While the advances in medicine have extended the lives of so many children into adulthood new challenges arise. The numbers of fortunate people surviving places a new challenge for mental health, family relationships, and economic survival. Family and personal relationships are important as well as support groups.
The people surrounding a patient with cystic fibrosis suffer emotionally more than the patieint.
Watch this video for an inspirational story from Claire. Share the message and contribute to the Cystic Fibrosis Foundation.
The Vertex pharmaceutical company in a partnership with the Cystic Fibrosis Foundation have developed a program creating a "pipeline' of genetic treatments for C.F. Many are in Clinical Trials, and many have already been approved. This is a major reason for long term survival of patients with cystic fibrosis.
Live Video: Claire Wineland and Cystic Fibrosis | The Mighty
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Wednesday, February 8, 2017
Monday, February 6, 2017
A Guide To Budget Reconciliation: The Byzantine Rules For Disassembling The Health Law | Kaiser Health News
Repeal and/or amend the ACA ? How it will take two years (2018). Maybe.
If you thought constructing and passing the ACA was difficult...just you wait !
After capturing the White House, Republicans put repealing the health law at the top of their to-do list. But since they can’t get around a Democratic filibuster in the Senate, they are forced to use an arcane legislative tool called budget reconciliation to disassemble parts of the law. KHN’s Julie Rovnerand Francis Ying explain the process.
Once again the tools that the Congress can use are inadequate and obsolete, leading to a further possible stalemate which only serves to hurt all.
Perhaps another reason to 'drain the swamp' . HHS Secretary, Tom Price, will have his hands full. Hopefully his medical judgments will prevail. He also has the power of "Executive Order' something which President Trump has used already to meet his campaign promises.
A Guide To Budget Reconciliation: The Byzantine Rules For Disassembling The Health Law | Kaiser Health News
If you thought constructing and passing the ACA was difficult...just you wait !
After capturing the White House, Republicans put repealing the health law at the top of their to-do list. But since they can’t get around a Democratic filibuster in the Senate, they are forced to use an arcane legislative tool called budget reconciliation to disassemble parts of the law. KHN’s Julie Rovnerand Francis Ying explain the process.
But Congress can’t use reconciliation to change parts of the health law like provisions requiring insurance companies to provide certain benefits or sell coverage to people with preexisting conditions. Those don’t directly affect federal spending.
That has led insurance companies to complain that they will go broke if they still have to sell to sick people, but healthy people won’t have any incentive to get covered. In that case, they say, only sick people will buy insurance, and premiums will skyrocket.
And the new Republican Congress seems set on using the technique to take apart the health law. Whether that’s a good idea may depend on whether you favor or oppose the Affordable Care Act.
Once again the tools that the Congress can use are inadequate and obsolete, leading to a further possible stalemate which only serves to hurt all.
But even as Congress spins its wheels. Price can push forward by using his discretion to undo crucial elements of Obamacare. That’s largely thanks to the Obama administration, which granted its health officials authority to write and implement hundreds of rules tied the law. The Trump administration now plans to use that same license to undo as much of Obamacare as it can.
“The statute itself gave [HHS] a lot of discretion,” said Edmund Haislmaier, a senior research fellow at the Heritage Foundation, who worked on health policy for the Trump transition team. “Live by the administrative state, die by the administrative state.”
A Guide To Budget Reconciliation: The Byzantine Rules For Disassembling The Health Law | Kaiser Health News
Friday, February 3, 2017
World's smallest MRI helps tiny babies - BBC News
Infants are not small people. One size MRI does not fit for diagnostics. MRI scanners have been specifically designed for shoulders, arms, knees, and other smaller structures. Smaller scanners expose patients to less irradiation.
The MRI images are more detailed and higher resolution.
Doctors in Sheffield are pioneering the use of a compact MRI scanner for imaging the brains of premature babies.
The machine, at the Royal Hallamshire Hospital, is one of only two purpose-built neonatal MRI scanners in the world.
At present, ultrasound is normally used to scan the brains of newborns.
Prof Paul Griffiths, of the University of Sheffield, said MRI was better at showing the structures of the brain and abnormalities more clearly.
So far about 40 babies have been imaged in the MRI scanner, which was built by GE Healthcare with funding by the Wellcome Trust.
MRI scans are rarely performed on severely premature babies because the risks involved in transferring and handling a sick infant can outweigh the benefits.
It is not known how much a neonatal MRI machine would cost, should the system eventually get commercialised, but full-size scanners are typically priced at several hundred thousand pounds.
Cincinnati Children's Hospital has a 1.5 Tesla neonatal MRI scanner that was adapted from adult orthopaedic use.
World's smallest MRI helps tiny babies - BBC News
Wednesday, February 1, 2017
Who really wants to blow up the FDA? Not the drug industry
Health Train Express is following the issues that POTUS is addressing in regard to health care.
Following his not too surprising nomination of Tom Price for the head of HHS, he now turns his attention to another big player, the Food and Drug Administration. While the FDA plays a major role in the safety of food products in the United States, not much is said about that during political campaigns or in decision making. It's role in pharma, medical devices, and now mobile health applications draws headlines.
What most industry reporters usually mention is the length of time and the expense of developing new drugs, and how that contributes to increased drug costs.
President Trump has repeatedly said that the FDA needs to be overhauled. He’s talked about speeding up drug approvals and reducing regulations — he’s vetted possible FDA heads who want to put drugs to market before we know they are effective. But, outside the White House and Capitol Hill, is there anyone who agrees with this? STAT’s Damian Garde takes a look.
Trump has big plans to fix drug prices. Here’s your reality check
Eli Lilly has raised the price of insulin more than tenfold since 2001 and is now facing a class-action lawsuit and threats of a congressional investigation.
Following his not too surprising nomination of Tom Price for the head of HHS, he now turns his attention to another big player, the Food and Drug Administration. While the FDA plays a major role in the safety of food products in the United States, not much is said about that during political campaigns or in decision making. It's role in pharma, medical devices, and now mobile health applications draws headlines.
What most industry reporters usually mention is the length of time and the expense of developing new drugs, and how that contributes to increased drug costs.
President Trump has repeatedly said that the FDA needs to be overhauled. He’s talked about speeding up drug approvals and reducing regulations — he’s vetted possible FDA heads who want to put drugs to market before we know they are effective. But, outside the White House and Capitol Hill, is there anyone who agrees with this? STAT’s Damian Garde takes a look.
Trump has big plans to fix drug prices. Here’s your reality check
Eli Lilly has raised the price of insulin more than tenfold since 2001 and is now facing a class-action lawsuit and threats of a congressional investigation.
Amgen has repeatedly raised the price of Enbrel, a blockbuster anti-inflammatory treatment that has been on the market for nearly 20 years. The price of J&J’s competing Remicade rose by 63 percent between 2011 and 2016.Since 2010, Merck has raised its drug prices by more than 9 percent on average, and Novartis has increased the price of the cancer drug Gleevec from $26,400 in 2001 to more than $120,000 this year.
There have also been cases where drug prices have acutely skyrocketed, in come cases over 1,000 %. drug for treating pinworm, an intestinal parasite was sold for $ 3.00 a dose, and now costs $ 300.00 dollars. Anthelmintics, such as mebendazole, pyrantel pamoate, and albendazole, are active against Enterobius vermicularis.
Mebendazole is now being studied as a drug to prevent cancer. (coincidence, or opportunistic ??
His pledges, which will need to be fleshed out, would likely require work from the Food and Drug Administration. Trump also said Tuesday that he would soon appoint a commissioner to lead the agency.
The industry, for its part, has rolled out an advertising campaign backed by tens of millions of dollars to burnish its public image. Industry officials described Tuesday’s meeting with Trump as a chance to get in the door with the new president after his incendiary comments. Depending on the time of the year, and politically expedient slogans pharma can change it's mantra.
Late in 2014, the Amgen announced their original restructuring plans to reduce payroll was too modest, upping its goal on job cuts to 4,000. And the pharma giant followed up in the spring of 2015 by axing about 300 staffers after Bradway decided to shutter the Onyx campus obtained with its acquisition of Kyprolis.
Trump confronts big Pharma on Pricing
On Tuesday, though, Bradway became a job creator.
“We’ll be adding 1600 jobs at Amgen this year,” he told President Donald Trump, minutes after the president had finished a harangue about the new American jobs he expected in exchange for reduced regulations.
It may be unwise to paint the whole of pharma with the same accusations. Politicians focus on the "outliers" to prove a point. Readers should carefully consider the source and not take pronouncements at face value.
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Senate Finance Committee OKs Tom Price, MD, for HHS Chief
The Senate Finance Committee today approved the nomination of Rep. Tom Price, MD, (R-Ga), to head the Department of Health and Human Services (HHS) and serve as President Donald Trump's point person in repealing and replacing the Affordable Care Act (ACA).
The 14 to 0 vote reflected the partisan tumult engulfing the nation's capital during Trump's first few weeks in office. All the votes came from Republican members of the committee because, for a second day in a row, the 12 Democratic members boycotted executive sessions to confirm both Dr Price and Steven Mnuchin, the president's nominee for Treasury secretary. Ranking member Sen. Ron Wyden (D-Ore) said the committee should not move forward on the nominations until it addresses "unanswered questions and misleading statements" by both men. Democrats contend that Dr Price has not come clean about alleged conflicts of interest regarding his investments in healthcare companies, which he has denied.
Dr Price's nomination now goes before the full Republican-controlled Senate for a vote. Because the Senate changed its rules when Democrats were in power to exempt cabinet-level appointments from a filibuster, Dr Price needs only a simple majority, or 51 votes, for confirmation. Republicans hold 52 seats.
Ignoring all the expected Republican/Democratic debate over ethics and politics, his confirmation will be unique in that he is the first physician in my memory to serve in this capacity.Trump has chosen a man who understands the medical system as a practicing physician. In the past, leaders have been from other sectors of government who in many cases were assessed on performance as heads of other departments. Few physicians are confident in non clinicians when it comes to making medical decisions.
Just recently chair of the House Budget Committee, Dr Price has been an adamant foe of the ACA and government regulation that he considers burdensome for physicians. Trump has said that once confirmed, Dr Price will work with the White House to introduce a plan to replace the healthcare reform law, one that will provide "insurance for everybody." If confirmed, the orthopedic surgeon would then help implement the replacement plan.
Senate Finance Committee OKs Tom Price, MD, for HHS Chief
Monday, January 30, 2017
Finally, mHealth is the winner : Software as a drug? - Health Files by Rajendra Pratap Gupta
The line between pharma and health information technology is blurring. SAAD (Software ad a drug stands alongside . of SAAS (Software as a Service)
The progress is punctuated by the FDA which will require vetting of health software when it is linked to treatments. No such requirement has been proposed for electronic health records, but is now being required for mobile health applications and/or remote monitoring.
In the past the FDA (Food and Drug Administration) was responsible for the safety of food stuffs. It is also responsible for the safety and efficacy of pharmaceuticals, and medical devices. The vetting of pharmaceuticals is complex and very expensive. The cost of new drug development is quoted as between 450 million dollars and 900 million dollars. Pharma uses these figures to justify the cost of new proprietary formulations. The patents are valid for 16 years. When a new drug makes the 16 year mark it becomes available to other pharmaceutical companies to be sold as generic drugs, and the cost drops significantly.
If and when SAAD becomes available for diagnosis and treatment it will require FDA approval. Usually this takes at least 12 to 24 months, unless there are urgent medical considerations. I would expect a price increase for SAAS.
Therefore it is not at all a guaranteed win.
Finally, mHealth is the winner : Software as a drug? - Health Files by Rajendra Pratap Gupta | ET HealthWorld
The progress is punctuated by the FDA which will require vetting of health software when it is linked to treatments. No such requirement has been proposed for electronic health records, but is now being required for mobile health applications and/or remote monitoring.
In the past the FDA (Food and Drug Administration) was responsible for the safety of food stuffs. It is also responsible for the safety and efficacy of pharmaceuticals, and medical devices. The vetting of pharmaceuticals is complex and very expensive. The cost of new drug development is quoted as between 450 million dollars and 900 million dollars. Pharma uses these figures to justify the cost of new proprietary formulations. The patents are valid for 16 years. When a new drug makes the 16 year mark it becomes available to other pharmaceutical companies to be sold as generic drugs, and the cost drops significantly.
If and when SAAD becomes available for diagnosis and treatment it will require FDA approval. Usually this takes at least 12 to 24 months, unless there are urgent medical considerations. I would expect a price increase for SAAS.
Therefore it is not at all a guaranteed win.
Finally, mHealth is the winner : Software as a drug? - Health Files by Rajendra Pratap Gupta | ET HealthWorld
Thursday, January 26, 2017
Here's what primary care doctors really think about Obamacare - LA Times
Conducted in December and January and published online Wednesday in the New England Journal of Medicine, the new survey shows that nearly three-quarters of general practitioners favored making changes to the Obama administration’s signature healthcare reform measure.
But in this nationally representative sample of primary care doctors, only 15% favored the law’s repeal. Among responding physicians who voted for Donald Trump, only 38% favored the law’s repeal.
That makes the repeal of the Affordable Care Ac, also known as Obamacare, far less popular among the physicians on the front lines of medicine than it is in the American body politic. A Kaiser Family Foundation poll taken after the November 2016 election found that 26% of Americans wanted to see Obamacare repealed.
Among the survey’s most striking findings was strong support for an extension of the Affordable Care Act that is absent from any GOP proposals: Two-thirds of primary care physicians endorsed the idea that any healthcare reform should include a public insurance option resembling Medicare that would compete with private plans.
Study coauthor Dr. Craig Evan Pollack, an internal medicine specialist at Johns Hopkins University School of Medicine, said he was struck by the strength of physicians’ opposition to measures that increased complexity and shifted costs toward patients. He suggested it was a direct result of doctors’ experience in caring for patients.
“As physicians, we see people struggle with out-of-pocket costs, deciding which types of care they’re able to afford and making very challenging decisions,” said Pollack. Primary care physicians, he added, “try to advocate for their patients.”
The new survey reflects the answers of 426 physicians drawn from a master file of the American Medical Assn. and is considered a nationally representative sample. Its findings appear to mark a significant shift in physicians’ opinions about the Affordable Care Act. In the opening months of 2015, 48% of primary care physicians had a favorable opinion of the Affordable Care Act and 52% viewed it unfavorably.
Dr. David Grande, an internal medicine physician at the University of Pennsylvania’s Perelman School of Medicine, said that as the Affordable Care Act got up and running, virtually all of his colleagues have treated new patients who had previously been uninsured or who struggled to hold on to insurance.
NASA just made all the scientific research it funds available for free -
All of this research data contains medical studies and biologic studies. It also contains the development of sensors for remote monitoring of vital signs, blood glucose monitoring. It is a treasure chest of data.
NASA just announced that any published research funded by the space agency will now be available at no cost, launching a new public web portal that anybody can access.
The free online archive comes in response to a new NASA policy, which requires that any NASA-funded research articles in peer-reviewed journals be publicly accessible within one year of publication.
Right now, there are some 861 research articles in the database, and you can expect that number to keep rising as NASA-funded researchers get on board with the new policy.
As you’d expect, there’s an enormous spread of research already on offer, ranging from exercise routines to maintain health during long-duration space missions, to the prospects for life on Titan, and the risk of miscarriage for flight attendants exposed to cosmic radiation.
But not all NASA-funded research can be found in the archive. As the space agency indicates, patents and material governed by personal privacy, proprietary, or security laws are exempt from having to be included in PubSpace.
It also follows a growing general trend towards more openness in science research and academia more broadly. With frustration stemming over the commercial control wielded by the companies who own most academic publishing, some researchers are bypassing established journals altogether by uploading their work directly to the internet.
Others are illegally sharing scientific papers online in a dramatic bid to spread knowledge. At the same time, there are calls in Europe to make all published science funded by the public free.
NASA just made all the scientific research it funds available for free
Tuesday, January 24, 2017
Wills Eye Hospital Studies Glaucoma App
"There's an App for that !
The result was somewhat surprising
All of us are aware of the cross over between technology and medicine. Often these developments are fueled by young engineers who decide to become physicians, or biomedical engineers.
It doesn't seem unreasonable that the smartphone in your pocket could be used for medical applications, education, remote monitoring, reminders, and access to your personal health information.
The list of 'mobile apps' grows daily. A search on Googe for Smartphone Medical Apps yields over 800,000 results. Some of them are duplicated, however the number of search returns is quite impressive.
Someone posits the market value generously. There are several caveats.
1. Buyers are not always consistent users. Studies reveal that purchasers often are curious and evaluate the application, but do not continue to use it for it's intended purpose, for one reason or another.
2. Reality often does not meet consumer expectation.
3. Treatments based upon the mobile app are dangerous unless the device and software are vetted by the FDA. Some apps are considered medical devices and must be approved for an IDE(Investigative Device Exemption prior to commercial marketing
The following are key features from the Wills Eye Glaucoma app:
- Educational videos about glaucoma, how to use eye drops, benefits of glaucoma laser treatment, and surgery
- A tutorial on how to take a visual field examination
- An eye drop reminder feature
- An appointment reminder feature
- Storage of medical information
- Tracking of eye pressure results
Monday, January 23, 2017
Federal Judge Blocks Anthem-Cigna Merger
Aetna and Humana to defend pending transaction - The Health Section
Yahoo News:
Aetna Inc.’s $37 billion deal to buy rival insurer Humana Inc. was blocked by a federal judge, thwarting one of two large mergers that would reshape the U.S. health-care landscape. Aetna said it was considering an appeal.
The transaction would violate antitrust laws by reducing competition among insurers, U.S. District Judge John D. Bates in Washington ruled on Monday. With the deal defeated, Aetna owes Humana a $1 billion breakup fee under the terms of the merger agreement.
“We’re reviewing the opinion now and giving serious to consideration to an appeal after putting forward a compelling case,” T.J. Crawford, an Aetna spokesman, said. A Humana spokesman didn’t immediately respond to a request for comment.
The government case against the merger focused on the market for private health plans for the elderly, known as Medicare Advantage. The U.S. argued the Aetna-Humana deal would have eliminated competition between the insurers in 364 counties in 21 states and likely forced seniors to pay higher premiums for Medicare Advantage plans. It also threatened competition on the insurance exchanges set up under Obamacare, the Justice Department said.
The government case against the merger focused on the market for private health plans for the elderly, known as Medicare Advantage. The U.S. argued the Aetna-Humana deal would have eliminated competition between the insurers in 364 counties in 21 states and likely forced seniors to pay higher premiums for Medicare Advantage plans. It also threatened competition on the insurance exchanges set up under Obamacare, the Justice Department said.
Aetna countered that the Medicare market is much larger than the Justice Department claims because it includes both Medicare Advantage plans and original Medicare, providing more choice for seniors than the government portrayed. Competition on the exchanges isn’t an issue, they said, because Aetna withdrew from all 17 counties at issue in the government’s case.
The judge sided with the government’s view of the Medicare Advantage market. “In that market, which is the primary focus of this case, the merger is presumptively unlawful—a conclusion that is strongly supported by direct evidence of head-to head competition as well. The companies’ rebuttal arguments are not persuasive,” Bates wrote.
Judge John B. Bates ruled the "proffered efficiencies do not offset the anticompetitive effects of the merger." A finalized deal would "substantially lessen" competition in the Medicare Advantage market and public exchanges, the federal judge concluded.
from Bloomberg
The government case against the merger focused on the market for private health plans for the elderly, known as Medicare Advantage. The U.S. argued the Aetna-Humana deal would have eliminated competition between the insurers in 364 counties in 21 states and likely forced seniors to pay higher premiums for Medicare Advantage plans. It also threatened competition on the insurance exchanges set up under Obamacare, the Justice Department said.
Aetna countered that the Medicare market is much larger than the Justice Department claims because it includes both Medicare Advantage plans and original Medicare, providing more choice for seniors than the government portrayed. Competition on the exchanges isn’t an issue, they said, because Aetna withdrew from all 17 counties at issue in the government’s case.
from Bloomberg
The government case against the merger focused on the market for private health plans for the elderly, known as Medicare Advantage. The U.S. argued the Aetna-Humana deal would have eliminated competition between the insurers in 364 counties in 21 states and likely forced seniors to pay higher premiums for Medicare Advantage plans. It also threatened competition on the insurance exchanges set up under Obamacare, the Justice Department said.
Aetna countered that the Medicare market is much larger than the Justice Department claims because it includes both Medicare Advantage plans and original Medicare, providing more choice for seniors than the government portrayed. Competition on the exchanges isn’t an issue, they said, because Aetna withdrew from all 17 counties at issue in the government’s case.
The judge sided with the government’s view of the Medicare Advantage market. “In that market, which is the primary focus of this case, the merger is presumptively unlawful—a conclusion that is strongly supported by direct evidence of head-to head competition as well. The companies’ rebuttal arguments are not persuasive,” Bates wrote.
Commentary (author)
Medicare Advantage plans are not true Medicare (original) plans. They are contracted entities of private insurers. Medicare Advantage plans represent a growing penetration of the overall Medicare market. These advantage plans are contracted and paid by Medicare. They offer their own risk management, quality assurance, and a relatively closed provider network.
The penetration rate varies widely from state to state, county to county, and rural vs metropolitan regions. The Kaiser Foundation offers specific figures on Advantage Plan penetration.
Saturday, January 21, 2017
The Spectacular Incompetence of 3rd Party Payers adds to Provider Burnout
The details of the Affordable Care Act are lost in translation. This post details the major problems with the provider-CMS insurance bureaucracy. It is also the major reason for most physician burnout. Whether or not the Affordable Care Act is repealed this is one of the major problems for any revised system.
To paraphrase Tolstoy, all competence is alike, but every incompetence is incompetence in its own way. Every time I think I’ve seen the horizon of incompetence, I’m dealt a surprise. The sun never sets on incompetence. In healthcare, incompetence can be found in odd places, such as three recent examples encountered with third party payers.
Case 1: Downgrading Caviar to Boiled Salmon
A patient was referred for a CT angiogram run off – which is a CT scan of the arteries of the belly, pelvis, both legs and feet – a very detailed and costly study. The cardiologist suspected a pseudo-aneurysm of the femoral artery. The exam was an overkill, I felt, as the femoral arteries could be covered in a CT angiogram of the abdomen and pelvis – you don’t need to image down to the toes. I was confident that a pseudo-aneurysm in the femoral artery would not extend to the arteries of the feet – it would be a world record, if it did. I suggested we stop the exam in the middle of the thigh. “That’s fraud,” warned the chief technologist, who was also an expert in billing.
The Spectacular Incompetence of 3rd Party Payers | THCB
To paraphrase Tolstoy, all competence is alike, but every incompetence is incompetence in its own way. Every time I think I’ve seen the horizon of incompetence, I’m dealt a surprise. The sun never sets on incompetence. In healthcare, incompetence can be found in odd places, such as three recent examples encountered with third party payers.
Case 1: Downgrading Caviar to Boiled Salmon
A patient was referred for a CT angiogram run off – which is a CT scan of the arteries of the belly, pelvis, both legs and feet – a very detailed and costly study. The cardiologist suspected a pseudo-aneurysm of the femoral artery. The exam was an overkill, I felt, as the femoral arteries could be covered in a CT angiogram of the abdomen and pelvis – you don’t need to image down to the toes. I was confident that a pseudo-aneurysm in the femoral artery would not extend to the arteries of the feet – it would be a world record, if it did. I suggested we stop the exam in the middle of the thigh. “That’s fraud,” warned the chief technologist, who was also an expert in billing.
“Why is it fraud to restrict the field of view to the area of clinical relevance?” I asked.
“You can’t bill for a CT angiogram run off and only do the abdomen and pelvis. That’s fraud.”
“You can’t bill for a CT angiogram run off and only do the abdomen and pelvis. That’s fraud.”
“Why don’t we bill just for CT angiogram of the abdomen and pelvis?” I asked.
“You can’t bill just for the abdomen and pelvis, the patient has been pre-authorized for a run off.”
“You mean I can’t do less and bill for less when the patient has been pre-authorized for more and the insurer will pay more?” I asked.
Case 2: Cutting your nose to spite your face
A young man had a cardiac MRI for palpitations. During the exam I spotted a hole in the heart – a left-to-right shunt. It was an incidental finding. I thought we should get flow measurements through the aorta and pulmonary artery – it would be useful information which could help the management, because the timing of repair of shunts depends on these parameters.
A young man had a cardiac MRI for palpitations. During the exam I spotted a hole in the heart – a left-to-right shunt. It was an incidental finding. I thought we should get flow measurements through the aorta and pulmonary artery – it would be useful information which could help the management, because the timing of repair of shunts depends on these parameters.
“Can’t do flows. He hasn’t been pre-authorized for them,” said the tech.
“Just do it. Don’t bill – I’ll take the flak,” I offered.
“Can’t, we’re forbidden to do more than has been ordered,” the tech protested.
The referring cardiologist agreed and put an order for flow mapping. However, the order needed authorization from insurers. I phoned the insurer who connected me to a physician from the advanced imaging management elite squad – also known as radiology benefit managers. The chap, a most boring metronome, told me that the first line test for left-to- right shunt was an echocardiogram. I explained that the patient, a young professional with a demanding job, would have to take another day off work – we could easily nip the issue in the bud within five minutes. But the chap continued like a broken down record, “Our guidelines say echocardiogram first.”
The referring cardiologist agreed and put an order for flow mapping. However, the order needed authorization from insurers. I phoned the insurer who connected me to a physician from the advanced imaging management elite squad – also known as radiology benefit managers. The chap, a most boring metronome, told me that the first line test for left-to- right shunt was an echocardiogram. I explained that the patient, a young professional with a demanding job, would have to take another day off work – we could easily nip the issue in the bud within five minutes. But the chap continued like a broken down record, “Our guidelines say echocardiogram first.”
I slammed the phone and muttered “ducking tosser” under my breath.
The patient came back another day for an echocardiogram and another day for another cardiac MRI for flow measurements because the echocardiogram was not clear enough. Imagine – two separate days of taking time off work, driving on the interstate, and finding parking, could so easily have been avoided. Not to mention that the insurer could have saved money. To say nothing about time wasted by physician, imaging department and unnecessary increased exposure to radiation. This was a purely administrative issue, and flies in the face of several well established medical guidelines. 'primum non nocere' and eliminated any judgment factor on the part of the legaly respomsible provider.
The patient came back another day for an echocardiogram and another day for another cardiac MRI for flow measurements because the echocardiogram was not clear enough. Imagine – two separate days of taking time off work, driving on the interstate, and finding parking, could so easily have been avoided. Not to mention that the insurer could have saved money. To say nothing about time wasted by physician, imaging department and unnecessary increased exposure to radiation. This was a purely administrative issue, and flies in the face of several well established medical guidelines. 'primum non nocere' and eliminated any judgment factor on the part of the legaly respomsible provider.
Case3: Charity is fraud Provider Confusion
I spotted a mass in the kidney at the edge of the field of view, which looked like cancer, in an elderly man having a cardiac MRI.
I spotted a mass in the kidney at the edge of the field of view, which looked like cancer, in an elderly man having a cardiac MRI.
“Let’s go lower and cover the kidneys, and the bladder,” I asked the technologist.
“I can’t. That’s fraud. Covering the kidneys will make this an MRI of the abdomen, which the patient doesn’t have a script for.” The technologist said.
“Fraud! WTF,” I barked.
“It is Medicare fraud if you do more for the patient than what you’ve billed for,” explained the technologist. I was losing my marbles – but I wasn’t going to relent with this one.“Just do it – put my name down. Say I insisted. And if it’s fraud to do more than I billed for, I’ll happily go to Guantanamo Bay for fraud.”
“Fraud! WTF,” I barked.
“It is Medicare fraud if you do more for the patient than what you’ve billed for,” explained the technologist. I was losing my marbles – but I wasn’t going to relent with this one.“Just do it – put my name down. Say I insisted. And if it’s fraud to do more than I billed for, I’ll happily go to Guantanamo Bay for fraud.”
The kidneys were covered. I overcalled the finding in the kidney – the patient did not have cancer. However, the technologist was correct – it can be considered fraud to dispense billable services (such as an MRI of the abdomen) to Medicare patients without billing Medicare. This reminds me of a physician I once met, who specializes in physical medicine and rehabilitation, and runs a direct pay practice. She doesn’t accept Medicare, Medicaid or any insurance. She sees kids of undocumented migrants for free one afternoon a week, but won’t extend the same courtesy (i.e. waiving charges) to patients on Medicaid because she fears she might be fried for fraud.
Charity is fraud with Medicare and Medicaid. Allow that to sink for a moment.
I understand it is fraud if you buy a ticket from Philadelphia to New York and get off at Boston, but how is it fraud if you buy a ticket to Boston and get off at New York? Who makes these rules? Who are these people? Which parts of their brain light up on functional MRI? What do they eat for breakfast? How can a country which gave the world Edison, Wright brothers, and Kim Kardashian produce such imbeciles?
I understand it is fraud if you buy a ticket from Philadelphia to New York and get off at Boston, but how is it fraud if you buy a ticket to Boston and get off at New York? Who makes these rules? Who are these people? Which parts of their brain light up on functional MRI? What do they eat for breakfast? How can a country which gave the world Edison, Wright brothers, and Kim Kardashian produce such imbeciles?
It is hard to maintain disdain for such buffoonery for too long because such spectacular incompetence is an art, a practiced art to be precise, but art nonetheless, and art induces wonder, eventually. But even this explanation is wrong. Third party payers are not incompetent. They may seem to be, but they’re not.
The reason insurers, and Medicare, would rather pay more, than less, for an exam, that is cut off their nose to spite their face, is that they don’t trust physicians. They don’t trust physicians because fifty years of health economics has yielded a spectacular insight – physicians, like crack dealers, are guilty of supplier-induced demand. This meme is now structurally embedded in payers.
The information to discern between physicians inducing their demand and physicians curbing their demand is too costly to obtain. So third party payers have a blanket rule – you can neither upgrade nor downgrade an imaging study, and if you do you’ll be paid nothing or will be done for fraud.
Don’t get me wrong – I’m flattered that I induce my demand in healthcare (I wish I could induce my demand in other areas, too). But a costly game of chicken is being played between payers and providers. It’s a game of reverse chicken actually, where both sides avoid staring at each other, and adapt to each other’s pathologies. The costs of this game may be forgivable but the inconvenience to patients is inexcusable.
The Bottom Line
There is an ever present tension between providers, hospitals, and insurance companies.
There are good reasons for this state of mind. Have you ever examined a bill from the emergency department and/or hospital visit or surgical procedure? This 'Alice in Wonderland' example truly astounds. Hospitals routinely send statements to the plans for tens of thousands of dollars and accept payments of less than 30% of the billed amount. Is this fraud? Technically, it is not since plans and hospitals negotiate contracts to lesser amounts. However if a patient is not insured they would receive a statement saying they owed the full amount. A heart stopper for the patient. This has been an ongoing situation since I began medical practice over 40 years ago, and it has become much worse. It becomes even worse if one attempts to examine why, the details of which are buried in bureaucratic mandates and rules regarding formulas for reimbursement, including the diagnostic related group, which reimburses based upon diagnosis rather than fee for services. Another set of payment reform in being added to the mix, that of value based payments,k which correlates the quality measures the hospital uses based upon an arbitrary metric created by 'health experts and committees which may have no real world value.
Disclaimer
The vignettes have been modified from their true state to protect patient health information and to protect the author from HIPAA vigilantes and bounty hunters. However, the gist of the vignettes is correct.
The Spectacular Incompetence of 3rd Party Payers | THCB
Friday, January 20, 2017
Trump’s Nominee For Agriculture Has Key Health Role |
Although consumers may simply think of the Department of Agriculture (USDA) as responsible for overseeing the farming industry, it also plays a key role in promoting health. The department is influential in maintaining the nation’s health in four key areas:
Nutrition Assistance
Although food insecurity across the nation has declined in recent years, the USDA found 12.7 percent of all households in 2015 faced hunger. The department helps address this problem by managing the nation’s food assistance initiatives. The Supplemental Nutrition Assistance Program (SNAP) is among the best known of those efforts. SNAP, formerly called food stamps, provides a monthly stipend to eligible residents through an Electronic Benefit Transfer, or EBT, card to use at any qualifying grocer. Since its inception, SNAP has become the nation’s largest safety net for the hungry, feeding more than 44 million Americanslast year. There are additional programs through the school dietary program, the Summer Food Service Program distributes meals at public areas such as churches and playgrounds. This program helped feed 2.6 million children every day during the program’s peak month of July in 2015. Department of Health and Human Services, the department issued the 2015-2020 Dietary Guidelines for Americans
Supporting Rural Medicine
Among those efforts is the Distance Learning and Telemedicine Grants, which distributes millions of dollars to strengthen telecommunications in rural communities and increase access to resources such as teachers and doctors
Among those efforts is the Distance Learning and Telemedicine Grants, which distributes millions of dollars to strengthen telecommunications in rural communities and increase access to resources such as teachers and doctors
Health Education
Since 1969, the Expanded Food and Nutrition Education Program has worked with low-income families to develop healthy diet and exercise habits and educate them about food safety.
Preventing Foodborne Illness Nationally And In Your Home
The USDA helps protect the food supply through the Food Safety and Inspection Service. The office monitors the importation of meat, poultry and egg products by issuing safety certifications to some foods from other countries and auditing their food inspection systems.
The USDA helps protect the food supply through the Food Safety and Inspection Service. The office monitors the importation of meat, poultry and egg products by issuing safety certifications to some foods from other countries and auditing their food inspection systems.
Domestically, the same agency monitors food processing and distribution through microbiological testing. It also maintains a system that tracks and alerts potentially dangerous foods. For consumers, the office maintains a USDA Meat and Poultry Hotline to answer individual questions about food preparation.
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Amid the cacophony of confirmation hearings for Cabinet nominees, President-elect Donald Trump reportedly has settled on former Georgia Gov. Sonny Perdue to fill the final Cabinet-department vacancy: secretary of Agriculture.
Trump’s Nominee For Agriculture Has Key Health Role | California Healthline
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