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Discharged from the hospital without answers; the death of Jane Q. Patient

Kevin — Fri, 20 Nov 2009 12:00:41 PST

by Dan Walter

We found out that her real name was Cindy Chapman, and that she died alone and afraid.

Cindy was a paralegal, an activist and a fighter of lost causes who lived in Worcester, Massachusetts. She was part of an online community called RATEMDs, where she had many soul mates. Her posts on health care were funny and cynical and wise. Her screen name was Jane Q. Patient.

My wife, Pam, was especially fond of trading comments and barbs with her. Like others on the forum, Jane Q. was prone to drop off the screen for days or weeks at at time. But she always resurfaced with stories of her battles with the system, her fights for the poor as a paralegal, or her volunteer efforts with the Obama campaign. A few months ago, as the fight for health care reform was reaching a fever pitch, Jane started posting about her own medical complaints. She told of emergency room visits and fights over insurance, and pain, pain, pain. Her postings became erratic, with uncharacteristic typos, misspellings, and fragmented thoughts.

When Jane Q. dropped off the screen again, Pam set out to find her. Having traded some private emails, Pam knew Jane’s real name and had a general idea of where she lived.

After relentless Google searching, Pam hit upon a column by Diane Williamson in the Worcester Telegram. It was the story of Cindy Chapman’s final days. The 48 year old native New Yorker lived with her cat in a room off Worcester Common. She had been suffering terrible back pains over the summer and had been taken by ambulance to the University of Massachusetts Memorial Medical Center Emergency Room on four occasions.

Each time she was discharged with some pain killers, but no answers.

The last time she went there she refused to be discharged and the hospital called the police to eject her from the ER on the grounds that she was exhibiting drug seeking behavior. She was put in a cab and sent home. She called one of the few people she knew in the neighborhood. She said that she was in terrible pain and that she was scared and she didn’t know what to do.

Her neighbor called six primary care physicians before finding one who would accept Medicare and could see her without waiting a year. This doctor found that Cindy Chapman had end stage cancer of the lungs, liver and spine. Two weeks later she was dead.

As the Senate prepares to take up the health care bill, The New York Times quotes one analyst as saying that “All industries stand to gain from this legislation.” But the real question we need to be asking ourselves is whether the Cindy Chapmans of the world stand to gain anything from our new approach.

We’d better hope so. After all, there was a reason she called herself Jane Q. Patient.

Dan Walter is a writer based in Deale, MD.

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Are older nurses being forced out of the profession?

Kevin — Fri, 20 Nov 2009 10:00:15 PST

Originally published in HCPLive.com

by Colleen O’Leary, RN, MSN, AOCNS

Last time I talked about how I had never really experienced the concept of nurses eating their young in action.

However, I have seen the opposite begin to evolve. I see this as a bigger issue in nursing these days. The “putting out to pasture” of seasoned, experienced nurses is happening more often and for a variety of reasons.

First, and foremost, is simply the fact that the pool of nurses inevitably follows the general aging of the nation. As baby boomers who once filled the halls of healthcare institutions caring for others begins to age, they will certainly have a more difficult time meeting the demands of current healthcare. More and more institutions are requiring nurses to work longer and longer shifts, changing from an 8-hour day to a 12-hour day. This, along with the fact that patients in the inpatient settings have much higher acuity and a variety of complex issues, makes the demands on nurses even greater.

I know for myself that when I was working 12-hour shifts, I could only do two in a row. If I had to do the third one without a break, I was exhausted. I can only imagine how someone five, 10, or even 15 years older than me would feel. In fact, I remember one time when a new young nurse just starting out came to me and sheepishly asked, “What do you do when you go home after working a 12-hour shift?” He was finding that he was very tired and often unable to do anything but go home, have dinner, and go to bed. If someone that young has difficulty imagine how it is for the older nurse.

Not only are the hours and the complexity of patients difficult, but also the physical strain. Because patients have such high acuities, they often require turning, positioning, and moving that can cause stress on the nurse’s back, neck, arms, and legs. Injuries among nurses are much higher than even injuries among construction workers. Again, more stress and difficulty for the older nurse.

Another point to take into consideration is the advent of new technologies for diagnostics, assessment, and documentation. Often, when facilities start to change to electronic medical records, it’s the older nurses who have the most difficulty. The younger nurses grew up with advanced technology everywhere around them. I remember the first computer class I had to take in college taught us how to do keypunch machines. There were giant computers in a lab that you had to schedule time to use to do your work. Then you carried around a stack of cards with little computer generated holes punched in them, that when read, gave a story. Then many years later when I took a nutrition class and was told we had to do a computer program, I was terrified. I didn’t know how to use computer programs. How times have changed… But that’s the point. If you haven’t grown up with that being a part of your everyday life, it’s very difficult for some to catch on and take hold of new technology.

Finally, the recent change in the economy has put a different kind of strain on older nurses. Where they might have been thinking of retiring, they now find that they must remain in the workforce to survive. I’m just afraid of what is going to happen over the next couple years when the economy starts to rebound; people are feeling safer and we see a mass exodus of retiring nurses. I think it will be a time of extreme nursing shortage and we should start planning for it now.

But what makes nursing different than other professions that are facing an aging workforce, and what is it that really bothers me the most? It’s the concept of not just aging but of truly “putting out to pasture.” If an older nurse has not worked their way through the ranks and is still in the trenches of bedside or chairside nursing, how much support are they getting? Forget the concept of the seasoned nurses not nurturing and helping the newcomers.

As I’ve said, I have not seen that phenomena. But what I have seen is a sense of impatience towards the older nurse; an underlying feeling that they just can’t cut it and not a great sense of wanting to help them. Not only the impatience, but it’s almost a disdain for them. It’s as if they don’t highly regard the years of experience as valuable because the person might have a more difficult time with the newer techniques. I’m not sure how we got to this point. I’m sure it has something to do with the whole outlook that each of the generations have on work, socializing, and facing the world, but it is a bit disheartening to see around me. I have always learned to respect those with more experience and try to learn something from them. That doesn’t mean that I think that we should allow someone who cannot physically do the job stay in the job.

But I think we could, as a profession, hold up our experienced nurses and learn something from them instead of always thinking we need to teach them something.

Colleen O’Leary is a staff educator of medical oncology at Northwestern Memorial Hospital who blogs at Oncolog-e Nurse Talk.

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How should the FDA regulate the social media advertising of drugs?

Kevin — Fri, 20 Nov 2009 08:00:20 PST

Originally published in MedPage Today

by Emily P. Walker, MedPage Today Washington Correspondent

Drug and device makers are urging the FDA to establish clear guidelines that will allow the industry to discuss and promote products in the unsettled world of online social media.

The FDA is hearing testimony from drug and device companies, online marketing experts, and consumer groups about what steps the agency should take to move medical advertising and promotion into online communities.

“The Internet is an important tool for consumers looking for answers about medications,” Michele Sharp, a spokeswoman for Eli Lilly, said at the FDA gathering today.

“We must be visible and relevant in the places where patients, caregivers, and payers are looking. These days, that includes the Internet and social media. We believe we can and should pay a significant role to provide patients information.”

So far, despite growing use of social media platforms such as as blogs, Twitter, and Facebook, the bulk of drug company advertising is geared toward TV and magazines.

One reason is that the FDA has clearly spelled out the rules governing those traditional platforms: The ads must not be false, misleading, or lacking facts, and they must show a fair balance of the risks and benefits of the drug or device.

But how those rules apply online is unclear. For instance, if a drug company wanted to use Twitter to promote a new drug, does it have to include the risks of the drug in the tweet? Twitter only allows for 140 characters, and the litany of risks for some drugs could fill a tweet encyclopedia.

What if a compliant YouTube ad for a medical device is copied by a user who reposts it minus the last 30 seconds, when the narrator is rattling off the device’s risks? In that case, is the device company at fault?

Or, in another instance of many social media hypotheticals, what if a patient advocacy message board for diabetics is riddled with misinformation about a drug? Should the drug company correct the information? If so, should the company be required to list the drug’s side effects in its post?

Rules governing a company’s involvement on online platforms are so opaque that many companies just steer clear of communicating about their products on such sites.

But avoiding a growing arena where consumers and doctors have conversations about medical topics is ignoring reality, panelists at the FDA hearing said.

An estimated 83% of all Internet users search for health information on the Web, according to a survey by the Pew Research Center.

“We need to be a part of the online conversation,” agreed Elizabeth Forminard of Johnson & Johnson.

Sharp said Eli Lilly has mostly avoided using online media because it’s not sure how to comply with FDA rules. “We’re looking for the FDA to guide us,” she said.

One solution promoted by a number of speakers, including Jeffrey Francer of PhRMA, is for the FDA to approve use of its logo for drug companies to place on content that meets the agency’s standards.

Another panelist suggested that clicking on the logo would take the user to either an FDA Web page, or the company’s page, which would clearly list information, including benefits and risks, of the given drug.

One panelist who is an advocate for women and children’s issues, said using a standard logo to indicate FDA’s stamp of approval would be troublesome.

“The content of a blog or Web site can be accurate, but incomplete. It can be accurate about the benefit, but just fail to mention the risks,” said Diane Zuckerman, president of the National Research Center for Women and Children.

Zuckerman noted that today’s accurate information might be out-of-date tomorrow.

“Things change, and it would be very difficult to have some sort of FDA seal of approval,” she said.

Forminard of Johnson & Johnson suggested companies be held accountable for content they created, whether it is posted on the company’s own site, or a third-party site, such as a newspaper’s Web site.

But companies cannot be held accountable for content they don’t create, she said.

All companies at the hearing said they thought providing more information “just a click away” would suffice. This would be easier than having to jam a list of benefits and risks in a limited space, such as an ad that appears in search engine.

The companies also agreed that it would be unreasonable to expect drug and device companies to police the entire Internet for false or misleading statements about their products.

Online promotion of drugs and devices isn’t just geared toward consumers.

The FDA will have to grapple with rules for sites that are aimed at physicians, such as VuMedi, a surgeons-only site that allows users to share videos on surgical procedures and comment on them. Some of those videos are posted by device companies, but they are always clearly identified as such, said Robert Winder, CEO of VuMedi.

Winder said sites for physicians shouldn’t be subjected to the same rules as those that govern direct-to-consumer advertising.

The FDA’s hearing continues tomorrow, when more representatives from drug, device, and marketing companies are slated to speak about adverse event reporting.

The agency won’t be making decisions on industry involvement in social media anytime soon. It is keeping its public comment docket open on this subject until February 2010.

But in the constantly changing online world, one speaker had a word of advice as the agency develops its rules:

“If the rules are too narrow or inflexible, the minute we figure out how to do it, they will be out of date,” said Philomena McArthur of Johnson & Johnson.

Visit MedPageToday.com for more prescription news.

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Primary care disrespect starts early in medical school

Kevin — Fri, 20 Nov 2009 04:00:32 PST

In medical schools, primary care continues to be among the least respected fields a student can choose.

No where is that more starkly illustrated than in Pauline Chen’s recent New York Times piece, where she tells a story of a bright medical student who had the audacity to choose primary care as a career:

Kerry wanted to become a primary care physician.

Some of my classmates were incredulous. In their minds, primary care was a backup, something to do if one failed to get into subspecialty training. “Kerry is too smart for primary care,” a friend said to me one evening. “She’ll spend her days seeing the same boring chronic problems, doing all that boring paperwork and just coordinating care with other doctors when she could be out there herself actually doing something.”

This lack of peer respect is one reason why only 2 percent of medical students choose primary care internal medicine as a career.

Regular blog readers will know that the generalist-specialist salary disparity, combined with the paperwork and high professional dissatisfaction rate, are major reasons why future doctors are avoiding primary care medicine.

But there remains an implicit bias among medical educators favoring procedure-based medicine, mostly due to the disproportionate amount of dollars specialists bring to an academic institution. Hospitals and medical schools give specialists unspoken, preferential treatment, and that sentiment trickles down to medical students.

There’s no doubt that influencing future doctors away from primary care starts from the earliest stage of medical training.

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Can less aggressive cancer screening recommendations be better for patients?

Kevin — Thu, 19 Nov 2009 12:00:19 PST

by Amy Tuteur, MD

Doctors have understood for some time that it was inevitable. The American Cancer Society has acknowledged that cancer screening has been oversold.

It seems like every day you read in the newspaper that what was standard medical care yesterday is now no longer recommended. Don’t doctors know anything? Well, actually they do. And what seems like paradoxical behavior, no longer recommending aggressive screening for certain cancers, actually represents a more sophisticated understanding of the way in which cancer behaves.

The classic understanding of cancer is that once a cancer forms it will continue to grow steadily until it kills the patient. Cancer was viewed as if it were an infectious disease like syphilis. It starts small and easy to treat, may remain hidden for long periods of time, but eventually spreads to other parts of the body becoming incurable along the way. If cancer did indeed spread like that, the aggressive screening programs would make perfect sense.

But decades of research and clinical experience have led to a more sophisticated understanding of cancer. It has always been known that cancers from different parts of the body behave in very different ways. Ovarian cancer is extremely aggressive, while basal cell cancer of the skin grows very slowly. Breast cancer can and does spread to bones and brain, while colon cancer is most likely to spread only to the liver.

More recently we’ve learned that each cancer can be broken down into different subtypes, some more aggressive than others, and some better treated with one regimen instead of another. For example, breast cancers are now analyzed for the presence of hormone receptors on the outside of the cancer cells. The presence or absence of certain receptors tells us whether specific treatments will be helpful or useless, making it easier to target the cancer with the treatment most likely to work.

We have also learned that some cancers follow the model of an infectious disease like syphilis, starting small and curable and ending up throughout the body and incurable, many do not. Some cancers start small and explode aggressively. Others start small and stay small for decades. This more sophisticated understanding is a direct result of being able to diagnose cancer earlier. We now have a much better and far more nuanced understanding of the natural history of various cancers. It has become apparent that rather than finding all cancer, we need only find cancers that are aggressive and can ignore those that are known to grow very slowly if at all.

What’s the big deal? Isn’t cancer screening beneficial regardless of the natural history of the particular cancer? No, it’s not and therein lies the reason for the American Cancer Society’s call for less screening of certain cancers.

The goal of cancer screening is and has always been to reduce cancer deaths and disability, and therefore, that’s how cancer screening should be judged. By that standard, some forms of screening are total successes. For example, the Pap smear, the screening test for cancer of the cervix, has been an unalloyed bright spot in the war against cancer. The test is inexpensive and reliable, the follow up test to actually diagnose cancer (biopsies of the cervix) is harmless, and very few if any women are treated unnecessarily. Screening for cervical cancer saves many lives and has few long term side effects.

By the same standard, prostate cancer screening has been a terrible disappointment. The PSA blood test, the screening test, is notoriously unreliable. Even more problematic is the fact that many prostate cancers grow extremely slowly and are unlikely to spread. Most problematic is that the treatment has very serious side effects, impotence and incontinence. Screening for prostate cancer with the PSA test (and finding tiny cancers) saves no more lives than screening with a prostate exam (which can find cancers that are somewhat larger) and leaves many men with unnecessary long term side effects.

Whereas every cervical cancer is probably dangerous to the patient and the treatment has few long term side effects in any case (since cervical cancer is most commonly diagnosed in women who have completed childbearing), most prostate cancers are not dangerous to the patient and the treatment is often undertaken unnecessarily. It’s bad enough to endure impotence and incontinence as the side effect of life saving treatment. It is tragic to endure it as the side effect of unnecessary treatment.

Breast cancer is similar to prostate cancer. While frequent mammography is more likely to diagnose cancer, there has not been a corresponding decline in breast cancer deaths. Treating many more women with chemotherapy, lumpectomy and mastectomy has produced very few additional lives saved.

The solution to this conundrum, of course, is to develop more sophisticated screening tests, tests that can discriminate between life threatening cancers and non-life threatening cancers. In the meantime, the existing screening tests should be judged on their ability to save lives, not on their ability to diagnose cancer, since many cancers don’t need to be treated.

Screening everybody for everything and screening them often is a very blunt tool that seemed appropriate when we had an unsophisticated understanding of cancer. Now that our understanding of cancer has deepened, the use of screening tests should reflect our new knowledge.

Simply put, screening tests should be reserved for situations in which they save lives. Dialing back on screening tests is not a step backward, it is a step forward in treating only those who need to be treated and not harming anyone else in the process.

Amy Tuteur is an obstetrician-gynecologist who blogs at The Skeptical OB.

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How to choose the right electronic health record (EHR) consultant

Kevin — Thu, 19 Nov 2009 10:00:37 PST

Originally published in HCPLive.com

by Jonathan Bertman, MD

You may have seen advertisements, or may already have been contacted by people who’ve promised to help you figure it all out so you can get your share of the stimulus money. Be wary. The truth is that the Obama administration is still defining many essential elements of the Health Information Technology for Economic and Clinical Health Act (HITECH), and full details about the exact reimbursement process will not be known until the fourth quarter of this year, at the earliest.

Nonetheless, there is a growing field of people who call themselves “EHR consultants.” They promise to advise you on which system to purchase for your needs, help set up and integrate the necessary hardware and software, and perhaps even troubleshoot any on-going problems you may have. Sounds tempting, right?

The difference is in the details
Let me stress that many EHR consultants are legitimate and can provide valuable services at a reasonable price. But there are some pitfalls to avoid. First, let’s define the difference between a consultant and a reseller. A consultant should be completely independent and have no relationship, financial or otherwise, with the vendors they recommend or refer to you. Conversely, a reseller receives payments from an EHR vendor for providing leads or getting a practice to purchase that specific EHR. An ethical consultant (ie, a reseller) will let you know upfront that they have a fiduciary relationship with one or more vendors, and then you can make an informed decision on the advice they provide. Many consultants and EHR/technology “experts,” however, quietly arrange kick-backs with various EHR vendors and fail to disclose this conflict of interest to their perspective clients.

There is one quick way to tell if you’re dealing with a consultant or a reseller. A reseller’s services should be free to you because the vendor is picking up the tab by paying the reseller a percentage of the sale, or some other pre-arranged fee. You know in advance that a reseller is going to steer you toward a particular product, and you can thus take what they say with the same healthy dose of skepticism that we apply to information we receive from drug reps.

On the other hand, if you are paying for services and recommendations, then you are dealing with a consultant who should be giving you unbiased advice. Unfortunately, a good number of consultants accept fees from doctors but then also receive referral fees from vendors for sending them potential clients. These payments may be in the form of cash, discounted hardware and software, or anything else of value.

The wild frontier
The EHR industry is relatively young and appears to be one of the exciting growth areas in an otherwise slumping economy. But this has resulted in a Wild West-like frontier where the various players (eg, vendors, consultants, resellers, state and local groups, and other agencies) can say just about anything without disclosing anything. And many IT companies and other consultants (even physicians seeking to earn some extra money) have agreements with software companies to receive payment for steering potential clients toward a specific vendor. Surprisingly, many of these otherwise honest people feel that if they aren’t specifically asked if they receive compensation from vendors (whether it be for directing leads, providing a recommendation, reselling, or even providing consultant services to the EHR vendor), they don’t need to share this information with their client or colleague.

You need to ensure that the information you receive from these “experts” is unbiased and based on the reasonable approach of matching your practice’s needs with the available solutions. A few key steps could save you tens of thousands of dollars in hardware and software expenses, not to mention the frustration of being cajoled into purchasing an overpriced and unusable EHR that you’ll regret later:

• When considering an EHR consultant, ask them pointblank if they have any relationship with one or more vendors, and ask exactly how those relationships work.

• Ask the consultant how many practices of similar size and specialty they have helped in the past, and get at least three different practice names and contact information to confirm that they were pleased with the consultant, would recommend their services, and would use them again.

• For smaller practices, be especially wary of consultants who also sell IT hardware and/or technical support. In my experience, IT consultants tend to recommend significantly more complex (and expensive) hardware and software than is necessary for the average small medical practice.

The third point deserves a bit more discussion, since many of the consultants in the EHR space also provide IT services and sell computers, servers, and other hardware. The main problem with hiring an IT consultant for guidance is that all too often these technologically -minded people push equipment and policies that are significantly more expensive and complex than is reasonable to run a small practice.

In my experience as an EHR vendor, all too frequently when an IT consultant is used, the practice ends up not only spending much more on hardware than my non-IT-consultant practices, but they have much less of an understanding of their system and thus an inability to troubleshoot issues that arise from time to time. In fact, Amazing Charts (my EHR company) recently raised prices for additional providers because we found that larger practices tend to have overly complex technology infrastructures based on the recommendations of their IT consultants. These systems take more time and energy to troubleshoot, and much more frequently, hardware and network issues are the source of the difficulties that lead to downtime.

Everybody does it, right?
Even big companies can be guilty of up-selling unnecessary equipment to small practices. For example, Amazing Charts used to recommend our users contact Dell to get advice and affordable systems. While Dell certainly makes good and affordable hardware, many of our clients called Dell and ended up directed to Dell telesales representatives who regularly scared them into purchasing big servers, tape backup systems, and other equipment because they were a “medical practice.” Most of the up-selling of robust servers and other equipment is completely unnecessary if you perform regular data backups and follow basic networking guidance.

When a consultant does recommend a specific product, whether an EHR system or anything else, do some online research to find out what others have to say. The American Association of Family Physicians (www.aafp.com) has a good site for researching EHR software (ie, the Center for Health IT). Message boards can be another useful research resource, if you have time to sort through all the garble.

The most important take-away from this month’s column is to make sure that your independent EHR consultant is not actually shilling for someone else. Get it in writing so you have some legal recourse if you make a purchase and have buyer’s regret a few months later.

Jonathan Bertman is Physician Editor-in-Chief of MDNG: Primary Care/Cardiology Edition.

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Why health reformers should be worried about the breast cancer screening backlash

Kevin — Thu, 19 Nov 2009 04:00:22 PST

What if a non-partisan, authoritative entity wrote a robust, evidence-based guideline, but nobody followed it?

That is precisely what’s happening with the USPSTF’s recent revision of their breast cancer screening recommendations. The change most find problematic is their recommendation that women younger than 50 not undergo any breast cancer screening, such as with a mammogram.

Here are their reasons explaining why:

The harms resulting from screening for breast cancer include psychological harms, unnecessary imaging tests and biopsies in women without cancer, and inconvenience due to false-positive screening results. Furthermore, one must also consider the harms associated with treatment of cancer that would not become clinically apparent during a woman’s lifetime (overdiagnosis), as well as the harms of unnecessary earlier treatment of breast cancer that would have become clinically apparent but would not have shortened a woman’s life. Radiation exposure (from radiologic tests), although a minor concern, is also a consideration.

Adequate evidence suggests that the overall harms associated with mammography are moderate for every age group considered, although the main components of the harms shift over time. Although false-positive test results, overdiagnosis, and unnecessary earlier treatment are problems for all age groups, false-positive results are more common for women aged 40 to 49 years, whereas overdiagnosis is a greater concern for women in the older age groups.

They’re completely right, of course. As I previously wrote in a USA Today op-ed on this issue, “For every inspiring story of a person cured from cancer made possible by early detection, there are untold stories of many more who suffer from the side effects of unnecessary invasive procedures stemming from false positive test results.”

But some patients are rebelling against these new guidelines, as noted in this article from The New York Times, New Mammogram Advice Finds a Skeptical Audience. A few doctors, too, are refuting the new recommendations as well. Suspiciously, they are mostly radiologists and oncologists. Cynics may wonder whether there is a financially-motivated basis for their dissent.

What’s fascinating is how mammogram screening has now turned rabidly political, with conservatives making the ridiculous link to “rationing.” And Kathleen Sebelius, the secretary of health and human services, tried to distance herself from the USPSTF, stressing that, “I would be very surprised if any private insurance company changed its mammography coverage decisions as a result of this action,” and that, “our policies remain unchanged.”

What, then, is the point of making any guidelines at all, if our government urges everyone to ignore them?

Progressive reformers, who generally espouse comparative effectiveness data and evidence-based medical practice as a means to control costs, should be very worried about the backlash these guidelines are eliciting.

If recommendations from an entity like the USPSTF – as non-partisan and robust as it gets – gets so much resistance from doctors, patients, and even the government itself, findings from a comparative effectiveness body stand absolutely no chance of changing medical practice.

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Senate health reform plan analysis

Kevin — Wed, 18 Nov 2009 20:31:41 PST

Originally published in MedPage Today

by Emily P. Walker, MedPage Today Washington Correspondent

After weeks of closed-door meetings, the Senate leaders released their $849 billion healthcare reform bill on Wednesday evening, paving the way for a procedural floor vote soon.

The bill, combining versions approved by the Finance Committee and the Senate Health, Education, Labor and Pensions (HELP) Committee, would create a new public insurance plan, and expand coverage to an additional 31 million people, meaning that 94% to 98% of all legal residents would have insurance.

Senate Majority Leader Harry Reid (D-Nev.) said the $849 billion, 10-year cost of the bill would be more than offset by savings and would ultimately result in a $127 billion reduction in the federal deficit over the next decade.

Although it’s similar to the $1.1 trillion legislation passed by the House of Representatives Nov. 7, the Senate version differs in several ways.

Notably, an anti-abortion amendment that was included in the House bill is not part of the Senate measure. The House amendment, sponsored by Rep. Bart Stupak (D-Mich.) would bar the government from offering abortion in its public plan, and make it illegal for private insurers who participate in the exchange from providing abortion coverage, except in the case of rape, incest, or when the woman’s health is in danger.

The Senate language is much less restrictive with regard to abortion. It reiterates the Hyde Amendment, a law that bans federal funds from being used to pay for abortion. It would allow the Health and Human Services Secretary to decide whether to allow women in the public option to have abortion coverage, as long as no federal funds were used to pay for the abortion.

The bill would expand Medicaid to cover those with incomes of up to 133% of the federal poverty line. Those who earn between 133% and 400% of the federal poverty line would receive subsidies to buy insurance through an insurance exchange.

It would require everyone to have insurance, or else pay a $95 penalty in 2014, and a $750 penalty by 2016 for not having insurance.

Also, the Senate bill would pay for expanding coverage in a different manner than the House bill.

It would impose an excise tax on so-called “Cadillac” health insurance plans, which cost more than $8,500 a year for individuals or $23,000 for a family.

The latest version of the bill raised that threshold slightly, so fewer people would be subject to the tax. Although many of those plans are part of executive compensation packages, many also cover blue-collar employees whose unions negotiated healthcare coverage in lieu of pay increases. If the Senate bill passes, it would need to be combined with the House measure.

The Senate bill would also impose a Medicare payroll tax on those who earn more than $200,000.

The bill would also levy a surprising new 5% tax on elective cosmetic surgery and procedures. It also taxes device companies and drug companies.

Like the House bill, the Senate bill would create a new public health insurance option. However, state legislatures could opt out of offering their residents the government-run plan by enacting specific legislation.

The Senate measure would also create state-run insurance cooperatives through which residents could band together to purchase insurance.

Reid has said he hopes to have the important procedural vote before Senators leave for Thanksgiving break.

It’s not clear whether Democrats will have the 60 votes necessary to break an expected Republican filibuster that would prevent a vote on the bill — which is thought to have enough votes to pass. To accomplish that, every Democrat would have to support the bill, along with the two independents in the Senate — Bernard Sanders of Vermont and Joseph Lieberman of Connecticut.

But Lieberman has said he won’t support the measure if it includes a public plan, and it does.

Visit MedPageToday.com for more health policy news.

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How a personal injury lawyer views the medical malpractice system

Kevin — Wed, 18 Nov 2009 11:00:51 PST

Personal injury lawyer Eric Turkewitz responds to my recent USA Today piece on fixing the medical malpractice system.

by Eric Turkewitz

In a USA Today op-ed, Kevin Pho tackles the medical malpractice liability system. Some stuff I agree with, but suggestions regarding improvement of the current system are unlikely to work.

Kevin correctly states that malpractice legal fights often go on for years. In New York, it could easily take three years to get to trial, and often more. And Kevin also correctly states that significant sums of money are wasted on litigation, as opposed to compensation, writing that “These costs do not justify this level of inefficiency.”

But inefficiency doesn’t seem to be the right word. Why would a slam dunk case such as a retained sponge take years to get to trial? I write this from personal experience, where defendants often don’t bother to even ask how much the patient wants to settle the case until the time of trial. Is such a delay the fault of the patient’s lawyer, who won’t get paid until the suit is over and who has an interest in moving the case fast? Not very likely. In one of my first posts as a blogger (No, Your Medical Malpractice Case Will Not Settle Fast) I identified three reasons why it happens:

* If the insurance companies make your life miserable — even on slam dunk cases of retained surgical equipment — then attorneys won’t take smaller suits because it isn’t worth the immense amount of time and money needed, thereby decreasing the overall number of malpractice cases;
* Defense lawyers bill by the hour and have no incentive to reach a quick disposition; and
* If the patient gets a favorable verdict in New York, then interest on the money starts to run from the time of that judgment, not from the time of the incident. Thus, the insurance companies continue to hold and use the money for investments in the interim.

These “inefficiencies” are cured rather easily. If interest runs from the date of malpractice, and not the date of the verdict, all of a sudden the insurer suffers a loss by delaying as interest piles up. Currently the statutory interest rate in New York is 9%, so it is easy to see the significance of such a change.

Kevin also suggests that a type of health court might be appropriate. But New York has experimented with a similar format in the past, and it caused even longer delays and ultimately failed. These were malpractice panels that included a judge, an attorney experienced in handling malpractice cases, and a doctor from each specialty that was sued. If there was a unanimous finding, the finding would go to the jury.

The first, and most significant, problem was finding doctors to sit on these panels, which is what caused years of delay to an already protracted litigation system.

The second problem was that, unlike jurors, there was no way to question panelists regarding any biases they might have, the way a juror might be questioned.

The third problem was that witnesses did not appear before the panels and there was therefore no cross-examination. Submissions were made confidentially, and a short hearing was held that might have lasted an hour, at most. This format made it impossible to resolve disputed issues of fact.

The fourth problem arose when, if a unanimous panel finding went to the jury, the losing side would invariably subpoena the doctor that appeared, and then cross-examine the physician on the flaws in the hearing that took place. Essentially,the panel never saw a single witness and was therefore unable to resolve disputed factual issues. This, in turn, made it even less likely that doctors would want to sit on panels.

The end effect was years of delay, more expense, and more complicated trials.

The final suggestion Kevin made was a “No Fault” type of system. But No-Fault as it applies to car accidents is already problematic as insurers do notorious quickie exams to deny coverage, and repeatedly claim that injuries the victim has, that they had never complained about prior to the accident, were pre-existing and not caused by the accident. Since most malpractice cases start with someone already ill or injured, you can expect the insurers to fight just as hard against the patients. The difference is that the fight will be so expensive for the patient that finding an attorney to handle the matter may well put a quick (and unjust) end to the issue.

Jury verdicts often get a bad rap, but that is because the verdicts people most likely see are the ones in the newspaper. They are in the newspaper, of course, because they were unusual.

But a survey of 594 federal judges back in1999 didn’t agree with that perception. The survey, done by the Dallas Morning News and Southern Methodist School of Law, found that:

* 91% believe the system is in good condition needing, at best, only minor work;
* 96% said they agree with jury verdicts most or all of the time; and
* Nine out of 10 judges said jurors show considerable understanding of legal issues involved in the cases they hear.

In fact, research has shown that bias in the courts on malpractice cases, to the extent it exists, is favorable to the medical profession, not the plaintiffs that have brought the suits.

So, I think that the current system can be tinkered with to make it more efficient by encouraging quicker resolution of cases. But it’s a mistake to think that juries can’t resolve cases fairly.

Eric Turkewitz is a personal injury lawyer who blogs at the New York Personal Injury Law Blog.

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Medical students post inappropriate content online

Kevin — Wed, 18 Nov 2009 10:00:33 PST

Originally published in Insidermedicine

The posting of unprofessional and inappropriate content online by medical students is a relatively common occurrence that medical schools are going to have to learn to deal with, according to research published in the Journal of the American Medical Association.

Here are some reasons why it is not desirable for medical students to post inappropriate content online:

• The content may contain information that violates patient confidentiality

• It can reflect poorly on the student’s institution and on physicians as a whole

• It can reflect poorly on students themselves, possibly impairing future employment opportunities

Researchers from the Washington D.C. VA Medical Center sent anonymous surveys to the deans of student affairs, or their counterparts, of all the medical schools belonging to the Association of American Medical Colleges. The survey included questions about whether students have been found to have posted inappropriate or unprofessional content online and what was done about it.

Overall, 60% of the deans responded to the survey, and among these respondents 60% reported that indeed students had posted inappropriate content online, including 13% who reported that students had posted information that violated patient confidentiality. Other common transgressions included the posting of profanity or frankly discriminatory comments or the posting of depictions of intoxication or sexually suggestive material. Among the 45 deans who reported an incident and responded to questions about how the situation was handled, 67% reprimanded the student informally, while 13% dismissed the student. Overall, 38% of deans reported having policies covering student-posted online content, and 11% of schools without such policies were developing them. Deans who reported incidents were more likely to report having such policies, believing the issues could be effectively addressed, and having higher levels of concern about the topic.

Today’s research demonstrates how the advent of social networking sites like Facebook and content-sharing sites such as Flickr and YouTube are creating a new challenge for medical schools with respect to how their students represent themselves online. Policies for handling unprofessional behavior will need to be implemented.

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