Calling A Code on Codes

As the Ball drops in Times Square, a new coding system will be rapidly approaching. 2014 will be the year of ICD-10.

The changes are unrelated to the Obama administration’s new health care law. But given the lurching start of the federal health insurance website, HealthCare.gov, some doctors and health care information technology specialists fear major disruptions to health care delivery if the new coding system — also heavily computer-reliant — isn’t put in place properly.

They are pushing for a delay of the scheduled start date of Oct. 1 — or at least more testing beforehand. “If you don’t code properly, you don’t get paid,” said Dr. W. Jeff Terry, a urologist in Mobile, Ala., who is one of those who thinks staffs and computer systems, particularly in small medical practices, will not be ready in time. “It’s going to put a lot of doctors out of business.”

Doctors already spend more time with the computerized EMR than with face to face patient encounters as it is. Switching to an entirely new coding system on top of an already cumbersome EMR is not going to enhance the doctor-patient relationship. What's suitable for large scale health systems and Accountable Care Organizations is not necessarily a good fit for a 3 doctor group in Jamaica, Queens. Top down mandates seem the antithesis of patient centered care. Don't expect great Press-Ganey's, folks.

Of course that's just my opinion. I could be wrong.

Clement Moore - The Reluctant Poet

The other night, we took a tour of some of NYC's finest Christmas light displays. While driving past the Chelsea Hotel, the driver told us the story of Clement Clark Moore.

... TRUTH BE TOLD, the 19th-century author who bequeathed us the image of a fat, jolly, white-bearded St. Nicholas ("His eyes — how they twinkled! his dimples how merry!") was himself a dour, straitlaced academician. As a professor of classics at the General Theological Seminary in New York City, Clement C. Moore's most notable work prior to "A Visit from St. Nicholas" was a two-volume tome entitled A Compendious Lexicon of the Hebrew Language.

Fortunately for us, the man had children.

Legend has it Moore composed "A Visit from St. Nicholas" for his family on Christmas Eve of 1822, during a sleigh-ride home from Greenwich Village. He supposedly drew inspiration for the elfin, pot-bellied St. Nick in his poem from the roly-poly Dutchman who drove his sleigh that day. 

... Moore, stodgy creature of academe that he was, refused to have the poem published despite its enthusiastic reception by everyone who read it. His argument that it was beneath his dignity evidently fell on deaf ears, because the following Christmas "A Visit from St. Nicholas" found its way after all into the mass media when a family member submitted it to an out-of-town newspaper. The poem was an "overnight sensation," as we would say today, but Moore would not acknowledge authorship of it until fifteen years later, when he reluctantly included it in a volume of collected works. He referred to the poem "a mere trifle."

http://urbanlegends.about.com/od/historical/a/clement_c_moore.htm

Of course today, Twas The Night Before Christmas  is all Clement Clarke Moore is remembered for.

As Paul Harvey used to say, "And now you know the rest of the story."

Holiday Wishes

Christmas/Holiday Greetings to All Elected Officials - State and National

December 20, 2013

Dear Friends
                                                                                                                                         

Thus far, healthcare reform has been a debacle. From website crashes, security breaches, and mass cancellations of insurance plans, the new law has turned hope into anger and despair. Healthcare was supposed to be patient centered, with the doctor patient relationship at the center of everything. Now, patients assured of keeping their doctors are losing them. Patients assured of keeping their healthplans are losing them. In fact more are losing coverage than gaining coverage. No one is happy about any of this. I suspect that deep down, whether D or R, Left or Right, you too are unhappy as well.

Fear not, real help is on the way. A group of motivated physicians are working together to assemble a blueprint for the way forward – a reform of the reform if you will. This time, it is the real healthcare experts, the patients’ physicians who will lead the reform. All we ask for at this time is for your time, your attention and your support. I promise you it will be worth it.

Doctors are not looking for credit. What we are looking for is the solution. During this season of hope and renewal, be of good cheer. We will find the solution. Our patients are counting on it.

Thank you for your attention.

Sincerely

Art

Health Insurance Does Not Assure Access To Care

The Mother of All Patient Access Battles is shaping up.

Americans who are buying insurance plans over online exchanges, under what is known as Obamacare, will have limited access to some of the nation’s leading hospitals, including two world-renowned cancer centres.

Amid a drive by insurers to limit costs, the majority of insurance plans being sold on the new healthcare exchanges in New York, Texas, and California, for example, will not offer patients’ access to Memorial Sloan Kettering in Manhattan or MD Anderson Cancer Center in Houston, two top cancer centres, or Cedars-Sinai in Los Angeles, one of the top research and teaching hospitals in the country.

After January 1, expect to see these signs in many doctors' offices.

It's For The Children

In today's NY Post, I come across this gem.

... Kelly said he was no fan of the Affordable Care Act, but when he received notice a few weeks ago that his current insurance plan was being canceled, he tried the New York State of Health Web site.

Kelly, 41, and his wife, Jennifer, 42, are self-employed and have always had to buy their own insurance. Kelly runs a title insurance business in Westhampton, and his wife is a pediatrician in private practice in Miller Place. “I initially went on with a lot of optimism,” he said.

Kelly said none of the plans offered out-of-network coverage, which was something he wanted. But even worse, they only covered his three older children, who are 3, 5 and 6.

When Kelly called a representative, he was told his daughter had to be 2 before she could be covered under a family plan. He would have to buy a separate plan for her, at monthly premiums that ranged between $117.21 and $369.31. The cost would be on top of a family plan with premiums ranging from $810.84 to $2,554.71 a month.

Let's back up a minute - pre-Obamacare - a family plan covered family members. Now, at least with one insurer in NY State, a family plan doesn't actually cover the family? And this is OK with NY State and the Feds? Who dreams up this mess, Old Man Potter from It's A Wonderful Life?

Head -> Desk.

Lemon of a Law

If PPACA, aka The Unaffordable Insurance Act, were a car, folks could recoup under the lemon law. We now know that if you like your plan, despite the president's "fix," you probably can't keep it. Some states like NY have already said it's too late to roll back that clock. Other states might be willing to go along but it depends on state regulators.

We also learn that if you like your doctor, you may not be able to keep your doctor. You may not be able to use your local hospital either, for that matter. Insurers have been both cutting their networks and decreasing their share of the payments to the doctors and hospitals for their services. Some prestigious NYC hospitals, like Langone Medical Center, have declined to participate in many of the new plans. Many doctors are also declining to participate or find (att some difficulty, I might add) that they've simply been dropped from the networks.

Without going into the Epic FAIL that is Healthcare.gov, many who are able to get to shop for insurance are experiencing firsthand the meaning of sticker shock. I guess that promise that folks would save about $2500 on their insurance costs was an "incorrect promise" also.

I ask you, when did we elect Joe Isuzu?

Mourning Time

Early this morning, my sister - in - law lost her courageous battle against an aggressive cancer. It had snuck up on her like the biblical thief in the night, making its presence known only when it had secured too strong a foothold to be removed. For about six months or so, chemotherapy was able to give her a few more days in the sun, a few more happy days with family and friends. But in the end, the disease broke through and she finally succumbed. Just as the comet was visible in the eastern sky, her soul left this mortal plane. She left for family and friends, a legacy of music and dancing, lilting laughter, a radiant smile, and great beauty of body, mind and soul. Dearest Awilda, you never really left for you always remain a part of us.

One woman leaves behind a legacy that will never be lost for she touched so many.

The Strength of One Woman

© Glorimar Fontanez

She played a different role in all our
lives, a mother, a sister, and a
grandmother, no matter what the love
we have for her is one, ask anyone
they'll tell you the same, she brought
us joy when we had pain , the strength
and love of one women held all of us
together even more now then ever, she
isn't physically here but we still
feel her near in every step we take
and every move we make, what she's
giving to us no one can ever replace.

Source: The Strength Of One Woman, Dying Poem http://www.familyfriendpoems.com/poem/the-strength-of-one-woman#ixzz2l6HHVyou 
#FamilyFriendPoems 

A Killer In The Community

What would you say if you knew an infectious disease which kills more people annually than AIDS, spreads by both skin to skin and airborne routes, and is resistant to all commonly used antibiotics was loose within the community? You'd doubtless want to know what public health authorities were doing about this. Well, Methicillin Resistant Staphylococcus Aureus or MRSA causes such infections and has gone from a predominantly hospital - acquired to a community - acquired infection as well. Despite the recent stories from the NFL about players infected with MRSA, the disease gets far too little attention, especially when compared with the brouhaha over Obamacare or the latest exploits of Miley Cyrus. The real scary news is that tracking by public health authorities is not universal. This seems absurd.

How did this condition get out of hand? It did so over many years, as we got complacent over the ease with which infectious diseases were handled by antibiotics. To be sure, there were outbreaks of occasionally resistant bugs but by and large, this was not a widespread problem. So we tended to reach for the Z-Pak or Amoxicillin for almost any respiratory illness, abandon old-fashioned topical antiseptics like iodine for neosporin ointment for cuts and scrapes, secure in the knowledge that our antibiotics would be successful. Unfortunately, bacteria are nothing if not resourceful and developed resistance over many generations as the susceptible strains fell by the wayside, leaving only the hardier strains intact. Moreover, antibiotic overuse, not only for illness but also in animal feed, played havoc with the body's normal flora, upsetting a balance which formed another line of defense.

While new promising treatments are on the horizon and work continues apace on vaccines, there are many who need help today and many more others potentially in harms way. What can we do? First, don't ask your doctor to prescribe an antibiotic for a cold. First, it won't work and second, this is what got us here in the first place. And don't think your physician a bad doctor because he or she won't reach for that prescription pad. Your doctor's trying to help you. In the long run, you'll thank him.

If you get a cut, wash it out with soap and water, one of our best antiseptic combinations. Grandma's iodine from the medicine cabinet would be a far better antiseptic than that new tube of neosporin.

If you belong to a gym, ask the manager about their cleaning regimens. Ideally, equipment and mats should be wiped down between uses to lessen the likelihood of skin to skin contact between patrons. It might pay to bring your own lysol wipes too, as well as your own clean towel, etc.

Finally, if ever there were a condition in need of a celebrity spokesperson, it's MRSA. This disease has been under the radar for far too long. We had and have countless celebrities raising AIDS awareness, but MRSA now kills more than AIDS. We need a MRSA spokesperson, a MRSA global fund, a MRSA telethon. Bill and Melinda Gates, please call your office.

Transvaginal Ultrasound - The Rest of the Story

Recently, an incredibly useful diagnostic tool for women's health has become embroiled in the firestorm of abortion politics. I'm speaking of transvaginal ultrasound and I'm here to try to set the record straight. Transvaginal sonography, or TVS, has been around for longer than you think, having come a long way from the first use by the Japanese in 1971. The technique was popularized in the late 1980's as a logical extention of women's healthcare. Rather than have a woman fill her bladder to point of significantt pain and disttress, a small, high frequency transducer is simply placed close to the organs of interest, resulting in images usually far more detailed than those obtained from the transabdominal route.

During this introductory phase of TVS, I was a practicing gynecologist and it seemed a natural extension of my pelvic examination. I was initially using a small standard pediatric transducer which was easily introduced, but switched over to the standard long-handled probe when I got the chance. As a shameless plug, I'd like to say I was, at least in my neck of the woods, a pioneer in this regard. I found quickly that I could evaluate potential difficulties in early pregnancy for those women who thought they were miscarrying and usually reassuring them that things were OK. I could also confirm the location of an early pregnancy, often a week earlier than transabdominally. This came in handy in those cases of suspected tubal pregnancy, which previously wasn't diagnosed until the woman presented to the emergency room in significant distress.

TVS also was able to characterize ovarian cysts, with endometriomas and dermoids usually exhibiting such a distinctive appearance that a definitive diagnosis became possible. Now, when coupled with sensitive color and power doppler, vascular signatures can be determined, facilitating the diagnosis of ovarian cancer, often at an earlier stage than before.

Today, TVS has many uses in both obstetrics and gynecology. Monitoring cervical length in patients at risk for preterm delivery is routine. TVS is often useful in evaluating fetuses for certain abnormalities such as anencephaly. In women undergoing IVF, monitoring of follicles and obtaining eggs via the transvaginal route is standard of care. TVS, especially with 3D probes, facilitates the monitoring of the location of possibly malpositioned IUD's. Three dimensional multiplanar transvaginal sonography produces images of the uterus which can rival an MRI, allowing cost-effective diagnosis of uterine malformations and location of fibroids and polyps. Instillation of saline into the uterus in patients with abnormal bleeding is now a standard technique for triaging therapy for these women.

So, once the political smoke is allowed to clear, we're left with one impression. Transvaginal ultrasound is an impressive advance in women's healthcare. It's truly frustrating that this diagnostic modality has become such a political football. I truly hope that the dust settles sooner rather than later.

If you have any questions, feel free to leave a comment or tweet me @sonodoc99 on Twitter.

Honey, They Shrank The Network

Repeatedly, President Obama reassured us that "if you like your doctor, you can keep your doctor. Now, we learn the President may have pulled a fast one.

... Elderly New Yorkers are in a panic after getting notices that insurance companies are booting their doctors from the Medicare Advantage program as a result of the shifting medical landscape.

That leaves patients with unenviable choices: keep the same insurance plan and find another doctor, pay out of pocket or look for another plan where their physician is a member.

New York State Medical Society President Sam Unterricht is demanding a congressional probe after learning that one health carrier alone, UnitedHealthcare, is terminating contracts with up to 2,100 doctors serving 8,000 Medicare Advantage patients in the New York metro region.

While other carriers are similarly cutting doctors from their provider lists, United seems clearly head and shoulders above the rest.

Curiously, United is now involved with another aspect of Obamacare - the Obamacare website fix.

The government on Friday named a UnitedHealthGroup Inc. subsidiary as “general contractor” to oversee the troubled federal website designed to sign up Americans for health insurance under national health care reform.

When QSSI was awarded the contract to build the Obamacare Data Hub, questions of conflict of interest arose. In fact, when the QSSI purchase flew under the SEC radar, Sen. Orin Hatch raised the issue.

... He asked Health and Human Services (HHS) Secretary Kathleen Sebelius in an Oct. 19 letter for a full account of contractors hired to set up the national exchange and a list of administration officials who signed off on those awards.

“I am seeking more information about the contracts associated with the entities selected to build the federally facilitated exchange (FFE) and the federal data services hub that will support the FFE,” he wrote.

Hatch wants to know whether HHS reviewed UnitedHealth Group’s purchase of QSSI to determine whether it creates conflicts. 

Make no mistake, the insurers are using the highly popular Medicare Advantage Plans as a test case. If they can successfully eliminate doctors and products which they feel are too costly for them, their efforts will soon expand to all their insurance plans and networks. People have to be on high alert and call their friends, employers and both local and federal representatives.

They told me that if I voted for Mitt Romney, corporate entities would soon control all aspects of healthcare in the US ... and they were right.

Smart Health Insurance Shopping

So you've seen those ads on TV and want to buy individual health insurance on the Exchange/Marketplace. You need to do some homework before you shop. The first thing you need to do is that if you have a doctor or doctors, you should make a list. It's important to know whether your physician will be participating in any of the plans you intend to buy. Remember the part in the President's speech about how you could keep your doctor? Well, that isn't necessarily so. 

If your doctor is not a plan participant, then you will have to consider the plan's Out of Network benefit. Some plans have better coverage than others. Also, many of the newer networks will have fewer, not more, physicians so Out of Network could end up being a major expense depending on your coverage.

You need to know is that the premium will not be the only cost associated with health insurance. The lower the premium usually means the higher the copayment and deductibles. This may not mean that much if you're young and without chronic illness, but if you find yourself seeing multiple physicians on a regular basis, these costs can add up quickly. The true cost of health insurance is much like the true cost of owning a car. The monthly payments are only a part of the story. 

Fortunately, you don't have to rush out and buy health insurance today. You have until mid-December to buy a policy whose coverage won't start until January 1. Ask questions. If you don't like what you're hearing, ask more questions. Make lists. Do your homework. To paraphrase the old Sy Syms commercial, an educated consumer is the best health insurance customer.

Autism - Much Heat But Little Light

Just a mention of the word Autism to an expectant mom is enough to cause terror. In today's parlance, autism is not one disorder but a spectrum of disease - ranging from the savant of Rain Man to those afflicted with Asperberger's Syndrome. Merriam Webster  defines autism thusly:

 a developmental disorder that appears by age three and that is variable in expression but is recognized and diagnosed by impairment of the ability to form normal social relationships, by impairment of the ability to communicate with others, and by stereotyped behavior patterns especially as exhibited by a preoccupation with repetitive activities of restricted focus rather than with flexible and imaginative ones.

The recently developed DSM V criteria for outlining the diagnosis of autism may be found here.

But what causes autism? The truth is that by and large, the cause is unknown. This is not for lack of theorizing, however, as there is quite a laundry list of usual suspects and some unusual, including:

vaccines
prenatal ultrasound
rainy climate
valproic acid during pregnancy
cosmetics
nail polish
shampoos
air pollution
household chemicals
labor induction
birth spacing
antibody proteins
television
low levels of glutathione
diet
intestinal flora
genetics

All of these putative causes have their proponents, some with great celebrity, but as of yet, the cause remains elusive. That's the real sticky part. Humans can obviously handle good news. Humans can also handle bad news if given time to fully digest. The one thing we handle poorly is the unknown. And that is truly what makes autism so frightening. A good deal learned recently from the human genome project suggests that there are genetic variations which may either directly cause or predispose to much of the autism spectrum. But this is not the whole story, There are undoubtedly sporadic cases which arise out of the blue, without any warning from family historical data. Many groups of investigators are working to piece together the puzzle that is autism. One such group (in which I have no part) has begun the Earli Study.

EARLI is a network of research sites that will enroll and follow a large group of mothers of children with autism at the start of another pregnancy and document the newborn child’s development through three years of age. The EARLI Study will examine possible environmental risk factors for autism and study whether there is any interplay between environmental factors and genetic susceptibility.

I wish all groups godspeed and good luck in their hunt to unmask the culprits underlying these disorders.

Faster please.

Think Your Doctor Is In A Funk? Your Doctor Would Agree With You

While most doctors are satisfied with their job, most agree the stress levels have increased in recent years, with one out of five admitting to feeling just plain burnt out. In an AMA commissioned study, doctors offered that the EMR was the number one negative factor impacting doctors' morale.

• "What we've created is a monster, when really what we were shooting for was good patient care," said a physician about the government's program to promote "meaningful use" of EHRs with bonuses and penalties. The extra time spent "working the chart" to satisfy meaningful use requirements, the physician said, takes away from face time with the patient.
• "I am not a clerk," added a cardiologist who complained how the technology increased data entry responsibilities. Sixty-one percent of physicians surveyed are like-minded, saying that EHRs require them to perform tasks others could handle.
• "The EHR is not just a one-time investment," said a physician with practice management duties. "It's a hugely expensive, ongoing, every-freaking-day investment."

Other complaints including information's being lost in a maze of data, confusing dropdown menus, and lack of a standard for interoperability. Doctors' offices still rely on faxing hard copy and then having to scan information back into the record.

The electronic record isn't the only stressor. Having to jump over multiple and ever-increasing regulatory hurdles compounds the difficulties doctors face. Struggling to meet government's "Meaningful Use" requirements may be the most prominent hurdle. While striving to provide better patient care by adhering to regulation, office visits take longer. Struggling to keep to the schedule shortens the time actually spent with the patient. Not only does this result in a less than satisfactory doctor-patient relationship but increases the likelihood that an error may occur, potentially, a serious error.

Additionally, some large groups base pay incentives on "productivity." This also impacts adversely on the time spent with the patient and the quality of that time. Finally, in an era of declining payment from third party payors, doctors feel it's not about profitability anymore - it's about viability.

So next time you think your doctor is stressed and rushing, he is. Why not take his hand and offer some encouragement? He'll thank you for it.

You can read the study here.

Universal Noninvasive Prenatal Testing for Down's Syndrome?

Today's NY Times returns us to Noninvasive Prenatal Testing for Down's Syndrome. 

... The newest screening test, highly accurate and noninvasive, relies on fetal genetic fragments found in the mother’s blood. Available commercially from four companies, this test is so accurate in detecting Down syndrome that few, if any, affected fetuses are missed, and far fewer women need an invasive procedure to confirm or refute the presence of Down, according to studies in several countries.

The new test, done late in the first trimester of pregnancy, can also detect other genetic diseases, like extra copies of chromosomes 13 and 18, and a missing sex chromosome. It is not yet approved by the Food and Drug Administration, however, and the American College of Obstetrics and Gynecology currently recommends it only for women at high risk for having a baby with a chromosomal abnormality.

The author then cites Tufts' Dr. Diana Bianchi as claiming that a "low risk" woman can get this test done if she's willing to pay for it. Actually, that may not always be true. NY State still tightly regulates laboratories' offering these tests and has been restricting the use of this technology to those at highest risk - age, history, or finding on ultrasound.

There are some drawbacks to these tests. 

... In a recent article in The New England Journal of Medicine, however, Stephanie Morain, a doctoral candidate at Harvard who studies medical ethics, and her co-authors said the fetal DNA tests have some disadvantages. They miss some chromosomal abnormalities detected by standard screening techniques, and they are “not widely covered by insurance.” Prices for the tests range from about $800 to more than $2,000, although some companies offer “introductory pricing” specials at about $200.

The high variation in pricing suggests that as the technology is offered to those women at lower risk, the price should come down to the lower range. It's my belief that insurance coverage may actually serve to keep prices higher rather than lower, but that's for another day.

While the article goes on to say the  tests are only  valid only in singleton pregnancies, some labs are performing the test for women who are carrying twins.

Some caveats - the first being that these tests presently only test for specific chromosomes so that a normal result does not mean a normal baby. In fact, there is no normal baby test. Conversely, an abnormal test result should be confirmed by an invasive test before making any final decisions. Having personally witnessed a mistaken result, I cannot emphasize this enough at the present time.

Finally, I agree with Dr. Bianchi  that the recent research findings in mice give hope that the day that Down's Syndrome can be ameliorated by prenatal therapy may be sooner rather than later. 

Faster Please.

Flu Shots For The Expectant Mom?

It's that time of year again and the drug store chains are all advertising flu shots. But for expectant moms, safety is a prime consideration. So what about flu shots in pregnancy? Are there any special risks during pregnancy? And are these vaccinations safe for mom and baby?

The CDC has a great deal of useful information on Flu Shots in Pregnancy.

Influenza is more likely to cause severe illness in pregnant women than in women who are not pregnant. Changes in the immune system, heart, and lungs during pregnancy make pregnant women more prone to severe illness from influenza as well as hospitalizations and even death. Pregnant women with influenza also have a greater chance for serious problems for their unborn babies, including premature labor and delivery.

But are they safe? Again, the CDC has the answer

Yes. The seasonal flu shot has been g.iven safely to millions of pregnant women over many years. Flu shots have not been shown to cause harm to pregnant women or their babies.

There is one caveat - the nasal spray vaccine is not recommended for use during pregnancy.

The CDC has more at the link.  Read the whole thing.

Soy - Yes Or No

After the WHI Study resulted in women's abandoning estrogen replacementt therapy after menopause, the use of soy-based phytoestrogens became popular. Today's NY Times, however, asks if it's it's safe to eat soy.

... As far as any downside, most of the health concerns about soy stem from its concentration of phytoestrogens, a group of natural compounds that resemble estrogen chemically. Some experts have questioned whether soy might lower testosterone levels in men and cause problems for women who have estrogen-sensitive breast cancers. Animal studies have found, for example, that large doses of phytoestrogens can fuel the growth of tumors.

It should be pointed out that soy and other phytoestrogens have only weak estrogenic effects so cancer concerns are probably overblown. In fact, there is some evidence that moderate soy intake may actually decrease cancer risk.  There is one caveat. This only holds for  soy-based food. Supplements are highly concentrated and poorly studied so all bets are off.

Remember, if something is truly all-natural, why does it come in a factory-sealed bottle?

Here's to your health.

Life After Cancer

According to the American Association for Cancer Research, there are over 13 million cancer survivors living in the US today. That number is supposed to grow to 18 million by 2022. The CDC found that about half are women  and one third are younger than 65 years old. For younger survivors, the question of fertility is an important issue.

Today's NY Timess hightlights this concern.

... At one time, oncologists rarely worried about the reproductive side effects of treatment because so few pediatric patients survived. But as more children with cancer live into adulthood — death rates have plunged 66 percent since the 1970s — the landscape of fertility has changed. Doctors are offering patients preservation options at the time of diagnosis, and researchers are finding that for many survivors, the odds of overcoming clinical infertility are surprisingly good.

Last month, a large study in The Lancet Oncology found that about two thirds of female survivors who sought out fertility treatments as adults ultimately became pregnant — a rate of success that mirrored the rate among other infertile women. 

Women with newly diagnosed cancers need to ask about fertility-sparing options, now more available than ever. Doctors, in turn, need to broach the subject with their patients. Cancer does not have to mean the "End of the Line." There is life after cancer.

Oh yes, for one more week, September is Gynecologic Cancer Month.

It's All About The Data

Today, we learn Google is launching a healthcare company.

... Larry Page, chief executive, unveiled the venture, called Calico, with a characteristically ambitious and vague claim that “with some longer term, moonshot thinking around healthcare and biotechnology, I believe we can improve millions of lives”.

While outlining a highly ambitious overall goal for the new company, however, Google did not disclose any information about how much it would invest in the venture, which areas of healthcare science the spin-off company would specialise in, or what the initiative was likely to lead to in terms of new products.

Big Data is the big mantra. But we need to ask the critical question before things get out of hand: Who Owns The Data?

Stay tuned.

The Color of Debt

This morning, I had the pleasure of receiving an article  co-authored by MSSNY's former Student Councilor Robert Dugger MD, The Color of Debt. 

The conclusion -

Black medical students had significantly higher anticipated debt than Asian students. This finding has implications for understanding differential enrollment among minority groups in US medical schools.

Interestingly, whites did not fare as well as Asians either.

The study does have so e weaknesses, with more than a hint of selection bias. Nevertheless, the matter warrants serious reflection by policymakers and further investigation.

Kudos again to Dr. Dugger for this publication.

The Dark Side of Wellness at Penn State

Rising employee healthcare costs are the bane of employers across the country. HR departments deal with the issue of providing benefits while keeping expenses manageable. Wellness programs are one possible solution to this quandry - healthy employees need fewer services. But wellness itself may have costs as well. Recently, Pennsylvania State University launched its own wellness program, Taking Care of Your Health. However, in order to encourage participation, PSU chose a coercive stick rather than a carrot approach.

The plan requires nonunion employees, like professors and clerical staff members, to visit their doctors for a checkup, undergo several biometric tests and submit to an extensive online health risk questionnaire that asks, among other questions, whether they have recently had problems with a co-worker, a supervisor or a divorce. If they don’t fill out the form, $100 a month will be deducted from their pay for noncompliance. Employees who do participate will receive detailed feedback on how to address their health issues.

At a university where some employees earn less than $50,000 annually, the faculty members contended that an $1,200 annual surcharge for nonparticipation — or $2,400 if the employee has a spouse or domestic partner on the school’s plan when that person has the option of coverage from his or her own employer — amounted to a strong-arm tactic. What’s more, they argued, the online questionnaire required them to give intimate information about their medical history, finances, marital status and job-related stress to an outside company, WebMD Health Services, a health management firm that operates separately from the popular consumer site, WebMD.com.

This has sparked calls for a faculty insurrection. 

Over at The Healthcare Blog, Vik Khanna and Al Lewis suggest an alternative strategy for the outraged faculty.

... However, there is an alternative approach, and one that will break the bank in HR: get every preventive test possible and then get all the follow-up care you can for every conceivable dubious or positive result, many of which will be false positives.  Faculty should also use their paid time off to rest up from the physical and emotional stress of getting all this unnecessary medical care and perhaps even think about filing workers comp claims since these stressors are all directly job related.

PSU administrators thought they could slip this coercive program in during the summer downtime and that the white collar faculty, without benefit of union strong arms, would simply rollover and comply. They chose ... poorly.

Healthgrades Epic Fail

In selecting a new doctor, many check like to check them out online at rating sites such as Healthgrades.com. The more satisfied the patients, the better the doctor, right? Well, it ain't necessarily so. Check out the case of a Texas neurosurgeon.

... The article chronicles how a neurosurgeon in Texas permanently injured and likely even killed multiple patients during surgery and how the Texas Medical Board failed to timely respond to complaints that were raised. As a result, the neurosurgeon, Christopher Duntsch, continued operating on patients and patients continued having bad outcomes from his surgeries. 

This does not sound like a doctor I'd want to see or refer folks to, does it? Well, according to Healthgrades (until they scrubbed his profile,) this was a highly rated doctor.

... the same doctor who was reported to have caused the deaths of several patients and who reportedly permanently injured multiple other patients was rated as a 4.3 out of 5 in patient satisfaction. Dr. Duntsch rated above the national average in every one of Healthgrades’ patient satisfaction survey details except the total wait time in exam rooms – where he rated the same as the national average.

Now Healthgrades.com has decided to remove all of the satisfaction information from Dr. Duntsch’s profile, so all you’ll see is a bunch of blanks on his ratings page. But I got a screen grab of the ratings before Healthgrades erased them.

While patient satisfaction is important, high ratings are not equivalent to high quality care. As the author of the Whitecoat piece demonstrates, this doctors' patients thought highly of him until they woke up dead. The author goes further:

In fact, Healthgrades.com has many complaints about the accuracy and validity of its ratings. It is rated at the lowest score by 88% of all people giving it a rating onConsumerAffairs.com. I had one reader write me about how Healthgrades.com published that he was still seeing patients when he has been retired for 10 years, how Healthgrades published his home phone number, and how patients call his home phone number at all hours of the day and night, then yell at him because he is retired.

When physicians complain about such sites, what is the response? Press Ganey CEO Patrick Ryan suggests physicians "Suck It Up." Oh and did I mention that Healthgrades CEO Roger Holstein is a member of the Board of Press Ganey?

Quis custodiet ipsos custodes?

I Robot

It seems as if you cannot open a magazine, listen to the radio or watch a tv program without catching an ad for robotic surgery. The surgical robot is indeed a remarkable instrument with the potential to take minimally invasive surgery to a whole other level. However, the proliferation of surgical robots also has a downside. Witness today's NY Times:

... The new study follows a series of reports critical of robotically assisted surgery. Documents surfacing in the course of legal action against Intuitive have outlined the aggressive tactics used to market the equipment and raised questions about the quality of training provided to surgeons, as well as the pressure on doctors and hospitals to use it — even in cases where it is not the physician’s first choice and she has little hands-on experience.

Nevertheless, robotic surgery has grown dramatically, increasing more than 400 percent in the United States between 2007 and 2011. About 1,400 da Vinci systems, which cost $1.5 million to $2.5 million, have been purchased by hospitals, according to Intuitive’s investor reports.

The expansion has occurred without proper evaluation and monitoring of the benefits, said Dr. Martin A. Makary, an associate professor of surgery at Johns Hopkins and the senior author of the paper.

“This whole issue is symbolic of a larger problem in American health care, which is the lack of proper evaluation of what we do,” Dr. Makary said. “We adopt expensive new technologies, but we don’t even know what we’re getting for our money — if it’s of good value or harmful.”

As of yet, it's been difficult to demonstrate that the expensive robots result in outcomes that are worth the investment. ACOG released a statement on robotic surgery concluding:

... Aggressive direct-to-consumer marketing of the latest medical technologies may mislead the public into believing that they are the best choice. Our patients deserve and need factual information about all of their treatment options, including costs, so that they can make truly informed health care decisions. Patients should be advised that robotic hysterectomy is best used for unusual and complex clinical conditions in which improved outcomes over standard minimally invasive approaches have been demonstrated.

While it's a poor carpenter who criticizes his tools, periodically we need to know that a particular tool is, as R Crumb's Mr. Natural put it, "the right tool for the right job."

Also, if you are considering robotic surgery, be sure to ask the surgeon some very specific questions about experience, volume, and outcomes. 

Of course that's just my opinion. I could be wrong.