Sunday, April 29, 2012

In Hopeful Sign, Health Spending Is Flattening Out
The New York Times
April 28, 2012

The growth of health spending has slowed substantially in the last few years, surprising experts and offering some fuel for optimism about the federal government’s long-term fiscal performance.

Much of the slowdown is because of the recession, and thus not unexpected, health experts say. But some of it seems to be attributable to changing behavior by consumers and providers of health care — meaning that the lower rates of growth might persist even as the economy picks up.

Because Medicare and Medicaid are two of the largest contributors to the country’s long-term debts, slower growth in health costs could reduce the pressure for enormous spending cuts or tax increases.

In 2009 and 2010, total nationwide health care spending grew less than 4 percent per year, the slowest annual pace in more than five decades, according to the latest numbers from the Centers for Medicaid and Medicare Services. After years of taking up a growing share of economic activity, health spending held steady in 2010, at 17.9 percent of the gross domestic product.

The growth rate mostly slowed as millions of Americans lost insurance coverage along with their jobs. Worried about job security, others may have feared taking time off work for doctor’s visits or surgical procedures, or skipped nonurgent care when money was tight.

Still, the slowdown was sharper than health economists expected, and a broad, bipartisan range of academics, hospital administrators and policy experts has started to wonder if what had seemed impossible might be happening — if doctors and patients have begun to change their behavior in ways that bend the so-called cost curve.

If so, it was happening just as the new health care law was coming into force, and before the Supreme Court could weigh in on it or the voters could pronounce their own verdict at the polls.

“The tectonic plates might be beginning to shift,” said Karen Davis, the president of the Commonwealth Fund, a nonprofit research group in New York. “It’s hard to believe everything that’s been tried over the last decade to slow spending wouldn’t be making a difference.”

Experts were surprised, for instance, at a drop in spending on some hospitalized seniors — people enrolled in Medicare, whose coverage the recession should not affect. They also noted that some of the states where health care spending slowed most rapidly were states that were not hit particularly badly by the recession, suggesting that other factors were at play.

“The recession just doesn’t account for the numbers we’re seeing,” said David Cutler, a Harvard health economist and former adviser to President Obama. “I think there’s much more going on.”

The implications of a bend in the cost curve would be enormous. Policy makers on both sides of the aisle see rising health care costs as the central threat to household budgets and the country’s fiscal health. If the growth in Medicare were to come down to a rate of only 1 percentage point a year faster than the economy’s growth, the projected long-term deficit would fall by more than one-third.

The growth of health costs slowed in the 1990s as health maintenance organizations became more popular. That played a role in both gains in household income — less money on employer-provided health benefits means more money for raises — and in budget surpluses, economists argue.

Some experts caution that there remains too little data to determine whether the current slowdown will become permanent, or whether it is merely a blip caused by the economy’s weakness.

“If there’s something else going on, we don’t know what it is yet,” said Gail Wilensky, a health economist who headed Medicare and Medicaid during the administration of President George Bush. “The most honest thing to say is that, one, the reduction in use is greater than the recession predicts; two, we don’t understand why yet; and, three, you’d be foolhardy to say that we can understand it.”

She argued that the unusual decline in not just income but also wealth during the recession might be one factor cutting down on use of the health care system.

But many other health experts say that there is just enough data to start detecting trends — even if the numbers remain murky, and the vast complexity of the national health care market puts definitive answers out of reach.

Many experts — and the Medicare and Medicaid center itself — point to the explosion of high-deductible plans, in which consumers have lower premiums but pay more out of pocket, as one main factor. The share of employees enrolled in high-deductible plans surged to 13 percent in 2011 from 3 percent in 2006, according to Mercer Consulting.

That means thousands of consumers with an incentive to think twice about heading to the doctor. One study by the RAND Corporation found that health spending among people who shifted into a high-deductible plan dropped 14 percent — though the study also found that enrollees cut back on some care that tended to save money in the long run, like vaccinations.

A second factor is a dearth of expensive, novel drugs coming onto the market, experts said, as well as growing pressure to use generics. “There just aren’t as many blockbusters,” said Professor Cutler, the Harvard economist.

Finally, and most important, health economists point to a shift toward accountable care, in which providers are paid for the quality of care, not the quantity.

There are about 164 “accountable organizations” in the United States, according to research by Leavitt Partners. Hundreds of other insurers and health systems have enacted some of the features of accountable care, like assigning specially trained nurse practitioners to patients with multiple chronic conditions to make sure they take their medications and to prevent hospitalizations...

Obama healthcare reforms lead to $1.3 billion in insurance rebates

Obama healthcare reforms lead to $1.3 billion in insurance rebates
By Noam N. Levey
April 26, 2012

U.S. consumers and businesses will receive an estimated $1.3 billion in rebates from insurance companies this year, according to a new study quantifying a key early benefit of the healthcare law that President Obama signed in 2010.

That will translate into anywhere from a few dollars to more than $150 for some 15 million consumers nationwide, the new report by the nonprofit Kaiser Family Foundation found.

Obama’s healthcare law requires insurers to spend a minimum portion of customers’ premiums on medical care, a provision championed by consumer groups concerned that companies were hiking premiums to pay for executive salaries, shareholder dividends and other expenses unrelated to their customers’ care.

Starting last year, if insurers did not meet these targets – known as medical loss ratios – they had to pay rebates this year to people enrolled in their plans.

The Kaiser study, which analyzed rate documents filed with state regulators nationwide, found 486 health plans nationwide that will be required to pay rebates, with the largest number in the so-called individual market serving people who do not get health coverage through work.

Nearly a third of all consumers in this market, which is widely seen as the most trouble-plagued in the country, will be eligible for a rebate.

Approximately a quarter of consumers in the small group insurance market and less than a fifth of consumers in the large group market qualified for rebates.

The study also found wide variation in states, with insurers selling individual health plans in some states such as Alaska, Maryland and Pennsylvania required to provide average rebates of around $300. In Hawaii and Maine, by contrast, no insurers in the individual market will have to provide rebates.

Data was not available for California because HMOs in the state are not subject to the same reporting requirements...

Friday, April 27, 2012

Doctors are not very happy

Physician Frustration Grows, Income Falls -- But a Ray of Hope
Mark Crane

Physician income overall has declined since 2010, yet there are tiny glimmers of hope in some specialties. Frustration is mounting, however, and doctors in every specialty are bracing for what they expect to be further income declines as healthcare elements are implemented, such as ACOs and required treatment and quality guidelines.

Those are some of the insights from Medscape's Physician Compensation Survey Report: 2012 Results. The report is based on a survey that garnered responses from more than 24,000 US physicians representing 25 specialties.

"Physicians' sense of worry may be greater than the reality, but it's understandable," said Judy Aburmishan, CPA, a partner in FGMK, LLC in Chicago, a firm that represents physicians and other healthcare providers. "Hospitals are buying up private practices both in primary care and the specialties. The heavy-handed message they send out is that if you don't join us, you won't survive. There is great uncertainty and fear about what healthcare reform will mean for physicians once it's fully implemented."

Some of the major findings from Medscape's 2012 report:

1. Dissatisfaction with medicine is intensifying, although a majority of physicians would again choose the same career path. In 2012, just over half of all physicians (54%) would choose medicine again as a career, far less than in the previous year's report, where 69% of physicians would choose medicine again.

2. The top-earning specialties in 2012 were the same as in the previous year, even though their incomes declined in general. In 2012, radiologists and orthopedic surgeons again topped the list at a mean income of $315,000, followed by cardiologists ($314,000) and anesthesiologists ($309,000). The same 4 specialties were in the leading positions in last year's survey. The bottom-earning specialties also remained similar: pediatrics ($156,000), family medicine ($158,000), and internal medicine ($165,000).

3. Who's up, who's down since 2010? "Decreased reimbursement" is the overall buzz-phrase, yet a minority of specialties saw modest gains. The biggest income increases were in ophthalmology (+9%), pediatrics (+5%), nephrology (+4%), oncology (+4%), and rheumatology (+4%). The largest declines were in general surgery (-12%), orthopedic surgery (-10%), radiology (-10%), and neurology (-8%).

4. Do men or women earn more? Overall, male physicians earn 40% more than female physicians, although that difference is only 23% in primary care. Experts say that the difference is related to choice of specialties and lifestyle preferences that women choose.

5. Don't write off private practice! Although physicians are rushing toward employment, partners in private practice far outearn physicians in other work environments. Overall, partners in private practice earn significantly more than solo practice owners and employed physicians, who earn less than either group.

6. The "rich doctor" myth may be just that, although "rich" is relative. Overall, only 11% of physicians say they consider themselves rich, while about 45% say their incomes are no better than that of many nonphysicians, and another about 45% say, "My income probably qualifies me as rich, but I have so many debts and expenses that I don't feel rich." The specialties with the highest percentage of physicians who felt rich were pathology (15%), radiology, oncology, and gastroenterology (14% each).

7. Doctors in all specialties are swamped with paperwork. A third of physicians (33%) spend more than 10 hours per week on paperwork and administration.

8. One healthcare reform goal of reducing "unnecessary care" garners negative response. The vast majority (67%) of physicians said they won't reduce the amount of tests, procedures, and treatments they perform (in order to comply with insurer treatment guidelines) either because the guidelines aren't in their patients' best interests or because doctors still need to practice defensive medicine.

Doctors bemoan paychecks that most plebes would kill for MSN April 28, 2012 Nearly half of all doctors say they regret choosing a career in medicine, according to an annual survey conducted by Medscape. Only 54 percent of doctors said they'd make the same career choice again, down from 69 percent last year. Lower incomes from "decreased reimbursement" apparently play a role in this dissatisfaction, though certain specialties enjoyed modest income gains. But even though physicians made mean incomes that ranged from $156,000 (pediatricians) to $315,000 (radiologists, orthopedic surgeons) per year, only 11 percent of doctors considered themselves rich (cough, cough), and 45 percent agreed with the statement "My income probably qualifies me as rich, but I have so many debts and expenses that I don't feel rich." Physician, cheer thyself.

Friday, April 13, 2012

Chris Stenrud, HHS deputy assistant secretary for public affairs

Politico Pulse

...HAPPY TRAILS to Chris Stenrud, HHS deputy assistant secretary for public affairs. Today’s his last day at HHS, and he’s heading back to Kaiser Permanente to manage its public advocacy and public affairs efforts. He’ll be splitting his time between D.C. and California, but he’ll be based in the District for now...

Sunday, April 8, 2012

Paul Bernstein, Kaiser Executive Medical Director for San Diego, talks about his writing career

Dr. Paul Bernstein has written a new book, Flashblind, about doctors who failed moral tests. Bernstein is judgmental, but he has engaged in eerily similar activities.

Renowned Surgeon Finds Time To Write Thrillers
08 Apr 2012
Posted by Mike Sirota

I’ve known Dr. Paul Bernstein ever since he and his wife, Judy, joined a read & critique group that I facilitated back in the ’90s. Both have since been published, their initial books receiving much critical acclaim. While some people think that surgeons often sit high atop their Medical Mount Olympus, Paul is one of the nicest, down-to-earth guys you would ever want to meet. He recently took time from his insane schedule to answer some questions and discuss Flashblind, his latest medical thriller.

Talk about your medical background.

PB: I’m a graduate of the University of California (UCSD) medical school and completed my residency in Head and Neck Surgery at University Hospital in San Diego. I’m board certified in Head and Neck Surgery and a fellow in both the American College of Surgeons and the American Academy of Facial Plastic Surgery.

I am the Area Medical Director for Kaiser Permanente San Diego and past Regional Chief of Head and Neck Surgery for Southern California. My medical awards include the Physicians’ Exceptional Contribution Award (Partner of the Year) in 2005 and the Schilling Award for Compassionate Care in 2007.

I’m an assistant clinical professor with UCSD’s Department of Head and Neck Surgery and started the Mohs Surgery Program in San Diego. I’ve been the Chairman of the Head and Neck Division of the American Cancer Society for over fifteen years and was awarded the ACS Community Service Award twice.

When and why did you decide to start writing novels?

PB: I started writing novels in the 1990s. As a history major at UCLA before medical school, I enjoyed writing and telling an interesting story. Your read & critique groups were inspiring and your teaching invaluable in helping me take my skills from an average story teller to an engaging author...

Organ donor's surgery death sparks questions

Health officials say they have no "position on what caused the patient's death."

Paul Hawks didn't get a second opinion about whether he was healthy enough to give away 60% of his liver.

Organ donor's surgery death sparks questions

By Elizabeth Cohen, Senior Medical Correspondent
April 8, 2012

(CNN) -- Before dawn on her 57th birthday, Lorraine Hawks and her husband, Paul, piled into their brother-in-law Tim Wilson's Lexus in Pelham, New Hampshire, with Lorraine and her sister Susie in the back seat and the men up front. As the two couples drove to the Lahey Clinic in Burlington, Massachusetts, Lorraine and Paul teased Tim mercilessly.

"By 5 o'clock today, you're going to have a Republican liver!" they taunted Tim. "You're going to love Ann Coulter! You're going to love Glenn Beck!"

"No way!" protested Tim, a staunch Democrat. He swore that even with a chunk of his Republican brother-in-law's liver inside him, he'd never be conservative. The foursome joked and laughed during the 45-minute drive to Lahey. At the hospital, the sisters kissed their husbands goodbye, and the men were wheeled into operating rooms, where surgeons would remove 60% of Paul's liver and give it to Tim, who suffered from advanced liver disease.

As Lorraine sat in the waiting room with Susie that May morning two years ago, she prayed her husband's liver lobe would cure her brother-in-law. She prayed for her husband, too, but she was less worried about him, since she says the surgeons had reassured them while liver donation wasn't without risks, it was safe for Paul, a 56-year-old man in good health.

Neither of Lorraine's prayers came true. Tim died less than a year later, after receiving the transplanted part of Paul's liver. He was 58. Her husband died that very day on the operating room table.

"We walked into the hospital a married couple, and I left the hospital at the end of the day as they loaded my husband onto the coroner's truck," says Lorraine, who has hired a lawyer and plans to file a lawsuit against the hospital.

'He didn't hesitate to say yes'

Paul Hawks, an electrician for the Florida Department of Transportation, was one of more than 4,500 people in the United States in the past 25 years who have donated a section of their liver while still alive. Death is rare -- besides Paul, three other donors have died since 1999.

The relatives of the other donors -- they died in 1999, 2002 and 2010 -- have gone public, but this is the first time Lorraine has discussed her husband's death.
"I had no idea he'd had an abnormal EKG," says Lorraine Hawks. "If I had known, I never would have let him have the surgery."

"I want everyone to know what a generous, wonderful man Paul was. When he found out Tim needed a liver, he didn't hesitate to say yes," said Lorraine, a school bus aide for children with special needs in Tampa, Florida. "They weren't blood relatives, but they were a perfect match, and he felt privileged that God was going to let him help Tim regain his health."

Living organ transplants are a miracle of modern medicine. In all, more than 100,000 people in the U.S. like Paul have donated a kidney, a liver lobe or another body part while still alive to save someone else's life. Most of the time, the surgeries go well. Not only are donor deaths rare, but major complications of any kind are the exception rather than the rule.

This makes it all the more difficult for Lorraine to understand why her husband was one of the few who didn't make it.

'We tried very hard to save Paul ...'
DPH does not have a position on what caused the patient's death
Jennifer Manley, Massachusetts Department of Public Health

After her husband was wheeled into surgery, Lorraine, her father-in-law and Susie walked around the block a bit and got a bite to eat in the hospital cafeteria. Then shortly after 1 p.m., about four and a half hours after the surgery began, Lorraine says the coordinator of the transplant team came out to talk to them.

Sitting next to Lorraine, their knees nearly touching and speaking in a near whisper, Lorraine says the coordinator told her they were having trouble getting Paul's blood to coagulate and that an expert had been called in. Then about an hour later, the coordinator came out again to say her husband was having "irregular heart rhythms."

"She was acting real strangely, and we were so frightened," Lorraine remembers.
Live donor relations

The coordinator's cell phone rang, and she answered it. She hung up and rubbed Lorraine's arm, which Lorraine found strange, and told her she'd be back in five minutes.

When she returned, she asked the family to come into a small, private waiting room. Lorraine remembers her father-in-law screaming, "Tell me what happened to my son!" But the coordinator wouldn't say anything. The family sat there for about 40 minutes. Then the coordinator asked the family to go into a conference room farther away from the waiting area.

"We're looking at each other and said this can't be good," Lorraine recalls. "We walked, crying, holding onto each other."

Suddenly the conference room filled with doctors, counselors and pastoral staff.

"We tried very hard to save Paul ..." Lorraine remembers one of the doctors saying. She was sobbing so hard she didn't hear the rest of his sentence. Then the surgeon who did Paul's operation, her eyes red and puffy, got down on her knees to speak with Lorraine eye-to-eye.

"I saw her mouth moving, but I couldn't hear what she was saying," Lorraine remembers. "My brain was on fire."

Lorraine stayed with her husband's body until the coroner came to take him away. She says the next day people from the hospital called her six times, offering condolences and to pay for Paul's funeral. She didn't want to talk to them.

A few weeks later, back home in Tampa, Lorraine read a statement online from the Lahey Clinic's then-CEO, Dr. David Barrett.

"Lahey Clinic and its transplant team are extremely saddened by the loss of a gentleman who died while donating a portion of his liver to his relative," Barrett said. "Since the inception of its live donor liver transplantation program in 1999, Lahey Clinic has performed more than 200 of these complex life saving surgical procedures."

Reading the article made Lorraine feel worse, she says. It still didn't explain why her husband had died.

Then in July, about two months after her husband's death, Lorraine stopped by her post office after grocery shopping to pick up her mail. In her box was a thick envelope from the Massachusetts Department of Public Health. Inside was a nine-page report with the details of what happened during Paul's surgery.

Finally, she thought, her questions would be answered. Finally, she would find out why her husband died.

'Donor ... could not be resuscitated'
Donor survival rates

The Department of Public Health report gives a rare and gruesome picture of a surgical procedure gone horribly wrong.

The department's account is based on medical records, operating room communications and two days of interviews with the attending transplant surgeon and other doctors, nurses and administrators.

After Lorraine and Susie kissed their husbands good-bye, Paul and Tim were wheeled into separate operating rooms. Everything went fine until about four hours into the operation, when a vein that carries blood away from the liver partially tore off and started bleeding.

Paul's surgeons immediately called for assistance. More doctors and nurses arrived in his operating room. It was to be the beginning of a two-and-a-half-hour fight to save Paul.

The partially torn vein came all the way off, and doctors sewed up that tear, but then they noticed bleeding coming from somewhere else. As they searched for the source, a clamp on a vein got knocked off, injuring the vein. Repairing that injury, they noticed more tears. They fixed those tears, all the while giving Paul blood products and drugs to raise his blood pressure.

It seemed like Paul might be getting better, but then he started to bleed from several areas all at once. His heart started to beat very fast. Doctors performed CPR and when that failed, they cut his chest open, massaged his heart directly, and shot drugs into his heart to get it going again. But none of it worked.
We walked, crying, holding onto each other.
Lorraine Hawks

"The patient had a cardiac arrest secondary to excessive bleeding & could not be resuscitated," the report states.

Paul Hawks was pronounced dead at 3:01 p.m. on May 24, 2010.

Pamela Johnston, a spokeswoman for the Lahey Clinic, one of the largest liver transplant centers in the country, declined to comment about the details in the state's report. Lahey voluntarily stopped operating on living liver donors for about four months.

The Massachusetts Department of Public Health did not cite the hospital for any deficiencies. The Lahey Clinic conducted its own internal investigation into Paul's death and hired outsiders to conduct an external investigation. Lahey declined CNN's request for copies of both these reports.

More red flags

Lorraine read the Department of Public Health report sitting in her car in the parking lot of the Tampa post office. As she read the details of her husband's failed surgery, she wondered whether all the tears and bleeding were anyone's fault or were they just unavoidable consequences of surgery, inevitable events that statistically speaking happen sometimes, and Paul was just unlucky?

Three other items in the Department of Public Health report raised even more questions.

First, she found out Paul had been given a pre-operative EKG, and it was abnormal. It showed he might possibly have had a past heart attack, but then follow-up testing showed no evidence of poor blood flow to his heart.

"I had no idea he'd had an abnormal EKG," she says now. "If I had known, I never would have let him have the surgery."

The report doesn't say whether Paul knew about his abnormal EKG, or if a cardiologist was called in to evaluate whether his heart was strong enough to tolerate surgery. Johnston, the Lahey Clinic spokeswoman, declined to answer questions about the EKG or about any aspect of Paul's surgery or pre-operative care.
Lorraine Hawks may never know all the reasons why her husband died that May afternoon.
Lorraine Hawks may never know all the reasons why her husband died that May afternoon.

Secondly, the report pointed out that a special, high-speed blood pump wasn't used to give Paul blood.

The $20,000 device pumps blood at least three times faster than other pumps. Called a Belmont Pump, it's saved soldiers' lives as they lay massively bleeding on battlefields in Afghanistan and Iraq.

Lahey owns a Belmont Pump. At the time of Paul's surgery, it was nearby in Tim Wilson's operating room. But as Paul lay bleeding to death for two and a half hours, no one brought it in to his operating room.

"It's portable," says George Herzlinger, president of Belmont Instrument, which makes the device. "It weighs 27 pounds. You just wheel it over."

Thirdly, the report describes how Paul's surgeons never activated a set of procedures used when a patient is massively bleeding.

Called the "Massive Blood Transfusion Protocol," it directs surgeons to call the hospital's transfusion services and activate a set of procedures so a patient who's bleeding profusely can most efficiently get the blood products he needs.

The report notes that surgeons thought none of these things -- the abnormal EKG, the lack of the high-speed pump, the inactivated protocol -- contributed to his death...