Testing 1, 2, 3
Is overtesting undermining patient and system health?
- Margaret J. McGregor, MD CCFP MHSc⇓
- Correspondence: Dr Margaret J. McGregor, Centre for Clinical Epidemiology and Evaluation, Department of Family Practice, Room 713, 828 W 10th, Vancouver, BC V5Z 1L8; telephone 604 873-3666; fax 604 875-5179; e-mailmrgret@mail.ubc.ca
- Danielle Martin, MD CCFP
+Author Affiliations
Health care costs are rising in Canada, and not mainly because of population aging. One of the fastest growing areas of health services spending is laboratory testing. Laboratory tests are not free. McGrail and colleagues recently demonstrated that in British Columbia (BC), $174 million more was spent on laboratory testing and imaging in 2005 and 2006 compared with 1996 and 1997.1 Research further reports a 37.4% increase in laboratory testing over this time (S. Sivananthan and colleagues, unpublished data, 2012). These increases are even after accounting for population aging and inflation.
Overtesting is a relatively understudied topic, and overuse rates vary by test and by study.2,3 However, as physicians we know that many of the decisions to order tests start in the family doctor’s office.4 Van Walraven and colleagues found that family physicians in Ontario were more than 7 times more likely than specialists to order potentially redundant repeat tests for hemoglobin, sodium, creatinine, thyrotropin, total cholesterol, ferritin, and hemoglobin A1clevels.5
Scale of medical decisions shifts to offer varied balances of power
Patients never used to worry about making healthcare decisions. They didn't have to. Their doctors made just about all of their decisions for them. Everyone simply assumed that doctors knew what was best.
But that paternalistic view of doctors as know-it-alls has gone by the board, says Dr. Clarence Braddock, vice dean for education at the David Geffen School of Medicine at UCLA. "Now doctors are seen as the experts on medical information and choices," he explains, "but patients are seen as the experts on what those choices mean in their own lives."
The upshot? Doctors still make decisions sometimes, but sometimes patients make them, and sometimes doctors and patients make them together. Doctors and bioethicists are engaged in a vigorous debate about the relative merits of these various approaches. Meanwhile, you may want to consider which suits you best as a patient.
Your doctor is still the boss of you:Doctors make the decisions, but they also give patients a good rundown of their situation, answer questions and explain treatment options. The difference between this approach and the old one, then, is simply that patients are more informed. But that may be significant. Research has shown that the better patients understand doctors' instructions — why they're important, how they're supposed to work — the better the outcomes for patients, quite possibly because they're more likely to comply.
In a 2005 study at Baylor College of Medicine in Houston, researchers interviewed 53 doctors in Texas, Louisiana and Maryland about how and why they went about making clinical decisions, and most of them reported taking this approach. One cardiovascular surgeon said, "Usually I had a recommendation. I felt that was my job." Then, he added with a laugh, "I didn't go through 16 years of study to let people make their own decisions." Similarly, a pediatrician said, "Pretty much you always have to ultimately make a decision because that's what they came to you for."
LePage won’t sign for bonds, three years after shutting down 20-year-old program
Posted June 07, 2014, at 12:09 p.m.
AUGUSTA, Maine — MaineGeneral Medical Center wanted to build a 192-bed hospital in Augusta. The large, state-of-the-art building would replace three smaller, older facilities in Augusta and Waterville. Hospital officials believed the new place would be more efficient and safer for patients.
But they needed $280 million to make it happen.
For the past two decades, they could have joined a pool of other Maine nonprofits looking for cash. They could have issued a tax-exempt bond together, got help from a quasi-state agency and received an interest rate lower than any could have gotten separately.
Instead, the hospital had to go out on its own. It ended up with a poor bond rating and a 7 percent interest rate, rather than one closer to 5 or 6 percent.
MaineGeneral will spend an extra $42 million — $1.4 million a year for 30 years — over the life of the loan.
“It certainly did hit operations, and we had to dig a lot deeper to make it happen,” Mike Koziol, senior vice president and chief financial officer for MaineGeneral, said.
The hospital couldn’t join a nonprofit pool because in 2011, shortly before it went looking for financing, Gov. Paul LePage effectively shut down the 20-year-old program. During his first months in office, he refused to sign a pool bond package, preventing hospitals, colleges, community charities and other nonprofits from issuing bonds together through the quasi-state agency Maine Health and Higher Education Facilities Authority.
Three years later, he still hasn’t signed and the program is still shut down.
The governor’s spokesman did not return calls or respond to an email seeking comment Friday. In 2011, LePage said he refused to sign because the program amounted to using the state’s name without voters’ approval. He said Maine’s credit rating would suffer if one of the nonprofits fails to pay back its loan money.
Proponents of the program say no nonprofit has ever defaulted on a pool bond, and there are safeguards in place if one ever does. They say the risk is minimal, if there is any risk at all.
They believe Mainers are not hurt by the program but by its shutdown.
Posted June 02, 2014, at 4:15 p.m.
AUGUSTA, Marine — In a strident letter delivered Monday, Republican Gov. Paul LePage told Democratic legislative leaders not to “stick their noses” into executive branch business.
The letter was a response to one sent to the governor last week by Senate President Justin Alfond, D-Portland, and House Speaker Mark Eves, D-North Berwick, in which the lawmakers urged LePage to immediately terminate a controversial $925,000 contract with the Alexander Group and recoup the nearly $502,000 the state has already paid the consulting firm.
The Alexander Group, which received a no-bid contract in September 2013 to review Maine’s welfare system, has long been the subject of Democratic scorn, but recent evidence that the company plagiarized several other groups in its Maine reports have kicked the controversy into overdrive.
After the plagiarism was revealed by the BDN, LePage on May 23 suspended all further payment to the group. He pledged to investigate the plagiarism and said firm action, including clawback of previous payments and termination of the contract, was possible. Federal investigators have also announced they would review the contract to determine if the federal funds used to pay the consultant were used appropriately.
In his letter Monday, LePage taunted Alfond and Eves.
“I have received your letter about the Alexander Group contract,” he wrote. “After the defeats you suffered during the past legislative session, I understand your need to score political points. But please stay out of the executive branch’s business.”
He also criticized the Legislature for not approving several of his initiatives this year, including welfare reform efforts, a bill to increase funding for Maine’s nursing homes and a bill to hire more judges, prosecutors and drug enforcement agents to carry out a ramped-up “War on Drugs.”
Democrats approved variations of the governor’s bills, but LePage and some Republicans did not support their changes, and none of the initiatives passed into law.
“It is inexplicable that you would rather insert yourselves into the executive branch’s business while doing everything you can to ignore welfare reform, drug crime and elderly Mainers,” he wrote. “Don’t worry yourselves about what the executive branch is doing.”
LePage did not indicate whether he had decided on any punitive action against the Alexander Group, nor did he answer concerns raised by Alfond and Eves in their letter that the contract with the Alexander Group did not contain performance guarantees or other provisions to allow the state to recoup any of the more than $500,000 already paid to the consultant.
Posted June 05, 2014, at 10:32 a.m.
“This is truly a case of egregious fraud, waste and abuse of taxpayer dollars,” Senate President Justin Alfond and House Speaker Mark Eves said in a May 28 letter to Gov. Paul LePage.
They were referring to the reports on Maine general assistance programs produced by the Alexander Group, which were plagiarized, contain significant errors and offer no helpful analysis of complicated state policies. Alfond and Eves urged LePage “to take all steps necessary” to immediately terminate the nearly $1 million no-bid contract.
There is nothing in Alfond and Eves’ letter to disagree with. The two write about how the contract was awarded with no public or legislative input, and no proper vetting of contractor Gary Alexander; they describe how it has been paid for in part with state and federal tax money that otherwise would have gone to social service programs; and they outline how it included no basic warranties or performance guarantees.
So, they asked, given such serious concerns about the product and lack of protections written into the contract, what is LePage’s plan for recovering the funds paid thus far?
“We are particularly interested in understanding what legal options you believe are available to the state. Upon review of the underlying contractual documents, we have serious concerns that protections are not in place,” they said.
The LePage administration may have suspended all future payment to the consulting firm on May 23, but it had already paid more than $500,000 to Alexander. Will — and can — LePage get the money back?
It’s a completely reasonable question to ask. LePage himself said May 23 that the state intended to run Alexander’s work through a plagiarism detector, and he promised penalties — including the possibility of canceling the contract entirely — if the plagiarism accusations were true. And they are.
Privatization won’t fix the VA
By Suzanne Gordon
The Boston Globe, May 27, 2014
First it was Social Security, then Medicare and Medicaid, and then the public health care option under Obamacare. Now, in the wake of recent allegations that veterans hospitals put patients on secret wait lists, Republicans are calling for the privatization of the Veterans Health Administration, the nation’s largest public health care system which provides cost-effective and high quality care to 6.2 million veterans.
It is of course unacceptable if patients suffered as a result of any delays. But regardless of what went wrong at any VA facility, turning veterans over to private sector insurers and for-profit hospitals is not the solution.
With its salaried staff of nearly 280,000, the VA has long been a model for health care delivery. The VA’s 152 hospitals, 900 clinics, 300 mental health centers, and other facilities — many located in rural areas that the private sector ignores — care for more than 230,000 people a day. In a recent survey of veterans for the American Customer Satisfaction Index, patients rated the system’s services as equal to or better than private sector health care facilities.
One reason is the VA’s systematic efforts to improve quality care and patient safety. The VA computerized medical records long before private hospitals. The VA conducts widespread training on inter-professional communication and teamwork that decreases patient deaths and injuries due to the kind of medical mistakes and problems that kill over 400,000 patients a year. In 2007, the VA launched a successful initiative to dramatically reduce the dangers of one the deadliest hospital superbugs — methicillin-resistant Staphylococcus aureus.
The VA has singular expertise in the treatment of post-traumatic stress disorder. Many injured soldiers have returned from Iraq and Afghanistan with what is known as poly-trauma — PTSD plus traumatic brain injury and limb amputations. Few primary care physicians — or even specialists — have much experience treating such cases in the private sector. In fact, without the VA, vets would have trouble getting any primary care services given the serious shortage of primary care providers in this country.
Because the VA is a public entity, its facilities actually display greater accountability — and more transparency to patients and their families — than private health care systems. When veterans have a VA-related beef — or in-house whistle-blowers a tale to tell — they are quick to notify their elected representatives. Such complaints regularly trigger individual constituent service queries from members of Congress or, as is the case today, oversight hearings by House and Senate committees. (Good luck triggering a similar rapid response to patient or staff complaints in the private sector.)
http://www.pnhp.org/print/news/2014/june/privatization-won’t-fix-the-va
The Boston Globe, May 27, 2014
First it was Social Security, then Medicare and Medicaid, and then the public health care option under Obamacare. Now, in the wake of recent allegations that veterans hospitals put patients on secret wait lists, Republicans are calling for the privatization of the Veterans Health Administration, the nation’s largest public health care system which provides cost-effective and high quality care to 6.2 million veterans.
It is of course unacceptable if patients suffered as a result of any delays. But regardless of what went wrong at any VA facility, turning veterans over to private sector insurers and for-profit hospitals is not the solution.
With its salaried staff of nearly 280,000, the VA has long been a model for health care delivery. The VA’s 152 hospitals, 900 clinics, 300 mental health centers, and other facilities — many located in rural areas that the private sector ignores — care for more than 230,000 people a day. In a recent survey of veterans for the American Customer Satisfaction Index, patients rated the system’s services as equal to or better than private sector health care facilities.
One reason is the VA’s systematic efforts to improve quality care and patient safety. The VA computerized medical records long before private hospitals. The VA conducts widespread training on inter-professional communication and teamwork that decreases patient deaths and injuries due to the kind of medical mistakes and problems that kill over 400,000 patients a year. In 2007, the VA launched a successful initiative to dramatically reduce the dangers of one the deadliest hospital superbugs — methicillin-resistant Staphylococcus aureus.
The VA has singular expertise in the treatment of post-traumatic stress disorder. Many injured soldiers have returned from Iraq and Afghanistan with what is known as poly-trauma — PTSD plus traumatic brain injury and limb amputations. Few primary care physicians — or even specialists — have much experience treating such cases in the private sector. In fact, without the VA, vets would have trouble getting any primary care services given the serious shortage of primary care providers in this country.
Because the VA is a public entity, its facilities actually display greater accountability — and more transparency to patients and their families — than private health care systems. When veterans have a VA-related beef — or in-house whistle-blowers a tale to tell — they are quick to notify their elected representatives. Such complaints regularly trigger individual constituent service queries from members of Congress or, as is the case today, oversight hearings by House and Senate committees. (Good luck triggering a similar rapid response to patient or staff complaints in the private sector.)
http://www.pnhp.org/print/news/2014/june/privatization-won’t-fix-the-va
Lack of funding is the real VA scandal
By Suzanne Gordon
Beyond Chron (San Francisco), June 3, 2014
As the firestorm about wait times at VA facilities continues, political representatives from both parties insist that waits must be eliminated for veterans seeking care. Now that Republicans have succeeded in forcing the resignation of Secretary of the Department of Veterans Affairs, Eric Shinseki, who resigned last week – the new focus is on seeking partial privatization of the system by allowing veterans to get care from private sector doctors – care that would be paid for by the government program. None of the current calls to action, however – whether they include criminal prosecutions of those responsible for secret waiting lists, or channeling vets into the private sector – will fix the wait times at the VA that keep vets from getting needed care.
There are two primary reasons for the problem of wait times. One has to do with Congress’ consistent failure to provide adequate funding so that the VA could hire more staff to care for an increasing number of veterans who live longer with complex service and age related health problems. The other – which may be the biggest and hardest to solve problem of them all – has to do with the US healthcare system’s persistent refusal to provide the number of physicians who deliver primary care services in this country.
Let’s look at the issue of funding. Over the course of the past ten years or more, the VA has been taxed with a population of veterans who have very particular problems. Many of those who survived the Vietnam and first Iraq war are often poor, sometimes homeless, have serious mental health problems and more than the usual share of age related health problems.
Added to this group are veterans who made it through the recent wars in Iraq and Afghanistan. They have survived long enough to be VA patients but with serious and equally special health problems. A not atypical VA patient might have a traumatic brain injury (TBI), plus an amputation, on top of Post Traumatic Stress disorder, combined with the normal problems of people who live longer in advanced industrialized societies – heart disease, diabetes, obesity, cancer, or asthma.
In spite of this increasing load of combat and age related problems, Congress has refused to allocate more funding to the VA.
In February of 2014, Independent Senator Bernie Sanders of Vermont proposed a bill that would have allocated $21 billion that would have improved access to healthcare, education, and other services for US veterans. Republicans – the same ones railing against Shinseki in particular and the VA in general – blocked killed that bill. Here is one typical comment that illustrates the tenor of the debate about adequately funding veterans’ care. “I don’t think our veterans want their program to be enhanced if every penny of the money to enhance those programs is added to the debt of the United States of America,” said Senator Jeff Sessions, (R-Alabama). If you go to this website you’ll hear even more: http://www.sanders.senate.gov/newsroom/video-audio/flashback-republicans...
The same politicians who killed Sanders’ bill are trying to find out what and who is at the bottom of the VA wait list crisis. It is clearly in their interests to ignore any serious discussion of how precisely the VA supposed to care for all the veterans who depend on its services with the limited resources it has been allocated – resources which Republicans staunchly refuse to increase.
This, in turn, leads to the broader and far more stubborn problem of the persistent shortage of primary care providers in the US.
http://www.pnhp.org/print/news/2014/june/lack-of-funding-is-the-real-va-scandal
Beyond Chron (San Francisco), June 3, 2014
As the firestorm about wait times at VA facilities continues, political representatives from both parties insist that waits must be eliminated for veterans seeking care. Now that Republicans have succeeded in forcing the resignation of Secretary of the Department of Veterans Affairs, Eric Shinseki, who resigned last week – the new focus is on seeking partial privatization of the system by allowing veterans to get care from private sector doctors – care that would be paid for by the government program. None of the current calls to action, however – whether they include criminal prosecutions of those responsible for secret waiting lists, or channeling vets into the private sector – will fix the wait times at the VA that keep vets from getting needed care.
There are two primary reasons for the problem of wait times. One has to do with Congress’ consistent failure to provide adequate funding so that the VA could hire more staff to care for an increasing number of veterans who live longer with complex service and age related health problems. The other – which may be the biggest and hardest to solve problem of them all – has to do with the US healthcare system’s persistent refusal to provide the number of physicians who deliver primary care services in this country.
Let’s look at the issue of funding. Over the course of the past ten years or more, the VA has been taxed with a population of veterans who have very particular problems. Many of those who survived the Vietnam and first Iraq war are often poor, sometimes homeless, have serious mental health problems and more than the usual share of age related health problems.
Added to this group are veterans who made it through the recent wars in Iraq and Afghanistan. They have survived long enough to be VA patients but with serious and equally special health problems. A not atypical VA patient might have a traumatic brain injury (TBI), plus an amputation, on top of Post Traumatic Stress disorder, combined with the normal problems of people who live longer in advanced industrialized societies – heart disease, diabetes, obesity, cancer, or asthma.
In spite of this increasing load of combat and age related problems, Congress has refused to allocate more funding to the VA.
In February of 2014, Independent Senator Bernie Sanders of Vermont proposed a bill that would have allocated $21 billion that would have improved access to healthcare, education, and other services for US veterans. Republicans – the same ones railing against Shinseki in particular and the VA in general – blocked killed that bill. Here is one typical comment that illustrates the tenor of the debate about adequately funding veterans’ care. “I don’t think our veterans want their program to be enhanced if every penny of the money to enhance those programs is added to the debt of the United States of America,” said Senator Jeff Sessions, (R-Alabama). If you go to this website you’ll hear even more: http://www.sanders.senate.gov/newsroom/video-audio/flashback-republicans...
The same politicians who killed Sanders’ bill are trying to find out what and who is at the bottom of the VA wait list crisis. It is clearly in their interests to ignore any serious discussion of how precisely the VA supposed to care for all the veterans who depend on its services with the limited resources it has been allocated – resources which Republicans staunchly refuse to increase.
This, in turn, leads to the broader and far more stubborn problem of the persistent shortage of primary care providers in the US.
http://www.pnhp.org/print/news/2014/june/lack-of-funding-is-the-real-va-scandal
Shifts in Charity Health Care
TEXARKANA,
Tex. — On a hazy, hot evening here, Janice Marks ate a dinner of turkey
and stuffing at a homeless shelter filled with plastic cots before
crossing a few blocks to the Arkansas side of town to start her night
shift restocking the dairy cases at Walmart.
The
next day, David Tramel and Janice McFall had a free meal of hot dogs
and doughnut holes at a Salvation Army center in Arkansas before heading
back to their tent, hidden in a field by the highway in Texas.
None of the three have health insurance.
But had Ms. Marks, 26, chosen to sleep on the side of town where she
works, or had Mr. Tramel and Ms. McFall, who are both in their early
20s, made their camp where they had eaten their dinner, their fortunes
might be different.
Arkansas accepted the Medicaid expansion in the Affordable Care Act. Texas did not.
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