HEALTH CARE - Doctor's Orders

"Reassessing the value of care for chronic health conditions" PBS NewsHour 1/18/2017

Excerpt

SUMMARY:  Surgeon Atul Gawande says we need to reconsider healthcare's focus on generously rewarding physicians who practice heroic interventions, rather than those who practice incremental medicine for chronic conditions.  Gawande talks with William Brangham about the value of that kind of care, and the potential effects of a Republican repeal of the Affordable Care Act.

DR. ATUL GAWANDE, The New Yorker:  When you think about the future of health care and where we're going at this moment of debate, there's a transformation going on that involves a recognition that our focus in medicine has been on heroic interventions, like the kind that I do now as a surgeon.

But the biggest gains are coming right now from incremental medicine, from a commitment to the kind of steady, overtime management of complex problems like chronic illnesses that can add years to people's lives.  But that's work done by some of the people with the least resources in our health care system.

WILLIAM BRANGHAM (NewsHour):  So, who practices incremental medicine in our health care system today?

DR. ATUL GAWANDE:  Well, good examples, just look at the list of who the lowest-paid people are.

Pediatricians are at the bottom.  You would also look at internists.  You would look at psychiatrists.  You would look at family physicians, HIV specialists.  People who take care of chronic illnesses by seeing people carefully over time, those are the people who get the least money.

The people who have the most [pay] are people like orthopedic surgeons, interventional cardiologists.  And my point isn't that — you know, that we're — that there is something wrong with heroism.

My own son has a congenital heart condition, where his life was saved by a cardiac surgeon stepping in at 11 days of life to save his life.  But he is now 21 years old because of constant monitoring and working with him with a primary care physician and people who controlled his blood pressure, recognized problems before they arose, dealt with learning issues that were related to his condition.

And that's the only reason now that he's getting to live a long and healthy life.  That's what we're not rewarding.  They don't have the kind of resources and commitment that we are giving to people like me.  I have millions of dollars of equipment available to me when I go to work every day in an operating room.

The clinicians who keep my son going are lucky if they can have a nurse.

BRIEF BUT SPECTACULAR - Dr. BJ Miller

"In facing death, this doctor sees a way to live well" PBS NewsHour 10/6/2016

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SUMMARY:  Dr. BJ Miller does not work to heal patients, but to ensure quality of life amid advanced or serious illness.  Sometimes people suggest his job is depressing, but Miller doesn’t see it that way.  When people are dying it changes how they live, he says.  Miller gives his Brief But Spectacular take on dying and living.

SYRIA - Targeting Doctors

Assad War Criminal

"Repeatedly targeted by airstrikes, Syrian doctors feel abandoned" PBS NewsHour 8/15/2016

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SUMMARY:  In Syria's ongoing war, doctors are under attack in the very places they expect to be safe, their hospitals.  Last week, pro-government forces bombed a maternity hospital in the northwestern city of Idlib -- just one of the more than 375 strikes on medical facilities since the revolution began, according to Physicians for Human Rights.  Special Correspondent Marcia Biggs reports.

MARCIA BIGGS, Special Correspondent:  It is a war crime to target medical facilities, but, in Syria, bombs rain down on hospitals, doctors and patients.

Just in the last few weeks, pro-government forces bombed a maternity hospital in Idlib, supported by 'Save the Children.'  And airstrikes hit six hospitals around Aleppo.  Nurses gathered babies from their incubators, the strike narrowly missing their ward.

Rami Kalazi is no stranger to airstrikes like these.

DR.  RAMI KALAZI, Aleppo Neurosurgeon:  I was sleeping here, and my colleague is here.  And the attack happened.  We came out alive.  I don't know how.

MARCIA BIGGS:  Kalazi was one of Aleppo's last remaining doctors.  We caught up with him in Turkey.  He said he believes these hospitals were targeted.

DR.  RAMI KALAZI:  They are the artery of life in the city.  Can you imagine a life in city without hospitals?  Who will treat your kids?  Who will make the surgeries for the injured people?  So, they are targeting these hospitals because they know, if these hospitals were completely destroyed, the life will be completely destroyed.

MARCIA BIGGS:  Eastern Aleppo had already suffered a massive blow in April, when Al Quds Hospital, supported by 'Doctors Without Borders,' and the city's main pediatric hospital, was destroyed by two consecutive airstrikes.

DR.  RAMI KALAZI:  It was a very hard night.  Every one or two hour, we had an airstrike, and we had to treat some injured people.

MARCIA BIGGS:  Soon he realized the full extent of the damage, more than 50 people dead, including six members of hospital staff.

DR.  RAMI KALAZI:  They were all friends.  So, it was emotionally so hard, because you are treating your friend.  You know how hard is that.  And you see that he is in danger, he may not live, he may not survive.  It was a horrible night.

"In ravaged Aleppo, the fight for survival can begin before birth" PBS NewsHour 8/18/2016

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SUMMARY:  In Aleppo, Syria's largest city and a stronghold of the Islamic State, warfare usually means an end to life, not its beginning.  Recently, a woman nearing labor and walking to the hospital was seriously injured in a bombing.  But after an emergency cesarean section and a long struggle to help the infant breathe, a cry was heard.  Filmmaker Waad Al-Kateab documents this dual fight for life.

HEALTH - Government Site For Money-to-Doctor Links

"What to be Wary of in the Govt’s New Site Detailing Industry Money to Docs" by Charles Ornstein, ProPublica 9/30/2014

The government’s new website on drug and device company ties to doctors will be incomplete and may be misleading — for now.

The government's release today of a trove of data detailing drug and device companies' payments to doctors has been widely hailed as a milestone for transparency.  But it is also something else; a very limited window into the billions in industry spending.  Before you dive in and search your doctor, here are five caveats to keep in mind.

• The data doesn’t cover all payments.

The Physician Payment Sunshine Act, part of the 2010 Affordable Care Act, called for the first public release of this data 18 months ago.  But because of delays writing detailed rules implementing the law, the first release of data will happen today and it will only cover payments for a few months, from August to December 2013.   So if you search for your doctor and you do not find him or her, it doesn't mean that he or she didn't receive a payment.  Also, those few months may not be representative of a company's spending over an entire year.  Some companies may try to concentrate promotional talks at the start of a year, and those wouldn't be represented in this data.  Some of these problems will be resolved by the time the government releases data on payments for the full calendar year 2014, expected next summer.

• By design, some data on research payments won't be included.

The Sunshine Act allows drug and device companies to delay the publication of data related to research of new products or, in some cases, new uses for existing products.  The payments won't be made public until the product is approved by the Food and Drug Administration, or four calendar years after the payment was made, whichever comes first.  It is unclear how much money is involved, but, again, just because a doctor doesn't show up as receiving a research payment doesn't mean he or she hasn't received one.  Beyond that, not all types of health professionals are included.  You'll find physicians (medical doctors and osteopaths), dentists, chiropractors, podiatrists and optometrists.  But companies do not have to report payments to nurse practitioners or physician assistants, so you won't find them.

• Because of errors, additional data isn't being released.

CMS has acknowledged that one third of the payment records submitted by companies for last year had data problems that could lead to cases of mistaken identity.  The names associated with those payments won't be released today.  Federal officials are asking companies to recheck the data, which should be released publicly next year.  CMS officials discovered the problem while investigating a physician's complaint that payments were being attributed to him even though they were made to another physician with the same name.  In the process of reviewing that issue, it found "intermingled data," meaning physicians were being linked to medical license numbers or national provider identification numbers that were not theirs.

• Not all payments have the same significance.

When consumers go to the federal website, they will see payments divided into different categories; consulting fees, speaking fees (called "services other than consulting"), research payments, honoraria, gifts, entertainment, food and beverage, travel and lodging, educational items, charitable contributions, royalties, ownership interests, and grants.  Those different types of payments signal different levels of involvement with a company.   Educational items, for instance, include medical textbooks and reprints of journal studies given to doctors.  Research payments can include more than the pay a doctor got to lead a study. Payments for clinical studies may include costs associated with patient care, supplies, as well as the time spent by health care professionals treating patients and managing the study.  Educational items that directly benefit patients (such as anatomical posters) and medication samples do not have to be reported and won't be displayed.

• This is the first federal release of this data: Expect errors.

While the payments database is a far cry from Healthcare.gov — and less complex – it's reasonable to expect some glitches.  CGI Federal, the company that led what turned out to be the botched launch of Healthcare.gov, is also responsible for the release of the payment data.  Beyond that, drug and device manufacturers sometimes make their own errors.  Doctors have similar names, and a payment made to one may be attributed to a different one.  The government gave doctors a 45-day window to review and dispute payments attributed to them before the information becomes public, but it's unclear how many did.  The American Medical Association, as well as pharmaceutical and device trade groups, say the process has been confusing.  Probably, many doctors will notice payments attributed to them in the days to come when they search their names in Google.  If you can't find what you're looking for on the government's website, you might try our Dollars for Docs feature, where we have been tracking payments by some large companies for four years.  We've just added data from 2013, and have included 17 drug companies accounting for half of United States drug sales that year.  In some cases, that will be more complete than the federal data.   If you have a question about what your doctor received, you should ask your doctor.

HEALTH CARE - Experience of an American Doctor in UK

"An American Doctor Experiences an NHS (UK) Emergency Room" by
Dr Jennifer Gunter, Huffington Post Blog 8/14/2014

You know it's going to be one of those days when one of the first tweets on vacation (in UK) inquires about the closest hospital.

Victor, one of my 11-year-olds, had something in his eye courtesy of a big gust of wind outside of Westminster Abby.  He was complaining enough to let me flip his eyelid and irrigate his eye on the square in front of Big Ben.  (I'm sure several people thought I was torturing him).  Despite an extensive search and rinse mission no object or relief was to be found.  I fretted about going to the hospital.  It wasn't the prospect of navigating a slightly foreign ER, but simply the prospect of the wait.  While I am a staunch supporter of the British NHS in the back of my mind I envisioned a paralyzingly full emergency room and an agonizing 18 hour wait only to find he had nothing in his eye (the basic antechamber of Hell scenario).  To ensure we really needed to go I gave Victor a choice between the emergency room and a toy store (Gunter's third rule), but he declined the toys so off we went to St. Thomas hospital, conveniently right over the bridge.

The hospital was on the aging side and a little drab, but clean and well-marked.  I didn't have to ask anyone for directions.  We had to take a number to be registered, but waited less than five minutes.  I gritted my teeth a bit in preparation for the we-are-not-from-the-UK conversation, but it wasn't an issue at all.  I offered my US insurance number for billing, but was told they didn't need it.  The clerk was, however, impressed with the fact that I flipped his eyelid and irrigated his eye before coming.  "Well, you did all the right things," and looking at his red and watering eye she smiled and said.  "Looks like you are in the right place."

Registration completed, we waited to be seen by the children's part of the ER.  A registrar (resident) did a quick triage within five minutes of our registering (also impressed with the eye irrigation) and then a nurse did his vitals and took a history.  After that we waited less than 15 minutes for the registrar to do a formal assessment.  He wanted ophthalmology to do the evaluation.  I was a bit surprised the ER doc wouldn't do it, but every facility is different and when they found out that Victor was born at 26 weeks and had retinopathy of prematurity they got a bit jumpy.  Everyone does.  I was OK with ophthalmology checking him out.  What I have learned from years of medicine is don't mess with the local order.

We were walked over to the urgent care clinic and were warned that the ophthalmology registrar was covering the whole hospital so it might be a while.  This was our longest wait, about 20-30 minutes.  She was very nice (also working on her PhD).  Dr. Katie Williams (she gave me permission to use her name and her photo) diagnosed Victor with a corneal abrasion and easily snagged the offending speck of dirt wedged under his eyelid.  Once removed Victor exclaimed, "It's gone!," and within a minute or two the redness cleared up.  She put in antibiotic ointment and gave us a tube to use at home.

"So where do I pay?" I asked Dr. Williams.

The answer, you don't.  Perhaps they might bill us, she just wasn't sure.

I was about as dumfounded at her answer as she was at my asking.

I protested that it wasn't fair.  We had used services and I was very prepared to pay.  I also have insurance that covers emergencies when out of network, so I was pretty sure I would be reimbursed at least some of the visit.  However, we were just sent away.  They do have my address so it is possible I will get a bill in the mail.

I am very curious what similar care would have cost in the US.  The saddest commentary of all is that it is really impossible to tell as billing practices are so bizarre and opaque.  My guess is it would be a minimum of $1000 in America for cash (which is egregious).  If I ever get a bill from the UK, I'll post a follow-up.  If anyone has had similar care in the US and received a bill please do post in the comments.

But what of this idea that national health care means DMV-purgatory worthy waits, Dementor-staffed death panels, Saxon-age medical equipment, and incompetent care?  Well, I can tell you we had great care at St. Thomas and Dr. Williams was fantastic.  The slit lamp wasn't brand new, but it worked just fine.  Sure it's an N of one, but I've been to the ER more times than I can count with my other son and this was as smooth as the best care we've had in the United States.

We could have hit the ER at an opportune time, but to expand my N I've also asked many people about their medical care while I've been in the UK.  Not one person wanted to abandon the NHS.  I've heard of excellent care and some care that was lacking, but the bad care has nothing to do with the "national" part.  Rather it was diagnostic errors or a full hospice unit, things that I hear about with the same incidence back in the world of commercial insurance.  Take away the accents and I could easily have been listening to a group of Americans discussing their care.  With one exception, no one in the UK is left wondering what the price will be or gets an egregious bill.

It makes you wonder exactly what frightens Americans about the NHS?

My answer, the cause is Republican propaganda paid for my Big Pharma.

VETERANS ADMINISTRATION - The Poorly Controlled Bureaucracy

A case of too many VA patients, not enough doctors.

"Reverse incentives of VA health care made fixing the numbers easier than fixing the system" PBS NewsHour 6/9/2014

Excerpt

GWEN IFILL (NewsHour):  The Veterans Affairs Department today released a new audit documenting widespread delayed patient care.

It’s based on a nationwide review of 731 of its hospitals and outpatient clinics.  According to the internal report, 57,000 veterans have been waiting 90 days or more for their first medical appointment; 64,000 others appear to have fallen through the cracks, after enrolling with the agency and requesting medical care.

And in another major finding, 13 percent of schedulers said their supervisors had asked them to falsify appointment schedules to make the wait times appear shorter.  The audit also found that a 14-day target for scheduling appointments wasn’t attainable.

Joining me to discuss the report are Dr. Sam Foote, whose complaints about wait times and bookkeeping in Phoenix led to an investigation in that area’s VA system.  He was a VA doctor for 24 years.  And Ralph Ibson, national policy director of the Wounded Warrior Project, which provides services to veterans.  He previously served as the VA’s deputy assistant general counsel.

MEDICARE - Newly Released Data Raises Concern on Doctor Payouts

"Medicare data raises fresh questions about concentrated payout for few doctors" PBS NewsHour 4/9/2014

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JUDY WOODRUFF (NewsHour):  An unprecedented release of data today is putting a new spotlight on what doctors are paid in the long-running battle over how to trim the nation’s health care spending.  The data, the first of its kind released by Medicare, offers a rare look at how $77 billion was paid by the government to 880,000 providers in 2012.

Among the key findings, just 3 percent of doctors and medical providers received at least one-quarter of all those payments.  News analyses also showed Medicare paid nearly 4,000 doctors and providers more than $1 million apiece that year.  The release of the data has long been the subject of an argument among consumer groups, watchdogs and doctors’ trade groups.

We look closer now at what the initial analyses showed with Shannon Pettypiece.  She reports for Bloomberg News.  And Dr. Ardis Dee Hoven, she’s the president of the American Medical Association, which had long opposed the release of this data.

HEALTH - More Tools to Pick Your Doctor

"Beyond Ratings: More Tools Coming to Pick Your Doctor" by Charles Ornstein, ProPublica 4/8/2014

For years, patients have had few ways to compare doctors beyond their reputations. With a huge Medicare data release this week, that may soon change.

This story was co-published with Los Angeles Times.

This week, the federal government is planning to release a massive database capable of providing patients with much more information about their doctors.

The Centers for Medicare and Medicaid Services, the government agency that runs Medicare, plans to post on its website detailed information about how many visits and procedures individual health professionals billed the program for in 2012, and how much they were paid.

This new trove of data, which covers 880,000 health professionals, adds to a growing body of information available to patients who don't want to leave picking a doctor to chance.  But to put that information to good use, consumers need to be aware of what is available, what's missing and how to interpret it.

So, what's out there?

As it stands, patients can go to websites such as Yelp or Healthgrades to read reviews of their doctors submitted by other patients.  They can go to the websites of state medical boards to find out whether a doctor has faced disciplinary action.  If they're really adventurous, they can seek out lawsuit filings.

At its website, ProPublica maintains a database (Dollars for Docs, link below) on which patients can check whether their doctors have received payments or gifts from any of more than a dozen pharmaceutical companies.  Another ProPublica database (Prescriber Checkup, link below) allows patients to look at which medications a doctor has prescribed to patients in Medicare's prescription drug program.  The data enables patients to compare doctors with their peers, seeing if they have unusual practices or conflicts of interest.

This fall, under a little-debated part of the Affordable Care Act, the federal government will release data on personal, promotional and research payments to doctors from all pharmaceutical and medical device companies.  Armed with this information, patients will be able to at least ask whether their doctors have prescribed a drug because it is the best one for their patients — or because of a financial relationship.

It's important to remember, though, that data can sometimes be misleading.  There's a big difference between, say, a hospice doctor giving almost every patient a narcotic and a podiatrist doing the same thing.

As my colleagues and I at ProPublica learned, seeming anomalies are sometimes easily explained.  One Alaska nurse practitioner, for example, appeared to write an excessive number of orders for antipsychotics.  But when we reached her to ask why, she told us that she wrote prescriptions for only a few days at a time to monitor patients' responses.  Her explanation was borne out in the data.

These new tools all have limits.  They won't tell you whether one doctor's patients are sicker than another's and need different therapies.  They won't tell you about a doctor's bedside manner or willingness to return a phone call at 3 a.m.  They won't tell you about a doctor's surgical skill.

It's also far from certain whether patients will embrace the tools.  Currently, an array of information is available about hospitals and nursing homes, but it's unclear that it has made much of a difference in where patients seek care.  Some people would simply prefer to make decisions the old-fashioned way, relying on community networks rather than data.

Still, our experience in making data available suggests lots of people are eager to use this information to drive healthcare choices.  Millions have visited our Prescriber Checkup and Dollars for Docs news applications.

Moreover, despite grumbling from the American Medical Association and others in the medical establishment, the healthcare system has not collapsed because patients are learning more about their providers.

We're still a ways off from having enough information to do an overall comparison of the quality of care from one physician to another.  But Medicare should be applauded for its new release of data, and it should continue to do more.  It should also encourage private insurers and other public programs to follow suit.

Access to information is crucial if patients are to have any hope of answering that most basic of questions:  How does my doctor practice medicine?

HEALTH - Doctors Paid to Advise and Promote Big Pharma

"Double Dip:  Doctors Paid to Advise, Promote Drug Companies That Fund Their Research" by Charles Ornstein and Ryann Grochowski Jones, ProPublica 3/25/2014

Excerpt

This story was co-published with The Boston Globe.

Pharmaceutical companies pay for the clinical trials that Dr. Yoav Golan conducts on antibiotics at Tufts Medical Center.

They also pay him tens of thousands of dollars a year to give speeches and advice on behalf of their drugs.

If Golan worked at some teaching hospitals, he would be barred or severely restricted from accepting both research funding and personal payments for promotional speaking or consulting from drug makers.  These hospitals fear the money could influence clinical findings, or at least create the appearance of a conflict of interest.

Yet Tufts and many other academic medical centers allow doctors to accept overlapping payments — and some doctors still take them.

A ProPublica analysis shows that more than 1,300 practitioners nationwide received both research money and speaking or consulting fees from the same drug maker in 2012.  All told, they received more than $90 million in research grants — plus nearly $13 million for speaking engagements and another $4 million for consulting.

Critics say doctors who conduct a clinical trial while accepting personal payments from the company sponsoring the study can feel beholden to the drug maker.

“The pharmaceutical company has a paramount stake in a favorable outcome.  The [research] grant recipient has a stake in a favorable outcome and the honorarium recipient or consultant has yet another stake in the outcome,” said David Rothman, director of the Center for Medicine as a Profession at Columbia University.  “It’s not only my lab.  It’s my mortgage.”

ProPublica used its Dollars for Docs database, which tracks payments to practitioners by 15 drug companies, to conduct the review.  Not every company discloses all types of payments — research, speaking and consulting — or distinguishes between the types.  The analysis covered the nine companies that disclosed payments in this form.

Golan, an infectious disease specialist, was the only doctor who received speaking, consulting, and research payments from three companies in 2012, the most recent year for which data has been compiled.  Pfizer, Merck, and Forest Labs gave Tufts $51,000 for his research that year, in addition to paying him $125,000 to speak about their drugs and $13,000 for consulting.  His speaking fees ranked second nationally among all the researchers examined, and his total personal payments ranked fourth.

Golan referred questions to the public relations department at Tufts Medical Center, which said in a statement that Golan complies with its research conflict-of-interest policy and that officials keep a close watch over his work.

“Dr. Golan’s work has contributed to the development of two important antibiotics, including the first antibiotic developed in the past 25 years to treat the growing threat of deadly C. difficile,” the statement said.

Pharmaceutical companies’ payments for promotional speaking and consulting appear to have decreased in recent years, as blockbuster drugs have lost patent protection and the push for transparency has advanced.  Beginning this fall, all drug companies will have to publicly disclose payments they made to doctors, under the Physician Payment Sunshine Act, part of the 2010 Affordable Care Act.

But industry-backed clinical studies, which can lead to advances in care, have largely been seen as a separate matter.

ProPublica’s is the first large-scale analysis of how frequently researchers receive additional payments from companies that fund their clinical trials.  About 10 percent of researchers for the nine companies examined for this story also received money for speaking or consulting, or both.

One doctor’s conflicts:  When research meets promotion

Dr. Yoav Golan, an infectious disease specialist at Tufts Medical Center, received speaking, consulting and research payments from three companies in 2012, the only physician in ProPublica’s Dollars for Docs database that met those criteria.  Some ethicists question doctors’ abilities to stay impartial when receiving both research and personal payments from pharmaceutical companies.