Originally published in MedPage Today

by Kristina Fiore, MedPage Today Staff Writer

For patients without known heart disease, the diagnostic yield of coronary angiography appears to be low, researchers found.

Only about 38% of those referred to the cath lab for the elective procedure had obstructive coronary artery disease, Manesh R. Patel, MD, of Duke University, and colleagues reported online in the New England Journal of Medicine.

“In patients without known heart disease, we should carefully re-evaluate our process for determining how we send people to the cath lab,” Patel told MedPage Today. “It is still a very important place for patients with acute MI, unstable symptoms, and certainly for patients for whom we’re concerned about artery blockages.”

But, Patel continued, physicians need to “maximize the workup — what’s the most efficient way to do all the tests in order to determine if someone has obstructive coronary artery disease.”

Current guidelines for triaging patients for cardiac catheterization recommend a risk assessment and noninvasive testing.

Yet the methods for determining how invasive tests are ordered “are far from perfect,” said Cam Patterson, MD, PhD, of the University of North Carolina at Chapel Hill, who was not involved in the study. Patterson also noted that “having an angiogram in 2010 doesn’t mean that a patient is buying himself a stent or a bypass surgery,” he wrote in an e-mail to MedPage Today.

To investigate patterns of noninvasive testing and the diagnostic yield of catheterization among patients with suspected coronary artery disease, Patel and colleagues assessed 398,978 patients seen at 663 hospitals between January 2004 and April 2008 who were logged in the American College of Cardiology National Cardiovascular Data Registry.

Patel noted that this population accounts for roughly 20% of the patients going into a cath lab. The vast majority are seen for other indications including heart attack and heart failure. The researchers also excluded patients who’ve had a prior heart procedure such as a valve replacement or stent.

They defined obstructive coronary artery disease as stenosis of 50% or more of the diameter of the left main coronary artery, or 70% or more of a major epicardial vessel.

Median patient age was 61; 52.7% of the sample population was male.

At catheterization, the researchers found, 37.6% of patients had obstructive coronary artery disease.

The percentage was similar — 41% — when the definition of obstructive disease was expanded to include stenosis of 50% or more of any coronary vessel.

There was also a similar percentage of patients with no coronary artery disease: 39.2%.

“That [only] 38% had an occlusion … was surprising to us,” Patel said. Yet he noted that when data were included on patients with known disease or a previous condition or procedure, the rate of detection increased to 60.3%.

And being able to rule out a heart attack is reassuring for both patients and doctors, said Ralph Brindis, MD, of the University of California San Francisco and an author of the study.

“A normal cath is incredibly reassuring and may actually save money in the long run as the patient and the physician don’t repeatedly do noninvasive tests and repeatedly admit the patient to the hospital based on their anxiety or uncertainty,” Brindis said.

“The real question here is what is the ‘correct’ percentage of normal caths in this patient population that should be the ideal benchmark,” he added. “We do not yet know this answer.”

The researchers also assessed noninvasive testing prior to angiography, and found that 84% of patients had some form of noninvasive test — whether it was electrocardiography, echocardiography, CT angiography, or a stress test. The database did not provide information on specific tests.

Those with a positive result on a noninvasive test were moderately more likely to have obstructive coronary artery disease than those who didn’t have any testing (41% versus 35%, P<0.001; OR 1.28, 95% CI 1.19 to 1.37).

The researchers also saw risk factors for disease that were congruent with previously known risk factors:

* Male sex (OR 2.70, 95% CI 2.64 to 2.76)
* Older age (OR 1.29, 95% CI 1.29 to 1.30)
* Presence of insulin-dependent diabetes (OR 2.14, 95% CI 2.07 to 2.21)
* Presence of dyslipidemia (OR 1.62, 95% CI 1.57 to 1.67)

Based on those findings, Patel said that “every step along the way in determining who gets to the cardiac cath lab needs to be improved.”

Step one, he said, is to determine more efficiently a patient’s risk for significant blockages: “Can we improve our metrics in ways of identifying patients with chest pain who might have obstructive coronary artery disease.”

The second is to determine which noninvasive test might be most appropriate for this population instead, and several trials investigating this are under way.

“We need those types of studies to tell us who should be getting noninvasive tests and how well they work,” Patel said.

In an accompanying editorial, David J. Brenner, PhD, of Columbia University Medical Center in New York City, wrote that the study is correct in suggesting the need for optimizing “the application of gatekeeper tests such as myocardial perfusion scintigraphy in order to decrease the disturbingly large proportion of invasive coronary angiographic procedures that yield negative results.”

With so many high-tech imaging tools available, he wrote, “it is essential to optimize their use.”

The researchers acknowledged that the study was limited because they couldn’t distinguish between types of noninvasive tests, and they had no information on the “undoubtedly large population” of patients who were evaluated but didn’t undergo catheterization.

Visit MedPageToday.com for more cardiology news.

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A personal health record (PHR) has been touted as a way for patients to better keep track of their health information. Google Health and Microsoft HealthVault lead the way.

But what happens if the company storing your data gets bought, goes bankrupt, or simply decides to discontinue their system?

Well, those who stored their data with Revolution Health are finding out first hand.

The troubled company, which started off with so much fanfare, yet died in a whimper, recently announced they’re shutting down their personal health record service.

According to American Medical News, “Industry insiders say Revolution joins a long list of vendors who launched PHRs with a big splash, only to find little interest from consumers.”

Most of my patients don’t use a personal health record, and prefer that I enter the data in myself, or export it from from my electronic record system. The problem is, i) there isn’t enough time in a 15-minute patient visit to help patients enter in their data, apart from what I already do in my own system, and ii) many online personal health record sites aren’t compatible with the systems doctors are using.

Leaving the data entry to the patient is inefficient, and a sure way to minimize the adoption rate. Indeed, “the most successful PHR-type systems have been created by health care organizations and have benefits to patients, he added, such as e-mailing with physicians, online appointment scheduling and the ability to look at information entered by their physicians.”

That means a successful personal health record have to be well-integrated with, or designed by, existing hospital and physician systems, making it harder for a third-party system, such as the defunct Revolution Health service, to gain traction.

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by Susan Giurleo, PhD

If you are a physician, therapist or any other helping professional whose business model relies on third party manged care reimbursement you are engaged in the world’s worst business model.

Let me start with a story to set the stage.

Imagine you are a bright, idealistic college student. You’re good at academics, want to make a difference in the world and have hundreds of career options in front of you.

After lots of thought and planning you invest $100,000 in a graduate education. After all is said and done, you are in school anywhere between 2-12 years past your college graduation. You train to change people’s lives, heal what pains them. You make a difference and you sacrifice your life goals to prioritize your career. You may delay getting married, having children, taking vacations.

You do good work, finish school and training proving yourself and set out to make a living practicing in your area of expertise.

The first order of business is to figure out how you will get paid for all of your good work. The standard business model is accepting payment from a third party.

This third party decides how much your work is worth.

The third party sets limits on how much work you can do with each customer.

The third party can reject your invoices at any time for any reason.

The third party prohibits you from discussing your fees with other providers of the same service.

There are many of these third party payers and they all pay different, seemingly arbitrary rates.

The third party can change what they pay you at any time.

If you don’t follow all of the rules of the third party they don’t have to pay you at all.

The business model requires you to rely on an outside source to determine what you work is worth, set your rates and reimburse you on their terms. They can change the rules at any time. Outside forces constantly and consistently determine your bottom line. You have no choice, no chance to test price points. If you want to add a new service that isn’t recognized by the third party, they don’t pay you. The third party tells your customers that you are responsible for accessing their funding on their behalf, so no one knows what they really pay you or what your services are worth.

If you have any entrepreneurial spirit at all, please re-read the above paragraphs and tell me if you would sign up for this business model. Honestly, it’s ridiculous, don’t you think? Who in their right mind would invest $100,000 and years of their life in education, training and business and then turn over all hope of a profit to an outside entity?

Why don’t health care providers do anything about the model?
Doctors, therapists and other health care providers are not business people. We are not trained to pay any attention to how we get paid or who pays us. Many of us work in organizations that take care of all the administrative silliness so are have no idea how broken the system is. We are trained to do work that “insurance will pay for,” or to “find something that the insurance will reimburse.”

Nice, huh? Your doctors are trying to find things wrong with you so they can get paid. It’s not their fault. It’s the business model and no one questions it.

Those who understand that business model, CEOs of insurance companies think it is a great business model. They call the shots, they are in charge, they have the power and they make lots of money managing your business and our health care. Those in power never want to give it up.

As providers we are also brainwashed that if we don’t accept this crazy business model our patients will be harmed. “How will they afford care? Who will take care of them?” But, in the USA, we don’t want to provide a public health plan to help out those who are less able to afford care, so providers are put in a bind: take the lousy capitalist model that puts you in a subservient position to third party payers, or be a guilt ridden, selfish person for not buying into the model and getting the respect and pay you deserve.

What can we do about it?
Create different business models. Take ownership of our careers. Declare, “We’re not going to take it anymore!”

Imagine what would happen if doctors, therapists, dentists, and all other helping professionals declared this at once? What if we only worked with third party payers who treated us with respect? What if we only accepted insurance that had a real person answer our calls and handle our questions? What if we dropped insurers who pay us insulting rates and make us fill out 5 pages of busy work to access that cash?

And what if we informed patients that it is their insurance company that restricts their care, pays low rates, makes us wait on hold for hours? Or how about we put the onus on the patient to submit all insurance claims, understand how complex and time consuming it all is? It’s their care after all. [And don't tell me the public 'can't figure it out.' They figure out auto insurance, life insurance, home insurance. They can figure it out. Now we just enable ignorance].

Do you think the public would speak up? Complain to their insurance company, employers, government officials, congresspeople and senators? Well, yeah, they would. Would health care policy need to change if the providers of care stood up and demanded respect, a fair system and lower overhead costs?

Let’s not agree to business models imposed upon us. Let’s educate ourselves about business and empower both the medical profession and consumers to be proactive in how health care is accessed and paid for. If we are told that health care is a business, and entrepreneurs run the system, let’s even the playing field so that the competition is fair.

We have a choice.

Susan Giurleo is a psychologist who blogs at the BizSaavy Therapist.

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by Susan Biali, MD

Ten years ago, I was an Emergency Medicine Resident and wanted to die. Today, I’m a general practitioner in part-time practice and am in love with life. What made the difference? I signed up for a dance class.

Reports on physician burnout list the personality traits that set us up for trouble: we’re excessively conscientious, feel overly responsible, want to please everyone, and function on an extremely high level – even if we’re overloaded, exhausted, or our personal life is falling apart. We burn out because we bend over backwards to help others, until something (like our minds or our health or our marriages) finally snaps. Now imagine this: what if we took some of that deep caring and hyper-responsibility, and turned it on ourselves?

When my depression hit bottom and I became a serious risk to myself and my patients, my chief resident asked me to take a stress leave. On impulse I went on a solo tropical vacation and one night at the resort, as I watched an exuberant group of salsa dancers burning up the stage, my eyes filled with tears. I suddenly remembered that when I was a little girl, I practiced incessantly in the basement to my ABBA records, preparing myself for the moment that I would live my dream and finally become a “Solid Gold Dancer”. That night, in that darkened tropical theater, I knew how I would save my life.

I went home, resigned from my residency, got my license to practice as a GP, and signed up for my first salsa dance class. With the same determination and drive that I used to plow through medical school, I took responsibility for my own wellness, focused on pleasing the child in me that wanted to play more, and set my sights on performing at a high level in non-medical areas of life, such as dancing, writing and friendship. I grabbed and held onto life – and threw away my anti-depressants.

I never imagined that I’d end up with my own flamenco dance company in Mexico, commuting back and forth across the continent every couple of weeks in order to both dance and continue practicing medicine (as I did for the last four years), or that I would write a book, Live a Life You Love: 7 Steps to a Healthier, Happier, More Passionate You about the lessons I learned about life and health during the process.

At work at the clinic, I’m still hyper-conscientious, double-checking medication doses and monitoring lab and X-ray results to ensure that nothing gets missed. Yet I’m even more vigilant about getting eight hours of sleep a night, eating three nutrient-rich meals a day, playing with my dog, laughing with my husband, and continuing to develop as a dancer.

I still fall off the wagon fairly regularly, putting too much energy into work and not enough into myself, until I catch myself or a minor health crisis, such as a cold or back injury, tells me I need to reevaluate my priorities. At the clinic, I do my best but have long stopped trying to be perfect. The other day, a new patient said to me: “You’re the most human doctor I have ever met.” Best compliment I ever got.

Susan Biali is a physician and author of Live a Life You Love: 7 Steps to a Healthier, Happier, More Passionate You.

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Originally published in MedPage Today

by Liz O’Brien

My grandmother and her hospital roommate — aged, tiny, frail, and sporting matching bright pink hairnets.

They looked like twins — two thin shrubs in winter that had each sprouted an improbable, big pink rose.

Although sick and scared, my grandmother had admired the pink hairnet on the lady in the next bed, so my mother bought her one too, to make her feel better.

It was 1966 and the first time my 77-year-old grandmother had ever been a patient in a hospital.

I felt sorry for her. Her English was broken, her understanding of medical science minimal, and her outlook definitely “old world.” She was here to find out why she felt so weak.

But over three days, as the parade of physicians, nurses, and assorted medical professionals marched in and out of her room, with endless examinations, questions, and tests, the poor lady found she had something more to worry about than ill health.

“How can we afford all this?” she whimpered again and again.

And my mother — who was probably wondering the same thing herself — nevertheless heartily reassured her, “Ma. Ma, don’t worry. Medicare sent all these doctors. Medicare is going to pay for it.”

This was our family’s first encounter with Medicare, which had been enacted shortly before my grandmother’s hospitalization. While my parents weren’t sure how this Medicare business worked, for the moment the “magic word” quieted my grandmother down — at least until the next doctor showed up.

Finally, she was discharged. The diagnosis was inconclusive and, I suspect, — this was over 40 years ago — probably there wasn’t much they could have done about whatever ailed her anyway.

Then the bills started to arrive — for hospital charges, tests, supplies, services, and specialists of all stripes. My parents’ eyes crossed in amazement at all the treatment my grandmother had received. And — yes! — Medicare delivered, paying off the bills as advertised.

“She was a goldmine for all those people,” my mother murmured, shaking her head.

“And yet,” she admitted,” You can have a lot wrong with you when you get old, so I guess they had to try everything they could think of.”

It was just that it was so expensive — unbelievably so for a working class family. We didn’t pay for it, but somebody’s tax dollars did. And, if Medicare in 1966 was anything like today, the doctors paid for it too — subsidizing my grandmother’s care with the reimbursement rates they accepted.

I bring up the memory in the light of all the talk today of healthcare reform and its costs.

In retrospect, my little old foreign-born grandmother, who at the time I pitied for her age and ignorance, was wiser than I thought.

“How are we going to afford all this?” was her immediate response.

Life had taught her a lesson. Peasant hardship in Eastern Europe, poverty as an immigrant in America, the Depression, the privations of World War II had made it clear: There’s no such thing as a free lunch. No matter how desirable, or important, or even essential it is to have something, it has to be paid for.

As does every single item in the proposed healthcare reform legislation.

And the tab is in the trillions — and will affect generations to come.

I know, insurance premiums and healthcare costs are high now. Reform is supposed to bend the cost curve, reduce the deficit, etc., etc.

I don’t pretend to know anything near what I’d need to know about the intricacies of healthcare policy and the complexities of our financial and government institutions to fully understand it all.

But one thing I do understand is the voice of common sense when I hear it.

“How are we going to afford all this?”

I don’t know, Grandma. I don’t believe in magic words.

What happened to my grandmother? She went to live with my parents and took up residence in my old bedroom. She lived for another 14 years, welcomed four great-grandchildren, and died in her sleep at the age of 91.

Liz O’Brien is production editor at MedPage Today and blogs at In Other Words, the MedPage Today staff blog.

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by Brian Eule

While the debate continues to rage over the health care reform bill in Washington D.C., today at Noon Eastern time, the newest class of 15,000-plus graduating medical students will get their marching orders, beginning their lives working in medicine.

It’s called Match Day and each year, on the third Thursday of March, the nation’s graduating medical school students gather with their classmates and wait for an envelope with their name on it.

Match Day is the culmination of four years of study, and months of an intense process leading up to this moment. These students have applied to hospitals and residency programs, selecting the field of medicine they hope to work in, the city they hope to live in. They have interviewed with doctors and program directors. They have created lists ranking their top choices, as have the residency programs, submitting it to a computer program to make their match. And they have waited, wondering where they will work and train in just a few short months after their medical school graduations. Today, inside those envelopes, a fragment of a sentence on a single sheet of paper, will inform them where they will begin this important stage of their lives.

Each medical school has its own tradition as to how the envelopes are handed out—some providing a mad dash to various corners of a room where staff members have divided the piles; others using a slow, nerve-wracking yet thrilling manner of calling students to the front of the room one by one. At Eastern Virginia Medical School, students dress in costumes, lightening the mood and adding to a party atmosphere. At Vanderbilt, they broadcast the ceremony online to any friends and family unable to attend. Often, the students are not alone. Spouses wonder where they will move, and children await the reactions on their parents’ faces.

Then they open the envelopes.

At the same hour today, screams, tears, hugs, and shouts of joy will erupt from rooms across the country. Much of the future of their field will remain unknown, as the country works through health care reform. But for the country’s newest class of doctors, today will give them a little more information as to their futures as doctors. And what awaits in their immediate future are long hours of intense training, sleepless nights of residency, and the rewards and responsibilities of caring for the lives of others.

Brian Eule is the author of Match Day: One Day and One Dramatic Year in the Lives of Three New Doctors.

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It’s well known that the use of imaging scans, like CTs, MRIs and PET scans, have been growing at an alarming rate.

But a recent study provides some stark numbers.

According to a recent CDC report, “MRI, CT or PET scans were done or ordered in 14 percent of ER visits in 2007, the report from the Centers for Disease Control and Prevention found. That’s four times as often as in 1996.”

Although a physician called that growth “astounding,” it’s really no surprise.

Emergency departments are becoming more crowded, and with patient satisfaction scores becoming more influential in financial incentives for physicians, sometimes just ordering a test is the path of least resistance.

Factor in the specter of defensive medicine, which, according to a survey from the Massachusetts Medical Society, accounts for up to 28% of tests ordered, it’s a wonder that more scans weren’t ordered.

Imaging scans are clear cost driver in health care, contributing $12 billion to Medicare’s bill. But costs won’t resonate with patients requesting the tests, or the doctors ordering them. One encouraging sign is the recent trend of publicizing the harms of scans, like radiation from CTs. I’m finding that patients are becoming increasingly aware of the risk, and making a more informed decision after I explain it to them.

It’s a small step forward.

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by Steve Wilkins, MPH

If the lack of time is the chief barrier to poor physician-patient communications, it logically follows that longer patient appointments are the solution. Ok, let’s say that I could wave a magic wand and add 5 or even 10 more minutes to the average primary care office visit. Would more time really make a difference?

Probably not.

A quick examination of just some of the key drivers of physician-patient communications reveals why:

More time will not change how physicians view the physician-patient relationship
A physician’s communication style is a “window” into how they view the physician-patient relationship, e.g., physician-centered versus patient-centered. One landmark study of physician communication styles found that almost two-thirds of physicians (IM and FP) in the study had a physician-centered view of how physicians and patients should relate to one-another.

More time will not change a physician’s communication style
While even the most physician-centered physician can incorporate elements of patient-centered communication in the medical interview process, the reality is that providers revert back to type. A provider with physician-centered directed orientation will still most likely interrupt the patient, not ask if the patient has questions and not use “teach-back” to make sure the patient understood what the physician said and so on.

More time will not likely change a physician’s reliance on observable patient characteristics when deciding how to treat patients
In addition to observable patient characteristics like age, gender, race and education, there is the person “behind the disease” who comes to the doctor with their own set of health beliefs, life experiences and treatment preferences. When the physician recommends a treatment that the patient does not believe will work, the likelihood of patient non-adherence is much greater than if the physician took the time to ask the patient their thoughts and collaborate with the patient on exploring the treatment that will work for both parties.

Time is not the problem when it comes to improving physician-patient communications. I don’t really believe that additional reimbursement to physicians for sub-optimal patient communications is the answer either.

Numerous studies have shown that patient-centered communication techniques in primary care practices can improve patient outcomes, change behavior and increase patient and provider satisfaction without increasing the length of the office visit.

Steve Wilkins is a former hospital executive and consumer health behavior researcher who blogs at Mind The Gap.

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by Vineet Arora, MD

A 21% cut for Medicare physician fees is set to go into place soon. This year, fixing physician payment has been overshadowed by all the talk about health insurance reform.

In fact, I remember being invited to talk about healthcare reform on a panel for medical students this past fall. As part of my remarks, I mentioned the 21% pending cut in physician payment and recall the questions and quizzical looks. Another panelist said – “oh but that won’t happen – they (meaning Congress) will fix it.”

Actually, the truth is we believed they would fix it . . at least in the short-term. After all, I have gone to Washington DC for the past 5 years for the American College of Physicians Leadership Day and have taken several residents and students with me through the years. Each year, we are fortunate to hear Bob Doherty, ACP Vice President and top health policy blogger, give a riveting update on what’s new on the Hill. And for the past 5 years, the recurring theme has been the need to fix the physician payment system and the ‘flawed formula’ that calls for the cuts.

I was even lucky enough to participate in a Congressional hearing on the issue in 2006. And every year, Congress has passed a short term fix to the problem. Believe it or not, there seems to be general agreement that the system for paying doctors needs to be fixed. The issue is how to pay for it. As discussed in the Wall Street Journal:

The calculus on this issue is always basically the same. There’s widespread political support for blocking scheduled pay cuts to doctors. But doing so is expensive. So rather than get rid of the formula that keeps calling for the cuts — which would require Congress to acknowledge that the country is going to be on the hook for billions of dollars in additional Medicare costs — Congress keeps passing these short-term patches.

As I have discussed topic over the years with a variety of students and residents, I have noted a lot of confusion on these issues. That isn’t entirely surprising since health policy isn’t a required course in medical school . . . but maybe it should be? To better understand this chain of events and why all of this is really happening, I’ve outlined some basic questions and answers below.

How are doctors paid? Doctors are still paid on a fee for service system for their time. When Medicare initially passed in 1965, to get physician support, Congress agreed to preserve the fee for service system. To determine the actual value of physician services, a ratio system (RVRS) was introduced in 1992 that determines the value of one service to another and adjusts for geography. Every five years, an AMA committee (RUC) composed of representatives from each specialty society debates the relative values of physician services and publishes the book that sets these ratios.

It is widely believed that the RUC is overrepresented by subspecialists who have led to undervalue of primary care services. More recent concerns about the incentives to ‘do more’ in the fee for service system have led to some to argue for the ‘bundling’ of physician payments.

What is the SGR? The Sustainable Growth Rate is a general marker of inflation. In 1998, due to concerns of escalating healthcare costs, Medicare payments for physicians were tied to the SGR. Unfortunately, healthcare inflation outpaces general inflation and since 2002, the cost of physician services has exceeded what would be predicted from the SGR. Hence, every year a predicted cut in Medicare physician fees to bring it back to the SGR. Each year, because a temporary fix is passed, the next year the cuts get worse.

What is pay-go? Because of pay-go rules, new legislation that increases spending has to include cuts elsewhere. In this environment, it makes it harder to pass a costlier bill. Unfortunately, a long-term fix means getting rid of the SGR and replacing it once and for all is very costly. So in this environment, it is easier to get a short term fix passed.

This year, the AMA, ACP, and other professional organizations stated they no longer support a short term fix and called for a full repeal of the SGR. In fact, because the ‘doc fix’ costs so much, it was removed from the calculation of the cost of the health reform bill to make it more likely that the health reform bill will pass. To get support of physicians for health reform, Democrats said they would pass a long-term doc fix.

Why do we have to fix this? As you can imagine, a 21% cut in Medicare physician fees would likely result in limited access for seniors and veterans. Reports already highlight that doctors will be forced to drop or delay seeing their Medicare patients until they know what will happen. Although many physicians ‘participate’ in Medicare, it is unknown how many may be limiting the number of Medicare patients they would see.

Since Medicare is the largest payer, it is likely that other insurers will follow suit and cut physician fees. Lastly, all the money and time that goes into the short term patches have left physicians tired, uncertain of the future and with little faith in the legislative process.

We need to fix this so we can move onto other pressing issues in healthcare.

Vineet Arora is an internal medicine physician who blogs at FutureDocs.

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Peter Yarrow of Peter, Paul & Mary has teamed up with CBS to deliver a serious health message to CBS viewers and audiences beyond: be screened for colon cancer.

(via Clinical Cases)

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