Surgery: Is Your Doctor Really There?

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A news article about a New York State law suit settlement raises question about surgical ben_franklinpractices that even I would never have thought to ask.

Here’s the account from Becker’s Hospital Review:

A New York Supreme Court judge ruled this week that a neurosurgeon was retaliated against by his former employer for objecting to a policy that allowed another surgeon to oversee two spine surgeries at the same time, according to The Boston Globe.

The judge ruled that University Hospital in Syracuse, N.Y., illegally forced James Holsapple, MD, out of his job after he objected to a policy that allowed Ross Moquin, MD, a specialist in complex spine surgery, to oversee two surgeries simultaneously. Dr. Holsapple raised concerns about the policy because although junior surgeons would assist Dr. Moquin when he was overseeing two surgeries at the same time, they were not qualified to perform the procedures, according to the report.

Dr. Holsapple alleged that on one occasion when Dr. Moquin was double-booked he was delayed in one operating room, which meant two unqualified surgeons had to finish the procedure being performed in the other room. Dr. Holsapple alleged the patient subsequently suffered a serious spinal fluid leak.

Double-booking surgeries may be a relatively common practice among senior surgeons. There was another lawsuit this spring regarding a double-booking at Massachusetts General Hospital, and there’s a law firm in Cleveland that is promoting its experience with lawsuits regarding double-booked surgeries.

There are known risks associated with this practice:

  • Longer anesthesia time for patients waiting for the attending surgeon who was delayed in the first procedure;
  • Lack of patient awareness (consent) regarding what portions of the surgery are performed by which surgeons or practitioners involved in the procedure;
  • Inadequate supervision of surgical residents and scope of practice creep with surgical assistants when the primary surgeon leaves for a second procedure;
  • Operating Room (OR) nurses reporting fears of “patient abandonment” to administration; and
  • Inadequate pre-procedure briefings and the absence of surgical debriefs. (2)

The practice of double-booking surgeries raises questions for patients and payers:

  • Should you be asking your surgeon about his booking practices and use of junior surgeons? How transparent should doctors and hospitals be about this practice?
  • If you (or your insurance) are paying for a senior surgeon and he’s not in the room, for what exactly are you paying? Should there be a rate reduction if the surgeon is only present for part of the procedure? Or do you want a doctor who will be with you the full time?

Sources:

  1. Alya Edison, “Physician who raised concerns about concurrent surgeries at NY hospital wins retaliation lawsuit,” Becker’s Hospital Review, 25 May 2017. http://www.beckershospitalreview.com/legal-regulatory-issues/physician-who-raised-concerns-about-concurrent-surgeries-at-ny-hospital-wins-retaliation-lawsuit.html
  2. “Concurrent (overlapping) surgery: addressing the risks,” Healthcare Risk Management Review, 26 September 2016. http://www.hrmronline.com/contributed-article/concurrent-overlapping-surgery-addressing-the-risks

Concussion: When in doubt, out!

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An international medical conference in Berlin has issued a consensus recommendation on the treatment of concussion in sports: When in doubt, take the player out.

According to a report in Medscape, there are a variety of diagnostic criteria for concussion, some more clearly objective and easier to ascertain than others:

 

  • Somatic symptoms (eg, headache), cognitive (eg, feeling as if in a fog), and/or emotional symptoms (eg, lability);
  • Physical signs (eg, loss of consciousness, amnesia, neurologic deficit);
  • Balance impairment (eg, gait unsteadiness);
  • Behavioral changes (eg, irritability);
  • Cognitive impairment (eg, slowed reaction times); and
  • Sleep/wake disturbance (eg, somnolence, drowsiness).

We know that concussions can have effects that range from very short duration to permanent, and that repeated concussions can magnify effects. We also know that a full recovery can take more than a year, if it is even possible. We know that children can suffer concussions whose effects last into adulthood.

What isn’t stated: what to do about non-sports concussions. How soon can a victim return to driving, if at all. If a pilot, a first responder or in some other occupation involving obvious risk, how soon should a victim return to work? How about someone responsible for stock or bond trading — if impaired reaction times can affect clients? Since most people don’t carry disability insurance, who pays them when they can’t work? (Social Security Disability only starts after one is out of work for two years.)

What’s the legal liability for forcing someone with a concussion back to work, when someone else is hurt as a result? Now that we know that forcing a truck driver of police officer back to work with a concussion could result in someone’s death, there should be a liability.  I guess the courts will sort that out.


Sources:

  1. Bert R. Mandelbaum, MD, “Concussion Consensus Calls for Caution,” MEDSCAPE, 23 MY 2017. http://www.medscape.com/viewarticle/880146?nlid=115245_1521&src=WNL_mdplsfeat_170530_mscpedit_wir&uac=153634BV&spon=17&impID=1357880&faf=1

 

 

The Latest Bearing Sign for the US Economy

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The Federal Highway Administration reports that highway travel has declined from theben_franklin last quarter of 2016. That fits with weak consumer spending data from the first quarter of this year — but is a surprise to many economists.

Retail sales at gasoline stations are down 4.8% from this time a year ago. Those sales include gasoline, snacks and other items stations sell.

In reporting this, the Wall Street Journal speculates on a number of possible causes, including immigration enforcement.

The Journal doesn’t cite two obvious causes:

  • The decline in tourist visits to the US — down 16% from a year ago, and
  • Uncertainty about healthcare costs that may be causing consumers to cut spending.

The drop-off in tourism affects all industries that serve tourists:

  • Hotels and recreational facilities
  • Transportation, including air, rental cars and gasoline
  • Restaurants

The decline in this industry is a big deal and affects a lot of jobs as well as city and state tax  revenue.

It doesn’t look like consumer spending is going to drive economic growth.  If it doesn’t, is there anything else that can? Historically, the answer largely is no.

Further, Trump has alienated trading partners who might be interested in seeing our economy recover — Mexico, Canada, China, Germany. The downside of “America First” might be “America Alone”.


Sources:

  1. “Americans Tap Breaks on Driving,” The Wall Street Journal, 27-28 May 2017, p. B12.
  2. Kate Taylor, “Tourism in the US has drastically declined since Trump was elected,” Business Insider, 17 May 2017. http://www.businessinsider.com/trumps-rhetoric-hurt-us-tourism-and-retail-2017-5

Health: Genetic Testing — Knowing Less than We Think We Know

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Two papers appearing today raise interesting questions about genetic testing.

  1. The first raises the question about insurer access to genetic testing records.
  2. The second states that some people who are genetically disposed to breast cancer don’t in fact get it — due to another genetic factor not previously considered.

In the first case, health and life insurers want access to genetic information in order to estimate more precisely the claims they are likely to face in providing insurance for a specific individual.

In fact, that approach violates the original logic of insurance — that insurance is sharing risks among a group of individuals, not writing a custom policy for a particular person.

Be that as it may, the second paper shows that what we know about genetics is still incomplete. That paper shows that persons with the BRCA mutation that disposes them to breast cancer don’t necessarily ever develop that cancer. The absence of cancer in these people may be linked to a COMT genetic variation. Right now, all that is know is that people with BRCA who don’t develop cancer tend to have the COMT variation; how it works isn’t known.

So, were an insurer to raise rates based just on the BRCA factor, the insurer could be getting an unnecessary, windfall profit on people with COMT.

Prudence says that we don’t know enough about the relationship of certain genetic factors and disease to make a universal case for inclusion of genetics in underwriting (pricing insurance). For some illnesses, maybe.  For all, no. That begs the question of whether inclusion of these factors fundamentally changed the definition of what insurance is.


Sources:

  1. Mercedeh Movassagh, Prakriti Mudvari, Anelia Horvath. Co-Occurrence of COMT and BRCA1/2 Variants in a Population. New England Journal of Medicine, 2017; 376 (21): 2090 DOI: 10.1056/NEJMc1701592
  2. European Society of Human Genetics. “Balancing rights and responsibilities in insurers’ access to genetic test results.” ScienceDaily. ScienceDaily, 25 May 2017. <www.sciencedaily.com/releases/2017/05/170525194817.htm>.

Tai Chi and Depression

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My wife and I started classes in tai chi some months ago, so I was curious about a new study about the impact of tai chi on depression.

The pilot study, conducted at Mass General in Boston, focused on Chinese-Americans. This group is just as subject to depression as the rest of the population, but tends to be skeptical regarding western therapeutic techniques.

The key finding of the study is that a twelve-week course of instruction in tai chi could lift depression symptoms, and could be used as the primary course of treatment for depression among Chinese-Americans.

The researchers made an assumption that there are cultural factors that make tai chi effective among Chinese-Americans that might make it ineffective with individuals from other backgrounds. Thus they limited the study just to Chinese-Americans, and even more narrowly, to those speaking Cantonese or Mandarin.

I’m not sure that limitation is appropriate.

  • First, while tai chi is a form of martial art, it is also exercise. Exercise is known to lift depression symptoms. (2) There’s no compelling reason to limit tai chi to those of Chinese descent.
  • Second, I’ve noticed that I feel better emotionally after an hour of tai chi.

Tai chi may be a virtually universal therapy. It has several forms, and there’s a low impact version that can be done easily by seniors.


Sources:

  1. Albert S. Yeung, Run Feng, Daniel Ju Hyung Kim, Peter M. Wayne, Gloria Y. Yeh, Lee Baer, Othelia E. Lee, John W. Denninger, Herbert Benson, Gregory L. Fricchione, Jonathan Alpert, Maurizio Fava. A Pilot, Randomized Controlled Study of Tai Chi With Passive and Active Controls in the Treatment of Depressed Chinese Americans. The Journal of Clinical Psychiatry, 2017; 78 (5): e522 DOI: 10.4088/JCP.16m10772
  2. Mayo Clinic, “Depression and Exercise: exercise eases symptoms.” http://www.mayoclinic.org/diseases-conditions/depression/in-depth/depression-and-exercise/art-20046495

 

Dying at Home

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Alzheimer’s if the primary cause of dementia in the US. It current impacts 5.5 million

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Incidence of Alzheimer’s by county in US

American adults, and that number is expected to increase to 13.8 million by mid-century.

What’s important is the shift in Alzheimer deaths from medical facilities to the home.

  • In 1999, 67.5% of Alzheimer’s deaths occurred in a nursing home or long term care facility; by 2014, that figure had fallen to 54.1%
  • In 1999, 14.7% of Alzheimer’s  deaths were in a hospital; in 2014, that had fallen to 6.6%.
  • In 1999, 13.9% of these deaths occurred at home; by 2014, this number had risen to 24.9%.
  • In 2014, 6.1% of the deaths were in hospice care.

What we can’t tell from these data are whether families are bringing loved ones home right before end of life, or whether they simply can’t afford the high cost of long term care facilities.

The data also don’t tell us the extent to which families are now relying on home health care services in lieu of nursing homes.


Sources: Taylor CA, Greenlund SF, McGuire LC, Lu H, Croft JB. Deaths from Alzheimer’s Disease — United States, 1999–2014. MMWR Morb Mortal Wkly Rep 2017;66:521–526. DOI: http://dx.doi.org/10.15585/mmwr.mm6620a1

 

ACA Repeal: Update

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I’ve been quiet about the recent AHCA legislation. Frankly, the House bill isn’t good for ben_franklinmost Americans, but the assumption is that the Senate will heavily revise the bill before it has a chance for passage. So it’s hard to say what the final legislation will be at this point.

Then it goes to conference committee and the result will return to each chamber for a vote.  So this is a long way from being done.

There are a number of articles enumerating the problems in the House bill. The major issues are

  • Loss of health insurance for millions of Americans
  • Impact on the solvency of hospitals and clinics serving rural areas — where most of the poor live
  • Reductions in Medicaid coverage, especially for children
  • Allowing states to reduce coverage standards in insurance (depart from the ACA’s Minimum Essential standards) — reducing what the insurance buyer gets for their money
  • Raising costs drastically for consumers between the ages of 50 and 64 (1)

With all of these issues, we are still expecting the repeal bill to result in sharply higher premiums for health insurance.

The only positives in this bill are tax reductions for the wealthy.

My major concern is with health screening and checkups. The ACA recognized that the main way to reduce health care expenditures is through early detection and treatment of disease. Removing access to doctors means later detection and much higher costs.

Example: breast cancer, cost of treatment by tumor stage

Stage

0                                         $71,909

I/II                                      $97,066

III                                      $159,442

IV                                      $182,655 (2)

Reduction is access to health care is a commitment to higher medical spending or to reduction of life expectancy.


Sources:

  1. Harris Meyer, “15 quick facts from CBO report on Obamacare repeal bill,” Modern Healthcare, 24 May 2017. http://www.modernhealthcare.com/article/20170524/NEWS/170529946?utm_source=modernhealthcare&utm_medium=email&utm_content=20170524-NEWS-170529946&utm_campaign=mh-alert
  2. Helen Blumen, Kathryn Fitch, Vincent Polkus, “Comparison of Treatment Costs for Breast Cancer, by Tumor Stage and Type of Service,” Am Health Drug Benefits. 2016 Feb; 9(1): 23–32.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4822976/