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Is it all in your head? Of course, it is. Your brain is where you think and feel. It is all biochemistry. It is also electrical. Medicine is just beginning to understand the process, due to the relatively recent addition of specialized imaging. It is now possible to see what is occurring in the brain by monitoring glucose uptake and locating the exact areas that "light up" when thinking, feeling, moving, or sensing our surroundings.
The irony of “it’s all in your head” is that although this phrase is often used inappropriately and dismissively, it is technically correct. The problem does indeed lie within the head. More specifically, it lies within the brain and its complex networks that we are just beginning to understand. Over the past 10 years, neuroimaging research studies have consistently identified brain abnormalities in patients with medically unexplained symptoms—yes, biologically based changes in the activity and connections of brain regions, such as the amygdala, prefrontal cortex, temporal-parietal junction, and other structures.1 These brain circuit abnormalities provide physiological explanations for once mysterious links between regions implicated in emotional processing and the generation of “physical” symptoms (eg, pain, fatigue, weakness). Jean-Martin Charcot, MD, a famous 19th-century French neurologist and early pioneer of this field, reportedly insisted that a “functional lesion” would be found when microscopes were sufficiently powerful.2 Well, our microscopes are getting better, and we are now starting to see evidence of the predicted functional or software disruptions in the brain.
We still do not fully understand what causes these software problems; however, recent research suggests a multifactorial etiology, including genetic predisposition, environmental risk factors (eg, childhood adverse events), and psychological stressors.
In the case of gastrointestinal disorders, we know that the GI system's neurologic system is equivalent to a second brain, in terms of weight and size. Our head brain is connected directly to the gut-brain by the Vagus nerve
The Clinical Encounter
Based on such attitudes, a typical physician-patient interaction may proceed as follows: (1) the physician provides a rundown of normal investigations, (2) the patient is told they have no known medical diagnoses, (3) a brief awkward exchange occurs, and (4) little further explanation, guidance, resources, or facilitation of an appropriate referral process is given. Even if the infamous phrase is not explicitly stated, this sequence leaves the patient to infer for themselves that it must be all in their head. Unfortunately, they do not perceive this as, “I have a real dysfunction of networks in my brain,” but instead understandably conclude that “they think I’m crazy” or “faking it.”4 Sometimes, patients may hear the distant utterance of, “Maybe you should see a psychiatrist,” as they exit the office door, but in this context, such advice is rarely productive.
Many of these patients can be so offended by this encounter that they quickly seek multiple second opinions and subsequent rounds of pricey and unnecessary investigations. Depending on the jurisdiction and medical record system, the original physician may be completely unaware of these additional rounds of care. Mounting negative and invalidating clinical interactions can become a source of distress and cause medical trauma. At this point, patients often either fall through the cracks or stumble on a fringe medical specialist or alternative medicine practitioner who may offer the “physical” diagnosis they’ve been yearning for. This could include a growing list of unsubstantiated metabolic deficiencies, infectious disorders, or autoimmune hypersensitivities. Anecdotally, the most common current example seems to be the diagnosis of chronic Lyme disease by unvalidated assays.5 Let me be clear that many of these practitioners are well-intentioned and can offer holistic approaches that medicine could learn a lot from. However, there appears to be a subset that takes advantage of these patients’ desire for “physical” diagnosis and exploit their vulnerabilities.
For the patient, receiving such a concrete, “organic” diagnosis often quells mounting anxiety, which in itself could be partially therapeutic. However, now wedded to their given diagnosis with no knowledge of their actual software problem, patients do not see a need to address underlying factors that may be contributing to their disorder nor do they receive the multidisciplinary care that they may so badly need. The saddest part of this epidemic is that if addressed early, these symptoms may be reversible; however, with delays to proper diagnosis and management, prognosis worsens considerably.
Included below are several helpful video programs of patients with FND.
Unfortunately, physicians trained in another era often used the term "conversion disorder" as a wastebasket term for a disorder that could not be measured with laboratory testing. Modern neuroscience and diagnostic imaging and soon biological markers will help make a diagnosis.
Research builds on the Sound Health Initiative, an NIH-Kennedy Center partnership in association with the National Endowment for the Arts.
"There is so much we still don’t know about the effects of music in health broadly, and this partnership aims to explore this uncharted territory."
-Dr. Francis Collins, NIH Director
"If people understood the power of arts in our lives, it would affect the way we make arts accessible to everyone."
-Renée Fleming, Kennedy Center Artistic Advisor at Large
"If people understood the power of arts in our lives, it would affect the way we make arts accessible to everyone."
-Renée Fleming, Kennedy Center Artistic Advisor at Large
The National Institutes of Health has awarded $20 million over five years to support the first research projects of the Sound Health initiative to explore the potential of music for treating a wide range of conditions resulting from neurological and other disorders. The National Endowment for the Arts contributed funds toward these awards. While music therapy has been in practice for many years, Sound Health research aims to advance our understanding of music’s mechanism of action in the brain and how it may be applied more broadly to treat symptoms of disorders such as Parkinson’s disease, stroke, chronic pain and many more. The research will also seek to understand the effect of music on the developing brain of children.
“We know that the beat of a metronome can steady the gait of someone with Parkinson’s disease, for example, but we don’t fully understand how that happens,” said NIH Director Francis S. Collins, M.D., Ph.D. “If we can pinpoint in the brain how music therapy works through the use of imaging and biomarkers, the hope is that we can improve its effectiveness and apply it more broadly to improve the lives of millions of people who suffer from neurological and other disorders.”
Through a series of workshops beginning in January 2017 that involved neuroscientists, music therapists, and supporters of both biomedical research and the arts, NIH developed the Sound Health research plan that informed today’s grant awards. With funding from 10 NIH institutes, centers and offices, Sound Health awardees will:
Investigate the impact of music and singing on the walking ability and gait of people with Parkinson’s disease and older adults, and how these methods influence the brain.
Study how repeated exposure to music — including songs stuck in your head sometimes referred to as earworms — contribute to the creation and consolidation of memories, and how music serves as a cue for retrieving associated memories even when memory structures of the brain involved in effortful memory retrieval are damaged, as in Alzheimer’s disease.
Analyze data from longitudinal studies that define growth curves of brain and behavior from childhood to adulthood to learn how brains are shaped by music and how musical training affects attention, executive function, social/emotional functioning, and language skills.
Examine mechanisms underlying the effects of music intervention on improving early speech and later language learning for developing infants, specifically those at-risk for speech and language disorders.
Assess the effects of active music interventions on multiple biomarkers to provide a more holistic understanding of how active music interventions work to mitigate cancer-related stress and its potential to improve immune function.
Study musical rhythm synchronization as a mechanism of healthy social development and how that is disrupted in children with an autism spectrum disorder, with the goal of developing music interventions for social communication.
Want To Reduce Suicides? Follow The Data — To Medical Offices, Motels And Even Animal Shelters
On Kimberly Repp’s office wall is a sign in Latin: Hic locus est ubi mors gaudet succurrere vitae. This is a place where the dead delight in helping the living.
For medical examiners, it’s a mission. Their job is to investigate deaths and learn from them, for the benefit of us all. Repp, however, isn’t a medical examiner; she’s a Ph.D. microbiologist. And as the epidemiologist for Washington County in Oregon, she was accustomed to studying infectious diseases like flu or norovirus outbreaks among the living.
But in 2012 she was asked by county officials to look at suicide. The request led her into the world of death investigations, and it also appears to have led to something remarkable: In this suburban county of 600,000 just west of Portland, the suicide rate now is going down. It’s remarkable because national suicide rates have risen despite decades-long efforts to reverse the deadly trend.
Northern California’s Humboldt County, where the suicide rate is higher than the statewide average, has begun implementing a system like Repp’s. Officials there have identified several unexpected locations, including public parks and motels, where people have died by suicide. They can now turn those sad facts into action plans.
In addition to place, certain life events precipitate suicidal ideation. Loss of a pet, rates were highest among older white men.
Loss of a pet was linked to evictions when patients can no longer house or care for a pet.
IF YOU NEED HELP
If you or someone you know is thinking about suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255, or use the online Lifeline Chat, both available 24 hours a day, seven days a week.
JAMA. Published online September 18, 2019. doi:10.1001/jama.2019.14732
In this Medical News article, experts discuss sensitive ways to tell older adults that they no longer need cancer screening when their life expectancy is less than 10 years.
Finding the Right Words to Stop Cancer Screening in Older Adults
During her geriatric medicine fellowship in 2012, Nancy Schoenborn, MD, took notice of the American Geriatrics Society’s new guideline on caring for older adults with multimorbidity. Its advice for clinicians to incorporate prognosis into their clinical decision-making “really made a lot of sense to me…and it was supported by evidence,” said Schoenborn, an associate professor in the Division of Geriatric Medicine and Gerontology at the Johns Hopkins School of Medicine.
But when she considered how physicians should implement that advice, she didn’t have the words for it. Literally. “[I]t wasn’t clear how we should talk about it,” she said. The issue was particularly salient in cancer screening guidelines, which often use the life expectancy of fewer than 10 years as the time to stop screening. Especially in primary care settings, where most cancer screening takes place, Schoenborn struggled with how physicians should tell healthy older patients they no longer need a mammogram, prostate-specific antigen test, or other routine cancer screening.
“If they pointed to the [guideline] and said, ‘Look, it says don’t screen if you have less than 10 years to live,’…that’s not going to go over very well,” she said. So Schoenborn went straight to the front lines. She and her colleagues interviewed older adults and primary care clinicians about how to discuss life expectancy in clinical decision-making and stopping cancer screening. In their most recent study, the investigators compared perspectives from both sides.
The study’s “good news is that there are several common themes that both the physicians and the patients agreed upon,” said Alexia Torke, MD, associate professor of medicine at the Indiana University School of Medicine, who has published research on cancer screening cessation. “That provides a good, brief framework for starting off this conversation,” added Torke, who wasn’t involved in the study.
Benefits vs Harms
Clinicians and older adults agree that talks about stopping cancer screening should include a discussion of the benefits and harms. “Every screening test has risks,” noted Elizabeth Eckstrom, MD, MPH, chief of geriatrics at the Oregon Health & Science University. “Mammography is a perfect example because there are so many false-positives. [W]ith colonoscopy…you could perforate the colon at a time when the person should never have had the procedure in the first place.”
When they’re armed with information about the pros and cons of screening, older adults in the study said the decision on whether to have the test should be their own. Clinicians agreed. Said one clinician who was interviewed: “I tell them that we are a team, so I explain the information and…then I leave it up to them.” But if older patients forgo screening, they also don’t want to feel that they’re receiving less care. “I would not want to just [stop screening] and then just not do anything else,” an older adult in the study said.
Perhaps the chief worry among clinicians was that by suggesting it’s time to stop cancer screenings, patients could become angry and feel their physician was giving up on them. “That was really a major concern and barrier” for clinicians, Schoenborn said. Added Eckstrom: “It’s a big deal emotionally for a lot of doctors.”
But older patients said they wouldn’t think badly of their physician for suggesting it’s time to stop screening. “They were actually not as reluctant as the doctors thought,” Schoenborn noted. “Many of them were willing, some had already stopped, and if they trusted their doctor it was not necessarily perceived as a negative thing.” In fact, patients in the study hoped clinicians would find that perception reassuring, she added.
Focusing on other health priorities “hopefully would give [clinicians] some place to start to have that conversation,” Schoenborn said. Eckstrom also has another strategy. “Sometimes I say, ‘You get to graduate from cancer screening; it’s a good thing. You don’t need this anymore,’” she explained. Some of her patients are relieved to learn they no longer need cancer screening tests. “Who wants another colonoscopy in their 80s?” she said.
Decades of public health messages have emphasized the importance of cancer screening. “We have these very clear, consistent messages that sit on the side of a [mailbox] or on a billboard: get your colonoscopy,” Torke said.
Clinicians and patients get into the routine of regular screening, and advocacy groups sport pink ribbons to encourage mammograms. “There is a lot of emotional attachment to doing that,” Schoenborn said. “It’s part of being a good citizen.”
But the time may be ripe for a “more public health approach to raise awareness in the public that stopping screening can be the right thing,” she added. “Maybe a first step is just to raise awareness that it’s not something we all have to do until we die.
From. JAMA, September 20, 2019 Elizabeth Thomas, DO1; Jennifer Milton, RN, MBA1; Francisco G. Cigarroa, MD
The effect of kidney disease on the nation’s health is significant and expensive. Kidney disease affects more than 30 million individuals in the United States and is recognized as the 10th leading cause of premature mortality. 2 Patients receiving dialysis who are younger than 80 years are expected to live less than one-third as long as their counterparts without ESKD.2 The estimated cost of Medicare spending for beneficiaries with chronic kidney disease and ESKD exceeded $114 billion in 2016.
Prevention, treatment, and research are essential strategies in the management of patients with kidney disease and are highlighted in the 3 goals of the executive order. The aim of the first and second goals is to reduce the burden of renal disease over time, whereas the third goal will provide the most immediate benefit for patients with ESKD. This goal focuses on deceased donors and living donors for kidney transplantation.
In the United States, the waiting list for a kidney is about 100,000 people. Alternatives for ESRD are renal dialysis, cadaver donors, and living donors. The success and survival rates are high in both cases, with rates approaching 85-95%. A living kidney donor yields the highest success and duration.
Attracting suitable donors include organ donation promotion through a choice listed on driver license cards, public service announcements, and joining the National Kidney Registry or register at your local hospital, medical university or by calling
Kidney donation is an amazing gift but is also major surgery involving:
Medical tests that will require at least one full day at the hospital.
1 – 3 days in the hospital after surgery.
Typically 2 – 4 weeks off work for recovery.
There are means to offset the loss of income for donors who have an income of less than 62,000 per annum.
The most successful kidney donors are immediate family members related by blood, such as brothers, sisters, cousins or close aunts and uncles. Gender has no determining effect.
Efforts to improve the live kidney donor program should include:
The Advancing American Kidney Health Executive Order serves as a framework for furhter improvement in the Live Kidney Donor programs.
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Viewpoint
September 20, 2019
The Advancing American Kidney Health Executive Order
An Opportunity to Enhance Organ Donation
Elizabeth Thomas, DO1; Jennifer Milton, RN, MBA1; Francisco G. Cigarroa, MD1
Author Affiliations Article Information
JAMA. Published online September 20, 2019. doi:10.1001/jama.2019.14500
author interview icon Interviews
Audio Interview (23:35)
The Advancing American Kidney Health Executive Order
On July 10, 2019, President Trump signed an executive order to launch “Advancing American Kidney Health,” an outline of policy priorities centered on advancing 3 main goals: (1) preventing kidney failure whenever possible through better diagnosis, treatment, and incentives for preventive care; (2) increasing patient choice through affordable alternative treatments for end-stage kidney disease (ESKD) by encouraging higher-value care, educating patients on treatment alternatives, and encouraging the development of artificial kidneys; and (3) increasing access to kidney transplantation by modernizing the organ recovery and transplantation systems and updating outmoded and counterproductive regulations.1
The effect of kidney disease on the nation’s health is significant and expensive. Kidney disease affects more than 30 million individuals in the United States and is recognized as the 10th leading cause of premature mortality.2 Patients receiving dialysis who are younger than 80 years are expected to live less than one-third as long as their counterparts without ESKD.2 The estimated cost of Medicare spending for beneficiaries with chronic kidney disease and ESKD exceeded $114 billion in 2016.2
Prevention, treatment, and research are essential strategies in the management of patients with kidney disease and are highlighted in the 3 goals of the executive order. The aim of the first and second goals is to reduce the burden of renal disease over time, whereas the third goal will provide the most immediate benefit for patients with ESKD. This goal focuses on deceased donors and living donors for kidney transplantation.
Regarding deceased donation, the executive order introduces strategies to improve the use of organs from deceased donors, but more can be done. For example, increasing the number of registered donors is critical to augmenting organ donation. Donor registries allow individuals to register their legally binding decision to donate rather than leaving the decision to their surrogate decision-maker. Data suggest that the most effective donation authorization strategy for the United States is to build on the current opt-in system and to increase the number of registered donors from 54% to more than 75%, considering that the majority of residents indicate they would donate their organs.3 This percentage increase would increase available organs for donation and could save thousands of lives. Moreover, educational campaigns, such as the establishment of RegisterMe.org and registration via the iPhone Health app, could substantially increase the number of registered donors. In addition, hospitals must ensure donor registrations are honored through staff and physician education as well as quality reviews and process improvements focused on root causes of any failure to proceed with procurement of organs from a medically suitable and registered organ donor.
Another important endeavor with the capacity to increase potential transplants involves how to better allocate kidneys from individuals with unique risks such as those (1) with a high kidney donor profile index (KDPI), (2) at increased risk for transmitting HIV, hepatitis B virus, or hepatitis C virus (HCV) (risk designated by the US Public Health Service), and (3) from donors infected with HCV. The KDPI is a numerical measure that combines 10 donor factors to summarize into a single number the quality of deceased donor kidneys relative to other recovered kidneys. It is a useful index, but should not be used in isolation because transplantation outcomes are dependent on variables from both the donor and recipient.
To decrease the number of organs not being used because of a high KDPI, transplantation programs would benefit from access to high-quality biopsies with prompt interpretations by experienced pathologists and ex-vivo perfusion to better characterize the quality of the kidneys and better predict outcome. For increased risk donors as defined by the Public Health Service, the standard use of nucleic acid testing minimizes the risk of unknowingly exposing a recipient to infections such as HCV and HIV. The estimated window period of risk (the time between acquisition of infection and serological detectability) with nucleic acid testing for HCV ranged from 0.027 to 32.4 per 10 000 donors and the window period of risk for HIV infection ranged from 0.04 to 4.9 per 10 000 donors based on the types of at-risk behaviors of the donor.4,5
Known HCV-positive donor organs can be given to HCV-negative recipients with informed consent, given the availability of antiviral therapies that achieve undetectable levels of HCV in 95% to 100% of patients with HCV infection after 12 to 24 weeks of treatment. Physicians and patients should understand the benefits of good organ function far outweigh the risks of infection in the majority of cases, given the effectiveness of nucleic acid testing and antiviral therapies. Although the Centers for Medicare & Medicaid Services and the United Network for Organ Sharing encourage transplantation centers to expand the use of these organs within the context of considering the benefits and risks to the patient, increasing the reimbursement by payers for using these organs would most likely incentivize their use and offset the higher costs of patient care and monitoring required after transplantation.
Living donors offer the most promising option for increasing the number of successful kidney transplants. The 5-year survival rate for patients receiving a kidney graft from a living donor is 85% on average vs 75% from a deceased donor, and the 10-year graft survival rate is 65% vs 48%, respectively.6 A living donor graft is less likely to develop delayed graft function that affects the overall quality and longevity of the transplanted kidney.6 Recipients of living kidney donors also do not have to wait for their transplant, whereas those without a living donor wait 5 years on average for their transplant. Similarly, recipients of living donor kidneys can avoid starting dialysis in most cases, will not accumulate the morbidities that accompany kidney disease or dialysis over time, maintain a higher quality of life, all of which reduce the costs to the health care system and Medicare spending. Estimated health care system costs are more than $89 000 per patient per year once dialysis has begun.7 By maximizing living donor transplants, more deceased donor organs will be available to patients who do not have a living donor.
Why are more living kidney donor transplants and other living donor organ transplants (such as liver) not occurring? The primary reasons are (1) recipient’s and donor’s incomplete knowledge of the adverse effects of kidney disease or another end-stage organ disease; (2) inadequate education regarding the safety and recovery of the surgical procedure; and (3) the concern for incurring debt and potential for long-term health risks.
Public health campaigns to communicate the importance and safety of living kidney donation are needed. Based on United Network for Organ Sharing requirements and policies, the living donor evaluation is extremely thorough and continually prioritizes the safety and well-being of the donor, both at the time of donation and for any estimated future risks. The perioperative mortality for donor nephrectomy is 3.1 per 10 000 donors.8 The estimated cumulative incidence of ESKD at 20 years after a donation is 50.9 per 10 000 donors.9 The absolute risk of developing ESKD is slightly higher among donors who are younger at donation (38.0 vs 41.0 years), black, male, obese (body mass index >30), is a first-degree relative of the transplant recipient, and who are less likely to live in a wealthy neighborhood, but this risk is still at less than 1%.10 Long-term survival among donors and healthy comparison patients is similar.8
The expansions in charitable assistance described in the executive order could serve to reduce the burden of lost wages, travel expenses, and other costs living donors encounter. It is imperative that federal donor-directed policies are put into place such that qualified and willing living donors are not disincentivized based on potential financial hardships related to donation, concerns about loss of employment, and apprehensions about increased health insurance premiums or loss of coverage after donation. These disincentives are not hypothetical but real. In some cases, inadequate post-donation coverage offered by the recipient’s insurance and limited donor insurance plans has led to the loss of otherwise qualified donors to provide life-saving grafts to their intended recipients. Although insurers may have effective coverage for preoperative evaluation and donation, they may have limited or no coverage for routine care required after donation, including federally mandated follow-up, and limited or no coverage for complications related to organ donation. Routine post-donation care is usually inexpensive, and complications are rare, so the lack of coverage is illogical and unacceptable.
The need to better support living donors is important not only to reduce the burden of end-stage organ failure but also from the obligation of the community to support those generous individuals willing to be donors. Their gift is a sacrifice that deserves gratitude. There should be federal protection against loss of employment and consistency among all private payer insurance companies to cover any donor-related health care costs to a living donor for 1 year after organ donation. Options under Medicare should exist to reimburse unpaid medical expenses after donation not covered by private payers. Private insurance or federal funding should be provided to donors for all reasonable travel and accommodations related to donation. Federal mandates should protect living donors from having the status of a preexisting condition simply due to their donor status. This kind of support would allow many willing donors to realize their desire to donate and it could provide life-saving organs to recipients in need.
This Viewpoint uses provisions in President Trump’s 2019 American Kidney Health Executive order calling for an increase in access to kidney transplantation to discuss strategies to increase deceased and living donor pools, improve the allocation of organs from higher-risk donors, and support the...
Groupon-type deals for health care aren’t new. They were more popular in 2011, 2012 and 2013, when Groupon and its then-competitor LivingSocial were at their heights.
Emory University medical fellow Dr. Nicole Herbst was shocked when she saw three patients who came in with abnormal results from chest CT scans they had bought on Groupon.
Yes, Groupon — the online coupon mecca that also sells discounted fitness classes and foosball tables.
Similar deals have shown up for various lung, heart and full-body scans across Atlanta, as well as in Oklahoma and California. California Groupon also offers discount coupons for expectant parents looking for ultrasounds, sold as “fetal memories.”
While Herbst declined to comment for this story, her sentiments were shared widely by the medical community on social media. The concept of patients using Groupons to get discounted medical care elicited the typical stages of Twitter grief: anger, bargaining, and acceptance that this is the medical system today in the United States.
But, ultimately, the use of Groupon and other pricing tools is symptomatic of a health care market where patients desperately want a deal — or at least tools that better nail down their costs before they get care.
“Whether or not a person may philosophically agree that medicine is a business, it is a market,” said Steven Howard, who runs Saint Louis University’s health administration program.
By offering an upfront cost on a coupon site like Groupon, Howard argued, medical companies are meeting people where they are. It helps drive prices down, he said, all while marketing the medical businesses.
For Paul Ketchel, CEO and founder of MDsave, a site that contracts with providers to offer discount-priced vouchers on bundled medical treatments and services, the use of medical Groupons and his own company’s success speak to the brokenness of the U.S. health care system.
MDsave offers deals at over 250 hospitals across the country, selling vouchers for anything from MRIs to back surgery. It has experienced rapid growth and expansion in the several years since its launch. Ketchel attributes that growth to the general lack of price transparency in the U.S. health care industry amid rising costs to consumers.
“All we are really doing is applying the e-commerce concepts and engineering concepts that have been applied to other industries to health care,” he argued. “We are like transacting with Expedia or Kayak while the rest of the health care industry is working with an old-school travel agent.”
Some doctors complain the proposed legislation would empower insurers to keep narrower networks and limit access to crucial health services. In California, a fierce battle over surprise medical bills pits docs against insurers
For the second time in as many years, California legislators are debating a bill that would protect patients from paying surprise medical bills when they inadvertently get treatment from doctors who are not covered by their insurance.
Under the bill, AB 72, consumers would only pay the equivalent of in-network rates if, for example, during surgery covered by insurance, they are treated by an out-of-network anesthesiologist, or have X-rays read by an out-of-network radiologist. AB 72 is in the California Senate and must be approved before going to the state assembly and governor. The state legislature has until Aug. 31 to act, or the bill effectively dies in committee.
The legislation was sponsored by state Assemblyman Rob Bonta (D-Alameda), who sponsored a similar bill last year that languished over the finer points of what the lower, in-network-style payment would be.
Surprise medical bills occur in a small percentage of overall health care transactions, but they often result in thousands of dollars in unanticipated charges that are difficult for many people to afford. Patients get hit with these extra charges because, in the course of getting treatment, one or more ancillary providers aren’t on their insurance plan, even if the main provider, like a surgeon, is. That ancillary provider maybe someone who routinely works with a particular surgeon or hospital, or just happens to be the only one available that day, said Bonta, so even if patients do all their homework to make sure they are covered, it isn’t enough.
In California, this fight is on full display and the proposal is generating harsh criticism from some doctors because they have to take that lower rate or go to arbitration.
“We’re supposed to hire an attorney or go off to a dispute resolution process, spend hours getting ready, and then hours at the process?” said Dr. Michael Couris, a San Diego ophthalmologist. “You’re telling me this is a tenable position? This is laughable.”
Some independent physicians argue the current proposal would only empower insurers to keep narrower networks, ignore independent physicians and small practices, and limit access to crucial health services.
Emergency Room surprise bills are common as well.
Mystery Solved: Private-Equity-Backed Firms Are Behind Ad Blitz on ‘Surprise Billing’
Two doctor-staffing companies are pushing back against legislation that could hit their bottom lines.
The emergency department doctor you see in the emergency room does not work for the hospital. He (She) is employed by an outside contract group who negotiated a contract with the hospital for care. This theoretically avoids the issue of hospitals employing physicians directly. It eliminates the cost of benefits, vacation pay and deductions for taxes and health insurance. Early this summer, Congress appeared on its way to eradicating the large medical bills that have shocked many patients after emergency care. The legislation to end out-of-network charges was popular and had support from both sides of the aisle. Legislation is also proposed in California and other states regarding surprise emergency medical bills. The bills were well on their way to becoming law when a curious thing happened. Private-Equity-Backed Firms launched an ad Blitz on ‘Surprise Billing’. Then, in late July, a mysterious group called Doctor-Patient Unity showed up. It poured vast sums of money (Dark Money) now more than $28 million — into ads opposing the legislation, without disclosing its staff or its funders.Trying to guess who was behind the ads became something of a parlor game in some Beltway circles. Whether this was by design or happenstance is moot, the end result will be the same.Now, the mystery is solved. The two largest financial backers of Doctor-Patient Unity are TeamHealth and Envision Healthcare, private-equity-backed companies that own physician practices and staff emergency rooms around the country, according to Greg Blair, a spokesman for the group.“Doctor-Patient Unity represents tens of thousands of doctors across the country who understand the importance of preserving access to lifesaving medical care and support a solution to surprise medical billing that protects patients,” said Mr. Blair, who issued the statement weeks after the group was first contacted about the campaign. “We oppose insurance-industry-backed proposals for government rate-setting that will lead to doctor shortages, hospital closures and loss of access to medical care, particularly in rural and underserved communities.” The two health staffing companies have both previously been accused of shifting the cost of uncompensated care in billing disputes to patients. Both say that's no longer the case and that they support a federal solution to surprise billings. But they don't like the congressional panels' approach, which they call government "rate-setting."Ending surprise bills, a big concern for voters of all stripes, was viewed as one of the only health issues in Congress with bipartisan appeal and the backing of the Trump administration. Everyone agreed that a patient who followed the rules and went to an in-network hospital shouldn't get slammed with enormous bills because he or she ended up with an out-of-network provider, such as an emergency physician or anesthesiologist. But insurers, employers, doctors and hospitals from the beginning have vigorously fought over how to solve the problem and who should pay.Two sources affiliated with Doctor-Patient Unity confirmed that Envision Healthcare and TeamHealth are funding a portion of the $28.6 million campaign that runs from July 30 to Sept. 17 in states including Alabama, California, Colorado, and New Hampshire, according to Advertising Analytics. The sources wouldn't say who else is involved but confirmed the two companies are funders.These two entities provide physicians through an obscure system which purchased multiple physician groups, not just in emergency medicine, but also many other hospital-affiliated physicians, HOSPITALISTS | CRITICAL CARE | RADIOLOGY | ANESTHESIA | WOMEN/CHILDREN | SURGICAL |andn OFFICE MEDICINE. It is a commonly accepted practice and affords ease of recruitment for hospital and physician groups.Greg Blair, a spokesperson for Doctor Patient Unity, also confirmed the two companies are funders, and in a statement said the pair represent tens of thousands of doctors who support an alternate approach to ending surprise medical bills that's been enacted in New York and Texas. Those states both use independent mediators to settle payment disputes — an approach known as arbitration — not a government-set pay scale.“We oppose insurance industry-backed proposals for government rate setting that will lead to doctor shortages, hospital closures and loss of access to medical care, particularly in rural and underserved communities,” Blair said in the statement.Envision and TeamHealth both confirmed they back Doctor Patient Unity and echoed similar sentiments.TeamHealth Executive Vice President Dan Collard said the group wants to submit billing disputes between health providers and insurers to arbitration instead of using government-set benchmark rates."We will continue to fight an insurance industry proposal to use government rate setting as a vehicle to increase their profits at the expense of potential hospital closures and doctor shortages in underserved communities," Collard said.
Burnout among physicians is a symptom of something larger: the moral injury of being unable to provide high-quality care in today's health care systems.
Physicians on the front lines of health care today are sometimes described as going to battle. It’s an apt metaphor. Physicians, like combat soldiers, often face a profound and unrecognized threat to their well-being: moral injury.
Moral injury is frequently mischaracterized. In combat veterans it is diagnosed as post-traumatic stress; among physicians, it’s portrayed as burnout. But without understanding the critical difference between burnout and moral injury, the wounds will never heal and physicians and patients alike will continue to suffer the consequences.
Burnout is a constellation of symptoms that include exhaustion, cynicism, and decreased productivity. More than half of physicians report at least one of these. But the concept of burnout resonates poorly with physicians: it suggests a failure of resourcefulness and resilience, traits that most physicians have finely honed during decades of intense training and demanding work. Even at the Mayo Clinic, which has been tracking, investigating, and addressing burnout for more than a decade, one-third of physicians report its symptoms.
We believe that burnout is itself a symptom of something larger: our broken health care system. The increasingly complex web of providers’ highly conflicted allegiances — to patients, to self, and to employers — and its attendant moral injury may be driving the health care ecosystem to a tipping point and causing the collapse of resilience.
Related: Fighting the silent crisis of physician burnout
The term “moral injury” was first used to describe soldiers’ responses to their actions in war. It represents “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” Journalist Diane Silver describes it as “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.”
The moral injury of health care is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of health care.
Most physicians enter medicine following a calling rather than a career path. They go into the field with a desire to help people. Many approach it with almost religious zeal, enduring lost sleep, lost years of young adulthood, huge opportunity costs, family strain, financial instability, disregard for personal health, and a multitude of other challenges. Each hurdle offers a lesson in endurance in the service of one’s goal which, starting in the third year of medical school, is sharply focused on ensuring the best care for one’s patients. Failing to consistently meet patients’ needs has a profound impact on physician wellbeing — this is the crux of consequent moral injury.
Physicians are smart, tough, durable, resourceful people. If there was a way to MacGyver themselves out of this situation by working harder, smarter, or differently, they would have done it already.
In order to ensure that compassionate, engaged, highly skilled physicians are leading patient care, executives in the health care system must recognize and then acknowledge that this is not physician burnout. Physicians are the canaries in the health care coalmine, and they are killing themselves at alarming rates (twice that of active duty military members) signaling something is desperately wrong with the system.
Senior citizens are often the target of scams. One must be constantly aware of unsolicited offerings which could compromise your personal identity or defraud you or a loved one.
The U.S. Department of Health and Human Services Office of Inspector General is alerting the public about a fraud scheme involving genetic testing.
Genetic testing fraud occurs when Medicare is billed for a test or screening that was not medically necessary and/or was not ordered by a Medicare beneficiary's treating physician.
Scammers are offering Medicare beneficiaries "free" screenings or cheek swabs for genetic testing to obtain their Medicare information for identity theft or fraudulent billing purposes. Fraudsters are targeting beneficiaries through telemarketing calls, booths at public events, health fairs, and door-to-door visits.
Beneficiaries who agree to genetic testing or verify personal or Medicare information may receive a cheek swab, an in-person screening or a testing kit in the mail, even if it is not ordered by a physician or medically necessary.
If Medicare denies the claim, the beneficiary could be responsible for the entire cost of the test, which could be thousands of dollars.
Protect Yourself If a genetic testing kit is mailed to you, don't accept it unless it was ordered by your physician. Refuse the delivery or return it to the sender. Keep a record of the sender's name and the date you returned the items.
Be suspicious of anyone who offers you "free" genetic testing and then requests your Medicare number. If your personal information is compromised, it may be used in other fraud schemes.
A physician that you know and trust should assess your condition and approve any requests for genetic testing.
Medicare beneficiaries should be cautious of unsolicited requests for their Medicare numbers. If anyone other than your physician's office requests your Medicare information, do not provide it. If you suspect Medicare fraud, contact the HHS OIG Hotline.
By Elisabeth Rosenthal Ms. Rosenthal, a journalist, and physician is a contributing opinion writer
It’s easy to criticize pharmaceutical and insurance companies. But we spend much more on hospitals.
As voters fume about the high cost of health care, politicians have been targeting two well-deserved villains: pharmaceutical companies, whose prices have risen more than inflation, and insurers, who pay their executives millions in salaries while raising premiums and deductibles.
But while the Democratic presidential candidates have devoted copious airtime to debating health care, many of the country’s leading health policy experts have wondered why they have given a total pass to arguably a primary culprit behind runaway medical inflation: America’s hospitals.
Data shows that hospitals are by far the biggest cost in our $3.5 trillion health care system, where spending is growing faster than the gross domestic product, inflation and wage growth. Spending on hospitals represents 44 percent of personal expenses for the privately insured, according to Rand.
A report this year from researchers at Yale and other universities found that hospital prices increased a whopping 42 percent from 2007 to 2014 for inpatient care and 25 percent for outpatient care, compared with 18 percent and 6 percent for physicians.
So why have politicians let hospitals off scot-free? Because a web of ties binds politicians to the health care system.
Every senator, virtually every congressman and every mayor of every large city has a powerful hospital system in his or her district. And those hospitals are as politically untouchable as soybean growers in Iowa or oil producers in Texas.
The practice of indentured servitude is alive and well in U.S. teaching hospitals. Those laboring under its yoke are known as medical residents.
Hundreds of years ago, poor immigrants were forced to become indentured servants to repay the cost of their passage to the U.S. by performing years of hard labor. This practice lives on for U.S. physicians-in-training, who have no choice but to serve years of indentured servitude to teaching hospitals in order to qualify for a medical license or board certification. We know them as medical residents.
In recent months, the announcement that Hahnemann University Hospital would be closing in September has cast a pall of uncertainty over the future of hundreds of residents who suddenly did not know how or whether they would complete their training. Instead of helping residents find new hospitals that would best support their education, Hahnemann executives, in dealing with Chapter 11 bankruptcy proceedings, simply auctioned its 550 residency slots to the highest bidders, a consortium of regional hospitals, for a sum of $55 million.
The hospital’s recent “sale” of medical residents and their residency slots showcases how some teaching hospitals have subordinated their training mission in favor of the pursuit of profits.
The residents were commoditized and sold as chattels to the highest bidder. Had this occurred to any other group, there would almost certainly have been public outrage. Curiously, there was little protest by entities that oversee the education and well-being of resident physicians. The response from the Association of American Medical Colleges was half-hearted, with a representative telling the Philadelphia Inquirer that the sale “was a big surprise.” Medicare objected to the sale, not because it should be illegal to treat residents as transferable property but because the sale would not allow Medicare to recoup past overpayments to Hahnemann.
To independently practice medicine, students must complete multiyear residencies at accredited hospitals after they graduate from medical school. Once they are matched with a program during the fourth year of medical school, their multiyear funding is tied to the program with which they’ve matched for the duration of their training. Finding a new position mid-way through residency is not trivial, making the instability of a residency program highly stressful for residents.
Teaching hospitals have argued over the years that training physicians comes at a substantial expense. But studies show that graduate medical education programs positively affect hospital finances to the tune of $160,000 to $218,000 per resident physician. In the U.S., Medicare funds a fixed number of residency slots with direct government grants of at least $100,000 per resident — and that does not include the market value of services provided by the resident during his or her training. This amounts to about $15 billion a year in government funding for residencies.
The Hahnemann sale underscores how few strings are attached to this support.
The labor market for residents is controlled by nonprofit teaching hospitals through an intentionally monopolistic entity: the National Resident Matching Program. It is responsible for matching students with residency slots at teaching hospitals during their last year of medical school. These training programs are accredited by the Accreditation Council for Graduate Medical Education. Prospective residents can apply only through a single standardized process called The Match, which allows them to express a preference for where they would like to work, but ultimately locks them into a multiyear employment contract with a single hospital.
This framework allows a sticky web of private governing bodies in medicine, including the Association of American Medical Colleges, the National Resident Matching Program, the Accreditation Council for Graduate Medical Education, and a consortium of hospitals, to dictate the compensation and training conditions for medical residents.
Stop treating medical residents like indentured servants - STAT:
Medical groups are warning that new federal data-sharing rules, enabling people to get their health records through a smartphone, could lead to invasions of privacy.
Apple’s Health Records app lets people send a subset of their medical data to their iPhones from more than 300 health centers.
Americans may soon be able to get their medical records through smartphone apps as easily as they order takeout food from Seamless or catch a ride from Lyft.
But prominent medical organizations are warning that patient data-sharing with apps could facilitate invasions of privacy — and they are fighting the change.
The battle stems from landmark medical information-sharing rules that the federal government is now working to complete. The rules will for the first time require health providers to send medical information to third-party apps, like Apple’s Health Records after a patient has authorized the data exchange. The regulations, proposed this year by the Department of Health and Human Services, are intended to make it easier for people to see their medical records, manage their illnesses and understand their treatment choices.
Yet groups including the American Medical Association and the American College of Obstetricians and Gynecologists warned regulators in May that people who authorized consumer apps to retrieve their medical records could open themselves up to serious data abuses. Federal privacy protections, which limit how health providers and insurers may use and share medical records, no longer apply once patients transfer their data to consumer apps.
Tech executives are promoting data-sharing in health care. From left, Taha Kass-Hout of Amazon, Aashima Gupta of Google and Peter Lee of Microsoft attended a conference in July for Medicare’s Blue Button system.CreditMicrosoft
Without federal restrictions in place, the groups argued, consumer apps would be free to share or sell sensitive details like a patient’s prescription drug history. And some warned that the spread of such personal medical information could lead to higher insurance rates or job discrimination.
“Patients simply may not realize that their genetic, reproductive health, substance abuse disorder, mental health information can be used in ways that could ultimately limit their access to health insurance, life insurance or even be disclosed to their employers,” said Dr. Jesse M. Ehrenfeld, an anesthesiologist who is the chair of the American Medical Association’s board. “Patient privacy can’t be retrieved once it’s lost.”
There are now many electronic medical records that allow smartphone access, such as Epic (MyChart), DrChrono, Kaiser and countless others. When retrieving medical records directly via a desktop computer your records are secure. For EHRs that are HIPAA compliant, the vendor must show compliance for desktop retrieval. If you are using a smartphone and the app provided by the institution it should also be HIPAA compliant.
Dr. Don Rucker, the federal health department’s national coordinator for health information technology, said that allowing people convenient access to their medical data would help them better manage their health, seek second opinions and understand medical costs. He said the idea was to treat medicine as a consumer service, so people can shop for doctors and insurers on their smartphones as easily as they pay bills, check bus schedules or buy plane tickets.
The new rules are emerging just as Amazon, Apple, Google, and Microsoft are racing to capitalize on health data and capture a bigger slice of the health care market. Opening the floodgates on patient records now, Dr. Rucker said, could help tech giants and small app makers alike develop novel consumer health products.
The regulations are part of a government effort to push health providers to use and share electronic health records. Regulators have long hoped that centralizing medical data online would let doctors get a fuller, more accurate picture of patient health and help people make more informed medical choices, with the promise of better health outcomes.
In reality, digital health records have been cumbersome for many physicians to use and difficult for many patients to retrieve.
Americans have had the right to obtain copies of their medical records since 2000 under the federal Health Insurance Portability and Accountability Act, known as HIPAA. But many health providers still send medical records by fax or require patients to pick up a paper or DVD copies of their files.
The new regulations are intended to banish such bureaucratic hurdles.
Dr. Rucker said it was self-serving for physicians and hospitals, which may benefit financially from keeping patients and their data captive, to play up privacy concerns.
“The moment our data goes into a consumer health tech solution, we have no rights,” said Andrea Downing, a data rights advocate for people with hereditary cancers. “Without meaningful protections or transparency on how data is shared, it could be used by a recruiter to deny us jobs,” or by an insurer to deny coverage.
When Apps Get Your Medical Data, Your Privacy May Go With It - The New York Times:
Author information: Hannah T. Neprash, PhD1; Michael L. Barnett, MD, MS2,3 Author affiliations: 1Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis 2Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts 3Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
Physicians were more likely to prescribe opioids later in the day and when appointments were running behind schedule.
After seeing dozens of patients in a hectic and long day in the clinic, when a doctor is faced with another patient in pain, it may be easiest to prescribe opioids and move on to the next one. New research suggests that doctors who practice with this habit could be contributing to the opioid epidemic.
A study published in JAMA Network Open on Friday reveals that physicians were more likely to prescribe opioids later in the day and when appointments were running behind schedule.
“Physicians play a crucial role in the opioid epidemic and it’s important to find the factors that drive decisions to prescribe opioids,” said Hannah Neprash, an assistant professor of health policy and management at the University of Minnesota and the study’s lead investigator. “Many studies have looked at looked at differences in prescribing patterns between physicians but few have looked at variation within physicians.”
The study utilized claims and electronic health data in 2017 for 678,319 patients with new pain who saw 5,603 physicians at health care clinics. The patients’ complaints ranged from back pain and headaches to muscle and joint aches. The researchers looked at the order of appointments and whether an appointment started at its scheduled time. Opioid prescriptions were compared to prescriptions of non-steroidal anti-inflammatory drugs and physical therapy.
When working with patients in pain who want opioids, offering them alternative therapies such as NSAIDs or physical therapy can require time-consuming discussions, Neprash said. “Prescribing opioids may be the quick fix when they do not have enough time to discuss non-opioid options.”
In 2017 there was six times the number of opioid-related deaths compared to 1999. While much of the opioid epidemic is due to illicit drug use, prescription opioids still play a large role. The authors note that if prescribing practices remained constant throughout the day, 4,459 opioid prescriptions would not have been written in 2017.
The study draws attention to demands placed on doctors who are incentivized to see as many patients as possible. The authors recommend protocols to guard against physician fatigue, arguing that if time pressures are affecting opioid prescriptions, other major medical decisions could also be at risk.
This should come as no surprise to a clinician. Pain is bad, and immediate relief is wanted by the patient and physician. Prescribing a pill gratifies both doctor and patient rewarding the encounter clinically, and gratifying a fee for service (pain relief). In today's medical environment satisfaction surveys are supreme. Health insurance companies and plans regularly survey patient's satisfaction quotients based on many subjective metrics.
Dr. Mark Linzer, director of the Office of Professional Worklife at Hennepin Healthcare in Minneapolis, said adding more clinical team members, such as physician assistants and nurse practitioners, could help diffuse the workload of the day and allow clinicians to spend more time with patients. He also proposed making individual visits longer for certain patients in order to provide the time needed to address pain and other sensitive medical problems.
“I suspect this is the tip of the iceberg: that time pressure has numerous adverse consequences, and that these poor outcomes could be attenuated by providing the time that complex patients (including those with acute and chronic pain) need with their clinicians,” said Linzer, who was not involved in the study.
“The conversation that avoids narcotics just takes time,” he said
Was the doctor on time?
Was the staff courteous?
Are you satisfied with the results of your encounter?
How long did you have to wait?
Would you recommend this doctor to a friend or family member?
None of these questions ask for an objective response. None of them are measuring the real quality of care (ie, clinician accuracy). In most cases, patients are incompetent in assessing their doctor's clinical competence.
Worse than that are newer measures of supposed physician competence, MOC (maintenance of competence) (taken five to ten years after initial board certification). Many insurers now list whether a doctor is maintaining MOCs. These tests and certifications reveal no correlation of results, patient satisfaction, nor a reduction in medico-legal events. It may set a totally irrelevant and inaccurate measure of physician quality of care.
