Planning the Patient-Centered Health Plan for America


Current Issue:

The Mammography Debate Continues

Over-diagnosis and over-treatment
WE RECENTLY NOTED THE U.S. PREVENTIVE SERVICES TASK FORCE ON MAMMOGRAPHY SCREENING ALONG WITH
DR. ROBBINS CAUTIONS IN THE 1980’S – WE RETURN TO THE DEBATE: SEE THE HPUSA MARCH ISSUE.
THERE ARE VALID CONCERNS ABOUT THE OVER-DIAGNOSIS AND OVER-TREATMENT OF “DUCTAL CARCINOMA IN SITU” (DCIS) AND SMALL, SLOW-GROWING INVASIVE BREAST CANCERS WITH MAMMOGRAPHY SCREENING.

Over-diagnosis

Since the introduction of mammography in the 1980s, the number of women diagnosed with DCIS has increased a lot. In 2015, it is estimated that there will be about 50,000 new cases of DCIS [38].

Over-diagnosis occurs when a mammogram finds DCIS or small, invasive breast cancers that would have never caused symptoms or problems if left untreated. These breast cancers may never grow and some may even shrink on their own. Or, a person may die from another cause before the breast cancer became a problem.

Some researchers estimate that about 20 to 30 percent of DCIS and invasive breast cancers found with mammography may be over-diagnosed [23].

Over-treatment

Although DCIS is non-invasive, without treatment, the abnormal cells can sometimes become invasive over time. Left untreated, about 40 to 50 percent of DCIS cases may progress to invasive breast cancer [39]. (These numbers are estimates.) Higher grade DCIS may be more likely than lower grade DCIS to turn into invasive cancer if left untreated.

At this time, there is no way to tell which cases of DCIS will become invasive breast cancer and which will not. So, women with DCIS are treated with lumpectomy (also called breast conserving surgery) plus radiation therapy or mastectomy. Some women are also treated with hormone therapy.

Since not all cases of DCIS will become invasive breast cancer, some women with DCIS may be over-treated. These women never would have developed invasive breast cancer, with or without treatment.

Researchers are studying ways to identify the cases of DCIS most likely to turn into invasive breast cancer. This would allow treatment to be targeted to those who are at higher risk and might allow some people to avoid treatment.

At this time, however, the standard of care is to treat every case of DCIS as if it might turn into invasive breast cancer.

Learn more about DCIS.

Read more from our Chief Scientific Advisor, Dr. Eric Winer, as he comments on the issue of mammography leading to over-diagnosis and over-treatment.
What does this mean for you?

Despite some ongoing debate, mammography is still the most effective screening tool used today for the early detection of breast cancer.

While any health decision is a personal one that involves weighing benefits and risks, most health organizations recommend women get mammograms on a regular basis. . .  Read more . . .

Learn more about breast cancer screening recommendations for women at average risk.
Learn more about breast cancer screening recommendations for women at higher risk.
See more at: http://ww5.komen.org/BreastCancer/TheMammographyDebate.html#sthash.V7WfdMIz.dpuf

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Well-Meaning Regulations May Worsen Quality of Care

Previous Issue:

Physician Assisted Killing

A patient with obstructive sleep apnea came in for his annual evaluation. He had been snoring for decades, but about six years ago, his wife noted that his snoring stopped abruptly in the middle of the night. She observed her husband and noted that his chest was still moving, as if he was breathing, but there was no snoring. She then put her hand over his mouth and nose and did not find any air movement. She woke her husband immediately and after a loud strider, he began breathing. She insisted he see his pulmonologist as soon as he could obtain an appointment. He was immediately scheduled for a Polysomnogram (sleep study). This confirmed the diagnosis of sleep apnea (no breath) and determined the optimal pressure to set the Continuous Positive Airway Pressure (C-PAP) device on to wear at night to assure continuous breathing while asleep. This was working fine.

As I was finishing my exam and writing his prescriptions, he casually mentioned that a friend of the family, who had sleep apnea, had respiratory failure requiring oxygen. His C-PAP was powered by oxygen pressure rather than compressed air. The friend was getting increasingly depressed over his disability and told my patient that sometimes he thought that he would just turn the machine off and end it all. Although my patient tried to joke him out of this approach, he apparently decided one night that he’d had enough. He turned off the machine and the oxygen and quietly died during the night. This is a peaceful way ending one’s life without any pain. It also is a quiet way to commit suicide with any physician accomplist.

With all the emphasis on physician-assisted suicide, it is indeed unfortunate, if not absolutely heinous, that physicians should play the role of executioner. That such a proposition can be passed by public vote underscores the lack of basic medical knowledge we have been unable to provide to the public. They don’t need an executioner to write a lethal dose of barbiturates. The patients have numerous lethal doses of medications already in their possession. Most patients now get a 90-day supply of medications. If there are any cardiac, blood pressure, narcotic, hypnotic or psychiatric medications among them, it would not even take a full bottle to do the fateful tragic deed. Whether in The Netherlands, Oregon or Europe, we should never have to worry about whether our doctor is wearing the white coat of healing or the black cloak of an executioner.

A doctor in The Netherlands confided in me during a break in a medical meeting in Amsterdam that he once admitted an elderly lady to the hospital. She said she worried about being put to death while in the hospital. The doctor I was speaking with assured her that he would watch over her to make sure that didn’t happen. The next weekend, he signed her out to a colleague. When he came back on Monday, he looked for her and couldn’t find her. The nurse said she had “died.” He quickly summoned his colleague as to what happened. He was told, “We needed the bed.” He said he now felt it was a horrible tragedy for physicians to be involved in assisted suicide. It is more often an execution and not for a medical or “relief-of-pain” reason that is commonly given. It may be just an administrative decision on allocation of beds.

Statistics in Oregon, the first state in which physicians are allowed to kill patients who request it, indicate that perhaps as many as half of these patients have not signed a valid request that they wanted to be executed. These hospital mistakes are permanent. They are not simple medication errors that the Institute of Medicine feels are so tragic. Many of them are inconsequential and can be easily reversed. Physician execution of patients can never be reversed.

Healthcare is such a private matter we may never know how many were put to death for nefarious reasons. I’ve had a number of patients complained that they were convince that a family member was killed during their last hospital stay.  A colleague confided in me that a patient he was seeing in consultation, who was in respiratory failure, was given a large dose of morphine and died during the night. The dose given would be appropriate for an otherwise healthy patient, e.g. one with herniated disc pain or a bone fracture.  Patients in lung failure need all their energy to breath and stay alive. A dose of most narcotics or sedatives will place such a patient into permanent rest. And it was not picked up in medical death chart review. Physicians are required by California law to relieve pain. Hence, it’s an easy way to quietly extinguish a life without raising any eyebrows. It also avoids prosecution.

Updated from MedInfoLine2005

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Well-Meaning Regulations Worsen Quality of Care or can even make it Lethal.

Previous Issue:

Modernization can at times be very expensive and misdirected

In the 1980s, Dr. Eugene Robin, a Research Pulmonologist at Stanford, had a weekly column in the San Francisco Examiner. Having had a very distinguished career writing research papers, books, editing journals, chairing international symposia, he thought he’d try his hand in the popular press. In this column, he explored numerous areas of medicine for the lay public. He eventually had a column on the Risks of Mammography. He cited that doing regular mammograms in young women could actually increase the risks of breast cancer. He never had another column. We all just assumed that it was not politically advantageous for the Examiner to continue in an arena in which they couldn’t control such content. The uninformed public would not be able to accept such content “which every American ‘knew’ could not be true.” Everyone knew that a screening test for a disease just could not cause the disease they were screening for. The News media knew that public opinion was more valid than the professor’s opinion – even if based on scientific evidence.

Now after 30 years, this discussion is once again open to debate. Freedom of speech can only be suppressed for so long. We return to –The Mammography Debate

Mammography for breast cancer screening

Most major health organizations have concluded that mammography saves lives. However, there is ongoing debate over:

  • How much benefit there is from mammography (especially in younger women)
  • The over-diagnosis and over-treatment of breast cancer

The benefit of mammography for women ages 40 to 49

Mammography in women 40 to 49 saves lives, but the benefit is less than for older women.

Some health organizations have concluded that the modest survival benefits of mammography in women in their 40s outweigh the risks of false positive results. The National Comprehensive Cancer Network recommends routine mammography for women starting at age 40 and the American Cancer Society recommends starting at age 45 [15,105].

The U.S. Preventive Services Task Force meta-analysis of eight randomized controlled trials found that mammography modestly reduced the risk of breast cancer mortality (death) in women 40 to 49 [13]. This study found that to prevent one breast cancer death, 1,904 women 40 to 49 would need to be screened with mammography [13].

Weighing the benefits and risks, the Task Force does not recommend routine mammography for all women in their 40s [13].

Instead, the Task Force, as well as the American College of Physicians, recommends that women 40 to 49 discuss the benefits and risks of mammography screening with their health care providers. Then together, they should make informed decisions about when to start mammography screening [13,18,105]. The American Cancer Society recommends informed decision-making for women ages 40 to 44 [105].

Informed decisions are guided by a woman’s breast cancer risk profile. Women at higher risk of breast cancer are more likely to benefit from mammography [18,105]. Decisions should also be guided by a woman’s preferences based on the potential pros and cons of mammography [18].

The U.S. Preventive Services Task Force recommends that routine mammography screening begin at age 50 [13].

To be continued in July 2014 HPUSA . . .

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Well-Meaning Regulations Worsen Quality of Care.

Previous Issue:

Modernization can at times be very expensive and misdirected

I served my internship at Wayne County General Hospital. We were the first class of 36 interns to work in the new 500 bed orange and silver aluminum hospital in the form of a Grecian cross-a square center with four arms of equal length. The old hospital had the standard characteristic large 40 to 60 bed wards that most of the public hospitals had in the 1960s, whether county, city or state. Furthermore, Michigan was the first state that place doctors under that state wage laws which was $300 a month for full time work. The majority of the hospitals in the United States were paying $25 to $50 a month. Since at that time most house staff were unmarried and received free room and board at the hospital, it was a living wage. We felt privileged. There were 500 beds on four floors above the street level with 125 patients on each floor, as I recall. There were 2 five bed rooms in the corner of each floor which was one wing of a red cross, the rest of the rooms had 4 beds, with a couple of two bed semi-private rooms for special medical needs such as isolation or an occasional high level county official.

Going from 40 and 60 bed open wards to the large number of semi-private rooms required a large increase in nursing staff. Whereas two RN’s could oversee 40 or 60 patients in the old facility, it would take two RNs to oversee every three or four rooms of four patients each. The county balked at the expense of tripling the number of RNs for the same number of patients.  The county hired efficiency experts to evaluate the RNs and to reduce their number. They recommended exactly what they were hired to do.

The doctors observed the nurses working feverishly at the desk taking down the orders we had written and proceeding to implement them. The efficiency experts making their rounds would count out loud the number of nurses at the desk: one, two, three, four nurses at the desk not seeing patients. We asked them what they thought the numbers meant. One said, obviously you’re over staffed when more than one nurse is sitting at the desk. Shouldn’t they be out on the floor doing some nursing?

The experts obviously had no understanding of nursing. When their report was submitted, and administration tried to reduce the number of nurses, a firestorm erupted. For a while it looked like we might not have RNs at all. I don’t think the doctors were very thrilled with the prospect that they might end up bathing their patients and emptying their bedpans.

Eventually the administration tossed out the expensive study and we all went back to practicing medicine and the nurses resumed the care of our patients.


Are we having the same problems today, except on a more massive scale? Don’t we have medical efficiency experts, the insurance carriers, HMOs, Medicare, Medicaid telling us how to practice medicine? Telling us what tests we are allowed to order, what drugs we are able to use, which hospital we are allowed to admit our patients, which consultants are approved, which x-ray facility is in our patient’s insurance plan, which laboratory will they reimburse, which respiratory company are we allowed to order oxygen for our patients in lung failure.  And since each insurance carrier and HMO has their own preferred drug formulary and consultants, it sometimes is not easy to steer a patient in the correct direction. This top-down management ultimately comes from the White House, the Senate, the House, and the Supreme Court who don’t seem to have a clue as to what the practice of medicine entails.

Instead of being lean and efficient, it is turning out to be costly and inefficient. Many of our patients are relating horror stories as to having been on medications for decades which were working beautifully and now, because of new regulations or an insurance change, being placed on substitutes and their blood pressures are out of control; they are wheezing more than ever because their bronchodilators  have been changed by a new insurance company; their new oxygen company took two months to get oxygen to them while they are gasping for breath not being able to walk to the next room; how much their health insurance premiums have increased; how much their medications cost and health care costs have spun out of control.
The patients have now partially accommodated to these huge changes over the past two years. It would create havoc to toss out these changes that Obamacare made, without a smooth transition to a market base plan.

The most dangerous campaign statement is to “REPEAL” and “REVISE” when no one has submitted a revised plan that the public will accept. This could destroy the Conservative Political Party from making constructive changes and the “Tax /Spend/ and Regulate” party would proceed to destroy American Medical and Health Freedom. Their success is really guaranteed with the ease in which the “Tax /Spend/ and Regulate” party operates.  Since the regulation of human beings is essentially impossible, as the Fascists, Communist, and the Socialists have well demonstrated but still don’t believe, they can continue to SPEND, then with the progressive income TAX, it is easy to increase taxes on the masses which may not fully understand what they are approving, and when this doesn’t go as planned, they have to REGULATE our freedom as we drift backwards into a Statist Civilization. We will then have to try to advance to a free society again repeating what our forefathers accomplished by establishing American Freedom. How many hundreds of years will it take to reach 1776 again?

Follow this HealthPlanUSA column for some answers to our health care conundrum.
America, it is critical to wake up before it’s too late.

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Well-Meaning Regulations Worsen Quality of Care.

Previous Issue:

Atlas Shrugged Part II

Atlas Shrugged’ Film Banks on Election Fever
By DON STEINBERG, WSJ

To a strict bottom-line capitalist, the new movie “Atlas Shrugged Part II” might not look like a model enterprise. “Atlas Shrugged Part I,” released last year, cost businessman John Aglialoro about $25 million (and 19 years) to bring to the screen. Its domestic box-office take was a tepid $4.6 million. Critics’ reviews, arguably, were worse.

Few flops earn sequels. But Mr. Aglialoro, chief executive of exercise-equipment maker Cybex International CYBI 0.00% and a longtime disciple of “Atlas Shrugged” author Ayn Rand, thinks the timing is right. Rebuffed by Hollywood, he and fellow producer Harmon Kaslow, whose horror credits include “Cemetery Gates” and “Boo,” have built their own studio, hopeful that a nation embroiled in debate over the distribution of wealth will put “Part II” in the black. The urgency quickened when Mitt Romney named as his running mate another Rand acolyte, Rep. Paul Ryan (though he has soft-pedaled his enthusiasm for her in the campaign). The movie hits theaters Oct. 12.

“Atlas Shrugged,” published in 1957, was the last novel by the Russian-born Ms. Rand, who at age 12 saw her father’s business confiscated in the Bolshevik Revolution. The 1,100-page book, written in three parts, is a futuristic fable about the dangers of collectivist government. Call it poli-sci-fi. It’s set in an America with a faltering economy, misled by bureaucrats who keep devising ways to take money from successful innovators in the name of public good.

Business leaders, meanwhile, are mysteriously vanishing. It turns out they’re going on strike, fed up with supporting the world—hence the title. They decamp to a hidden gulch and pledge to “never live for the sake of another man.” The heroine, Dagny Taggart, is desperately trying to save her family’s railroad company and discovers possible salvation in a motor that could generate limitless energy by capturing static electricity from the air. But its inventor, John Galt, already has taken his leave.

The polarizing book has been labeled the Bible of Selfishness. It also has inspired millions. Mr. Aglialoro says he was “zapped” when he read “Atlas” in his 20s.

“I thought, ‘Wow, gee, you’re entitled without guilt to your own life,’ ” he says. “Benevolence and charity are wonderful things, when they’re voluntary and on your terms. But what arrogance to have an entitlement society that expects it. Or to feel that you’ve got to ‘give back.’ I don’t know what the hell you took in the first place that you feel you have to give back.”

The film adaptation became its own saga. The mercurial Ms. Rand adapted her novel “The Fountainhead” for a King Vidor film starring Gary Cooper in 1949 and hated much of the movie, according to a 2004 biography by Jeffrey Britting. After her death in 1982, repeated efforts to turn her “Atlas” into cinema fizzled. Angelina Jolie was attached; Philadelphia Flyers owner Ed Snider optioned the rights; Randall Wallace (“Braveheart,” “Pearl Harbor”) wrote a script that covered the opus in a single film. In 1992, Mr. Aglialoro paid $1 million for a 15-year lease on the film rights, a duration he had to extend.

“I thought it would be a short period of time for investors to come in,” he says. “But all these entities couldn’t get it done. Ultimately, it’s not a movie Hollywood wants to embrace.”

Finally made on a modest budget (after huge start-up expenses, production was around $5.5 million), “Part I” was pounded by critics, who rated it at 11% “fresh,” lower than “Showgirls” and “Ishtar,” according to RottenTomatoes.com. Viewers, however, scored it at 74%.

“Part II” faced a new setback when Cybex lost a liability lawsuit in 2010 alleging that one of its weight machines had tipped over on a woman, leaving her paralyzed.

“I feel so sorry for her,” Mr. Aglialoro says. “She jumped up on there and pulled the machine back on herself while she was stretching.” The parties settled for $19.5 million in February. Cybex stock dropped so low the company faced delisting.

“The lawsuit was crippling,” Mr. Aglialoro says. He put just $5 million into “Part II” but recruited additional investors, allowing Atlas Productions to spend $10 million on production and $10 million more on marketing. The new film will open on three times as many screens as the first installment. It’s slicker and faster-paced, with a train crash and a jet-plane chase. The lead roles have all been filled by different actors, with Samantha Mathis replacing Taylor Schilling as Taggart. Cameos include Sean Hannity, Grover Norquist and Teller of Penn & Teller (Teller speaks). And in inspired casting, the two top government officials are played by Ray Wise and Paul McCrane, who were murderous hoods together in “RoboCop” and have spent careers portraying creepy villains with oversize foreheads.

The producers showed snippets to supporters of presidential candidate and fervent libertarian Ron Paul at the Republican convention and held screenings at the Heritage Foundation and Cato Institute in Washington.

“I’m making this as a warning,” says Mr. Aglialoro. “It’s about what happens when heroic producers disappear, and they leave the job of creating prosperity to the moochers and, God forbid, the politicians.”

Mr. Kaslow admits that after all their effort, one hurdle remains: “The challenge is that our audience doesn’t go to the movies that often.”

WSJ:  http://online.wsj.com/article/SB10000872396390444592404578032291709944404.html

Previous Issue:

Misdirection in our Country at Large

Occupy Wall Street

By Dr. Thomas Sowell

The current Occupy Wall Street movement is the best illustration to date of what President Barack Obama’s America looks like. It is an America where the lawless, unaccomplished, ignorant and incompetent rule. It is an America where those who have sacrificed nothing pillage and destroy the lives of those who have sacrificed greatly.

It is an America where history is rewritten to honor dictators, murderers and thieves. It is an America where violence, racism, hatred, class warfare and murder are all promoted as acceptable means of overturning the American civil society.

It is an America where humans have been degraded to the level of animals: defecating in public, having sex in public, devoid of basic hygiene.

It is an America where the basic tenets of a civil society, including faith, family, a free press and individual rights, have been rejected.

It is an America where our founding documents have been shredded and, with them, every person’s guaranteed liberties.

It is an America where, ultimately, great suffering will come to the American people, but the rulers like Obama, Michelle Obama, Harry Reid, Nancy Pelosi, Barney Frank, Chris Dodd, Joe Biden, Jesse Jackson, Louis Farrakhan, liberal college professors, union bosses and other loyal liberal/Communist Party members will live in opulent splendor.

It is the America that Obama and the Democratic Party have created with the willing assistance of the American media, Hollywood, unions, universities, the Communist Party of America, the Black Panthers and numerous anti-American foreign entities.

Barack Obama has brought more destruction upon this country in four years than any other event in the history of our nation, but it is just the beginning of what he and his comrades are capable of.

The Occupy Wall Street movement is just another step in their plan for the annihilation of America.

“Socialism, in general, has a record of failure so blatant that only an intellectual could ignore or evade it.”

—Thomas Sowell

Thanks to Dr. Loofbourow for bringing this to our attention. 11-13-11

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Regulations under Obama will worsen not only Freedom, but Quality of HealthCare.

Past Issue:

Hospitals taking over private practices

by Manoj Jain, MD, MPH

A decade and a half ago, when I moved to Memphis, I proudly hung a sign outside an office I shared with another doctor. It had my name followed by an MD. I had started my own small business as a solo practitioner in medicine.

Over the years, the practice has grown. I now have several employees and my own office, with the names of several other doctors alongside mine on the sign.

But across Memphis and the nation, health care delivery systems are shifting, and doctors are radically changing how they practice medicine. In a matter of a few years, small and large medical practices are crumbling, lumping, merging, or rebuilding — depending on one’s perspective.

According to the Medical Group Management Association, in 2005 more than 65 percent of medical practices were physician-owned. Within three years that figure had dropped to 50 percent, and by now I suspect it is much lower.

So why all these changes, and ultimately what will it mean for patients?

For one, providing health care is becoming increasingly complex. Keeping up with innumerable regulations from private insurers and the government, transitioning to electronic medical records (EMR) and caring for a growing population of chronically ill patients make it nearly impossible for a full-time practicing doctor to manage patients and a practice. For example, last year, I invested $15,000 in an EMR only to scrap it because it did not connect efficiently with hospital computer records.

There is another more significant reason for the demise of physician-owned practices. Two years ago, a cardiologist educated me over a coffee at Starbucks about the way Medicare was changing its payments. For the technical component of an echocardiogram, a hospital-outpatient department receives $450, while a physician-owned cardiology office gets $180. “It doesn’t make sense. We are going to go out of business.” According to rumors, that’s what was happening with many large private practices that had invested heavily in technology and diagnostic equipment. With the cuts, the practices were not sustainable.

So why did Medicare cut payment to doctors for office procedures? Many studies have found that if doctors have medical equipment in their offices, they tend to overuse it. One study showed that doctors who have an MRI machine in their office tend to order three times more MRI scans per 1,000 office visits compared to other physicians. For a cardiologist it was 2.6 times more cardiac echoes, according to a 2009 Medicare Payment Advisory Commission’s report. Overuse of imaging studies is a major factor contributing to skyrocketing health care costs.

So I asked a few doctors why did Medicare not cut payments to the hospitals. Some say, “That is coming soon,” while others say, “The hospital lobby was stronger than the doctor lobby.”
Whatever the case, the new health care landscape gives hospitals greater control over local health care resources. But as one hospital CEO told me, “I really don’t want to take over doctor practices. Managing doctors is like herding cats. But there is no choice.” . . .

Manoj Jain is an infectious disease physician and contributor to the Washington Post. He can be reached at his self-titled site, Dr. Manoj Jain.

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