texas, attorneys lose their economic incentive to pursue even the most righteous claims. Pointing to more than 20 years of research, extensive surveys and interviews, Daniels and Martin illustrated the sorry effect of the tort reform movement in Texas on the ability of plaintiffs to obtain judgments.

PopTort referred to a Rand study of a few years ago that reinforced the idea that the best way to reduce medical malpractice claims is to clean up your medical act, not deprive harmed patients of their rights. That study focused on California, where there was a highly significant correlation between the frequency of adverse medical events and malpractice claims. According to the study, “On average, a county that shows a decrease of 10 adverse events in a given year would also see a decrease of 3.7 malpractice claims."

Its conclusion? “[N]ew safety interventions potentially can have positive effects on the volume of malpractice litigation — a desirable result to seek out, even beyond the immediate impact of medical injuries avoided.”

Then there was the paper three physicians published in 2011 about a comprehensive obstetric patient safety program at Presbyterian Hospital-Weill Cornell Medical Center in New York. “[I]mplementing a comprehensive obstetric patient safety program,” they wrote, “not only decreases severe adverse outcomes but can also have an immediate impact on compensation payments.”


  • 2009 compensation payments were almost 100% less than the average 2003-2006 payments ($27,591,610 to $250,000)

  • average yearly compensation payment from 2007 to 2009 was $2,550,136 versus an average of $27,591,610 in 2003 to 2006 (yearly saving of $25,041,475)

“How is it,” PopTort wondered, “that some respected opinion leaders don’t seem to care about addressing the problem of deaths, injuries, claims and lawsuits with proven patient safety solutions, but instead would rather focus on reducing accountability and the legal rights of sick and injured patients after they’ve been hurt? And by the way, then forcing taxpayers to pick up the tab for their care and letting the med mal insurance industry make out like bandits.

“It's obvious, but it bears repeating: The best way to reduce malpractice litigation is not to take away the rights of injured patients, but to reduce the amount of malpractice.”

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June 19, 2015

Sleep Less, Eat More

Being tired and grumpy the next day seems punishment enough for a lousy night’s sleep, but recent research indicates that chronic sleep disruption might have another unpleasant effect: It makes you overeat.

The paper, published in the Journal of Health Psychology, analyzed how a crummy night’s sleep affected eating habits and other behaviors among both children and adults.

"It is well recognized that food intake is implicated in many chronic health issues including obesity, diabetes and heart disease, and diet is often a target of treatment to prevent the onset of these conditions", the researchers said in a news release. "[U]nderstanding the mechanisms linking disrupted sleep patterns to increased food intake is important for informing both prevention and treatment interventions for chronic health conditions."

Anyone who has ever struggled with weight or other eating issues knows that what, when and how much you eat can be driven by how you feel, what you’re thinking about and what’s going on around you. Diet can be important in treating chronic health disorders, but the point of this research was to take a closer look at how sleep affects these factors.

After a bad night's sleep, ghrelin, the hormone that controls appetite, is revved up, emotional stress is greater and the restless sleeper wants food to compensate for a lack of energy. Impulse control diminishes, so your tired self gives in, and eats more.

To learn more about sleep problems, see Patrick’s newsletter, “The Struggle to Sleep.”

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