October 30, 2014

Why Has the Cost of Generic Drugs Gone Crazy?

Because of their traditionally lower cost, generic drugs have long been preferred by those who pay for prescription medicine — patients and insurers. But lately, the price of generic drugs has skyrocketed, and people in power want to know why.

Two members of Congress, Rep. Elijah E. Cummings (D- Maryland) and Sen. Bernie Sanders (I-Vermont), sent a letter to 14 pharmaceutical companies informing them that they’re investigating "the recent staggering price increases for generic drugs used to treat everything from common medical conditions to life-threatening illnesses."

Cummings serves on the House Oversight and Government Reform Committee; Sanders chairs the Senate Subcommittee on Primary Health and Aging.

An example of the surging, inexplicable price of medicine, say the congressmen, is albuterol sulfate, which is prescribed for people who have asthma. In October 2013, the average price of 100 pills was $11; in April, it was $434.

A year ago, 500 tablets of doxycycline hyclate, an antibiotic, cost $20; in April, it was $1,849.

David Lazarus, the consumer columnist for the Los Angeles Times, examined what’s going on with generics, and the congressional interest. The letters to the drug companies make no assumptions or claims, he pointed out. They simply seek information about operation and production costs.

But anyone familiar with how Big Pharma works knows that it usually doesn’t play well with others, (see our blog, “Cost of Cancer Drugs Is Killing People.”) and, as Lazarus indicated, the fact that U.S. lawmakers have launched an inquiry pretty well confirms that people are suspicious that the drug prices don’t reflect fair trade.

We regularly report about Big Pharma efforts to delay the introduction of generic drugs by paying off their manufacturers in order to extend one company’s exclusivity for its brand version, and it’s hardly a secret in the halls of power. Nor, as Lazarus noted, is the ongoing consolidation among generic drug makers that thins the supplier ranks and raises costs.

In addition to reduced competition among manufacturers, shortages of raw materials to make drugs regularly cause problems, and problems are expensive. But, Lazarus wrote, that might not explain some triple-digit price hikes.

"Most generics are increasing in price by an average 10% a year," Bryan Birch, chief executive of Truveris, which monitors prescription drug costs, told Lazarus. "But we've seen some popular drugs increase by more than 650% in the last year."

Birch talked about simvastatin, the generic equivalent of Zocor, a highly successful cholesterol drug, and clomipramine hydrochloride, the generic for the antidepressant Anafranil. Prices for each rose more than 650% from June 2013 to June 2014, Birch told The Times.

A professor of pharmaceutical economics at the University of Southern California told Lazarus that the cost of some generic meds has risen as much as 1,000% in recent months, and called that inflation "obscene."

If you’re not aware of such huge increases, it might be because you’re not paying the drug’s price, only the copay imposed by your insurance coverage. So those big bumps are absorbed primarily by insurance companies. But if you think they simply swallow that bitter pill, you probably also think the moon landing was a fake.

Insurance companies like to make money just like drug companies, and when their drug costs rise, they take it out on consumers, through higher monthly premiums.

More than 8 in 10 U.S. prescriptions are filled with generic drugs, according to the FDA. The Generic Pharmaceutical Assn., according to Lazarus, claims the popularity of generics saves consumers more than $200 billion in annual health-care costs.

But even with our widespread use of generics, Americans pay more for prescription drugs than anybody else. In the world.

"Generic drugs were meant to help make medications affordable for the millions of Americans who rely on prescriptions to manage their health needs," Sanders said. "We've got to get to the bottom of these enormous price increases."

Every expert Lazarus interviewed blamed industry consolidation as key to rising prices. Many economists think at least six companies should compete in a generic drug market to keep prices reasonable, but only two or three manufacturers now make some generic meds.

“Some of the biggest generic drug companies — Mylan, Actavis and Teva Pharmaceutical Industries — have been aggressively snapping up other manufacturers in recent years,” Lazarus wrote, “reducing the number of players in the market.”

A few months ago, Mylan announced it would buy a controlling stake in Abbott Laboratories' generics business outside the U.S., which would give Mylan even more power to influence prices (and, not incidentally, lower the taxes it would pay after moving its headquarters to the Netherlands).

Shortages of raw materials indeed might be an issue in price inflation, but it’s difficult to know exactly what goes on throughout a drug's supply chain. It often starts in China or India, so how do you know if a shortage is the result of a lack of raw materials, or deliberate strategy?

At least one expert Lazarus interviewed had a contrary opinion. William Comanor, head of pharmaceutical economics and policy studies at UCLA, said many generic drugs might be priced too low.

"The prices we pay don't account for all the costs that come with running a drug company, such as having a steady supply," he told the reporter.

That means generic drug prices that are too low prevent manufacturers from investing in long-term supplies, causing disruption in inventories abroad and U.S. prices to vary wildly.

Comanor also said that sometimes, it’s just "disequilibrium," which means predictable supply-and-demand market forces aren't working as they should. Prices go crazy for no obvious reason.

Predictably, an executive of the Generic Pharmaceutical Assn. told Lazarus that Cummings and Sanders are focusing on only a handful of drugs and ignoring thousands of other "safe, affordable" generic meds.

Uh huh. Tell that to people who need albuterol sulfate or simvastatin.

And, as Lazarus said, if safe, affordable meds really are characteristic of the generic market, their manufacturers “have nothing to fear from a little congressional scrutiny.”

But if “it can be shown that prices in some instances have skyrocketed because of unethical or unfair business practices, then the industry should feel a firmer pull on the regulatory leash.”

To learn more, see Patrick’s recent newsletter, “Becoming a Smarter Buyer of Prescription Drugs.”

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October 29, 2014

Expensive Proton Beam Technology Booms as Its Potential Remains Unclear

For years we’ve been writing about the overuse of proton beam therapy for cancer patients. But manufacturers and the doctors who use the massive, expensive equipment it requires remain head-scratchingly gung-ho.

Proton therapy is radiation that uses high-energy beams to shrink tumors. According to the Mayo Clinic, “Proton therapy has shown promise in treating several kinds of cancer. Research of proton therapy continues, as doctors try to determine who may benefit from proton therapy treatment.”

Clearly, it’s in the development stage, so why are so many providers so keen to grow the market for this incredibly expensive procedure when its potential remains unknown? A recent report by Kaiser Health News (KHN) and NPR noted that there are 14 U.S. centers in operation, with a dozen under construction. The cost for each is about $200 million.

So some industry professionals were surprised when Indiana University announced in September that it would shutter its proton therapy facility in Bloomington. Their reaction is confusing to anyone who’s paying attention — there’s little evidence, the KHN/NPR story pointed out, that proton therapy is superior to more traditional forms of radiation for almost all types of cancer. (See our blog, “Better Care with the Tried and True, or the Seduction of the New?”)

Amitabh Chandra is a professor at Harvard’s Kennedy School of Government who studies U.S. medical care. He was among those surprised at Indiana’s announcement, even though, as he told KHN/NPR, “we do know it is substantially more expensive and substantially more lucrative for physicians and providers to use this technology.”

In the Washington, D.C. area alone, three proton therapy centers are being built — one at Johns Hopkins, one at MedStar Georgetown University Hospital and one at the Maryland Proton Treatment Center. All three D.C.-area facilities are full-speed-ahead with their plans, two of which told KHN/NPR that the D.C.-Baltimore region was sufficiently larger than Bloomington and could support the huge projects. The third told the reporters that theirs is smaller and will be more cost-effective than the others.

But Indiana’s decision wasn’t made in a vacuum. Its review committee decided that it just wasn’t worth spending the money necessary to update its facility. And even more telling, its insurers have declined to subsidize proton therapy for common diseases including prostate and breast cancers. One of its insurers, Cigna, concluded that proton therapy for all tumors except a rare eye cancer was not shown to be more effective than other forms of radiation therapy.

Given the cost of the equipment, it’s no surprise that proton beam therapy costs as much as six times what standard radiation therapy costs for prostate cancer, according to Cigna. And it’s hardly a lone voice: Other major insurers including Aetna and Blue Shield of California also limit what they’ll cover with proton therapy.

When insurance does cover expensive care that isn’t superior to less expensive options, guess what? The cost of everyone’s health care rises.

Facilities that pay for fancy equipment, and doctors who train to use it, aren’t going to sit around waiting for patients to present with rare forms of cancer — they’re going to use the equipment for which the payments are due, and they’re going to charge as much as they can for it.

Of course, the providers and researchers involved with building new proton beam facilities believe wholeheartedly in its value. They note the potential of proton therapy to kill cancer with pinpoint accuracy, sparing surrounding tissue from damage. They say that it’s just a matter of time before clinical trials prove that proton therapy is worth the extra money.

Indiana University doesn’t think so. Neither do we.

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October 27, 2014

Congress Imposes Greater Oversight of Hospice Care

A recent wave of media attention to the shortcomings of hospice care — and the dangers they produce for patients — has prompted Congress to approve legislation subjecting such facilities to more frequent inspections.

As the Washington Post showed in a series this year, blogged about here and here, the hospice industry has grown significantly in recent years, and it doesn’t always uphold the original ideal of hospice care — minimizing patient pain and discomfort at the very end of life. It’s about comfort, not treatment.

Too often, hospice facility priorities are about quantity, not quality of care.

According to the Washington Post, passage of the bill means hospice agencies will have to undergo government inspections at least once every three years.

Currently, inspections occur about once every six years, and sometimes as many as eight years.

The legislation also requires closer scrutiny of hospices where too many patients live longer than six months. That’s the industry threshold for “end of life” care. If a lot of people at a certain hospice are living longer than six month, it’s a sign that the facility might be accepting patients they know aren’t close to death in order to make more money off of them for a longer period of time.

Most hospice revenue comes from Medicare, so there’s a public financial concern here as well as patient care.

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October 27, 2014

How "Tort Reform" Is Hurting Medical Care for Everyone

It's bad enough that damage caps and other so-called "reforms" punish patients who have suffered preventable injuries from medical malpractice. But new research says it's much worse: These reforms actually worsen quality medical care for all patients. And they don't have any desirable tradeoffs like making care more affordable or attracting more doctors to a state.

Blogger Joanne Doroshow of the Center for Justice and Democracy, a patient rights advocate, reviews the evidence in a new piece on Huffington Post.

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October 26, 2014

Independent Report Shows Hypocrisy of Attacks on Medical Malpractice Claims

When the conversation turns to public policy, and how to protect individual rights, the nonprofit, nonpartisan organization Public Citizen calls itself “the people’s voice.” This month it has been particularly articulate on the state of medical malpractice lawsuits and claims. They're low, and there is no reason to cut back on patients' rights to bring claims for preventable injuries.

The group’s new report concluded that although medical malpractice payments rose slightly last year, payouts remained at an historic low. Public Citizen analyzed data from the federal government’s National Practitioner Data Bank (NPDB) to show that the dollar value of malpractice payments in 2013 was the second lowest in the last 15 years.

Confirming what we’ve shown in previous blogs, the analysis supports that while the number of avoidable errors occurring in hospitals remains disturbingly high, liability payments for these errors has declined.

In a statement accompanying the release of the report, Robert Weissman, president of Public Citizen, said, “Medical malpractice should be treated as a health issue, not an economic one. And the cure is not reducing access to justice for victims of malpractice, but eliminating avoidable medical errors and negligence.”

But many states continue to cap the amount harmed patients may receive in a malpractice judgment, and take other steps to make it harder to sue doctors, like the recent wave of laws in some southern states to make it almost impossible to sue for malpractice in emergency rooms. (A new study on those states finds no evidence that the immunity laws have had any benefit in rolling back the ordering of wasteful and unnecessary tests by ER doctors who are supposedly terrified of being sued.)

In the Public Citizen study, although both the number and the cumulative value of medical malpractice payments made on behalf of doctors increased in 2013, the amounts were small, and it’s the first time in a decade we’ve seen such an increase.

At the same time, however, medical liability insurance rates dropped.

According to the report:

  • The number of payments made on behalf of doctors rose slightly, from 9,370 in 2012 to 9,677 in 2013.

  • The value of malpractice payments on behalf of doctors in 2013 was $3.3 billion; in 2012, it was $3.1 billion.

  • Payments in 2013 accounted for about 0.11% of U.S. health-care costs, roughly the same as in 2012.

The number and value of medical malpractice payments have declined steadily for more than a decade, since, as Public Citizen notes, the American Medical Association (AMA) deemed the liability climate in a dozen states a “crisis.” If lower cost for malpractice insurance coupled with diminishing malpractice awards constitutes a “crisis,” what in the world do you call hundreds of thousands of preventable medical errors every year?

“As the purported crisis over medical liability costs to doctors has receded, we are learning that the actual crisis over avoidable medical errors is worse than we ever knew,” Taylor Lincoln, research director for Public Citizen’s Congress Watch division said in the statement. “The time has come for the AMA to exhibit as much concern over the tragedies stemming from avoidable medical errors as it has over medical liability insurance costs.”

Read the full Public Citizen report here.

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October 23, 2014

Big Pharma Lawsuit Threatens Program That Is the Only Hope for Many Patients

The Pharmaceutical Research and Manufacturers of America (PhARMA) is unhappy with the billions of dollars the drug industry rakes in every year, so it has filed another lawsuit to stop needy medical facilities from getting certain drugs at discount prices.

As reported by the Wall Street Journal’s (WSJ) Pharmalot blog, the lawsuit is just the latest punch in an ongoing feud between Big Pharma and the federal government over a discount drug program that enables “safety net” hospitals to get “orphan” drugs at a discount.

Safety net hospitals and clinics serve low-income, uninsured and otherwise vulnerable patients. They can be public, private and/or nonprofit, and have in common only the commitment to care for people with limited or no access to health because of financial, insurance or health conditions.

Orphan drugs, as we’ve reported, are meds that treat extremely rare diseases. Because so few people have the disorders they address, the market is too small to sustain the drugs’ research and development. So the feds offer drug makers incentives to develop them. Because their market is so small, they’re incredibly expensive.

The discount drug program, known as 340B, requires drug makers to offer discounts of as much as half the cost for all outpatient drugs to safety net hospitals and clinics. The WSJ said there are about 2,000 such facilities.

In the summer, the federal government imposed a rule Big Pharma didn’t agree with. Safety-net facilities may obtain orphan drugs at a discount to treat conditions other than the one for which orphan status was granted.

The intention of Congress in devising the rule, the WSJ explained, was to maintain incentives for drug makers to get orphan status for their drugs — and marketing exclusivity — and simultaneously enable hospitals and clinics to obtain needed medicines at affordable prices.

It was the second time the government tried to issue the rule. It did so in 2013, and PhARMA filed a lawsuit to cease all discounts, claiming that the government misread the law. The trade group also claimed that drug manufacturers would suffer financially to the degree their ability to develop orphan drugs would be threatened.

According to Drugwatch.com, the world’s 11 largest drug companies netted $711.4 billion from 2003 to 2012. In 2012 alone, they earned nearly $85 billion in profit. If this industry can’t afford to invest in life-saving R&D, who can?

In the U.S., the drug industry spent $3.5 billion promoting its wares to consumers in 2012; in 2011, one manufacturer, Boehringer Ingelheim, spent $464 million advertising its blood thinner Pradaxa, a drug with demonstrable problems that have created legal problems for the company and considerable harm to patients.

Big Pharma won the first legal round over the discount rule. Earlier this year, a federal judge said that the feds lacked the authority to make such a rule, but also that they could issue a new one, which materialized over the summer. And the drug manufacturers responded as they did the first time: They sued.

It’s the same old story. PhRMA still says the government misinterprets federal law, and isn’t happy that the feds have threatened to order drug makers to issue refunds for discounts they didn’t offer, or otherwise punish companies for failing to comply.

A spokesman for the Safety Net Hospitals for Pharmaceutical Access, which represents nearly 1,000 health-care institutions that participate in the 340B program, told the WSJ, “Once again, big pharma is trying to increase its prices at the expense of rural and cancer hospitals and their patients. These providers depend on 340B savings to serve needy patients and, in many cases, to keep their doors open.”

The hospital trade group said that that only five drug makers and biotech companies are complying with the rule to offer discounts. PhRMA claimed that is has no idea how its individual members respond to the rule.

Really? Then how do they know how supposedly harmful it is? As always, the pharmaceutical industry believes it can, and should, have it both ways.

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October 21, 2014

Restoring Legal Rights to Victims of Medical Malpractice

In the 20 years between 1992 and 2012, medical malpractice claims in the U.S. decreased by 57%, and not because the quality of medical care improved. It was because the legal system made the pursuit of parties who committed medical errors more difficult.

So wrote attorney Shanin Specter in a recent commentary in the Philadelphia Inquirer. He called this travesty of justice a “silent crisis” because so many victims of medical negligence go not only uncompensated but unheard for the harms they suffered.

He deplored this state of affairs in his state, Pennsylvania, which has tallied 43.3% fewer medical malpractice cases in the last 10 years, resulting in an almost 50% decrease in payouts by the state’s insurance department. Good for that department’s budget, bad for the suffering patients who deserved to be compensated.

And Pennsylvania’s numbers are better than the national average, because that state does not impose a cap on judgments for pain and suffering.

Readers of this blog know that such caps, which limit how much money a harmed patient can recover in court regardless of the nature or severity of the medical mistake, not only deprive people of their rightful redress, but chill the whole process. Attorneys can’t afford to take cases they believe they have little chance of winning, or in which the judgments would be too small. Invariably, medical malpractice attorneys work on spec — that is, clients don’t pay for their services unless and until they are awarded damages in court. Then their advocates get a cut.

Another wave of so-called "reform" is the change in legal standards that virtually immunize some doctors, notably those working in emergency rooms, from any lawsuit unless the patient can prove something close to intentional harm and not mere carelessness. As we noted recently in this blog, new research has found that the ostensible purpose for such legal changes, to reduce so-called "defensive medicine," doesn't work. Medical costs are the same; only injured patients are hurt when they get no legal redress for their preventable harms.

Medical malpractice cases have declined, Specter noted, by more than half even in states that don’t have caps. The number of paid claims per physician career show such a steep decline, he wrote, that “the average physician will never be involved in a medical-malpractice claim that results in the payment of money.”

A telling consequence of this reality is that, according to Specter, malpractice insurance rates have fallen nationally about 20% since 2006.

The quality of medical care in some areas has improved, Specter allowed, but “studies continue to show very high error rates, with no evidence of improvement.” (See our blog, “Protecting Yourself from the Thousand-a-Day Toll of Medical Error.”)

The changes in law that deprive harmed patients of their rights not only have lowered the cost of insurance coverage for health-care providers, but have reduced the amount people can recover for what they lost in future earnings potential, for periodic payments of future medical and personal care expenses, and have limited where plaintiffs may prosecute their complaints. “The cumulative effect of these changes,” Specter wrote, “is to deter roughly half of lawsuits and prevent roughly half of the payments for claims.”

“Every action,” he pointed out, “has an equal and opposite reaction.” And as you might imagine, it’s not to your benefit.

Between 2009 and 2013, plaintiffs won only 16 in 146 jury trials in four suburban counties in Pennsylvania.

“Given these odds,” he noted, “and the reduced value of the claims, it's no wonder that law firms report that they accept only about 1% of medical-malpractice inquiries for representation.”

Here’s what Specter recommends to remedy the wrong:

1. “Malpractice victims and defendants should play by the same rules as other tort victims and defendants.” (A tort is a civil wrong that can be redressed by awarding damages.)

Medical-malpractice cases, Specter said, should be allowed to be filed in any county where at least one of the defendants regularly conducts business, as is allowed in Pennsylvania for motor vehicle accident cases, premises liability cases, contractual disputes and nearly all other civil matters. Including malpractice cases in this club would avoid abuse of the rules, such as transferring cases to a place so inconvenient as to dissuade people from pursuing their claims.

2. “[T]here is a significant issue about whether it is fair to pay less to victims of medical malpractice than to victims of other torts. Only the medical profession enjoys special rules with respect to reduction to present worth of lost earning capacity and periodic payments of future medical and personal care expenses.”

Spectoe suggested such caps violate the constitutional guarantee of equal protection, and that the special-venue rules violate equal protection.

In conclusion, Specter wrote, “The pendulum has swung too far in favor of health-care providers and their insurers and against medical-malpractice victims. It's time to move toward the center.”

In our opinion, it’s long past that time. People have been hurt by the hand of others, and they shouldn’t have to fight for fairness.

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October 20, 2014

Nursing Home Standards to Get an Upgrade

The federal government will improve and strengthen the standards on the Medicare website that consumers use to research their options when a loved one needs long-term care.

A story published earlier this month by the New York Times, detailed how Nursing Home Compare, the government’s rating program for more than 15,000 U.S. nursing homes, will get an upgrade.

The Times said the rating system has become the gold standard for evaluating nursing homes since it was established five years ago, despite the fact that two of its major rating criteria — staffing levels and quality statistics — are self-reported by the nursing homes, and generally not verified by the federal government. That will change.

As of January, nursing homes will have to report their staffing levels each quarter via an electronic system that can be verified with payroll data. And a national auditing program will focus on whether the so-called quality measures rating (based on information collected about every patient) is accurate.

And in response to the knowledge that nursing homes often use heavy drugs to sedate their patients, the facilities’ ratings will take into consideration the percentage of their residents who are given antipsychotic drugs. These dangerous meds often are given inappropriately. Nursing homes have been reporting the practice — 1 in 5 long-term nursing home residents receives antipsychotic drugs — but it hasn’t figured into how they are rated. (See our blog, “Nursing Homes Escape Oversight, Patients Suffer.”)

The new, verified data will be collected next year, but won’t be reflected in the ratings until 2016.

Better late than never.

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October 19, 2014

Immunizing Doctors from Lawsuits Doesn't Reduce Medical Costs

An article of faith among doctors is that they order huge numbers of unnecessary and expensive tests like MRIs and CT scans solely to protect themselves from malpractice lawsuits. If this "defensive medicine" really happens, immunizing doctors from lawsuits should cut down on wasteful testing and save us all a lot of money.

A new study from the RAND Institute finds no evidence of any such savings when emergency medicine doctors obtained virtual lawsuit immunity from the legislatures of three states: Georgia, Texas and South Carolina. The study was published in the prestigious New England Journal of Medicine.

Use of tests like CT and MRI, overall costs and decisions to admit patients from the ER to the hospital -- all of these showed no different trend in the three immunity states compared to control states that had not immunized their emergency doctors.

The researchers, led by a UCLA emergency medicine doctor named Daniel Waxman, studied millions of ER visits since the three states passed their malpractice reforms in 2003 (Texas) and 2005 (Georgia and South Carolina).

All three states changed their legal standards for what a patient has to prove to win a malpractice case, getting rid of the time-honored ordinary negligence/carelessness standard that applies to everyone else who hurts someone. Now, patients must prove that the emergency room doctor was "willful and wanton" (Texas) or "grossly negligent" (GA and SC). That means the patient must show the doctor actually knew there was a high risk of serious injury and ignored it. As a practical matter, that provides virtual immunity from lawsuits.

In all three states, lawsuit filings against hospital emergency rooms have plunged since the new legal standards went into effect. So the medical industry, especially malpractice insurers, has saved a lot of money at the expense of injured patients. But what about the costs of patient care? That's where the new study found no evidence of any changes in the habits of ER doctors. They still test at the same rate and keep patients overnight at the same rate.

So does "defensive medicine" really exist? If you ask doctors in surveys, they insist it does. For example, a survey of ER doctors cited in the RAND study found 70 percent claimed they often ordered unnecessary tests as lawsuit protection, and most of those cited MRI and CT as their most recent act of defensive medicine.

The concept of "defensive medicine" has always been a head-scratcher for lawyers like me who represent patients in malpractice suits. Most of the time, defensive medicine is like defensive driving; it's just good, cautious medical practice to test rather than guess and to proceed as if the patient might have a serious condition and not blow off troubling findings. And nobody ever sues a doctor for not ordering a test. They sue when a test wasn't ordered and a catastrophe resulted because the test could have caught some serious process in time to turn it around. A truly unnecessary test, ordered only to protect the doctor and not the patient, would be insurance fraud if it really happened.

That's why I'm skeptical of these anonymous doctor surveys that claim high rates of bogus testing. I think what's going on is that doctors are looking for bogey men to blame for the high costs of medicine, and who better than lawyers?

The new RAND study doesn't prove that all of the testing in modern ERs is absolutely necessary. But it does show that you cannot blame the lawyers for unnecessary testing. And maybe more important, it shows that cutting back on patients' rights for legal accountability for serious injuries is not a good idea.

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October 16, 2014

Suggested Reading: He Just Wanted to Die at Home

Last month’s report “Dying in America” by the Institute of Medicine was an analysis of the shortcomings of U.S. health care at the end of life, as Nina Bernstein knows only too well. Writing in the New York Times, her account of one man’s last months was a poignant tale of how things can go so wrong.

In “Fighting to Honor a Father’s Last Wish: To Die at Home,” Bernstein tells the story of Joseph Andrey, 91, and his daughter, Maureen Stefanides, who desperately tried to liberate him from the nursing homes where he had been an on-again/off-again patient against his will. All he wanted to do was go home to die, but the system — “hospitals, nursing homes, home health agencies, insurance companies and the shifting crosscurrents of public health care spending” — conspired against him and thwarted his daughter every time she tried to fulfill his wishes.

Andrey had been discharged repeatedly by a hospital to a nursing home supposedly for rehabilitation, but his stays had left him weaker and more likely to get infections that complicated his ability to go home, and for his loved ones to take care of him there. He endured a cycle of poor care no one should have to experience.

As much as anything, the profit motive was responsible for his misery.

“As for dying at home,” Bernstein wrote, “‘you can’t believe the forces of the system that are arrayed against it,’ said Jack Resnick, once a health system executive and now a doctor with a geriatric house-call practice on Roosevelt Island. ‘The way the reimbursement system works, these decisions are not made on the basis of what the individuals need. They’re based on what the institutions need.’”

Read the whole story here. To learn more about how this sort of situation arises, and how you can reduce your chances of repeating it, see Patrick’s newsletter this month, “Medical Care at the End of Life.”

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October 15, 2014

Nurses Decry Texas Hospital’s Ebola Response

The full story continues to unfold about what happened with the first U.S. Ebola-diagnosed patient at Texas Health Presbyterian Hospital, but this week, nurses at that facility went public with their own concerns.

As described in a story by the Los Angeles Times, a group of nurses who either treated the Ebola patient, Thomas Eric Duncan, or had first-hand information from those who did, said the hospital’s response was confused and chaotic when Duncan arrived at the emergency room, and that he languished for hours in a room with as many as seven other patients. They claimed that hospital authorities resisted isolating him.

They also said that the nurses treating him had insufficient gear and had not been given training for handling such a patient. A few days ago, as the facts about Duncan’s initial treatment began to emerge, our blog “Ebola Patient’s ER Discharge Was Classic Malpractice” enumerated the ways in which Presbyterian Hospital appeared to breach accepted safe practices.

It’s incredibly rare for medical staffers to call out their colleagues or employers, and this group did so in a conference call with reporters. But in an interview after the nurses' statement was released, a friend of Nina Pham, the Presbyterian nurse who contracted ebola as a result of her care for Duncan, told The Times that Pham had not complained about problems at the hospital before or after she was assigned to care for Duncan.

She said Pham had confidence in the hospital's protocols for preventing infection, and called her a “brilliant” and caring nurse.

As individuals, the nurses lodged their allegations anonymously, but provided a statement read by Deborah Burger, co-president of National Nurses United (NNU). Although the nurses from Presbyterian Hospital are not members of a union, the NNU has been upfront in criticizing the general failure of hospitals to prepare for ebola. So the nurses in Dallas asked the NNU to air their grievances so they wouldn’t be at risk of getting fired.

NNU Executive Director RoseAnn DeMoro would not confirm the number of Dallas nurses who signed the statement or how many were on the media call.

They decided to speak out after their colleague Pham was diagnosed, and dissed. They were — and are — angry that health officials were suggesting that Pham was at fault for her situation, that she had made a mistake that exposed her to the virus. They want to hold the hospital responsible for its mistakes.

Duncan wasn’t isolated from other people, they claim; that eventually happened only by demand of a supervising nurse who nevertheless, they said, “faced stiff resistance from other hospital authorities.”

They also claim that his lab samples were sent through the usual hospital tube system “without being specifically sealed and hand-delivered. The result is that the entire tube system … was potentially contaminated.”

The statement said the hospital had no clear rules on how to handle Ebola patients, despite months of alerts from the U.S. Centers for Disease Control and Prevention (CDC) about the possible presentation of ebola in the U.S.

“There was no advanced preparedness on what to do with the patient,” they said. “There was no protocol. There was no system.”

If nurses had questions, they claimed, they were directed to call the infectious disease department, but it had no answers either. Essentially, they were on their own in dealing with what they called “copious amounts” of Duncan’s highly contagious bodily fluids even though they had no wrist tape to secure their gloves, no booties and only flimsy gowns that did not cover their necks.

“Hospital officials allowed nurses who interacted with Mr. Duncan to then continue normal patient-care duties,” the statement said, potentially exposing others to the virus.

And how are these deficiencies Pham’s fault?

The L.A. Times acknowledged that it could not independently confirm the nurses’ allegations, which differ sharply from the situation hospital officials have described. But their account is withering as information accumulates, and another hospital staffer has been diagnosed with the virus.

Earlier in the day when the nurses' allegations were released, the hospital said Pham's condition was improving, and issued a statement from her. She said she was “blessed to be cared for by the best team of doctors and nurses in the world.”

We can only hope it’s true, because it certainly appears as though hospital administration was deeply deficient and, apparently, unwilling the tell the truth.

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October 15, 2014

Ultrasound Is Better than CT for Kidney Stones

Despite the increased use of CT scans to diagnose kidney stones for emergency department patients, the imaging technology is no better than an ultrasound exam, and ultrasound is safer.

Ultrasound, according to a recent study published in the New England Journal of Medicine, (NEJM) is the preferred first-line diagnostic tool when someone presents at the ER with the extreme pain characteristic of kidney stones. It was clear that although ER physicians routinely turn to CT scans for kidney stone diagnosis, "Ultrasound is the right place to start," concluded the study’s senior author, Dr. Rebecca Smith-Bindman. She’s a professor at UC San Francisco.

The issue, as readers of this blog will recognize, is radiation. CT scans expose patients to significant amounts of radiation; ultrasound scans don’t.

In addition, ultrasound isn’t as expensive as CT. Those two realities make Smith-Bindman’s case compelling: "Radiation exposure is avoided, without any increase in any category of adverse events, and with no increase in cost."

Usually, a CT exam is conducted by a radiologist. An ultrasound exam can be done by a sonographer (ultrasound technician), physician or radiologist.

If the ultrasound isn’t sufficient, patients can always follow up, at their physician’s discretion, with a CT scan. That technology renders a three-dimensional image by coordinating a series of X-rays taken from multiple angles.

As noted on ScienceDaily.com, according to a National Health and Nutrition Examination Survey in 2010, 1 in 11 people reported having had at least one kidney stone. And the use of a CT scan to diagnose them has increased by a factor of 10 in the last 15 years.

In the NEJM study, conducted at 15 medical centers, emergency room patients whose pain was suspected to be due to kidney stones were randomly assigned to one of three imaging groups. People in one group received an ultrasound exam performed by an emergency room physician onsite. People in another group received similar ultrasonography performed by a radiologist, who is a specialist in the procedure. People in another group received an abdominal CT scan, also conducted by a radiologist.

With six months of patient follow-up, ScienceDaily reported, the health outcomes for 2,759 patients were just as good with ultrasound as with a CT scan. Patients fared no worse when emergency physicians instead of radiologists performed the ultrasound exam. Serious adverse events, pain, return trips to the emergency department and hospitalizations did not differ significantly among groups.

As we wrote in our earlier blog, this is another episode in the if-you-build-it-they-will-come (and pay) story of medical technology being written by hospital emergency rooms. So if this scenario describes your situation, and the doctor wants to do a CT scan first, question it. Ask why an ultrasound is not the first choice, and if you don’t get a reasonable answer, decline the CT in favor of the ultrasound.

To learn more about kidney stones, see our blog, “Treating Kidney Stones Often Has Complications.”

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