Health Care Reform Articles - October 11, 2015

Heart Scan Can Fine-Tune Risk Estimate for Patients Considering Statins

By GINA KOLATA

OCTOBER 5, 2015

Treatment guidelines suggest that nearly half of those over age 40 — nearly 50 million people in the United States — at least consider a cholesterol-lowering statin to reduce heart attack risk.

But a new large study of people who had an inexpensive heart scan found that half of those who were statin candidates had no signs of plaque in their heart and very little chance of having a heart attack in the next decade.

Some cardiologists say the results could go a long way toward helping patients make a more informed choice about whether to begin taking the drugs.

The test is a CT scan that looks for calcium in coronary arteries, a signal that plaque is present. It used to be expensive — about $500 — but now typically costs between $75 and $100. Still, it is generally not covered by insurance and so is not often used to assess risk. The X-ray dose is about that of a mammogram.

Advocates for the scan say it should be used to “de-risk” people. It can let those who do not want to take statins know whether their chance of a heart attack is actually extremely low.

“Maybe this is a tool to actually do less,” said Dr. Harlan M. Krumholz, a Yale cardiologist and senior author of the paper, published on Monday in the Journal of the American College of Cardiology.

For those who have no objections to taking statins, there is no need for a heart scan, Dr. Krumholz said. But for those who are reluctant to take them, he said, “I am willing to use this to refine their risk estimate.”

Others say the test can lead to an array of other medical problems, some of which are gravely serious.

“The only reason to do things is to feel better or to live longer,” said Dr. Peter Libby, a cardiovascular disease specialist at Harvard’s Brigham and Women’s Hospital. With the scans, he said, that has yet to be established.

Heart researchers have long known that plaques in coronary arteries start out as pimplelike bumps but get waxy and hard and filled with calcium as time passes. Calcium shows up as white flecks in CT scans. The hard plaques are not the dangerous ones — it is the softer ones that rupture and cause a heart attack. But the amount of calcium in arteries can give a good idea of the presence or extent of coronary artery disease.

Dr. Krumholz and Dr. Khurram Nasir, a preventive cardiologist at Baptist Health South Florida, who conceived the new study, reasoned that research on heart scans had not been designed to help doctors make treatment decisions they face today.

HTTP://MOBILE.NYTIMES.COM/2015/10/06/HEALTH/HEART-SCAN-CAN-FINE-TUNE-RISK-ESTIMATE-FOR-PATIENTS-CONSIDERING-STATINS.HTML?EMC=ETA1&_R=0&REFERER=

Getting the Diagnosis Wrong

By DANIELLE OFRI, M.D.

 OCTOBER 8, 2015

Last week a middle-aged woman came to my office because she had abdominal pain. This is a daily occurrence for doctors who work in general medicine, emergency departments or urgent care centers. There are days when the presence of abdominal pain seems as ubiquitous as the presence of oxygen, and this ubiquity can sometimes dull the sense of urgency. But every doctor knows that the list of possible causes of abdominal pain — what’s called the differential diagnosis — is as extensive as it is varied. It includes the common (acid reflux) and the rare (porphyria), and the benign (constipation) as well as the life-threatening (a tear in the aorta or intestine).

As I talked with my patient and examined her abdomen, my mind ran through this list, prioritizing what diagnoses seemed more likely while trying to keep in mind the more serious conditions that I couldn’t afford to miss. But the question remained in my head: Would I get the diagnosis correct?

Diagnostic accuracy is fiendishly difficult to measure precisely, but it is estimated that doctors get it wrong in one out of 10 to one out of 20 cases. Up until now, the focus of the patient safety movement has been on errors of medical treatment — incorrect medications or dosages, postoperative complications, hospital-acquired infections. But diagnostic errors — incorrect or delayed diagnoses — may be more common and potentially more deadly. The Institute of Medicine has taken up the subject, and its new report offers the chilling observation that nearly everyone will experience at least one diagnostic error in their lifetimes.

Refreshingly, the report did not simply point the finger at the incompetence of individual physicians, as both lawsuits and popular news media tend to do. Rather, it described a Borgesian health care system that seemed designed to stymie the diagnostic thought process. It noted that our reimbursement system favors procedures over discussing and thinking about a case. That is, more money would be paid out if I ordered a magnetic resonance imaging exam for my patient with abdominal pain than if I spent extra time talking with her and sorting out the details.

HTTP://WELL.BLOGS.NYTIMES.COM/2015/10/08/GETTING-THE-DIAGNOSIS-WRONG/?SMPROD=NYTCORE-IPHONE&SMID=NYTCORE-IPHONE-SHARE

Blue Cross eliminates most popular individual plan

Ameet Sachdev

Big changes are coming next year for Blue Cross and Blue Shield of Illinois individual health plans, causing stress among some consumers before open enrollment on the state's health insurance exchange begins Nov. 1.

The state's largest health insurer is eliminating its most popular individual plan, called Blue PPO, which has the largest network of doctors and hospitals of any plan the company offers, because it was too costly for the company. The plan will still be available for employer groups next year.

Tony Schor of Highland Park, who bought Blue Cross insurance for his family of four through a broker, said he was startled when he got a letter from the company a few weeks ago telling him his plan was being discontinued at the end of the year.

"I'll be honest with you, I'm concerned," said Schor, a small-business owner. "I'm truly at the edge of my seat because I don't know what the new plan will look like."

Schor is one of 173,000 members enrolled in the Blue PPO who will have to find a new plan. It's a significant upheaval in the Illinois individual market. Two out of every five Blue Cross customers who buy individual or family plans on the exchange or direct from the company are covered by the broad PPO. It's popular despite being the most expensive single-state plan Blue Cross offered for 2015.

"This is huge," said Rich Fahn, president of Excell Benefit Group, an independent broker in Northbrook. "I have clients calling every day panicking about it."

http://www.chicagotribune.com/business/ct-blue-health-plans-1011-biz-20151009-story.html

Faith in an Unregulated Free Market? Don’t Fall for It

Robert Schiller - OCT. 9, 2015

Perhaps the most widely admired of all the economic theories taught in our universities is the notion that an unregulated competitive economy is optimal for everyone.

In this optimal economy, each person is said to be a free actor who makes decisions purely in his or her own self-interest. Economists on both the right and left commonly say that these fundamental ideas tie our values of freedom and individuality to the success of our economies.

The problem is that these ideas are flawed. Along with George A. Akerlof, university professor at Georgetown and a fellow Nobel laureate in economic science, I have used behavioral economics to plumb the soundness of these notions.

In our book, “Phishing for Phools: The Economics of Manipulation and Deception” (Princeton, 2015), we question the all-commanding relevance of the free-market theory to our actual lives and economies. While we confirm the importance of free markets, we have found that market regulation has been crucial, and believe that will continue to be true in the future.

Don’t get us wrong: George and I are certainly free-market advocates. In fact, I have argued for years that we need more such markets, like futures markets for single-family home prices or occupational incomes, or markets that would enable us to trade claims on gross domestic product. I’ve written about these things in this column.

But, at the same time, we both believe that standard economic theory is typically overenthusiastic about unregulated free markets. It usually ignores the fact that, given normal human weaknesses, an unregulated competitive economy will inevitably spawn an immense amount of manipulation and deception.

We use the word “phishing” as a metaphor for a range of seemingly harmless modern market manipulations — like putting candy bars and gossip magazines at the checkout counter, where bored or tired adults and the parents of whining children will be tempted to spend a few extra dollars. And we coined the word “phool” to describe someone who does not understand how much thought and effort have gone into manipulating him or her.

http://www.nytimes.com/2015/10/11/upshot/faith-in-an-unregulated-free-market-dont-fall-for-it.html?action=click&pgtype=Homepage&module=c-column-middle-span-region&region=c-column-middle-span-region&WT.nav=c-column-middle-span-region

Selling expensive health care lemons

By Dr. Philip Caper, Special to the BDN

Posted March 14, 2013, at 11:11 a.m.

In 1970, University of California economist George Akerlof wrote a paper titled “Selling Lemons.” In it he explained that a market characterized by a large asymmetry of information between seller and buyer would also soon become characterized by a decrease in the quality of goods and dominated by crooked sellers and gullible buyers. In 2001 he won the Nobel Prize for his work.

Sad to say, I can think of no market that better fits these criteria than health care. In a March 4 TIME Magazine cover story, “The Bitter Pill: Why Medical Bills Are Killing Us,” reporter Steven Brill dissects a number of hospital bills and traces the detailed charges back to their origins. He concludes, “everyone along the supply chain – from hospital administrators (who enjoy multimillion-dollar salaries) to the salesmen, executives and shareholders of drug and equipment makers — was reaping a bonanza. The only exceptions, I found, were those actually treating the patients — the nurses and doctors.”

When you need medical care there is absolutely no way you can accurately determine ahead of time what that care will cost you. Don’t hope to get anything approaching a rational explanation for what you are charged after the fact, either. The best you can hope for is that whatever insurance you have will cover most of the costs. If not, you are at the mercy of the hospital and, if you can’t pay, its collection agency.

So you can’t know much about the prices of health care. How about the appropriateness or quality of that care? Again, unless you are a doctor you have very few ways to independently judge the safety or benefits of tests, procedures or prescriptions.

And sometimes not even then. Even among well-trained and conscientious doctors, a great deal of uncertainty exists about the risks and benefits of tests and procedures they order and perform.

As the number of doctors who have become employees of profit or nonprofit corporations has increased (now about 80 percent of Maine doctors and rising), they have come under pressure to increase the number of “units of service” they provide — visits, tests, procedures and prescriptions — in order to maximize the revenues and profits of the institutions that employ them.

Lately, the need for many commonly performed procedures has come under question by both government and private health care organizations. The U.S. Preventive Services Task Force recently warned against the routine performance of some, including mammograms for young women, hormone replacement therapy for older women, prostate cancer tests for older men and drug treatment to prevent osteoporosis. Many are now thought to do more harm than good.

Similarly, the American Board of Internal Medicine, one of the medical profession’s most important credentialing bodies, recently launched a program called “Choosing Wisely.”Its purpose is to identify tests and procedures that are overused, and to persuade doctors and patients to use fewer of them. More than 35 medical specialty societies have joined this campaign, each selecting five or more tests or procedures that they believe are significantly overused. Among these are imaging procedures, such a CT scans and MRI, the use of which has exploded in frequency and cost in recent years. It is almost impossible for patients to accurately assess the need for and quality of care.

I still believe that most health care workers want to do the right thing by our patients. But our corporatized and business-oriented health care system is making it increasingly difficult.

http://bangordailynews.com/2013/03/14/opinion/selling-expensive-health-care-lemons/print/

Maine Doctors Support Single Payer

By Julie Keller Pease, M.D.
The Times Record (Brunswick, Maine), Letters, Oct. 7, 2015

I was interested to read the article in Friday’s Times Record about the “Broader health care debate for 2016.” Giving prominence to “single payer” makes sense because only a single-payer plan can cover everyone for all medically necessary care, eliminate financial barriers to care, and allow free choice of doctor and hospital. Single payer healthcare would also control costs. Noted healthcare economist Dr. William Hsiao, when he visited Maine in 2010, estimated that if Maine moved to a single-payer system of health care, the state would save $1 billion during the first year alone.

Currently, the criticism of single payer (mentioned in the article) is that it would require a tax increase. In his fiscal study of H.R. 676, “The Expanded and Improved Medicare for All Act,” economist Dr. Gerald Friedman estimated that 95 percent of all households would actually SAVE money. This is because any increase in taxes would be more than offset by a massive decrease in insurance premiums and out-of-pocket expenses. Further, a streamlined single-payer system would reap about $400 billion annually in savings by slashing wasteful administrative costs, the government would be able to use its negotiating clout to bargain for lower drug and medical supply prices and it would be allowed to take other proven measures to save money.

Maine doctors support single payer. In January 2014, 450 Maine physicians responded to a survey question from the Maine Medical Association: “When considering the topic of health care reform, would you prefer to make improvements to the current public/private system or a single-payer system such as a 'Medicare for all' approach'? Nearly 65 percent of Maine doctors preferred the single-payer option, a jump from about 52 percent in a 2008 MMA survey that asked the identical question.

If you’re interested in learning more about health care for all, I urge you to visit the websites of Physicians for a National Health Program (www.pnhp.org) and Maine AllCare (www.maineallcare.org). Please join us in our advocacy for health care for everyone in Maine.

Dr. Julie Keller Pease resides in Brunswick.

http://www.pnhp.org/print/news/2015/october/maine-doctors-support-single-payer

Want to Become a Doctor? Don't be so Sure

Christopher Cai

Recently, my friend “Tim” told me that he no longer wished to become a doctor. He had already taken the Medical College Admissions Test (MCAT) and all his premedical course requirements. But a summer shadowing physicians whom he described as  “always unhappy” convinced him to cut his losses.

“I worked hard the last three years,” he explained to me. “But I don’t want to be miserable forever.”

Medicine is a demanding and often thankless profession. Long and stressful hours, years of training, little sleep, and heavy debt can all take their toll. One survey suggested that 9 out of 10 doctors are unwilling to recommend healthcare as a profession. Nearly 400 doctors commit suicide every year.

This comes at a time when the U.S. needs more physicians. The American Association of Medical Colleges (AAMC) projects that the U.S. physician shortage will balloon to 90,000 by 2025.

With stakes this high, medical schools look for candidates who convey with certainty their interest in medicine. Doctors are long-term public investments: It takes over a decade to train a physician and residency programs are subsidized by the U.S. government. What’s more, medical schools understandably do not want to waste precious seats on candidates who change their minds later. According to the AAMC, over 48,000 individuals applied for 20,000 seats in 2014.

It is, therefore, no surprise that pre-meds must convey certainty when they apply to medical school.  Like many other candidates, Tim did this by narrowing his academic and extracurricular involvements at university, sacrificing exploration to push through rigorous requirements and gain clinical experience.

But while Tim’s involvements appeared attractive on a medical school application, they did little to convince him that medicine was the profession for him.  This is the problem with premedical education in the U.S.: Too often the cart comes before the horse.

Certainty is often the prerequisite for interest in medicine, rather than the logical product of exploration. At my university, pre-med classes, which are often designed to cull or “weed-out” students, are obstacles to be hurdled rather than opportunities for intellectual exploration.

I have pre-med friends who, in addition to attending classes, spend twice as many hours in the library as in their beds. There’s little incentive to step off the academic treadmill. Introspection and self-exploration, normal parts of a college education, mean falling behind the competition.

Extracurricular activities that provide “clinical experience” become commodities. One pre-med club offers “points” for members who carpool or set up tables at club events. These points can later be exchanged to shadow physicians who have partnered with the club.

https://www.doximity.com/doc_news/v2/entries/2062707?_r=1&_ref=digest&doc_news_entry_title_id=977821&signature=b8c93ef9caa005db32070e03610d6f6142627abb&token=095e0606a5c106682f73e49509487c90443a990f&user_id_hash=61356d3f2335b25967bb0e2fc066190c840f9e52