1. Pursuant to the New York Insurance Law, may a medical provider, such as an ambulance company
issued a certificate to operate under N.Y. Pub. Health Law § 3005, bill a patient directly for prehospital
emergency ambulance services where a New York authorized insurer or health maintenance organization
("HMO") has made partial payment of a bill?
2. Pursuant to the New York Insurance Law, may a medical provider, such as an ambulance company
issued a certificate to operate under N.Y. Pub. Health Law § 3005, bill a patient directly for prehospital
emergency ambulance services where a New York authorized insurer or health maintenance organization
has denied payment entirely?
Conclusions:
1. Pursuant to N.Y. Ins. Law §§ 3216(h)(24), 3221(l)(15) and 4303(aa) (McKinney Supp. 2006), the
ambulance company may not bill a patient directly for prehospital emergency ambulance services where
a New York authorized insurer or HMO has made partial payment of a bill under an insurance contract
that provides major medical or similar comprehensive-type coverage. However, if such a contract is
not involved, these provisions do not apply and there is no prohibition in the Insurance Law against
the ambulance company billing the patient directly for the balance of the bill.
2. Yes. The ambulance company may bill a patient directly for prehospital emergency ambulance
services where a New York authorized insurer or HMO has denied payment entirely, subject to the remedies
available to the patient.
Facts:
This inquiry is general in nature.
Analysis:
N. Y. Ins. Law § 4303 (McKinney Supp. 2006) applies to non-profit health plans and HMO's. Although
HMO's are primarily regulated by the New York Health Department, their subscriber contracts are regulated
by the Insurance Department as if they were subscriber contracts of non-profit health insurers. See
N.Y. Public Health Law § 4406(1) (McKinney 2002).
N.Y. Ins. Law § 4303(aa) (McKinney Supp. 2006) provides, in relevant part, as follows:
(aa)(1) Every contract issued by a hospital service company or health service corporation which provides
major medical or similar comprehensive-type coverage shall include coverage for prehospital emergency
medical services for the treatment of an emergency condition when such services are provided by an
ambulance service issued a certificate to operate pursuant to section three thousand five of the
public health law.
(2) Payment by an insurer pursuant to this section shall be payment in full for the services provided.
An ambulance service reimbursed pursuant to this section shall not charge or seek any reimbursement
from, or have any recourse against an insured for the services provided pursuant to this subsection,
except for the collection of copayments, coinsurance or deductibles for which the insured is responsible
for under the terms of the policy.
(3) An insurer shall provide reimbursement for those services prescribed by this section at rates
negotiated between the insurer and the provider of such services. In the absence of agreed upon rates,
an insurer shall pay for such services at the usual and customary charge, which shall not be excessive
or unreasonable.
(4) The provisions of this subsection shall have no application to transfers of patients between
hospitals or health care facilities by an ambulance service as described in paragraph one of this
subsection. . . .
N.Y. Ins. Law § 3221(l)(15) (McKinney Supp. 2006), which applies to group or blanket accident
and health insurance policies issued by commercial insurers and N.Y. Ins. Law § 3216(h)(24) (McKinney
Supp. 2006), which applies to individual accident and health insurance policies issued by commercial
insurers contain identical provisions.
In accordance with the above, if the insurance contract provides major medical or similar comprehensive-type
coverage, it must include coverage for prehospital emergency medical services for the treatment of
an emergency condition when such services are provided by an ambulance service issued a certificate
to operate pursuant to section three thousand five of the public health law. The insurer must provide
coverage for emergency ambulance services based upon the rates negotiated between the insurer and
the provider of such services. If no participating provider contract exists, the insurer must pay
for the services at the usual and customary charge, which shall not be excessive or unreasonable.
Once the insurer makes payment at the usual and customary charge, the provider must accept such
payment as payment in full. The provider may not bill the patient directly for emergency ambulance
services for the balance of a bill, except for the collection of copayments, coinsurance or deductibles
that the insured is responsible for under the terms of the insurance contract.
Please note that N.Y. Ins. Law §§ 3216(h)(24), 3221(l)(15) and 4303(aa) (McKinney Supp. 2006)
are applicable only to insurance contracts that provide major medical or similar comprehensive-type
coverage. Thus, if such a contract is not involved, these provisions do not apply and there is no
prohibition in the Insurance Law against the ambulance company billing the insured directly. In addition,
these provisions do not address a situation in which a New York authorized insurer or HMO has denied
payment entirely for emergency ambulance services (i.e. where the insurer or HMO states that coverage
was not in effect or that treatment was not medically necessary). In such cases, the ambulance company
may bill the patient directly, subject to the remedies available to the patient.
If the ambulance company or patient disputes a payment made by the insurer or HMO as not constituting
the usual and customary charge or disputes the fact that no payment was made, the ambulance company
or patient may raise the issue with the insurer or HMO and/or file a complaint with the Department's
Consumer Services Bureau.
Lastly, the New York Attorney General's Office has conducted an investigation on balance billing
by ambulance companies. For further information, the inquirer was directed to contact the Attorney
General's Office at (518)474-7330 or access their web site which is located at http://www.oag.state.ny.us.
This opinion does not provide an analysis of the No-Fault Insurance Law, which would result in
a different analysis and conclusion, since the inquirer already had OGC Opinions on this subject.
1 Please note also that this opinion is limited to an interpretation of the New York Insurance
Law. No opinion is rendered on any other laws.
For further information you may contact Associate Attorney Pascale Jean-Baptiste at the New York
City Office.
1 See OGC Opinion No. 03-02-18, dated Feb. 18, 2003 and OGC Opinion No. 03-04-36,
dated April 30, 2003; see also OGC Opinion No. 05-05-29, dated May 28, 2005.
"... Balance billing is on the rise nationally. In 2011, around 8 percent of privately insured individuals used out-of-network care, 40 percent of which resulted in unanticipated medical costs due to balance billing, reports Health Services Research . ..."
"... Balance billing complaints are up 1,000 percent in Texas . ..."
"... The rise in balance billing is partially attributable to a lack of network transparency with patients. ..."
"... The New York Times ..."
"... Kaiser Health News ..."
"... In 2014 Aetna sued a physician at Monmouth Medical Center in Long Branch, N.J., a hospital within Aetna's network, who did not notify a patient he would not accept Aetna's discounted reimbursement rate, according to the lawsuit. The physician charged Aetna $31,939 to treat abdominal pain in the patient. After Aetna paid the amount it deemed reasonable - $2,811, based on Medicare rates - the physician balance billed the patient for an additional $10,635. ..."
Patients, caught in the financial crosshairs, often feel powerless to negotiate costs. Consumer
advocacy groups and federal and state legislators are turning their attention to balance billing
practices this year with renewed vigor, forcing payers and providers to find other ways to settle
financial disagreements.
Here are 20 things to know about balance billing.
1. Balance billing is on the rise nationally. In 2011, around 8 percent of privately insured individuals
used out-of-network care, 40 percent of which resulted in unanticipated medical costs due to balance
billing, reports
Health
Services Research . In 2015, a nationwide study from
Consumers Union found nearly one third of privately insured Americans received an unanticipated
bill when their health plan paid less than expected for medical services within the past two years.
2. Balance billing complaints are up 1,000 percent in Texas . According to the
Texas Department of Insurance , balance billing complaints rose from 112 in 2012 to 1,334 in
2015, an increase of 1,000 percent.
3. Lack of provider, network transparency. The rise in balance billing is partially attributable
to a lack of network transparency with patients. In many cases patients are unaware they have received
out-of-network care until they receive a balance bill in the mail. Nearly 70 percent of individuals
with unaffordable out-of-network medical bills did not know the healthcare provider was not in their
plan's network at the time of care, according to a survey conducted by
Kaiser Family Foundation and The New York Times .
4. Emergency room services to blame, in part. A
Health Services Research survey found in 2011, 68 percent of inpatient involuntary contact with
out-of-network physicians was related to emergency care. These kinds of unanticipated medical bills
may arise when a hospital participates in an insurer's network but its employed emergency physicians
do not. For example, more than half of the hospitals in some Texas insurers' networks did not have
a single physician on staff covered by the insurer, according to a 2015 study from the Centers for
Public Policy Priorities in Austin.
5. Balance billing and contracted physicians. Many hospitals use physician outsourcing firms for
anesthesiologists, emergency physicians, pathologists and radiologists, or will bring in an outside
assistant surgeon to help with procedures. In many cases, these physicians do not participate in
the same network as the hospital, unbeknownst to the patient. When physician groups and insurers
are unable to resolve reimbursement disputes, patients can be served with much higher out-of-network
charges. In Texas, for example, the specialty services most likely to submit balance bills are anesthesiologists,
lab services, surgery and radiology, reports the
Texas Department of Insurance .
6. Payers will fight out-of-network physicians with lower reimbursement rates. Last year, health
insurance giant UnitedHealthcare said it would scale back how much it pays out-of-network physicians
who practice at in-network hospitals, accusing physicians of demanding excessively high reimbursement
levels, according to
Kaiser Health News . During a
billing dispute with out-of-network Bayonne (N.J.) Medical Center, the insurer accused the hospital
of charging out-of-network rates 10 to 12 times higher for a medical service than area hospitals
participating in United'snetwork. If a payer refuses to match physician reimbursement rates, the
financial burden is passed on to the patient. In the aforementioned dispute between Bayonne and UnitedHealthcare,
the patient was balance billed $1,170 for a total of five stitches.
7. Insurers are narrowing networks in an effort to reduce costs. As insurance companies have narrowed
provider networks to keep premiums down, the number of patients who inadvertently received
out-of-network care has jumped at hospitals, particularly with regard to contracted physicians.
8. Payers have sued providers for 'excessive' out-of-network fees. Aetna
has sued a half dozen out-of-network physicians in recent years, alleging gross over charging
for medical services. In 2014 Aetna sued a physician at Monmouth Medical Center in Long Branch, N.J.,
a hospital within Aetna's network, who did not notify a patient he would not accept Aetna's discounted
reimbursement rate, according to the lawsuit. The physician charged Aetna $31,939 to treat abdominal
pain in the patient. After Aetna paid the amount it deemed reasonable - $2,811, based on Medicare
rates - the physician balance billed the patient for an additional $10,635.
9. Balance billing can occur even when a payer adjusts out-of-network emergency bills to in-network
rates for patients. A patient recently accused Duke University Medical Center in Durham, N.C., of
balance billing his account for an out-of-network rate after the patient submitted in-network payment
rates to Blue Cross Blue Shield. Owing to the medical emergency of his situation,
Matthew
Aitken said he received an in-network rate from Blue Cross Blue Shield of North Carolina. However,
Mr. Aitken alleged Duke proceeded to charge him for the remainder of the bill at the higher out-of-network
rate, resulting in a bill nearly double that of Mr. Aitken's out-of-pocket limit.
10. Air ambulance billing disputes, complaints on the rise. In rural areas of the U.S. the high
price for life-saving
air ambulance flights has grabbed media attention as rural residents, faced with excessive balance
billing, have turned to state and federal auditors for intervention. Those in rural areas often must
rely on air ambulance flights in life-or-death situations in lieu of feasible ground transportation.
Reimbursement rate disputes between payers and medical air transport companies have strapped patients
with devastating medical bills. When Amy Thomson's newborn daughter was in heart failure, Ms. Thomson
had to use an air ambulance service in rural Montana for transport to a more capable facility. At
the time her insurance company, PacificSource, did not have an in-network air ambulance company near
her family, reports
Montana Public Radio . Ms. Thomson received a $43,000 balance bill from Airlift Northwest
after PacificSource contributed a policy cap of $13,000.
11. Provider-based billing practices. Consumers have been increasingly vocal about surprise medical
bills derived from
provider-based billing practices. Provider-based billing allows a healthcare organization to
bill patients for physician care in addition to a service charge for the patient's use of hospital
facilities and equipment. In some cases, a patient may be responsible for the service bill if their
insurance declines to pay or if the patient has a high deductible health plan. Large hospitals like
Cleveland Clinic have faced increased scrutiny for provider-based billing practices. After paying
a $30 copayment for in-network care with a Cleveland Clinic chiropractor,
Julie Beinhardt reported receiving a balance bill of $3,000 for provider-based service fees her
insurance plan refused to cover.
12. President Barack Obama signed legislation against provider-based billing. Last year, President
Obama signed
legislation outlawing provider-based billing at off-campus outpatient facilities. The legislation
does not apply to existing outpatient centers that already engage in the practice, however.
13. The president's 2017 budget proposal includes a provision to eliminate surprise medical bills.
Although details are minimal, the president's 2017 budget proposal includes a provision to eliminate
balance billing privately insured patients. The administration would address the issue by requiring
physicians who regularly provide services in hospitals to accept in-network rates for service reimbursement,
even if they aren't in the insurer's network.
14. About a quarter of U.S. states have laws that protect consumers from out-of-network medical
bills incurred by emergency care. According to a study from
Kaiser Family Foundation , 24 states have implemented laws that restrict providers from balance
billing in emergency care situations, including California, Delaware, New Jersey, New York and Pennsylvania,
among others.
15. More states are proposing independent dispute resolution between payers and providers in balance
billing cases. Independent dispute resolution establishes a legal space in which providers and health
insurers can settle disagreements regarding balance billing without involving the patient. The states
of
Illinois
and New Yorkhave arbitration methods in place, and
Florida ,
Washington and
Pennsylvania are currently considering a similar resolution methods.
16. New York has some of the strongest consumer protection laws. Under
New York law , consumers are generally protected from owing more than their in-network copayment,
coinsurance or deductible on bills they receive for out-of-network emergency services. Patients can
complete an assignment of benefits form that absolves them of financial responsibility and allows
the provider to pursue payment from the health plan in balance billing disputes.
17. Florida state legislature is currently embroiled in a fight to pass balance billing laws.
Legislation to outlaw balance billing in Florida has continued to creep through the state legislature
since last fall. Introduced in both the house and senate, the bills have sparked conflicting and
outspoken opinions from patients, payers, hospitals and physicians. Hospitals have largely denounced
the bill, blaming balance billing disputes on payers that demand allegedly unsustainable reimbursement
rates, reports
Sunshine State News .
18. The "End Surprise Billing Act". Federal lawmakers are making moves to outlaw balance billing
nationally. Co-sponsored by 25 lawmakers, the End Surprise Billing Act would protect patients from
balance billing who went to in-network facilities for emergency services, reports
Consumerist . In non-emergency cases, it would require providers to notify patients
within 24 hours if an out-of-network specialist will be involved in an episode of care.
19. Consumers don't know how to navigate the legal waters. According to a
Consumer Union report, 57 percent of patients who encountered balance billing from contracted
physicians within the last two years paid in full because they didn't know their rights to fight
the bills. An overwhelming majority (87 percent) did not know which agency or department in their
state government is tasked with handling complaints about health insurance. "So many times, people
just give up [in surprise billing disputes]," Elisabeth Benjamin, vice president of health initiatives
with Community Service Society of New York, told
NPR .
20. The New York Times dedicated a series to consumer encounters with surprise healthcare
bills. Elisabeth Rosenthal's series in The New York Times entitled
Paying Til it Hurts examined the personal and financial implications of excessive, unexpected
medical costs on Americans, their families and their healthcare consumption. Ms. Rosenthal's installments
often feature individuals with unaffordable balance bills like
Peter Drier , who was served a $117,000 balance bill for an out-of-network physician's assistant
he never knew was present during surgery.
(businessinsider.co.id)
83 Posted by EditorDavid on Sunday December 11, 2016 @09:34PM from the damn-it-Jim-I'm-a-doctor-not-a-supercomputer
dept.
"Supercomputing has another use," writes Slashdot reader
rmdingler , sharing a story that
quotes David Kenny, the General Manager of IBM Watson:
"There's a 60-year-old woman in Tokyo. She was at the University of Tokyo. She had been diagnosed
with leukemia six years ago. She was living, but not healthy. So the University of Tokyo ran
her genomic sequence through Watson and
it was able to ascertain that they were off by one thing . Actually, she had two strains
of leukemia. They did treat her and she is healthy."
"That's one example. Statistically, we're seeing that about one third of the time, Watson is
proposing an additional diagnosis."
On Monday Google launched a new app for Android called Trusted Contacts that
allows users to share their locations and some limited other information with a
set of close friends and family members. The system is a two-way road, so a
user can actively share her location with her Trusted Contacts, and stop
sharing it at her discretion. But, when a problem or potential emergency comes
up, one of those contacts can request to get that user's location to see where
she is at any moment. The app is designed to give users a way to reassure
contacts that they're safe, or request help if there's something wrong.
Two new posts on this website have me contemplating, once again, the terrible possibility that
psychiatry is hurting more people than it helps. Reporter Sarah G. Miller notes in "1 in 6 Americans
Takes a Psychiatric Drug" that prescriptions for mental illness keep surging. As of 2013,
almost 17 percent of Americans were taking at least one psychiatric drug , up from 10 percent
in 2011, according to a new study. "Antidepressants were the most common type of psychiatric drug
in the survey, with 12 percent of adults reporting that they filled prescriptions for these drugs..."
This increase in medications must be boosting our mental health, right? Wrong. In "Is Mental
Health Declining in the U.S.?," Edmund S. Higgins, professor of psychiatry at the Medical University
of South Carolina, acknowledges the "inconvenient truth" that
Americans' mental health has, according to some measures, deteriorated ...
(betanews.com)
30
Posted by
BeauHD
on Tuesday November 29, 2016 @05:40PM
from the
medical-breakthrough
dept.
BrianFagioli
writes from a
report via BetaNews:
Diabetic eye disease is caused by retinopathy. Affected
diabetics can have small tears inside the eye, causing bleeding. Over time,
they can lose vision, and ultimately, they can go blind. Luckily, Google has
been trying to use machine learning to detect diabetic retinopathy. Guess what?
The search giant has seen much success. Not only are the computers
able to detect the disease at the same level as ophthalmologists
, but
Google is actually slightly better!
"A few years ago, a Google research
team began studying whether machine learning could be used to screen for
diabetic retinopathy (DR). Today, in the
Journal of
the American Medical Association
, we've published our results: a deep
learning algorithm capable of interpreting signs of DR in retinal photographs,
potentially helping doctors screen more patients, especially in underserved
communities with limited resources,"
says Lily Peng
, MD Ph.D., Product Manger at Google. She goes on to say "our
algorithm performs on par with the ophthalmologists, achieving both high
sensitivity
and specificity
. [...] For example, on the validation set described in
Figure 2, the algorithm has a F-score of 0.95, which is slightly better than
the median. F-score of the 8 ophthalmologists we consulted (measured at 0.91)."
(japantimes.co.jp)
115
Posted by EditorDavid
on Sunday December 11, 2016 @03:34PM
from the
scans-of-the-setting-sun
dept.
"The Japanese city of Iruma has introduced
scannable adhesive barcodes to tag fingernails of senior citizens with dementia
who are prone to getting lost as a way to help concerned families find missing
loved ones," writes
HughPickens.com
, citing this article from
Japan Times
:
The
adhesive QR-coded seals for nails -- part of a free service launched last month
and a first in the country -- measure just 1 cm (0.4 inches) in size. "Being
able to attach the seals on nails is a great advantage," says a city worker.
"There are already ID stickers for clothes or shoes but dementia patients are
not always wearing those items." If an elderly person becomes disorientated,
police will find the local city hall, its telephone number and the wearer's ID
all embedded in the QR code.
Japan is grappling with a rapidly aging population
, with senior citizens
expected to make up a whopping 40 percent of the population
around 2060
.
The article describes Japan as "a country where 4.8 million people aged 75 or
older hold a license... Last month, police started offering discounts for
noodles at local restaurants to elderly citizens who agreed to hand in their
driving licenses."
(bbc.com)
38
Posted by msmash
on Thursday December 01, 2016 @07:35PM
from the
security-woes
dept.
Security researchers have warned of flaws in medical implants in what they say
could have fatal
consequences
. The flaws were found in the radio-based communications used
to update implants, including pacemakers, and read data from them. From a BBC
report:
By exploiting the flaws, the researchers were able to adjust settings
and even switch off gadgets. The attacks were also able to steal confidential
data about patients and their health history. A software patch has been created
to help thwart any real-world attacks. The flaws were found by an international
team of security researchers based at the University of Leuven in Belgium and
the University of Birmingham.
(eurekalert.org)
560
Posted by
BeauHD
on Wednesday November 30, 2016 @08:00AM
from
the
time-for-a-check-up
dept.
cold fjord
writes:
State
level marijuana legalization efforts across the U.S. have been gaining traction
driven by the folk wisdom that marijuana is both a harmless recreational drug
and a useful medical treatment for many aliments. However, some cracks have
appeared in that story with indications that marijuana use is associated with
the
development of mental disorders
and the
long-term blunting of the brain's reward system of dopamine levels
. A new
study has found that marijuana appears to have a widespread effect on blood
flow in the brain. EurekAlert reports: "Published in the
Journal of Alzheimer's Disease
, researchers using single photon emission
computed tomography (SPECT), a sophisticated imaging study that evaluates blood
flow and activity patterns, demonstrated
abnormally low blood flow in virtually every area of the brain studies in
nearly 1,000 marijuana users
compared to healthy controls, including areas
known to be affected by Alzheimer's pathology such as the hippocampus.
According to Daniel Amen, M.D., 'Our research demonstrates that marijuana can
have significant negative effects on brain function. The media has given the
general impression that marijuana is a safe recreational drug, this research
directly challenges that notion. In another new study just released,
researchers showed that marijuana use tripled the risk of psychosis. Caution is
clearly in order.'"
"... "One should know what the cost of the procedure is, and that is something that is just impossible to figure out before or after the procedure," Luthra says. "I had no way of knowing beforehand there were going to be these six different types of providers . . . sending me bills." ..."
Sanjiv Luthra of Los Altos, Calif., suffered from the pain and fatigue of rapid-onset
arthritis so severe that he couldn't walk 10 feet until he underwent double knee-replacement surgery
in 2006. Now, two years later, he can walk and run, but he still suffers the fallout from another
ailment:
medical bills.
Six hours in an operating room, two knee replacements, medications and a five-day
hospital stay added up to a bill of $80,000, Luthra estimates. That's not counting bills for an anesthesiologist,
physical therapy, additional medicines and special exercise equipment to help him recover.
"One should know what the cost of the procedure is, and that is something that
is just impossible to figure out before or after the procedure," Luthra says. "I had no way of knowing
beforehand there were going to be these six different types of providers . . . sending me bills."
Luthra's insurance company was able to negotiate with the hospital so that it
paid about $20,000, and he parted with about $5,000, including expenses outside the hospital.
But individual patients can haggle for lower medical bills, too. Here are tips
on how to go about it.
Work up the courage to ask. It's not just insurance companies that can negotiate.
"The typical insurer gets about a 60% discount," says Gerard Anderson, the director
of the Johns Hopkins Center for Hospital Finance and Management. "If you go into the hospital and
ask the
chief financial
officer
,
you may get a 30% discount, but you have to ask for it. It's totally up to the discretion of the
CFO how much they or the person in the billing office are willing to give you."
Although it's common to negotiate with a real-estate agent or car salesperson
you probably never will see again, it's much more difficult to negotiate with a doctor you trust
to make you well and to provide continuing care for your family. Only 31% of Americans have tried
to negotiate the price of medical bills, a survey by Consumer Reports National Research Center indicated.
But of those who tried, 93% have been successful at least once, and more than a third saved more
than $100.
Explore low-cost treatments. Many doctors incurred large loans to finance medical school and probably understand the need to get
a fair price as well as you do.
But even though almost 80% of physicians will prescribe a generic medication over
a brand-name drug to save patients money, far fewer consider patient costs when recommending diagnostic
tests (51%) or choosing between hospitalization and outpatient treatment (40%), according to a survey
of physicians by the Center for Health System Change and the
University of
Chicago
If money is an issue, you need to ask your doctor if cheaper, medically sound
options are available. The trick is to keep it friendly and ask nicely. For minor health ailments
such as ear infections and pinkeye, drugstore clinics list reasonable prices upfront, with no negotiating
required.
Find the correct person. Although they are heavily involved in treatment decisions, doctors may not be directly involved in
other billing issues, so you need to find a person with the ability to adjust your bill.
"I would suggest the consumer go to the office manager," says Timothy Cahill,
a health-care consultant in Louisville, Ky., who has negotiated hospital bills on behalf of patients.
The office manager should be able to direct you to the person in charge of billing.
Offer cash payments. This could be a mutually beneficial solution for you and the medical establishment.
"Paying cash is worth a lot to a doctor in terms of time and trouble, and it is
a lot less complex for the hospital to deal with," says Shankar Srinivasan. He is a co-founder and
the chief technology officer of Vimo.com, a company that uses public records to figure out what prices
insurers negotiate with hospitals. Cash, he says, saves hospitals the trouble of negotiating financing
terms, paying credit card transaction fees and sending collection agencies after patients who fail
to pay.
Scrutinize the bill and your insurance. If you don't have the cash to pay a large medical bill, you need to educate yourself about what your
insurance should cover and try to negotiate a discount off the sticker price.
"As a consumer, just like a detective, you have to really understand the specifics
of your insurance benefit plan, take the initiative of setting up conference calls (including yourself,
the hospital and your insurance company) proactively, and you have to document everything," says
Luthra, who is chief operating officer of the health-care-consulting company Benu. "You don't just
pay the bill as is."
This article was reported and written by Emily Brandon for
U.S. News & World Report.
"... The average balance billed to patients was $622.55 , though the study reported bills as high as $19,603.30. But, ERs are not the only source of surprise bills. ..."
"... Even when a patient goes to a hospital for routine surgery, and takes care to choose an in-network hospital and in-network surgeon, the anesthesiologist, radiologist or pathologist assigned to the case may be out of network, and follow up with a surprise bill. ..."
"... If you have a serious medical emergency, your nearest hospital may not be in-network and all your treatment may result in out-of-pocket expense for high surprise bills. But, even if you visit an in-network ER, you have little control over the choice of doctor: By definition, you are facing an emergency, and must take whoever is available. ..."
"... Check with your state insurance regulator to see if your state has any consumer protections against surprise bills. ..."
"... At present, California, Colorado, Connecticut, Florida and New York do have such protections against unexpected balance bills - either for out-of-network ER situations alone or for additional types of surprise bills. ..."
"... If your state does not offer protection against surprise bills, check first to make sure the provider is really not in your network. Back offices and billing companies deal with many plans and sometimes make mistakes. Providers who are in your network have to accept the insurer's contracted rate. ..."
"... If the provider is out of network, do some research on an independent website, such as fairhealthconsumer.org , to estimate what the procedure typically costs in your locality. ..."
"... If neither the insurer nor the provider is willing to budge, do not be afraid to seek help. If you get your insurance through your employer, your human resources department may be able to intervene. Call your state representative or your local consumer protection office. With the right assistance, you might be able to reduce the bill, if not make it go away entirely. ..."
Surprise bills are never a welcome surprise. Typically, they arrive after you arranged care from
a doctor and a hospital that were both in your health plan's network, but then you were unexpectedly
treated by one or more other providers who, unbeknownst to you, were outside that network.
When
these out-of-network providers send you a bill for their services, you may have to pay the full amount
out of pocket or, if your health plan covers out-of-network care, to pay the balance of the bill
that your insurance fails to cover. And the balance bill generally requires you to pay more than
the out-of-pocket amount you would have owed if you had been treated by an in-network provider.
Emergency rooms are one of the most common locations where healthcare results in surprise bills.
As detailed recently in
an article by two Yale
scholars in the New England Journal of Medicine, in more than one in five cases nationwide, ER
visits to an in-network facility involved out-of-network physicians. The average balance billed
to patients was
$622.55, though the study reported bills as high as
$19,603.30.
But, ERs are not the only source of surprise bills.
Even when a patient goes to a hospital for routine surgery, and takes care to choose an in-network
hospital and in-network surgeon, the anesthesiologist, radiologist or pathologist assigned to the
case may be out of network, and follow up with a surprise bill.
Several states have already
enacted laws to protect consumers against surprise bills, although some of the statutes protect
patients only in the case of balance bills for out-of-network ER services for a serious medical emergency.
Currently, the issue is being discussed in a number of statehouses. In the meantime, here are steps
you can take to protect yourself from such surprises.
Prevent surprise bills
The best defense against a surprise bill is prevention. If you have a serious medical emergency,
your nearest hospital may not be in-network and all your treatment may result in out-of-pocket expense
for high surprise bills. But, even if you visit an in-network ER, you have little control over the
choice of doctor: By definition, you are facing an emergency, and must take whoever is available.
However, for a planned surgery or other procedure, you probably have time to speak up. Make sure
that your doctor and hospital are in your plan's network. Check with them and with your plan. Ask
your physician and your hospital in advance if they can arrange to have only in-network providers
treat you.
Some hospitals may have no in-network specialist for care you might require. Find out if another
hospital in your area can provide all your necessary services on an in-network basis. In some areas,
there may be no in-network specialists available of the type you need. In that case, inform your
plan that its network lacks necessary services and find out if the terms of the plan or state law
provide you protection from large balance bills in such circumstances.
Always refer to your plan by its exact official name. Often insurers have multiple plans with
similar names but different networks. If you use the wrong plan name when inquiring about a plan's
network, you may get a wrong and costly answer. Make your inquiries and requests in writing so you
have documentation. Ask for the names of the providers who will be involved in your care, and check
with your insurer and with the providers themselves to see if they are all in your plan's network.
Check if your state protects consumers
If you do get a surprise bill, take action. Check with your state insurance regulator to see
if your state has any consumer protections against surprise bills. Many states have laws that
require HMOs to protect consumers from surprise bills, especially with respect to necessary ER services.
Fewer states have similar protections for other types of health plans, such as PPOs and EPOs.
At present, California, Colorado, Connecticut, Florida and New York do have such protections
against unexpected balance bills - either for out-of-network ER situations alone or for additional
types of surprise bills. Generally, these laws provide that the consumer is required to pay
only the amount he or she would owe for the services if provided in-network. States have different
mechanisms for settling the balance, but they generally involve the insurer and the provider, not
the patient.
If your state does not provide protection
If your state does not offer protection against surprise bills, check first to make sure the
provider is really not in your network. Back offices and billing companies deal with many plans and
sometimes make mistakes. Providers who are in your network have to accept the insurer's contracted
rate.
If the provider is out of network, do some research on an independent website, such as
fairhealthconsumer.org, to estimate
what the procedure typically costs in your locality. If your plan's reimbursement is based on
an amount that is less than the typical charge, you can use this information to ask the plan to pay
the provider on the basis of at least the typical rate. If the out-of-network provider's charge is
higher than the typical rate, you might be able to negotiate with the provider to reduce your costs.
You can try to persuade the provider to reduce the charge, or to discount an excessive balance bill,
by showing the provider that his or her charge is above the typical market rate.
If neither the insurer nor the provider is willing to budge, do not be afraid to seek help.
If you get your insurance through your employer, your human resources department may be able to intervene.
Call your state representative or your local consumer protection office. With the right assistance,
you might be able to reduce the bill, if not make it go away entirely.
Robin Gelburd, JD, is the president of
FAIR Health, a national, independent
nonprofit with the mission of bringing transparency to healthcare costs and insurance reimbursement.
FAIR Health oversees the nation's largest repository of private healthcare claims data, comprising
over 21 billion billed medical and dental charges that reflect the claims experience of over 150
million privately insured Americans. Follow on twitter
@FAIRHealth
Two excellent resources-Healthcare Blue Book and FAIR Health-can give you estimates of how much
health care services should cost in your area. Plus, your insurer's website may also provide a tool
that will allow you to compare costs.
Notable quotes:
"... But the bill did come-all $9,000 of it. The ambulance company charged $6,500, including a $300 fee for the linens and a $30 charge for aspirin. The E.R. billed the remaining $2,500. "My mouth literally dropped open when I saw the cost," she says. ..."
"... "I've always heard emergency room visits were costly, but $9,000 for nothing more than a conversation that lasted one minute? That's robbery," she says. ..."
"... "Employers often try to stay away from filing a claim under worker's compensation, so it does not impact their experience rating or trigger an [occupational safety and health administration] review, but it would save her money." ..."
It's no secret that hospital bills in the U.S.-especially ones from the E.R.-can often hit
astronomical proportions.
According to a recent cost study conducted by researchers at Stanford University, the
University of Minnesota, the University of California, San Francisco and the Ecologic Institute,
the median charge for an emergency room trip in the U.S. comes in at $1,233. But where it really
gets interesting is when you look at the specific reasons for those E.R. visits: The researchers
found that the treatment price for a headache could range from $15 to a whopping $17,797. As for
a sprained ankle, it could set someone back a paltry $4 or up to $24,110!
So what gives with these wildly fluctuating price points?
For starters, most emergency room prices are inflated based on the rates at which insurance
companies will reimburse the hospital on a patient's behalf. That's why a single aspirin can cost
$30 per pill in the E.R., which is more than six times the price for a bottle of them at the drug
store.
On the flip side, patients will often contact the hospital or surgeon's billing office to ask
for a cost reduction, further adding to the inconsistency in pricing. It's a practice that often
works in a patient's favor, says billing advocacy specialist Sharon Salters of Medical Cost
Advocatea professional medical bill negotiation service.
And then there's also the fact that most hospitals offer discounts to self-paying
individuals-especially if there's a risk that they might not pay at all.
So to help shed some light on the complexities of hospital medical billing for the average
consumer, we asked three people to share their craziest emergency room stories, the even crazier
bills that followed-and the steps they took to remedy them.
... ... ...
The Emergency: Head Injury
The Bill: $9,000
A few months ago, Amanda Harris, 27, of Morristown, N.J., fainted at work, hitting her head in
the process. Due to liability concerns, her production company required Harris to take an
ambulance to the emergency room, despite her refusal. "I didn't even have a cut on my head, just
a slight bump. No headache, no nausea, no confusion, nothing," she says.
Harris waited for over an hour in the E.R. before her husband told the nurse that they were
leaving. Minutes later, a doctor spoke to Harris for under a minute, confirming that she was fine
to go. "He didn't do any tests-no light in my eyes, no blood pressure," says Harris. "I left
thinking I wouldn't even get a bill."
But the bill did come-all $9,000 of it. The ambulance company charged $6,500, including a $300
fee for the linens and a $30 charge for aspirin. The E.R. billed the remaining $2,500. "My mouth
literally dropped open when I saw the cost," she says.
What This Patient Did: Harris called her insurer and fought the bill.
Luckily, her insurance covered all but a $3,000 deductible-but she was too exhausted to push for
more. "I've always heard emergency room visits were costly, but $9,000 for nothing more than a
conversation that lasted one minute? That's robbery," she says.
What the Expert Says: Even though Harris didn't want to take an ambulance,
Salters says that her company's suggestion was well-advised. "However, she should consider
working with her employer to file the claim with her company's worker's compensation carrier,"
says Salters. "Employers often try to stay away from filing a claim under worker's compensation,
so it does not impact their experience rating or trigger an [occupational safety and health
administration] review, but it would save her money."
How You Can Avoid Outrageous E.R. Bills (Really!)
When it comes to a trip to the E.R., the reality is that there's usually no time to shop
around and compare prices in advance. But if you do some research before an emergency happens,
you could potentially keep costs significantly down.
Consider Urgent Care for True Non-Emergencies. If your medical problem isn't life-threatening (think sprains, minor cuts and
fevers), you can visit an urgent care center instead. An Annals of Internal Medicine Study found
that the average urgent care visit from 2005 and 2006 cost $156-compared with $570 for the same
visit to an emergency room.
Double-Check Your Bill.
Hospital billing systems aren't perfect, so it's wise to keep track of any treatments that you
receive in the E.R.-including time spent in the operating room, which can cost up to $200 a
minute! To prevent billing mistakes, ask for an itemized statement before you're discharged, so
you can compare it with your own record-keeping.
Negotiate Your Health Care Costs.
Most importantly, don't be shy when it comes to bargaining. Two excellent resources-Healthcare
Blue Book and FAIR Health-can give you estimates of how much health care services should cost in
your area. Plus, your insurer's website may also provide a tool that will allow you to compare
costs.
The negotiation can seem like a lot of extra work, but the payoff can be tens of thousands of
dollars in savings shaved off a potentially outrageous E.R. bill.
"... The goal of the majority of providers is to increase total "sales" by ordering many procedures and or drugs that are not needed. Much of this is done from ignorance and is not necessarily indicative of a purely capitalistic motive. ..."
I was a practicing cardiologist in the US for over 30 years. I, as most other practicing cardiologist,
was trained and fully believed the prevailing methods of diagnosis and treatment were not only
correct but absolutely necessary. Several decades of experience taught me this is not close to
being accurate. The majority of medical tests, and much of the treatment, is not only unnecessary,
but harmful and/or dangerous. The goal of the majority of providers is to increase total "sales"
by ordering many procedures and or drugs that are not needed. Much of this is done from ignorance
and is not necessarily indicative of a purely capitalistic motive.
David Goldhill is one of the few authors that have experienced this travesty and is educated
and intelligent enough to understand the consequences of this nationwide epidemic and the needless,
wasteful, and dangerous care. His ability to sort through all of the "noise" prevalent in the
governmental and media diatribe and isolate the real problem as full insurance for everyone is
unique. This system is doomed for failure. There will never be enough resources to fund medical
care as long as the consumer is not the payer. They will always demand more and the providers
are happy to accommodate them.
I have left the US and am presently living in Beijing, China, attempting to establish purely
preventive heartcare clinics. This is more general education regarding diet, smoking, sedentary
lifestyle, and alcohol abuse. than traditional western medicine. Less income, but certainly more
satisfying.
About a third of all cardiac stents implanted in patients are unnecessary, says cardiologist David
Brown of Stony Brook University School of Medicine
Notable quotes:
"... About a third of all cardiac stents implanted in patients are unnecessary, says cardiologist David Brown of Stony Brook University School of Medicine. That amounts to more than 200,000 stents a year, and controversy surrounding this practice has spurred nationwide litigation and a federal investigation into several cases involving illegal kickbacks and allegations of cardiac stent malpractice. ..."
"... Blood clots can occasionally form in an inserted stent, which can then lead to the artery narrowing once again. In some cases, the blood vessel can become completely blocked – a condition called in-stent thrombosis. ..."
"... Most patients that undergo stenting are prescribed blood thinners in the wake of the procedure to ensure such events don't occur. ..."
"... Cardiac stents are big business for hospitals and their staff, with the average private insurance reimbursement for a procedure totaling $25,000. By placing a stent inside an artery, surgeons can restore blood flow that has been compromised in heart attack patients, or give help to patients at risk for future heart attack. But when misused or overused in patients, cardiac stents can prove fatal, as they did for former postal service worker Bruce Peterson. ..."
"... Peterson developed several blood clots and blockages due to his weakened heart, which ultimately caused his untimely demise, argues his widow Shirlee Peterson. ..."
"... Nortin Hadler, a UNC Chapel Hill professor of medicine told Bloomberg News, "Stenting belongs to one of the bleakest chapters in the history of Western medicine. Cardiologists "are marching on" because "the interventional cardiology industry has a cash flow comparable to the GDP of many countries" and doesn't want to sacrifice the revenue, he said. ..."
About a third of all cardiac stents implanted in patients are unnecessary, says cardiologist
David Brown of Stony Brook University School of Medicine. That amounts to more than 200,000 stents
a year, and controversy surrounding this practice has spurred nationwide litigation and a federal
investigation into several cases involving illegal kickbacks and allegations of cardiac stent malpractice.
For the most part, stenting procedures are relatively low in risk and moderately safe. However,
as with any surgical procedure – even a minimally invasive one – there is a risk of developing complications.
Blood clots can occasionally form in an inserted stent, which can then lead to the artery narrowing
once again. In some cases, the blood vessel can become completely blocked – a condition called in-stent
thrombosis.
Most patients that undergo stenting are prescribed blood thinners in the wake of the procedure
to ensure such events don't occur.
Additionally, manipulating arteries with a stent or any other sort of medical procedure can lead
to the walls of the blood vessel becoming injured or damaged. The innermost layer of coronary arteries,
known as the endothelium, is particularly susceptible to this sort of damage; the result can be the
formation of scar tissue in the area of the stent, and this too can lead to the artery re-narrowing
in a process known as restenosis. Treating Restenosis can involve an additional stenting procedure,
though in severe cases where a stented artery recloses it may be necessary to have a patient undergo
a coronary artery bypass to remedy the condition.
Overuse of cardiac stents leads to patient deaths
Cardiac stents are big business for hospitals and their staff, with the average private insurance
reimbursement for a procedure totaling $25,000. By placing a stent inside an artery, surgeons can
restore blood flow that has been compromised in heart attack patients, or give help to patients at
risk for future heart attack. But when misused or overused in patients, cardiac stents can prove
fatal, as they did for former postal service worker Bruce Peterson.
After suffering chest pain, Peterson paid a visit to cardiologist Dr. Samuel DeMaio, who inserted
21 stents in his patient's chest over a period of eight months, including five mesh tubes in a single
artery. Peterson developed several blood clots and blockages due to his weakened heart, which
ultimately caused his untimely demise, argues his widow Shirlee Peterson.
She later sued DeMaio for cardiac stent malpractice – an increasingly common charge in a Dr. Darshan
P. Godkar, MD - Cedar Knolls, NJ - Cardiology & Interventional Cardiology & Internal Medicine Healthgrades.comqaDr.
Darshan P. Godkar, MD - Cedar Knolls, NJ - Cardiology & Interventional Cardiology & Internal Medicine
Healthgrades.com
Nortin Hadler, a UNC Chapel Hill professor of medicine told Bloomberg News, "Stenting belongs
to one of the bleakest chapters in the history of Western medicine. Cardiologists "are marching on"
because "the interventional cardiology industry has a cash flow comparable to the GDP of many countries"
and doesn't want to sacrifice the revenue, he said.
Cardiac stent problems cost $2.4 billion a year
The U.S. health care system spends an estimated $2.4 billion a year caring for patients that received
unnecessary cardiac stents, says Dr. Sanjay Kaul, of Cedars-Sinai Medical Center. Patients face a
much greater risk for complications like coronary scar tissue, blood clots and uncontrolled bleeding
from anticoagulant medications – all of which can be life-threatening. Jim Simecek told Bloomberg
that he is on blood-thinning medicine for the rest of his life to prevent clots in the cardiac stents
he received from a Cleveland doctor who is currently the subject of a federal probe.
Sixty-four year old Monica Crabtree's cardiac stent problems caused a torn artery, which resulted
in an infection and her death, according to her husband. He also pursued legal action after it was
determined by another cardiologist that Monica's stent was completely needless. The surviving spouse
recovered $240,000 in a malpractice settlement brought against the surgeon.
FDA reports hundreds of deaths attributed to cardiac stents
Some 773 patient deaths linked with cardiac stents were logged with the FDA last year, according
to Bloomberg. Though this figure has jumped more than 70 percent since 2008, with recent media coverage
on cardiac stent overuse and ongoing federal investigations, cardiologists may be using fewer stents
and only on suitable patients.
John Harold, president of the American College of Cardiology said the doctors who have been charged
with cardiac stent malpractice or fraud are essentially "outliers" in their community, and that these
surgeons fail to represent the "overwhelming majority."
Author James Bovard has described our society as an "attention deficit democracy," and the speed
with which important events are forgotten once the media loses interest might surprise George Orwell.
Consider the story of Vioxx, a highly lucrative anti-pain medication marketed by Merck to the
elderly as a substitute for simple aspirin. After years of very profitable Vioxx sales, an FDA researcher
published a study demonstrating that the drug greatly increased the risk of fatal strokes and heart
attacks and had probably already caused tens of thousands of premature American deaths. Vioxx was
immediately pulled from the market, but Merck eventually settled the resulting lawsuits for relatively
small penalties, despite direct evidence the company had long been aware of the drug's deadly nature.
Our national media, which had earned hundreds of millions of dollars in advertising revenue from
Vioxx marketing, provided no sustained coverage and the scandal was soon forgotten.
Furthermore, the press never investigated the dramatic upward and downward shifts in the
mortality rates of elderly Americans that so closely tracked the introduction and recall of Vioxx;
as
I pointed out in a 2012 article , these indicated that the likely death toll had actually been
several times greater than the FDA estimate. Vast numbers Americans died, no one was punished, and
almost everyone has now forgotten.
We can also do the opposite experiment. Lower the level of fat in people's blood and the insulin
resistance comes right
down . If we clear the fat out of the blood, we also clear the sugar out. That explains the
finding that on the high fat, ketogenic diet, insulin doesn't work very well. Our bodies become
insulin resistant. But as the amount of fat in our diet gets lower and lower, insulin works better
and better-a clear demonstration that the sugar tolerance of even healthy individuals can be impaired
by administering a low-carb, high-fat diet. We can decrease insulin resistance, however, by
decreasing fat intake.
Had this procedure done to check heart due to abnormal stress test. Did not need any stents
or any other procedure as everything was negative. I about had a heart attack when I opened
the bill!!!
Medical Center: Kadlec Medical Center Richland, WA.
My angiogram was done through the wrist area, with no stents, and was over in 20 minutes.
30 k ...really? I wish I was one of the millions in the U.S. that had no insurance to rape,
then I could have gotten it for free. So now I am looking at 2k I owe immediately!!!!! This
price is ridiculous and Kadlec Medical Center in Richland Washington should be ashamed and
the community should be appalled. Shame on you Kadlec!!!!
People in their 20s and 30s are being treated for varicose veins,
knee joint problems and other conditions usually associated with old age.
Bad postures and
sedentary lifestyles have led to a rise in the number of younger people experiencing complaints
such as back pain and haemorrhoids, according to analysis by Bupa.
Two excellent resources-Healthcare Blue Book and FAIR Health-can give you estimates of how much
health care services should cost in your area. Plus, your insurer's website may also provide a tool
that will allow you to compare costs.
Notable quotes:
"... The ambulance company charged $6,500, including a $300 fee for the linens and a $30 charge for aspirin ..."
It's no secret that hospital bills in the U.S.-especially ones from the E.R.-can often hit astronomical
proportions.
According to a recent cost study conducted by researchers at Stanford University, the University
of Minnesota, the University of California, San Francisco and the Ecologic Institute, the median
charge for an emergency room trip in the U.S. comes in at $1,233. But where it really gets interesting
is when you look at the specific reasons for those E.R. visits: The researchers found that the treatment
price for a headache could range from $15 to a whopping $17,797. As for a sprained ankle, it could
set someone back a paltry $4 or up to $24,110!
So what gives with these wildly fluctuating price points?
For starters, most emergency room prices are inflated based on the rates at which insurance companies
will reimburse the hospital on a patient's behalf. That's why a single aspirin can cost $30 per pill
in the E.R., which is more than six times the price for a bottle of them at the drug store.
On the flip side, patients will often contact the hospital or surgeon's billing office to ask
for a cost reduction, further adding to the inconsistency in pricing. It's a practice that often
works in a patient's favor, says billing advocacy specialist Sharon Salters of Medical Cost Advocatea
professional medical bill negotiation service.
And then there's also the fact that most hospitals offer discounts to self-paying individuals-especially
if there's a risk that they might not pay at all.
So to help shed some light on the complexities of hospital medical billing for the average consumer,
we asked three people to share their craziest emergency room stories, the even crazier bills that
followed-and the steps they took to remedy them.
... ... ...
The Emergency: Head Injury
The Bill: $9,000
A few months ago, Amanda Harris, 27, of Morristown, N.J., fainted at work, hitting her head in
the process. Due to liability concerns, her production company required Harris to take an ambulance
to the emergency room, despite her refusal. "I didn't even have a cut on my head, just a slight bump.
No headache, no nausea, no confusion, nothing," she says.
Harris waited for over an hour in the E.R. before her husband told the nurse that they were leaving.
Minutes later, a doctor spoke to Harris for under a minute, confirming that she was fine to go. "He
didn't do any tests-no light in my eyes, no blood pressure," says Harris. "I left thinking I wouldn't
even get a bill."
But the bill did come-all $9,000 of it. The ambulance company charged $6,500, including a
$300 fee for the linens and a $30 charge for aspirin. The E.R. billed the remaining $2,500.
"My mouth literally dropped open when I saw the cost," she says.
What This Patient Did: Harris called her insurer and fought the bill. Luckily,
her insurance covered all but a $3,000 deductible-but she was too exhausted to push for more. "I've
always heard emergency room visits were costly, but $9,000 for nothing more than a conversation that
lasted one minute? That's robbery," she says.
What the Expert Says: Even though Harris didn't want to take an ambulance, Salters
says that her company's suggestion was well-advised. "However, she should consider working with her
employer to file the claim with her company's worker's compensation carrier," says Salters. "Employers
often try to stay away from filing a claim under worker's compensation, so it does not impact their
experience rating or trigger an [occupational safety and health administration] review, but it would
save her money."
"... Price-gouging by ambulance services, including those run by municipalities, was always a disreputable exercise, preying on people who suffer emergency illnesses or injuries. ..."
"... The federal Medicare rate isn't usually high enough to cover all the ambulance costs, so the Legislature is right to go above it. But 300 percent is too high. ..."
When the Legislature finally produced a measure to prevent ambulance companies from gouging out-of-network
patients and their insurers, it set a limit of 300 percent of the federal Medicare reimbursement
rate or the ambulance's regular fee, whichever is lower. This is a ceiling that might function more
like a floor, pushing ambulance firms to raise their rates to 300 percent of Medicare. It's a bad
idea.
Price-gouging by ambulance services, including those run by municipalities, was always a disreputable
exercise, preying on people who suffer emergency illnesses or injuries. And when insurers decided
to fight back by reimbursing patients a set amount, rather than pay whatever the ambulance demanded,
they, too, threw patients under the wheels: Ambulances expected the patients to make up the difference
between the insurers' rate and the ambulance's. Few situations better illustrate patients' frustrations
with the health care system.
So the unwanted task of deciding on an appropriate level of reimbursement fell to the state. And
it should surprise no one that both insurers and ambulance services are lobbying for the best possible
deal, while grumbling about government interference. Fire departments and other municipal offices
that operate ambulances are hoping their friends in the Legislature can deliver a generous fee.
The federal Medicare rate isn't usually high enough to cover all the ambulance costs, so the
Legislature is right to go above it. But 300 percent is too high. Patrick should veto the bill
and ask the House and Senate to send it back to him with a lower price ceiling.
"... Also consider using Medicare rates as a guide; the federal health system for people 65 and older typically has the lowest reimbursement rate for hospitals and medical providers. Your hospital may not agree to charge you its Medicare fee, but this figure is a good starting point for any negotiation. ..."
"... don't hesitate to appeal its decisions. You'd be surprised how often carriers overturn their earlier rejections. ..."
Conversely, you may be able to wrangle a cash discount for agreeing to pay your entire cost at
once.
You may also be able to successfully bargain down the particular dollar amounts you've been charged.
Tell the billing department that if your insurance requires, say, a 20% co-payment to the hospital,
you'll pay only 20% of the insurer's negotiated rate with that hospital. That's usually far less
than the initial rate quoted - the figure charged to uninsured patients.
Go online to check the rates other local hospitals charge for the procedure you had. Then, if
you find your bill was way out of line, use this data as ammunition to try to get your fees lowered.
You can get this type of information at such sites as
Clear
Health Costs, Healthcare
Blue Book and FAIR Health.
Also consider using
Medicare rates as a guide; the federal health system for people 65 and older typically has the
lowest reimbursement rate for hospitals and medical providers. Your hospital may not agree to charge
you its Medicare fee, but this figure is a good starting point for any negotiation.
2. Vigilantly review the bills. "It's very common for hospital bills to contain
errors and overcharges, so make sure you've actually received the services they said you did," Detweiler
says.
Candice Butcher, vice president of
Medical Billing Advocates of America,
says if you're discharged in the morning (as most patients are), protest if you're socked with a
full daily-room rate for the date you left the hospital.
And if you brought your medications with you, make sure you weren't charged for them by the hospital.
"This frequently happens," Butcher says.
Also, dispute any additional fees on the bill for routine supplies, like gowns, gloves or sheets.
These items should be factored into the hospital daily-room charge, because, Butcher says, they are
"considered the cost of doing business."
3. Challenge your health insurer's decisions, when warranted. Keep track of any
hospital bills the company rejects on grounds that the procedure or drug isn't covered by your policy.
If you believe the insurer should be paying more, don't hesitate to appeal its decisions. You'd
be surprised how often carriers overturn their earlier rejections.
4. Negotiate billsonce you know how much you'll have to pay out of pocket.
If you just want extra time to send the money, Dale says, "it is relatively easy to speak with hospital
or clinic business office staff to arrange a payment plan."
Conversely, you may be able to wrangle a cash discount for agreeing to pay your entire cost at
once.
You may also be able to successfully bargain down the particular dollar amounts you've been charged.
Tell the billing department that if your insurance requires, say, a 20% co-payment to the hospital,
you'll pay only 20% of the insurer's negotiated rate with that hospital. That's usually far less
than the initial rate quoted - the figure charged to uninsured patients.
Go online to check the rates other local hospitals charge for the procedure you had. Then, if
you find your bill was way out of line, use this data as ammunition to try to get your fees lowered.
You can get this type of information at such sites as
Clear
Health Costs, Healthcare
Blue Book and FAIR Health.
Also consider using
Medicare rates as a guide; the federal health system for people 65 and older typically has the
lowest reimbursement rate for hospitals and medical providers. Your hospital may not agree to charge
you its Medicare fee, but this figure is a good starting point for any negotiation.
5. Consider hiring a pro. Since hospital bills are hairy, messy beasts, it may
be worth your while to bring in a patient- or medical-billing advocate (Detweiler recommends the
advocacy firm Copatient.com, which charges
30% of what it saves you) or an attorney. "It's like hiring a CPA to do your taxes," Dale says.
Be sure you won't be required to pay this expert any fees upfront. Patient advocates typically
charge 20 to 30% of your savings; some put a cap on their fees. Karis' firm, for example, charges
no more than $3,000. Attorneys often charge 30% of the savings they achieve.
... ... ...
Caroline Mayer is a consumer reporter who spent 25 years working for The Washington Post.
Follow her on
Twitter
TWTR -0.69% @consumermayer.
"... My husband suffered a heart attack when we were on vacation, and I called an ambulance. He's OK now, but we've been billed more than $6,000 for his 15-minute ride to the hospital. As it turns out, the ambulance service wasn't in our health insurer's network, so they paid only a small portion of the bill. We're making small payments on the balance, but the initial bill seems so high. The collector calls all the time to demand we pay the balance in full. Is there anything we can do to get the bill looked at and possibly lowered? ..."
"... Fortunately, medical bills are not always set in stone, and there may be ways for you to negotiate a lower balance. ..."
"... I recommend you first review an itemized copy of the bill for any errors. Look for duplicate charges, inaccurate service dates or incorrect mileage. If you spot any errors, take it up with the billing department immediately. ..."
"... Standard practice for insurers is to negotiate with providers to pay merely a fraction of the cost. ..."
"... Medicare negotiates, on average, a 73% discount. ..."
"... Negotiating with an ambulance service or any medical provider is not easy, but it is possible. Be persistent. If your efforts prove fruitless, you can always consider hiring a professional ..."
My husband suffered a heart attack when we were on vacation, and I called an ambulance.
He's OK now, but we've been billed more than $6,000 for his 15-minute ride to the hospital. As
it turns out, the ambulance service wasn't in our health insurer's network, so they paid only
a small portion of the bill. We're making small payments on the balance, but the initial bill
seems so high. The collector calls all the time to demand we pay the balance in full. Is there
anything we can do to get the bill looked at and possibly lowered?
Answer:
I'm glad to hear your husband is recovering, but I am sure the stress of an unexpected medical
bill isn't helping him heal. Ambulance bills are notoriously costly, but yours seems to be inflated.
Fortunately, medical bills are not always set in stone, and there may be ways for you to negotiate
a lower balance.
I recommend you first review an itemized copy of the bill for any errors. Look for duplicate charges,
inaccurate service dates or incorrect mileage. If you spot any errors, take it up with the billing
department immediately.
Even if the bill is correct, you should still set up a time to speak with someone in the billing
office-someone with the authority to negotiate on your balance. Go into the conversation equipped
with the knowledge that Medicare and insurance companies rarely pay the hefty price tags that consumers
see.
Standard practice for insurers is to negotiate with providers to pay merely a fraction of the
cost. In the case of inpatient hospital bills, for example, a NerdWallet
study
found Medicare negotiates, on average, a 73% discount. While the ambulance service
may not agree to such a large discount for you, coming to any negotiation equipped with such knowledge
will put the company on notice that you aren't going to lay down and take its bullying or an inflated
bill.
... ... ...
Negotiating with an ambulance service or any medical provider is not easy, but it is possible.
Be persistent. If your efforts prove fruitless, you can always consider hiring a professional
. A
medical billing advocate
is able to represent clients' interests much in the way an attorney
would advocate for you in a courtroom. Their experience and expertise in the field can sometimes
prove more effective (and less stressful) than taking on a stubborn provider alone.
"... As a practicing physician who is fed up with the way insurance carriers have managed to take over the delivery of health care in this country, my comments, I warn you, will be brutally frank. The way the game is played, the providers of health care bill as much as they believe they can get away with. ..."
"... That's because they are in business to make money - that's why it's called "for profit" health care. The insurance carriers try their damn best to find excuses to not pay as many of these charges as they can. Same reason. These two conspirators become co-conspirators when they play the game of "crap runs down hill". ..."
"... So here's my advice. Don't pay any "balance billing" no matter what they choose to call it. Activate the pump that sends the crap back uphill. Write letters to the provider asking for specifics as to the balance billing. ..."
Unfortunately sometimes the only way to get around denial of precertification is to ask your
doctor to lie. I had an MRI after a fainting episode that showed possible MS, which runs in my
family. All other diseases were excluded. The medical recommendation is to get a follow-up MRI
in 6-months. Because I wasn't having active symptoms, the follow-up MRI was not precertified when
ordered by my neurologist. I went to my family physician for help, she requested the MRI, saying
I was having headaches (everybody gets one occasionally, right?). I immediately got the necessary
MRI and am now being treated. I think the insurance company didn't really want to deny the MRI,
they wanted to delay expensive treatment, which was the likely outcome.
I am currently appealing a claim with HealthLink. Too long to go into but it involves an Intensive
Outpatient Treatement program for my 20 year old son. There own guidelines state that this may
well be the best initial choice for treatment. However, they advised us when they would not precertify
that he needs to fail at out patient treatment and community support. Really? So I get to the
External appeal process. Healthlink contracts with MCMC to provide the physician to do the reveiw.
Can we say conflict of interest? She spits out the same verbage used to deny the precertification
but mentions criteria that is no longer being used to asses such cases. Or and then there is the
mention of my son's "wearable cardioverter defibrillor" has nothing to do with our case. So I
appeal to the State of Illinois (eye roll) and am told I cannot appeal a denial of a precertification.
I must have a denied claim. OK, but I can't get to the denied claim as HealthLInk won't even percert
the care. Who are these people?
I recently had to deal with the insurance company VS primary care provider VS patient VS lab
test provider. Its a cluster-expletive. Even trying to keep track of who said what when is difficult.
Not too mention the hours upon hours of your precious time it *will* consume.
Short summary:
I had a severe flu (possibly swine flu) and made a doctor's appointment. They were very busy and
couldn't see me for 2 weeks. When I came in for my appointment, I had recovered from the flu.
My appointment was reclassified as well-care. My job's health insurance plan was revised two months
prior to exclude well-care. I was now on the hook for 100% of the cost of the visit. The doctor
ordered a full blood work since I was a new patient.
I realize it was my fault that I didn't know well-care wasn't covered. Lesson learned - I've
read my EOB a couple times now, cover to cover. Unfortunately, I still only kind of know what
is covered.
As a practicing physician who is fed up with the way insurance carriers have managed to
take over the delivery of health care in this country, my comments, I warn you, will be brutally
frank. The way the game is played, the providers of health care bill as much as they believe they
can get away with.
That's because they are in business to make money - that's why it's called "for profit"
health care. The insurance carriers try their damn best to find excuses to not pay as many of
these charges as they can. Same reason. These two conspirators become co-conspirators when they
play the game of "crap runs down hill".
That's when they come up with things like "co-pays", "deductibles", "co-insurance", and a whole
host of creative ways of attempting to coerce the patient to pick up the tab.
So here's my advice. Don't pay any "balance billing" no matter what they choose to call
it. Activate the pump that sends the crap back uphill. Write letters to the provider asking for
specifics as to the balance billing.
Don't accept their response. Write again. Write to the insurance carrier and appeal.
Then write the provider with the appeal number from the insurance company. Keep it going round
and round. If contacted by a collection agency, write back explaining your appeals and that your
financial condition won't allow you to pay without getting a disposition from your claim, and
a better explanation from the provider as to why the procedure wasn't covered. Tell them to not
contact you again. Tell them that you refuse to pay until you get a decent explanation. Dare them
to sue you. CC a law firm on all correspondence. Make the providers get hurt enough to fight against
the carrier. Bust up their friendship. Neither will hire a lawyer to get you. The publicity is
the only thing they are afraid of.
I am in the process of filing a claim for the first time ever. Cigna denied coverage for an
operation after the fact. This was not even a marginal case, it was an obvious medical need. I
suspect that insurance companies simply play the odds, deny and spread the costs to hospitals,
surgeons, patients and maybe themselves. A lot less than paying the whole thing. This has nothing
to do with medicine, as I have discovered. It is about how to boost revenues and damn fairness
and the patient. Plan to fight and publicize my fight. This is as clean cut a case that can be
found.
Having handled over 4000 health care appeals over the past 15 years, this article is a pretty
good basic overview (so long as most of the Comments are ignored). The Affordable Care Act may
ultimately be helpful in making this hodgepodge of rules more uniform, but that remains to be
seen. The ultimate message for patients must remain clear: It is imperative to FIGHT for the care
you need using all available resources and expertise at your disposal!
#7 is correct: it is a game to the health insurance companies. They routinely deny perhaps
40% of all claims thinking that most people will just shrug off the denial and go away. The key
is to keep calling, resubmitting and fighting the portion that they have denied. I have received
initial denials for the most ludicrous reasons: the doctor retired; there is no such doctor at
that address, etc... It is a game designed for the health insurance companies to win UNLESS you
fight back.
"If you feel too frail or overwhelmed to pursue an appeal yourself, nonprofit groups like the
Patient Advocate Foundation can provide guidance for free."
A single person battling a life-threatening illness or condition is, of course, going to be
overwhelmed and frail. Insurance companies bank on it. My suggestion is to start with advocacy
first. Insurance companies make things difficult because they are in the business of making money,
not helping patients. They want you to give up. When you have another person or two in your corner
everything moves along better. Especially when the advocate knows how to fight hard and isn't
afraid to speak frankly. There are witnesses to what is happening and you are taken more seriously.
It is ironic that there is now Health Proponent, a company that will fleece you in order to
"advocate" for you. Only in America, folks.
I had to have all my teeth extracted before I could begin treatment for throat cancer. I did
not have enough dental insurance, and the oral surgeon's office told me that medical had informed
them it would not pay the remainder.
I contacted mymedical insurance company, which recommended that I wait for a denial and then
appeal. I pointed out that by that time I would be quite sick from the radiation, and would like
to deal with it while I was still capable. Turns out there is a board that considers these things,
so I had both of the oral surgeons, my oncologist, and my ENT all write letters to this board.
The medical insurance company paid for the whole thing, since it was proven to be a medical necessity.
Now, if we could just get the oral surgery place to refund all that we paid, plus the dental
insurance, so that the dental insurance can in turn use my benefit to help repay us for the dentures
. . .
This happens all the time. There are gajillions of codes used by the insurance companies. If
your healthcare provider uses an incorrect code, then the insurance company won't pay the bill.
Call the insurance company and find out what the codes should be. Then call or visit your health
care provider and bring them up to date on the codes. Blue Cross and Blue Shield have all of their
codes listed on their Internet site.
I have a friend who broke his back in a car accident and as a result has had ongoing medical
issues. He told me that he treats the denials as a game. You submit the entire claim, they reject
part of it, you resubmit the rejected part, they pay part and reject part, and you keep on going
until you get your money. It seems cruel, but an insurance company's profit is the amount of money
each year that they do not pay out in claims, so the incentive to deny is very strong.
After some back and forth, Medicare paid its share of a claim that I, rather than my doctor,
submitted,
I then submitted the claim to my secondary insurer who, after further back and forth, said that
it could not pay the claim because it had been agent for my former employer and no longer had
access to the employer's funds. The employer in turn, after more back and forth, says it plans
tosubmit this and other claims to the current secondary employer for payment rather than pay them
directl y. The process seems to go on forever.
mary browning is a trusted commenter miami beach, FL
July 11, 2011
Good heavens, why should it take instructions that would require a graduate degree? In other
countries none of this mess would be required. Disgraceful.
If you are sick and don't feel up to doing things, how, indeed could you do what you are said
to do to simply get what is required or due to you?
Stop. Just sue them and put them on the defensive. Denial of claims is the way the criminal
health insurance companies provide record salaries to the gangsters who run the companies, and
big dividends to their share holders.
Appealing a health insurance denial which involves a substantial financial liability can be
viewed like any other do-it-yourself endeavor. If you are comfortable handling a matter upon which,
say, $75,000 or more is at stake (which is not uncommon), good luck. On the other hand, if the
stakes are high, you may want consider having it handled by an attorney who specializes in this
area of practice
As someone who went through this process recently, I would make the following suggestions:
1) Be very legalistic in your approach to the appeal, and quote appropriately from the policy
and from law (this of course assumes you have a solid legal basis for your appeal).
2) Inform the insurance company in writing that if they require a full appeal, you will hire legal
counsel to research and document your appeal.
3) Remind the insurance company that under ERISA, if you ultimately win, you are entitled to reimbursement
of your legal fees and expenses.
This won't win obviously if you are on shaky legal ground. But if the insurance company is
on shaky ground and just trying to avoid paying a claim (which was the case with us), this sort
of saber rattling can help resolve the question quickly before you end up in a formal appeal.
The insurance company doesn't want you to hire a lawyer if you have a good chance of winning.
Assistance with appeals and grievances from denials of health insurance claims is a service
that many state Attorneys General provide for free, so check with your Attorney General's office
before paying someone to assist you with the process.
"... As part of her husband's benefits package, Isaac had access to a medical billing assistance company called Health Advocate . It negotiated with the physician's health-care group to reduce her bill to $7,000. ..."
When Annrose Isaac's twins were born prematurely, she thought her insurer would cover their stay
in the neonatal intensive care unit. "The hospital was in our network, but it turned out the physician
in the NICU who saw our daughters didn't participate with our insurer," says the Westwood (New Jersey)-based
financial planner. "All of a sudden we were getting bills for over $30,000."
As part of her husband's benefits package, Isaac had access to a medical billing assistance
company called Health Advocate.
It negotiated with the physician's health-care group to reduce her bill to $7,000.
More than 60 percent of all U.S. personal bankruptcies are linked to illness and unpaid medical
bills, according to a 2009 Harvard University study, even though 78 percent of those filing for bankruptcy
because of illness have some form of health insurance. So hiring a medical billing advocate can be
an essential part of the cure to financial ills.
Yet finding the right advocate can be tough, and those in the direst situations can ill afford
the typical $75- to $130-an-hour rate. "This business is painfully slow-growing," says Becky Stephenson,
co-president of the Alliance of Claims Assistance Professionals
(ACAP), an advocate trade group. "There are a lot of people with problems but not a lot of people
willing to pay you to help them." Despite long experience, Stephenson herself has trouble making
a good living purely from advocacy, so she supplements her income by serving as an expert witness
in medical lawsuits.
Employees working at sizable companies may already have access to a health advocate. Just over
half of U.S. companies with more than 500 employees offer it as a benefit, according to Steven Noeldner,
a senior consultant for Mercer's Total Health Management practice. Many employees don't know the
benefit exists, he says, and the services generally aren't as customized as those of an independent
billing advocate.
Credential Check
Unlike with more established professions such as accounting or law, there is no standard credential
to look for when seeking a qualified advocate. At the most basic level you should ask if an advocate
has certifications in medical bill coding from either the American
Academy of Professional Coders or the American Health Information
Management Association.
Many people with those designations aren't advocates, however, working instead for hospitals or
insurers. And understanding the codes is only half the battle. Because of the complexity of our health-care
system, you'll need someone who specializes in your specific kind of billing problem.
A good place to start is Claims.org, ACAP's website. It lets
you search for experienced advocates by state. In a case like Isaac's, you'd need someone who specializes
in hospital bills. Other advocates specialize in Medicare appeals, long-term care insurance, workers'
compensation and insurance for special needs children.
Privacy Issues
The best way to find the right specialist is to ask the advocate for a resume and references.
This can be tricky, because laws about disclosing private medical information are so strict that
some advocates have difficulty providing references. In order to do so, their clients must agree
to discuss their medical history.
Stephenson specializes in hospital bill audits. She studies itemized bills line by line, identifies
padding and mistakes and negotiates lower rates. Prior to starting her Austin (Texas)-based advocacy
firm VersaClaim in 2002, she ran an organization that helped
doctors affiliated with hospitals set up their practices. That included all aspects of hospital billing.
A registered nurse for 12 years, Stephenson has an intimate knowledge of medical terminology and
hospital procedures. "I ask questions like, Are there dosages of medications that are not compatible
with my medical experience in real life?" she says. "Do the charges look realistic, or is there an
$85 Tylenol?"
Location Matters
Another important factor to consider is an advocate's location. State laws vary in how they regulate
insurers and hospitals. For Katalin Goencz, an advocate in Stamford, Connecticut, location is often
irrelevant because she specializes in Medicare appeals: "The rules for Medicare are federal and pretty
much universal, so the client's location doesn't really matter."
For a patient negotiating a lower bill directly with a local hospital or private insurer, having
an advocate who knows the specific state regulations helps. State rules for advocates can also vary
dramatically. Florida has some of the strictest. "Due to the large senior population in our state,
we have a strong urge to make sure our people adjusting medical claims are licensed, competent and
held to a high standard," says Matthew Guy, a spokesman for
Florida's Division
of Agent and Agency Services, which licenses and regulates advocates.
The state's Public Adjuster license for advocates requires licensees to be fingerprinted, have
a criminal background check and hold a $50,000 surety bond. "If there's any wrongdoing by the adjuster,
we can take the bond amount and use that towards restitution for the consumer," Guy says. Adjusters
must pass an exam and take 24 hours of continuing education classes every two years.
Contingency Basis
A handful of advocates will work on contingency if they think you have a negotiable claim. Most
will impose strict conditions to ensure they get paid if they win. "When I started my practice, I
did everything on contingency but learned very quickly that a lot of consumers who want you to take
their case on contingency in the end don't want to pay you," says Sheri Samotin, a billing advocate
at Life Bridge Solutions in Naples, Florida.
Now Samotin requires a credit-card authorization up front for an amount sufficient to cover what
her estimated contingency fee will be if her work succeeds. If the client doesn't pay within 10 days
of a settlement being reached, she charges the card. Her fee is 35 percent of the client's medical
bill savings.
Samotin is unusual in the advocacy world as she is more of a generalist, taking on all kinds of
medical billing problems, including those of the uninsured. She has 25 years of experience in the
health-care industry, so she has the knowledge to handle different kinds of problems, Samotin says.
For a monthly $285 fee she will manage her clients' entire billing life -- a common need for seniors
who have lost their capacity or desire to manage daily finances.
Instead of being a member of ACAP, Samotin is a member of the
American Association of Daily Money Managers, a trade group for generalists. Only a handful of
the AADMM's 700-plus members have the skills to also handle medical billing advocacy, Samotin says.
Nor does she expect rapid growth in the field.
"Because this is a disorganized profession, people entering the field have to be entrepreneurs,"
she says. "They have to hang out their shingle and go out and get clients. In my experience, the
majority of people who are good medical analysts and advocates are not necessarily good business
getters."
So until the profession matures, finding a good advocate will remain difficult, no matter how
vital the service is.
(Lewis Braham is a freelance writer based in Pittsburgh.)
To contact the editor responsible for this story: Suzanne Woolley at
[email protected]
"... There are also companies who claim they have a network of physicians throughout the state who offer medical services for 50 percent off or more. ..."
But you can fight back against skyrocketing medical costs.
"I've heard discounts up in the area
of 30 percent sometimes, which can be pretty significant," said Cathryn Perron, director of program
development with Consumer Credit Counseling.
She says it's possible to negotiate down your medical bills - everything from ambulance rides
to surgery. She says you can also bargain with your dentist, the lab that does your blood tests,
the eye doctor - even the company that makes you prescription medication.
"Each company has a specific number you can call to fill out an application and many times, you'll
get a discount, or you'll get the product free through the drug companies, if you qualify financially,"
Perron said.
All you have to do, with or without insurance, is make a call. Each case is handled differently.
In most cases, everyone wants to pay the bill, but they're afraid to contact their doctor or hospital.
They'll work with you to make sure the cost is paid.
So how do you pay less?
There are a number of options:
Offer to pay in cash - You may get an up-front discount of 10 percent or more.
Ask about a payment plan - They're usually interest-free and determined by your budget.
If you don't have insurance - Some hospitals will give you a discount that is equal to what it
may have given the insurance company.
Charity care - Bills are forgiven, based on your income and expenses, but you'll have to fill
out hardship paperwork.
"You'll most likely have to provide proof of income, they'll ask about your monthly living expenses
and your other bills that you have to pay every month," said Perron.
Sholar called Indianapolis EMS.
"He says, 'Sir, you got to pay for the ambulance, all the stuff in the ambulance, the two people
who drive the ambulance. That's just the way it is'," he said.
But he didn't give up.
"This bill says $1,300. She said, 'Yeah, that sounds about right.' I said, 'Let me talk to a supervisor',"
Sholar said. "The supervisor's name is John. John wasn't too happy."
Mike put on the pressure and the bill was reduced by $532. The wounds to his buttocks are healed,
but the other injury he got that night, on his thumb, is a constant reminder of the cost of healthcare.
"I don't need no X-rays, I don't need no other stuff. Just give me the stitches and I still haven't
received a bill for that," he said.
But he's ready to negotiate and he says, in the future, he'll also weigh the costs before calling
911.
"I would have put a rag over it and got a ride here," he said.
Tips to Negotiate Your Medical Costs
Consumer Credit Counseling and Apprisen offer tips to get your medical bills reduced:
First and foremost be informed. Understand what type of medical insurance coverage you have and
what your co-pays or financial responsibilities are. Some insurance companies have contracts with
certain medical providers to offer a discount if you receive treatment from a "preferred provider."
We encourage individuals to meet with their Human Resource department or contact their insurance
company to speak with a representative about their coverage and benefits prior to receiving medical
treatment. This could reduce your financial responsibility significantly.
Apprisen recommends for you to review your itemized statement from your medical provider. If you
feel there are discrepancies or charges in question, contact your medical provider to meet with their
Patient Account Specialist to discuss your questions or discrepancies. Communication is a vital part
of resolving your issues. Simply ignoring communication from your medical provider will not resolve
the issue and could potentially lead to a negative impact on your credit rating if resolution is
not reached.
Whether you have insurance or not, you are encouraged to contact your medical provider prior to
treatment (if possible) to discuss costs associated with your treatment and to work out the possibility
of negotiating those costs down. Many medical providers will consider giving discounts to individuals
who are willing to pay the balance in full upon services rendered or within a short period
of time after receiving treatment. If you find yourself in a position where you are not able to pay
the balance in full, consider negotiating with your medical provider for a monthly repayment plan
interest free. You are encourage to analyze your personal budget to insure you are able to make the
financial commitment to your medical provider. Negotiating your medical bill then failing to follow
through with the financial payment arrangement could negate your hard effort to reduce your medical
bill.
If you are uninsured, you are encouraged to meet with a Patient Account Specialist or a "decision
maker" to see if you qualify for any financial hardship programs. Most hardship programs require
you to provide evidence of your financial situation and the award is based on financial need. Be
prepared to give a full budget disclosure in order to be considered for the hardship program.
Apprisen's mission is "To help people improve their financial well-being through counseling, community
outreach and financial education."
You can call Apprisen at 1-800-355-2227 or visit
apprisen.com.
There are also companies who claim they have a network of physicians throughout the state who
offer medical services for 50 percent off or more. You can find out more about those companies at
objectivedx.com.
"... Every economist in the world can quickly explain how a 10 percent tariff on imported steel will lead to corruption. The same logic applies to drug patents, although since they are the equivalent of tariffs many thousand percent (they typically raise the price of protected drugs by factors of ten or even 100 or more), the incentives for corruption are much greater. ..."
"... kickback scheme between a major drug manufacturer and a mail order pharmacy. ..."
"... Gary Tanner, the former Valeant executive, entered into a secret relationship with Philidor's chief executive, Andrew Davenport, federal authorities said. ..."
Pharmaceutical Executives Indicted: Protectionism Leads to Corruption #43,641
Every economist in the world can quickly explain how a 10 percent tariff on imported steel
will lead to corruption. The same logic applies to drug patents, although since they are the equivalent
of tariffs many thousand percent (they typically raise the price of protected drugs by factors
of ten or even 100 or more), the incentives for corruption are much greater.
This is why every economist in the world should have been nodding their heads saying "I told
you so" when they read this New York Times article * about a kickback scheme between a major drug
manufacturer and a mail order pharmacy. Unfortunately, there were no economists mentioned in this
piece. And, it is quite possible that most economists support this form of protectionism, in spite
of the enormous inefficiency and corruption that results. (Yes this is a major point in my free
book, "Rigged: How Globalization and the Rules of the Modern Economy Were Structured to Make the
Rich Richer." ** )
Former Valeant and Philidor Executives Charged in Kickback Scheme
By KATIE THOMAS and MATTHEW GOLDSTEIN
Gary Tanner, the former Valeant executive, entered into a secret relationship with Philidor's
chief executive, Andrew Davenport, federal authorities said.
With multiple homes, a full-time private chef, vacations, entertainment and $746 for pet
care, Alicia Stephenson needs more than $400,000 a month to meet her living expenses, according
to testimony from a financial expert who specializes in divorces.
Cathleen Belmonte Newman, a certified divorce financial analyst, said she completed a "lifestyle
analysis" to determine that Stephenson would need $433,991 "net" in monthly maintenance to
keep up a standard of living similar to what she had during her marriage to Richard Stephenson,
the multimillionaire founder of the Cancer Treatment Centers of America hospital network. …
Much of the trial, now in its third week, has featured testimony from Alicia Stephenson's
friends and business associates who have outlined her lavish lifestyle during the marriage:
trips on private jets, several homes complete with staff and high-end furnishings and artwork,
millions of dollars in jewelry, couture clothing, fancy parties, expensive vehicles, motorcycles
and yachts. …
All paid for by cancer patients and, truth be told, by their insurance companies.
Edit: from a comment on the article, a story about CTCA:
10
Simple Steps To Naturally Lower Your Cholesterol
From: [...]
Book Review: Cholesterol Down by Dr. Janet Brill
Cholesterol Down is for the 105 million Americans who have high
cholesterol. The author, Dr. Janet Brill, a registered and
licensed dietitian/nutritionist, exercise physiologist, and
certified wellness coach has spent years counseling patients on
cardiovascular disease prevention, researching, and writing on
the subject of cholesterol. Her work has been published in the
International Journal of Obesity and the International Journal
of Sport Nutrition.
Cholesterol Down provides readers with the information they need
regarding cholesterol -- what it is and how it works both for
and against the body. It is significantly endorsed by Dr.
Jennifer H. Mieres, the National Spokesperson for the American
Heart Association. She states, "The simple, consistent, and
inexpensive lifestyle therapy outlined in her {Dr. Janet
Brill's} Cholesterol Down Plan could be the most important
investment you make in your future health." Dr. Brill explains
LDL, the bad portion of cholesterol, and offers an effective
combination therapy of foods, scientifically based, that are as
effective as statins. Besides lowering LDL, the following
ten-step program also offers further health benefits.
First, eat 1 cup of oatmeal every day. The U.S. Department of
Agriculture recommends three whole-grain servings daily. This is
linked to reduced risk of heart disease, stroke, type 2
diabetes, obesity, some cancers, lower blood pressure, and
improved bowel movement. Oatmeal lowers LDL, may raise HDL--the
good portion of cholesterol, and studies show that the more
consumed, the greater the benefit.
Second, eat a handful of almonds daily, approximately 30.
Read
more ›
2 Comments
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Must
Reading for Those Interested in Their Health
I have a personal interest in this
particular subject so I was pleased to be asked to read and
review "Cholesterol Down," a book which definitely should be
read by anyone with a current cholesterol problem and, for that
matter, by anyone in the younger set who wants to prevent such a
problem from occurring in his or her future. If I had had this
information many decades ago, I probably could have prevented or
at least delayed the coronary problems I am now fighting. After
my first heart attack five years ago, I had to face the fact
that some extraordinary changes were necessary and at the top of
that list was diet. I was placed on a "Mediterranean" diet which
is very similar to the diet which Dr. Brill recommends in her
book.
Dr. Brill suggests ten simple steps to lower one's cholesterol
without resorting to prescription drugs. I am all in favor of
that because nothing disturbs me more within the medical area of
my life than the taking of prescription drugs. I try to avoid
that sort of thing like the plague. I much prefer to utilize
"natural" remedies whenever and wherever possible. So far I've
been fairly successful, having to take only one prescription
medication (an anti-clotting drug) and only because I have found
no comparable natural remedy.
This book is divided into two parts plus an appendix. The first
part of the book provides the reader with information about
cholesterol and heart disease, basically the scientific
foundations upon which Dr. Brill's ten-step plan is based. This
can be read first but it is not necessary. I read the second
part first, which actually describes the ten-step cholesterol
down plan, because I was specifically interested in reviewing
what the author suggests; one can always go back to the
scientific rationale later.
Read
more ›
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5.0 out of 5 stars
/span>
By
Tom Bruce
on November 25, 2007
Format: Paperback
Verified Purchase
Good
for what ails you
The book promises "10 Simple Steps to Lower Your Cholesterol"
and it delivers. The first section of this book deals with what
cholesterol is and what it does, and as this reader-friendly
author suggests, "If science is not your cup of tea, simply cut
to Part II." Part II is the meat of the book, listing the ten
simple - and they are - steps to lowering your cholesterol. Not
only simple, but affordable, too - much more so than prescribed
medicine. With each step, the good Doctor explains how each
process helps us reach our medical goal, gives the medical proof
that exists for each, presents case histories, and lists further
options and tips on how to additionally simplify each step. Yet,
if you're not into the medical jargon, this section of the book
is formated so you can skip over much of the material presented
and get the basic information you need in a few short
paragraphs. She does make it easy. The third and final section
of the book offers charts to help you follow this course, if
you're into such regimentation. There are also a few dozen
healthful recipes, few of which appealed to me. Now here's the
bonus part: as Brill explains, each of these steps will also
help in lowering blood pressure, aiding diabetics, fighting
obesity, forestalling aging, even stopping hair loss. So, if you
suffer from any of these ills and more, you can't go wrong with
this basic recipe for good health. After five weeks on this
regimen, my cholesterol numbers were back to normal. The one
problem I found with this diet, it was almost too much to eat.
Well, not too much, but very filling. I have followed a modified
version of the plan, mainly keeping in the oatmeal and
heart-friendly orange juice, and my numbers continue to be where
they should be months later.
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Before saying anything about nuclear stress test side effects, let's explain nuclear stress test
first. This test is designed to show your heart details. This way your doctor can determine irregularities
regarding your heart or arteries.
How does this test actually look like? First, metal electrodes are attached to the chest and back
of the patient; then the patient will have to run on a treadmill. While he is running, the electrocardiogram
is recording the entire activity. After that, the patient will get an injection and then the pictures
of his/her heart will be taken. This injections contain small amounts of radioactive substances which
is a reason why people believe this test is harmful for the body. However, experts agree that these
amounts are too small to harm any patient.
Although this test is useful for many reasons, it also has its side effects. Some of the following
effects may occur:
Headache – it can be mild or quite severe and last for a couple of hours. This side effect is
common among patients. It can be accompanied by nausea.
Pain in chest – another common side effect which appears shortly after the test, but soon disappears.
Breathing difficulties and heart rate changes – both of which come to normal after a while.
Some of the patients may experience bitter taste in their mouth.
All of these side effects are just temporary and they vanish in relatively short time. But before
going for this test, make sure to follow your doctor's instructions. He will probably tell you not
to drink or eat anything 4 hours before your test begins. Also you will be told not to take any medicines
and to wear sports clothes appropriate for running.
If you are pregnant , consult
your doctor before deciding to take this test. Also, if you are very ill, talk to your doctor about
some other option.
Many nuclear medicine centers are located in hospitals. A doctor who has special training in nuclear
heart scans-a cardiologist or radiologist-will oversee the test.
Cardiologists are doctors who specialize in diagnosing and treating heart problems. Radiologists
are doctors who have special training in medical imaging techniques.
Before the test begins, the doctor or a technician will use a needle to insert an intravenous
(IV) line into a vein in your arm. Through this IV line, he or she will put radioactive tracer into
your bloodstream at the right time.
You also will have
EKG (electrocardiogram)
patches attached to your body to check your heart rate during the test. (An EKG is a simple test
that detects and records the heart's electrical activity.)
During the Stress Test
If you're having an exercise
stress test
as part of your nuclear scan, you'll walk on a treadmill or pedal a stationary bike. During this
time, you'll be attached to EKG and blood pressure monitors.
Your doctor will ask you to exercise until you're too tired to continue, short of breath, or having
chest or leg pain. You can expect that your heart will beat faster, you'll breathe faster, your blood
pressure will increase, and you'll sweat.
Tell your doctor if you have any chest, arm, or jaw pain or discomfort. Also, report any dizziness,
light-headedness, or other unusual symptoms.
If you're unable to exercise, your doctor may give you medicine to increase your heart rate. This
is called a pharmacological stress test. The medicine might make you feel anxious, sick, dizzy, or
shaky for a short time. If the side effects are severe, your doctor may give you other medicine to
relieve the symptoms.
Before the exercise or pharmacological stress test ends, the tracer is injected through the IV
line.
During the Nuclear Heart Scan
The nuclear heart scan will start shortly after the stress test. You'll lie very still on a padded
table.
The nuclear heart scan camera, called a gamma camera, is enclosed in metal housing. The camera
can be put in several positions around your body as you lie on the padded table.
For some nuclear heart scans, the metal housing is shaped like a doughnut (with a hole in the
middle). You lie on a table that slowly moves through the hole. A computer nearby or in another room
collects pictures of your heart.
Usually, two sets of pictures are taken. One will be taken right after the stress test and the
other will be taken after a period of rest. The pictures might be taken all in 1 day or over 2 days.
Each set of pictures takes about 15–30 minutes.
Some people find it hard to stay in one position during the test. Others may feel anxious while
lying in the doughnut-shaped scanner. The table may feel hard, and the room may feel chilly because
of the air conditioning needed to maintain the machines.
Let your doctor or technician know how you're feeling during the test so he or she can respond
as needed.
It is essential to know the instructions on how to use an omron blood pressure monitor. It is vital
to get accuate readings. Omron makes sure that you have the equipment correctly fitted before use
because there is a light or sign telling you that it is attached correctly. It is also important
that your posture is correct
when taking such readings. For example, position your hand of the bp device on the other elbow when
using a wrist monitor. Once again full details and diagram instructions are provided with their equipment.
They make blood pressure readings simple and you will quickly incorporate these into your weekly
routine. Important – Take a morning and evening reading
You should choose a certain day of the week in terms of regularly checking your blood pressure
and stick with it. The procedure is very simple and straightforward. You should take your first reading
around one hour after waking up. Note the rating and then take a second reading around one hour before
going to bed. This will help get an accurate reading of what your levels are.
We have asked the question; how accurate are Omron blood pressure machines? Now let's ask a much
more general question that all of you should understand the answer to;
Why do I need to bother with blood pressure readings?
Hypertension may well be the medical term given for high blood pressure, but the name you should
associate it with is one which is widely used. That is "The Silent Killer". Many people are unaware
that they actually have high levels of blood pressure. They feel the odd twinge or headache, but
simply put this down to feeling a little under the weather.
The fact is that although possible symptoms such as severe headaches, fatigue, chest pains, or
a feeling of confusion could affect you, many feel that such symptoms are not associated with high
blood pressure, or they simply do not get very many of these symptoms.
Consider this; Hypertension is the biggest cause of strokes known, it also has a massive say in
the amount of heart related problems we suffer from.
If that is not enough reason for you to take blood pressure readings seriously then I feel nothing
will persuade you.
How can you keep those blood pressure levels in the 'healthy zone'?
Those who are overweight are increasing their risk of high blood pressure and the more overweight
you are the bigger your problems. This makes blood pressure monitors particularly important for this
group of people. You really need to address your weight issues, lifestyle and exercise regimen if
you are to get yourself back on track. It cannot be overstated just how important looking after yourself
is if you are to avoid high blood pressure problems.
Those of us who smoke, drink alcohol to excess and generally eat a poor diet are also leaving
ourselves wide-open to high blood pressure.
One diet in particular should help you!
There is a really effective diet for those with high blood pressure which is known as the DASH
diet. If you have home blood pressure equipment such as the wrist monitor versions that Omron provide
and you find that your blood pressure is creeping up the wrong way please ask your doctor about this
excellent diet.
It has been devised specifically to bring your blood pressure levels down, and if you follow it
to the letter it should have you back to normal in around 2 weeks of use.
Those 2 weeks could be the difference between a new you and a very poorly you!
One of the wisest investments you will make in terms of health
There may be lots of gimmicks or unnecessary bits of equipment for your health available today,
but please rest assured that home monitors for blood pressure are not gimmicks and they are highly
useful. So useful they could actually save your life. Try putting a price on that!
This is the other thing, the price of such equipment really is trifling in terms of how low it
is, and the peace of mind it will give you and your loved ones will pay for such a purchase many
times over.
Hopefully the above has shown you the answer to our question; how accurate are Omron blood pressure
machines, and you will use this advice to purchase one of their extensive range to suit your needs.
Remember; it could be a life saver!
Written by
Madlen Davies
The Bureau of Investigative Journalism
| Report
Pharmaceutical companies are fuelling the rise of superbugs by manufacturing drugs
in factories that leak industrial waste, says a new
report
which calls on them to radically improve their supply chains.
Factories in China and India -- where the majority of the world's antibiotics are
produced -- are releasing untreated waste fluid containing active ingredients into
surrounding areas, highlights the report by a coalition of environmental and
public health organisations.
Ingredients used in antibiotics get into the local soil and water systems,
leading to bacteria in the environment becoming resistant to the drugs. They are
able to exchange genetic material with other nearby germs, spreading antibiotic
resistance around the world, the report claims.
Ahead of a United Nations summit on antimicrobial resistance in New York this
week, the report -- by the European Public Health Alliance (EPHA) and pressure
group Changing Markets -- calls on major drug companies to tackle the pollution
which is one of its root causes.
They say the industry is ignoring the pollution in its supply chain while it
drives the proliferation of drug resistant bacteria -- a phenomenon which kills an
estimated 25,000 people across Europe and globally poses "as big a threat as
terrorism," according to NHS England's Chief Medical Officer Dame Sally Davies.
If no action is taken antimicrobial resistance (AMR) will kill 10 million
people worldwide every year -- more than cancer -- according to an independent
review into AMR last year led by economist Professor Jim O'Neill.
Changing Markets compiled previous detailed reports and conducted its own
on-the-ground research looking at a range of Chinese and Indian drug manufacturing
plants making products for some of the world's biggest pharmaceutical companies.
One of the world's biggest antibiotic production plants, in Inner Mongolia, was
found in 2014 to be "pumping tonnes of toxic and antibiotic-rich effluent waste
into the fields and waterways surrounding the factory," according to Chinese state
television.
In India, where much of the raw material produced by Chinese factories is
turned into finished drugs, various studies have found "high levels of hazardous
waste" and "large volumes of effluent waste" being dumped into the environment.
About a quarter of UK medicines are made in India.
"... Jashu Patel, an interventionalist in Jackson, Michigan, billed $2.7 million for procedures in 2007, according to a U.S. Justice Department case against him settled in July. (He is no relation to Mehmood Patel). ..."
"... The suit alleged Patel implanted needless stents in at least two patients, including one that led to a blood clot that killed an unnamed woman who had reported no symptoms of reduced cardiac blood supply. A stress test showed normal blood flow, and notes in her file said she didn't want interventions, said Julie Kovach, a cardiologist who worked with Patel and brought the case to the government's attention. ..."
"... "It was appalling," Kovach said in an interview. "Patel coerced her into getting a stent she didn't need, which killed her." ..."
"... "I do believe that Bruce was a guinea pig," she said. "That was the way it was done." ..."
When Bruce Peterson left the U.S. Postal Service after 24 years delivering mail, he started a
travel agency. It was his dream career, his wife Shirlee said.
Then he went to see cardiologist Samuel DeMaio for chest pain. DeMaio put 21 coronary stents in Peterson's
chest over eight months, and in one procedure tore a blood vessel and placed five of the metal-mesh
tubes in a single artery, the Texas Medical Board staff said in a complaint. Unneeded stents weakened
Peterson's heart and exposed him to complications including clots, blockages "and ultimately his
death," the complaint said.
DeMaio paid $10,000 and agreed to two years' oversight to settle the complaint over Peterson and
other patients in 2011. He said his treatment didn't contribute to Peterson's death.
"We've learned a lot since Bruce died," Shirlee Peterson said. "Too many stents can kill you."
Peterson's case is part of the expanding impact of U.S. medicine's binge on cardiac stents -- implants
used to prop open the arteries of 7 million Americans in the last decade at a cost of more than $110
billion.
When stents are used to restore blood flow in heart attack patients, few dispute they are beneficial.
These and other acute cases account for about half of the 700,000 stent procedures in the U.S. annually.
Among the other half -- elective-surgery patients in stable condition -- overuse, death, injury
and fraud have accompanied the devices' use as a go-to treatment, according to thousands of pages
of court documents and regulatory filings, interviews with 37 cardiologists and 33 heart patients
or their survivors, and more than a dozen medical studies.
'Marching On'
These sources point to stent practices that underscore the waste and patient vulnerability in
a U.S. health care system that rewards doctors based on volume of procedures rather than quality
of care. Cardiologists get paid less than $250 to talk to patients about stents' risks and alternative
measures, and an average of four times that fee for putting in a stent.
"Stenting belongs to one of the bleakest chapters in the history of Western medicine," said Nortin
Hadler, a professor of medicine at the University of North Carolina at Chapel Hill. Cardiologists
"are marching on" because "the interventional cardiology industry has a cash flow comparable to the
GDP of many countries" and doesn't want to lose it, he said.
Stenting abuse is by no means the norm, but neither is it a rarity. Federal cases have extended
from regional medical centers in Louisiana, Kentucky and Georgia to a top-ranked metropolitan hospital
system in Ohio.
Asset Seizure
A doctor practicing at a hospital owned by the Cleveland Clinic, rated the premier heart center
in the country by U.S. News and World Report, had his assets seized by federal agents in a stent
investigation, according to federal court filings in April. The Clinic has not been accused of wrongdoing,
and says it's cooperating with the investigation.
Two out of three elective stents, or more than 200,000 procedures a year, are unnecessary, according
to David Brown, a cardiologist at Stony Brook University School of Medicine in New York. That works
out to about a third of all stents.
Brown said his estimate is based on eight clinical trials of 7,000 patients in the last decade,
which he analyzed in the Archives of Internal Medicine last year. Two cardiology researchers who
have studied the use of stents say the number could be as low as about half Brown's estimate, and
one said it is probably larger.
Costs, Risks
Even the low end of these estimates translates into more than a million Americans in the past
decade with implants in their coronary arteries they didn't need, said William Boden, chief of medicine
at a Veterans Administration hospital in Albany, New York. Boden was the principal investigator of
a 2007 study known as Courage that found stents added no benefit over medicines, exercise and dietary
changes in stable patients.
Unnecessary stents cost the U.S. health care system $2.4 billion a year, according to Sanjay Kaul,
a cardiologist and researcher at Cedars-Sinai Medical Center in Los Angeles. Patients who received
them are living with risks including blood clots, bleeding from anti-clotting medicine and blockages
from coronary scar tissue, any of which can be fatal, Kaul said.
Monica Crabtree died at age 64 after one of her arteries was torn in a stent procedure that led
to infection, according to her widower, Gary Crabtree. He received at least $240,000 from a 2011
settlement of his lawsuit against her doctor, after a second cardiologist reviewed the case and told
him the stent wasn't needed. Crabtree choked up speaking about his late wife and showed pictures
of their 47 years together.
Worried Shaving
"It wasn't just a simple mistake," said the retired auto worker in Largo, Florida. "If the stent
was something she really needed, I could have handled it. But it was a total loss of life that didn't
need to happen."
Jim Simecek, of Medina, Ohio, said he worries every morning that a nick from shaving could bleed
out of control. Simecek, who works at a Ford dealership, said he has to take blood-thinning medicine
for life to ward off clots in the six stents he received from a Cleveland-area cardiologist who's
under federal investigation for his stent work.
"It's as if your heart was open and somebody was sticking a knife in," said Rhonda McClure, 54,
referring to eight stents she received from a Kentucky cardiologist who agreed in June to plead guilty
to a federal Medicaid-fraud charge for falsifying records used to justify a stent he placed.
Patient Letters
Cardiac stents were linked to at least 773 deaths in incident reports to the U.S. Food and Drug
Administration last year, according to a review by Bloomberg News. That was 71 percent higher than
the number found in the FDA's public files for 2008. The 4,135 non-fatal stent injuries reported
to the FDA last year -- including perforated arteries, blood clots and other incidents -- were 33
percent higher than 2008 levels.
The FDA declined to comment on whether the reports were a cause for concern. It said adverse-event
reports tied to medical devices have increased overall due to agency efforts. It also said the data
can contain incomplete and unverified accounts from reporting parties.
More than 1,500 patients have gotten letters from hospitals since 2010 alerting them that their
stents may have been unnecessary. In Philadelphia, the University of Pennsylvania Health System sent
700 such notices in April.
Stenting Decline
At least 11 hospitals have settled federal allegations of charging for needless stenting and other
misdeeds in the catheterization labs where the procedures are performed. Federal probes of stenting
practices continue in at least five states. In Louisiana and Maryland, cardiologists went to federal
prison last year for implanting the devices and charging for them without medical justification.
A third doctor has agreed to do time in a plea bargain.
"There is a huge financial incentive to increase the number of these procedures," said Jamie Bennett,
a former assistant U.S. Attorney in Baltimore who handled stent investigations. "The cases we have
seen to date are just the tip of the iceberg."
Since Boden's Courage study, stenting procedures have declined by about 20 percent. Still, this
July, a panel of experts convened by the American Medical Association and the Joint Commission, a
hospital accreditor, named elective stenting as one of five overused treatments that too often "provide
zero or negligible benefit to patients, potentially exposing them to the risk of harm."
Better Choices
Doctors are using fewer stents and choosing more-appropriate patients than they were a few years
ago, according to John Harold, president of the American College of Cardiology, the specialty's main
professional group. Harold said that "real-world clinical practice" and research indicates Brown
probably overestimated how many people with coronary artery disease could be handled initially only
with drug-based treatment.
He said there are examples of inappropriate use and the ACC is taking steps to "address and correct
the imbalance" with treatment guidelines and by urging more hospital oversight. Cardiologists who've
been accused of fraud or are serving prison time are "outliers" who don't represent the "overwhelming
majority."
Lawyers for John McLean, a Salisbury, Maryland, cardiologist convicted of billing for unwarranted
stenting, argued in a federal appeal last year that inappropriate usage is widespread and their client
was prosecuted for behavior that's the industry norm.
Lost Appeal
They cited a 2011 study in the Journal of the American Medical Association that found only half
of elective stent procedures nationally were appropriate under usage guidelines written by societies
of heart specialists. The study found 12 percent were inappropriate, and 38 percent fell into the
uncertain category of the guidelines.
"The study demonstrated clearly that a large number of stable patients receive coronary artery
stents that are later found to be inappropriate or questionable," the appeal argued. "The same was
true of the patients in Dr. McLean's practice." McLean's appeal was denied in April. He is serving
an eight-year sentence.
Elective-stent patients typically see rapid quality-of-life improvements, including in their ability
to work and be active, according to Ted Bass, president of the Society for Cardiovascular Angiography
and Interventions, whose members specialize in cardiac implants. The Courage trial found stents,
compared to medication and lifestyle changes, were better at relieving chest pain for as long as
two years after placement -- a benefit that ended by 36 months.
Profit Centers
First used in Europe in 1986, cardiac stents took off in the 2000s as cardiologists found them
to be more effective in heart attacks than angioplasty. In that earlier technology, a small balloon
is inflated to widen blood passages and then withdrawn. Stenting facilities, known as "cath labs,"
spread at hospitals and became profit centers.
Hospitals receive an average payment of about $25,000 per stent case from private insurers, according
to Healthcare Blue Book, a website that tracks reimbursements. The federal Medicare program pays
less. Doctors who implant stents earn a separate fee that averages about $1,000 and ranges from $500
to $2,850, according to Medicare and Blue Book data.
The procedure typically involves inserting the stent with a catheter through a small incision
in the groin area or wrist and snaking it through to heart vessels. It usually takes less than 45
minutes.
Kickbacks Alleged
Stony Brook's Brown, and Boden, who led the Courage study, argue that many elective patients should
be getting medical therapy before they risk stents. Only 44 percent try medication and lifestyle
changes before stenting, a 2011 study in the Journal of the American Medical Association found.
At least five hospitals have reached settlements with the Justice Department over allegations
that they paid illegal kickbacks to doctors for patient referrals to their cath labs. St. Joseph
Medical Center in Towson, Maryland, paid the government $22 million without admitting liability.
Prosecutors alleged the hospital paid kickbacks to a practice co-founded by Baltimore cardiologist
Mark Midei for stent referrals. His doctor's license was revoked in 2011 when the Maryland Board
of Physicians found he falsified records to justify unwarranted stents.
St. Joseph told 585 of its patients they may have received unnecessary stents. In May, 252 patients
reached a settlement with the hospital under confidential terms, according to Jay D. Miller, an attorney
for the plaintiffs.
Plea Agreement
The hospital settled the government's case "to avoid the expense and uncertainty of litigation,"
it said in a statement. Spokeswoman Julia Sutherland said the hospital declined to comment on any
patient lawsuits.
In an interview, Midei denied he stented without medical need. He took issue with experts who
deemed many of his stents needless, and said disagreement among cardiologists on cases is common.
Midei was not a party to the federal settlement. The government has said its investigation of the
case continues.
In June, Sandesh Patil, a cardiologist practicing at another St. Joseph hospital -- this one in
London, Kentucky -- agreed to plead guilty to charging Medicaid for a stent that wasn't medically
warranted under the program's rules. (Although both hospitals were once owned by the same parent,
the one in Maryland has been sold.)
Catheterization procedures multiplied at St. Joseph in London after Patil began practicing there
in 2000, when the hospital had a different name. In that year, the type of procedure used for stents
was done 210 times. They climbed to 929 by 2009, state data show.
Multiple Stents
Stenting income from Medicare alone was more than a sixth of the hospital's 2009 operating income,
based on data from American Hospital Directory, a research firm. When Patil left London in 2010,
catheterization procedures fell 34 percent from their 2009 high. Using the midpoint of the directory's
price range for such procedures, the decline would have cost the hospital about $15 million. David
McArthur, the hospital's spokesman, declined to comment on its revenues.
Rhonda McClure, one of Patil's patients, had her arteries catheterized 18 times by him and his
partners over four years, according to her deposition and other filings in a lawsuit she and 361
other patients have brought against Patil, St. Joseph and other doctors who practiced there. She
said she received eight cardiac stents. The defendants deny the negligence and fraud allegations
against them.
McClure's deposition says a cardiologist who reviewed her case after the stents told her that
scarring caused by "too many procedures" was her main problem.
Short Breath
McClure said she suffers from chest pain and shortness of breath, and has been told by her new
doctor that she may need more stents and surgery to keep her coronary arteries from closing. She
said she gets so tired she needs to sit and rest after walking down the stairs.
St. Joseph-London repaid Medicare $256,800 for unnecessary procedures and is cooperating with
federal prosecutors, McArthur said. He said Patil was never employed by St. Joseph and lost his privileges
to practice there in December 2010. Patil's attorney said his client had no comment.
Under his plea bargain, Patil agreed to serve 30 to 37 months in federal prison. He forfeited
his Kentucky medical license for five years. In 2012, he told a family court judge his monthly income
was $53,300.
"Thirty-seven months is nothing for all the injuries he done for money," McClure said.
Message Balancing
After the Courage trial shed doubt on stents' effectiveness for stable patients, stent-implanting
cardiologists felt unfairly attacked and organized a campaign to "better balance the messaging,"
said Bonnie Weiner, who was president of the Society for Cardiovascular Angiography and Interventions
at the time.
The society hired a public relations firm and paid it more than $300,000 a year to help publicize
the benefits of stents, according to the group's filings with the Internal Revenue Service. The firm
helped launch a consumer website for SCAI, SecondsCount.org, which has published several articles,
including one under the headline, "For many patients, open arteries are better than closed arteries."
SCAI collected $2.7 million in donations for "public education" between 2008 and 2011 from stent
makers Abbott Laboratories Inc., Boston Scientific Corp., Cordis Corp. and Medtronic Inc., its Web
site says. Manufacturers' sales of cardiac stents were about $5.5 billion globally last year, down
5 percent from 2011, according to the Health Research International consulting firm.
High Median
Medtronic spokesman Joseph McGrath said grants to SCAI for patient education are "unrestricted,"
and SCAI is solely responsible for how the funds are used. Spokesmen for Abbott, Boston Scientific
and Cordis declined to comment.
Interventional cardiologists, the specialty SCAI represents, earn a median income of $562,855
a year, as compared to $207,117 for family doctors, according to Medical Group Management Association,
which surveys physician practices. The interventionalists ranked 13th among 118 specialties tracked
by MGMA.
Michigan Death
Mehmood Patel, a Lafayette, Louisiana, cardiologist who went to prison last year on 51 counts
of charging for needless stents, made over $16 million in one three-year span, evidence in the case
showed. Prosecutors said he was driven by the desire to be the busiest cardiologist in town.
He unsuccessfully argued that he used his best medical judgment in every case and lost an appeal.
Patel is serving a 10-year sentence in a federal penitentiary.
Jashu Patel, an interventionalist in Jackson, Michigan, billed $2.7 million for procedures
in 2007, according to a U.S. Justice Department case against him settled in July. (He is no relation
to Mehmood Patel).
The suit alleged Patel implanted needless stents in at least two patients, including one that
led to a blood clot that killed an unnamed woman who had reported no symptoms of reduced cardiac
blood supply. A stress test showed normal blood flow, and notes in her file said she didn't want
interventions, said Julie Kovach, a cardiologist who worked with Patel and brought the case to the
government's attention.
"It was appalling," Kovach said in an interview. "Patel coerced her into getting a stent she
didn't need, which killed her."
False Claims
Kovach said that when she told the chief operating officer of the hospital where Patel worked
about the death, the executive, Karen Chaprnka, diverted the conversation. Reached recently by e-mail
through a hospital spokesman, Chaprnka said she "disagreed with the allegations made by Dr. Kovach."
"He's their cash cow," said Kovach, now co-director of a clinic that treats congenital heart disease
at the Detroit Medical Center. "They're not about to turn him in."
Patel and the hospital, Allegiance Health, agreed to pay the U.S. a total of $4 million to settle
the federal charges. Kovach was awarded $760,000 as a whistle-blower under the U.S. False Claims
Act. Allegiance disagreed with the allegations and settled the claims to avoid "lengthy litigation,"
it said in a statement.
Patel continues to practice at the hospital and must improve record-keeping to substantiate cardiology
procedures, Allegiance said. In the settlement, Patel agreed to hire a consultant to oversee treatment
of his patients and an auditing firm to monitor billings. He didn't return phone messages.
Cleveland Raid
In Ohio, Simecek, the worker at the Ford dealership, grew suspicious after his sixth stent from
cardiologist Harry Persaud at the Cleveland Clinic's Fairview Hospital in 2011. Simecek said he went
for a second opinion and was told he didn't need any of the stents. Now he said he has to take blood
thinners the rest of his life.
"With the littlest cut, the blood starts running," said Simecek. "What if I am in an auto accident?"
Persaud is under criminal investigation for health care fraud, mail fraud and money laundering, according
to federal court filings. Last October, Federal Bureau of Investigation agents raided his office
and removed financial records and patient files for procedures at three Cleveland-area hospitals.
The government has seized $343,634 from his and his wife's bank accounts, alleging the funds represent
the proceeds of fraud related to a "significant number" of unnecessary stent procedures.
Multiple, Elongated
The Cleveland Clinic found "problems related to the use of stents in some patients" at Fairview
and reported them to the government, according to spokeswoman Eileen Sheil. She would not say how
many patients were affected. Persaud resigned from the hospital staff last year.
At least 64 of Persaud's patients at St. John Medical Center in suburban Westlake received letters
from the hospital saying they may have received an unnecessary stent between 2010 and 2012, according
to spokesman Patrick Garmone, who said Persaud no longer practices there.
Persaud denied wrongdoing in court filings and said his stent procedures were proper. Neil Freund,
his attorney in lawsuits filed by patients alleging unwarranted stents, said "it is our intent to
defend these cases." He had no comment on the federal investigation.
Final Order
In Texas, the state medical board's final order in DeMaio's case found that the cardiologist placed
"multiple, elongated, overlapping" stents in patients in areas of "insignificant or only moderate
disease." Peterson, the retired mailman, was identified only as Patient C in the staff complaint.
No patient was mentioned in the final order.
Peterson was thriving in his new career in the travel business, his wife Shirlee said. He had
a heart attack in 1997, which didn't crimp his love of travel and dance, she said. "He was an awesome
man who never met a stranger," she said.
After his death, Shirlee Peterson said a friend told her she had a cardiologist who refused to
do multiple stents.
"I do believe that Bruce was a guinea pig," she said. "That was the way it was done."
DeMaio said Peterson was extremely sick when he came to him. He said it was significant that the
board's final order didn't use the word "excessive" in describing his stent work. That included 31
stents stretching for 14 inches inside the arteries of Patient B in the staff complaint.
"Any patient of mine who received a full metal jacket" -- interventional cardiology's term for
such extensive work -- "would have been turned down by at least one, if not multiple surgeons," DeMaio
said. He said he doesn't use stents as much these days because standards have changed and he doesn't
see as many seriously ill patients.
Hyperlipidemia is a mouthful, but it's really just a fancy word for too many lipids – or fats
– in the blood.
That can cover many conditions, but for most people, it comes down to two well-known terms:
high cholesterol and high triglycerides . Our bodies make and use a certain amount of cholesterol
every day, but sometimes that system gets out of whack, either through genetics or diet. Higher levels
of the
"good" HDL cholesterol are associated with decreased risk of heart disease and stroke. HDL helps
by removing cholesterol from your arteries, which slows the development of plaque. The "bad" LDL
cholesterol, on the other hand, can lead to blockages if there's too much in the body.
What's the treatment?
If you are diagnosed with hyperlipidemia, your overall health status and risks will help guide
treatment . Making healthy diet choices and increasing exercise are important first steps in
lowering your high cholesterol . Depending on your overall risk, your doctor may also prescribe
medication in conjunction with healthy eating and regular exercise.
"The combination of diet and regular physical activity is important even if you're on
medication for high cholesterol ," said Dr. Vincent Bufalino, an American Heart Association volunteer.
"It's the most critical piece."
Consulting a doctor is important, since each condition has it quirks. For people with high triglycerides,
for example, alcohol can be particularly dangerous. But for those with high cholesterol, a daily
glass of wine or other alcohol, along with healthy eating and exercise, may actually help, Dr. Bufalino
said.
Once I have it, can I reverse it?
Hyperlipidemia can be improved in many cases through healthy eating and regular exercise.
Here are some tips on how to manage your risk of high cholesterol.
Read food labels and choose foods with low cholesterol and saturated trans fat. For
people who would benefit from lowering their cholesterol, the American Heart Association recommends
aiming for a dietary pattern that limits saturated fat to 5 to 6 percent of daily calories and
reduces the percent of calories from trans fat.
Limit your intake of red meat and dairy products made with whole milk to
reduce your saturated and trans fat . Choose skim milk, lowfat or fat-free dairy
products. Limit fried food, and use healthy oils in cooking, such as vegetable oil.
Check your
family history of high cholesterol . Are you more prone to high cholesterol based on genetics?
If so, take steps to minimize your risk through diet and exercise.
Lose extra weight . A weight loss of 10 percent can go a long way to lowering your risk of
or reversing hyperlipidemia.
In late 2013, after an extensive review of evidence, the
National Heart, Lung and Blood Institute
updated cholesterol guidelines. Why did they do this? These new guidelines better identify those
at risk of atherosclerotic cardiovascular disease (ASCVD), and also better diagnose people who already
have ASCVD. Patients who have ASCVD are more likely to suffer a heart attack or stroke.
To determine if someone is at risk of developing ASCVD a
risk estimator
is available through Cardio Source. Information including Systolic Blood Pressure, a patient's race,
HDL Cholesterol and more are entered.
Depending on the level of risk, patients should take different courses of action. For all patients
who are determined to be at risk for ASCVD there are behavioral modifications they should implement.
These include: eating a heart-healthy diet, regularly exercising, avoiding tobacco products and maintaining
a healthy weight.
For lower risk individuals, there are other items to take into account on whether they are likely
to develop ASCVD. These include a family history of premature ASCVD,
LDL greater than 160, high sensitivity C-reactive protein, Coronary calcium score and Ankle/brachial
index.
For those with a high likelihood of developing ASCVD and for those individuals who already have
ASCVD, statins should be taken. The guidelines have also been updated. There are non-statin medications
also available for those patients unable to take statins (due to side effects or drug interactions).
Talk with your doctor to determine which medicine is best for you.
It wasn't the mountain of debt I was sure to incur since I'd already figured out how to get Uncle
Sam to pick up the bill (a small deal that put me in a military uniform for a decade). It wasn't
the fact that medical school would delay the litter of bouncing grandbabies she wanted to fawn over.
And it certainly wasn't because she'd miss me-she'd already seen too much of me and my dirty laundry
on weekends during college.
No, my mother was legitimately disappointed in me for choosing to enter the medical profession
simply because she had a deep-seated disdain for doctors. I could almost envision her sad disgrace
as she chatted with the neighbors during my final year as a resident in brain surgery:
Mom: "What's little Festus up to these days?"
Neighbor 1: "Oh he's doin' real good. He's got hisself a carwash business up in Magna
that pulls in a couple hundred a week. Lookin' to buy a bass boat for him and the misses."
Mom: "And Cletus?"
Neighbor 2: "Almost done with his ten years up at the state pen in Bluffdale. Won
an award for license plate stampin'. Trixie and the boys are real proud of him."
Neighbor 1: "And what's Eric doing?"
Mom: "He's still not married."
My mother never told me why she disliked doctors so much. I'm left to assume that she'd had a
number of bad interactions with them over the years, but she never bothered to back up her expressions
of disapproval with any sort of details. It took several years for my mother to warm up to the idea
that I had not turned to the dark side by becoming a doctor. I think a lot of it had to do with inertia-by
the time she finally decided to express any acknowledgement of my career decision, two more of us
boys were in medical school and I supposed she realized she couldn't be disappointed in all of us.
Now that I've been in practice a number of years I've finally learned what it was that so intensely
turned my mother off about doctors: they can be arrogant, condescending and impolite. Of course,
many of my readers are at this moment wondering if I'm also going to reveal other mysteries such
as "birds fly" and "dogs bark."
I had a roommate in medical school who was a great guy. He studied hard, didn't party too much,
and always managed to put the toilet paper on the right way (rolling out from the top down, in case
you were wondering). Years after we graduated and had gone our separate ways I had a phone conversation
with a physician assistant who'd gone to work for my old roommate. "It must be great working for
Dr. X," I added. A pause on the phone. "No," he said slowly, "he's a total jerk. Everybody hates
him."
I have two theories. One is that all medical students believe they will go on to become an Albert
Schweizer in their field-kind, self-sacrificing, benevolent-but somewhere along the way a certain
fraction of them let the glory of their career go to their heads and begin to treat patients and
underlings like chewing gum on a movie theater floor. What constitutes that percentage is in the
eye of the beholder. For my mother it was some where around the 98% mark. I'm a little more generous-I'll
say 20%.
My second theory is that all doctors believe themselves to be noble, kind, and beloved by all.
Rarely do I come across an arrogant doctor who recognizes him- or herself as such. Rather, almost
all of us think we're appropriately mannered. And we are . . . most of the time.
The rubber hits the road, though, when job-related stress enters the picture. A physician who
ends up an hour behind in a busy clinic can become snappy at his nurses and receptionists. A surgeon
who is elbow-deep in a case gone awry will turn her anger toward the anesthesiologist and scrub techs.
In both cases, the doctors in question feel they were simply reacting appropriately to the situation:
"Of course I yelled at my nurse. Doesn't she realize she is making me later than I already am?" or
"Of course I hurled the Metzenbaums across the room. Am I the only one in the OR who cares what happens
to this patient?!"
As any nurse will tell you, the true measure of a doctor's demeanor is not how he or she acts
during times of ease. Instead, the nature of a physician's soul is uncovered precisely during those
times when he or she has the most right to explode in a volcano of vulgarities and instrument-throwing.
A doctor who can keep cool while juggling 3 phone calls, a clinic filled with patients, and a patient
exsanguinating on the operating table is both rare and worthy of high esteem.
In fellowship I had the misfortune to work under a cardiologist described by all other fellows
thus: "She's fun socially but awful to work with." This proved to be true: at a staff party she was
great to have around, but when faced with the challenge of rounding on 15 patients in a two-hour
period she transformed into Medusa. Yet, I'm sure, if asked, she would maintain that she is polite,
kind, and patient-as long as the situation doesn't demand otherwise. The problem is that her definition
of "situation" was pretty much every day at work.
We doctors have chosen professions that are inherently filled with stress, deadlines, and treading
in deep emotional waters. None of that grants us a free pass to behave like spoiled toddlers. As
I see it, doctors should always follow 2 simple rules:
Rule #1: It is simply not allowable to be impolite, mean, nasty or snippy
with staff or patients even when you are in a stressful situation.
Rule #2: Whatever is stressing you is probably stressing those around you
as much or more. Under those circumstances you have to go out of your way to be kinder and more
understanding. As a doctor, you control the mood in the clinic and operating room even if you
can't control the situation.
I freely admit I am unable to always adhere to these rules but I at least recognize them and intend
to spend the rest of my career trying to do better. My mother passed away many years ago but I'm
hoping that somewhere up there she can look down and see that I didn't turn out to be so terrible
after all.
Loan Eby says:
May 15, 2012 at 4:26 pm Bedside manner
I was with my mom when her doctor told her she had Stage IV pancreatic cancer. After learning
my mom had 6-months to live, I remember walking out of Good Sam in Kearney and running into my
high school friend who was a nurse there. My friend greeted me with a smile because she had not
seen me in years. I told her the devastating news and how awful the doctor was to my mom. She
told me he was one of the best oncologists around. If he was the best round, I would have hated
to see their worst. Thank you for your post.
Nikki says:
May 15, 2012 at 4:44 pm It's refreshing to read Dr. Van De Graaff post. I have worked with
many Dr. and nurses in my time in the medical field. Sometime you get the nice fun loving Dr.
/ nurse or sometimes they are possessed, as a clinic worker it's my job ( and I take pride in
it) to not let it get so bad in the clinic and if it does everyone better start doing their best
to make the situation the best they can. I don't think that there is a day that goes by we aren't
laughing even when we are all a little crazy. It's nice to know that when you behave badly you
know you shouldn't….
Lance Taylor says:
May 15, 2012 at 10:53 pm Treat other how you would expect to be treated, and all will be well.
Sandra says:
May 18, 2012 at 8:42 am My mother also had the same attitude towards physicians. However,
my mother took everything in stride and always voiced her opinion. A few times she would bluntly
express to the physician/nurse when they were not very nice and did not answer her questions.
It was interesting to see the look on the physician/nurse's faces; it is evident that they were
not aware how they come across to their patients at any given time. Sometimes it is up to the
patient to express to their care provider how they are treating the patient. I saw first handed
how their attitudes changed each time my mother came into the clinic for the chemo/radiation treatments.
I would advise others to ask the provider/nurse how is your day going, it is amazing how their
attitude can fall into a positive manner when someone shows interest in them as a person not just
a physician/nurse. Thanks for sharing your story Dr. V.
RS says:
June 26, 2012 at 11:00 am I have to say, your mother raised you right! Its not everyone that
knows the correct way to put the toliet paper on! Your attitude is refreshing and you make your
profession proud! Your well written article should be a reminder to everyone that we should all
treat those around us with dignity and respect.
Leslie says:
August 13, 2012 at 10:22 am I am a retired respiratory therapist, my father was a pharmacist
who owned his own pharmacy and I have 3 cousins and an uncle who are physicians. I say that because
I want you to know that I have been around physicians all of my life. All that being said I would
come alot closer to your mother's 98%(probably around95%) than your generous 20%. That would include
my uncle. To find a physician who is both a good dr and a good person is rare indeed. For decades
I had to endure tamtrum throwing doctors. Now we have added millions of doctors from middle eastern
countries who have NO respect for women, zero manners and have such thick accents the poor little
old people have no clue what the physician just said, let alone who he actually was(no name, no
specialty, no time for questions, no business card).
My opinion has been for years that if you can't keep your cool under stressful conditions then
you need to be a plumber. Anyone who doesn't think that every level of healthcare is extremely
stressful-think again. Yelling at people who have done no wrong only makes them more nervous and
more likely to really make a mistake. Yep, a plumber. You can make as much money(perhaps more).
You can make your own hours. No insurance companies to deal with.
Think about it. Some people make everyone happy by entering a room…and others by leaving.
Jonathan hersch says:
August 14, 2012 at 2:05 pm I find that my patients say the same thing about other doctors
as your mother. Certainly many have let this career go to their head. I have many techniques to
control my anger and frustration when things are going bad in the operating room. It's hard but
a must.
I find myself hanging out with doctors who are like myself. Laid back and don't take life too
serious. The rest are hard to get along with. Patients feel the same.
KEITH BARKLEY says:
April 10, 2013 at 9:34 am I had the privelege of meeting DR. van de Graaf after a trip to
the hospital via rescue squad. These people really saved my life.I was near death and Dr van de
Graff helped preform a miracle for me.I haved been exposed to many medical people over the past
80+ years and I will critisize few of them – – but Dr van de Graff is truly a special person –
as well as Dr.
The American Heart Association (AHA) and the American College of Cardiology (ACC) recently released
new cardiovascular disease prevention guidelines . They are an egregious example of much that
is wrong with medicine today.
The guidelines propose a vast expansion of the use of statins in
healthy people, recommending them for about 44 percent of men and 22 percent of healthy women
between the ages of 40 and 75. According to calculations by John Abramson, lecturer at Harvard
Medical School, 13,598,000 healthy people for whom statins were not recommended based on the 2001
guidelines now fall into the category of being advised to take moderate or high intensity statin
therapy.
The American Heart Association (AHA) is a nonprofit organization with a mission to "build
healthier lives free of cardiovascular disease and stroke." Yet in its 2011-2012
financial statement , the AHA noted $521 million in donations from non-government and
non-membership sources and many well-known large
drug companies, including those who make and market statins, contribute amounts in the $1
million range.
Seven of the 15 authors disclosed ties to industry.
Originally, the panel chair, Neil J. Stone, MD of Northwestern University, declared that he has
had no ties to industry since 2008. Jeanne Lenzer, writing in the British Medical
Journal (BMJ) last month, interviewed Dr. Stone who said: "When I was asked by NHLBI [National
Heart, Lung and Blood Institute] to chair the [cholesterol] panel, I immediately severed ties
with all industry connections prior to assuming my role as chair." However, prior to 2008, he
accepted funding and consultancy fees from multiple pharmaceutical companies, including Abbott,
AstraZeneca, Pfizer, Merck, and Schering-Plough among others. Dr. Stone also told the BMJthat
he will "definitely" not take any industry funding for two years. Are we to believe that by severing
his ties in 2008 his mind became an instant tabula rasa, completely devoid of any conscious or
unconscious bias towards the drug companies which had been paying him? To do so strains the bonds
of credulity past the breaking point.
The financial ties between large pharmaceutical companies
and the AHA are numerous and very remunerative for the AHA, including huge donations from Abbott,
Bayer, Boehringer Ingelheim, Bristol-Myers Squibb (BMS), Eli Lilly, Merck and Pfizer. BMS, along
with Merck and Pfizer are
national sponsors of AHA's Go Red For Women> heart disease awareness campaign whose
web site tells patients "If your doctor
has placed you on statin therapy to reduce your cholesterol, you can rest easy-the benefits outweigh
the risks" The site also proclaims that "Zocor and Pravachol - have the fewest side effects,"
and "statins may only slightly increase diabetes risks." The
Women's Health Initiative
, a federal study of over 160,000 healthy women to investigate the most common causes of death,
disability and poor quality of life in postmenopausal women, showed that a healthy woman's risk
of developing diabetes was increased 48 percent compared to women who were not on a statin. And
contrary to what statin apologists say about statins only increasing diabetes risk in people who
are at high risk of developing it anyway, for example the obese, women on statins in the
Women's Health Initiative
who were of normal weight increased their risk of diabetes 89 percent compared to same weight
women not taking a statin.
In 2010, AHA received $21,570 from statin maker AstraZeneca to run
an AHA course about
"emerging strategies with statins" at the Discovery Institute of Medical Education and almost
$100,000 for learning projects including "debating controversial topics in cardiovascular disease."
The AHA defended
the deceptively marketed and controversial cholesterol drug Vytorin. Did that have anything
to do with the $2 million a year the AHA was taking from marketer Merck/Schering-Plough Pharmaceuticals?
The
AHA also rakes in millions from food companies which are also million dollar donors and which
pay from $5,490 to $7,500 per product to gain the "heart-check mark" imprimatur from the AHA,
renewable, at a price, every year. The foods so anointed have to be low in fat, saturated fat,
and cholesterol yet Boar's Head All Natural Ham
somehow made the cut as
did Boar's Head EverRoast Oven Roasted Chicken Breast . Such processed, high-sodium meats
raise blood pressure, the risk of cardiovascular disease and the risk of diabetes.
A review of almost 1,600
studies involving one million people in ten countries on four continents showed that a 1.8-ounce
daily serving of processed meat raised the risk of diabetes by 19 percent and of heart disease
by 42 percent.
The new guidelines might make sense if statins were truly as effective as their proponents
claim, and if they had no adverse effects. But they have an increasing list of side effects, which
affect at least
18 percent of people who take them. These range from muscle pain, weakness and damage to cataracts,
cognitive dysfunction, nerve damage, liver injury and kidney failure.
As Jerome Hoffman, M.D.,
Professor Emeritus of Medicine at UCLA wrote recently with regard to these guidelines: "How did
we arrive at a place where conflicted parties get to make distorted semi-official pronouncements
that have so much impact on public policy?" How indeed? By Barbara Roberts, M.D. is an Associate
Clinical Professor of Medicine at the Alpert Medical School of Brown University. She is the author
of
The Truth about Statins and How to Keep from Breaking Your Heart: What Every Woman
Needs to Know about Cardiovascular Disease . Martha Rosenberg is a health reporter and author
of Born with a Junk Food Deficiency.
"... A 1982 study in the journal Medical Care found that a mandatory second opinion program for Massachusetts Medicaid patients led to a 20% drop in certain surgeries, such as hysterectomies, that were considered more likely to be done unnecessarily. ..."
"... "We expect the physician to know what's best for a patient," says William Root, chief compliance officer at Louisiana's Department of Health and Hospitals. "We put so much faith and confidence in our physicians, (and) most of them deserve it. But when one of them is wrong or goes astray, it can do a lot of damage." ..."
Jonathan Stelly was 22, a semi-pro baseball player aiming for the big leagues, when a fainting
spell sent him to his cardiologist for tests. The doctor's office called afterward with shocking
news: If Stelly wanted to live to age 30, he was told, he'd need a pacemaker.
Stelly knew it would be the end of his baseball dream, but he made a quick decision. "I did what
the doctor said," he recalls. "I trusted him."
Months after the surgery, local news outlets reported that the Louisiana cardiologist, Mehmood
Patel, was being investigated for performing unnecessary surgeries. Stelly had another doctor review
his case. Then another. And another. They all agreed: He needed blood pressure medication, but he
never needed the pacemaker.
Today, Patel is in prison, convicted of billing Medicare for dozens of unnecessary heart procedures.
Stelly, now 34, still has the pacemaker – but the doctors shut it off years ago.
"Baseball was my life, and he took that away," Stelly says. "For nothing."
... ... ...
Tens of thousands of times each year, patients are wheeled into the nation's operating rooms for
surgery that isn't necessary, a USA TODAY review of government records and medical databases finds.
Some, such as Stelly, fall victim to predators who enrich themselves by bilking insurers for operations
that are not medically justified. Even more turn to doctors who simply lack the competence or training
to recognize when a surgical procedure can be avoided, either because the medical facts don't warrant
it or because there are non-surgical treatments that would better serve the patient.
... ... ...
Since 2005, more than 1,000 doctors have made payments to settle or close malpractice claims in
surgical cases that involved allegations of unnecessary or inappropriate procedures, according to
a USA TODAY analysis of the U.S. government 's National Practitioner Data Bank public use file, which
tracks the suits. About half the doctors' payments involved allegations of serious permanent injury
or death, and many of the cases involved multiple plaintiffs, suggesting many hundreds, if not thousands,
of victims. <
... ... ...
A 2011 study in the Journal of the American Medical Association reviewed records for 112,000
patients who had an implantable cardioverter-defibrillator (ICD), a pacemaker-like device that corrects
heartbeat irregularities. In 22.5% of the cases, researchers found no medical evidence to support
installing the devices.
... ... ...
"Don't just take a doctor's word," says Patty Skolnik, who founded Citizens for Patient Safety
after her son, Michael, died at 22 from complications in what she says was unnecessary brain surgery.
"Research your doctor, research the procedure, ask questions, including the most important one: 'What
will happen if I don't get this done?'"
... ... ...
A 1982 study in the journal Medical Care found that a mandatory second opinion program for
Massachusetts Medicaid patients led to a 20% drop in certain surgeries, such as hysterectomies, that
were considered more likely to be done unnecessarily. A 1997 study in the Journal of the American
College of Surgeons looked at 5,601 patients recommended for surgery and found that second opinions
found no need for the operation in 9% of the cases. Among those who got the countervailing second
opinion, 62% opted not to have the operation.
But many patients simply aren't inclined to question their doctors.
"We expect the physician to know what's best for a patient," says William Root, chief compliance
officer at Louisiana's Department of Health and Hospitals. "We put so much faith and confidence in
our physicians, (and) most of them deserve it. But when one of them is wrong or goes astray, it can
do a lot of damage."
"Everyone will experience one meaningful diagnostic error in their lifetime," Dr. John Ball recently
told NBC News. Ball, who chairs the Committee on Diagnostic Error in Medicine, helped draft a report
on the alarming rates of late or misdiagnosis in U.S.
healthcare settings – the consequences of which are often catastrophic if not fatal
for some patients.
Prevalence of medical misdiagnoses
According to the study:
Every year, an estimated 5 percent of adults treated on an outpatient basis experience a diagnostic
error.
Diagnostic mistakes are to blame for at least 10 percent of patient deaths, according to autopsy
reports.
Incorrect or late diagnoses account for 6 to 17 percent of reported adverse events in hospitals.
In sum, the majority of American adults will suffer the effects of misdiagnosis or diagnostic
error at some point in their lives.
Doctors afraid to admit their mistakes
The report suggests that better training and guidelines can help reduce incidence of diagnostic
errors in clinical settings. However, we live in a culture where doctors and hospitals are
not always willing to speak freely about mistakes, making it that much more challenging to learn
from near misses.
"If people are afraid to speak up, then bad things can continue to happen," Ball said.
This sentiment was echoed back in 1998 by The Institute of Medicine, which found that medical
errors and surgical mistakes claimed the lives of tens of thousands of American patients each year.
The organization also called for a "culture of confession" in the hopes that healthcare
professionals wouldn't be afraid to fess up their blunders. With a more open dialogue among medical
providers regarding botched surgeries and missed
diagnoses, new approaches could be developed to help prevent the same errors from repeating themselves.
Ball also says that pathologists and radiologists should get more involved in clinical care and
patient diagnosis for more accurate testing.
Real life examples of diagnostic errors
The life-altering consequences of diagnostic mistakes are all too familiar to
Susan Sheridan of Boise, Idaho. Sheridan's husband died after his doctors
failed to diagnose an aggressive cancer in
his spine, and her child – who is now an adult – was rendered permanently disabled after physicians
failed to treat his infant jaundice.
In 1995, her newborn son Cal developed a dangerous condition known as
kernicterus which is caused by high levels of bilirubin. At just a few days old his skin
had turned a bright orange, but Sheridan's concerns were continually dismissed by pediatricians.
By the time the correct diagnosis was finally made, Cal had suffered extensive
brain damage leading to
cerebral palsy. He is both hearing and speech impaired,
uses a walker and will need medical care for the remainder of his life.
Sheridan hopes that other families will never have to endure similar heartache and loss and has
since become the director of patient engagement for the Patient-Centered Outcomes Research Institute
(PCORI). Still, Sheridan laments that there is no organization or system where medical errors
can be logged and tracked.
"The first thing I wanted to do was tell somebody, so they could make sure that will never happen
again."
"... Is it any coincidence that the US is one of the few developed countries that allows drug advertising on television ? I've lost count of the number of times I've wanted to throw something at the TV when I hear the phrase " … ask your doctor whether Drug X is right for you !". ..."
"... Better yet, just avoid the TV at all costs. You are simply being manipulated. ..."
"... If you did not choose to put something in front of your eyeballs, you can be highly confident that somewhere, there's a serious conflict between the message being delivered and your best interests. ..."
Is it any coincidence that the US is one of the few developed countries that
allows drug advertising on television ? I've lost count of the number of times
I've wanted to throw something at the TV when I hear the phrase " … ask your
doctor whether Drug X is right for you !".
OTOH maybe that's a plus. If its being promoted on TV then avoid it at all
costs until you've read the independent trial evidence.
Better yet, just avoid the TV at all costs. You are simply being
manipulated.
If you did not choose to put something in front of your eyeballs, you can
be highly confident that somewhere, there's a serious conflict between the
message being delivered and your best interests.
And even if you did choose it, be careful what the producer's motives
were…
"... We are talking about "medical industrial complex" here. So this is a systemic problem: Dangerous drugs, "blockbuster drugs" are just the tip of an iceberg. ..."
"... Hospitals became more of a money making machines and the duration of your stay in hospital often is determined by the insurance you have and doctors financial motives, not by your disease. ..."
"... First step of the government take over all pharmaceutical research could be government paying for all clinical trials. What could the industry object? It would mean much less financial risk for the firms - an incentive. ..."
"... Read more about this for profit fantastic here - I think I've got it right: http://ontodayspage.blogspot.com/2016/06/will-500000-americans-year-die-for-lack.html ..."
We are talking about "medical industrial complex" here. So this is a systemic problem:
Dangerous drugs, "blockbuster drugs" are just the tip of an iceberg.
When profit motive replaces Hippocratic oath terrible things happen. And this is what happened under
neoliberalism. "Greed is good" is the new morality.
That include useless surgeries, such as cardiac stenting (which is a mass practice in the USA).
Actually any area where control is difficult and the same doctor recommends the procedure and later
does the surgery is suspect.
When you're a hammer everything looks like a nail.
Hospitals became more of a money making machines and the duration of your stay in hospital often
is determined by the insurance you have and doctors financial motives, not by your disease.
First step of the government take over all pharmaceutical research could be
government paying for all clinical trials. What could the industry object? It would
mean much less financial risk for the firms - an incentive.
No matter who pays for the research it is the same university researchers doing the work - as far
as I know. Government could fund the whole thing without any need for greed.
* * * * * *
Right now, 10,000 Americans die weekly (!) of heart failure. Formerly there was no improvement and certainly
no cure. In 2012 a small clinical trial or a balloon inserted around the heart to assist pumping ended
with 5 actual cures, most improved and a few held steady. A much larger trial of 200 is being attempted
to get FDA approval …
… but is in Limbo (from my reading) by inability to get investors to pony up for more than 100 of
the 200 - $30 million short being the reason. The flip side of profit based research ripoff.
I'm sure today's 5 million heart failure sufferers in the US would gladly pony up $6 apiece. Maybe
one of them should start a go-fund-me for $30 million. Maybe investors would not want them to.
* * * * * *
Gilead - the same company that brought us Sovaldi - now has developed a drug that claims to be 95% effective
against all versions of hepatitis: Epclusa. At $75,000 a treatment (that may only cost them $150 to
manufacture) X 300 million worldwide sufferers, that comes to $22.5 trillion (with a "t") to treat all.
I'm sure they need most of that for future research (or divert it to pay for the living and business
expenses for every man, woman and child in the US, Canada and Mexico for one year).
"... A pharmacist friend of mine told me never to take any drug that hasn't been on the market for at least 5 years. The FDA is toothless and is corrupt just like every other regulatory agency in this country. Big pharma is primarily concerned with huge profits like "blockbuster" (expensive) and drugs that you have to take over a long period of time and this is probably one reason why a lot of research on superbugs isn't being done. There's no money in it. ..."
A pharmacist friend of mine told me never to take any drug that hasn't been on the market for at
least 5 years. The FDA is toothless and is corrupt just like every other regulatory agency in this country.
Big pharma is primarily concerned with huge profits like "blockbuster" (expensive) and drugs that you
have to take over a long period of time and this is probably one reason why a lot of research on superbugs
isn't being done. There's no money in it.
"... An accompanying editorial came to a scathing conclusion: The surgery is "a highly questionable practice without supporting evidence of even moderate quality," adding, "Good evidence has been widely ignored." ..."
"... "We have randomized clinical trials that produce the highest quality of evidence. They strongly suggest that the procedure is next to useless. If there is any benefit, it is very small and there are downsides, expense and potential complications." ..."
"... What decisions in medicine today give priority to what is best for the patient? Unnecessary surgery is only one component of patient care taking a back seat to money. Pharmaceutical companies remove lower-priced drugs from market and set sky-rocketing prices for drugs that remain. Devices, such as morcellators that spread cancer during surgery and vaginal mesh that can irreversibly ruin a woman's health, are still being used despite their terrible impacts because of the money in it for the device makers and doctors who use them. ..."
"... Capitalism works when consumer protection laws are enforced to protect consumers from predatory suppliers. American consumers have been left to fend for ourselves. We must not trust our doctors to provide sound health care. Instead, we are forced to do our own research and draw our own conclusions from credible, independent sources, to the extent they still exist. ..."
"... DO NOT look to news articles for medical advice! And lastly, know that medical doctors are often biased too much against surgery, while surgeons are often biased too much in favor of surgery. ..."
"... As a physician, and this is me speaking for myself, I feel that unnecessary surgeries, procedures, and diagnostic tests are a byproduct of a culture where people would prefer a pill or surgery to behavioral change and where doctors are compensated well to provide this (called the "perverse incentive." ) ..."
"... Patients demand surgery, demand an MRI and feel upset if physical therapy doesn't fix their problem instantly. Ironically, I am a physician who eschews any diagnostic or procedure that I don't deem necessary, but some patients will complain if they don't get their quick fix and will deem you a bad physician. If orthopedic surgeons perform fewer of arthroscopies they will see their salaries slashed. ..."
"... One of my former surgical professors, the head of the department of surgery in a major New York teaching hospital once told me "Asking a surgeon if you need an operation is like asking a barber if you need a haircut." Obviously it is more complicated than that and I am not suggesting that surgeons do not carefully consider the needs of the patients. It is true that when your background and training is in surgery, or any particular discipline, that becomes the lens through which you view the world. ..."
Before a drug can be marketed, it has to go through rigorous testing to show it is safe and effective.
Surgery, though, is different. The Food and Drug Administration does not regulate surgical procedures.
So what happens when an operation is subjected to and fails the ultimate test - a clinical trial
in which patients are randomly assigned to have it or not?
The expectation is that medical practice will change if an operation turns out not to help.
If only.
It looks as if the onus is on patients to ask what evidence, if any, shows that surgery is better
than other options.
Take what happened with
spinal fusion , an operation that welds together adjacent vertebrae to relieve back pain from
worn-out discs. Unlike most operations, it actually was tested in four clinical trials. The
conclusion : Surgery was no better than alternative nonsurgical treatments, like supervised exercise
and therapy to help patients deal with their fear of back pain. In both groups, the pain usually
diminished or went away.
The studies were completed by the early 2000s and should have been enough to greatly limit or
stop the surgery, says Dr. Richard Deyo, professor of evidence-based medicine at the Oregon Health
and Sciences University. But that did not happen, according to
a recent report . Instead, spinal fusion rates increased - the clinical trials had little effect.
Spinal fusion rates continued to soar in the United States until 2012,
shortly after Blue Cross of North Carolina said it would no longer pay and some other insurers
followed suit.
"It may be that financial disincentives accomplished something that scientific evidence alone
didn't," Dr. Deyo said.
Other operations continue to be reimbursed, despite clinical trials that cast doubt on their effectiveness.
In 2009, the prestigious New England Journal of Medicine published results of separate clinical
trials on a popular back operation,
vertebroplasty ,
comparing it to a sham procedure. They found that there was no benefit - pain relief was the same
in both groups. Yet it and a similar operation, Kyphoplasty, in which doctors inject a sort of cement
into the spine to shore it up, continue to be performed.
Dr. David Kallmes of the Mayo Clinic, an author of the vertebroplasty paper, said he thought doctors
continued to do the operations because insurers pay and because doctors remember their own patients
who seemed better afterward.
"When you read a study, you reflect on whether it is representative of your patient population,"
Dr. Kallmes said. "It is easy to conclude that the answer is 'no.' The mean age in the study is different
or 'I do it differently.'"
"I think there is
a placebo effect not only on patients but on doctors," Dr. Kallmes adds. "The successful patient
is burned into their memories and the not-so-successful patient is not. Doctors can have a selective
memory that leads them to conclude that, 'Darn it, it works pretty well.'"
The latest controversy - and the operation that arguably has been studied the most in randomized
clinical trials - is surgery for a torn
meniscus , a sliver of cartilage that acts as a shock absorber in the knee. It's a condition
that often afflicts middle-aged and older people, simply as a consequence of degeneration that can
occur with age and often accompanying
osteoarthritis . The result can be a painful, swollen knee. Sometimes the knee can feel as if
it catches or locks. So why not do an operation to trim or repair the torn tissue?
About 400,000 middle-aged and older Americans a year have meniscus surgery. And here is where
it gets interesting. Orthopedists wondered if the operation made sense because they realized there
was not even a clear relationship between
knee pain and meniscus tears. When they did
M.R.I. scans on knees of middle-aged people, they often saw meniscus tears in people who had
no pain. And those who said their knee hurt tended to have osteoarthritis, which could be the real
reason for their pain.
Added to that complication, said Dr. Jeffrey N. Katz, a professor of medicine and orthopedic surgery
at Harvard Medical School, is the fact that not everyone improves after the surgery. "It is not regarded
as a slam-dunk," he said. As a result, he said, many doctors have been genuinely uncertain about
which is better - exercise and
physical therapy or surgery. That, in fact, was what led Dr. Katz and his colleagues to conduct
a clinical
trial comparing surgery with physical therapy in middle-aged people with a torn meniscus and
knee pain.
The result: The surgery offered little to most who had it. Other studies came to the same conclusion,
and so did a meta-analysis
published last year of nine clinical trials testing the surgery. Patients tended to report less pain
- but patients reported less pain no matter what the treatment, even fake surgery.
Then came yet another study
, published on July 20 in The British Medical Journal. It compared the operation to exercise
in patients who did not have osteoarthritis but had knee pain and meniscus tears. Once again, the
surgery offered no additional benefit.
An accompanying editorial
came to a scathing conclusion: The surgery is "a highly questionable practice without supporting
evidence of even moderate quality," adding, "Good evidence has been widely ignored."
So what should patients be told? Should they even be offered the surgery?
Patients should be told that physical therapy is a good first-line therapy for pain relief, Dr.
Katz said, but that surgery also relieves pain. Pain relief can take longer with physical therapy,
he says. With surgery, he said, patients have to recover from the operation but are likely to be
back at work within two weeks.
"At the end of the day," he said, "patients ought to choose."
Of course, how they choose might depend on how the choice is presented.
Here's how Dr. Gordon H. Guyatt, a professor of medicine and epidemiology at McMaster University
in Hamilton, Ontario, who wrote the editorial in The British Medical Journal, would deal with the
clinical trial data:
"I personally think the operation should not be mentioned," he says, adding that in his opinion
the studies indicate the pain relief after surgery is a placebo effect. But if a doctor says anything,
Dr. Guyatt suggests saying this: "We have randomized clinical trials that produce the highest
quality of evidence. They strongly suggest that the procedure is next to useless. If there is any
benefit, it is very small and there are downsides, expense and potential complications."
Hearing that, he says, "I cannot imagine that anybody would say, 'Go ahead. I will go for it.'"
Dr Deyo's comment, "It may be that financial disincentives accomplished something that scientific
evidence alone didn't," may be the biggest understatement made about how modern medicine works.
What decisions in medicine today give priority to what is best for the patient? Unnecessary
surgery is only one component of patient care taking a back seat to money. Pharmaceutical companies
remove lower-priced drugs from market and set sky-rocketing prices for drugs that remain. Devices,
such as morcellators that spread cancer during surgery and vaginal mesh that can irreversibly
ruin a woman's health, are still being used despite their terrible impacts because of the money
in it for the device makers and doctors who use them.
Capitalism works when consumer protection laws are enforced to protect consumers from predatory
suppliers. American consumers have been left to fend for ourselves. We must not trust our doctors
to provide sound health care. Instead, we are forced to do our own research and draw our own conclusions
from credible, independent sources, to the extent they still exist.
Invasive treatments require careful scrutiny of the risk/benefit ratio and an individual approach.
While the risks are fairly easy to quantify, this article just begins to skim the surface of an
incredibly complex research problem: how to evaluate the benefit and effectiveness of a surgical
intervention such as knee surgery? what do you compare it to? medicine? physical therapy? a sham
procedure? all of the above? How do you measure quality of life? functional outcome? While the
author hits upon some real issues in health care, I would issue this statement of caution: Medical
research is full of bias that is usually invisible to the lay audience.
The conclusions of such
research can be overblown by the media looking for sensational content. DO NOT look to news articles
for medical advice! And lastly, know that medical doctors are often biased too much against surgery,
while surgeons are often biased too much in favor of surgery.
As a physician, and this is me speaking for myself, I feel that unnecessary surgeries, procedures,
and diagnostic tests are a byproduct of a culture where people would prefer a pill or surgery
to behavioral change and where doctors are compensated well to provide this (called the "perverse
incentive." )
Patients demand surgery, demand an MRI and feel upset if physical therapy doesn't
fix their problem instantly. Ironically, I am a physician who eschews any diagnostic or procedure
that I don't deem necessary, but some patients will complain if they don't get their quick fix
and will deem you a bad physician. If orthopedic surgeons perform fewer of arthroscopies they
will see their salaries slashed.
The US has one of the least cost effective medical systems in
the world, and despite all of the money spent, we still have some of the worst preventative care
and highest infant mortality rates in the developed world. I used to work in private practice
and now work at an HMO because I was tired of being asked to recommend more studies or surgeries
to make more money. Our healthcare needs and overhaul, but the American people also need to shift
their beliefs about what is good healthcare. More is not always better.
One of my former surgical professors, the head of the department of surgery in a major New
York teaching hospital once told me "Asking a surgeon if you need an operation is like asking
a barber if you need a haircut." Obviously it is more complicated than that and I am not suggesting
that surgeons do not carefully consider the needs of the patients. It is true that when your background
and training is in surgery, or any particular discipline, that becomes the lens through which
you view the world.
That's what Dr. Dean Kereiakis told Angioplasty.Org when characterizing the results of the
long-awaited Dual Antiplatelet Therapy (DAPT) study, which were presented today at the annual
American Heart Association Scientific Sessions in Chicago.
Dr. Kereiakes is the co-principal investigator
for this five year study of 10,000 patients, which adds to the knowledge base of whether long-term
treatment with aspirin and a thienopyridine, such as Plavix, after stent implantation is
beneficial to patients.
Reviewed by a board-certified
physician. Updated We have all heard the claims that cardiologists are inserting too many
stents
in patients with
coronary artery disease (CAD) . And the fact is that this happens much more often than we would
like to think.
So what should you do if your doctor says you need a stent? Are you one of those people who actually
do need a stent - or should your doctor be talking to you about medical therapy instead?
If your doctor tells you that you need a stent, it is likely he or she will attempt to explain
why. But the issue can be quite complicated, and your doctor may not be entirely clear in his/her
explanation. And you may be too stunned by the news that you need a stent to concentrate completely
on what you are being told.
Fortunately, if your doctor says you need a stent, there are three simple questions you can ask
which will tell you what you really need to know. If you ask these three questions, you stand a much
better chance of getting a stent only if you really need one.
Question One: Am I Having A Heart Attack?
If you are in the early stages of an acute heart attack, the immediate insertion of a stent can
stop the damage to your heart muscle, and can help reduce your chances of suffering cardiac disability
or death. If the answer to this question is "yes," then a stent is a very good idea.
Unstable angina
, like an actual heart attack, is a form of
acute coronary
syndrome (ACS) - and therefore it should be considered a medical emergency. The early insertion
of a stent can stabilize the ruptured
plaque that
is producing the emergency, and can improve your outcome.
If the answer to this question is "yes," placing a stent is most likely the right thing to do.
No need to go on to Question Three.
Question Three: Isn't There Medical Therapy I Can Try First?
If you get to Question Three, it means that you are not having an acute heart attack or unstable
angina. In other words, it means you have stable CAD. So, at the very least, placing a stent is not
something that needs to be done right away. You have time to think about it, and to consider your
options.
It is the patients with stable CAD who, according to the best clinical evidence available, are
receiving far too many stents. In stable CAD, stents turn out to be very good at relieving
angina ,
but they do not prevent heart attacks or reduce the risk of cardiac death. So, the only really good
reason to insert stents in people with stable CAD is to relieve persistent angina when aggressive
treatment with medication fails to do so.
The Best Approach For Stable CAD
The best treatment for people with stable CAD is to take every step that is available to stabilize
plaques in the coronary arteries -- that is, to keep the plaques from rupturing.
(It is the rupture of a plaque that produces ACS in the first place).
If your angina persists despite this kind of aggressive medical therapy, then by all means a stent
is something that should be strongly considered. But keep in mind that a stent only treats one particular
plaque, and that most people with CAD have several plaques. Furthermore, while most of these plaques
are considered "insignificant" by traditional measures (since they are not producing much blockage
in the artery), it now appears that the majority of cases of ACS occur when one of these "insignificant"
plaques suddenly ruptures.
What this means is that, whether or not you end up getting a stent for your stable CAD, you still
will need aggressive medical therapy to prevent the rupture of one of those "other" plaques, the
"insignificant" ones, the ones for which too many cardiologists may express little or no interest.
Summary
If you are told you need a stent, you can quickly determine how badly you need one, if at all,
by asking three simple questions. These questions are so easy for your doctor to answer - generally
with a simple yes or no - that there will be no excuse for his/her failing to take them up with you.
But if it turns out that you have stable CAD, and therefore a stent is at least not an emergency,
you are owed a full discussion about all your treatment options before you are pressured
into a stent.
"... The Finance Committee reportedly found that Abbott Laboratories, which manufactures stents, had long been in the practice of rewarding Dr Midei financially for being a high-volume user of its stents. ..."
"... "Stenting in stable angina is open to debate in some circumstances as to whether it reduces mortality but every study done shows it is effective in relieving symptoms," he said. ..."
"... New England Journal of Medicine ..."
"... Journal of the American College of Cardiology ..."
"... There is also another interesting dynamic operating here. In the days when the cardiologists did "medical therapy" and the Cardiothoracic surgeons did bypass procedures, the cardiologists were the gatekeepers to the surgical therapy, referring on those who had failed medical therapy. The dynamics have now changed with interventional cardiology – there is no gatekeeper to interventional therapy – cardiologists self-refer for intervention – procedures from which they derive considerable profit. It would be difficult to argue that this has had no influence on the stent rate. ..."
"... As an interventionist, I unfortunately know of at least one cardiologist who stents clearly non-significant disease a la Dr Midei. He doesn't "believe" in FFR or MIBI scans! It is very hard to prove though. ..."
UP TO one-third of coronary stents inserted in patients with stable coronary artery disease
(CAD) in Australia each year ― about 3500 stents - may be unnecessary, potentially harmful and
costing the nation millions of dollars, according to a leading cardiologist.
Professor Richard Harper, emeritus director of cardiology at MonashHeart, Monash Medical Centre
in Melbourne, said any experienced interventional cardiologist would admit that many coronary
lesions with 50‒70% stenosis were being stented in Australia without certain knowledge that the
particular lesion was causing ischaemia.
Medicare statistics show that, last year, there were 22 383 operations for insertion of a stent
or stents in Australia (20 780 in 2008 and 21 204 in 2007), for which Medicare paid $6.78 million
($6.24 million in 2008 and $6.2 million in 2007).
These payments do not include the cost of a coronary angiography, radiological services and
preparation, or aftercare.
The average cost of coronary angiography with stent insertion, including hospital stay, is
$18 300 of which Medicare pays $1647.
Professor Harper said about 50% or more of stents were inserted in stable CAD patients and
the remainder were in patients with acute heart attack, for which stenting was almost always warranted.
A rapid online publication of a detailed paper written by Professor Harper on the use of stents
in CAD patients has been published by the MJA
.
He was commenting after the issue of unnecessary stenting hit the headlines in the United States,
with the revelation that Baltimore cardiologist Dr Mark Midei may have implanted 585 stents that
were medically unnecessary from 2007 to 2009.
An article in theheart.org , the website for cardiovascular health professionals,
said a US Senate Finance Committee report called the Midei imbroglio "a clear example of potential
fraud, waste, and abuse".
(1)
The Finance Committee reportedly found that Abbott Laboratories, which manufactures stents,
had long been in the practice of rewarding Dr Midei financially for being a high-volume user of
its stents.
However, many US cardiologists believe Dr Midei is being treated unfairly.
The Cardiac Society of Australia and New Zealand (CSANZ)'s Interventional Council chair, Associate
Professor Andrew MacIsaac, said any fraud or criminal behaviour by a cardiologist, as was being
alleged in the US, was appalling and would be totally unacceptable.
However, he had never heard of it occurring in Australia and it was different from doctors
having a diversity of opinion over the appropriate indications for coronary stenting.
"Stenting in stable angina is open to debate in some circumstances as to whether it reduces
mortality but every study done shows it is effective in relieving symptoms," he said.
Professor Harper said the problem with what he considers to be unnecessary stents in Australia
"lies in our system of reimbursement for coronary procedures".
He said patients often had more than one coronary lesion and the only sure way to tell which
one was the cause of the myocardial ischaemia was by measuring fractional flow reserve (FFR) -
or the effect of the narrowing on blood flow - during coronary angiography.
However, FFR was not commonly undertaken in Australia because the flow wire was costly and
not adequately reimbursed in either the public or private system.
The procedure was also fiddly, took time and resulted in fewer stent insertions - a procedure
which attracted a much higher fee.
"Faced with a 50-70% coronary stenosis, it is easier and more remunerative for an interventional
cardiologist to stent the lesion rather than measure FFR - particularly when there is a two-thirds
likelihood that the result will show no need for the stent," Professor Harper said.
Medicare statistics show that, last year, only 385 procedures for FFR were carried out in Australia
(234 in 2008 and 131 in 2007).
Professor Harper said the health system should be restructured to make it more financially
viable to measure FFR.
He said a pivotal randomised study in the New England Journal of Medicine last year,
of 1000 patients with multi-vessel coronary artery disease, showed that routine measurement of
FFR in patients undergoing percutaneous coronary intervention with drug-eluting stents significantly
reduced the rate of death, non-fatal myocardial infarction and repeat revascularisation compared
with patients who had stents inserted on the basis of angiography alone.
(2)
The patients who underwent FFR had fewer stents implanted at a lower cost.
The results were replicated in a follow-up study at two years, which was reported in the
Journal of the American College of Cardiology .
(3)
Professor MacIsaac said CSANZ had been lobbying for more than 10 years for the establishment
of a national registry of coronary interventions to audit outcomes and quality assurance.
However, it was still waiting for federal and state funding.
"A database has essentially been prepared but there is no funding mechanism to implement the
collection or analysis of the data," he said.
"If we really want to be assured that everything is fine, that would be the way to go."
A Medicare spokeswoman said the unnecessary insertion of cardiac stents had not been identified
as a specific compliance issue.
"However, health professionals should be aware that when Medicare Australia has a concern that
items are being claimed without meeting the item requirements, an audit may be conducted," she
said.
Medicare Australia treated all allegations of non-compliance seriously and encouraged anyone
who suspected potential fraud or non-compliance under the Medicare program to call the Australian
Government Services Fraud Tip-off Line on 131 524.
There is also another interesting dynamic operating here. In the days when the cardiologists
did "medical therapy" and the Cardiothoracic surgeons did bypass procedures, the cardiologists
were the gatekeepers to the surgical therapy, referring on those who had failed medical therapy.
The dynamics have now changed with interventional cardiology – there is no gatekeeper to interventional
therapy – cardiologists self-refer for intervention – procedures from which they derive considerable
profit. It would be difficult to argue that this has had no influence on the stent rate.
Very interesting and informative article with some good comments – need more like this.
– Highlights a long-standing major problem with Medicare failing to keep up with technology,
but would interventionalists change their habits if Medicare changed? In the public sector
the Medicare rebate usually doesn't matter; in private they'll charge (and should charge)
what they feel is the appropriate fee. What is needed is proper peer review and clinical
governance in both sectors.
– Probably highlights the need for better funding of cognitive work compared to intervention.
– As far as MIBI scans go, not all labs are equal. If I can, I get mine done in hospital
labs with regular through-put where they regularly correlate results with angiography.
– Predictable response from the Medicare bureaucrat, but not understanding the issue
at all (nothing to do with fraud, and everything to do with delivering a better outcome
more cheaply).
Myocardial perfusion studies are well reimbursed and are an arm's length procedure. It is
also rumoured that stress echo, not an arm's length procedure, works.
As an interventionist, I unfortunately know of at least one cardiologist who stents
clearly non-significant disease a la Dr Midei. He doesn't "believe" in FFR or MIBI scans! It
is very hard to prove though.
The article makes some very important and quite radical points about diagnosis and assessment
of chest pain and atherosclerosis.
But they then assert that in patients with ischaemia, revascularisation improves outcomes,
and that patients with significant ischaemia should have invasive angiography.
This is unproven. All the randomised trials of stable angina show that revascularisation
may reduce short term angina but does not reduce mortality or myocardial infarction rates.
If they want to reduce the cost and wastage in modern cardiology just restrict PCI to those
patients in whom angina is limiting or in whom an adequate trial of medical therapy has failed
to control symptoms.
This will reduce the numbers of interventions by far more than 30%.
If and when FFR measurements are shown to reduce mortality or AMI then the conclusions of this
article will be evidence based. At the moment they are not.
Whilst many procedures are beneficial to patients, vast numbers of procedures are performed
on patients in whom no proven long-term benefit has been demonstrated.
Has there been a greater racket in the history of medicine?
The MJA article also states that stenting non-ischaemic lesions (ie with normal FFR) worsens
the prognosis. This is of concern.
The article also suggests abolishing the item number for MIBIs and using CT coronary angios
to diagnose CAD – not sure that this is a viable option for patients with significant renal
failure or even in areas where CT coronary angio is relatively new; seems like an exclusively
teaching hospital perspective.
And this overuse does not cover the large number of patients having multiple stents and
ending up with a definitive operation some time and multiple infarcts later
John.
This is happening in australia now. Have 3 drug eluting stents fitted with no tests prior,same
niggles of exertional pain continued at start of exersise then dissapeared for duration of
1.5 hours bike ride after stents.niggles of chest pain lasted approx 4 months after stenting.
Never breathless/overweight/or smoked,very athletic. Father 100 years old no cardiac history.
Have had conformation of my angiogram confirmed that there were no restrictions by leading
USA medical institution, that needed intervention. Qld cardiologist also falsified his files,
where do I go now?.
Hundreds of thousands of Americans may undergo unnecessary
angioplasty
and stent procedures to open clogged
heart arteries each year,
a landmark study suggests.
Of the more than 1.2 million angioplasty procedures performed each year, at least 50% of them
are done on an elective basis in people with stable coronary artery disease, says Stephen Nissen,
MD, president of the American College of Cardiology (ACC) and head of cardiovascular medicine at
The Cleveland Clinic.
In people with coronary artery disease, plaque builds up in the arteries, making it harder for
blood to get through,
thereby depriving the heart muscle of oxygen. This can lead to chronic
chest pain that worsens during
exercise and to
heart
attacks .
During angioplasty, a balloon at the end of a long tube is threaded through an artery in the groin.
The doctor shimmies the probe up through the patient's leg and into the arteries of the heart, inflating
the tiny balloon at the spot where the vessel has narrowed.
To keep the vessel open, doctors usually add a stent to the end of the balloon catheter. These
metal, mesh-like tubes prop open
clogged
arteries to restore
blood flow.
Angioplasty Still Best for Some
The study's results do not apply to people who get stents because they are in the midst of a
heart attack
or whose chest pain suddenly gets worse, doctors stress. For them, angioplasty is a proven lifesaver.
Additionally, angioplasty is better at relieving the chest pain associated with
angina , says
researcher William Boden, MD, of Buffalo General Hospital/Kaleida Health in Buffalo, N.Y.
"For an individual patient, angioplasty may still be the best option," he tells WebMD. "But there
has been an implication that if you give patients drug therapy rather than angioplasty, you're giving
them less than optimal treatment.
"Now we know that if you opt for medicine, you are not putting patients at risk," Boden says.
The study, known as COURAGE, was released at the annual meeting of the American College of Cardiology
and simultaneously published online by The New England Journal of Medicine .
Stent Patients as Likely to Die, Have Heart Attack
The researchers studied 2,287 people with stable coronary artery disease who experienced chest
pain for about two years, with an average of 10 episodes per week. All had at least a 70% blockage
in one or more heart arteries.
Then, about half the participants also underwent angioplasty, usually with stents.
Over the next five years, 19% of those in both groups died or had a heart attack. Similar numbers
of people in both groups -- about 12% -- were hospitalized for heart problems.
However, there were some benefits to angioplasty. People who had the procedure were 40% less likely
to need another procedure to open up blocked heart arteries. And, particularly in the first two years,
they reported better quality of life and less frequent episodes of chest pain.
But over time, some of the differences started to dissipate. By five years later, 74% of people
who had angioplasty were angina-free vs. 72% of those who got drugs alone, a difference so small
it could be due to chance.
Results Stun Medical Community
Boden notes that COURAGE is "the first properly-sized study to answer the question of whether
angioplasty and stents reduce the risk of death and heart attacks in people with stable coronary
artery disease."
The results came as a shock to many in the cardiology community -- even to the researchers themselves.
"The study was designed with the hypothesis that the combination of angioplasty and optimal medical
therapy would be superior," Boden says. "But the results do not support its benefit in reducing heart
attacks and death when used as an initial management strategy."
So why would so many doctors recommend a costly procedure without strong evidence it works?
The average cost of having an angioplasty was $38,000 in 2003, according to the American Heart
Association.
Nissen thinks it's because "it seems so intuitively obvious: If you open up a block artery, you'll
fix the problem."
American Heart Association President Raymond J. Gibbons, MD, chief of cardiology at the Mayo Clinic,
adds that there's a financial incentive for doctors. "People get paid for how many procedures they
do," he tells WebMD.
But this study "clearly shows there is no advantage to PCI [percutaneous coronary intervention,
or angioplasty] as an initial strategy. It's unnecessary," Gibbons says. "Angioplasty should be reserved
for patients [who can't be helped] by medical therapy."
Adds Nissen, "This study will change a lot of thinking. The benefits of angioplasty in people
with stable chest pain is very modest, at most. It should be reserved for patients for intolerable
symptoms."
Results Questioned
But many doctors who perform angioplasties say the procedure's proven benefits in relieving angina,
or chest pain, is getting lost in the shuffle.
Donald Baim, MD, chief medical officer of Boston Scientific, a manufacturer of drug-eluting stents,
says, "COURAGE is not a catastrophic failure. [It shows that angioplasty plus stents] improves symptoms."
Marty Leon, MD, of Columbia University Medical Center, says, "There are so many deep flaws in
the way this study was executed and planned. It was rigged to fail," and it did. "This study should
not affect treatment patterns."
Boden says the criticism is unfounded, pointing out that the researchers purposely studied people
at medium to high risk of having a heart attack or dying -- "the very people you would expect to
benefit most from the procedure."
"... Last year, the DOJ joined two whistleblower lawsuits against Asad Qamar, who owned the Institute of Cardiovascular Excellence in Ocala, Florida. The lawsuits alleged that he regularly billed for unnecessary procedures and violated the Anti-Kickback Statute by waiving Medicare copayments. ..."
"... Months later, the Centers for Medicare & Medicaid Services banned Qamar from the Medicare program ..."
"... Qamar was Medicare's second-highest paid physician in 2012, earning $18.3 million. In 2013, he made $16 million, more than seven times the amount received by the next highest earning Florida cardiologist, according to data collected by ProPublica. ..."
"... Unnecessary cardiology procedures have been a focal point for government investigators over the last year, and some have questioned whether Medicare's fee-for-service model incentivizes unnecessary surgeries. ..."
, Washington, DC - One of the country's highest paid physicians agreed to a three-year exclusion
to settle claims that he billed Medicare for medically unnecessary cardiac procedures, according
to the Department of Justice.
Last year, the DOJ joined two whistleblower lawsuits against Asad Qamar, who owned the Institute
of Cardiovascular Excellence in Ocala, Florida. The lawsuits alleged that he regularly billed for
unnecessary procedures and violated the Anti-Kickback Statute by waiving Medicare copayments.
Months later, the Centers for Medicare & Medicaid Services banned Qamar from the Medicare
program , prompting support from a Super PAC of former patients who were "disgusted and distressed"
by the government's portrayal of Qamar.
In addition to a three-year exclusion from Medicare, Qamar will pay $2 million and forgo an additional
$5.3 million in suspended claims.
Qamar was Medicare's second-highest paid physician in 2012, earning $18.3 million. In 2013,
he made $16 million, more than seven times the amount received by the next highest earning Florida
cardiologist, according to data collected by ProPublica.
Unnecessary cardiology procedures have been a focal point for government investigators over
the last year, and some have questioned whether Medicare's fee-for-service model incentivizes unnecessary
surgeries.
Posted on
December 8, 2010 by
Maggie Mahar Over
the weekend, the New York Times published a head-turning tale about Dr. Mark Midei, a star cardiologist
at St. Joseph Medical Center in Townson, Maryland. According to federal investigators, Dr. Midei
implanted potentially dangerous cardiac stents in the arteries of as many as 585 patients who didn't
need them. A hard worker, he managed to knock off those 585 procedures in just two years, from 2007
to 2009. Medicare paid $3.8 million of the $6.6 million charged for the treatments.
The report reveals that Midei was a favorite son of Abbott Laboratories, the company that manufactured
the stents. Indeed, in August of 2008, Abbott celebrated the fact that the handy doctor had inserted
30 of the company's cardiac stents into trusting patients in a single day: "Two days later, an Abbott
sales representative spent $2,159 to buy a whole, slow-smoked pig, peach cobbler and other fixings
for a barbecue dinner at Dr. Midei's home." Employees from St. Joseph's attended the feast.
Although St. Joseph's has not admitted to any wrongdoing, last month it agreed to pay a $22 million
fine to settle charges that it paid illegal kickbacks to Dr. Midei's medical practice in exchange
for patient referrals. In other words, it seems that the hospital encouraged the doctor to implant
those tiny mesh tubes in his patients' arteries. Certainly, hospital executive knew that they were
making handsome profits on Midei's stent procedures. This is why they paid him those "bonuses" to
shepherd unwitting patients to their cath-lab where doctors can diagnose heart attacks, and quickly
open arteries. Midei was a rainmaker.
Clinical guidelines generally suggest that an artery be at least 70 percent blocked before a stent
is used to open it up, and St. Joseph's rules consider anything less than 50 percent blockage to
be "insignificant." But court documents allege that some of Midei's patients were told they had blockages
in the 90 percent range, while a subsequent review of their records shows blockages closer to 10
percent or less.
Medical Journals Have Been Telling Us This for Years
But what I find most disturbing is that the story about Dr. Midei is not new; nor is it
"news." As Dr. Nortin Hadler , author of Worried Sick , argues in his guest-post
below, medical research suggests that stents have been overused, nationwide, for years ,
exposing patients to needless risk and exorbitant expense.
In January of 2006, an article published in the journal Circulation observed that although
there has been a dramatic increase in artery-opening procedures in order to prevent heart attacks
over the last 10 to 15 years, the rate of heart attacks stayed relatively constant. The findings
came from two studies, one done in the U.S. and one done in Canada.
At the time Dr. Thomas Graboys, a professor of medicine at Harvard Medical School, told the
Center for Medical Consumers that stents "are virtually useless, in stopping the progress of
the disease itself." "The public is looking for a magic bullet," Graboys warned. "Go to a non-hospital-based
doctor in the community. A well-trained internist can take care of the lion's share of people with
coronary heart disease. The vast majority of people do well on medication-cholesterol-lowering
drugs, antihypertensives, low-dose aspirin ."
For an expert opinion on "the best" and most persuasive of the many studies that raise serious
questions about invasive heart procedures, see Dr. Hadler's post below.
Nevertheless, as the
Center for Medical Consumers reported in 2006 : "The number of people undergoing artery-opening
procedures continues to rise not only because they are huge money-makers , but they are also very
effective at relieving the severe chest pain of angina, which is a common symptom of heart disease."
Patients like the "quick fix" of the stent treatment for angina. Medication doesn't work as rapidly.
Writing about the Midei case over at Kevin M.D,.
Bob Wachter , Professor of Medicine and Chief of the Division of Hospital Medicine at the University
of California, San Francisco, comments on the patient response: "Most of his patients were probably
quite content – many had chest pain and a stent undoubtedly seemed like an appropriately aggressive,
high-tech cure. 'He put two stents in almost immediately,' said one grateful patient. 'I felt relief.'
"Although this patient, 66-year-old Peggy Lambdin, later received a letter indicating that her
coronary artery was less than 50 percent blocked (clinically meaningless and not an indication for
stenting), she was unfazed," Wachter observes. "No one can ever tell me that I didn't need that stent,'
she told the Baltimore Sun. 'I feel like [Dr. Midei] saved my life.'
" Moreover, I'm guessing that Dr. Midei's complication rate was quite low ,"
Wacther continues, " as it usually is when one does procedures on healthy people
. He probably followed all the protocols mandated by accreditors and the relevant specialty societies.
(Oh yeah, except for the ones regarding professionalism.)
"The problem is this," he concludes, "as long as the cardiologist reading the cath is the one
who pulls the trigger on the intervention, we have a potential Fox/Henhouse problem."
"Gizmo Idolatry"
What may be most troubling about the Medei imbroglio is that it highlights how our infatuation
with high-tech medicine tempts us to ignore medical evidence. The popularity of stents is all part
of a mindset that Drs. Bruce Leff and Thomas E. Finucane have termed "
gizmo idolatry
."
Back in June of 2006, a few months before I began HealthBeat, I wrote a post about our use of
stents for The Health Care Blog. It was titled: "
Tech: Is Newer Better? It's a Coin Toss ." Below, an excerpt :
"Last week The Annals of Internal Medicine roiled the medical world by publishing a study suggesting
that the drug- coated stents produced by companies like Boston Scientific and J&J may not
be quite as miraculous as first advertised . (You will
find the abstract here
) Following a two-year study, researchers at the Cedars-Sinai Medical Center in Los Angeles are
now suggesting that the 'putative superiority' of drug-coated stents is founded on questionable premises.'
Or as The Wall Street Journal put it, the clinical trials of drug-coated stents (mostly funded
by manufacturers), may 'have exaggerated their real-life advantage.' [Dr. Midei was using a new generation
of drug-coated stents.]
"Stents, you may remember, are those tiny metal scaffolds that cardiologists use to prop arteries
open after they have been cleared of fatty deposits. Since they were approved in the early 1990s,
manufacturers have made a fortune peddling the devices which, they say, can prevent a future heart
attack while avoiding riskier and more invasive bypass surgery. Today, stents are used in
85% of all coronary interventions in the United States .
"Before turning to the new Cedars Sinai study, it should be said that THCB has long harbored
doubts as to whether these cunning devices represented the best solution for quite so many patients.
Back in 2003, THCB quoted a Stanford study which suggested that, over the long term, patients with
multi-vessel disease would achieve better outcomes, at a lower cost, if they opted for the bypass
operation. In 2005 THCB questioned the cost-effectiveness of the new, improved "drug-coated" stents
that are designed to prevent the growth of scar tissue inside the artery. . .
Yet "drug-coated stents have become wildly popular, thanks in part to what The Annals of Internal
Medicine describes as 'aggressive marketing' and the unbridled expectations of patients. Wall
Street likes them too. At $2300 a pop (vs. a mere $700 for the uncoated, bare-metal variety), the
newer stents are far more profitable. Despite the hoopla, nine months ago THCB was once again
forced to ask 'Are Stents A Waste of Money?' after reading about a study of 826 patients, published
in Lancet , which suggested that the drug-coated stents made by J&J and Boston Scientific
aren't cost-effective for all patients and should be restricted to those at highest risk for heart
attack.
"A second 2005 study, published in The New England Journal of Medicine , added to the uncertainty
about the widespread use of stents by reporting that patients suffering minor heart attacks
do equally well with drug therapy . 'In a study colliding with established practice,
recovery from small heart attacks went just as well when doctors gave cardiac drugs time
to work as when they favored quick, vessel-clearing procedures ," the NEJM reported.
"The surprising Dutch finding raises questions over how to handle the estimated 1.5 million Americans
annually who have small heart attacks – the most common kind. Most previous studies support the aggressive,
surgical approach. . . . Meanwhile, just last fall, Dr. Eric Topol, chairman of the cardiology
department at the Cleveland Clinic, warned Consumer Reports : 'Unfortunately, the extensive
use of such stents is far ahead of the data that can be cited to support them .'
"But it's not just that manufacturers over-estimated the benefits; they underestimated the new
risk that the coated stent introduces. For after reviewing outcomes research, Cedars Sinai's clinicians
found that the drug-coated stents increase the danger that a blood clot will form inside
the stent– months, or even years after the procedure. Such clots can be life-threatening
. . .
"The stent story illustrates a major problem in our money-driven health care system. When
a product is very profitable, it is promoted to the skies-and, in such cases manufacturers tend to
put the very best face on their clinical research . A startling study published last month
in the Journal of the American Medical Association comparing clinical trials funded by for-profit
entities to clinical trials funded by nonprofit entities underlines the point: it seems that that
the industry-funded trials were far more likely to report positive findings .
"Finally, most patients (and even many physicians) tend to assume that, when it comes to medical
technologies, 'newer' means 'better.' This is why, when asked to participate in a randomized clinical
trial, some patients refuse, fearing that they will 'miss out' on receiving what they assume is the
newer, better product. Yet the odds that the bleeding-edge therapy represents an improvement
over existing technology are only about 50/50. As Americans we tend to believe in what's new-as if
medical science progressed in a straight linear fashion, one breakthrough after another, from Madame
Curie to me . As a result, we pay more-and more-and more-as drug makers and device-makers
flood the market with 'new, improved' products."
In Money-Driven Medicine: The Real Reason Health Care Costs so Much , I quote Kaiser Permanente
CEO George Halverson who points out that few modern researchers are willing to risk betting their
own money on their newest products or procedures. In some cases, he reports, when health care plans
have been asked to cover a new, as yet unproven treatment, they have said: 'Try it. If it works,
we'll pick up the bill. If it fails, then it's your cost, not ours.'
" Researchers virtually never take the bet because they 'know that most research fails
,' says Halvorson. "So having their personal incomes tied to the actual success of their
unproven care isn't at all attractive. There is some irony in the fact that the same researchers
who enthusiastically extend hope to individual patients are, almost without exception, far too practical
about the actual value of their experimental care to risk their own income."
Monday, the Times ' story acknowledged that " Prosecutors, malpractice lawyers
and state medical boards are only now waking up to the issue . . .The Texas Medical Board
last month accused a widely known cardiologist in Austin of inserting unnecessary stents. In September,
federal prosecutors accused a cardiologist in Salisbury, Md., of performing unnecessary stent surgeries,
and last year a Louisiana doctor was sentenced to 10 years in prison for inserting unneeded stents.
. . "
The Times went on to quote Dr. Steven Nissen, chief of cardiovascular medicine at the Cleveland
Clinic: "What was going on in Baltimore is going on right now in every city in America." Nissen added
that he "routinely treats patients who have been given multiple unneeded stents. We're spending a
fortune as a country on procedures that people don't need."
I would love to see the Times expand on these comments by exploring the larger national problem.
Ideally, the nation's paper of record would launch an investigation by looking into the use of stents
in its own backyard-Manhattan.
Why the Delay in Acting on the Problem?
Why has it taken so long for state medical boards to "wake up?
I am afraid that many hospitals have resisted the news for one simple reason: procedures that
involve stents are extremely lucrative. In 2007
Business
Week told the story of how stents rescued New York's Mt. Sinai hospital:
"The 2,000-doctor hospital was struggling in March, 2003, when Dr. Kenneth L. Davis took over
as chief executive. During the previous six months, Sinai had lost $50 million, partly as the result
of tougher caps on Medicare reimbursement rates. . . . While trimming costs, Davis also decided to
build up practices in high-margin specialties. 'Interventional cardiology was one of myriad areas
where we were eager to facilitate growth,' Davis explains. Dr. Samin Sharma, Mt. Sinai's "King of
Stents," ran a cath lab which was central to this campaign, performing procedures that typically
brought in as much as $20,000 a piece for the hospital.
"Sharma convinced his bosses that to capitalize fully on the stent boom, Mount Sinai should turn
his cath lab into a 24/7 operation. At a cost of $400,000 a year, he figured, the hospital could
put enough doctors and nurses on call to do emergency angioplasties late at night and on weekends.
Soon the lab was averaging 15 off-hours patients a month. Interventional cardiology became
a key revenue source for Sinai. By the end of 2006 the hospital's total patient revenues had grown
41%, to $1.2 billion. Cardiology services, excluding surgeries such as heart bypass, contribute 15%
of that, most of which comes from Sharma's cath lab ."
This is one of many such stories. Two years ago, a physician at another prestigious Manhattan
hospital explained to me why his hospital didn't offer palliative care: "The COO would rather put
the money into expanding the cath lab; it's far more profitable."
Let me add that I don't think that most doctors who recommend procedures using stents are motivated
by greed. As Dr. Hadler points out in his guest post, there are many ways for physicians to rationalize
their use. Professional pride plays a role: doctors who implant stents firmly believe that they are
helping their patients.
Since 2007 Study, Use of Stents Has Dropped, but Many Remain Undaunted
Not everyone has ignored the research. The
Baltimore Sun notes that "after a landmark 2007 study in the New England Journal of
Medicine concluded that stents were often not beneficial," enthusiasm waned. "In 2009,
Medicare paid 'just' $3.5 billion for stent procedures nationwide, down from about $5 billion
a year before the 2007 study " was released.
According to the Sun : "The 2007 study didn't find that stents are worthless, just that
not implanting a stent can often be as good - and avoids the real risks of complications or even
death from the procedure. But hospitals can't bill $12,000 for deciding not to implant a
stent, even if that's the best thing for the patient ."
Some physicians remain clearly undeterred by the research.
For example,
the Sun reports , "Dr. Midei's [use of stents] increased, by his own estimate, 50 percent,
to about 1,200 a year."
As for Mt. Sinai's Stent star, Cardio Brief , a blog for cardiologists and other cardiovascular
health care professionals, heard from Dr. Sharma just last year, shortly after
the Brief reported that Columbia University cardiologist Jeffrey Moses had earned $2.5
million in 2006-7, vaulting him to 8th place in the Chronicle of Higher Education 's Hit Parade
of individuals receiving the "highest total compensation at private colleges, 2006- 2007." Apparently
Dr. Sharma was miffed . He got in touch with the blog to point out that "
he performs 1,500 complex coronary interventions each year, which apparently is an American
record ," Cardio Brief noted. "Sharma also wanted to let us know that the Chronicle
's list failed to include Sharma's own salary of $2.75 million which would have put him ahead
of Moses."
Health Care Reform Legislation Points to Solutions
Bob Wachter recalls that when the Midei scandal broke, a reporter asked him "Why didn't peer
review catch this?"
Peer review is improving Wachter says, but cases like Dr. Midei's don't trip any alarms. Patient
who think he saved their lives don't complain. Still, there are ways stop them.
"Obviously, the Mideis of the world could be caught by requiring that every cath undergo an independent
second reading," Wacther adds. His point is that the physician who diagnoses the need for stents
shouldn't be the one who also performs the procedure. "Some insurers in New Jersey now require such
readings before they authorize a stent, and at least one SoCal Kaiser hospital mandates that each
cath be presented at a conference before a treatment decision is rendered, analogous to what many
tumor boards do for cancers."
No doubt many of the New Jersey insurers' customers-and some physicians-object to the requirement.
But this is an example of how insurers can add value to health care, not by trying to make treatment
decisions themselves, but by calling for more collaboration. If a second doctor must sign off on
the reading, this could stop a serial stenter in his tracks. It's one thing to close your eyes when
a colleague is wheeling one patient after another into the cath lab, quite another to associate your
name with his activity.
Under health care reform, doctors are more likely to be looking over each others' shoulders. There
will be incentives to join Accountable Care Organizations where doctors or doctors and hospitals
work together, and all share in the financial rewards if they are able to avoid waste. Under the
Affordable Care Act (ACA) bonuses will encourage doctors to move away from fee-for-service, and toward
working on salary (as doctors already do at multi-specialty clinics such as Kaiser or the Mayo Clinic)
or accepting "capitated" payments.
In Massachusetts, Blue Cross/Blue Shield, which owns about 45 percent of the private insurance
market in the state, already has moved to a combination of capitation and bonuses for higher quality
care. BCBS pays contracting groups of doctors to provide all care, including inpatient services,
for its members. The payments are risk-adjusted for age, gender, and health status. Any savings the
physicians achieve remain with their group, unless they share the risk with a hospital; in the latter
case, part of the savings flow back to the hospital.
Physicians and hospitals also can
receive
bonuses of as much as 10 percent by doing well on nationally recognized process and outcomes
measures. The Massachusetts Blues program is the first major global capitation effort on the East
Coast in a decade. Capitation has remained more common the West, where HMO penetration remains greater.
The Centers for Medicare and Medicaid is determined to move away from "fee- for service" payment
because we know that inevitably, it leads to more procedures, yet earlier this year,
the Commonwealth Fund reported that "physicians and industry leaders [feel] that cost reductions
of 20 percent to 30 percent are achievable under well-constructed global payment models" which pay
doctors a lump sum to keep patients well. Meanwhile "patient care suffers in the fee-for-service
environment." Medicare will not force physicians to give up fee-for-service, but those who cling
to being paid "piece work" are less likely to be eligible for the bonuses that reward collaboration
and better outcomes.
Under the Affordable Care Act doctors who create a "medical home" also will be rewarded if they
are able to keep their patients healthy and out of the hospital, while avoiding invasive treatments.
For heart patients, medication, and diets like Bill Clinton's "plant diet" are likely to be favored.
In addition, the Medicare Payment Advisory Commission (MedPAC) has suggested that when Medicare
spots high volume combined with high profits margins, this is a place to look for overtreatment.
The Accountable Care Act allows the Secretary of HHS to lower fees for "overvalued medical services."
One would expect that she will take MedPAC's advice and that especially in light of the Senate Finance
Committee report, as well as legal action in a number of states, procedures involving stents would
come under scrutiny.
Finally, as
I reported earlier this year , a more proactive Food & Drug Administration has announced that
it plans to begin requiring drug makers and device makers to disclose details about their clinical
trials-providing detail on their failures as well as their successes. Greater transparency will make
it much harder for those who manufacture stents to paint a rosy picture of risks versus benefits-the
FDA aims to make sure that these companies are not hiding information about risks.
Reform Will Mean More Team Work
Wachter goes on to suggest that team work can also reduce medical errors-including overtreatment.
Many at the hospital must have known what Midei was doing, he suggests, but looked the other way.
" Cardiologists don't perform caths on desert islands – they are assisted by cath techs and
nurses . In my experience, these folks become as adept at reading cath films as any physician.
If the allegations against Midei are true, it strains credibility to think that no one in the lab
knew that inconsequential lesions were being read as tight stenoses and treated with stents.
" And what about hospital administrators ?" he asks. "While it is possible that
no St. Joe's leader knew precisely what was happening, I'm guessing that some did but chose to look
the other way: the pressure to steer clear of the golden-egg-laying goose must have been intense.
Perhaps the fact that the hospital's CEO and two other senior executives resigned after the case
broke provides a clue as to who knew what when.
"Cases like this one are terribly troubling," he continues, "not just because they harm individual
patients but because they do violence to the trust that is so fundamental to the physician-patient
relationship.
" But these cases also force us to consider the kind of culture that could allow such
a fraud to take root and go on for years – a culture that likely prized the hospitals' and
physicians' financial health over the clinical health of their patients. If the allegations are true,
the penalties should be severe, not only for Dr. Midei but also for leaders who knew – or
should have known – what was going on, yet remained silent ."
Under reform, "accountability" is likely to extend beyond the individual patient-doctor relationship.
Physicians and hospitals that work together-and are paid as a team-will become accountable for each
other.
Yes, but physicians rarely go to jail for malpractice.
Even in Redding, California, where a doctor performed hundreds of unnecessary bypasses and angioplasties,
he did not go to prison.
Part of the problem is that in these cases, the doctor may well have thought that he was helping
the patients.
The physician himself becomes part of a mass cultural delusion about the efficacy of certain procedures.
People are thanking and congratulating him– patients, their relatives, the hospital, etc.
He may well believe he is saving lives.
Though of course there are extreme cases where a doctor is consciously over-treating, but I suspect
those are very rare.
Reply ↓
whilst I'm enthusiastic about CMS moving toward capitation, I'm not holding my breath. In the
meantime, simply releasing payment information would help the press and public target such excess,
as the WSJ piece on prostate care indicates.
Reply ↓
NG –
Just to clarify –
As long as a doctor has obtained a signed consent, they are pretty much immune from assault charges,
unless of course they engage in sexual or other illegal activity with a patient. As Maggie says,
doctors who engage in inappropriate care are guilty of malpractice, a violation of contract (civil)
law, not criminal law.
If it can be demonstrated that a doctor was willfully negligent or engaged in fraudulent behavior,
many, perhaps most, malpractice policies have clauses that obsolve the insurance company of responsibility,
potentially leaving the doctor responsible for the entire cost of settlement or judgements themselves.
In practice, this is rarely invoked except in cases involving falsifying records after the fact,
perjury, and other similar things, but in theory it could be in some cases. Court findings of
fraud or willful negligence also expose the doctor to potential punitive financial damages, in
addition to the usual compensatory damages. Malpractice insurance generally does not cover punitive
damages.
In addition, of course, doctors are subject to investigation and censure by their hospitals, potentially
leading to loss of privileges (the right to work in the hospital) or other lesser sanctions, and
by state medical boards, potentially leading to loss of license or other lesser sanctions.
Finally, if there is a finding that a doctor willfully or fraudulantly billed for false charges
to Medicare, Medicaid, or private insurance, the doctor would be liable for a judgement of insurance
or Medicare fraud. That can result in criminal charges and in permanent or temporary loss of the
right to bill Medicare for services.
Reply ↓
VA–
You are correct-you if you make physical contact with your victim, that's battery.
But doctors can go to jail for malpractice–typically if they are found guilty of fraud and malpractice.
A doctor who knowingly performs unnecessary surgery– or hospializes patients who don't need to
be hospitalized– is bilking the insurer while harming the patient, and can go to jail.
Intent is very important.
Of course very, very, very few doctors ever intend to harm a patient. But some do set out to over-charge
insurers, Medicare or Medicaid, and sometimes the patient suffers the "collateral damage."
I'm not an attorney, so I don't know whether a prosectuor has
to prove intent, or whether there are cases where criminal negligence could put a doctor in jail.
Ordinarily, though doctors are not imprisoned for malprctice because society acknowledges that
we all are human and even the very best doctors make mistakes.
Reply ↓
Maggie,
I have a different take on this.
First, my own experience goes like this. I had quintuple bypass surgery in 1999. I was told that
I probably had a small heart attack sometime in the past and never realized it as there was some
minor heart damage. I was put on maximum medical therapy after the surgery and have been on it
ever since. I take a beta blocker, an ACE inhibitor, a statin, an anti-spasmodic drug and a blood
thinner plus baby aspirin. After six years, an angiogram following new complaints of chest pain
found one artery that was 85% blocked and a stent was inserted on the spot which took only an
incremental 15 minutes or so beyond the time for the angiogram by itself. While I occasionally
have some chest pain from time to time, it's minor and the medical regimen continues and will
continue indefinitely.
I was glad to get the stent at the time of the angiogram rather than have to come back for a separate
procedure. If a second doctor had to sign off to confirm the need for one or more stents, it would
delay treatment and add to the patient's anxiety. If the first and second doctor each worked for
the hospital with their compensation tied, at least in part, to the hospital's revenue and profit,
I'm skeptical how many times the first interventional cardiologist would be overruled.
Instead, when payers, including commercial payers as well as Medicare and Medicaid notice that
a particular doctor and/or hospital is performing an unusually large number of procedures of any
type, timely unannounced post-procedure audits should be performed by experts hired and paid for
by the payers. If clearly unnecessary procedures are being done, especially when claiming that
a blockage is much greater than the film shows it to be, the consequences for the doctor should
be swift and severe including prosecution for fraud and, possibly, loss of his medical license.
If hospital compliance departments want to perform their own audits as well, more power to them.
With regard to the studies that claim to show that there is no benefit from stents regarding either
life expectancy or preventing future heart attacks or strokes, they don't speak to the quality
of life implications of reduced chest discomfort. Chest discomfort, especially if it occurs at
rest and not during or shortly after eating is not only stressful, it can be perceived as life
threatening. By contrast, pain from, say, arthritis, is both annoying and can negatively affect
quality of life, but it's not life threatening. That's a huge difference to those of us who live
with heart disease.
Finally, the new reform driven approach to pay hospitals modest bonuses if they meet certain quality
standards is not likely to be as effective as you think or imply. Hospitals that don't do procedures
don't get paid. For capitation or bundled payments to work, they would need probably to be assured
of total revenue equal or at least close to what they are generating today. For most hospitals,
60% of their costs are fixed and 40% are variable. It's not that easy for them to reduce costs
in the short term.
As an aside, I recently met with the CEO, who is also a physician (OBGYN), of a large hospital
system in the NYC metropolitan area and the CFO of a well known hospital system in Pennsylvania.
Both said that they could not make money if they had to take Medicare rates from all comers even
if there were no uncompensated care.
Reply ↓
Barry –
Your story is a good example of why anecdotal results don't mean much.
It is true that people with angina often get faster relief from stents than medical treatment,
but it is also true that medical treatment is usually successful at providing relief from angina
after a short interval, an interval that can usually be bridged successfully with use of morphine
and nitrates. On the other side of the coin, stent patients have much higher incidence of problems
related to stent failure, re-stenosis, and delayed stent complications, plus face the risk of
acute complications, including death, during the procedure.
In fact, in most stent patients the stent most likely is responsible for the pain effects for
only a fairly short time, at which point the maximal medical therapy they are almost always on
as well takes over and carries most if not all of the weight.
Studies still do suggest that stenting is the preferred treatment in either acute heart attacks
or in unstable angina, but the studies are very convincing, as shown elsewhere on this and the
related thread, in showing that there is no real advantage and most likely a slight disadvantage
to managing both standard angina and non-symptomatic coronary artery disease with stents instead
of medical therapy alone.
Reply ↓
Barry–
]
The research shows that
stent procedures offer relief from the pain of angina for a while–but not forever.
It's fast, but a band-aid fix.
Drugs and a change of diet
can help the patient for a much longer period of time.
And as Pat S. points out in his comment, pain-relieving drugs can help patients until the other
medications kick in.
As for whether hospitals can make money on Medicare-or lowered Medicare payments– sse the Medicare
Payment Advisory Commission report which I have referenced in the past showing that
most hospitals do turn a profit on most Meidcare patients.
As for hospital CEOs at overpaid hospitals in NYC and PIttsburgh who tell you they couldn't surive
on Medicare paymtents? (I'm pretty sure I know the hospitals you are referring to) What did you
think these CEO's would say?
As for Medicare paying hospitals less: this will begin quite soon. Medicare will be penalizing
hospitalis with excessive readmissions, and, each year, they will be cutting annual increases
to all hospitals by 1%.
Medicare wants to put hospitals under some fianncial pressure because MedPAC reserach shows
that when hospitals are under financial pressure, they learn to become more efficient–and, in
fact, beginning making a profit on those Medicare reimbursements.
As Pat S. points out, in his comment, anecdotes (or stories you hear from people with an ane
to grind) are one thing; MedPAC's well-documented analysis is another.
These CEOs are making 7-figure salaries as a reward for running a hospital as a revenue center
(as opposed to a patient-care center).Of course they will say that the government isn't paying
hospitals enough.
Pat S.
Yes–tand hank you.
But in your last paragraph I think you mean "but the studies are NOT very effective" ???
If so, let me know, and I can go in and make the fix.
Reply ↓
Pat –
Do you have any data on the percentage of stent placements that go into patients who are either
asymptomatic or have stable angina? I don't understand why and under what circumstances asymptomatic
patients would ever be sent to the cath lab in the first place. Conversely, I also wonder how
many patients who receive stents would have been better off for the longer term with a CABG.
Maggie –
The PA hospital system is based in Philadelphia, not Pittsburgh. The CFO said their current margin
on their Medicare business overall ranges from 0 to -10%. They make decent money on the surgical
procedures but the medical admissions, as a group, are more problematic from a financial standpoint.
He also said that in the two years prior to this year, their costs per adjusted admission grew
3.5% with the comparable number for this year at 2.0%. Meanwhile, Medicaid pays them less than
70% of their costs with more payment reductions coming due to state fiscal pressures. If Medicare
payments rise only 1% or so while their costs continue to go up at 2%, it's a formula for continued
cost shifting to commercial insurers.
The main area where all hospitals have the potential to get better is in reducing 30 day readmission
rates and they are all working on that. ACO's certainly have the potential to do a better job
with care coordination, especially if decent electronic records are in place and used. The trend
toward more hospital employed physicians makes it easier to consolidate vendors and standardize
operating room protocols. At the same time, they could lead to even greater concentration of market
power which could result in healthcare costs even greater than they would have been under fee
for service even with global payments, bundled payments for surgical procedures or partial capitation.
The powerful hospitals will vigorously resist value based insurance design though BCBS of Massachusetts
is moving ahead with the introduction of a tiered in network insurance product on January 1, 2011.
While I strongly support that approach, I suspect that, in the end, we may well wind up with an
all payer system but Medicare and, especially, Medicaid will have to pay more than they do now.
That's a heavy lift in the current fiscal environment.
Reply ↓
As you know, a profit margin turns on the cost of operations.
MedPAC has found that the cost of operations at a great many hospitals is much, much higher
than it needs to be. This is because they are terribly inefficient.
Just one example: they have three or four ORs that are all very busy during the morning and
more or less empty in the afternoon.
This is because many surgeons prefer to operate in the morning, and if these surgeons bring in
business, hospital administrators do their best to please them.
These hospitals need only two ORs.
As for hospitals having greater market power as physicians and hospitals consolidate, the
government pays more and more hospital bills, "the makket" is not going to determine prices. Government
(taxpayers) already pays more than 50% of all health care bills in the U.S.
Going forward, govt's share will grow (as more people age into Medicare, and as as Medicaid
and SCHIP expand).
Note what happened this year when the Secretary of HHHS negotiated with Medicare Advantage insurers
on prices: next year, premiums will be 1% lower than they were this year, and Sebelius insisted
that they slash co-pays for extremely expensive drugs for cancer, MS, etc.
In other words, government is beginning to regulate prices. (Medicare Advantage insures will
be pushing back, refusing to overpay drugmakers, hospitals, etc.)
The Affordable Care ACt also cuts increases in payment to hospitals and nursing homes by 1%
a year–every year. This provision is designed to put pressure on hospitals to become more efficient.
As MedPAC research show, when hospitals are under some financial pressure, they find a way
to cut waste in what it costs them to deliver care.
Reply ↓
Barry–
Pat didn't say that "asymptomiatic patients" undergo stent procedures.
He said that patients suffering from angina–who have never had heart attacks- undergo these
procedures.
This is true.
And, research shown that while angioplasty with stents offers them quick relief from pain,
over the long term, their angins often comes back.
Medication and change of diet, on the other hand, is much more likley to lead to long-term
relief from angina.
More imporantly, when patients undergo angioplasty with stents, long-term repeated reserach
shows that their chances of suffering a heart attack–or dying from a haert attack– are NOT REDUCED..
Reply ↓
Barry –
Non-symptomatic patients end up in cath lab because of results of other tests - ecg, stress ecg,
nuclear cardiology, lab tests, and these days especially coronary artery CT. These tests are advocated
as screening tests and are obtained for things like clearance to begin exercise programs, "executive"
physicals, family history or other risk factors, or just plain general prinicples. When they have
positive findings, the logical next step is to send the patient to cath. Part of this is pure
overkill, and part of it is due to some physicians' desire to locate patients with the so-called
"widowmaker" lesion - significant stenosis in the left main coronary artery - before they suffer
severe or life threatening events.
The result goes: screening suggested for one reason or another > abnormal results in screeing
> cath > abnormal cath findings > stenting. It is a good example of the problem of accidentally
creating disease by the doctor boxing themselves in with testing that was not needed in the first
place.
I have no idea of what the percentages of people who are non-symptomatic who end up getting stents,
but simple angina is the most common cause of heart cath and stenting in many centers.
I personally once had a stress ecg - clear back when I was in my late 40′s - as a screening
test at the urging of my doctor despite being asymptomatic at the time. Fortunately, it was negative
and everything ended there.
Reply ↓
Maggie –
Actually, I did say that asymptomatic patients undergo cath and stenting, under the circumstances
that I outlined in my answer to Barry. The problem is that some, probably many or most, cardiologists
believe that once they discover what they consider to be a significant stenosis they more or less
HAVE to treat it to prevent it from causing the patient problems down the road.
As to the sentence: it may be awkward because of the parenthetical phrase, but what it says,
minus the aside, is:
"the studies are very convincing in showing that there is NO real advantage and most likely a
slight disadvantage to managing both standard angina and non-symptomatic coronary artery disease
with stents instead of medical therapy alone."
(caps added to "no" for empnasis.)
Reply ↓
Pat –
Thanks for the explanation of how non-symptomatic patients wind up in a cath lab. It makes perfect
sense. In my own case in 2005, there were some symptoms and a stress test showed a significant
adverse change from my prior stress test a year or so earlier.
I understand that stent placement is a lucrative procedure for both the hospital and the interventional
cardiologist. I wonder, though, what role defensive medicine plays in the equation as compared
to how decisions about how to treat screening test findings are determined in other countries.
I could see where formula based protocols might be developed here that would call for a stent
if the percent blockage is above X depending on where it is – maybe a lower threshold for the
Left Main or, perhaps, the LAD as compared to one of the distal branches. Even if the interventional
cardiologist knows that the patient has stable angina or is non-symptomatic, if the percent blockage
is above the threshold, and he doesn't put a stent in, what if the patient has a heart attack
in the next week / month / year? The path of least resistance in our litigious culture is to insert
the stent. Oh, and by the way, it pays well too. If the docs in other countries perceive, correctly,
that, as a practical matter, they are unlikely to ever be sued, even if the screening results
are positive, the patient may not be sent to the cath lab if he/she is non-symptomatic or has
stable angina. My sense is that defensive medicine may be an important part of the equation that
determines interventional cardiologists' practice patterns in the U.S. even though its effect
cannot be specifically determined or quantified.
Reply ↓
"This is pretty much what happened in one notorious case,that of Shasta Regional Medical Center
in the small town ofRedding, California. There, two rogue cardiologists, Chae Hyun Moon and Fidel
Realyvasquez Jr., headed a team that performed extraordinary volumes of unnecessary and recklessly
dangerous heart operations. In the end, both would lose their licenses, and each would pay a $1.4
million fine in lieu of federal criminal prosecution. Yet for years before, their building reputations
as top-notch cardiologists brought in patients from all over Northern California. In gratitude,
the hospital pampered them with department chairmanships and perks. Dr. Moon even enjoyed occasional
use of the hopital's emergency helicopter to fly to golf tournaments.
Our Lady of Lourdes Regional Medical Center in Lafayette, Louisiana, provides another example
of how high-volume rogue surgeons can escape scrutiny for years, either because hospital administrators
don't know, or profit from pretending not to know, how dangerous they are. At Lourdes, there were
rumors for years that one of its surgeons, a Dr. Mehmood Patel, was performing vast amounts of
unnecessary heart operations. Yet it wasn't until one of Patel's fellow doctors at last secretly
sued him in federal court under a special whistleblower law that the hospital revoked his admitting
privileges. The hospital subsequently agreed to pay a fine of $3.8 million but still denies it
had any way of knowing about the safety or effectiveness of Dr. Patel's care.
As the number of specialists in a community grows, many people cut out visits to their primary
care physicians altogether. Instead, they skip from one specialist to another according to what
body part gives them reason to complain that day, all the while gathering more and more bottles
for the medicine cabinet." Phillip Longman "Best Care Anywhere"
Reply ↓
run 75441-
Yes, the Redding story eptiomizes what has been happening.
I interviewed some of the victims of Redding when I wrote Money-Driven Medicne. Very sad stories.
And I do blame the hospitals. While looking at overtreatment, Dartmouth researchers realized that
Redding was doing an extraordinary number of bypasses and angioplasties. Dartmouth helped expose
the problem.
Dartmouth is on the ohter side of the country. Administrators at the California hospital should
have realizled that something unusual was going on.
Reply ↓
Barry –
This is the usual complicated stew of motives for performing tests and procedures that are not
scientifically warranted. The main issue, in truth, is probably that the doctors believes that
they are doing the right thing, based on their grasp of the science and their personal feelings
about what they are doing, possibly influenced by personally not having kept up on the science
and by the continued insistence of academic doctors with career stakes and of reps from supply,
equipment, and drug companies that the evidence against the procedures are flawed, incomplete,
or don't apply to a brilliant person like themselves who gets far better results than the people
at institutions where the research is done .
It is very very hard for doctors to admit to themselves that something they have been doing
for a while is now demonstrated to be of little value or even potentially harmful. The rest of
the complicated motives behind this, ranging from the desire of their hospitals to keep expensive
equipment paying for itself to personal prestige to the financial rewards to the feeling that
if they don't do something they might be sued all enter into the mix, but the first is the main
thing.
The interesting thing is that the article in the Times suggests that the tide has turned
and that doctors are actually at greater risk of litigation from DOING the procedure than from
NOT DOING it. This is relatively unusual in medical circles, although there have been some
spectacular cases of litigation for performing a procedure that is useless or causes harm. The
most spectacular was the case of retrolental fibroplasia causing blindness in infants who had
been given too high of levels of oxygen in intensive care nurseries, usually because of prematurity.
A small group of unfortunate pediatricians who had been somewhat behind the curve on the issue
ended up being sued by the children when they reached adulthood, 18 to 21 years later. In many
cases, the malpractice insurance that was in force for the incidents had been acquired two decades
earlier and had cash limits that were way too low for the settlements and judgements that were
being given, leaving the pediatricians, many of whom had already retired, to pay 7 figure awards
out of their own pockets. That lesson influenced a lot of doctors from my generation, who saw
all this happen early in our careers, but lessons that don't quite fit with personal ego and ambition
have a tendency to be forgotten after a while, especially by younger people who did not see the
events first hand.
Reply ↓
Pat –
Thanks for the very thorough and nuanced explanation. It makes a lot of sense as usual. I think
it's encouraging that doctors may be starting to perceive greater litigation risk from doing this
procedure as opposed to not doing it. In the meantime, with modern data analytics, I think
both public and private payers could more aggressively audit some of these cases to confirm medical
necessity, especially when they notice unusually large numbers of procedures being performed by
a given institution or a specific physician or group.
Reply ↓
I have been researching, investigating, speaking & writing on the ugly reality of physician misbehavior
for more than a decade. I've seen it from the inside and out.
What any cursory investigation reveals is truly jaw-dropping:
NO other profession injures & kills more citizens unnecessarily;
No segment of professionals escape more appropriate discipline upon being found guilty
2,500+ doctors are found responsible of Felony-level crimes each year – another 5,500 convicted
of "lesser" bad behavior.
Health Care almost never reports its own miscreants to authorities, as they are mandated
by law to do.
The Nat'l Practitioner Data Bank holds files on a whopping 1/4 million physicians – just
since 1985. A shocking number of them fall into the categories of "Dangerous" or "Questionable."
And that 250,000 is considered an extremely low number, by those who understand the scope of
the misbehavior.
As a society, we are getting exactly what we tolerate – which as of this writing, includes
skyrocketing health care costs, and almost exactly 500 innocent deaths . . . per day.
We are being enormously group-stupid in not bringing the roof down on the bad boys of medicine.
Thanks for the comment–I am afraid you are entirely right.
Why don't doctors police themselves and blow the whistle on bad doctors?
I've read that the "hazing" experience of med school causes doctors to bond with
each other: "anyone who has gone through this deserves to be a doctor."
That hazing–which includes being humiliated by people who are supposed to be
training you– makes doctors extremely sensitive to criticism.
These things may be true of many–though not necessarily most doctors.
A more practical reason is that doctors are concerned about being sued if they try to
blow the whistle on other doctors. (We need better laws protecting whistle-blowers).
Finally–and I am afraid this is a major reason– a great many hospital CEO's protect their
"rainmakers" –and this includes doctors who bring in revenues by doing too many surgeries (even
when
they are very tired), too many unnecessary and expensive tests, etc. Often, if they're moving
too fast and
doing too much, they make mistakes. If a colleague tries to bring this to the attention of the
administration,
he may find himself in trouble. The politics inside hospitals can be ugly.
I wonder if you might want to write a guest post about this?
Click on "Contact Maggie" on the blog's home page.
"... An internal review by Tennessee-based Hospital Corporation of America found unnecessary heart procedures being performed at several facilities, according to The New York Times. ..."
"... A 2011 study in the Journal of the American Medical Association found that only half of 144,000 nonemergency heart catheterizations - typically the use of tiny balloons and stents to clear blocked arteries - were appropriate; 38 percent were "uncertain" and 12 percent were "inappropriate." ..."
"... "It's presented in the media as if it's an aberrancy, when actually it's the rule," said Dr. David Brown, an interventional cardiologist and professor of medicine at SUNY-Stony Brook School of Medicine of the unnecessary heart procedures. "The medical system is addicted to the revenues that it generates." ..."
"... Comparisons to common practice among doctors and hospitals may not be the best barometer of proper patient care. Studies show that doctors often do not adhere to best practices when they treat patients who have plaque buildup in their coronary arteries but whose condition is stable. ..."
"... About 600,000 procedures are performed every year to clear coronary artery blockages, according to the American Heart Association. The procedure involves snaking a catheter through the patient's arteries and clearing the blockage with a tiny balloon and a small wire cage - the stent - that holds the artery open. ..."
"... But studies show that medicine alone is as effective in patients with stable heart disease and that many procedures to clear blockages are unnecessary. Brown published a review of eight studies and found "there's absolutely no evidence" for substituting stents for medical therapy in patients with stable heart disease, he said. ..."
"... Editor's Note: ProPublica is working on a project to document cases of harm to patients. You can share your story by filling out our Patient Harm Questionnaire , or by joining our ProPublica Patient Harm Community on Facebook . ..."
by Marshall Allen
As Hospital Corporation of America comes under scrutiny, experts say unnecessary heart procedures
are common, costing taxpayers, driving insurance premiums and putting patients at risk.
An internal review by Tennessee-based Hospital Corporation of America found unnecessary heart
procedures being performed at several facilities, according to The New York Times.
New accusations that one of the nation's largest hospital chains performed more than a thousand
unnecessary heart procedures grabbed headlines this week, but the practice is far from unique in
U.S. health care.
A
2011 study in the Journal of the American Medical Association found that only half of 144,000
nonemergency heart catheterizations - typically the use of tiny balloons and stents to clear blocked
arteries - were appropriate; 38 percent were "uncertain" and 12 percent were "inappropriate."
"It's presented in the media as if it's an aberrancy, when actually it's the rule," said Dr.
David Brown, an interventional cardiologist and professor of medicine at SUNY-Stony Brook School
of Medicine of the unnecessary heart procedures. "The medical system is addicted to the revenues
that it generates."
The New York Times
reported this week that the U.S. attorney's office in Miami is investigating allegations that
patients underwent unnecessary heart treatments at facilities owned by Tennessee-based Hospital Corporation
of America, a 163-hospital chain.
According to the Times, an internal HCA review found unnecessary procedures being performed at
several facilities, including more than 1,200 at Lawnwood Regional Medical Center & Heart Institute,
in Fort Pierce, Fla.
HCA did not return a call for comment, but said in a
statement posted on its website that there's wide disagreement among physicians about which procedures
are medically necessary and its use of stents was within the range of those at other hospitals.
Comparisons to common practice among doctors and hospitals may not be the best barometer of
proper patient care.
Studies show that doctors often do not adhere to best practices when they treat patients who
have plaque buildup in their coronary arteries but whose condition is stable.
About 600,000 procedures are performed every year to clear coronary artery blockages, according
to the American Heart Association. The procedure involves snaking a catheter through the patient's
arteries and clearing the blockage
with a tiny balloon and a small wire cage - the stent - that holds the artery open.
But
studies show that medicine alone is as effective in patients with stable heart disease and that
many procedures to clear blockages are unnecessary. Brown
published a review of eight studies and found "there's absolutely no evidence" for substituting
stents for medical therapy in patients with stable heart disease, he said.
The American Heart Association
recommends putting patients with stable heart disease on blood thinning medication before they
try a stent,
said the authors of a May 2011 study in the Journal of the American Medical Association. Yet
it happens in fewer than half of the cases where doctors use stents,
the study found .
There is some debate about the scope of the problem.
Dr. William Zoghbi, president of the American College of Cardiology, says there are "pockets"
around the country where unnecessary procedures are more prevalent. The college offers seminars and
guidelines on appropriate use for doctors, he said, and keeps a national registry so they can compare
their practices to others. Zoghbi said the educational efforts are showing signs of success.
Unnecessary stenting persists in part because doctors are not explaining the medication-alone
option to patients, said Dr. Michael Barry, president of the Informed Medical Decisions Foundation,
which has created a
guide of treatment choices for patients with stable heart disease .
Barry was part of a team of researchers that surveyed 472 Medicare patients with stable heart
disease about their interactions with doctors who performed nonemergency stent procedures on them.
A key finding : Only 6 percent of the patients said their doctor offered medication as an alternative
to a stent.
Correction: This post originally said that the Archives of Internal Medicine
found that only half of 144,000 nonemergency heart catheterizations were appropriate. It was actually
the Journal of the American Medical Association.
I'm in healthcare and can tell you that there's an enormous amount of unnecessary procedures performed
for the $$$. Also a lot of billing for procedures never performed, and even in some cases for patients
never even seen. Some of the worst fraud and abuse is in cardiology, and… gastroenterology. Ted
Very fine article. It is not just about "stents". Virtually all aspects of medicine from colonoscopies
to mammography, to PSA's to what we pay for medications is part of the huge issue of "more is better"
practice of US Medicine Inc. Warren Liebman
I see that your survey is about patients that suffered harm through the insertion is stents. I had
day surgery for a procedure unrelated to my heart. I had heart failure in the recovery room and was
sent by ambulance to the nearby heart center where I had three stents inserted the next day.
My cardiologist thought the stents were the best alternative. I deferred to his opinion as I was
unqualified to make the decision.
I was on Plavix for three years and now just blood pressure and cholesterol drugs. I am very pleased
with the outcome.
Carefully read the HCA online document that alleges that the number of cardiac caths and stent procedures
has decreased per year.
Missing from the document is the number of HCA cath labs and HCA cardiologists doing the procedures.
As we know, HCA downsized so if it has fewer hospitals and or fewer cardiologists then there may
be an increase in the number of procedures done per remaining hospital or remaining cardiologist.
Greg
Given the setup, this is the inevitable result. With insurance in the way, doctors jump through hoops
to get paid and money is invisible to the patient. Put those together, and the doctor has strong
incentive (even if we completely ignore pressure from the pharmaceutical and other supply companies)
to give everybody the most expensive health care possible, whether or not it's the best.
As Warren points out, stents are wonderful tools. But sledgehammers are also wonderful tools,
and I wouldn't want to use such a tool to clean a dirty window. When you have the right tool for
the right job, there's not much better.
And since, in this country, we confuse "health care" with "health insurance"-two completely unrelated
things except through their placement in the dictionary-we drive to make it worse, every time.
And note, the organization in the middle always benefits. And they sell the idea to doctors that
the problem with health care is fraudulent malpractice claims (i.e., blame the patient), while selling
the idea to patients that we need protection from the big, bad doctor bills.
It's one of the best scams running, really. You keep the parties blaming each other AND play on
the fear and implied threat that "it'd be a shame if something…happened to your health," while raking
in profits from a biased system.
The placement of a stent in a coronary artery that has no blockage (as described in the NY Times)
is fraud. It also exposes the person receiving the stent to life-threatening complications at the
time of the procedure and for years afterward. This is a criminal act that should be prosecuted aggressively.
Innocent people deserve protection. Salvador
I myself have had 6 procedures done, and they have been done because of actual blockage. My cardiologist
that I have now is a very good Doctor; who use other ways of preventive care for someone like me,
before doing any kind of senseless procedure. He communicates with me in every aspect of the disease
that I have. As far I am concerned here in Austin Tx. I have had 2 cardiologist and have been wonderful,
and I see no fraud in any of the cases that I have been with. what ever goes on in those parts of
the country its because they have Dr. who don't care about their patients; only about how to rip
off the federal government. Jason Buc
So what are the guidelines for who ought to be stented vs those that ought to be treated with pharmacology?
Is there ever a proper non-emergent stent? I am familiar with guidelines for who gets cathed emergently
vs those that ought to receive fibrinolytics in the presence of mi. Salvador
I don't know any guidelines, I am merely stating incidents that has happened to me. Believe me when
I say that at the time of my procedures I felt I was on my dying bed massive MI and it took a lot
out of me. I am still struggling but not as bad as I was then, and I am also under a major meds regimen,
including blood thinner Effient. I have tried many other thinners that have failed me and appears
that this one is doing its job (Effient). Sharon
This is just the beginning of this reporting I hope ProPublica because you are hitting on THE most
important driver of the ever increasing costs of healthcare. There is very little health in healthcare
but there are huge profits.
And who pays when things go wrong? It's not the manufacturers or the doctors because you know
frivolous lawsuits. The patients' in this country, if they were informed consumers would want more
legitimate lawsuits that would weed out faulty products and procedures. Instead what we get are lawsuits
that vilify a doctor when he doesn't use an expensive scan or treat with an expensive drug. Those
lawsuits are allowed to proceed, step right up we'll help you sue your doctor. But when a product
like gadolinium based contrasting agents is maiming and killing millions and GE is the manufacturer
with the least stable product, the injuries go uncompensated. In these situations we have to pick
up these costs through higher premiums, our largest employers pay and so do health insurance companies
and the government. No matter what you think about health insurance companies and how evil they are
they still shouldn't have to pay for GE's faulty products or other faulty products. Those costs should
be borne by the ones that caused them. Great work ProPublica. I'm be watching and waiting for more
reporting.
While many unnecessary procedures are performed, some are actually related to the fact that patients
consider one approach as 'doing something', and the medical approach as being passive and less thorough.
A physician who does not perform a procedure has nothing to lose by recommending it. Any complications
are the result of the operator. But if a procedure is not recommended and an event occurs, such as
a heart attack, a physician may be blamed by the patient for 'not doing enough'. The fact that medical
therapies may indeed be better than procedures is not strongly embedded in the culture of patients.
And there is an aura of higher technology to procedures compared with medications.
This is an attitude that needs to change, both on the part of physicians and patients.
Perhaps everything that is being discussed here may make sense to some but not all. I'm sure that
people are not ignorant; when they are being treated by a good Dr. or a very bad Dr.: that is why
its always best top go for first, second, and even third diagnoses. As the old cliche goes we are
only human, and we all make mistakes, must not be taken as advise when it comes down anybodies health.
I my self am against lawsuits of any kind, as this is very degrading on both parts. Plus it goes
contrary to what I believe and what I have been taught through the word of God. One thing I will
say in the six procedures that I have had; I would rather do it all over again instead of having
open heart surgery. The basic fact is, that we all have the cure within ourselves if we know how
to do what is right, admittance, acceptance, and avoidance.
"... the drug companies are truly into discovery they would've gone straight after the helicobacter...Had these drugs [Tagamet and Zantac] not existed, the drug companies would have jumped on our findings ..."
"... Petersen, p.144 ..."
"... New York Magazine cover story "Corruption in the Kitchen," Oct. 17, 1988. ..."
Jonas Salk discovered a polio vaccine in 1955 and the world cheered. Polio deaths declined from 37,476
in 1954 to 910 cases in 1962. Salk refused to patent it. "Can you patent the sun?" he asked. Barry
Marshall discovered a cause [helicobacter] and cure for stomach ulcers in 1984 and practically nobody
heard about it for more than 10 years. What was the difference? Ulcer victims were being treated
with two multibillion-dollar pharma palliatives, Tagamet and Zantac. These expensive drugs relieved
the symptoms but didn't cure the disease. The bottom line was greed. The powerful industries making
huge profits from ulcers were simply not interested in curing their patient-customers if it meant
losing their profits.
America's medical industrial complex became so wedded to the heavily marketed pills that it
was not until 1994, 10 years after [Marshall's discovery] that a government panel announced that
ulcers should be treated with antibiotics. One year after that announcement only about 5% of ulcer
patients were receiving antibiotics. And by 1997 the government had been forced to begin a public
information campaign urging doctors to change their practices. The government pointed out that
curing an ulcer with a 17 day course of antibiotics cost less than $1,000. This was less than
1/10 of the expense of using years of the expensive acid suppressing drugs. -Melody Petersen,
Our Daily Meds, p.144-145
After Marshall and his collaborator J. Robin Warren were awarded the Nobel Prize for Medicine
in 2005, Marshall said, "If the drug companies are truly into discovery they would've gone straight
after the helicobacter...Had these drugs [Tagamet and Zantac] not existed, the drug companies would
have jumped on our findings ." ( Petersen, p.144 )
The fact that the medical industrial complex suppressed the cure for stomach ulcers for nearly
15 years raises crucial questions about trusting a system which demonstrably favors corporate profits
over patient health. If a young scientist like Barry Marshall were to step outside the box of traditional
thinking today and discover a cheap, relatively easy cure for cancer, could we be sure that the medical
establishment, now making billions of dollars on cancer treatments, would rush to support such a
breakthrough? Or would they hem and haw, procrastinate, find excuses, and sweep it under the rug,
as they did for 15 years with the antibiotic treatment for ulcers?
In this critical time of medical reform, the ulcer story rings loud warning bells against sustaining
a business controlled system whose first concerns are maximizing the bottom line rather maximizing
public health. It is a powerful case example of the fundamental corruption underlying the very idea
of a profit oriented health system. Legislators reexamining and revising our health system need to
dissect this travesty and put it under a powerful microscope to see how doctors and Pharma conspired
to suppress a basically simple discovery of a cure for a widespread disease. This story shows the
need for building in powerful public interest safeguards into any reformed system to prevent such
a travesty from occurring in the future. The ulcer story is strong evidence why the influence of
profit-making interests need to be treated like malignant cancer cells and carefully excised from
any reformed medical system so that doctors judgments are always and incontrovertibly made in the
best interests of their patients, not pharma or the insurance corporations, nor their own fees.
You don't have to be a "communist" or "socialist" to realize that there is an inherent contradiction
between the profit motive and the health motive. All you have to be is a caring person with a loved
one mistreated by the current failed health care system. When people are able to find health though
simple or cheap regimes, the current profit-oriented medical system has no motive to encourage those
methods or systems to develop or be widely known. The "alternative medicine"movements spawned by
the Sixties cultural revolution have clearly been responding to the issues raised by a pharma driven
health culture.
Besides the ulcer story, another damning example against bottom line medicine is Celiac disease
and its sibling gluten intolerance. Celiac disease afflicts an estimated 2 million Americans, yet
only five percent of the people afflicted by it are aware of the nature [and cure] of their illness.
Many people suffering from it are misdiagnosed as having "irritable bowel syndrome" or another chronic
digestive disease, or when their symptoms are anemia and fatigue, they are liable to being misdiagnosed
as having chronic fatigue syndrome, depression, or other fatigue-causing disorders.
Why is there such confusion? Again the crucial factor is that Celiac disease is inexpensive to
cure. There is no medicine, no surgery, all there is, is dietary change-removing foods containing
gluten [wheat, rye, barley] from the diet. Unfortunately, dietary cures are of little or no interest
to our profit oriented medical system. When nobody but the patient profits from a cure based upon
dietary change, American medicine has little motivation for diagnosing and spreading the word that
something as universal as "the staff of life" might be making you or your loved ones sick. As Celiac
disease is not immediately life threatening, undiagnosed people with gluten intolerance are treated
symptomatically with palliatives with little or no attention paid to the cause and cure to the problem.
The fact that there is a genetic tie-in to Celiac disease makes the failure of the medical system
to identify it and treat it even more egregious. The customary medical history that patients fill
out could ask about a family history of Celiac disease or its defining, often confused, symptoms,
to alert doctors of the possibility of the presence of Celiac through a genetic relationship.
I gained first hand experience with the degradations of the profit motive upon public health when
I worked three illuminating years as a New York City health inspector. ( New York Magazine cover
story
"Corruption in the Kitchen," Oct. 17, 1988. ) Doing health inspections, it became obvious
that most exterminator companies were not committed to doing their job completely. If they did, it
might put them out of business. Over time I learned that the use of certain exterminator companies
strongly correlated with the presence of vermin, while others, a distinct minority, correlated with
cleanliness. Dominance of the palliative mind set keeps exterminators and drug companies in business.
Customers always need more treatment. The bugs go into hiding, but are not exterminated and the bugs'
hosts need to keep coming back and paying for more treatment whether it be for mice, roaches, or
ulcers.
Ideally a medical system effectively working to maximize health would not only treat illness with
the most effective treatments, it would also focus upon preventative medicine by working to raise
public awareness of the threats of customary addictive substances like nicotine and alcohol. Upgrading
the U.S. to a socially advanced medical system that the nation could be proud of would start with
deprogramming America's hidden cradle-to-grave advertising persuaders that addict the masses to tobacco,
alcohol, and unhealthy food and drinks. Mary Louise Hartman gets it in
a letter published
in the New York Times [9/21/09]:
I recently toured the Coca Cola center in Atlanta. The marketing glitz was beyond belief. It's
no wonder that half the world is now addicted to sugary beverages. If this same marketing genius
was used to promote healthier foods and beverages, we wouldn't have to deal with the current obesity
epidemic and its ensuing health care demands.
A progressive new approach to advancing public health might begin with levying taxes on the promotion
of unhealthy products like alcohol, tobacco, fatty foods and, of course, sugary Coca Cola-and its
competitors, and channel the revenues into a national public health fund. If we had pro-active taxes
on the advertising of cigarettes, alcoholic beverages, sugar drinks, and fatty foods, the culturally
conditioned abuse of these products might decline and revenue from their would be used pay to treat
the deleterious effects of their consumption. This would lead producers to create healthier products,
as has recently been seen in the mainstreaming of the grass roots organic food and alternative health
care movements that arose from the Sixties.
Those politicians with direct personal experience with the failings of our medical system have
the best motivation for bringing change in our healing institutions. President Obama's indelible
experience with his mother's cancer and the late Senator Kennedy's family's cancer experiences led
them to put their exceptional powers of persuasion to work making the health care system work better.
And even conservative legislators like Barry Imhof [Oklahoma] and Ben Nelson [Nebraska] appear to
have some personal connections to Celiac disease, and have taken baby political steps to raise awareness
of gluten intolerance in the form of a Senate resolution. [Sept 13, 2006]
I, too, know personally of what I speak. This blogger watched his wife turn pale and balloon to
frightening dimensions in the hospital after eating a piece of toast two days following an appendectomy.
She then suffered through a week's worth of horrific testing trying unsuccessfully to diagnose the
problem. When she was gingerly recovering at home a week later, [still undiagnosed and released against
the head surgeon's advice] she asked to change her breakfast menu from oatmeal to Cream of Wheat
for variety's sake, and took a radical turn for the worse. In a fortuitous post-op visit with her
surgeon, she was pale again and could hardly stand. Fortunately her doctor's old college roommate
was a leading food allergist and he asked what she had been eating. When we listed the change to
Cream of Wheat, he asked if anyone in the family was gluten intolerant. My wife's aunt was. Bingo!
Considering gluten intolerance in the U.S., we are talking about an estimated 2 million undiagnosed
or wrongly diagnosed people. For those who are finally diagnosed, it is estimated that it takes 11
years of suffering to find the source of their illness. In perhaps the most famous case of Celiac
disease, Elisabeth Hasselbeck's self diagnosis and recovery had to come from a cultural trip back
into the pseudo-primitive world of reality TV. As a contestant on the Survivor reality show,
Hasselbeck voluntarily took up a pre-agricultural [pre wheat] "primitive" diet, and to her surprise
discovered that her chronic stomach distress disappeared - only to return again when she came back
to "civilized life" and gluten foods.
When we come face to face with the illness and disease of people we deeply care for, the obscenity
of roadblocks created by criteria of profit and loss or artificial lines of political philosophy
becomes crystal clear. Would John McCain, whose wife Cindy has a terrible migraine headache condition,
want to see a cure for migraines suppressed the way the cure for ulcers was? When it comes to sickness
and health, politics or profits should be the last concern. As Kennedy and Obama have so eloquently
put it, doing what is right about universal health care is a matter of our national character. Human
beings, someone's child, someone's parent, someone's mate, someone's employee should have access
to the best known knowledge, analyses, and cures. This great country needs to construct a health
system that puts the causes and cures of the sick and suffering first and foremost, whether they
be cheap or expensive. The decisions defining the causes and cures of illness should not, cannot,
be left in the hands of people and corporate powers whose primary concerns are the bottom line. We
cannot patent the sun and we cannot patent good health, nor should we.
"... Blood clots can occasionally form in an inserted stent, which can then lead to the artery narrowing once again. In some cases, the blood vessel can become completely blocked – a condition called in-stent thrombosis. ..."
"... Most patients that undergo stenting are prescribed blood thinners in the wake of the procedure to ensure such events don't occur. ..."
"... Cardiac stents are big business for hospitals and their staff, with the average private insurance reimbursement for a procedure totaling $25,000. By placing a stent inside an artery, surgeons can restore blood flow that has been compromised in heart attack patients, or give help to patients at risk for future heart attack. But when misused or overused in patients, cardiac stents can prove fatal, as they did for former postal service worker Bruce Peterson. ..."
"... Peterson developed several blood clots and blockages due to his weakened heart, which ultimately caused his untimely demise, argues his widow Shirlee Peterson. ..."
"... Nortin Hadler, a UNC Chapel Hill professor of medicine told Bloomberg News, "Stenting belongs to one of the bleakest chapters in the history of Western medicine. Cardiologists "are marching on" because "the interventional cardiology industry has a cash flow comparable to the GDP of many countries" and doesn't want to sacrifice the revenue, he said. ..."
About a third of all cardiac stents implanted in patients are unnecessary, says cardiologist
David Brown of Stony Brook University School of Medicine. That amounts to more than 200,000 stents a
year, and controversy surrounding this practice has spurred nationwide litigation and a federal
investigation into several cases involving illegal kickbacks and allegations of cardiac stent
malpractice.
For the most part, stenting procedures are relatively low in risk and moderately safe. However,
as with any surgical procedure – even a minimally invasive one – there is a risk of developing
complications.
Blood clots can occasionally form in an inserted stent, which can then lead to the artery
narrowing once again. In some cases, the blood vessel can become completely blocked – a condition
called in-stent thrombosis.
Most patients that undergo stenting are prescribed blood thinners in the wake of the
procedure to ensure such events don't occur.
Additionally, manipulating arteries with a stent or any other sort of medical procedure can lead
to the walls of the blood vessel becoming injured or damaged. The innermost layer of coronary
arteries, known as the endothelium, is particularly susceptible to this sort of damage; the result
can be the formation of scar tissue in the area of the stent, and this too can lead to the artery
re-narrowing in a process known as restenosis. Treating Restenosis can involve an additional
stenting procedure, though in severe cases where a stented artery recloses it may be necessary to
have a patient undergo a coronary artery bypass to remedy the condition.
Overuse of cardiac stents leads to patient deaths
Cardiac stents are big business for hospitals and their staff, with the average private
insurance reimbursement for a procedure totaling $25,000. By placing a stent inside an artery,
surgeons can restore blood flow that has been compromised in heart attack patients, or give help to
patients at risk for future heart attack. But when misused or overused in patients, cardiac stents
can prove fatal, as they did for former postal service worker Bruce Peterson.
After suffering chest pain, Peterson paid a visit to cardiologist Dr. Samuel DeMaio, who inserted
21 stents in his patient's chest over a period of eight months, including five mesh tubes in a
single artery.
Peterson developed several blood clots and blockages due to his weakened
heart, which ultimately caused his untimely demise, argues his widow Shirlee Peterson.
She later sued DeMaio for cardiac stent malpractice – an increasingly common charge in a Dr.
Darshan P. Godkar, MD - Cedar Knolls, NJ - Cardiology & Interventional Cardiology & Internal
Medicine Healthgrades.comqaDr. Darshan P. Godkar, MD - Cedar Knolls, NJ - Cardiology &
Interventional Cardiology & Internal Medicine Healthgrades.com
Nortin Hadler, a UNC Chapel Hill professor of medicine told Bloomberg News, "Stenting belongs
to one of the bleakest chapters in the history of Western medicine. Cardiologists "are marching on"
because "the interventional cardiology industry has a cash flow comparable to the GDP of many
countries" and doesn't want to sacrifice the revenue, he said.
Cardiac stent problems cost $2.4 billion a year
The U.S. health care system spends an estimated $2.4 billion a year caring for patients that
received unnecessary cardiac stents, says Dr. Sanjay Kaul, of Cedars-Sinai Medical Center. Patients
face a much greater risk for complications like coronary scar tissue, blood clots and uncontrolled
bleeding from anticoagulant medications – all of which can be life-threatening. Jim Simecek
told Bloomberg that he is on blood-thinning medicine for the rest of his life to prevent clots in
the cardiac stents he received from a Cleveland doctor who is currently the subject of a federal
probe.
Sixty-four year old Monica Crabtree's cardiac stent problems caused a torn artery, which resulted
in an infection and her death, according to her husband. He also pursued legal action after it was
determined by another cardiologist that Monica's stent was completely needless. The surviving spouse
recovered $240,000 in a malpractice settlement brought against the surgeon.
FDA reports hundreds of deaths attributed to cardiac stents
Some 773 patient deaths linked with cardiac stents were logged with the FDA last year, according
to Bloomberg. Though this figure has jumped more than 70 percent since 2008, with recent media
coverage on cardiac stent overuse and ongoing federal investigations, cardiologists may be using
fewer stents and only on suitable patients.
John Harold, president of the American College of Cardiology said the doctors who have been
charged with cardiac stent malpractice or fraud are essentially "outliers" in their community, and
that these surgeons fail to represent the "overwhelming majority."
"... Jashu Patel, an interventionalist in Jackson, Michigan, billed $2.7 million for procedures in 2007, according to a U.S. Justice Department case against him settled in July. (He is no relation to Mehmood Patel). ..."
"... The suit alleged Patel implanted needless stents in at least two patients, including one that led to a blood clot that killed an unnamed woman who had reported no symptoms of reduced cardiac blood supply. A stress test showed normal blood flow, and notes in her file said she didn't want interventions, said Julie Kovach, a cardiologist who worked with Patel and brought the case to the government's attention. ..."
"... "It was appalling," Kovach said in an interview. "Patel coerced her into getting a stent she didn't need, which killed her." ..."
"... "He's their cash cow," said Kovach, now co-director of a clinic that treats congenital heart disease at the Detroit Medical Center. "They're not about to turn him in." ..."
"... Patel continues to practice at the hospital and must improve record-keeping to substantiate cardiology procedures, Allegiance said. In the settlement, Patel agreed to hire a consultant to oversee treatment of his patients and an auditing firm to monitor billings. He didn't return phone messages. ..."
"... "I do believe that Bruce was a guinea pig," she said. "That was the way it was done." ..."
When Bruce Peterson left the U.S. Postal Service after 24 years delivering mail, he started a
travel agency. It was his dream career, his wife Shirlee said.
Then he went to see cardiologist Samuel DeMaio for chest pain. DeMaio put 21 coronary stents in
Peterson's chest over eight months, and in one procedure tore a blood vessel and placed five of
the metal-mesh tubes in a single artery, the Texas Medical Board staff said in a complaint.
Unneeded stents weakened Peterson's heart and exposed him to complications including clots,
blockages "and ultimately his death," the complaint said.
DeMaio paid $10,000 and agreed to two years' oversight to settle the complaint over Peterson and
other patients in 2011. He said his treatment didn't contribute to Peterson's death.
"We've learned a lot since Bruce died," Shirlee Peterson said. "Too many stents
can kill you."
Peterson's case is part of the expanding impact of U.S.
medicine's binge on cardiac stents -- implants used to prop open the arteries
of 7 million Americans in the last decade at a cost of more than $110 billion.
When stents are used to restore blood flow in heart attack patients, few
dispute they are beneficial. These and other acute cases account for about half
of the 700,000 stent procedures in the U.S. annually.
Among the other half -- elective-surgery patients in stable condition --
overuse, death, injury and fraud have accompanied the devices' use as a go-to
treatment, according to thousands of pages of court documents and regulatory
filings, interviews with 37 cardiologists and 33 heart patients or their
survivors, and more than a dozen medical studies.
'Marching On'
These sources point to stent practices that underscore the waste and patient
vulnerability in a U.S. health care system that rewards doctors based on volume
of procedures rather than quality of care. Cardiologists get paid less than
$250 to talk to patients about stents' risks and alternative measures, and an
average of four times that fee for putting in a stent.
"Stenting belongs to one of the bleakest chapters in the history of Western
medicine," said Nortin Hadler, a professor of medicine at the University of
North Carolina at Chapel Hill. Cardiologists "are marching on" because "the
interventional cardiology industry has a cash flow comparable to the GDP of
many countries" and doesn't want to lose it, he said.
Stenting abuse is by no means the norm, but neither is it a rarity. Federal
cases have extended from regional medical centers in Louisiana, Kentucky and
Georgia to a top-ranked metropolitan hospital system in Ohio.
Asset Seizure
A doctor practicing at a hospital owned by the Cleveland Clinic, rated the
premier heart center in the country by U.S. News and World Report, had his
assets seized by federal agents in a stent investigation, according to federal
court filings in April. The Clinic has not been accused of wrongdoing, and says
it's cooperating with the investigation.
Two out of three elective stents, or more than 200,000 procedures a year,
are unnecessary, according to David Brown, a cardiologist at Stony Brook
University School of Medicine in New York. That works out to about a third of
all stents.
Brown said his estimate is based on eight clinical trials of 7,000 patients
in the last decade, which he analyzed in the Archives of Internal Medicine last
year. Two cardiology researchers who have studied the use of stents say the
number could be as low as about half Brown's estimate, and one said it is
probably larger.
Costs, Risks
Even the low end of these estimates translates into more than a million
Americans in the past decade with implants in their coronary arteries they
didn't need, said William Boden, chief of medicine at a Veterans Administration
hospital in Albany, New York. Boden was the principal investigator of a 2007
study known as Courage that found stents added no benefit over medicines,
exercise and dietary changes in stable patients.
Unnecessary stents cost the U.S. health care system $2.4 billion a year,
according to Sanjay Kaul, a cardiologist and researcher at Cedars-Sinai Medical
Center in Los Angeles. Patients who received them are living with risks
including blood clots, bleeding from anti-clotting medicine and blockages from
coronary scar tissue, any of which can be fatal, Kaul said.
Monica Crabtree died at age 64 after one of her arteries was torn in a stent
procedure that led to infection, according to her widower, Gary Crabtree. He
received at least $240,000 from a 2011 settlement of his lawsuit against her
doctor, after a second cardiologist reviewed the case and told him the stent
wasn't needed. Crabtree choked up speaking about his late wife and showed
pictures of their 47 years together.
Worried Shaving
"It wasn't just a simple mistake," said the retired auto worker in Largo,
Florida. "If the stent was something she really needed, I could have handled
it. But it was a total loss of life that didn't need to happen."
Jim Simecek, of Medina, Ohio, said he worries every morning that a nick from
shaving could bleed out of control. Simecek, who works at a Ford dealership,
said he has to take blood-thinning medicine for life to ward off clots in the
six stents he received from a Cleveland-area cardiologist who's under federal
investigation for his stent work.
"It's as if your heart was open and somebody was sticking a knife in," said
Rhonda McClure, 54, referring to eight stents she received from a Kentucky
cardiologist who agreed in June to plead guilty to a federal Medicaid-fraud
charge for falsifying records used to justify a stent he placed.
Patient Letters
Cardiac stents were linked to at least 773 deaths in incident reports to the
U.S. Food and Drug Administration last year, according to a review by Bloomberg
News. That was 71 percent higher than the number found in the FDA's public
files for 2008. The 4,135 non-fatal stent injuries reported to the FDA last
year -- including perforated arteries, blood clots and other incidents -- were
33 percent higher than 2008 levels.
The FDA declined to comment on whether the reports were a cause for concern.
It said adverse-event reports tied to medical devices have increased overall
due to agency efforts. It also said the data can contain incomplete and
unverified accounts from reporting parties.
More than 1,500 patients have gotten letters from hospitals since 2010
alerting them that their stents may have been unnecessary. In Philadelphia, the
University of Pennsylvania Health System sent 700 such notices in April.
Stenting Decline
At least 11 hospitals have settled federal allegations of charging for
needless stenting and other misdeeds in the catheterization labs where the
procedures are performed. Federal probes of stenting practices continue in at
least five states. In Louisiana and Maryland, cardiologists went to federal
prison last year for implanting the devices and charging for them without
medical justification. A third doctor has agreed to do time in a plea bargain.
"There is a huge financial incentive to increase the number of these
procedures," said Jamie Bennett, a former assistant U.S. Attorney in Baltimore
who handled stent investigations. "The cases we have seen to date are just the
tip of the iceberg."
Since Boden's Courage study, stenting procedures have declined by about 20
percent. Still, this July, a panel of experts convened by the American Medical
Association and the Joint Commission, a hospital accreditor, named elective
stenting as one of five overused treatments that too often "provide zero or
negligible benefit to patients, potentially exposing them to the risk of harm."
Better Choices
Doctors are using fewer stents and choosing more-appropriate patients than
they were a few years ago, according to John Harold, president of the American
College of Cardiology, the specialty's main professional group. Harold said
that "real-world clinical practice" and research indicates Brown probably
overestimated how many people with coronary artery disease could be handled
initially only with drug-based treatment.
He said there are examples of inappropriate use and the ACC is taking steps
to "address and correct the imbalance" with treatment guidelines and by urging
more hospital oversight. Cardiologists who've been accused of fraud or are
serving prison time are "outliers" who don't represent the "overwhelming
majority."
Lawyers for John McLean, a Salisbury, Maryland, cardiologist convicted of
billing for unwarranted stenting, argued in a federal appeal last year that
inappropriate usage is widespread and their client was prosecuted for behavior
that's the industry norm.
Lost Appeal
They cited a 2011 study in the Journal of the American Medical Association
that found only half of elective stent procedures nationally were appropriate
under usage guidelines written by societies of heart specialists. The study
found 12 percent were inappropriate, and 38 percent fell into the uncertain
category of the guidelines.
"The study demonstrated clearly that a large number of stable patients
receive coronary artery stents that are later found to be inappropriate or
questionable," the appeal argued. "The same was true of the patients in Dr.
McLean's practice." McLean's appeal was denied in April. He is serving an
eight-year sentence.
Elective-stent patients typically see rapid quality-of-life improvements,
including in their ability to work and be active, according to Ted Bass,
president of the Society for Cardiovascular Angiography and Interventions,
whose members specialize in cardiac implants. The Courage trial found stents,
compared to medication and lifestyle changes, were better at relieving chest
pain for as long as two years after placement -- a benefit that ended by 36
months.
Profit Centers
First used in Europe in 1986, cardiac stents took off in the 2000s as
cardiologists found them to be more effective in heart attacks than
angioplasty. In that earlier technology, a small balloon is inflated to widen
blood passages and then withdrawn. Stenting facilities, known as "cath labs,"
spread at hospitals and became profit centers.
Hospitals receive an average payment of about $25,000 per stent case from
private insurers, according to Healthcare Blue Book, a website that tracks
reimbursements. The federal Medicare program pays less. Doctors who implant
stents earn a separate fee that averages about $1,000 and ranges from $500 to
$2,850, according to Medicare and Blue Book data.
The procedure typically involves inserting the stent with a catheter through
a small incision in the groin area or wrist and snaking it through to heart
vessels. It usually takes less than 45 minutes.
Kickbacks Alleged
Stony Brook's Brown, and Boden, who led the Courage study, argue that many
elective patients should be getting medical therapy before they risk stents.
Only 44 percent try medication and lifestyle changes before stenting, a 2011
study in the Journal of the American Medical Association found.
At least five hospitals have reached settlements with the Justice Department
over allegations that they paid illegal kickbacks to doctors for patient
referrals to their cath labs. St. Joseph Medical Center in Towson, Maryland,
paid the government $22 million without admitting liability.
Prosecutors alleged the hospital paid kickbacks to a practice co-founded by
Baltimore cardiologist Mark Midei for stent referrals. His doctor's license was
revoked in 2011 when the Maryland Board of Physicians found he falsified
records to justify unwarranted stents.
St. Joseph told 585 of its patients they may have received unnecessary
stents. In May, 252 patients reached a settlement with the hospital under
confidential terms, according to Jay D. Miller, an attorney for the plaintiffs.
Plea Agreement
The hospital settled the government's case "to avoid the expense and
uncertainty of litigation," it said in a statement. Spokeswoman Julia
Sutherland said the hospital declined to comment on any patient lawsuits.
In an interview, Midei denied he stented without medical need. He took issue
with experts who deemed many of his stents needless, and said disagreement
among cardiologists on cases is common. Midei was not a party to the federal
settlement. The government has said its investigation of the case continues.
In June, Sandesh Patil, a cardiologist practicing at another St. Joseph
hospital -- this one in London, Kentucky -- agreed to plead guilty to charging
Medicaid for a stent that wasn't medically warranted under the program's rules.
(Although both hospitals were once owned by the same parent, the one in
Maryland has been sold.)
Catheterization procedures multiplied at St. Joseph in London after Patil
began practicing there in 2000, when the hospital had a different name. In that
year, the type of procedure used for stents was done 210 times. They climbed to
929 by 2009, state data show.
Multiple Stents
Stenting income from Medicare alone was more than a sixth of the hospital's
2009 operating income, based on data from American Hospital Directory, a
research firm. When Patil left London in 2010, catheterization procedures fell
34 percent from their 2009 high. Using the midpoint of the directory's price
range for such procedures, the decline would have cost the hospital about $15
million. David McArthur, the hospital's spokesman, declined to comment on its
revenues.
Rhonda McClure, one of Patil's patients, had her arteries catheterized 18
times by him and his partners over four years, according to her deposition and
other filings in a lawsuit she and 361 other patients have brought against
Patil, St. Joseph and other doctors who practiced there. She said she received
eight cardiac stents. The defendants deny the negligence and fraud allegations
against them.
McClure's deposition says a cardiologist who reviewed her case after the
stents told her that scarring caused by "too many procedures" was her main
problem.
Short Breath
McClure said she suffers from chest pain and shortness of breath, and has
been told by her new doctor that she may need more stents and surgery to keep
her coronary arteries from closing. She said she gets so tired she needs to sit
and rest after walking down the stairs.
St. Joseph-London repaid Medicare $256,800 for unnecessary procedures and is
cooperating with federal prosecutors, McArthur said. He said Patil was never
employed by St. Joseph and lost his privileges to practice there in December
2010. Patil's attorney said his client had no comment.
Under his plea bargain, Patil agreed to serve 30 to 37 months in federal
prison. He forfeited his Kentucky medical license for five years. In 2012, he
told a family court judge his monthly income was $53,300.
"Thirty-seven months is nothing for all the injuries he done for money,"
McClure said.
Message Balancing
After the Courage trial shed doubt on stents' effectiveness for stable
patients, stent-implanting cardiologists felt unfairly attacked and organized a
campaign to "better balance the messaging," said Bonnie Weiner, who was
president of the Society for Cardiovascular Angiography and Interventions at
the time.
The society hired a public relations firm and paid it more than $300,000 a
year to help publicize the benefits of stents, according to the group's filings
with the Internal Revenue Service. The firm helped launch a consumer website
for SCAI, SecondsCount.org, which has published several articles, including one
under the headline, "For many patients, open arteries are better than closed
arteries."
SCAI collected $2.7 million in donations for "public education" between 2008
and 2011 from stent makers Abbott Laboratories Inc., Boston Scientific Corp.,
Cordis Corp. and Medtronic Inc., its Web site says. Manufacturers' sales of
cardiac stents were about $5.5 billion globally last year, down 5 percent from
2011, according to the Health Research International consulting firm.
High Median
Medtronic spokesman Joseph McGrath said grants to SCAI for patient education
are "unrestricted," and SCAI is solely responsible for how the funds are used.
Spokesmen for Abbott, Boston Scientific and Cordis declined to comment.
Interventional cardiologists, the specialty SCAI represents, earn a median
income of $562,855 a year, as compared to $207,117 for family doctors,
according to Medical Group Management Association, which surveys physician
practices. The interventionalists ranked 13th among 118 specialties tracked by
MGMA.
Michigan Death
Mehmood Patel, a Lafayette, Louisiana, cardiologist who went to prison last
year on 51 counts of charging for needless stents, made over $16 million in one
three-year span, evidence in the case showed. Prosecutors said he was driven by
the desire to be the busiest cardiologist in town.
He unsuccessfully argued that he used his best medical judgment in every
case and lost an appeal. Patel is serving a 10-year sentence in a federal
penitentiary.
Jashu Patel, an interventionalist in Jackson, Michigan, billed $2.7
million for procedures in 2007, according to a U.S. Justice Department case
against him settled in July. (He is no relation to Mehmood Patel).
The suit alleged Patel implanted needless stents in at least two
patients, including one that led to a blood clot that killed an unnamed woman
who had reported no symptoms of reduced cardiac blood supply. A stress test
showed normal blood flow, and notes in her file said she didn't want
interventions, said Julie Kovach, a cardiologist who worked with Patel and
brought the case to the government's attention.
"It was appalling," Kovach said in an interview. "Patel coerced her into
getting a stent she didn't need, which killed her."
False Claims
Kovach said that when she told the chief operating officer of the hospital
where Patel worked about the death, the executive, Karen Chaprnka, diverted the
conversation. Reached recently by e-mail through a hospital spokesman, Chaprnka
said she "disagreed with the allegations made by Dr. Kovach."
"He's their cash cow," said Kovach, now co-director of a clinic that
treats congenital heart disease at the Detroit Medical Center. "They're not
about to turn him in."
Patel and the hospital, Allegiance Health, agreed to pay the U.S. a total of
$4 million to settle the federal charges. Kovach was awarded $760,000 as a
whistle-blower under the U.S. False Claims Act. Allegiance disagreed with the
allegations and settled the claims to avoid "lengthy litigation," it said in a
statement.
Patel continues to practice at the hospital and must improve
record-keeping to substantiate cardiology procedures, Allegiance said. In the
settlement, Patel agreed to hire a consultant to oversee treatment of his
patients and an auditing firm to monitor billings. He didn't return phone
messages.
Cleveland Raid
In Ohio, Simecek, the worker at the Ford dealership, grew suspicious after
his sixth stent from cardiologist Harry Persaud at the Cleveland Clinic's
Fairview Hospital in 2011. Simecek said he went for a second opinion and was
told he didn't need any of the stents. Now he said he has to take blood
thinners the rest of his life.
"With the littlest cut, the blood starts running," said Simecek. "What if I
am in an auto accident?"
Persaud is under criminal investigation for health care fraud, mail fraud and
money laundering, according to federal court filings. Last October, Federal
Bureau of Investigation agents raided his office and removed financial records
and patient files for procedures at three Cleveland-area hospitals. The
government has seized $343,634 from his and his wife's bank accounts, alleging
the funds represent the proceeds of fraud related to a "significant number" of
unnecessary stent procedures.
Multiple, Elongated
The Cleveland Clinic found "problems related to the use of stents in some
patients" at Fairview and reported them to the government, according to
spokeswoman Eileen Sheil. She would not say how many patients were affected.
Persaud resigned from the hospital staff last year.
At least 64 of Persaud's patients at St. John Medical Center in suburban
Westlake received letters from the hospital saying they may have received an
unnecessary stent between 2010 and 2012, according to spokesman Patrick Garmone,
who said Persaud no longer practices there.
Persaud denied wrongdoing in court filings and said his stent procedures
were proper. Neil Freund, his attorney in lawsuits filed by patients alleging
unwarranted stents, said "it is our intent to defend these cases." He had no
comment on the federal investigation.
Final Order
In Texas, the state medical board's final order in DeMaio's case found that
the cardiologist placed "multiple, elongated, overlapping" stents in patients
in areas of "insignificant or only moderate disease." Peterson, the retired
mailman, was identified only as Patient C in the staff complaint. No patient
was mentioned in the final order.
Peterson was thriving in his new career in the travel business, his wife
Shirlee said. He had a heart attack in 1997, which didn't crimp his love of
travel and dance, she said. "He was an awesome man who never met a stranger,"
she said.
After his death, Shirlee Peterson said a friend told her she had a
cardiologist who refused to do multiple stents.
"I do believe that Bruce was a guinea pig," she said. "That was the way
it was done."
DeMaio said Peterson was extremely sick when he came to him. He said it was
significant that the board's final order didn't use the word "excessive" in
describing his stent work. That included 31 stents stretching for 14 inches
inside the arteries of Patient B in the staff complaint.
"Any patient of mine who received a full metal jacket" -- interventional
cardiology's term for such extensive work -- "would have been turned down by at
least one, if not multiple surgeons," DeMaio said. He said he doesn't use
stents as much these days because standards have changed and he doesn't see as
many seriously ill patients.
Heart stents are small wire-mesh tubes which are used to keep previously clogged
arteries open. Following heart bypass surgery and angioplasty, the stents are
left in the artery to prevent it from re-closing. Stents gained widespread use in
the medical community during the 1990s. Original designs were bare metal devices
inserted into the arteries.
Since 2003, newer types of heart stents containing a
medication coating have dominated the stent market. The
Johnson and Johnson Cypher heart stent
was introduced in 2003 and the
Boston Scientific Taxus heart stent
was introduced in 2004. These medicated
stents have been linked to an increased risk of serious blood clots which could
occur years after the stent is implanted.
Medicated
stent lawsuits
are being reviewed by the lawyers at Saiontz & Kirk, P.A. for
individuals who have suffered:
The lawyers at Saiontz & Kirk are investigating potential heart stent
lawsuits for individuals throughout the United States who have experienced
problems.
Drug eluting stents were designed to prevent the formation of scar tissue
inside of the cardiac arteries which could be caused by bare-metal stents. The
drug-coating is intended to reduce inflammation at the site of the stent which
could lead to tissue growth. The intended benefit of the drug coating is that it
reduces the risk of new blockages forming by this scar tissue. However, recent
studies have shown the drug coating could actually increase the risk of more
serious and deadly blood clots.
The drug coating prevents heart cells from creating a biological lining around
the metal of the stent. This leaves the metal exposed, which acts as a clot
magnet for months and even years after the stent is implanted. When these blood
clots form, it leads to a major heart attack or death approximately 70% of the
time.
As a result of the increased risk of heart stent blood clots, experts have
recommended that patients take a blood thinning medication for significantly
longer than what the manufacturers have been recommending. Currently the warning
label for the Cypher heart stent recommends only three months of blood thinner and
the Taxus heart stent recommends only six months. The increased risk of late
stent thrombosis may require individuals to take a blood thinner for years, or
even the rest of their lives. However, the necessity for continued use of
anti-clotting drugs could carry additional risks. For example,
Plavix side effects
could include severe gastrointestinal bleeding, ulcers,
heart attacks and strokes.
Since the heart stent problems have become more widely known, there has been a
change in philosophy regarding the use of stents in heart patients. Many experts
are indicating that drug coated stents have been used in many situations where
bare-metal stents or long-term drug therapy would be a safer alternative. Only
20% of the drug eluting stents implanted each year are for patients meeting the
profile for which they were approved by the FDA.
MEDICATED STENT LAWSUITS
It has been estimated that over 2,000 deaths each year could have been caused
by drug coated heart stent problems. Although cardiologists previously expressed
concerns about the safety of drug coated stents, the manufacturers have attempted
to minimize the risks. They have previously taken the position that there is no
difference in the risk of clotting between medicated stents and older bare metal.
However, recent studies have established that this information is incorrect.
The medicated heart stent lawyers at Saiontz & Kirk, P.A. are reviewing
potential lawsuits for individuals who have received a drug coated stent.. If
you, a friend or family member have received a cardiac stent and suffered blood
clots, heart attack or death, you may be entitled to compensation. There are no
fees or expenses unless a recovery is obtained.
"... Though the Elyria doctors say they are doing a good job and caring well for their patients, some experts say doctors with financial incentives to prescribe costly treatments cannot be completely unbiased when assessing how to treat a patient. "It's sort of like, you go to a barber and ask if you need a haircut," says Dr. David D. Waters, chief of cardiology at San Francisco General Hospital. "He's likely to say you do." ..."
Aug 21, 2006 | NewsTarget
(NewsTarget) Recent statistics show that a medical clinic in Elyria,
Ohio prescribes profitable angioplasties for heart patients nearly four
times as often as the rest of the country, which has raised questions
among experts as to why the Elyria cardiologists recommend the procedure
so often.
Almost all of the angioplasties at the Elyria hospital are performed
by a group of cardiologists at the North Ohio Heart Center. The group's
leader, Dr. John W. Schaeffer, says his group treats cardiac patients
"very aggressively," and says his
doctors simply
detect disease more often than doctors in the rest of the country and
are quicker to intervene.
However, outside experts say they are concerned that the Elyria
doctors represent a larger trend in U.S. medicine, in which doctors make
medical decisions based more on financial incentives than what is best
and safest for the patient.
For example, Medicare pays the Elyria
hospital $11,000
per angioplasty that uses a drug-coated stent, which earns the
cardiologist
roughly an extra $800. The Elyria doctors performed 3,400 angioplasties
in 2004, which is three times the rate of the procedure in Cleveland,
just 30 miles away. Dr. Eric Topol, a nationally recognized cardiologist
at the Cleveland Clinic, says the Elyria hospital's high rate of
angioplasties lacks "a good explanation," and says Elyria does not seem
to have different risk factors than the rest of Ohio, which has much
lower angioplasty rates.
"It's clear that when doctors and
surgeons are
financially rewarded for treating patients with certain profitable
procedures, many will find a myriad of ways, either consciously or
unconsciously, to come up with a diagnosis that benefits their personal
bank accounts," said Mike Adams, a consumer health advocate and critic
of unnecessary
surgical
procedures.
"This particular practice in Ohio seems to be an
angioplasty factory rather than anything resembling genuine health
care."
Other healthcare systems have adopted a way of paying doctors that
effectively removes financial incentives for prescribing profitable
treatments.
Kaiser Permanente says its Ohio patients are less likely to
undergo the kinds of cardiac procedures performed at the Elyria hospital
because its cardiologists work on a salary basis rather than being paid by the
procedure.
Though the Elyria doctors say they are doing a good job and caring
well for their patients, some experts say doctors with financial
incentives to prescribe costly treatments cannot be completely unbiased
when assessing how to treat a patient. "It's sort of like, you go to a
barber and ask if you need a haircut," says Dr. David D. Waters, chief
of cardiology at San Francisco General Hospital. "He's likely to say you
do."
"... But stents haven't been shown to reduce the risk of heart attacks in patients without symptoms, says James Beckerman, a cardiologist at the Providence Heart and Vascular Institute in Portland, Ore. Stents also don't help these patients live longer. And Nissen notes that stents themselves can become clogged up, causing greater problems. ..."
"... Bush spokesman Ford said Tuesday that, while Bush didn't experience those symptoms, "the stent was necessary. His annual physical includes a stress test. EKG changes during the stress test yesterday prompted a CT angiogram, which confirmed a blockage that required opening." ..."
"... Nissen said he's concerned about "overtesting" and overtreating people like Bush when they have no symptoms. ..."
"... "He did a 100-kilometer bike ride," says Nissen, a feat that would be impossible for someone on the verge of a heart attack. "How can a stent make him better?" ..."
"... People without symptoms also don't need annual stress tests, in which patients walk on a treadmill while doctors perform a test called an EKG, or electrocardiogram, Nissen says. ..."
Patients typically will take blood thinners, such as aspirin and clopidogrel, which help prevent
further clots, McPherson says. Doctors will also test Bush's cholesterol to see if he needs to take
statins, which help reduce cholesterol and which, like clopidogrel and low-dose aspirin, would be
taken for the rest of his life.
At 67, Bush is at an age that puts him at higher risk of a heart attack, McPherson says.
Yet Bush, an avid jogger and bicyclist, is exceptionally fit for a man of any age. Since leaving
office, Bush has hosted 100-kilometer bicycle rides for wounded troops, the most recent in May near
Waco.
But even a healthy lifestyle won't prevent all heart disease, McPherson says. And while the stent
indicates that Bush has an increased risk of heart attack, managing his risk factors, such as his
cholesterol and blood pressure, will help keep him healthy.
The Cleveland Clinic's Steven Nissen questions whether Bush will really benefit from a stent.
Doctors typically place stents only in patients who are having heart attacks or significant symptoms,
such as chest pain, says Nissen, chairman of cardiovascular medicine at the Cleveland Clinic. Stents
can help keep blood flowing and reduce the risk of a heart attack in these patients.
But stents haven't been shown to reduce the risk of heart attacks in patients without symptoms,
says James Beckerman, a cardiologist at the Providence Heart and Vascular Institute in Portland,
Ore. Stents also don't help these patients live longer. And Nissen notes that stents themselves can
become clogged up, causing greater problems.
Bush spokesman Ford said Tuesday that, while Bush didn't experience those symptoms, "the stent
was necessary. His annual physical includes a stress test. EKG changes during the stress test yesterday
prompted a CT angiogram, which confirmed a blockage that required opening."
A significant number of patients end up with stents after a routine physical, McPherson says.
That's because some patients who experience occasional chest pain or shortness of breath may not
tell anyone about their symptoms until a doctor asks.
Nissen said he's concerned about "overtesting" and overtreating people like Bush when they
have no symptoms.
"He did a 100-kilometer bike ride," says Nissen, a feat that would be impossible for someone
on the verge of a heart attack. "How can a stent make him better?"
People without symptoms also don't need annual stress tests, in which patients walk on a treadmill
while doctors perform a test called an EKG, or electrocardiogram, Nissen says.
Bush likely "got the classical thing that happens to VIP patients, when they get so-called executive
physicals and they get a lot of tests that aren't indicated. This is American medicine at its worst."
While it's possible to have a major artery blockage without symptoms, Nissen says that screening
everyone with stress tests would end up doing more harm than good. That's because these screenings
can lead to risky medical procedures that don't offer any proven benefit.
Still, McPherson notes that experts agree it makes sense to test certain professionals, such as
school bus drivers and airline pilots, because a sudden heart attack on the job could cost many lives.
"... Medical mistakes are the third leading cause of death in the U.S. - and are often occasioned by excessive testing and treatment delivered in an uncoordinated way by doctors who know lab tests, but don't know their patients. ..."
"... Clearly, too much medicine can be very bad for your health ..."
"... The biggest culprit in overtreatment is over testing. We have developed sophisticated technology that discovers incidental "diseases" that would have little or no impact on our lives and then treats them with disproportionately blunderbuss interventions that often cause more harm than good. ..."
"... Aggressive treatments that are delivered for non-aggressive "diseases" cause more problems than they solve. ..."
"... Not so long ago, doctors routinely bled their patients, gave them emetics and cathartics, and poisoned them with heavy metals. Future observers of our current practice will find some of what we are doing now equally wrong headed and harmful. ..."
"... Diagnostic inflation has also resulted in overtreatment of diabetes, hypertension, osteoporosis, attention deficit disorder, most problems that lead to orthopedic surgery, and lots more of what constitutes everyday medical practice. ..."
"... Most destructive has been the commercialization of medicine as a big business - healing art transformed into profitable cash cow. Perverse financial incentives encourage disease mongering, false advertising, over testing, quick diagnosis, and unnecessarily aggressive treatment. ..."
"... Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM-IV task force. ..."
wrote that the first "Preventing
Overdiagnosis" conference was easily the most important meeting I had ever attended.
Last week's third "Preventing Overdiagnosis" conference, held at the National Institutes of Health
in Washington, D.C. was even better. The conference was sponsored by the National Cancer Institute
in collaboration with Oxford University, the British Medical Journal, Consumer Reports, and Bond
and Dartmouth Universities. Hundreds of presentations covered the causes, consequences, and cures
of overdiagnosis from every conceivable angle and laid out an agenda for future action. The international
audience of 350 was as bright a group as I have ever encountered in almost 50 years of attending
medical meetings.
The topic is the highest priority public heath problem we face in the U.S. and increasingly around
the world. Medical mistakes are the third leading cause of death in the U.S. - and are often
occasioned by excessive testing and treatment delivered in an uncoordinated way by doctors who know
lab tests, but don't know their patients.
Clearly, too much medicine can be very bad for your health . And it is also a disaster
for the health of our economy. The U.S. spends $3 trillion a year on heath care - more than the GDP's
of all but four countries in the world. Because one-third of this enormous investment is sheer waste,
it is no surprise that we get lousy outcomes compared to countries that spend much less, but spend
much more wisely.
The biggest culprit in overtreatment is over testing. We have developed sophisticated technology
that discovers incidental "diseases" that would have little or no impact on our lives and then treats
them with disproportionately blunderbuss interventions that often cause more harm than good.
Rates of breast, prostate, and thyroid cancer increased dramatically not because people are sicker,
but because disease definition has been broadened to inflate diagnosis. Much of what is now called
"cancer" is not really cancer at all, or so slow growing that it is not really health or life threatening.
Aggressive treatments that are delivered for non-aggressive "diseases" cause more problems
than they solve. Our current excess of therapeutic zeal follows a long historical tradition
of well intended, but overly exuberant, doctors harming their patients with really terrible treatments.
Not so long ago, doctors routinely bled their patients, gave them emetics and cathartics, and
poisoned them with heavy metals. Future observers of our current practice will find some of what
we are doing now equally wrong headed and harmful.
Diagnostic inflation has also resulted in overtreatment of diabetes, hypertension, osteoporosis,
attention deficit disorder, most problems that lead to orthopedic surgery, and lots more of what
constitutes everyday medical practice.
Overtreatment is driven by many powerful and interacting forces and will be difficult to tame.
Most destructive has been the commercialization of medicine as a big business - healing art
transformed into profitable cash cow. Perverse financial incentives encourage disease mongering,
false advertising, over testing, quick diagnosis, and unnecessarily aggressive treatment.
Often the best medical decision is to cautiously watch and wait, but this is discouraged by reimbursement
mechanisms that favor quickly jumping in with potentially harmful, very expensive, and often unnecessary
treatments. The powerful medical-industrial complex will exert all its considerable financial and
political might to protect its profits, even if this means compromising patient welfare and eating
up the economy. The obvious solution here is to substitute capitation for crazy fee-for-service incentives
that reward the health system for doing more.
Too much medicine has also been driven by a medical research enterprise that systematically rewards
scientists, journals, and the media for hyping often-false positive findings. Negative findings that
would encourage the public to have a healthy skepticism about exaggerated claims are buried.
The result: patients accept, and even clamor for, testing and treatment that is more likely to
harm than help. People fear the risks of illness too much and fear risks of treatment far too little.
A great deal of conference time was thus productively devoted to the communication tools necessary
to help right this imbalance. Patients must become informed consumers to balance the benefits of
treatment with its risks and protect themselves from a system pushing them to always want more than
may be good for them.
Regulators of medical excess no longer regulate. Seven years ago, the Food and Drug Administration,
approved only one third of drug applications. This year, it has approved 96 percent. And drug companies
are increasingly winning the right to mislead both the public and physicians, with false advertising
and pushing off-label prescription.
Quality Assurance programs also play an unwitting role. Historically, QA has focused on identifying
the things that should have been done during the course of treatment, but were left out. As a result,
nine tenths of QA measures tap errors of omission, only one-tenth errors of commission. Unless this
imbalance is redressed, QA will continue to drive doctors to do too much, even in situations where
less would be more.
Unless applied cautiously, 'Personalized' or 'Precision' medicine may make things worse, becoming
the next slick advertising gimmick to justify the use of treatments that have failed to prove their
effectiveness in large groups. A more precise medicine would offer much less, not more, treatment.
The battle to tame medical excess is classic David vs. Goliath. But, fortunately, David has some
potentially effective pebbles and might sometimes does come from being in the right. Thirty years
ago, Big Tobacco seemed as impregnable as the medical-industrial complex, but it was toppled by its
obvious outrageousness, dedicated opposition, public and media awakening, and lawsuits. The same
combination, along with the inevitable need for cost containment, will eventually tame the medical
beast- the question is how long will this take and how much harm will be done to patients and the
economy before we get back to patient-driven, rather than profit driven medicine.
The conference wasn't perfect. There was a preaching to the choir feeling. Future conferences
should invite debate with leaders from the forces promoting overtreatment - e.g., the insurance industry,
Pharma, hospital associations, physician specialty groups, and consumer advocacy. Government and
employers wind up footing the lion's share of medical costs and need to hear how much of their expenditure
is not only wasteful financially, but also bad for the people they are trying to help.
The conference was attended by about a dozen science writers interested in the topic, but it did
not itself become the big media story it can and should be. More intense public relations could lead
to numerous stories alerting the public about which specific tests and treatments are most overdone
and most risky.
And there could have been more discussion about how best to unite the various groups fighting
against medical excess and hype. 'Choosing Wisely'; the Lown Foundation's 'RightCare' initiatitive;
the HeathNews Review; the British Medical Journal; Consumer's Reports; and the many researchers and
educators engaged in the field are all individually wonderful, but might collectively be more effective
if their efforts were better coordinated.
Bottom line: Medical marvels are oversold and overbought. Doctors need to be more humble and safety-conscious.
We can't overstep our knowlege base without putting our patients at risk. Patients and doctors need
to accept the uncertainty and limits of medicine. False certainty leads to terrible decisions.
We must not ignore the most important ethic in medicine laid out 2500 years ago by Hippocrates:
First Do No Harm.
Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM-IV
task force.
One motivation for insurance fraud is a desire for financial gain. Public healthcare programs
such as
Medicare and Medicaid are
especially conducive to fraudulent activities, as they are often run on a
fee-for-service
structure.[20]
Notable quotes:
"... Recent studies show that medicine and angioplasty with stenting have equal benefits. Angioplasty with stenting does not help you live longer, but it can reduce angina or other symptoms of coronary artery disease. ..."
"... Angioplasty with stenting, however, can be a life-saving procedure if you are having a heart attack ..."
A few days ago I answered the same question about Coronary Artery Bypass Graft (CABG) surgery.
The indications are essentially the same.
Stents are used to open blockages in a tubule structure. They are most commonly known for their
use in the coronary arteries but may be used in other areas as well. In the arteries they are
used to spread the artery open where a blockage or narrowing has occurred. Some patients are
served well by stents but others require CABG. The decision is normally made by the cardiologist.
Stenting or CABG is determined by the number of blockages, the severity and their location(s).
Normally, you go in for a catheterization.
If blockages are found and stents are needed, it will
normally be done at that time. If CABG is required, they will complete the catheterization then
arrangements will be made to perform the CABG.
To see the question on CABG and my and others answers click this link:
There are a ton of other information sources. If you would like more just contact me by going to
my profile. There you can click on "Email Terry S" or click the link below.
The main purpose of a stent is to counteract significant decreases in vessel or duct diameter by
acutely propping open the conduit by a mechanical scaffold or stent. Stents are often used to
alleviate diminished blood flow to organs and extremities beyond an obstruction in order to
maintain an adequate delivery of oxygenated blood. Although the most common use of stents is in
coronary arteries, they are widely used in other natural body conduits, such as central and
peripheral arteries and veins, bile ducts, esophagus, colon, trachea or large bronchi, ureters,
and urethra.(Wikipedia)
Most of the time, stents are used to treat conditions that result when arteries become narrow
or blocked. The devices are also used to unblock and keep open other tube-shaped structures in
the body, including the ureters (the tubes that drain urine from the kidneys to the bladder) and
bronchi (the small windpipes in the lungs).
Stents are commonly used to treat coronary heart disease (CHD). If you have coronary artery
disease that does not cause symptoms, you can be treated with either medicine or angioplasty with
stenting.
Recent studies show that medicine and angioplasty with stenting have equal benefits.
Angioplasty with stenting does not help you live longer, but it can reduce angina or other
symptoms of coronary artery disease.
Angioplasty with stenting, however, can be a life-saving procedure if you are having a heart
attack
Other reasons to use stents include:
* Keeping open a blocked or damage ureter * Treatment of aneurysms, including thoracic aortic aneurysms
* Unblocking a large artery, such as the carotid artery (carotid endarterectomy) * To keep bile flowing in blocked bile ducts (biliary stricture)
* Helping you breathe if you have a blockage in the airways
Dr Frank
Stents are inserted routinely now at angioplasty to improve the chances of keeping the vessel
open. They would be used for any lesion where the vessel is wide enough to take them. Since the
routine use of better anti platelet drugs, clopidogrel, the risk that the stent itself will clot
has been reduced dramatically.
Source(s): GP for more years than I care to remember Dr Frank · 9 years ago
"... A Westlake cardiologist was convicted of performing unnecessary catheterizations, tests, stent insertions and causing unnecessary coronary artery bypass surgeries as part of a scheme to overbill Medicare and other insurers by $7.2 million, law enforcement officials said. ..."
A Westlake cardiologist was convicted of performing unnecessary catheterizations,
tests, stent insertions and causing unnecessary coronary artery bypass surgeries as part of a scheme
to overbill Medicare and other insurers by $7.2 million, law enforcement officials said.
Dr. Harold Persaud, 56, was convicted of one count of health care fraud, 13 counts of making false
statements and one count of engaging in monetary transactions in property derived from criminal activity.
He was acquitted on one count of making a false statement.
"The evidence presented at this trial was troubling," said U.S. Attorney Steven M. Dettelbach. "Inflating
Medicare billings alone would be bad enough. Falsifying cardiac care records, making an unnecessary
referral for open heart surgery and performing needless and sometimes invasive heart tests and procedures
is inconsistent with not only federal law but a doctor's basic duty to his patients."
"This doctor violated the sacred trust between doctor and patient by ordering unnecessary tests,
procedures and surgeries to line his pockets," said Stephen D. Anthony, Special Agent in Charge of
the FBI's Cleveland Office. "He ripped off taxpayers and put patients' lives at risk."
"Medical providers have a duty and obligation to provide only those services that are medically necessary
and are in the best interests of the patients under their care," said Lamont Pugh III, Special Agent
in Charge, U.S. Department of Health & Human Services, Office of Inspector General – Chicago Region.
"This conduct shows a disregard for patient needs in exchange for financial gain at taxpayer expense.
The OIG will continue to work with our law enforcement and prosecutorial partners to identify fraudulent
health care schemes and hold individuals accountable for their actions."
Persaud had a private medical practice at 29099 Health Campus Drive in Westlake and had hospital
privileges at Fairview Hospital, St. John's Medical Center and Southwest General Hospital, according
to court documents and trial testimony.
Persaud devised a scheme to defraud and obtain money from Medicare and other insurers. The scheme
took place between Feb. 16, 2006, through June 28, 2012. According to according to court documents
and trial testimony, his activities in furtherance of the scheme included:
Persaud selected the billing code for each customer submitted to Medicare and private insurers, and
used codes that reflected a service that was more costly than that which was actually performed;
Persaud performed nuclear stress tests on patients that were not medically necessary;
He knowingly recorded false results of patients' nuclear stress tests to justify cardiac catheterization
procedures that were not medically necessary;
Persaud performed cardiac catheterizations on patients at the hospitals and falsely recorded the
existence and extent of lesions (blockage) observed during the procedures;
He recorded false symptoms in patient records to justify testing and procedures on patients;
Persaud inserted cardiac stents in patients who did not have 70 percent or more blockage in the vessel
that he stented and who did not have symptoms of blockage;
He placed a stent in a stenosed artery that already had a functioning bypass, thus providing no medical
benefit and increasing the risk of harm to the patient;
He improperly referred patients for coronary artery bypass surgery when there was no medical necessity
for such surgery, which benefitted Persaud by increasing the amount of follow-up testing he could
perform and bill to Medicare and private insurers;
Persaud performed medically unnecessary stent procedures, aortograms, renal angiograms and other
procedures and tests.
As a result of this scheme, Persaud overbilled and caused the overbilling of Medicare and private
insurers in the amount of approximately $7.2 million, of which Medicare and the private insurers
paid approximately $1.5 million, according to the indictment.
This case is being prosecuted by Assistant U.S. Attorneys Michael L. Collyer and Chelsea Rice following
an investigation by the Federal Bureau of Investigation and the U.S. Department of Health and Human
Services – Office of Inspector General
Heart stents are small wire-mesh tubes which are used to keep previously clogged
arteries open. Following heart bypass surgery and angioplasty, the stents are
left in the artery to prevent it from re-closing. Stents gained widespread use in
the medical community during the 1990s. Original designs were bare metal devices
inserted into the arteries.
Since 2003, newer types of heart stents containing a
medication coating have dominated the stent market. The
Johnson and Johnson Cypher heart stent
was introduced in 2003 and the
Boston Scientific Taxus heart stent
was introduced in 2004. These medicated
stents have been linked to an increased risk of serious blood clots which could
occur years after the stent is implanted.
Medicated
stent lawsuits
are being reviewed by the lawyers at Saiontz & Kirk, P.A. for
individuals who have suffered:
The lawyers at Saiontz & Kirk are investigating potential heart stent
lawsuits for individuals throughout the United States who have experienced
problems.
Drug eluting stents were designed to prevent the formation of scar tissue
inside of the cardiac arteries which could be caused by bare-metal stents. The
drug-coating is intended to reduce inflammation at the site of the stent which
could lead to tissue growth. The intended benefit of the drug coating is that it
reduces the risk of new blockages forming by this scar tissue. However, recent
studies have shown the drug coating could actually increase the risk of more
serious and deadly blood clots.
The drug coating prevents heart cells from creating a biological lining around
the metal of the stent. This leaves the metal exposed, which acts as a clot
magnet for months and even years after the stent is implanted. When these blood
clots form, it leads to a major heart attack or death approximately 70% of the
time.
As a result of the increased risk of heart stent blood clots, experts have
recommended that patients take a blood thinning medication for significantly
longer than what the manufacturers have been recommending. Currently the warning
label for the Cypher heart stent recommends only three months of blood thinner and
the Taxus heart stent recommends only six months. The increased risk of late
stent thrombosis may require individuals to take a blood thinner for years, or
even the rest of their lives. However, the necessity for continued use of
anti-clotting drugs could carry additional risks. For example,
Plavix side effects
could include severe gastrointestinal bleeding, ulcers,
heart attacks and strokes.
Since the heart stent problems have become more widely known, there has been a
change in philosophy regarding the use of stents in heart patients. Many experts
are indicating that drug coated stents have been used in many situations where
bare-metal stents or long-term drug therapy would be a safer alternative. Only
20% of the drug eluting stents implanted each year are for patients meeting the
profile for which they were approved by the FDA.
MEDICATED STENT LAWSUITS
It has been estimated that over 2,000 deaths each year could have been caused
by drug coated heart stent problems. Although cardiologists previously expressed
concerns about the safety of drug coated stents, the manufacturers have attempted
to minimize the risks. They have previously taken the position that there is no
difference in the risk of clotting between medicated stents and older bare metal.
However, recent studies have established that this information is incorrect.
The medicated heart stent lawyers at Saiontz & Kirk, P.A. are reviewing
potential lawsuits for individuals who have received a drug coated stent.. If
you, a friend or family member have received a cardiac stent and suffered blood
clots, heart attack or death, you may be entitled to compensation. There are no
fees or expenses unless a recovery is obtained.
"... Angioplasty is performed in more than 600,000 patients a year – roughly half of them Medicare patients – often as an alternative to bypass surgery. ..."
"... A study published in the Journal of the American Medical Association in 2011 pegged the cost to the health care system at an estimated $12 billion a year. ..."
"... The procedure also has risks. About 5 percent of people suffer complications including bleeding, blood clots, infection, heart rhythm disturbances and even death from heart attack. ..."
"... When doctors install drug-coated stents, as most now do, patients must take aspirin and certain anti-clotting medications for a year to guard against life-threatening clots. ..."
"... But the need to rein in unnecessary procedures is still considered so pressing that the American College of Cardiology in 2012 published "appropriateness" criteria to guide physicians' judgment. ..."
"... Monroe ranks near the top of hospital referral regions with the highest level of "potentially avoidable hospital costs," according to the Commonwealth Fund Scorecard on Local Health System Performance. ..."
"... The question is: Are they doing things that need to be done? Or are they widget makers, putting in widgets because that's what the system incents them to do?" ..."
"... In 2012 alone, Paulus received $305,967 from Medicare for 923 catheterizations and angioplasties. His work accounted for more than 15 percent of all of the procedures performed in the region and made him the sixth-busiest cardiac catheterization specialist in the nation. Federal investigators were so struck by the hospital's high catheterization rates that they launched a probe of its catheterization laboratory. ..."
"... Last spring, the hospital agreed to pay the government $41 million to settle allegations that, between 2006 and 2011, the hospital submitted millions of dollars' worth of "false claims" to Medicare and Medicaid for performing angioplasties and implanting stents in "numerous" patients who did not need them, according to an FBI press release. ..."
"... "The decision to do the procedure is made by the person who would benefit from the procedure," says Dr. David O. Williams, a cardiologist at Brigham and Women's Hospital in Boston. ..."
Dr. Gregory Sampognaro is one of the busiest interventional cardiologists in the
United States, clearing out clogged coronary arteries in hundreds of patients
every year. Sampognaro ranked 17th in the U.S. in 2012 in the number of these
procedures, according to a U.S. News & World Report analysis of Medicare data.
What makes these numbers noteworthy is that Sampognaro works not in a medical
mecca like New York or Chicago but in Monroe, Louisiana, a fading
Mississippi-delta agricultural community of 54,000 in one of the poorest
congressional districts in the U.S.
Sampognaro is one of dozens of cardiologists in communities outside major metro
areas who are performing catheterization procedures – such as
diagnostic angiograms and artery-clearing angioplasties
– at higher rates than
doctors working at big city hospitals that serve as major cardiac referral
centers, the U.S. News analysis found.
While no one has accused Sampognaro of doing anything wrong, experts who have
reviewed the U.S. News data say it raises a critical question, not just for
patients seeking coronary care in Monroe but for those in other parts of the
country: How many of these catheterization procedures are medically advisable and
how many put patients at unnecessary risk and add billions of dollars to the
nation's medical bill?
"You have to wonder what's going on," says Harvard physician and historian Dr.
David Jones, author of "Broken Hearts: The Tangled History of Cardiac Care." "Are
these doctors going to get bigger paychecks at the end of the month for doing more
of these procedures? That may be an uncomfortable question to ask, but it's
something patients should wonder about."
By his own account, Sampognaro does most of the procedures in Monroe.
"I already know that I'm one of the busiest cardiologists in the country," he
says. "The reason is geography. I practice in an extremely underserved area. There
are only four interventional cardiologists in northeast Louisiana. I'm one of
four. In Shreveport, there's probably 30. Want to know why? No one wants to live
in Monroe, except people who are from here. Now, if I was in some big city I
wouldn't have those numbers because there are interventional cardiologists on
every corner."
Dwight Vines, Monroe's economic development officer, says it's "generally known"
in Monroe that if you go see Sampognaro, he's likely to send you to the hospital
for a procedure. "He sent me over." Vines says. "He does a lot of this."
Until recently, U.S. doctors and their practice patterns were protected from
scrutiny by a legal ruling that shielded Medicare data from public release. A U.S.
District Judge lifted the ruling in 2014, making it possible for U.S. News and
other organizations to
examine Medicare data
that reveal how doctors practice medicine, how much
money they make and how they compare to their peers.
Angioplasties and related procedures are some of the most common and controversial
in medicine.
A study
published in the Journal of the American Medical Association in 2011 pegged the
cost to the health care system at an estimated $12 billion a year.
Interventional cardiologists like Sampognaro insert a small tube called a catheter
into a blood vessel in the patient's groin or wrist, and guide it to the coronary
arteries. There they obtain diagnostic images and remove blockages. Expandable
devices called stents are then inserted to prop open the blocked artery.
Angioplasty's benefits are unquestioned for patients in the grip of a heart
attack. Clearing a clogged artery and restoring the heart's blood supply can save
a patient's life. In the two-thirds of patients who are not having heart attacks,
however, angioplasty's benefits are far less clear. Angioplasty can relieve chest
pain from chronic angina, but it cannot prevent heart attacks or prolong survival.
Patients with unstable angina reap more symptom relief from angioplasty than from
drug treatment. In chronic, stable heart-disease patients, studies show, drug
treatment may work just as well angioplasty .
The procedure also has risks. About 5 percent of people suffer complications
including bleeding, blood clots, infection, heart rhythm disturbances and even
death from heart attack.
When doctors install drug-coated stents, as most now do,
patients must take aspirin and certain anti-clotting medications for a year to
guard against life-threatening clots.
"This is a very controversial arena. Any number of people don't want this exposed.
Nobody wants to kill the goose that lays the golden egg," says William Boden,
chief of medicine at the Albany Stratton VA Medical Center in Albany, New York.
Boden was lead author of a study, published in 2007 in the New England Journal of
Medicine, showing for the first time that optimal drug treatment worked as
effectively as angioplasty and stenting in stable heart - disease patients.
A
flurry of subsequent studies have since confirmed the finding and underpin the
push to eliminate unnecessary procedures.
Experts have zeroed in on reducing the number of catheterizations as a way to slow
rising health care costs. The total has declined dramatically since Boden's study,
called Courage, appeared.
But the need to rein in unnecessary procedures is still
considered so pressing that the American College of Cardiology in 2012 published
"appropriateness" criteria to guide physicians' judgment.
Applying these standards
nationwide could cut the number of catheterization procedures significantly,
research shows. One study of more than 140,000 procedures, for instance, found
that nearly 12 percent were unnecessary and 38 percent were questionable.
The trouble is that it is difficult for anyone other than the cardiologist-or
someone else with access to the patient's confidential medical record-to determine
whether an interventional procedure is appropriate or not.
The Medicare claims data used in the U.S. News analysis lack the critical
information needed to make that determination.
But claims data can "flag hospitals
that would potentially have a lot of cases that would then need to be investigated
in more detail," says Edward Hannan, a professor of epidemiology at the State
University of New York at Albany who pioneered efforts to evaluate the
appropriateness of angioplasty procedures in New York State.
U.S. Attorney Kerry Harvey, who handles Medicare, Medicaid and other cases in
eastern Kentucky, says federal investigators use data-analysis techniques similar
to those used by U.S. News to
identify doctors and
hospitals
that merit a close look by medical experts.
The experts compare the doctor's notes and billing records with images of the
patients' arteries. "We retain cardiologists," he says. "We look for people with
great skills and no bias. You have these experts look at the films and compare
what they see with what they see in the medical record. We steer a wide berth
around medical judgment. If it's close we're going to give [physicians] the
benefit of the doubt." Sampognaro performs many of his procedures at a same-day surgery center called P&S
Surgical Hospital that he co-owns with 49 other physicians and a local
full-service hospital.
In 2012, Medicare paid Sampognaro $1.1 million, of which $276,601 was for 729
angiographies and angioplasties. Services to patients covered by commercial
Medicare HMOs or to patients under age 65 are not included, nor are copayments
from Medicare patients.
The average cath-lab physician performed 99 procedures in
2012. Sampognaro asserts that the number of patients suffering from heart disease
in the Mississippi Delta drives demand for his services. "We're also in the center
of the most unhealthy part of the country," Sampognaro says. "People eat bad,
they're overweight, the congressional district in this area is one of the poorest
in the country. Everybody has coronary artery disease."
Monroe's unhealthy population may partly explain why Medicare's cost per enrollee
there is 35 percent higher than the national average. But the parish's health
status isn't the only explanation.
Monroe ranks near the top of hospital referral
regions with the highest level of "potentially avoidable hospital costs,"
according to the Commonwealth Fund Scorecard on Local Health System Performance.
U.S. News did a second analysis to examine whether population patterns influenced
the number of procedures performed by cardiologists outside of urban areas. This
analysis broke down cardiac catheterization statistics by hospital referral
regions, which are geographic areas surrounding medical centers that serve as
regional health care hubs. Rather than focusing on raw numbers of procedures, the
second analysis calculated the procedure rate per 1,000 Medicare beneficiaries,
which puts all of the analyzed areas on the same footing, regardless of
population.
For every 1,000 beneficiaries in the region served by Monroe's hospitals , 59 went
through cardiac catheterization lab procedures in 2012. That was double the
national average and far higher than in cities that are home to major medical
centers. In San Francisco, for example, the rate was 13 per 1,000 Medicare
enrollees. The analysis resulted in similar findings for many other rural areas.
U.S. News conducted a final analysis that adjusted the regional rates to account
for the incidence of heart attack in each region in 2012. That analysis showed
heart attack rates explained little of the regional variation in cardiac
catheterization. Many of the rural communities with unusually high rates,
including Monroe, remained outliers even after adjusting for the heart attack
rate.
Dr. Christopher White, chief of interventional cardiology at the Ochsner Clinic
Foundation in New Orleans, taught Sampognaro in the late 1990s during a
cardiovascular disease fellowship. He says the U.S. News findings underscore the
importance of making sure physicians are not exposing patients to unnecessary
procedures.
"Making seven figures isn't unusual for an interventional cardiologist," White
says. "These guys work hard. They're putting in their 12- or 13-hour days.
The
question is: Are they doing things that need to be done? Or are they widget
makers, putting in widgets because that's what the system incents them to do?"
The U.S. News analysis flagged cardiologists in other communities as well. Judging
from their catheterization rates, doctors in the Huntington, West Virginia, region
were also among the busiest cardiologists in the United States. More than 91 of
every 1,000 Medicare enrollees in the region underwent procedures in 2012-a rate
nearly triple the national average. The probability that the high rates were due
to random variation was less than one in 1,000.
The doctor who submitted the largest bill for cardiac cath lab procedures in the
region in 2012 was Dr. Richard Paulus, a prominent cardiologist at King's
Daughters Medical Center in Ashland, Kentucky, an Ohio River community of 21,000,
just west of Huntington, where the hospital has eclipsed the steel industry as the
town's biggest employer. Paulus, who retired from the hospital in July 2014, is so
closely identified with King's Daughters that the heart pavilion there carries his
name.
In 2012 alone, Paulus received $305,967 from Medicare for 923 catheterizations and
angioplasties. His work accounted for more than 15 percent of all of the
procedures performed in the region and made him the sixth-busiest cardiac
catheterization specialist in the nation.
Federal investigators were so struck by the hospital's high catheterization rates
that they launched a probe of its catheterization laboratory.
Last spring, the
hospital agreed to pay the government $41 million to settle allegations that,
between 2006 and 2011, the hospital submitted millions of dollars' worth of "false
claims" to Medicare and Medicaid for performing angioplasties and implanting
stents in "numerous" patients who did not need them, according to an FBI press
release.
The settlement terms allowed the hospital to deny wrongdoing in the case. Paulus has not been charged. His lawyer, Robert Bennett, acknowledges that Paulus
is under investigation, but asserts that his client "adamantly denies wrongdoing
in this case."
Terre Haute, Indiana, ranked just after Huntington as the second-busiest region in
the country for cardiac catheterization. For every 1,000 Medicare enrollees in the
area, doctors performed 83 procedures. The Alexandria, Louisiana, region ranked
third, with a rate of 73 per 1,000. Physicians there billed for 3,355 cath lab
procedures. By contrast, in Las Vegas, a region that is home to a more than three
times the number of Medicare beneficiaries, physicians billed the federal health
plan for only 3,368 procedures.
"In a world where everything made sense, it would be the big cities that have
high-volume angioplasty centers," says Dr. Spencer King of Emory Healthcare in
Atlanta, an angioplasty pioneer who reviewed the U.S. News data.
A factor that may contribute to the high rates of angioplasties is that some
interventional cardiologists administer the stress tests and imaging studies that
determine whether a procedure is warranted.
For aggressive cardiologists, that approach has two potential benefits – it boosts
their income and gives them control over interpreting the tests. One way to
eliminate the conflict of interest, experts say, would be to shift responsibility
for giving the green light from the interventional cardiologist who performs the
procedure to the doctor who referred the patient in the first place. In most
hospitals, that's not the way it works.
"The decision to do the procedure is made by the person who would benefit from the
procedure," says Dr. David O. Williams, a cardiologist at Brigham and Women's
Hospital in Boston.
High volumes alone don't necessarily translate into unnecessary procedures. In
some cases, interventional cardiologists may perform large numbers of procedures
because they serve many doctors who refer patients for specialized testing and
treatment, says Dr. Gregory Dehmer, chief of cardiology at Scott & White
Healthcare in Dallas.
U.S. Attorney Harvey, who handled the Paulus case, agrees. "Just because you have
a provider who's a statistical outlier, that doesn't mean the provider has done
anything wrong," he says. " It simply raises questions. Sometimes there are
completely legitimate explanation why the data is what it is."
Even doctors who aren't swayed by financial considerations still wrestle daily
with the challenging question of whom to treat. The ACC's National Cardiovascular
Data Registry, which gathers clinical data on heart disease cases nationwide, has
moved to address the issue by encouraging cardiologists to monitor their own
practice patterns. Registry participation is voluntary, but the 1,600 member
hospitals supply data on 95 percent of the nation's angioplasties. Doctors can
explore their own procedure volumes, complications and outcomes against those of
other doctors, available as benchmarked averages. They seldom do, says ACC
cardiologist Dr. Ralph Brindis.
"Only a small percentage of physicians have gotten the message and bother to look
at their data," which have been available for about 18 months, Brindis says. The
registry is prohibited by its member hospitals from making detailed physician
performance data public, he adds.
Steve Sternberg is a senior writer for U.S. News and a data journalist
covering health care performance, health policy, clinical medicine and public
health. You can follow him on Twitter (
@stevensternberg
),
connect with him
on
LinkedIn
or email him at
[email protected].
Meador's perspective faults the medical industrial complex (MIC) for its encouragement of sickness
- after all, that is how it makes money, by repairing people, surgery and drugs.
To gain more immediate access to people's anxieties, their underlying hypochondiasis, "The Last Well
Person" takes aim at all the innuendos and commercial strategies that the MIC uses to gain access.
The response of the young doctor when he or she is asked to define a healthy person replies "a healthy
person is one who has not been fully worked up" is prescient, always another test to be done another
treatment to be given.
All of this streams from the simple fact that no one of us is emotionally or intellectually strong
enough to withstand constant intensive self-scrutiny. The magnifying mirror reveals many imperfections
that the medical system is eager to take care of
The whole array of pre-diagnoses, pre-cancer, pre-hypertension, pre-dementia feeds into this pattern.
I have personally participated in this labeling frenzy. I wrote a book "Diabetes Danger" that is
actually not about having diabetes but about not getting diabetes in the first place. In it I coined
the new term "pre-pre-diabetes" to classify those millions of people who do not yet qualify for the
specific diagnosis of diabetes or pre-diabetes (fasting blood sugar over 100, or a two-hour after
eating blood sugar over 140). There are 150 million Americans who are overweight or obese. There
are 200 million Americans who are physically inactive who are primed to become first pre-diabetic
and then frankly diabetic. They all have pre-pre-diabetes.
WHOA! HEADS UP!
My issuance of a blinking yellow or red light is certainly not intended to promote a doctor's visit
or a pill or even worse surgery. It is intended to inform. But when does health information overstep
into medicalization?
This is the precise critique given by editorials in recent
British Medical Journals about the World Health Organization's
use of the word "complete" well-being in its reach for world health standards. Insisting on the qualifier
"complete" leads to the notion that we are all sick or trying to become sick.
This is what "The Last Well Person" essay was all about.
On June 17, 2014, Dr. Arnold Relman, editor of the prestigious New England Journal of Medicine
from 1977-1991, passed away. During his tenure as editor, Dr. Relman highlighted health care policy
as a major issue for the Journal by publishing commentary and studies about the delivery of
health care and writing editorials about how health care is practiced and paid for.
Throughout his career, Dr. Relman was a champion for focusing on patient care rather than the
business of medicine. In his writings,
he expressed concern about
the "commercialization" of medicine, reminding his colleagues that medicine was a calling and
not a trade. He wrote thought-provoking articles on the conflict of interest of for-profit hospitals,
nursing homes, and diagnostic laboratories that put profits ahead of what he considered the patients'
best interests. As early as 1980,
he was quoted as saying,
"If we are to live comfortably with the new medical-industrial complex we must put our priorities
in order: the needs of patients and of society come first ... How best to ensure that the medical-industrial
complex serves the interests of patients first and of its stockholders second will have to be the
responsibility of the medical profession and an informed public."
Today, new therapeutics for specific diseases such as certain cancers and hepatitis C can cost
tens of thousands of dollars each month. Likewise, the costs of certain diagnostic tests are skyrocketing,
and hospital and physician expenses are billed on a procedure basis rather than on successful outcome.
And to make matters worse,
the major expenses in the health care system are for the treatment of chronic diseases, and these
continue to escalate out of control. The business of medicine has created a multitude of profitable
treatments for chronic disease, but we continue to see these diseases progressing in number and severity.
Why? Is it because we find ourselves locked into a financial model for disease prevention and treatment
that puts the patient second behind the preservation of the status quo in the medical-industrial
complex? I believe that this is part of the answer. We know the answer to the chronic disease epidemic
is not to be found in the development of another expensive medicine alone, but rather in harnessing
what we know now about the importance of applying personalized lifestyle medicine.
The patients' best interests are found in the understanding of how genetic uniqueness interacts
with lifestyle, diet, and environment. Through this understanding we will be able to design and implement
programs for individuals with proper support and incentives that will turn back the rising tide of
chronic disease. We need to return to the patient-centered care that Dr. Arnold Relman advocated
for throughout his professional life rather than continue with the present disease-centered system
if we truly want to reduce the burden of disease.
References:
Snyder A. Arnold "Bud" Relman. Lancet. 2014 Jul 12;384(9938):126.
Relman AS. Medical professionalism in a commercialized health care market. JAMA. 2007 Dec 12;298(22):2668-70.
Relman A. The new medical-industrial complex. N Engl J Med. 1980;303:963-70.
Bloom DE, Cafiero ET, Jané-Llopis E, Abrahams-Gessel S, Bloom LR, et al. 2011. The Global Economic
Burden of Noncommunicable Diseases. Geneva: World Economic Forum.
Speaking of hiding coffins, of course, it's well known that nursing homes leave the
corpse laying on the bed until the residents have been doped and roped, then sometime
after the midnight hour, the hearse pulls up.
Nursing homes deaths from malpractice and/or abuse exceed all the US deaths due to
'terrorism' ... and do so every year.
"5,000 deaths in 1999 may be due to negligence: Red flags for nursing home negligence
were listed on 5,000 death certificates of nursing home patients in 1999. These include
starvation, dehydration, or bedsores as the cause of death.
Between 1999 and 2001, almost one-third of all nursing home facilities were cited for
violations of federal standards that could cause harm, or that did harm elderly
residents of those facilities;
Nearly 10% of those nursing homes had violations that posed a risk of serious injury
or death, or that did cause deaths of elderly residents;
More than 40% of nursing home residents have reported abuse, and more than 90% report
that they or another resident of the facility have been neglected;
Research from 2010 indicates that up to
half of all nursing home attendants have
admitted abusing or neglecting elderly patients;
More than half of all Certified Nursing Assistants (CAN's) in elder care facilities
have admitted verbally abusing, yelling at, and using foul language with elderly
residents of care facilities.
More than 30% of all nursing homes experience some form of resident abuse: Nearly 1/3
of all nursing homes have residents that are subject to abuse, whether it's by staff or
other residents. These include malnutrition, physical abuse, psychological distress,
exploitation, neglect, and sexual abuse.
In 2005, almost all nursing homes had at least one deficiency: Statistics show that
in 2005, 91.7% of America's nursing homes were cited by health inspectors for at least
one deficiency.
90% of abusers are known: Nearly all of the time, those who abuse nursing home
residents are not strangers. That means staff members, residents, or familiar visitors
are almost always to blame for nursing home abuse. 30 incidents of aggression can happen
in one 8-hour shift: In one investigation, 12 nurses observed aggression between
residents 30 times in an 8-hour shift.
Only about 20% of abuse cases are ever reported: Many nursing home residents do not
have the mental presence or confidence to report abuse for themselves, and it may go
unnoticed by family and other caretakers, so often, nursing home abuse cases are not
reported.
92% of all nursing homes employ at least one convicted criminal: Nearly all nursing
homes open their doors to at least one convicted criminal, and there are no national
requirements for background checks for nursing home employees.
One-third of all nursing home patients are forced to take antipsychotic drugs
:
It is suspected that older adults are overmedicated with antipsychotic drugs in nursing
homes, used to prevent combative behavior, agitation, and outbursts by dementia
patients.
There are not enough nursing home beds to serve the entire elderly population: In
2008, there were only 1.8 million total nursing facility beds, but there were 18.8
million people aged 65-74, and 14.7 million people aged 75 or older.
More than 50% of nursing home residents don't have close relatives: Many residents of
nursing homes are without family support that can watch out for neglect or abuse.
One nurse's aid may care for up to 30 people: Often, the ratio of nurse's aids to
patients is 1:15, but it can go as high as 30. The recommendation is 1:3 during a meal
and 1:6 during non-meal times.
90% of US nursing homes have staff levels too low for adequate care: Statistics on
abuse and neglect are not so shocking when you realize that 90% of nursing homes do not
have the staff levels available to care for their patients effectively.
One out of four nursing homes is cited for death or serious injury to a resident: In
2001, one of of every four nursing homes received a citation for causing serious injury
or death to a patient.
Twenty complaints per nursing home were received in 2007: With 257,872 complaints
relating to quality of care, facilities, staffing, and other factors,
there was an
average of 20 complaints per nursing home in 2007.
The average cost for a room at a private nursing home in 2003 was $66,000, but that
figure may rise exponentially. The average annual cost for a private nursing home room
may be $175,000 by 2021: "
Something to look forward to in the New American Century, after the Demise of ACA.
The Nursing Home Industry,
and the politicians who are either shareholders in it, or OWNED BY shareholders in it,
are the Main Opponents of the growing movement to introduce loop-hole free and
well-supervised Voluntary Euthanasia Laws. The same opponents are working overtime to
marginalise Public Debate on the topic as "un-Christian" (extended Living Death for
warehoused oldies being far more "humane" and infinitely more profitable).
Moderate physical activity lowers your chances of getting a heart attack by 30% to 50%.
Aim for 30 minutes of exercise that gets your heart pumping at least 5 days a week. Brisk walking
or swimming are some good choices. On the other 2 days, do strength training, like lifting
weights.
If you've got a tight schedule, break your exercise routine into small chunks. Try a 15-minute
walk in the morning and another before lunch.
Common painkillers such as ibuprofen used by millions of people in the UK are linked
to an increased risk of heart failure, experts have said.
Non-selective non-steroidal anti-inflammatory drugs
(NSAIDs) could increase the risk of
being admitted to hospital. Previous studies have linked the drugs to abnormal heart rhythm –
which can cause heart failure – and an increased risk of heart attack and stroke if taken
regularly.
ADVERTISING
The drugs, together with a subgroup of anti-inflammatories known as selective COX-2
inhibitors, are used to control pain and inflammation and are commonly taken by people with
arthritis.
The study, published in the British Medical Journal, used data for almost 10 million
NSAIDs users from the UK, the Netherlands, Italy and Germany, who started treatment between
2000 and 2010. Overall, 92,163 hospital admissions for heart failure were identified among the
group.
The study found that people who had taken any NSAID in the previous 14 days had a 19%
increased risk of hospital admission for heart failure compared with people who had used
NSAIDs at any point in the past. The BMJ research was led by a team from the University of
Milano-Bicocca in Italy.
The risk of admission for heart failure increased for seven traditional NSAIDs (diclofenac,
ibuprofen, indomethacin, ketorolac, naproxen, nimesulide, and piroxicam) and two COX 2
inhibitors (etoricoxib and rofecoxib). The increased risk of hospital admission ranged from
16% for naproxen to 83% for ketorolac.
Researchers also found the risk of heart failure doubled for diclofenac, etoricoxib,
indomethacin, piroxicam, and rofecoxib used at very high doses, although they stressed this
should be interpreted with caution.
Even medium doses of indomethacin and etoricoxib were associated with increased risk,
the study said, but there was no evidence that celecoxib increased the risk of admission for
heart failure at commonly-used doses.
The experts said their study "offers further evidence that the most frequently used
individual traditional NSAIDs and selective COX 2 inhibitors are associated with an increased
risk of hospital admission for heart failure. Moreover, the risk seems to vary between drugs
and according to the dose."
In an accompanying editorial, two Danish health researchers said that because of the
widespread use of NSAIDs, "even a small increase in cardiovascular risk is a concern for
public health".
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They said the fact they can be bought over the counter in supermarkets "further fuels
the common misconception that NSAIDs are harmless drugs that are safe for everyone".
Professor Peter Weissberg, medical director at the
British
Heart Foundation
, said: "This large observational study reinforces previous research
showing that some NSAIDs, a group of drugs commonly taken by patients with joint problems,
increase the risk of developing heart failure. It has been known for some years now that such
drugs need to be used with caution in patients with, or at high risk of, heart disease. This
applies mostly to those who take them on a daily basis rather than only occasionally.
"Since heart and joint problems often co-exist, particularly in the elderly, this
study serves as a reminder to doctors to consider carefully how they prescribe NSAIDs, and to
patients that they should only take the lowest effective dose for the shortest possible time.
They should discuss their treatment with their GP if they have any concerns."
Figures from NHS Digital show that in 2015 there were 14,605,791 prescription items
dispensed in England for NSAIDs.
The Proprietary Association of Great Britain, the UK trade association representing
manufacturers of branded over-the-counter medicines, stressed that the people in the study
were given NSAIDs on prescription. Chief executive John Smith said: "This observational study
analysed prescription-only NSAIDs, used long-term by people with an average age of 77 years to
treat conditions such as arthritis.
"Prescribed NSAIDs contain a higher dosage than medicines available over the counter,
which the authors acknowledge would typically be used by younger people, at lower doses and
for shorter durations than those prescribed.
"The authors admit that the study has several limitations. The study does not provide
data on absolute risk, therefore the probability of these people developing heart failure
without the use of NSAIDs is unknown."
"... Some longer-term studies , though, failed to show that low-carbohydrate diets benefited glucose control. Even if diets are effective in the short term, Dr. Hall said, "the difficulty is adhering to the diet over the long term." In an analysis of weight loss diets (not specifically for diabetics) published this summer, he and Yoni Freedhoff of the University of Ottawa wrote: "Diet adherence is so challenging that it is poor even in short-term studies where all food is provided. When diets are prescribed, adherence is likely to diminish over the long term despite self-reports to the contrary." ..."
"... But short-term studies of just a few weeks, which constitute the bulk of the diet studies, can be misleading, said Dr. C. Ronald Kahn. "In the short term, the low-carbohydrate diet sometimes does better on glycemic control," he said. "But as time progresses, the difference mostly disappears. What counts is which diet helps most with long-term weight loss. " ..."
"... The reason the advantage sometimes seen with a low-carbohydrate diet tends to vanish, Dr. C. Ronald Kahn added, is probably a mix of people failing to adhere to the diets and their bodies' adjusting to them. ..."
"... Another issue with low-carbohydrate diets, researchers said, is the question of what will happen to overall health if diabetics actually follow the diet for years or decades. (Heart attacks are the major killer of people with diabetes.) ..."
"... "effects of a low-carbohydrate diet on lipoproteins and vascular biology could offset such a 'benefit.'" In other words, it is not clear if a lower insulin level would translate into fewer heart attacks. ..."
"... Half were able to lose weight and keep it off, and those who did maintained an average weight loss of 9.5 percent. Their diabetes was much improved. ..."
"... It is impossible, Dr. Hamdy said, to separate weight loss from the diet's effects on diabetes because people following such a diet - which limits but does not forbid things like breads, pasta and rice - also lose weight. ..."
"... What matters the most for controlling diabetes, Dr. Nathan said, "is how much weight you lose." ..."
A few years ago, Richard Kahn, the now-retired chief scientific
and medical officer of the American Diabetes Association, was
charged with organizing a committee to prescribe a diet plan for
people with diabetes. He began by looking at the evidence for
different diets, asking which, if any, best controlled diabetes.
"When you look at the literature, whoa is it weak. It is so
weak," Dr. Kahn said in a recent interview.
Studies tended to be short term, diets unsustainable,
differences among them clinically insignificant. The only thing
that really seemed to help people with diabetes was weight loss
- and for weight loss, there is no magic diet.
But people want diet advice, Dr. Kahn reasoned, and the
association really should say something about diets. So it, like
the National Institutes of Health, went with the
Department of
Agriculture's food pyramid
.
Why? "It's a diet for all America," Dr. Kahn said. "It has lots
of fruits and vegetables and a reasonable amount of fat."
That advice, though, recently came under attack in a New York
Times
commentary
written by Sarah Hallberg, an osteopath at a
weight loss clinic in Indiana, and Osama Hamdy, the medical
director of the obesity weight loss program at the Joslin
Diabetes Center at Harvard Medical School.
There is a diet that helps with diabetes, the two doctors said:
one that restricts - or, according to Dr. Hallberg, severely
restricts - carbohydrates.
"If the goal is to get patients off their medications, including
insulin, and resolve rather than just control their diabetes,
significant carb restriction is by far the best nutrition plan,"
Dr. Hallberg said in an email. "This would include elimination
of grains, potatoes and sugars and all processed foods. There is
a significant and ever growing body of literature that supports
this method." She is in private practice at Indiana University
Health Arnett Hospital and is medical director of a start-up
developing nutrition-based medical interventions.
But there are no large and rigorous studies showing that
low-carbohydrate diets offer an advantage, and, in fact, there
is not even a consensus on the definition of a low-carbohydrate
diet - it can vary from doctor to doctor.
"There have been debates for literally the whole history of
diabetes about which kind of diet is best," said Dr. C. Ronald
Kahn, chief academic officer at Joslin, and no relation to Dr.
Richard Kahn. But, he said, "the answer isn't so
straightforward."
In support of a diet like Dr. Hallberg's, there is one recent
short-term
study
, by Kevin Hall of the National Institute of Diabetes
and Digestive and Kidney Diseases and his colleagues, involving
17 overweight and obese men, none of whom had diabetes. They
stayed in a clinical center where they ate carefully controlled
diets. The researchers asked what would happen if calories were
kept constant but the carbohydrate composition of a diet varied
from high to very low. The answer was that insulin secretion
dropped 50 percent with the very low carbohydrate diet, meaning
that much less insulin was required to maintain normal blood
glucose levels.
"Since diabetes results when the body can't produce enough
insulin, perhaps it is a good idea to reduce the amount of
insulin it needs by eating very-low-carbohydrate diets," Dr.
Hall said.
Some
longer-term studies
, though, failed to show that
low-carbohydrate diets benefited glucose control.
Even if diets are effective in the short term, Dr. Hall said,
"the difficulty is adhering to the diet over the long term."
In
an analysis
of weight loss diets (not specifically for
diabetics) published this summer, he and Yoni Freedhoff of the
University of Ottawa wrote: "Diet adherence is so challenging
that it is poor even in short-term studies where all food is
provided. When diets are prescribed, adherence is likely to
diminish over the long term despite self-reports to the
contrary."
But short-term studies of just a few weeks, which constitute the
bulk of the diet studies, can be misleading, said Dr. C. Ronald
Kahn.
"In the short term, the low-carbohydrate diet sometimes does
better on glycemic control," he said. "But as time progresses,
the difference mostly disappears. What counts is which diet
helps most with long-term weight loss. "
The reason the advantage sometimes seen with a low-carbohydrate
diet tends to vanish, Dr. C. Ronald Kahn added, is probably a
mix of people failing to adhere to the diets and their bodies'
adjusting to them.
Another issue with low-carbohydrate diets, researchers said, is
the question of what will happen to overall health if diabetics
actually follow the diet for years or decades. (Heart attacks
are the major killer of people with diabetes.)
Insulin levels
may be better, but, said Dr. Rudolph Leibel, a director of
Columbia University's Naomi Berrie Diabetes Center,
"effects of
a low-carbohydrate diet on lipoproteins and vascular biology
could offset such a 'benefit.'" In other words, it is not clear
if a lower insulin level would translate into fewer heart
attacks.
Dr. Hamdy, whose
recommended
low-carbohydrate diet
is less restrictive than the one Dr.
Hallberg suggests, reports that many patients in his clinic have
been able to stay with the diet for as long as five years,
losing weight and keeping it off. He presented his
study
at the 2015 annual conference of the American Diabetes
Association and has submitted it for publication. It involved
129 patients.
Half were able to lose weight and keep it off, and
those who did maintained an average weight loss of 9.5 percent.
Their diabetes was much improved.
It is impossible, Dr. Hamdy said, to separate weight loss from
the diet's effects on diabetes because people following such a
diet - which limits but does not forbid things like breads,
pasta and rice - also lose weight.
But
multiple studies
have found that when it comes to weight
loss - the only proven way to help with blood sugar control over
the long term - there is no difference among diets that restrict
calories, fat or carbohydrates.
Experts like Dr. David Nathan, the director of the diabetes
center and clinical research center at Massachusetts General
Hospital and a professor of medicine at Harvard Medical School,
advise dieting for people with diabetes. But, he said, "when we
advise people to be on diets, the major goal is to lose weight."
What matters the most for controlling diabetes, Dr. Nathan said,
"is how much weight you lose."
"... Each year, the American people spend 60 billion dollars on weight loss programs and products. That breaks down to about 188 dollars for every man, woman and child in the country. We are a nation that is absolutely obsessed with losing weight, and yet obesity levels are hovering near all-time record highs. ..."
"... According to CNN, an astounding 70 percent of all Americans are overweight at this point. ..."
"... Well, our addiction to sugar plays a major role in this. If you were just to make one change to your diet, you could immediately start living a much healthier lifestyle. What I am talking about is soda. ..."
"... Many people that have cut all soda out of their diets have immediately started losing weight, and they often report feeling much better too. Other people have actually decided to completely cut all sugar out of their diets, and needless to say the health benefits have been nothing short of astounding. ..."
"... When you're worried about where your next meal is coming from, you do tend to try to conserve energy (sleep) and pack on the calories so you're ready to endure the famine, so yes it is no co-incidence that many welfare people are obese and tired or, if you prefer, fat and "lazy". ..."
"... I say people are fat because they have "brain damage". This "brain damage" can be cured / repaired without brain surgery. A lot of the time it could be "cured" by some good, hard work (if available) but first people need to admit what they're up against. ..."
"... Women these days, even the young girls I see in my classes are pretty fat by ANY standard. ..."
"... They are correct, it is a hormone problem; the hormone is insulin. And you are correct in up question to ask, are you hungry again within 2 hours of eating or does it take 5 hours between meals or snacks before you want anything else? If 2 hours or less then it's definitely insulin resistance. ..."
"... Poor activity levels affects hormones, staying up late on your electronic device and missing out on sleep affects hormones. Stress/anxiety affects hormones. ..."
The United States officially has an obesity crisis. According to a
brand new report that was just released by the Trust for America's Health,
at least one out of every five people meet the clinical definition for obesity
in all 50 states. But of course in some states things are far worse than that.
More than 35 percent of all adults are obese in four states, and the obesity
rate is between 30 and 35 percent in 21 other states. And it is important to
keep in mind that just needing to lose weight does not mean that you are obese.
According to the CDC, you have got to have a body mass index of at least 30.0
to meet the clinical definition for obesity.
Each year, the American people spend
60 billion dollars on weight loss programs and products. That breaks down
to about 188 dollars for every man, woman and child in the country. We are a
nation that is absolutely obsessed with losing weight, and yet obesity levels
are hovering near all-time record highs.
In 2015, Louisiana has the highest adult obesity rate at 36.2 percent
and Colorado has the lowest at 20.2 percent. While rates remained steady
for most states, they are still high across the board. The 13th annual report
found that rates of obesity now exceed 35 percent in four states, are at
or above 30 percent in 25 states and are above 20 percent in all states.
In 1991, no state had a rate above 20 percent.
Did you catch that last part?
I put it in bold for a reason. To me, it is absolutely incredible that no
state in the entire country had an obesity rate of more than 20 percent just
25 years ago.
How is that possible?
How could obesity explode to such a dramatic level in just a couple of decades?
Well, a lot of it has to do with what we eat and drink, and I will have some
comments about that below. But first, let's take a look at some more statistics
from this new report. It turns out that there seems to be
a significant link between obesity and poverty …
9 of the 11 states with the highest obesity rates are in the South and 22
of the 25 states with the highest rates of obesity are in the South and Midwest.
10 of the 12 states with the highest rates of diabetes are in the South.
American Indian/Alaska Natives have an adult obesity rate of 42.3 percent.
Adult obesity rates are at or above 40 percent for Blacks in 14 states.
Adult obesity rates are at or above 30 percent in: 40 states and Washington,
D.C. for Blacks; 29 states for Latinos; and 16 states for Whites.
The report also noted that it has been estimated that our obesity epidemic
costs the United States somewhere between 147 billion dollars and 210 billion
dollars every single year.
That is an enormous amount of money, and if we were all a bit healthier it
would benefit our society tremendously.
Sadly, as a society we have fallen into some very bad habits. For example,
the new report also found that the number of high school students that play
video games for at least 3 hours per day "has increased more than 88 percent
since 2003 (from 22.1 to 41.7 percent)".
When I was in high school, almost all of the kids couldn't wait to get outside
and play after school. But these days most playgrounds are parks are eerily
silent most of the time, and even if kids wanted to go use them the truth is
that many of them aren't very safe.
In the old days, parents could let their kids go outside and play freely
without having to worry about it. But in 2016, many of our communities are infested
by
addicts , gangs, sex predators, etc.
But that is a topic for another article. Last year,
Gallup also did a survey on obesity , and what they found lines up with
this new report very well...
-The national rate of obesity has risen to an all-time high of 27.7 percent.
That is up from 27.1 percent in 2013, and it is much higher than the 25.5
percent number that we were sitting at in 2008.
-At 19.0 percent, Hawaii has the lowest rate of obesity in the entire
country.
-At 35.2 percent, Mississippi has the highest rate of obesity in the
entire country.
-The rest of the top 10 includes West Virginia, Louisiana, Arkansas,
Oklahoma, Alabama, Kentucky, Indiana, Iowa and Missouri.
And remember, being obese is different from being overweight.
According to CNN, an astounding
70 percent of all Americans are overweight at this point.
Let that number sink in for a moment. 70 percent. So how did this happen?
Well, our addiction to sugar plays a major role in this. If you were just
to make one change to your diet, you could immediately start living a much healthier
lifestyle. What I am talking about is soda.
Many people that have cut all soda out of their diets have immediately started
losing weight, and they often report feeling much better too. Other people have
actually decided to completely cut all sugar out of their diets, and needless
to say the health benefits have been nothing short of astounding.
If you know me, you know that I like sugar, but I try to keep it at a very
reasonable level. But that is difficult, because sugar is in just about everything.
And if it isn't sugar, it is some other type of sweetener such as high fructose
corn syrup.
There are others that know much more about these things than I do, but I
just wanted to share with you a couple common sense things I have learned over
the years that can immediately help you if you are interested in a healthier
lifestyle.
Of course cancer loves sugar too, and so it is no wonder why we have a cancer
epidemic in this country. If you can believe it, Americans spend
100 billion dollars a year on cancer drugs alone.
We are literally digging our own graves with our forks, knives and spoons.
What we eat and what we drink are the biggest reasons why we have an obesity
epidemic in this nation, and if we will just take a few common sense steps we
could start turning around this crisis tomorrow
When you're worried about where your next meal is coming from, you do
tend to try to conserve energy (sleep) and pack on the calories so you're
ready to endure the famine, so yes it is no co-incidence that many welfare
people are obese and tired or, if you prefer, fat and "lazy".
These days I tend to believe the Gabriel Method (Book - look it up) :
We all know that the answer is diet and exercise, so why don't we do it?
Gabriel Method basically says to get counselling and I believe he is probably
right.
I say people are fat because they have "brain damage". This "brain damage"
can be cured / repaired without brain surgery. A lot of the time it could
be "cured" by some good, hard work (if available) but first people need
to admit what they're up against.
We all know that physically, the answer is "diet and exercise", so why
don't we do it? Ever met an unemployed fat person who INSISTS they don't
have time to exercise? You can call them out on their faulty logic - you
got 24 hours per day where the average worker is battling to have 16, but
they simply do not hear you. You may as well just say they are fat because
they have brain damage - it will save you from hours of tedious and pointless
bullshit arguments.
What about the people who do try to diet / exercise but "forget" after
a day or two?
Then there are those who exercise but keep getting bizarre injuries that
prevent further exercise.
Or the procrastinators who have all the good intentions in the world but
simply don't do anything.
May as well just say they have "brain damage".
"The Gabriel Method" makes an interesting assertion about our flight
/ flight response. If you're under extreme stress and you do NOT fight back
or run away but instead just stand there and take it, your body will decide
to defend itself my making itself bigger. So if the boss yells at you and
you just stand there and take it, then after he wanders off you should run
up and down the stairs or run around the block so your body decides it needs
to be lighter, not heavier, to endure this "threat".
Fit people can give unfit people good advice about diet and exercise
but then, in order to preserve their own sanity, they need to walk away.
The fat guy knows what he needs to do. All the "excuses" he gives are bullshit.
He just has "brain damage" and the only cure for the "brain damage" is counselling
( or sometimes a career change, or travel ).
Women these days, even the young girls I see in my classes are pretty fat
by ANY standard. It's a very sore subject to bring up with them but most
will tell you before you even ask, "It's a hormone problem" as they munch
down on a Quarter Pounder and Fries, supersized, and warsh it down with
a double whipped cream Mochachinno with a double shot of hazlenut syrup.
They are correct, it is a hormone problem; the hormone is insulin. And you
are correct in up question to ask, are you hungry again within
2 hours of eating or does it take 5 hours between meals or snacks before
you want anything else? If 2 hours or less then it's definitely insulin
resistance.
They are correct that hormone problems lead to obesity. Every function
in your body is regulated by hormones so hormones affect everything. And
any imbalance anywhere in diet, lifestyle affects hormones. Food is medicine.
Anything that disrupts your liver/gut function disrupts hormones. Poor
activity levels affects hormones, staying up late on your electronic device
and missing out on sleep affects hormones. Stress/anxiety affects hormones.
Women today start downing 3 servings of coffee before noon, without eating
breakfast, then eat processed snacks all afternoon/evening because they
are starving from lack of proper nutrition. Coffee was not meant to replace
sleep, food, or the energy-boosting effects of exercise. Yet you see girls
at the age of 10 or 11 walking out of Starbucks with 18-ounce suger-laden
double-shot mochas instead of breakfast. Higher insulin levels, higher cortisol
levels, and no food, great for the metabolism. Add a few more years of facebook
instead of exercise, being a student where you eat top ramen, pizza, and
beer, topped with alcohol, and there you go.
Then they are afraid of eating meat (no protein) or healthy fats. "like,
oh my god! do you know how many grams of fat are in that avocado?! Here,
have another Wheat Thin!")
It's probably a lot of things. We're more sedentary than we were back in
the '80s. I used to ride my bike all over the place when I was a kid. The
food is processed even more, and there is a lot of evidence that what is
grown today is less nutritious than it was back in the '50s.
I haven't had it tested, but it is a safe bet that the corn that I grow
has a higher protein content than any off of a megafarm. I doubt that you
can point at any one thing and yell "EUREKA!"
"... I really, really hate the continued conflation between insurance and health care. In the imaginary world of pop financial budget advice, they largely tell you that your health care should run between 6 to 8 percent of your income. We have a law that says you have to pay 9.5% of your income toward insurance that comes with a physical and some prenatal healthcare, for everything else you have to pay out between an average of slightly less than 10% of American Median Income. ..."
"... You want to friggin' fix ACA so that it works as well as the most expensive version of European universal health care, Hillary, then you make everyone, yes everyone, eligible for subsidies if the premiums go above 8% of their income. You make sure that the highest deductible ends where most of them have been beginning, and max out of pocket is mid three figures, not four and certainly not five, so that the most people are paying is about 14% of their income. ..."
"... But since no one in a Clinton administration is going to be doing this all this talk is, is just that talk. And pretty slim talk at that. So they get another year or two and increase the subsidies for the limited numbers who get them meanwhile everyone above a more realistic poverty rate is paying full freight on overpriced craptastic offerings and looking at paying upwards of 30% of their income on a yearly basis if they have a major health issue. ..."
I really, really hate the continued conflation between insurance and health
care. In the imaginary world of pop financial budget advice, they largely tell
you that your health care should run between 6 to 8 percent of your income. We
have a law that says you have to pay 9.5% of your income toward insurance that
comes with a physical and some prenatal healthcare, for everything else you
have to pay out between an average of slightly less than 10% of American Median
Income.
There is then the copay or co insurance on top of that, something that
runs another 10% or so. That's almost 30% of income or more, especially since
depending on your age and region, and making a little too much money there is
no cap on that premium as percentage of income (except as a get out of the fine
for refusing to waste your money on crap with only a little hassle).
You want to friggin' fix ACA so that it works as well as the most expensive
version of European universal health care, Hillary, then you make everyone, yes
everyone, eligible for subsidies if the premiums go above 8% of their income.
You make sure that the highest deductible ends where most of them have been
beginning, and max out of pocket is mid three figures, not four and certainly
not five, so that the most people are paying is about 14% of their income. You
make all, yes all, basic insurance plans have the same coverage (and you expand
the hell out of that bronze level coverage) with limited categories for region
and age (3 total there) AND you make all of them non profit, and require all
insurance companies to offer them. That's right the insurance companies don't
get to profit on them in any manner. Basic insurance is the cost of doing
business for them, for profits they can then offer the ACA equivalent of
Medicare supplemental plans. IOW you really do the expensive Swiss plan, which
for all the market based plan manure you hear about it, the health market is
not in any way free market it is regulated up the wazoo, up to and including
real price controls on providers.
But since no one in a Clinton administration is going to be doing this all
this talk is, is just that talk. And pretty slim talk at that. So they get
another year or two and increase the subsidies for the limited numbers who get
them meanwhile everyone above a more realistic poverty rate is paying full
freight on overpriced craptastic offerings and looking at paying upwards of 30%
of their income on a yearly basis if they have a major health issue.
"... "The ideas of the ruling class are in every epoch the ruling ideas" ..."
"... The German Ideology ..."
"... By Lambert Strether of Corrente . ..."
"... Yves dropped the phrase "the looting professional class," and I said "I've got to post on that!"
..."
"... The question we posed then as now: "How do these people live with themselves?" (For a discussion
of the medical aspects of opioids in general and the regulatory state of play, see here and here .)
..."
"... Based purely on timing, it seems likely that developments in the medical and pharmaceutical
industries played a significant role in setting off the epidemic of drug poisonings, which increased
more than sixfold in the white-middle-aged demographic between 1999 and 2013, and which played an important
role in raising its over-all mortality rate. By many accounts, the widespread misuse of prescription
drugs, particularly opioid painkillers, such as OxyContin, began in the late nineties and rapidly became
a chronic problem. ..."
"... There is, however, something that does make white men and women in the U.S. unique compared
with other demographics around the world: their consumption of prescription opioids. Although the U.S.
constitutes only 4.6 percent of the world's population, Americans use 80 percent of the world's opioids.
As Skinner and Meara point out in their study, a disproportionate amount of these opioid users are white,
and past studies have shown that doctors are much more willing to treat pain in white patients than
in blacks. ..."
"... The body count is comparable to the AIDS epidemic ..."
"... We calculated that about 500,000 middle-age Americans died who would still be alive. AIDS has
killed more than that but the numbers are in the same ballpark. The comparison is useful because people
have a hard time thinking about changes in mortality rates-so many per 100,000. And everyone knows about
HIV/AIDS: People wear ribbons and it is seen as a national tragedy. But there are no ribbons, no awareness
for this, and there should be. ..."
"... OxyContin was successfully marketed by Purdue Pharma ("successfully" rather in the way that
HIV is successful, only with different transmission vectors). ..."
"... The American Journal of Public Health ..."
"... Los Angeles Times ..."
"... I was shocked by the LA Times reporting on Purdue. They clearly knew that they were part of
the supply chain with Distributors, Pharmacies, Doctors and old fashioned drug dealers who were facilitating
thousands of deaths though Oxycontin addiction and overdoses. They set up safety monitoring committees
which did practically nothing by design. Selling death for profit. Shame on them. ..."
"... Purdue had one final shot at avoiding trial: A motion for summary judgment. … To make this
critical argument, the company tapped Eric Holder Jr ., who had been the nation's first African American
deputy attorney general. On Oct. 13, 2004, the man who would become President Obama's attorney general
argued that West Virginia prosecutors didn't have sufficient evidence to warrant a trial. ..."
"... I'm sure a Psychologist could say this more factually than I, but if you job depends on it
or at least benefits from it, 2 degrees of separation from cause and effect is enough to declare moral
innocence in ones mind. ..."
"... Professionals are intelligent enough to fool themselves into believing this with hi consistency.
In that respect they are no different from the looting bankers. ..."
"... The general idea is that the more distant an object is from the individual, the more abstract
it will be thought of, while the closer the object is, the more concretely it will be thought of. ..."
"... Ethical Amnesia . ..."
"... Although you are making a strong argument against our particular credentialed class, my sense
is that this behavior will arise in any social hierarchy with more than four or five levels. ..."
"... Distance makes it abstract. The dangerous part is when abstraction makes it distant…like when
a human is reduced to 'what do you do for a living?' – the polite version of 'How much do you make?'
"I am a professor." ..."
"... Does the professor know how many molecules have to be moved to make a buck? Not too many, with
oxycontin. A particularly efficient enterprise whose externality is the exact opposite of a ride on
the last ship out. ..."
"... Remember the famous Millgram experiment? Two degrees of separation- Physical because the subject
was behind a mirror in a "laboratory" observation room, and psychological because the "scientist" in
a lab coat supported and encouraged extreme levels of torture which the subjects complied with. ..."
"... Rather similar to the level of detachment exhibited by Obama when he participates in selecting
targets for assassination by remote control drone. Or Hellary Clinton chortling as she recalls viewing
video of Gaddafi being sodomized with a bayonet. ..."
"... Self-delusion is the opium of the people. ..."
"... I'm not sure it's simply a matter of obliviousness. In the case of the database designer, the
institution feeding him/her the data needs him/her to not get too curious, in other words to willfully
remain oblivious. This is quite often achieved by means of an implicit threat: in tech, it's usually
the threat of being replaced by someone much younger or by a H1B visa holder. In sales, individuals
and teams are often pitted against each other in strict competition, a practice that has ruined several
companies, most notably Sears. Marketing is an extremely cutthroat field, and firms will do practically
anything to one up each other, including the unethical and illegal. The implicit war of all against
all creates a Zeitgeist of insecurity that incentivizes looking the other way or adopting a cultivated
obliviousness. ..."
"... Yes those professions didn't strike me as too hot either. I.T. fields are flooded with H1Bs,
being a salesrep can at times be an easy job to get but often isn't (and so salesreps often put up with
a lot of crazy) etc.. ..."
"... We all pick our poison and how much we can live with. And yet most people believe in the ideology
of making people scramble for money. They think it makes people "work hard" or "compete" or "add value"
but just as absolutely it will make people cut corners. Because they have to because they need that
money to live. And yet we still think completion is good. ..."
"... There are still people trying to run up the down escalator. But people who own the escalator
keep cranking up the speed. ..."
"... As a life-long member of this credentialed professional class (specifically, media, even though
the credentials are informal at best), I can say from experience at several of the large media corporations
that many, if not most, employees in the editorial ranks are well aware of the damage the industry does
to this country (it's more abstract, perhaps, than the pharma example, but it's real). Many speak up,
but no one can speak up every time they are asked to execute an unethical or mindless order whose sole
goal is to increase ratings and, by extension, "shareholder value." ..."
"... well most heroin in the usa comes from mexico and the Jalisco Boys cartel, helped by nafta.
afghani heroin supplies europe and asia. just an fyi. ..."
"... Dreamland: The True Tale of America's Opiate Epidemic ..."
"... The story of oxycodone is one of rampant criminality: the clinical trials, the approval process,
and the marketing are all riddled with probable fabrications and manifest misrepresentations. ..."
"... The behavior described in this article is clearly terrible, but it doesn't seem fair to blame
20% of the population for this type of thing. You often advise us that generations don't have agency,
and the same can be said for economic classes. Most of the people in the richest 20% could be classified
as "professionals", as in doctors, lawyers, stock brokers, engineers, managers, etc., but I suspect
there are some master plumbers and electricians in that category as well. ..."
"... I think (a) the lessons of the Milgram experiment (trust your boss; go with the program) and
(b) the U. Sinclair notion of can't believe X if you're paycheck depends on not-X … these 2 factors
have a lot to do with the separation of the 20% from the 80%. They don't explain the origin, but I think
they speak to the persistence. ..."
"... See also pharmaceuticals promotion of effective pain management schemes and punishment of those
not adhering to the narrative. ..."
"... Profiting from supplying opioids is one thing, but what happens when billionaire real estate
developers and hedge fund cash start getting into the recovery and mental health business? ..."
"... In my opinion, Americans are getting slowly poisoned and they are not getting any help either
because the US food industry is allowed to sabotage the access to unadulterated foodstuff. This is one
of many reasons that people "here" hate the TTIP & Co: We don't want to be American! We don't want US
business practices. ..."
"... Looting is definitely the right term here. I suspect there are many actors who became fabulously
wealthy from the prescription opioid (and amphetamine – ADD medications like Adderal are analogues to
street Methamphetamine) scam. ..."
"... The kind of destructive social conduct was noted by cultural anthropologists studying cultures
affected by Euopean colonization. As the meaning of the culture was drained by colonial predation, the
societies degraded, people lost direction, language changed rapidly and the previous social networks
unraveled. Essentially, the colonized no longer saw or felt that there was a place for them. ..."
"... Everything about constant sitting is bad for the body, and when the sedentary body starts moving,
things get worse, because terrible movement patterns are ingrained. There'd have to be nationwide physical
therapy to solve it. I recommend reading and following 'deskbound' by Kelly Starrett, if you're a sedentary
person. ..."
So Yves and I were chatting the other day, the Yves dropped the phrase "the looting professional
class," and I said "I've got to post on that!" This is that post, and I'm going to use that
concept as a lens to examine the opioid epidemic in the white working class, since the professional
classes - and not all individuals so classed! - enabled so much of it. The question we posed
then as now: "How do these people live with themselves?" (For a discussion of the medical aspects
of opioids in general and the regulatory state of play, see
here and
here .)
Deaths from Opiods are like the AIDS Epidemic
Let's start by looking at the briefly famous Case-Deaton study, and its study of mortality in
the white working class, taking education levels as a proxy for class[1]. (For NC's late 2015 discussion
of the Case-Deaton study, with an embedded copy of the study itself,
see here , and for a follow-up from Barbara Ehrenreich,
see here .)
From WaPo , on the study and its interpretation:
The research showed that the mortality rate for whites between the ages of 45 and 54 with a
high school education or less rose dramatically between 1999 and 2013, after falling even more
sharply for two decades before that.
That reversal, almost unknown for any large demographic group in an advanced nation, has not
been seen in blacks or Hispanics or among Europeans, government data show. The report points to
a surge in overdoses from opioid medication and heroin, liver disease and other problems that
stem from alcohol abuse, and suicides.
[Deaton's] analysis: "There's this widening between people at the top and the people who have
a ho-hum education and they're not tooled up to compete in a technological economy. … Not only
are these people struggling economically, but they're experiencing this health catastrophe too,
so they're being hammered twice."
Another economist who reviewed the study for PNAS used almost the same words.
"An increasingly pessimistic view of their financial future combined with the increased availability
of opioid drugs has created this kind of perfect storm of adverse outcomes," said Jonathan Skinner,
a professor of economics at Dartmouth College.
(The Case-Deaton study had a moment in early 2016, as pundits connected it to Trump voters (
"America's Self-Destructive Whites" ), and then dropped off the radar. And it wasn't all that
easy to get Case-Deaton on the radar in the first place; it was
instantly rejected by the Journal of the American Medical Association (JAMA) and the
New England Journal of Medicine (NEJM), before being published in the less prestigious Proceedings
of the National Academy of Science.)
Let's look more closely at the potential role of opiods, and in particular OxyContin, in Case-Deaton
results.
Kevin Drum writes:
On a related note, the famous Case/Deaton paper showing a rise in white mortality since 2000
breaks out three categories of death: suicides, liver disease (a proxy for alcohol abuse), and
drug poisoning. All three have gone up, but poisoning has gone up far, far more than the others.
The first two have increased about 50 percent since 2000. Poisoning has increased about 1,500
percent. This coincides with the period when Oxy became popular, and probably accounts for a big
part of the difference between increased white mortality in America vs. other countries. Oxy is
a famously white drug, and may also account for the fact that mortality has increased among whites
but not blacks or Hispanics.
Based purely on timing, it seems likely that developments in the medical and pharmaceutical
industries played a significant role in setting off the epidemic of drug poisonings, which increased
more than sixfold in the white-middle-aged demographic between 1999 and 2013, and which played
an important role in raising its over-all mortality rate. By many accounts, the widespread misuse
of prescription drugs, particularly opioid painkillers, such as OxyContin, began in the late nineties
and rapidly became a chronic problem.
The Times analyzed nearly 60 million death certificates collected by the Centers for Disease
Control and Prevention from 1990 to 2014…
The analysis shows that the rise in white mortality extends well beyond the 45- to 54-year-old
age group documented by a pair of Princeton economists in a research paper that startled policy
makers and politicians two months ago…
While the death rate among young whites rose for every age group over the five years before
2014, it rose faster by any measure for the less educated, by 23 percent for those without a high
school education, compared with only 4 percent for those with a college degree or more.
The drug overdose numbers were stark. In 2014, the overdose death rate for whites ages 25 to
34 was five times its level in 1999, and the rate for 35- to 44-year-old whites tripled during
that period. The numbers cover both illegal and prescription drugs.
Rising rates of overdose deaths and suicide appear to have erased the benefits from advances
in medical treatment for most age groups of whites. Death rates for drug overdoses and suicides
"are running counter to those of chronic diseases," like heart disease, said Ian Rockett, an epidemiologist
at West Virginia University.
In fact, graphs of the drug overdose deaths look like those of deaths from a new infectious
disease, said Jonathan Skinner, a Dartmouth economist. "It is like an infection model, diffusing
out and catching more and more people," he said.
There is, however, something that does make white men and women in the U.S. unique compared
with other demographics around the world: their consumption of prescription opioids. Although
the U.S. constitutes only 4.6 percent of the world's population, Americans use 80 percent of the
world's opioids. As Skinner and Meara point out in their study, a disproportionate amount of these
opioid users are white, and past studies have shown that doctors are much more willing to treat
pain in white patients than in blacks.
You told the New York Times that HIV/AIDS is the only good analogue as far as these
death rates go. Can you expand on that comparison?
We calculated that about 500,000 middle-age Americans died who would still be alive. AIDS
has killed more than that but the numbers are in the same ballpark. The comparison is useful because
people have a hard time thinking about changes in mortality rates-so many per 100,000. And everyone
knows about HIV/AIDS: People wear ribbons and it is seen as a national tragedy. But there are
no ribbons, no awareness for this, and there should be.
"No ribbons." Odd, that. Or not[3].
Summing up: We're looking at a deadly epidemic, in the white working class, previously unnoticed,
fueled in part by OxyContin[2], and only briefly "on the radar." So where does the "looting professional
class" come in? To understand that, let's turn to how Oxycontin is marketed and delivered through
the pharmaceutical supply chain.
The "Looting Professional Class" as a Transmission Vector
OxyContin was successfully marketed by Purdue Pharma ("successfully" rather in the way that
HIV is successful, only with different transmission vectors).Pacific Standard has
a fine summary :
Starting in 1996, Purdue Pharma expanded its sales department to coincide with the debut of
its new drug. According to an article published in The American Journal of Public Health
, " The Promotion
and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy ," Purdue increased
its number of sales representatives from 318 in 1996 to 671 in 2000. By 2001, when OxyContin was
hitting its stride, these sales reps received annual bonuses averaging over $70,000, with some
bonuses nearing a quarter of a million dollars. In that year Purdue Pharma spent $200 million
marketing its golden goose. Pouring money into marketing is
not uncommon for Big Pharma , but proportionate to the size of the company, Purdue's OxyContin
push was substantial.
Boots on the ground was not the only stratagem employed by Purdue to increase sales for OxyContin.
Long before the rise of big data, Purdue was compiling profiles of doctors and their prescribing
habits into databases. These databases then organized the information based on location to indicate
the spectrum of prescribing patterns in a given state or county. The idea was to pinpoint the
doctors prescribing the most pain medication and target them for the company's marketing onslaught.
That the databases couldn't distinguish between doctors who were prescribing more pain meds
because they were seeing more patients with chronic pain or were simply looser with their signatures
didn't matter to Purdue. The
Los Angeles Times reported that by 2002 Purdue Pharma had identified hundreds of
doctors who were prescribing OxyContin recklessly, yet they did little about it. The same article
notes that it wasn't until June of 2013, at a drug dependency conference in San Diego, that the
database was ever even discussed in public.
Combining the physician database with its expanded marketing, it would become one of Purdue's
preeminent missions to make primary care doctors less judicious when it came to handing out OxyContin
prescriptions.
Beginning around 1980, one of the more significant trends in pain pharmacology was the increased
use of opioids for chronic non-cancer pain. Like other pharmaceutical companies, Purdue likely
sought to capitalize on the abundant financial opportunities of this trend. The logic was simple:
While the number of cancer patients was not likely to increase drastically from one year to the
next, if a company could expand the indications for use of a particular drug, then it could boost
sales exponentially without any real change in the country's health demography.
This was indeed one of OxyContin's greatest tactical successes. According to "The Promotion
and Marketing of OxyContin," from 1997 to 2002 prescriptions of OxyContin for non-cancer pain
increased almost tenfold.
(These people are super-smart, and you've got to admire the brilliance. It's shiny!) Pulling out
the professionals from that narrative, we have:
CEOs Marketing executives Database developers Marketing collateral designers The sales force Middle
managers of all kinds. And doctors.
But Purdue Pharma's marketing effort is not the only transmission vector. Let's look at the entire
supply chain. From
a report (PDF) by Kaiser titled "Follow the Pill" (and which might more useful be titled "From
Vat to Vein"):
The pharmaceutical supply chain is the means through which prescription medicines are delivered
to patients. Pharmaceuticals originate in manufacturing sites; are transferred to wholesale distributors;
stocked at retail, mail-order, and other types of pharmacies; subject to price negotiations and
processed through quality and utilization management screens by pharmacy benefit management companies
(PBMs); dispensed by pharmacies; and ultimately delivered to and taken by patients. There are
many variations on this basic structure, as the players in the supply chain are constantly evolving,
and commercial relationships vary considerably by geography, type of medication, and other factors.
….
The pharmaceutical supply system is complex, and involves multiple organizations that play
differing but sometimes overlapping roles in drug distribution and contracting. This complexity
results in considerable price variability across different types of consumers, and the supply
chain is not well understood by patients or policymakers. Increased understanding of these issues
on the part of policymakers should assist in making rational policy decisions for the
Medicare and Medicaid programs.
It certainly should, given that the entire supply chain is a vector for an AIDS-like epidemic,
eh? So, again, we have:
CEOs Marketing executives Database developers Marketing collateral designers The sales force Middle
managers of all kinds.
Except now not merely for Purdue's marketing effort, but for OxyContin manufacturers, wholesale
distributors, pharmacy benefit management companies, and pharmacies. That's a biggish tranche of
the 10%, no?
Conclusion
CEOs, marketing executives, database developers, marketing collateral designers, the sales force,
middle managers of all kinds, and doctor: All these professions are highly credentialed. And all
have, or should have, different levels of responsibility for the mortality rates from the opoid epidemic;
executives have fiduciary responsibility; doctors take the Hippocratic Oath; those highly commissioned
sales people knew or should have known what they were selling. Farther down the line, to a database
designer, OXYCONTIN_DEATH_RATE might be just another field. Or not! And due to information
asymmetries in corporate structures, the different professions once had different levels of knowledge.
For some it can be said they did not know. But now they know; the story is out there. As reader Clive
wrote:
Increasingly, if you want to get and hang on to a middle class job, that job will involve dishonesty
or exploitation of others in some way.
And you've got to admit that serving as a transmission vector for an epidemic falls into the category
of "exploitation of others."
But where does the actual looting come in? The easiest answer is through our regimen
of intellectual property rights.
Pacific Standard once
again :
In its first year, OxyContin accounted for $45 million in sales for its manufacturer, Stamford,
Connecticut-based pharmaceutical company Purdue Pharma. By 2000 that number would balloon to $1.1
billion, an increase of well over 2,000 percent in a span of just four years. Ten years later,
the profits would inflate still further, to $3.1 billion. By then the potent opioid accounted
for about 30 percent of the painkiller market. What's more, Purdue Pharma's patent for the original
OxyContin formula didn't expire until 2013. This meant that a single private, family-owned pharmaceutical
company with non-descript headquarters in the Northeast controlled nearly a third of the entire
United States market for pain pills.
Would Purdue's CEOs (and sales force) have been so incentivized to loot profit from the suffering
flesh of working class people without that looming patent expiration? Probably not. The epidemic,
then, might not have been so virulent. But I think the issue of looting is both deeper and more pervasive.
Returning to the story of Tony , the stressed-out pharmacist who wanted to do right by his patients,
instead of following the profit-driven scripts of his managers:
Recall again that corruption, as Zephyr Teachout explains, is not a quid pro quo, but the use
of public office for private ends. I think the point of credentials is to create the expectation
that the credentialed is in some sense acting in a quasi-official capacity, even if not an agent
of the state. Tony, a good pharmacist, was and is trying to maintain a public good, on behalf
of the public: Not merely the right pill for the patient, but the public good of trust between
professional and citizen, which Boots is trying to destroy, on behalf of the ruling idea of "shareholder
value." Ka-ching.
If economists ask themselves "What good is a degree?" the answer is "to signal a requirement
for a higher salary!" (because it's not easy to rank the professions by the quality of what they
deliver). We as citizens might answer that professionals are in some ways amphibians: They serve
both private ends and preserve public goods, and the education for which they are granted their
credentials forms them for this service. For example, a doctor who prescribes medications for
his patients because Big Pharma takes him golfing is no doctor but corrupt; he's mixed up public
and private. He didn't follow his oath.
Consider trust as a public good. We might, then, look at that public good as "good will" on the
balance sheet of the professional class. The looting comes as professionals draw down the good will
for (as executives) stock options, for (as managers) bonuses, for (as sales people) commissions,
and for the small fry salaries, wages, and the wonderful gift of continued employment status. And
all the professionals who willingly served as transmission vectors for the AIDS-like opioid epidemic
will be seen to have looted their professional balance sheet as the workings of the system of which
they were a part become matters of public knowledge.
How do they live with themselves?[4]
NOTES
[1]
The New Yorker does this beautifully exactly because it's so unconscious of its moves: "The big
puzzle is why the recent experience of middle-aged white Americans with modest educations
has been so different." Always credentials, eh?
[2] I don't want to get into a chicken-or-egg discussion of whether working class suffering fueled
the drugs, or working class drugs the suffering. Linear thinking isn't useful when an epidemic has
complex causes, so I say both, mutually reinforcing each other. For a humane look at the epidemic
in context, see
the writing ,
the tweeting
, and
the photography of Chris Arnade, former bond trader.
[3] The facts that researchers were "startled" by the Case-Deaton results, and that both NEJM
and JAMA immediately rejected their paper - on an epidemic of an AIDS-like scale, too - really does
cry out for explanation. Since it would be irresponsible not to speculate, I'd urge that consideration
be given to the idea that
(vulgar) identity politics , which is one of the "ruling ideas" in the professional classes,
makes virtue signalling by professionals on working class topics difficult, and virtue signalling
on white working class issues nearly impossible. Professors Case and Deaton are exceptions
to this rule, of course, but perhaps they were not virtue signalling at all, but acting as disinterested,
honorable scholars. There is always that possibility, even today!
[4] Let me issue my ritual disclaimer: I don't want to come off as priggish. If I had hostages
to fortune, and especailly if I had to support a family, especially in today's new normal, I might
put my head down and save ethics for the home. "Person must not do what person cannot do." - Marge
Piercy, Woman on the Edge of Time.
I was shocked by the LA Times reporting on Purdue. They clearly knew that they were part
of the supply chain with Distributors, Pharmacies, Doctors and old fashioned drug dealers who
were facilitating thousands of deaths though Oxycontin addiction and overdoses. They set up safety
monitoring committees which did practically nothing by design. Selling death for profit. Shame
on them.
Is this pharmaceutical, and many others, like the gun-makers in this case? Should they not
be excluded, but should be held accountable, as Hillary claims regarding gunmakers?
Having read to the end of comments below and not seeing this info, I think it is worthwhile
noting a couple of the identities of specific class agents who have had a hand in this. From
Part 1 of the LA
Times series:
1.To obtain FDA approval, Purdue had to demonstrate that OxyContin was safe and as effective
as other pain drugs on the market. Under agency guidelines for establishing duration, the company
had to show that OxyContin lasted 12 hours for at least half of patients. Purdue submitted
the Puerto Rico study, which showed that.
The FDA approved the application in 1995.
Dr. Curtis Wright, who led the agency's medical review of the drug , declined
to comment for this article. Shortly after OxyContin's approval, he left the FDA and,
within two years, was working for Purdue in new product development , according to
his sworn testimony in a lawsuit a decade ago.
2. In the fall of 2004, in a remote courthouse in Appalachia, the 12-hour dosing issue came
close to a public airing. The West Virginia attorney general was pressing a lawsuit against
Purdue demanding reimbursement of "excessive prescription costs" paid by the state through
programs for the poor and elderly. The state accused the company of deceptive marketing, including
the 12-hour claim.
…
Purdue's legal team made numerous attempts to get the suit dismissed or moved from state
to federal court, where the company had succeeded in getting many cases tossed out. All these
efforts failed.
Purdue had one final shot at avoiding trial: A motion for summary judgment. … To make
this critical argument, the company tapped Eric Holder Jr ., who had been
the nation's first African American deputy attorney general. On Oct. 13, 2004, the man who
would become President Obama's attorney general argued that West Virginia prosecutors didn't
have sufficient evidence to warrant a trial.
I'm not saying the computer programmer doesn't have a moral obligation to do the right thing.
But some class agents are clearly more powerful than others.
I'm sure a Psychologist could say this more factually than I, but if you job depends on
it or at least benefits from it, 2 degrees of separation from cause and effect is enough to declare
moral innocence in ones mind.
Professionals are intelligent enough to fool themselves into believing this with hi consistency.
In that respect they are no different from the looting bankers.
Excellent formulation, but can anybody back it up with analysis? (The nice thing about formulating
this as a supply chain is that the degrees of separation become quite evident.)
You might consider
Construal Level
Theory which considers psychological distance. The general idea is that the more distant
an object is from the individual, the more abstract it will be thought of, while the closer the
object is, the more concretely it will be thought of.
And of course as part of our increasingly mapped human nature there is Ethical Amnesia .
Although you are making a strong argument against our particular credentialed class, my
sense is that this behavior will arise in any social hierarchy with more than four or five levels.
Distance makes it abstract. The dangerous part is when abstraction makes it distant…like
when a human is reduced to 'what do you do for a living?' – the polite version of 'How much do
you make?' "I am a professor."
"Hey, I think that enhances your chance, as the spouse or partner, of getting on that last
ship out of a dying Earth."
(Instead of abstraction, an example is offered here).
Does the professor know how many molecules have to be moved to make a buck? Not too many,
with oxycontin. A particularly efficient enterprise whose externality is the exact opposite of
a ride on the last ship out.
Remember the famous Millgram experiment? Two degrees of separation- Physical because the
subject was behind a mirror in a "laboratory" observation room, and psychological because the
"scientist" in a lab coat supported and encouraged extreme levels of torture which the subjects
complied with.
Rather similar to the level of detachment exhibited by Obama when he participates in selecting
targets for assassination by remote control drone. Or Hellary Clinton chortling as she recalls
viewing video of Gaddafi being sodomized with a bayonet.
I'm not sure it's simply a matter of obliviousness. In the case of the database designer,
the institution feeding him/her the data needs him/her to not get too curious, in other words
to willfully remain oblivious. This is quite often achieved by means of an implicit threat: in
tech, it's usually the threat of being replaced by someone much younger or by a H1B visa holder.
In sales, individuals and teams are often pitted against each other in strict competition, a practice
that has ruined several companies, most notably Sears. Marketing is an extremely cutthroat field,
and firms will do practically anything to one up each other, including the unethical and illegal.
The implicit war of all against all creates a Zeitgeist of insecurity that incentivizes looking
the other way or adopting a cultivated obliviousness.
Even in the hallowed halls of academe, you see this play out. When the graduate student union
was negotiating its most recent contract with the U of Iowa, the dean of the graduate college
said straight out that the contract they wanted would "price them out of the market." Lo and behold,
since then, the University has met all of the increased demand on teaching (higher enrollment=more
classes) by hiring ad hoc contingent faculty. The number of permanent positions created to meet
this demand is functionally zero.
Purdue pharma saleswoman Kimberly workman…involved in first case of pill mill dox charged with
murder, dr denis deonanine (acquitted)…in sun sentinal article, june 11,2002, she is quoted as
having testified when confronted by pharmacist kenneth zie***** that deonanine was overboard and
going to be a problem…
her response was…
"well that's really a shame"…
but during trial pharmacist kenneth also testified kimberly called complaining when he stopped
selling the 160 dosage…
It appears that "in theory" she was not working for purdue as the trial progressed…
But…she $hows up on a web search as having submitted and funded a research study for purdue
in 2013.
as its original patent expired purdue arranged with the fda to "ban" any generics as being:
"too dangerous"…
but the new and improved(vit dem helpz oft demz german koompanee tex-know-low-geez) oxykraken
which now prevents the capacity to melt it on a spoon and shoot it up, is available with the new
expandapatent program from the fda (federal dollar addition) program…
Yes those professions didn't strike me as too hot either. I.T. fields are flooded with
H1Bs, being a salesrep can at times be an easy job to get but often isn't (and so salesreps often
put up with a lot of crazy) etc..
We all pick our poison and how much we can live with. And yet most people believe in the
ideology of making people scramble for money. They think it makes people "work hard" or "compete"
or "add value" but just as absolutely it will make people cut corners. Because they have to because
they need that money to live. And yet we still think completion is good.
Competition will get tough, when in the future, everyone needs to get a college degree, and
lacking money for tuition is no longer a setback, except the 'IQ not sufficiently high' barrier
(for those not taking the less traveled path).
Then, you will need a master's or a Ph.D. to beat back your fellow serf-competitors for that
money to live.
Maybe they are no different from the minimum wage worker who takes a job at McDonalds. We know
McDonalds food isn't healthy, it likely increases heart attacks, strokes, cancer, diabetes etc.
So is the minimum wage worker who is helping this by taking a job at Mikey D's also intelligent
enough to fool themselves into believing this with consistency and no different than the looting
bankers?
Oh the minimum wage worker might be more desperate for work, but frankly while they may pay
more, half the professions listed above don't have a good job market either if we are actually
going to be honest about things.
As a life-long member of this credentialed professional class (specifically, media, even
though the credentials are informal at best), I can say from experience at several of the large
media corporations that many, if not most, employees in the editorial ranks are well aware of
the damage the industry does to this country (it's more abstract, perhaps, than the pharma example,
but it's real). Many speak up, but no one can speak up every time they are asked to execute an
unethical or mindless order whose sole goal is to increase ratings and, by extension, "shareholder
value."
The chronic complainer will be considered a narcissistic idealist and eventually be fired (typically
in a downsizing purge) or, at best, be marginalized. The only hope for those honest people in
the ranks is to find an ally slightly higher in the food chain who is willing to fight some of
these battles. And that person, in turn, is also in the same boat anyway. The people with families
are in the tightest bind and I've never envied them (I have no family to take care of). For years
now I went home at night ashamed of what I do. The only satisfying days were those in which I
did speak up and someone above welcomed my opinion or even agreed. The worst days were when someone
above just laughed dismissively at my concerns.
Not to mention the Military-Industrial Complex where I think this type of analysis is directly
applicable, only the degree of separation is 3 or 4. I see this type of behavior in the building
industry. But with this Industry, Errors & Omissions Insurance tends to keep malfeasance and ignorance
at bay. Since my work has to be documented and the results are relatively immediate and prominent
in the Environment, the degree of separation is kept to one or zero. And maybe that is the solution?
Keeping the degree of separation at a negligible number?
The campaign contributions to both my state and CONgress Members by the opiate industry
is extensive. Which of course makes sense, as Massachusetts has a large footprint in this industry,
as well as opiate overdoses/deaths.
A recent article featuring a local police chief here shows that Narcan must now be used 2-3
times to revive folks. However, quantifying what an "epidemic" is has been difficult. If a friend
or family member has died from opiate over dosage, then it would probably appear to be an epidemic.
Then again, now that drug cartels from all corners of the globe can now manufacture opiates,
supply & demand rules, along with unfettered access to a market where appetites to get high need
to be satiated.
The lack of ethical behavior from the credentialed class has many origins. The best attitude
when dealing with the credentialed class is caveat emptor . Especially in a society where
accumulation of money (and celebrity) is the pinnacle of "success".
I'm part of the credentialed class, but after sour experience with other doctors, lawyers,
architects, priests, and politicians the only prudent path is to watch what they do, not what
they say.
Call me a freaky conspiracy theorist, but the availability first of oxy and then later of heroin
in North America coincides with the US occupation of Afghanistan. That's not an accident. Thebaine
isn't something we can synthesize yet, so it has to come from somewhere.
thank you for clarifying. now the mexican cartels are producing fentanyl which is even stronger
than heroin and adding it to heroin. police are reporting more overdoses because of this deadly
combo.
I remember a movie the panic in needle park where the junkies were always worried about then
the shipment would arrive. you might remember the french connection. that was the 70s when poppies
were grown in places like turkey.
Now there are never panics. there's always mexican black tar.
I checked it out a bit too, out of professional interest. To get started, one would need two
courses: "Introductory laboratory techniques" and "Experimental synthetic biology" both available
at the "Danish Technical University" (DTU) for a modest fee (About 800 USD). If there is enough
people signing up, they will run these courses over the summer holidays (usually, there is, the
summer courses are supplementary lessons for students who flunked their semester exams).
Part of the reason for the collapse and trouble we are in, is that scarcity is more or less
over, so, it has to be manufactured to protect all the investments in obsolete thinking and no-longer-needed
imperial acquisitions.
This analysis applies to the epidemic of doctor-prescribed amphetamines by adolescents and
increasingly younger children. Dr. Peter Breggin is a source for informed outrage on this issue.
"before being published in the less prestigious Proceedings of the National Academy of Science.)"
this raised an eyebrow, since the PNAS was about the most prestigious place to publish among biochemists
(when I was in that world, back in the 70s);
Prestige seems not to be the appropriate angle here, since the journals in question are all
in the same echelon. What's more interesting is a point Deaton himself makes about the second
rejection, namely that simply identifying an alarming phenomenon was insufficient in itself, that
they had to additionally provide some kind of causal justification for this phenomenon. This is
beyond strange and seems to indicate what you imply elsewhere in that paragraph, that there seems
to be a willful desire not to know this analogous to the way "education reformers" constantly
overlook the fact that poverty is the only reliable indicator of failing or sub par schools.
I presume education and neoliberalism is on the docket at some point? It's probably to most
well-documented example of crapification.
I appreciate this article in several ways, but you lose me with "Consider trust as a public
good".
This goes in contrast to the quote from Clive:
Increasingly, if you want to get and hang on to a middle class job, that job will involve
dishonesty or exploitation of others in some way.
We're over-populated and competing with each other, how could it be otherwise? Trust, without
some amount of research, coupled with a period of observation, is a completely naive idea. It
always entails risk. The conflation of "trust" with some kind of faith that has an actual
consequent effect is mystical thinking.
Trust can be observed in small isolated communities where everyone knows each other; in that
kind of context, dishonesty and exploitation are quickly recognized. That's the context from which
it entered our cultures and "moralities". But increase population drastically, and also increase
the range of movement between regions, and and the research and observation become complex, more
difficult to perform and even more difficult to persist. Socio-economic complexities make it easier
and easier to avoid the encumberments of past error, or dishonesty. (I hope I don't have to explain
how the internet fails to solve this problem, and also can't).
And even further, a form of trust is actually operating within exploitative groups like the
aggregates of CEOs/Marketing executives/Database developers/Marketing collateral designers/The
sales force/Middle managers of all kinds. The trusted principle is, play along and we'll all make
some money, and woe to the one that upsets our apple cart. To the extent that trust exists and
operates, it's not necessarily a good thing.
I would love to live in a world where trust, as a discrete positive value, was more viable,
but at the moment, this isn't it. So let's please get past that, and look at how we can conduct
ourselves as a community in which the members must continue to prove themselves in every instance.
Because that is what is required in any case.
Okay I lied. I actually like this world. The pretenses of trust are being shown for what they
are (which is, false and lazy). I think it's a good time to be alive and seek dignity; the fact
that it's becoming more difficult just makes it more important and worthwhile to do so. And global
warming, too? Bring it!
Hmm. I'm not sure that's true. I was thinking of what Graeber IIRC calls everyday communism;
the idea that stranger A asking B for directions to the post office gets directions to the post
office. Well, granted, not in some cultures that are really people pleasing, but at least you
won't get directions that take you over a hidden pit of knives, or under a tripwire that will
explode a bomb. That's a basic level of trust, society-wide, and I think these professionals are
violating it.
Now, if there's some economist-techie-geeky reason why that's not a public good I need to think
again, but it certainly seems like a public good to me.
No argument that the individuals in question (pros or otherwise) are violating trust, at least
collectively, and in some cases individually.But this doesn't mean that credentials are a good
medium for establishing trust. My argument is that short of verification by reference and observation,
there is no sure and durable source for trust (other than faith, which can even be maintained
after the trust has been violated). Verification and observation, those are the "public goods";
"trust" is their abstract product.
My travelling experiences suggest that asking a stranger for post office directions is considerably
more risky if one is clearly an outsider to the community (language, dress, complexion, etc).
No pits or bombs, but knives and similar weapons were involved more than once. But then, I do
not limit myself to the touristy destinations (in tourist context, the visitor is considered to
be something of a community member).
I think the ideal that a stranger will, or even should, get equal treatment with established
community members is suspect. It's one of the fallacies in the imperialist capitalist dream of
access to everywhere (and look, they have a McDonalds!), king for a day every day, no matter where
I go, because my money is good. Bourgeois socialists have funny blind spots in the vicinity of
conceits they retain from their native cultural contexts, I think this is one of them.
Strangers are either guests (which requires some kind of sponsorship, with conventions applying
to both courtesy and restraint), or potentially hostile until proven otherwise. This is the rule
of the road, and not just for humans. And the reasons for this go back to research (reference,
or the absence of it) and observation over time being the basis for valid trust. An ignorant visitor
and ignorant local are both at risk until sufficient information has been exchanged and accepted.
The risk may have nothing to do with malign intent; disease, ignorance of local safety concerns,
protection of natural resources…
The locals that waylaid me were (trying to) retain some of the wealth passing through their
turf for their local economy; the profits of tourist hotels and shops largely bypassed their communities.
I had absolutely no problem in principle with them doing it, and on some occasions made friends
from these initial encounters (in other cases merely escaping).
To tail it back to the original topic, then value of credentials (as a trust medium) weakens
in relation to the sizes of the population and the region. Hucksters busted in one town move on
to the next; the larger their range of options and marks, the easier it is for them. Credentials
can be forged, their references can be corrupted, their media can be hacked. As tokens of trust,
they're problematic at best. Credentials may not be intrinsically useless, but unless we understand
the operation of trust (by any media) in practice, and how it can fail, we shouldn't invoke them
as either a solution or a problem.
I think that the idea that fraud and corruption can be safely curtailed by philosophy or legislation
(something of a static trust mechanism) alone is also suspect; we're inquisitive problem solvers
and keen observers, any weaknesses of flaws in a system will eventually be discovered, and unless
understood and addressed, exploited. All living things do this (although not always as individuals,
or even at the phenotype level).
So what's the solution to corruption and fraud? Pay freakin attention and check the math. On
everything. Expect problems, and solve them as you go…. people make honest mistakes, too. But
don't get fooled twice.
The story of oxycodone is one of rampant criminality: the clinical trials, the approval
process, and the marketing are all riddled with probable fabrications and manifest misrepresentations.
Thanks for this useful summary!
Maybe someday our country will have a criminal justice system to punish acts like mass murder.
If you are a doctor seeing 4 patients per hour, 8+ hours per working day, and also covering
weekend rotations, you are time constrained. Given the brief time you are able to spend with patients
(plus the fact that the drug rep dropped in earlier), it is simpler for most doctors to write
one more prescription; they do it all day.
Having been looted for tens of thousands of dollars in out-of-pocket medical costs over the
past five years, this post hits home. Like other patients fed up with being on meds, I started
looking for alternatives. They exist.
Prediction: one of the next shifts in health care will be called Functional Medicine.
And it is one response, one 'push back' to the incentivized looting and drug dependency of current
medical care.
Here is a one-minute clip from a BBC series of a doctor taking a Functional Medicine approach:
https://www.youtube.com/watch?v=e3JNtgbT234
Note the absence of exam room settings; the doctor is going out into the community, including
people's homes.
And at no point does he simply hand out prescriptions; he dumps the crap out of their kitchen
cupboards, advises them on how to shop for groceries, introduces patients to new foods, works
out with at least one of them, and provides feedback about their progress.
His patients are far, far less likely to be looted than your conventional patient.
And he is able to develop the insight, time, and trust to be able to help patients make choices
that improve their health – in some cases, tremendously.
My link is to a BBC video, because I'm unaware of a US equivalent for this content.
I am, however, very aware of doctors in the US who are implementing versions of this, or trying
new ways to make more time to meet with patients, and create lifestyle-oriented interventions
(as opposed to writing prescriptions).
This is the future of health care, partly because the greed of looting is killing the Golden
Goose of the (insured) American middle class.
Good and decent people do not spend years of their lives in medical school in order to become
part of an entrenched system of looting: the people that I know, who are passionate about health
care, do not want to play by The Looting Rules. Those crappified rules lead to poor patient outcomes.
Smart, competent doctors do not want to squander their talent by enabling looters.
There are brilliant, insightful people who are thinking hard, and risking plenty, to develop new
means of health care delivery. They are gutsy as hell, and determined.
I think that this post could be multiple by 1,000,000 if you think of all the people who are
actively attempting to revitalize health care and make it more patient-focused. This post has
a tiger by the tail.
Kudos to Yves and Lambert for this gem.
For providing symptom relief to actual physical pain obviously marijuana is an alternative
to opiates, maybe not strong enough for late stage cancer and the like so opiates still have their
limited and legitimate uses, but an alternative for many other things being treated with opiates.
We're only allowed to legalize it now that the Oxy patent has worn off.
Minor semi-opiates like Kratum can also sometimes be used an alternative although they have
more addictive potential than marijuana.
"the looting professional class" the salaried (or professional (or "20%")) classes
The behavior described in this article is clearly terrible, but it doesn't seem fair to
blame 20% of the population for this type of thing. You often advise us that generations don't
have agency, and the same can be said for economic classes. Most of the people in the richest
20% could be classified as "professionals", as in doctors, lawyers, stock brokers, engineers,
managers, etc., but I suspect there are some master plumbers and electricians in that category
as well.
We don't have clear language for this (for some reason). I'm trying to tease it out by contextualizing
the professions in the supply chain, and by underlining that there are honorable professionals
in every field. I'm aware that the language is deeply imperfect - people have trouble speaking
in Venn diagrams, it seems to be a feature that English doesn't support - but I'm working to improve
it. As the granularity improves, the sense of agency improves. (Of course, I can think of professions
that shouldn't exist at all, like "Concentration Camp Guard" or "Trofim Lysenko Chair of Genetics"
but those are edge cases.)
Adding, income is a poor proxy for social relations, sadly. It's what we have!
This exchange and the one above with 'dk' pulled me in. I fear I don't have clear language
either, but I want to add this about 'trust' and the professional class:
I think (a) the lessons of the Milgram experiment (trust your boss; go with the program)
and (b) the U. Sinclair notion of can't believe X if you're paycheck depends on not-X … these
2 factors have a lot to do with the separation of the 20% from the 80%. They don't explain the
origin, but I think they speak to the persistence.
I would also refer to recent medical study on pain medications' effect on continuation of pain
sensation after pain relief occurring in placebo groups.
Profiting from supplying opioids is one thing, but what happens when billionaire real estate
developers and hedge fund cash start getting into the recovery and mental health business?
It is not surprising that JAMA and NEJM immediately rejected the paper. From the health care
community point of view Case-Deaton
(1) just tabulated the same CDC data that thousands of other people also do routinely in the same
way as soon as it is published each year – epidemiologists, actuaries, public health planners
etc. who also routinely do population adjustments and look at trends for the total population
and sub-populations. This isn't publishable. It's the equivalent of publishing baseball standings.
These trends were no secret.
(2) Everyone in actual health care besides the data tabulators already knew this – everyone except
the health care pundit class. All the emergency department staff and morgue staff and pathologists
and managers and people handling death certificates knew these as routine deaths – especially
in small town and rustbelt hospitals. Hospital mortality and underlying etiology – both for patients
and DOAs – is a big deal in every hospital and is reviewed by many people.
Thus their paper produced a "so tell me what I don't know" reaction in people in actual healthcare.
I totally agree with describing this as looting. It disgusts nearly everyone who have had to
deal with the results.
CDC has been publishing reports on the incredibly rising incidence in non-Hispanic whites for
years.
NCHS Data Brief ■ No. 22 ■ September 2009
Increase in Fatal Poisonings Involving Opioid Analgesics in the United States, 1999–2006
Margaret Warner, Lli Hui Chen and Diane m. Makuc
Vital Signs: Overdoses of Prescription Opioid Pain Relievers - United States, 1999–2008
Weekly. Mortality and Morbidity Weekly Report, November 4, 2011 / 60(43);1487-1492
The inclusion of database developers as a responsible party is absolutely absurd, and it betrays
an ignorance of what database (and software) developers do. We build the informational "machinery"
that stores and retrieves data, according to the specs handed to us by business types. We do not
typically monitor/summarize/report on the data itself as it rolls in, unless we happen to be specifically
tasked with such a thing.
It only proves the point if the McDonalds burger flipper is also guilty for also working for
a firm of questionable morality. Now of course one could argue that it's a lot different to work
at a firm producing Oxy than in fast food (even though the later does kill) and I don't think
that's unreasonable.
I just think that has absolutely NOTHING to do with being a professional or being a working
class prole. That factor is irrelevant.
What about if you work on the database for Coca Cola, are you guilty of increasing diabetes?
What about if you work upselling it (ie management says you must ask customers if they would like
to supersize their soda or something) at McDonalds?
Oxy may be worse that such things. We all pick our poison. Some people's picks go far further
than our conscience would ever allow us to go. Sometimes professionals have more wiggle room financially
but the stats on how few people have a few hundred or thousand bucks in savings makes that questionable.
I honestly suspect most jobs are a bit corrupt. Even if one works for a non-profit,even many
non-profits are stealing massive amounts of the donations for administration. Etc.
So you get asked to create a database that tracks sales rep's visits to specific doctors and
a doctor's number of prescriptions of all drugs and some specific drugs, (undoubtedly from a long
list) and from doing that, the developers are supposed to know that they just helped push opiod
addiction?
I'm REALLY not seeing your point.
The people that PLANNED this system MIGHT have known the purpose, and the system architect,
maybe, but the guys pushing out the code and making sure the database does what is asked probably
have NO IDEA about things like that. It's just not something they would even notice.
It seems to become a non-obvious question. We need MORE DATA :). No really we just need more
information.
Is the only med Purdue Pharma makes opiates? Then one could say one is working for an opiate
provider. Were the employees even full time employees of Purdue Pharma? Sure they might be H1Bs,
but also for a time limited database development job they are often 3-6 month contractors, it's
VERY common. You could argue the 1099s have some guilt even so though. There is even a possiblity
the database development was contracted out to an external firm.
Is it obvious the harm opiates cause? Well it is NOW. I guess it's why I tend to latch on to
the question of if the firm one works for is ethical because I don't believe the wrongdoing is
always obvious from say the data. But a firm itself could be said to be unethical and thus it
could be argued it is unethical to work for an unethical firm.
But if you don't understand what the functions the specs are describing, how can you build
a good database? And summarizing and reporting are often in the purview of the developer.
There is a point to be made here. Managed structures can insulate task fulfillers from the
full context(s) of their work. The implementors may not be immediately aware of or fully understand
the consequences and implications of their work.
But there are many scenarios where the database developer has, or should have, full knowledge
of the operational aspects of their work relating to compliance, safety, and contractual/fiduciary
responsibilities.
Take for example HIPAA, with several defined rules required for compliant implementation of
data management. The database developer should be at least aware of the specifics of the requirements,
since they directly address significant aspects of storage and retrieval functions. HIPAA compliance
is required by law for handling of any patient, treatment, provider, or payment information (protected
health information (PHI)).
Another example: political fundraising. It is explicitly illegal to sell or use names and addresses
of individuals from FEC records as a primary source for solicitations (
http://www.fec.gov/pages/brochures/saleuse.shtml
). However it is very easy to do so, and the data manager that does it is breaking the law,
as much as a person (or document) instructing them (who actually gets prosecuted is another matter
entirely).
Yea HIPPA requires compliance and knowledge on the part of a lot of involved employees, that
is part of the law itself. But that workers have knowledge of all aspects of a business is NOT
part of the law. So on the other hand management may be scamming the shareholders say and a database
developer might not know depending, just because knowledge is shielded in many ways.
In essence you are arguing that it is acceptable that your profession is fine and that you
can all be little Eichmanns now. Your profession has plausible deniablity built into its structure.
Speaking of credentialism, it was "prestigious" JAMA (and I would suggest applying the term
to an academic journal automatically casts doubt on its intellectual respectability) that once
rushed to publish a badly designed "study" ostensibly by a child who apparently was actually coached
by her mother's MD boyfriend, all to discredit an alternative medicine therapy because the AMA
hates alternative medicine. The method has continued to be studied, with intriguing articles being
published occasionally in less political, more research-oriented journals such as the Journal
of Orthopaedic Research and Annals of Internal Medicine.
For those interested in the subject, Therapeutic Touch International Association, therapeutic-touch.org,
provides some literature citations and an 89-page (pdf) copyrighted bibliography.
Moral: Avoid prestige (and Google ratings) when seeking information.
I know there's a problem with opioids. But for some of us its very beneficial, provided you
have a certain amount of self-discipline. Two years ago I was diagnosed with severe spinal stenosis.
It was so bad that I could hold a fork, button my shirt , or zipper my fly. If I didn't have surgery.
I would have been paralyzed and incontinent. The surgery worked. I lead a normal life. But without
Percocet, the pain would be unbearable. I've tried marijuana. It's not that effective. I do Tai-Chi
and physical therapy exercises. I even walk and swim. I worry that the pain puritans will take
power and insist that I must suffer.
The major changes that I have seen since 1961 include widespread pornography, casino gambling,
drug addiction, homelessness, forever wars, economic crashes and student debt. In each case someone
is making money and the costs to society are discounted. Privatizing gains. Socializing costs.
This post on the opioid epidemic is an excellent specific example of this. The gutting of the
Western Middle Class and the economy and morality that support it is extremely destabilizing.
Either there is a restoration of the rule of law and punishment for crimes against society or
"Peace and Prosperity" will be a quaint phrase from half a century ago. That is if mankind survives
climate change and/or the Cold War 2.0 with Russia.
"Although the U.S. constitutes only 4.6 percent of the world's population, Americans use 80
percent of the world's opioids."
Eighty percent? I'd love to see the data mining in that study. That's a ridiculous number.
Opioids are used in almost every culture, just not the drive-thru pharmacy variety.
My American colleagues, at the same age as me, are all, with a few exceptions, consuming a
ridiculous amount of prescription medicine for all manner of things.
My prejudiced opinion (because I don't really know) is that many of them started off with some
minor but chronic disease, then they got side-effects from the treatment, then they get treated
for the side effects, etcetera. The whole thing escalates and they are now bound to eating 15+
different "meds".
My father was trapped in this bullshit for maybe 20 years, before the government created "palliative
teams" – a team of doctors who will go through the medication and illness history of chronic patients.
They re-evaluate and re-design their treatment. Usually with life-saving effects, as in: Unexpected
years of improved quality of life.
The cause of the "minor, but chronic disease" is (again in my biased opinion) probably due
to unhealthy food; The medicated men can't cook, their wives cannot cook anything "from scratch".
They rely on food items in bags, boxes or frozen "because the nutritional values are printed on
them, so we know what we are getting(!)".
The exceptions … they can cook proper food.
In my opinion, Americans are getting slowly poisoned and they are not getting any help
either because the US food industry is allowed to sabotage the access to unadulterated foodstuff.
This is one of many reasons that people "here" hate the TTIP & Co: We don't want to be American!
We don't want US business practices.
Looting is definitely the right term here. I suspect there are many actors who became fabulously
wealthy from the prescription opioid (and amphetamine – ADD medications like Adderal are analogues
to street Methamphetamine) scam.
Just to put the scale of looting into perspective it should be noted, for readers that live
in New York City, that the Sackler family which founded Purdue Pharma funded the Sackler Wing
at the Metropolitan Museum of Art which houses the Egyptian Temple of Dendur and study centers
for Chinese and Japanese Art History. They are truly magnificent for those who have never visited.
Below is a link to additional organizations the Sackler family has endowed:
• The Raymond and Beverly Sackler Foundation Fellowship at Institut des Hautes Études Scientifiques
(IHÉS), France, to fund invited researchers from Israel at IHÉS, 1990
• The Raymond and Beverly Sackler American Fellowship at IHÉS, France, to fund invited researchers
from the USA at IHÉS, 2002
• Raymond and Beverly Sackler Institute of Biophysics, Raymond and Beverly Sackler Faculty of
Exact Sciences, Tel Aviv University, 2004
• The Raymond and Beverly Sackler Distinguished Lectureship at IHÉS, France, 2004
• The Raymond & Beverly Sackler Institute for Biological, Physical, and Engineering Sciences,
Yale University, 2008
• Raymond & Beverly Sackler Laboratories of Biomedical and Biophysical Studies, Rockefeller University,
2008
• Raymond and Beverly Sackler Center for Biomedical and Physical Sciences, Weill Cornell Medical
College, including a program in cardiac stem cell research dedicated to friend and colleague Professor
Isadore Rosenfeld, 2008
• Raymond and Beverly Sackler Fund for Biomedical and Physical Sciences (in honor of Phillip A.
Sharp), Massachusetts Institute of Technology, Cambridge, Massachusetts, 2010
• Raymond and Beverly Sackler Laboratory of Biomedical and Physical Sciences, University of Washington,
Seattle, Washington, 2010
• Raymond and Beverly Sackler Laboratories in the Physics of Medicine, University of Cambridge,
Cambridge, United Kingdom, 2010
• Raymond and Beverly Sackler Center for Biomedical, Biological, Physical and Engineering Sciences,
University of Connecticut Health Center, Farmington, Connecticut, 2011
• Raymond and Beverly Sackler Center for Biomedical, Physical and Engineering Sciences in honor
of Emilio Segre, University of California, Berkeley, 2011
• Raymond and Beverly Sackler Laboratories for Biomedical, Physical and Engineering Sciences in
honor of Saul J. Farber, New York University, School of Medicine, 2011
• Raymond and Beverly Sackler Center for Convergence of Biomedical, Physical and Engineering Sciences
in honor of David Baltimore, California Institute of Technology, 2012
• Raymond and Beverly Sackler Center for Convergence of Biomedical, Physical and Engineering Sciences
in honor of Herbert Pardes, New York Presbyterian Hospital, Columbia University Medical Center,
2012
• The Raymond & Beverly Sackler Convergence Laboratory, Tufts University School of Medicine, 2013
Not a bad payday for facilitating worldwide opioid addiction.
"He endowed galleries at the Metropolitan Museum of Art and Princeton University, the Arthur
M. Sackler Museum at Harvard University in Cambridge, Massachusetts, the Arthur M. Sackler Museum
of Art and Archaeology at Peking University in Beijing, the Arthur M. Sackler Gallery of the Smithsonian
Institution, in Washington, D.C., and the Jillian & Arthur M. Sackler Wing at the Royal Academy,
London. "
• Sackler Library at the University of Oxford
• Sackler Laboratories at the University of Reading
• Sackler Musculoskeletal Research Centre, University College London
• Sackler Institute of Pulmonary Pharmacology at King's College London[2]
• Sackler Crossing – a walkway over the lake at the Royal Botanic Gardens, Kew
• Sackler Biodiversity Imaging Laboratory at the Natural History Museum, London
The kind of destructive social conduct was noted by cultural anthropologists studying cultures
affected by Euopean colonization. As the meaning of the culture was drained by colonial predation,
the societies degraded, people lost direction, language changed rapidly and the previous social
networks unraveled. Essentially, the colonized no longer saw or felt that there was a place for
them.
In the present case, the working class that formed out of and as a consequence
of two world wars no longer has a place in this country. Thus, similar responses to this displacement.
In the present case, the colonizers are the credentialed class of mandarins who see themselves
as separate from their fellow citizens.
Something I think is lost in the opioid deaths discussion is the fact that these people had
real pain. Terrible pain. Treating that pain is good. But a doctor can't change a sedentary culture
that creates much of that pain. Everything about constant sitting is bad for the body, and
when the sedentary body starts moving, things get worse, because terrible movement patterns are
ingrained. There'd have to be nationwide physical therapy to solve it. I recommend reading and
following 'deskbound' by Kelly Starrett, if you're a sedentary person.
"To move large amounts of prescription painkillers in America, you need somebody to write the
prescriptions. You need doctors. Hiring doctors to sell drugs is easy, says George. He found his
doctors by posting ads on Craigslist. At their peak, when they were running the largest pill mill
operation in the U.S., the George twins had roughly a dozen doctors working for them.
George says not a single doctor he interviewed ever turned down a job offer. Although he was
always younger than the doctors he was interviewing-he was in his late twenties at the time-George
says he made a professional impression. "I had such a big office; it was an easy sell," says George.
"They didn't walk into some hole-in-the-wall place. The hours were good. The pay was good."
What the jobs lacked in prestige, they made up for in wages. According to George's indictment,
doctors at his clinics were paid a flat fee for each opioid prescription they wrote-typically,
$75 to $100 a pop. To help maximize their efficiency, doctors were given prescription stamps they
could use quickly, over and over. It was common for physicians at American Pain to see 100 patients
a day, he says. At that rate a doctor would earn roughly $37,500 a week-or $1.95 million a year.
It was a doctor who first advised him to go into the industry. At the time, he and his brother
were running a hormone-replacement therapy business and selling steroids online. Along the way
they got to know a doctor who told them that painkillers were a much bigger market and advised
them on how to get started. The doctor later died in a car crash overseas, but he left the George
brothers with a lucrative business model. According to prosecutors, the twins' pain clinics, over
their two-year run, sold 20 million oxycodone pills and brought in $40 million."
One minor cavil in your article, Lambert, and that concerns labelling PNAS a "less prestigious
journal", as opposed to JAMA or NEJM. Back in the day when I was an active research scientist,
publication of original work in PNAS was considered a very worthy accomplishment indeed, as were
papers published in Nature, Science, etc. It is a multidiscipline journal, taking in a broad cross-section
of the physical and social sciences, as well as medical research, wherein submission of articles
for publication must be done by a member of the National Academy of Sciences, a very "prestigious"
group, to say the least…peer-review and all that, of course. Now, whatever the reasons for manuscript
rejection by the two strictly medical journals, only their respective editors would know; but
I suspect it may have to do with…yes, "credentials", as neither of the two authors have any sort
of specialised medical background or even one in epidemiology, but are economists, not the usual
senior authors JAMA prefers. And, "failure" – a rather loaded word – to gain acceptance in a specialty
journal in no way reflects the essential merits of the work, which clearly has been reflected
in the immense reception and subsequent citations received in the lay press and media. I look
at this as JAMA/NEJM's loss, and PNAS's gain, quite simply.
I originally bought this book in May of 2011. I can't remember exactly why it spoke to me,
but I know I was looking for self esteem boosting books. I think maybe the title resonated because
I realized I was having some trouble with perfectionism. Accepting mistakes, compassion for myself,
forgiving myself, but also pushing forward to being a better person, a better worker, friend,
girlfriend, etc. It resonates today because I see how much of a perfectionist I can be, and how
much trouble I am having forgiving myself for past mistakes, and trying not to label myself because
of them. I am having trouble sufficiently feeling the guilt enough to change, letting that feeling
in, but then forgiving myself, and not letting those behaviors define who I am as a person.
How did the book address this?
-I think these quotes from the book really get to the heart of the message: "Perfectionism is,
at its core, about trying to earn approval and acceptance.... Healthy striving is self-focused--How
can I improve? Perfectionism is other-focused--What will they think?... Perfectionism is addictive
because when we invariably do experience shame, judgment, and blame, we often believe it's because
we weren't perfect enough. So rather than questioning the faulty logic of perfectionism, we become
even more entrenched in our quest to live, look, and do everything just right." Brown, Brene (2010-09-20).
The Gifts of Imperfection (p. 56-57). Hazelden. Kindle Edition.
-What I got from this is that perfectionism tricks us into thinking we have it all: we can feel
connected and invulnerable and in control. BUT, it is ultimately unsatisfying because it #1) it
is a lie. We aren't in control or invulnerable, or perfect. And #2) it requires us to change who
we are -- and the connection we most desire is a connection based on being truly known by another
person. So in order to feel connected AND known, we have to accept the reality that we are imperfect,
and we are vulnerable, and we are not in control.
-And while connection is obviously a huge source of joy, Brene also talks about the other kinds
of joy that perfectionism halts in its tracks: meaningful work, enjoyable hobbies, creative endeavors,
etc. Again, because perfectionism tries to give us a sense of control, and thereby tries to prevent
the possibility of loss, we often don't even try to have joyful things, or we deny the level of
joy something is giving us in order to feel less hurt when it leaves.
-And the book has a lot of great suggestions as to ways get past the feelings of inadequacy perfectionism
is rooted in, and also ways to lean into the vulnerability of imperfection. Another great topic
the book covered (and that it alerted me to) was the importance of shame as a barrier to self
acceptance and love and joy. (But as you will see below, I really recommend its sister book for
more on this piece). And I love Brene's emphasis on authenticity as a goal. It is fascinating
and inspiring.
Where I still don't feel resolution:
-One of the things she mentions to get when you are feeling shame is getting connected, sharing
your story. But I have a few concerns about that:
-She doesn't explain in detail WHO has earned the right to hear your story and HOW to cultivate
those friendships. If you are reading the book is stands to reason that you may very well not
have those friendships. If you are cultivating your authenticity and dealing with feelings of
inadequacy, you may have surrounded yourself with inauthentic and judgmental people because of
your need for approval from these types.
-Even if you are at some stage where you have a few compassionate and caring friends (which I
do feel lucky enough to have), it requires them to always be open to your shame at the moment
you need them without regard to the "stuff" they bring to the day. If you are feeling shame about
X today, and so are they, your attempt at connection may trigger their shame even deeper and they
will "imperfectly" push you away. I wanted her to talk more about those situations. It is great
when you can have an empathetic ear to listen, and it feels amazing, but even with the world's
best friends, you cannot always expect that will be available to you whenever you need it.
-And then even if you catch your friends on a day where they are feeling great, or can be present
to your needs and your shame, what if you are a "gusher," and you are at the beginning stages
of dealing with your inadequacy issues, and you feel shame "a lot"? You can become an emotional
drain to them, and push them away. I wanted some more information about self-soothing in shame
situations, or how to manage connecting with friends in those moments.
I am still not sure how I am going to be able integrate this intellectual understanding into a
daily practice. When I do something "wrong", especially something I have done wrong a hundred
times before, will I be able to lean into the guilt, instead of the shame? Will I be able to lean
into the vulnerability? Will I be able to be present to the vulnerability around me?
I know a big part of this is simply practice. And finding strategies that resonate. But the first
step for me is an intellectual understanding, and this is certainly worth reading if that is something
that is important to you.
You may have heard the word "bingeing" used casually. People binge on food, alcohol, or even a
series on Netflix (NFLX). But Binge Eating Disorder, or B.E.D., is the most common eating disorder
in the US. It impacts almost 3 million Americans, making it more common than anorexia and bulimia
combined.
And it may be vastly underreported.
B.E.D. was only recognized as an official disorder in 2013, which is when it was
added to the American Psychiatric Association's (APA) Diagnostic and Statistical
Manual of Mental Disorders (DSM).
For years, eating disorders were classified into one of three groups-anorexia, bulimia, and
"eating disorder not otherwise specified," making it difficult for individuals with B.E.D. to
seek treatment covered by insurance.
B.E.D. includes bingeing on average at least once a week for three months and feeling that
one's eating is out of control during a binge. Individuals with B.E.D. don't routinely try to
"undo" their excessive eating with extreme actions like throwing up or over-exercising.
While the exact cause of B.E.D. is unknown, certain theories suggest that adults with the
disease may have differences in brain chemistry that could reduce activity in impulse
control-related parts of the brain, increasing the "wanting"of a particular food. There is
evidence that family history and certain life experiences may also play a role.
The food industry-including names like Mondelez (MDLZ), Coca-Cola (KO), and General Mills (GIS)-has
come under fire for the role it plays in making food more addictive as well, including investing
in recipes that keep consumers wanting more.
On Thursday, Philadelphia
passed a sugar tax. Several studies have related sugar addiction to
more commonly-discussed addictive substances, including cocaine. But
analysts have included that
sugar taxes wouldn't impact the overall growth of the sugar industry, especially from developing
regions with growing middle classes, like Brazil and China.
B.E.D. has also received more focus in recent years, especially as one-third of Americans are
obese, according to the Centers for Disease Control and Prevention (CDC).
Global News Anchor Katie Couric hosted a panel on B.E.D. to discuss some of the most important
aspects of the disease.
Monica Seles became the youngest number 1 tennis player in the world at age 17 and won 9 Grand
Slam championships throughout her career, yet she struggled with binge eating disorder over the course
of her career. She's been outspoken about her struggles with binge eating disorder throughout her
successful tennis career and joined Couric to discuss her journey.ABC News Correspondent Mara Schiavocampo
also shared her story on her struggle with B.E.D. before losing 90 pounds.
Brad Lamm, an interventionist who founded one of the few treatment clinics for the disorder,
Breathe Life Healing Centers, discussed the scope of the disease and treatment remedies.
And I discussed how the industry may have contributed to the problem and the role insurance companies
are playing.
Nicole Sinclair is Markets Correspondent for Yahoo Finance.
This film takes an affecting look at the struggles of women to overcome eating disorders. Photographer
Lauren Greenfield goes inside the Renfrew Center in Coconut Creek, FL--a facility dedicated to helping
women and girls overcome these disorders.
Through the years, I have had several friends with anorexia and/or bulimia--so when I saw this
HBO documentary, I thought I'd give it a look. "Thin" tells the story of Florida's Renfrew Center
which is a treatment facility for eating disorders. Following four women specifically, we see
some of their emotional highs and lows and the Center's process of recovery in great detail. I've
always associated eating disorders with younger (college or high school age) women, so for me
it was fascinating to see the diverse cross section of older and even well-established women facing
these issues.
The women are candid and it seems as if we have an all access look into their lives. Particularly
interesting to me is how supportive friendships can be formed--but in some cases, those can also
be enabling. One clique, in particular, starts to take on a negative image when they start disregarding
the rules. The sincerity of some of the women wanting to get well is always a question--some work
the program hard, some fight it. And the staff must be caring, yet tough enough to cut through
the hypocrisy and deception. "Thin" also gives us a glimpse into some of the family dynamics which
might have helped to trigger these illnesses. One of the most memorable moments for me is when
a mother came to visit. She sits down to lunch with her daughter who is required to eat, and she
disparages and picks apart the food served. She is absolutely oblivious to the negative implication
this might have on her daughter.
Near the beginning of the picture, one of the women remarks about her life--"I used to have
a personality." This is an interesting and powerful idea. The women in trouble have gotten
so caught up in their illnesses, they've forgotten how to live. And this notion is repeated
throughout by many of the patients. In one of the more moving confessions, one 25 year old patient
speculates what her life might have been like had she gotten treatment when she was 15. It's so
emotionally raw (she is trying to convince 15 year old Brittany to take advantage of her youth)
because she recalls all the normalcy and joy she has missed out on.
Ultimately, this is a documentary. There is no happy Hollywood conclusion, just an insightful
look into an all too prevalent problem.
I definitely agree that this documentary is limited in it's portrayal of the "reality" of eating
disorders and treatment. For several reasons, this still isn't the ULTIMATE look into the lives
of eating disordered patients, though it's the best to date. Patients do die as a result of eating
disorders, 7%-10%, a fact that is not made out as a very serious in this film, any one of the
women portrayed were on the brink when they arrived. You lose the fact that most eating disorder
patients, patients with symptoms as serious as those of Shelly and even those with less serious
symptoms, spend their ENTIRE LIVES fighting. Spending years in many different types of treatment,
being treated, inside & outside residential treatment centers, as if they should "just eat" because
family members and friends don't understand. As frustrated as those around us can get, understanding
the thinking seems to be harder than most any other "mental" illness, because why can't we "just
eat?" I think this film does a good job of portraying how nurses and other personnel act towards
patients, and how patients, both inside and outside of treatment, feel that they are not only
misunderstood, but basically treated as though our illnesses are just a burden, so "get over it"
so to speak, when in fact it is MUCH more complicated.
The only other thing left out of this movie is the fact that men can also have eating disorders
and that there are treatment centers out there that are for males AND females, though many are
just for females. From my viewpoint, the film also shows the importance of small 6-8 patient residential
treatment centers since at least three of the four patients left too abruptly and returned to
their disordered behavior immediately after leaving treatment. Such a large group as The Renfrew
Center allows "cliques" to form, rivalries, and lack of trust which is a major source treatment
failure because patients won't open up to one another. In regards to the facility in this film,
the life of a patient is also limited, whereas other treatment centers with fewer patients find
help not just through talking & eating together, but through learning how to be comfortable with
everyday tasks like grocery shopping, eating at restaurants, finding hobbies that bring them joy,
and many other "outings" to treat the whole person and prepare them for a completely new (and
hopefully improved) life without an eating disorder.
The description above "Thin offers hope, but no happily-ever-after ending for these women"
is truely the lesson of the disorder and of this film. Like alcoholism, you never truely "recover,"
but if you are one of the lucky ones, you can reach a state of constantly being "in recovery,"
always with starvation and purging in the back of your mind.
Insurance companies today have somehow moved up in rank over our doctors, telling us when we're
well, what medications we can take, and what treatments will work, despite the fact that they
don't know us, don't have medical degrees, and don't know anything about anything. The statement
made "People treat it like a cold, but it's more like cancer" is not only how PEOPLE treat eating
disorders, but how INSURANCE treats them. This film should stand as a testament to all eating
disorders who are still struggling due to insurance companies who WON'T LET US GET HELP.
Glimpse into Eating Disorder Thinking & Treatment
As someone recovering from an eating disorder, I have noticed that there is a continuing problem
with much of the eating disorder literature and media available today; while it effectively serves
as an educational tool for those trying to understand the dark world of eating disorders, it can
often serve as a trigger for those trying to recover from an eating disorder. However I have found
that Lauren Greenfield's work, both on her Thin documentary and book, does not do this. In fact,
Greenfield's work is the first piece of information on eating disorders that has truly repulsed
me from the very condition of having an eating disorder. This is the first time I have ever felt
this way, and that is very significant, because the difficult part of breaking away from disordered
eating is actually seeing that it is a repulsive act.
For this reason, I highly recommend both the book and the documentary for those who actively
want to recover, and need inspiration, and to those who are having a difficult time understanding
why a friend or loved one is going through it. Greenfield pulls no punches and does not sugar
coat any aspect of the girls recovering at the Renfrew Center in Florida (to my knowledge there
are no males shown at this facility when the filming occurs, despite the fact that there are men
with eating disorders too) Be warned the footage is graphic - there is a lot of vulgar language,
views of these women throwing up (one even literally tosses her small dog out of the bathroom,
then locks the dog in a crate just so she can have privacy while she vomits), and both the book
and the DVD show women's scarred bodies both from self-mutilation and from suicide attempts.
All in all, I am very impressed with Greenfield's work. Well done.
The overall pattern of narcissistic behavior is emotional instability and aggressive behavior caused
by insecurity and weakness rather than any real feelings of confidence or self-esteem. One very interesting
and revealing feature of a narcissist (as well as several other types of psychopaths) is emotion-phobia
Notable quotes:
"... Narcissists abhor feeling influenced in any significant way. It challenges their sense of perfect autonomy; to admit to a feeling of any kind suggests they can be affected by someone or something outside of them. So they often change the subject when feelings come up, especially their own, and as quick as they might be to anger, it's often like pulling teeth to get them to admit that they've reached the boiling point - even when they're in the midst of the most terrifying tirade. ..."
Emotion-phobia: Feelings are a natural consequence of being human, and we tend to have
lots of them in the course of normal interactions. But the very fact of having a feeling in the presence
of another person suggests you can be touched emotionally by friends, family, partners, and even
the occasional tragedy or failure. Narcissists abhor feeling influenced in any significant way.
It challenges their sense of perfect autonomy; to admit to a feeling of any kind suggests they can
be affected by someone or something outside of them. So they often change the subject when feelings
come up, especially their own, and as quick as they might be to anger, it's often like pulling teeth
to get them to admit that they've reached the boiling point - even when they're in the midst of the
most terrifying tirade.
Lipstick & Liquor explores the secret in the suburbs. A growing number of women are abusing
alcohol and becoming alcohol dependent. Excessive alcohol use is the third leading cause of
preventable death among women between the ages of 35 and 55. It is a co
Excellent health
care documentary
By
Synapse
on May 28, 2013
Format: DVD
I am very impressed with the content of "Doctored." I
am familiar with some of the physicians attached to and
interviewed in the documentary. The thing that I enjoy
about it most is that it isn't negative, per se, about
the medical community, but rather it is positive about
"alternative" methods (most specifically chiropractic).
That said, it does expose some glaring weaknesses of
our current medical health care system which everyone
who participates in it needs to understand. While
medicine saves many lives every day, it is
statistically the number three killer in the US as
well, claiming 250,000 lives per year (B. Starfield,
M.D., July 26, 2000. JAMA 284(4). pp483-485).
What this documentary does is offer an alternative
to the mainstream of drugs and surgery. It also shows
how the American Medical Association has biased doctors
and patients, and stifled the profession of
chiropractic simply because it is a competitive system.
The film also shows many hopeless lives transformed
by chiropractic, nutrition, and other "holistic"
methods. I like documentaries that not only expose
weaknesses, but offer hope and alternatives for those
who have never been exposed to the whole truth. Highly
recommended!
YOU
MUST SEE
This documentary should be mandatory for everyone. It's
packed with realistic (sad) information and reveals the
truth about our healthcare system. Hey folks, it's all
about MONEY. Almost everyday I hear someone talk about
side effects of medication(s) they are taking, frequently
not even realizing the problem IS the medication(s). How
many Americans are medication FREE?? If you've taken a
blood pressure pill for 10 years, when will your blood
pressure come down? Think about it!!! How shameful that we
have not questioned doctors before they give us a flu
shot, put something in our IV, write one prescription
after another, recommend tests, etc. It's past time we
educated ourselves and take control of our own health by
making better lifestyle/dietary choices. The standard
American is so addicted to sugar, artificial sweeteners,
etc etc. but quick to complain about hypertension,
diabetes, headaches, exhaustion, and the list goes on. The
politics within the medical arena are REAL and it's not to
our advantage. Wake up America! Please watch "Doctored".
Hits Many Great
Topics A++ Documentary
This documentary made me cry because a story within it
related personally to me. I too had my MD. tell me surgery
was needed on my back and when I suggested maybe seeing a
chiropractor for the first time, my MD. said, "Don't waste
your time & money." This comment upset me knowing without
trying a chiropractor first, my only other step would be
surgery. Why not at least try it? Even though I had never
been to or trusted chiropractors, I went and seen one.
Long story short, I didn't need surgery and the time and
money I had spent previously on the MD. was actually the
waste of money, not the chiropractor!
This documentary is great. It clearly hits the topics
about chiropractors, vaccines, AMA, Big Pharma, gmos and
autism enough to cause the average person to start
questioning things.
"... recently started going back to the counselor on my own in an attempt to get advise on how to communicate and interact with my wife when she has sudden and unexplained outbursts of anger, irrational accusations and contradicting arguments. ..."
"... One thing that has become very clear to me after reading this book is that until a BPD person accepts responsibility for the things they say and do and that it's not everyone else, it will always be a struggle. ..."
"... Very informative and worth reading for anyone who is on the receiving end of unexplained and unpredictable outbursts of anger/rage, unexplained accusations, manipulative comments, and attempts to make you feel like you're always the problem. ..."
This was suggested to me by a counselor. My wife and I went to a marriage counselor 4 times before
she stopped going because it wasn't her priority. I recently started going back to the counselor
on my own in an attempt to get advise on how to communicate and interact with my wife when she has
sudden and unexplained outbursts of anger, irrational accusations and contradicting arguments.
I just finished reading the book and was amazed at how similar the content was to what I have been
subjected to and experiencing.
The chapter discussing how to communicate with a BPD person was
very informative and I've attempted to apply the method but my wife insists everyone is ganging up
on her, stabbing her in the back and that she can't trust anyone... even me. She refuses to accept
any responsibility for her behavior.
One thing that has become very clear to me after reading this book is that until a BPD person
accepts
responsibility for the things they say and do and that it's not everyone else, it will always be
a struggle. My greatest fear is the potential impact on our daughters as they grow up and witness
their mother's unexplained outbursts.
Very informative and worth reading for anyone who is on the receiving end of unexplained and unpredictable
outbursts of anger/rage, unexplained accusations, manipulative comments, and attempts to make you
feel like you're always the problem.
J. Albrighton April 24, 2016
There is some good info here.
I ran into a few stereotypes in the first chapter that he declares are true about
borderlines that are false. He claims that borderlines lack empathy and are manipulative. That
may be true for some borderlines, but that is not true for all. In fact, some borderlines can
feel the pain of others so intensely that they struggle with it. He claims that splitting is
the primary defense mechanism employed by the borderline, but not all borderlines do this.
There is some good info here, but there's enough bad mixed in that it's not worth the read.
There are other better borderline resources out there.
Despite 14 years of public education campaigns, only one-third of Americans know about national
recommendations for a minimum of 30 minutes of exercise a day, and fewer than half meet that goal,
a new study has found. The lack of awareness is greatest among men, the unemployed and people born
in the United States, the researchers said. Their finding camefrom [...]
"... Using human bronchial epithelial cells, which are commonly used to measure the carcinogenesis of toxicants, researchers confirmed fracking flowback water from the Marcellus Shale caused the formation of malignancies. ..."
Additional buried costs of Unconventional extraction are surfacing. Fracking and production liquids
are live costs – how often is liquids disposal cost breaken out for the life of the well?
"Though fracking industry proponents scoff at any intimation their so-called vital industry
poses even scant risks to the public, a new study published in Toxicology and Applied Pharmacology
just proved those critics right - fracking wastewater causes cancer.
"... I recently left a job with paid group insurance - navigating the ACA is not easy. The choices, parameters and benefits are rather opaque. Like your daughter, I can pay around $1200/month for coverage giving me a deductible 13x my group plans and an out of pocket cap 4x that of my group plan. ..."
This is so important. When Clinton reverses course to undermine a reasonable Sanders proposal,
aiming at what she once supposedly supported, she argues that the ACA is the best we can do. But
the ACA is a flawed mess, not as convoluted as Clinton's 1990s proposals but very complicated,
consumer unfriendly and limited in its benefits.
It is better than nothing but that is really
not as wonderful a thing as Clinton tries having it.
I recently left a job with paid group insurance
- navigating the ACA is not easy. The choices, parameters and benefits are rather opaque. Like
your daughter, I can pay around $1200/month for coverage giving me a deductible 13x my group plan's
and an out of pocket cap 4x that of my group plan.
People should not be satisfied with the ACA
as Clinton argues - nor should their frustrations with the program lead them to want to get rid
of a federal plan - rather, the push should be as Sanders has argued for Medicare for all.
kerfuffler -> o_lobo_solitario 30 Jan 2016 13:32
The absence of insurance and pharmaceutical money from the election coffers of the
president will mean he is not beholden to them. It's common knowledge that it was Dems taking
their money who scuttled the idea when Obama was considering it.
I'd rather vote for someone who holds it as a possibility than someone who dismisses it and
thereby paints all of us into a corner where we're forever exported by insurance and drug
companies. It may take a while, but taking corporate money out of politics is a good start.
kerfuffler 30 Jan 2016 13:12
It's very disappointing , shameful even, that The Guardian, a publication from The UK,
where the population has the benefit of the NHS, has been promoting Hillary Clinton and taking
every opportunity to belittle Sanders. We here in the USA need universal health care. My 30
year old daughter and her husband (healthy, no pre-existing conditions) are paying $1200 per
month on heath insurance. Yes, you read that right. Not even health care. It's extortion.
Clinton, funded by insurance companies, has taken to ridiculing Bernie Sander's call for
something she once believed in. Or did she? What does Mrs Clinton really believe?
With Sanders we know exactly where he stands on the issues. He has experience, has worked
long and hard in congress, and has never wavered from his own excellent judgement.
"... the most satisfied patients had a 26% greater risk of death compared to least satisfied patients. When patients in poor health were excluded, the risk of death for these highly-satisfied "healthy" patients increased to 44% more than their least-satisfied counterparts. ..."
"... I've seen this bias to overtest and overtreat first hand, and I can't imagine what people who are less than robust must go through. ..."
"... Manual breast exams by an experienced examiner are far better at detecting the dangerous growths, and thermal imagining is also more accurate than mammograms and does not involve radiation. But radiologists have an installed base of equipment and will hector you if you refuse to get a mammogram. ..."
"... I'm not about to let a doctor go on a fishing expedition in my knee, yet that seems to be considered acceptable. ..."
"... the Maggie Mahar book, Money Driven Medicine which shows why the market has failed. One big culprit is information asymmetry. ..."
"... In the medical arena, there is often a lack of good data as to what constitutes optimal practice. Among the many examples are the backing and forthing on hormone replacement therapy and the above mentioned mammograms. Now condiser: these treatments have been the subject of multiple large scale studies. Most protocols haven't been investigated this intensely. And even when there is good information, the patient is at the mercy of his medical providers, the drug companies, and device makers. He can't challenge their views; his best hope is to shop for a better practitioner, which is a costly, time consuming, and deeply flawed process (how can he judge whether a doctor is making sound recommendations?). ..."
People who like their doctors do get prescribed more tests and medications, generally speaking.And generally speaking, physicians who prescribe tests and medications
liberally are more popular.
There is an important study in the Archives for Internal Medicine last month, which escalates an
ongoing row as to whether patient satisfaction is in any way correlated with positive medical outcomes.
The answer is yes, and the correlation is negative.
This finding is of critical importance, not just in understanding why American medicine is a hopeless,
costly mess, but also as a window into how easy it is for buyers of complex services to be hoodwinked
by their servicer provider, whether via the provider being incorrectly confident about his ability
to do a good job or having nefarious intent.
Let's deal with health care case first. The study in question was large scale, of 52,000 patients
from 2000 to 2007. This summary comes from the
Emergency Physicians blog (hat tip Julie W):
Results of the study showed that patients who had the highest satisfaction ratings spent 9%
more on health care and prescription medications than did patients who had the lowest satisfaction
ratings. In addition, the most satisfied patients had a 26% greater risk of death compared
to least satisfied patients. When patients in poor health were excluded, the risk of death for
these highly-satisfied "healthy" patients increased to 44% more than their least-satisfied counterparts.
In commentary accompanying the article, Dr. Brenda Sirovich suggested that discretionary testing
is likely the cause of both the increased costs and the increased mortality in highly satisfied
patients. Patient perceptions, even if medically inappropriate, drive testing and treatment. Antibiotics
are harmful in patients with viral infections, yet a substantial subset of patients are not satisfied
without an antibiotic prescription for their colds. Large studies
show no link between PSA screening and either overall survival or prostate cancer survival.
However, any patient whose life has been "saved" by a PSA screen is often quite satisfied.
In both scenarios, there is no perceived negative effect from treatment. Patients will recover
from their colds with or without antibiotics. Patients likely would not have died from their prostate
cancer even if it was left untreated.
And consider: drug research shows a fairly significant placebo effect. So one would assume that
satisfied patients would show positive results merely from placebo effect. The fact that the overall
results are decidedly negative doesn't merely say that more treatment and more testing are ineffective,
it suggests they actually do harm.
The article uses the PSA test as an example of ineffective screening. I'm pretty healthy, yet
I've seen this bias to overtest and overtreat first hand, and I can't imagine what people who
are less than robust must go through.
Readers have seen me rant upon occasion in comments about mammograms. They are a terrible test.
They are bad at capturing the dangerous-fast moving cancers and produce a lot of false positives
(benign slow moving growths which won't kill you even if you live to be 100) which lead to unnecessary
procedures. Oh, and no one factors in the risk of annual exposure of soft tissue to radiation.
Manual breast exams by an experienced examiner are far better at detecting the dangerous growths,
and thermal imagining is also more accurate than mammograms and does not involve radiation. But radiologists
have an installed base of equipment and will hector you if you refuse to get a mammogram.
Similarly, there are only a few knee operations (surgeries for a torn medial meniscus and torn
ACLs) that have a high efficacy rate. Yet with my long-standing knee problem (which is my case is
due to foot and ankle instability but the overwhelming majority of orthopedists won't even look at
my gait), the standard answer from an orthopedist is, in the absence of ANYTHING sus on an MRI: "Let
me go in and have a look and I'll clean it up." I'm not about to let a doctor go on a fishing
expedition in my knee, yet that seems to be considered acceptable.
The inherent problem of medicine American-style was set forth longer form in the Maggie Mahar
book, Money Driven Medicine which shows why the market has failed. One big culprit is information
asymmetry. One of the conditions for a market to function well is that buyers and sellers have
perfect information. In the medical arena, there is often a lack of good data as to what constitutes
optimal practice. Among the many examples are the backing and forthing on hormone replacement therapy
and the above mentioned mammograms. Now condiser: these treatments have been the subject of multiple
large scale studies. Most protocols haven't been investigated this intensely. And even when there
is good information, the patient is at the mercy of his medical providers, the drug companies, and
device makers. He can't challenge their views; his best hope is to shop for a better practitioner,
which is a costly, time consuming, and deeply flawed process (how can he judge whether a doctor is
making sound recommendations?).
The other major element of market failure is the considerable disparity in buyer and seller power.
If you are very sick, you will do anything to get better, which includes spending a lot of money.
And our can-do, technology-loving culture favors doing more, whether beneficial or not.
We've seen how resistant patients are to evidence-driven medicine, particularly when the finding
is less is more. Women seemed distressed to be told that mammograms were being overadministered (the
old recommendation had been to get them annually starting at age 40, the new recommendations are
ex a family history of cancer, to start getting them at 50 and have them done every other year through
age 74). And patient confusion was not helped by
self-serving radiologists taking issue with the study conclusions. And we have drug companies
expertly playing on patients' "more must be more" bias: advertising aggressively for new drugs, when
they are typically much more expensive than older ones, often with little or no improvement in efficacy.
Doctors seem remarkably disinclined to argue with patients who want a particular drug (indeed, I've
seen how trigger happy doctors are to hand out pills. Say you are tired and in NYC that's treated
as code not for a vitamin B-12 shot, but either Adderall or anti-depressants).
The bigger issue is that in many fields, customers have no real ability to judge service quality.
Like the satisfied patients, they too often rely on proxies, like bedside manner or being with the
"right" firm, when big firms have first and second strings, and if you aren't an actual or prospective
big ticket you are usually better served finding a good partner at a smaller shop. I've been more
exposed to top lawyers and litigation by virtue of working on complicated deals, having some clients
get involved in lawsuits, and often talking shop with some savvy lawyer friends. As a result, I've
mainly have very good experiences the few times I have had to hire a lawyer, but even I had one stuff
up. And I've seen too many times in client situations where they appeared not to understand that
their counsel was not up to snuff for the task at hand, but it would have been close to impossible
to get them displaced.
I've similarly seen friends make bad decisions because they trusted their advisor when they shouldn't
have. I remember a long argument with a savvy investor friend who liked and trusted her broker at
Citigroup, and took his advice to buy Citigroup at $45. She wouldn't listen to contrary information,
in fact, she was convinced he had some special insight by virtue of being at the bank (as opposed
to he might be getting bonus credits). We know how well that trade worked out.
And that's one reason I'm more sympathetic with duped investors than other readers probably are.
Hindsight is always 20/20. The mortgage securities market had seemed to work well for nearly two
decades. Bernanke kept insisting household balance sheets were fine and there was no reason to worry
about housing prices, that prices would at worst stabilize. And most people trust people they do
business with. That's a big factor that enabled looting by the securities industry. People simply
don't want to believe that someone who seemed sincere and should have an interest in keeping them
as a client would fleece them.
The message, sadly, is clear: satisfaction is not always in a customer's best interest. But most
of us don't have the time or psychic energy to be vigilant.
My knee, ankle and hip pain were highly reduced by strengthening my legs. Strong leg muscles
protect the cartilage like an organic brace, and allow it to repair itself faster.
I've been focusing on Crossfit for my strength training. It's the most effective program I've
ever tried.
I've been weight training for 25 years with pretty heavy weights (and I come from a gene pool
disposed to be strong). My issue is not muscle strength. You don't have much in the way of muscle
in your ankles and if your feet and ankles are compromised, there is really not much you can do.
As physical therapists like to say, the injuries move up the chain.
First, this was a fantastic post. I can't tell you how many times people have harangued me
for not "trusting" my doctor more. Ummm, medicine is hard, and doctors
are not magicians, but humans subject to cognitive bias as much as anyone else (maybe more, based
on all the inane suggestions for prescription medicine I have received over the years).
Second, I'm sure you understand a lot more about your situation than I do, but I just want
to relate my own experience, and this is that my knee and ankle pain was dramatically reduced
with a huge focus on core strength and transforming my walking and running gait to make it come
overwhelmingly from my core (abs, gluts, lower back). Another (very!) anectdotal piece of evidence
is the case of the NBA player Grant Hill who lost years and years of his career to what was termed
degenerative ankle problems, but were "miraculously" cured when he was put with a trainer who
taught him about core strength and completely changed his gait. The guy who could barely walk
in his late 20s is still in the NBA at 39, and he has played almost every game for the last few
years (he had a five year stretch where he basically played about one season's worth of games).
Anyway, I have no idea whether this is applicable at all, but just wanted to pass along my own
personal experience. Sorry in advance if it is useless.
One of my takeaways from a circa 1980 MchEng Degree was from a girlfriend doing a masters in
biomechanics.
If you insist on "weight training" keep the weights close to your bodies centerline (big wght
x extention= big torque loads on joints.) Do yourself a favor and swim-cycle-iceskate (indoors in summer in shorts is great).
All good for joints, bone density, slow and fast twitch muscle fiber cardio etc.
Skip running, but we all know that already, right?
There is an obvious explanation for this result and it is not that satisfaction with your doctor
results in higher health care costs. The causal link is much simpler.
Healthy people for the most part do not spend much time thinking about doctors or health
care in general. They also have very low health care costs.
People with health issues do think more about their medical care and get more emotionally involved
with their doctors. They also have higher health costs.
This is a problem with the study that cannot be easily resolved by controlling for patient
health.
I don't see how you can claim that when the study DID screen out unhealthy people in a separate
analysis and focused only on people who were comparatively healthy and found that made the "satisfaction
is correlated with worse outcomes" finding even stronger. You are doing the equivalent of putting
your fingers in your ears and saying you don't believe the study findings.
You also misstated what the article seemed to think the causal chain was:
ineffective overtesting and treatment leads to higher patient satisfaction,
not that patient satisfaction leads to overtreatment. Your inaccurate summary suggests
you read only the headline and at best skimmed the rest.
I did not like the doctor who told me to keep an eye on the lump in my breast and tell him
in six months if it changed because I was too young to have cancer. True, I did not have cancer
and the outcome would have been the same if I had not had the biopsy, but I would have had six
months of anxiety and in fact it might have been cancer. When I read this types of studies I wonder
if this is what they are talking about. Maybe the people who have more tests and more treatment
are more anxious about their health and feel more need to understand their symptoms. I know people
who are able to ignore symptoms for years and convince themselves that nothing is wrong, and of
course usually it really isn't anything important. But I cannot do that. I'm a different person.
Cancer screenings and routine tests contribute greatly to my peace of mind. And if I have worse
outcomes, maybe it's because I'm a more anxious person. I don't believe that means that giving
me less testing or less treatment would make me healthier – more anxiety would I'm sure not be
a good thing.
Denise, at 34 my sister was diagnosed with breast cancer and later she tested positive for
the BRCA gene mutation. Like an idiot I had the test and I too had the mutation. I allowed myself
to be fear mongered into getting over screened and it will cost me my life. I now have a scleroderma
type diagnosis. I am in pain 24/7. And it infiltrated my brain, specifically my hypothalamus.
It altered the way my body handles stress, basically I can't stress anymore. What I'm trying to
say is I went from being terrified of cancer to not caring if I lived or died. I'm not saying
what you should do about your anxiety but my anxiety allowed me to be fear mongered into getting
scans I didn't need and now I have a disease that is likely going to take my life. There are no
free lunches.
You say it can be explained by healthy people getting less emotionally involved with their
doctors, and then say that one can't control for this by choosing healthy people for the study.
That doesn't make sense.
I've worked in the medical field for 30 years and this study makes perfect sense to me.
People who like their doctors do get prescribed more tests and medications,
generally speaking. And generally speaking, physicians
who prescribe tests and medications liberally are more popular. If a patient sees
a physician complaining of a "slipped disk" and is told an MRI will be ordered in 60 days if his
back is still hurting, how satisfied do you think that patient is likely to be? I have a good
friend who decided to quit drinking, not that he thinks he has a problem, mind you, but because
he wants to lose weight, and persuaded his GP to prescribe Antabuse in case he were to be tempted.
He just loooves his GP. I could give many more similar examples. Surely you aren't denying that
doctors succumb to pressure from their patients to prescribe medications they don't need and to
order unnecessary tests. And then we could add the unnecessary surgeries to the mix that weren't
even mentioned in the study.
There is definitely an app for that. In rural India they have clinics set up that are all computers.
They analyze blood, spit, skin, urine, etc and pop out a reliable diagnosis. You are prescribed
anything you need to recover, etc. Very cheap. And just consider genetic testing in conjunction
with the tests we currently have. Medicine is going down proportionally to sophistication of testing-analysis.
And it is high damn time.
Saw this on Book TV last weekend, this frustrated cardiologist wants to help consumers make
change by demanding from their doctors better use of technology as you describe is being done
in rural Indian clinics (as you say, it's about time!):
"The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health
Care"
Eric Topol
About the Program
Eric Topol, director of the Scripps Translational Science Institute and cardiologist at the Scripps
Clinic, contends that digital technology can make medical care more efficient and effective. However,
due to what the author argues is the medical community's resistance to change, technological advances
have yet to be fully accepted. Mr. Topol presents his thoughts on how to re-imagine health care
and the doctor-patient relationship at Kepler's Books in Menlo Park, California.
About the Authors
Eric Topol
Eric Topol is a cardiologist at the Scripps Clinic and genomics professor at The Scripps Research
Institute. He is director of the Scripps Translational Science Institute and co-founder of the
West Wireless Health Institute.
Further, we have 1000s die before they even get to see the doctor. The number could be as high
as 50K annually, but this usually brings forth squealing denials from the luddite vested interests.
The 'hands off my for profit entitlement' groups.
Yves, please pay attention to the really important studies in The Lancet on aspirin and cancer.
I am thinking of you comment on breast cancer. The studies are critical to know about.
Effects of regular aspirin on long-term cancer incidence and
metastasis: a systematic comparison of evidence from observational studies versus randomised trials
By Annemijn M Algra and Peter M Rothwell
Short-term effects of daily aspirin on cancer incidence, mortality, and non-vascular death:
analysis of the time course of risks and benefits in 51 randomised controlled trials
By Peter M Rothwell, Jacqueline F Price, Gerald R Fowkes, Alberto Zanchetti, Maria Carla Roncaglioni,
Gianni Tognoni, Robert Lee, FF Belch, Michelle Wilson, Ziyah Mehta, and Tom W Meade
Effect of daily aspirin on risk of cancer metastasis: a study of incident cancers during randomised
controlled trials
By Peter M Rothwell, Michelle Wilson, Jacqueline F Price, Jill FF Belch, Tom W Meade, and Ziyah
Mehta
If what you say about patient satisfaction is accurate, then the WHO study of health care world
wide would have to rank the U.S. even lower…! (WHO used a comprehensive set of public health measurements
like life expectancy, vaccination rates and infant mortality, plus patient satisfaction).
The U.S. ranked 37th in that study, between Costa Rica and Slovenia. McClatchy said that it
was as though the U.S. had the health care of Costa Rica, but paid six times more for it.
…
Marcia Angell writes in the NY Review of Books: "The problems I've discussed are not limited
to psychiatry, although they reach their most florid form there. Similar conflicts of interest
and biases exist in virtually every field of medicine, particularly those that rely heavily on
drugs or devices. It is simply no longer possible to believe much of the clinical research that
is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines.
I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades
as an editor of The New England Journal of Medicine." See
http://www.nybooks.com/articles/archives/2009/jan/15/drug-companies-doctorsa-story-of-corruption/
.
I've read (most recently, in Stephen M. Davidson's book, "Still Broken") that when insurers
or Medicare or Medicaid squeeze reimbursement rates, many doctors seem to react by increasing
the services they provide each patient – by roughly the amount necessary to maintain a steady
income.
We desperately need a wholesale shift to evidence-based medicine, for BOTH cost control AND
patient safety. Outcome data need to be collected and analyzed on a large scale, and the results
made widely available.
Ouch, ouch OUCH! Girl, you have nailed it on the head with this post. As some readers know,
I am now a professional patient/cripple, and spend most of my waking hours w/flamin' physicians.
I must constantly fight to avoid unnecessary, invasive testing. Yes, there's a lot wrong with
me physiologically, but I'm not stupid. I just aborted a 72 hour EEG (I'm having a lot of trouble
w/vertigo, but I know the cause – landlord putting fumes and lead dust in my apt in December.)
14-16 hours overnight was more than enough to observe the available phenomena. My job is to get
to the bottom of the diagnosis, not to bolster their bottom line.
I think part of the overall problem, as far as the public judging what is appropriate or necessary,
is ignorance. By which I mean the absence of hands-on science (Chemistry, Biology) in high schools.
Here in NYC I know many schools have no science labs; and there is enormous push-back on including
significant knowledge of human anatomy (reproduction). Even my very mediocre rural high school,
30 years ago, had this most basic training, but now it is rare in our city.
Another issue is very poor science reporting in the media. Many of the studies publicized,
per Marcia Angell, are bogus; but even so, the garbled, sloppy and solipsistic (is that redundant)accounts
only confuse and trivialize serious medical issues. How can the public stay abreast of new developments,
or fill in old gaps, with this Entertainment Tonight approach?
VERY interesting and counterintuitive to modern minds… but would have been perfectly understandable
to my grandmother.
Connects nicely with the well established but rarely published fact that 100k to 200k people
are killed by medical errors each year.
The more time you spend on tests and drugs, the more risk of uncontrollable infections, bad
prescriptions, cancer caused by radiation, etc.
Wonder if the study included people like me who are happy when a doctor hates tests and drugs,
and uses them only as an absolute last resort? After 20 years without any doctoring at all, I
finally found one with those characteristics, and I'm happy with him!
I strongly recommend the comment accompanying this article for those interested. Its discussion
of the "positive feedback" dynamic is on-target. I'll excerpt, as I think it is paywalled:
"Positive feedback systems abound in health care, for both physicians and patients. Diagnostically,
almost any unnecessary, or discretionary, test (particularly imaging) has a good chance of detecting
an abnormality. Acting on that abnormality has an excellent chance of producing a favorable outcome
(because a good outcome was already highly likely). Having obtained an excellent outcome, ostensibly
owing to a test that was seemingly unnecessary, a natural reaction would be thereafter to perform
(or, for patients, undergo) even more discretionary testing in patients with an increasingly negligible
likelihood of benefit-and greater risk of net harm."
As the author notes, "positive" feedback does not necessarily result in better care. Rather,
the term describes the ability of certain practices/attitudes to be self-reinforcing.
According to these researchers, evidence-based medicine is the problem, not the solution.
Tarnished Gold: The Sickness of Evidence-based Medicine [Paperback]
Steve Hickey PhD (Author), Hilary Roberts PhD (Author)
"Evidence-based medicine, the "gold standard" of medical decision making, is increasingly unpopular
with clinicians. They are right to have reservations. EBM breaks the laws of so many disciplines
that it cannot be considered scientific or even rational. Decision science and cybernetics show
the disturbing consequences of such flaws. EBM fosters marginally effective treatments, based
on population averages rather than individual need. Its mega-trials are theoretically incapable
of finding the causes of disease, yet swallow up research funds. Ultimately, EBM cannot avoid
risking patients' health. It is time for medical practitioners to discard EBM's tarnished gold
standard, reclaim their clinical autonomy, and provide individualised treatments to patients."
You nailed that one, liberal. Some don't want to hear that their tonics and incantations are
worthless, especially if they happen to own the place that sells the tonics and incantations.
I pretty much ignore my doctor's advice to get a mammogram or other tests I feel I don't need.
There's no history of breast cancer in my family though. However, I find myself constantly talking
doctors into figuring out what's actually wrong with me instead of pushing a pill at me, and usually
have a better idea of what it is than they do at first. So I do subtly push for certain tests
or sometimes request they try a certain medication.
I also do strength training and other fitness programs, watch my diet and take a few supplements.
I hear you on the B12 thing. I did once have an osteopath that used them regularly for tired patients,
other than that I've never had a doctor suggest one, and "tired" is a very typical symptom for
me when I'm not feeling well.
I think creating patient awareness about their treatment would be a better goal than "customer
satisfaction".
Your pull quote includes one of my pet peeves. Unless the study pool included the Virgin Mary
and/or the Prophet Elijah, the risk of death was 100% for all groups.
Just maybe, people are more satisfied with doctors who do not urge them to suffer unnecessarily.
I certainly would be. I'm with you not only on mammograms, but on all cancer testing and treatment.
The certainty of radical impairment of quality of life isn't worth the 5-20% chance of greater
quantity, in my judgment for myself.
If you want to fix your problem with fatigue, then check out: http://mpkb.org/
Its a big wiki, (over 400 pages) but if you are determined….. There is also a support group
in New York city. This is an excellent example of patient led research/community which is making
real progress.
See: Balance problems have been a part of my symptomology for many years. In fact in the early
days of my illness before I received any treatment I had severe vertigo attacks. These issues
have all cleared in recent years due to [the] MP.
There is a fabulous little book written by Olivier Clerc and titled "Medicine, Religion and
Fear". Very quick read. In that book, he clearly explains how religion used to be the answer to
every illness, since sin was at the root of it. Religion was "administered" by priests, the all
powerful god-chosen individuals able to "chase" the demons. The soul was what needed to be treated.
Every cold, every plague, every lumbago was caused by sin in people's life. Priests were in attendance,
dispensing their religious magic. People died, plagues spread but it wasn't because of the priests
incompetence: sin was powerful and the masses failed to adequately repent of it. Hence the constant
illnesses.
Many countries became secular with the advent of medicine and science, both banned by the church,
as they were the "tools of Satan". All of a sudden, the physicians became the new priests and
the root of every illness became known as "germs". Germs were the culprits and they had to be
killed at any cost. Science didn't care if they were good or bad: they were "germs" (they had,
in effect, replaced the "demons" of the middle-ages) and they needed to be eradicated. Our medicine
kills germs and takes no prisoner.
Both are extreme. Neither could have succeeded without… the collective fear of the masses.
Those same masses who would flock to church at the first sign of any epidemic and who, nowadays,
flock to hospitals for any ailment, without ever changing their lifestyle or taking responsibility
for their own well-being.
There is an information bias in medical screening that epidemiology is trying lately to fix.
And God bless them. The public does not understand yet, but here's an analogy:
If you are driving 100 miles, you can start paying tolls at mile 10
or mile 90. But either way you are still driving 100 miles and no further.
Just because a disease is discovered earlier, and a patient starts treatments earlier and possibly
for longer (at more expense), that does not mean life has been extended or morbidity alleviated.
Simply people can (and do) spend more time being sick because they have been classified as sick
sooner, before they felt sick. It is easy to mistake this as extended survival; it is not. Upon
closer investigation, extended life is often not the case. And in some instances health is subject
to increased risk because each medical intervention has a probability of failure and complication
(underestimated by physicians who like to think of themselves as doing good).
It is an ethical dilemma to recommend screening people that feel healthy, knowing that many
could become subject to false positive diagnoses, and uncomfortable and potentially dangerous
procedures. Epidemiology is trying now to discourage those persons with low risk of a disease
from being screened, but they do not yet understand. They perceive it as being deprived. Moreover,
some parts of the medical industrial complex may not want them to understand.
Also Yves, re blog thread about exercise… I think you used to work out at a women's gym in
midtown many, many years ago (think green shag rug). If my recall is correct, you had/still have
very high arches in your feet. Such anatomy can achieve a beautiful ballet point, but as you rightly
identify, such feet and ankles are difficult to strengthen. Weight lifting will not do it; that
only targets large, gross muscle mass. Ballet exercises would better do it, but these require
time and patience; some people might consider them boring; but thereby the many, smaller muscles
that are so critical for balance, coordination and placement are exercised. If you pursue ballet
exercises, having weak knees, be careful to avoid twisting at the knees. Rotate/strengthen at
hips.
I'm a little under-exercised myself compared to what I think is desirable. Alas.
Just because a disease is discovered earlier, and a patient starts treatments earlier and
possibly for longer (at more expense), that does not mean life has been extended or morbidity
alleviated. Simply people can (and do) spend more time being sick because they have been classified
as sick sooner, before they felt sick. It is easy to mistake this as extended survival; it is
not. Upon closer investigation, extended life is often not the case. And in some instances health
is subject to increased risk because each medical intervention has a probability of failure and
complication (underestimated by physicians who like to think of themselves as doing good). \
This is not junk science. This is a very important debate we must have. The wake up call for
me was in the middle of the ACA debate, the release of new recommendations on screening guidelines
for mammograms. What a disaster!
I finally went in for thermography last month. I decided to do both the breast thermography
and the whole body scan figuring I might as well get the whole body overview. Yes, it cost me
money (and it will every year when I go back), but when I finally got my full report, with the
full color scans of various body areas and the accompanying doctor's analysis of the scans, it
was unexpectedly very empowering and I decided that feeling alone was worth every penny spent.
What's great about thermal imaging is that it is easy to see and understand the results, and the
doctor's analysis was also easy to understand. When asked the nurse who had the thermography practice
how she got into it (guessing she was in her early 60's), she said "23 mammograms" and a huge
amount of frustration with the system. She had so many false positives (due to dense breast tissue,
which I also have) they kept sending her for more tests and ever more mammograms and she finally
got fed up with the whole process and all the radiation she had received and starting researching
other options. This lead her to set up one of the very few independent thermography practices
in Massachusetts. btw, she sends her scans to a group of doctors (with many years of experience
interpreting those) who analyze them and write up the official report. I had copies of the scans
& report sent to my primary care doctor's office and to my ob-gyn's office. Both had been pestering
me (though not excessively) in recent years to get a mammogram (I am 55 and never had one for
all the same reasons Yves has mentioned) and I had been putting them off. In the next couple of
months I will have my annual exams at both offices and it will be interesting to see what they
have to say about the thermography reports.
About the title of this post… I did find it a bit offputting. After a few years of looking
around, I am finally very happy with all 3 of my doctors (2 of whom are really NPs) because they
don't try to overmedicate or overtest me, and they actually listen when I tell them about my own
medical treatment research and treat me with respect. I tend to rely on acupuncture and chiropractic
to take care of most of my personal health issues and I need to see doctors that can deal comfortably
with that.
I'm also happy with my doctors but that is after flying all over the country to be told I don't
have a disease I know I have…it's just they are lying and bought and paid for by pharma. The diagnostic
guidelines were funded by the manufactures that are being sued. And guess what? No conflicts reported.
I called today about a thermography appointment because I want to get checked annually for
ovarian and breast cancer but also to see the extent of the fibrosis and to get a baseline. I
still have hope I can get better but the scar tissue will be tough. The woman I talked to didn't
have a clue what she was talking about regarding fibrosis so I sent her an article on thermography
being used on localized scleroderma. I wouldn't be surprised if the test never got off the ground
because of suppression by competitors or liability. In any case if you check back I would love
to know the name of the clinic you go to. I'm from the East Coast but live out west now. I could
hop on a plane and go to the clinic if they offer what I'm looking for which is a full body scan.
This is the clinic I went to
http://insideoutthermography.com/thermography_ma_nh.htm
It's in Byfield, MA, which is close to the NH border near the coast (~1 hr from Boston). Janice
is great, very knowledgeable and spiritually attuned as well (she's a holistic nurse). She has
been doing thermography since 2005 and trained at Duke
http://insideoutthermography.com/janice_anderson.htm
. As with anything else, not all thermography clinics are of the same quality nor are all
the training programs, but her background is excellent. You may not need to fly to New England
to get a scan… I'm guessing she would know a reputable thermography clinic closer to where you
live and would be happy to refer you.
yves, re: reports of mammo's are better at 50 than 40.
Yves, i mention this because, as you say, how do we know what report is correct. Yves, remember
the "eggs are bad" scare. And then 1 year later, "eggs are good". Then the next year, "eggs are
bad" again. How are you supposed to know which is true? How do we not know that there was a shortage
of eggs one year and then a surplus the next year?
Or to get even more conspiratorial, how do we know that the 1% aren't using the rest of us like
cattle? They say 'let's do a test. let's let them go without mammograms until later in life to
see how they do. Regardless that as elites, we get full body scans every 6 months because we are
so important'. But just think about it. What if they discover that the tests need to be increased?
Who would be the first to get tested? A bunch of broke young people with no insurance. Or a bunch
of wealthy ppl with trust funds.
I think Yves touches most of the right bases. Basically, it comes down to this:
Healthcare is not a commodity. It is a right. There
is no healthcare "market", just as there is no market for other rights.
Various observations:
Americans are woefully ignorant about even the simplest and most common disease processes.
I have often thought that by the time someone finishes high school they should have a basic understanding
of the half dozen most common conditions: heart disease, hypertension,
high cholesterol, diabetes, a few cancers, and the effects of tobacco, alcohol, and obesity.
And they should know the difference, at least, between a virus and a bacterium.
I am not talking about anything super in depth and it should be possible to develop a curriculum
given over 6-8 years that addressed all this. Of course, I also think such a curriculum should
be required to teach the basics of US history, government, and the Constitution.
Because Americans even college educated ones, even most of those who go to the internet for
information, don't really know what is going on in their own bodies, they have no way of assessing
either their physicians or their medical options. And those options by the way usually correspond
to their ability to pay or get their insurance to pay.
Overtesting is sloppy medicine. It is different from a screen. In a screen you expect a certain
level of false positives. An ineffective screen is one where that returns many false positives.
Physicians need to be upfront about how many of these there are. An initial screen is just that.
It eliminates a certain percentage of the population and targets a subset of it for further testing
and evaluation. The value of a good screen is in how many more people it correctly identifies
as having a disease, and what the health consequences would have been if those patients had not
been identified.
A bad screen is one that delivers false negatives, that is people who have the disease which
the screen misses.
One aspect that is not treated in the post is what is euphemistically referred to as medico-legal
issues or defensive medicine. This is what results in a lot of overtesting. Some physicians will
identify a patient or family as "litigious" and correspondingly test the hell out of them, not
because they need it, but to avoid any a lawsuit. It is sort of important to realize that even
good physicians can get hit with malpractice suits. Of course, even good physicians can make mistakes.
And to be honest, many stories people have told me about their medical experiences or those of
family members shock me at the level of malpractice that goes on, that they do not sue over. But
to return to my point, a malpractice suit can have a devastating impact on a physician and their
practice of medicine. I knew of one neurologist, a good one, who got hit by such a suit. Ever
after when he was brought in on a consult, he would order thousands and thousands of dollars of
testing, pretty much everything including the kitchen sink. This was fundamentally at odds with
the whole consultative process. A consult is ordered to determine what needs to be done. "Do everything"
is both extremely expensive and hardly helpful.
The way around overtesting is effective best care standards. Such standards can cover the vast
majority of patients and should give physicians ironclad protection in the courts, that is it
should be up to a judge to determine whether best care standards were met before a suit can go
forward. I think this approach would have a positive impact on both the medical and legal professions.
Nothing personal, but the very mention of the word "healthcare is a right", drives me freaking
nuts.
Mind you, I live in Canada.
Health care is the word used to brainwash people. What the gov can do is provide MEDICAL CARE
when one gets sick. However, in order not to get sick very often and be energetic, one has to
work out and eat healthy.
Work out = 80% "no impact" cardio 40 min every 2nd day. This is the only natural or evolutionary
thing, walking, running. Do not use treadmills, only elypticals. Any impact on joints must be
avoided. 20% very light weights. This is just for muscle strength, but muscle bulging is not evolutionary,
only walking is.
Eating healthy = Eating old style mediterranean food, which is basically my mother's food back
home.
Please, do not brainwash more people.
The discussion on healthcare has been around for years now, and you decide to make your stand
on my comment? Bizarre. It is called healthcare because it is about your bleeding health. Health
is much more than problems needing medical attention. It is a social good. Trying to make the
distinction you seem to be making is just a step toward commodification of healthcare which is
precisely what we need to move away from.
Brainwashing? Do your really expect to be taken seriously making such over the top statements?
Sir, everything is a commodity. Nothing escapes the absolute law of supply and demand, absolutely
nothing.
Trying to abolish supply/demand is like trying to abolish death.
My husband is a gastroenterologist who dreads the day that reimbursement is tied to patient
satisfaction, which is what is currently being recommended.
Overtesting and overtreating are at best wasteful and often
harmful, and yet patients are most satisfied when they leave the doctor with a prescription in
hand and a test scheduled.
My husband keeps up in his field and adheres to recommendations made in accordance with large-scale
studies that weigh the risks and benefits of endoscopy in different subsets of patients, yet patients
are annoyed if they do not feel that they are getting endoscoped often enough or getting the CT
or MRI they feel they deserve. A physician will be in a difficult position until there are clear
evidence-based guidelines that give doctors immunity from malpractice claims if the guidelines
are followed. Every test has its risks, and a physician is vulnerable (as he should be) if there
are complications and the test was done at the request of the patient, but was not necessary according
to the literature. On the flip side, lesions can be missed following guidelines and not testing,
even if the finding would have been totally serendipitous if the test had been done, and under
our present system the physician will be sued for lesions missed by not testing, even if he was
following guidelines. One can only imagine how much more unnecessary testing and treatment will
be performed once patient satisfaction determines physician reimbursement.
I think physicians have brought on a lot of their legal problems by allowing themselves to
be hoodwinked by the medical industrial complex – all the time. I mean come on why don't we know
what causes autism, MS, CFIDS, FM, scleroderma, ALS, Parkinson's, Lupus, sjogren's syndrome, and
on and on. I'll tell you why, they are afraid of industry and even when a cause is found it is
quickly covered-up like what is happening in my case. I have gadolinium-induced fibrosis (they
call it a differential of scleroderma but gadolinium was found in three different tissue samples
and at toxic levels in my urine four years post exposure), sjogren's syndrome (they call it dry
eye syndrome) Fibromyalgia, lichen sclerosis and CFIDS. And let's add in secondary adrenal insufficiency
(the endocrinology professor said it could be an infiltration of metal, gadolinium being a toxic
metal, into my hypothalamus) and Hashimoto's. And when less expensive tests become available the
FDA quickly squashes any opportunity to get them on the market as in the case of proteomics and
Correlogic, a company the NIH and the FDA likely drove into bankruptcy. There is a non-invasive
test for colon cancer that requires just a drop of blood so why isn't this on the market?
And I have waited ten years for Ovacheck which was jointly developed by the NIH and Correlogic
so even though we as tax payers paid for the development of this diagnostic test I can't get it
here in the US but it's approved in Europe. How silly is that? You might find your answer in this
Congressional Testimony.
http://www.correlogic.com/newsandevents/congressional.php
.
In conclusion I have no sympathy for doctors and I hope they lose their power. They certainly
deserve it. I was in finance, auditing and accounting for my entire career. I'm totally disabled
now because I was poisoned by GE and Bayer. If I once said I don't know what is causing that variance
of $1M or $1B I would have been fired. That's right no questions asked. And yet the medical profession
is allowed to say they don't know over 90% of the time.
The practise of medicine is so culturally specific that one almost might think the diseases
themselves are different.
The first time I went to France, I was surprised to discover that the treatment for practically
any illness there is administered via a syringe to the buttock – à chacun son gout , I
suppose.
Nor is homeopathy sneered at there, as it is in many places, though there is still a statue
of Hahnemann in Washington DC, I gather:
For many scarcity-oriented cultures, the first line of defense has always been diet, starve
a fever, feed a cold . When you looked at our denatured provisioning, is it any wonder the
state we find ourselves in? Bacterial antibiotic resistance via soil treated with animal manure
is also becoming a big issue in this respect:
I always ask my physician for dietary recommendations and/or exercise regimen, will not accept
pills until I have tried to find a solution under my own power, so to speak.
I solved borderline hypertension this way, via diet and exercise, successfully resisting the
strong pressure being exerted on me a couple of years back go onto HBP meds for the rest of my
life.
The nurse on my annual check-up this year said, "I don't know what you did, but it seems to
have worked." All the relevant indicators bar one were down, back in the "normal" range, as is
my BP itself.
A lot of people may well have a culture of "doctor, DO something!" And a lot of doctors may
well have a culture of
aggressively DOing things, with the very best of honest intent.
So people who want lots of things done are happier the more things their doctor actively or
even aggressively does.
Even if their health outcomes turn out poorer, they are happier, because their doctor met their
cultural expectations that a doctor is supposed to DO things . . . LOTS of things.
1) Daily aspirin as a chemopreventative antagonizes the COX pathways. This reduces tissue renewal
and tilts the immune system toward autoimmunity. Both effects are bad for the joints. A better
approach is to interrupt the cell cycle and induce terminal differentiation of transformed cells.
In the breast, low-dose naltrexone should do this, as should melatonin, butyrate, fish oils (which
antagonize prostaglandin pathways differently than COX inhibitors) and vitamin D3 (as long as
the dose isn't too high).
2) Most of the studies on estrogen replacement fail to look at net lifespan of the participants,
which improves on estrogen – despite the increase in cancer risk and stroke. These studies also
fail to check the homocysteine levels of participants. Estrogen stimulates nitric oxide production
in the arteries. When folate, TMG/betaine, B12, SAMe or other elements of the homocysteine recycling
pathways are low, homocysteine rises and nitric oxide release turn dangerously pro-oxidant. There
are risks to using folate to rehabilitate the tetrahydrobiopterin complex with aging (e.g., feeding
a preexisting cancer), but this simple fact from metabolic/nutritional medicine may explain many
of the "problems" reported with estrogen replacement.
"... 'Whenever possible, avoid products containing, or manufactured using, PFASs. These
include many products that are stain-resistant, waterproof or nonstick.'' ..."
Notable quotes:
"... DuPont's own instructions specified that it was not to be flushed into surface water or sewers. But over the decades that followed, DuPont pumped hundreds of thousands of pounds of PFOA powder through the outfall pipes of the Parkersburg facility into the Ohio River. The company dumped 7,100 tons of PFOA-laced sludge into ''digestion ponds'': open, unlined pits on the Washington Works property, from which the chemical could seep straight into the ground. PFOA entered the local water table, which supplied drinking water to the communities of Parkersburg, Vienna, Little Hocking and Lubeck - more than 100,000 people in all. ..."
"... By the late 1980s, as DuPont became increasingly concerned about the health effects of PFOA waste, it decided it needed to find a landfill for the toxic sludge dumped on company property. Fortunately they had recently bought 66 acres from a low-level employee at the Washington Works facility that would do perfectly. ..."
"... DuPont had for decades been actively trying to conceal their actions. They knew this stuff was harmful, and they put it in the water anyway. These were bad facts.'' He had seen what the PFOA-tainted drinking water had done to cattle. What was it doing to the tens of thousands of people in the areas around Parkersburg who drank it daily from their taps? What did the insides of their heads look like? Were their internal organs green? ..."
"... No one knows for certain how much PFOA is safe to drink. Rob Bilott's lawsuit against DuPont in West Virginia included anyone whose drinking water had levels above 0.05 parts per billion. But last June, based on a comprehensive review of previous health studies, Philippe Grandjean of the Harvard School of Public Health and Richard Clapp of the University of Massachusetts-Lowell named an ''approximate'' safe level of 0.001 p.p.b. Soon thereafter, the nonprofit Environmental Working Group analyzed two years of E.P.A. survey data to find that this threshold had been exceeded - in some cases by factors of 100 or more - in 94 water systems across 27 states. Below, the estimated number of people in each state whose drinking water is affected. ..."
"... Meanwhile the E.P.A., drawing from Bilott's research, began its own investigation into the toxicity of PFOA. In 2002, the agency released its initial findings: PFOA might pose human health risks not only to those drinking tainted water, but also to the general public - anyone, for instance, who cooked with Teflon pans. ..."
"... By 2003 the average concentration of PFOA in the blood of an adult American was four to five parts per billion. In 2000, 3M ceased production of PFOA. DuPont, rather than use an alternative compound, built a new factory in Fayetteville, N.C., to manufacture the substance for its own use. ..."
"... As part of its agreement with the E.P.A., DuPont ceased production and use of PFOA in 2013. The five other companies in the world that produce PFOA are also phasing out production. ..."
"... Bilott is currently prosecuting Wolf v. DuPont, the second of the personal-injury cases filed by the members of his class. The plaintiff, John M. Wolf of Parkersburg, claims that PFOA in his drinking water caused him to develop ulcerative colitis. That trial begins in March. When it concludes, there will be 3,533 cases left to try. ..."
"... Nathaniel Rich is a contributing writer for the magazine and the author of ''Odds Against Tomorrow.'' He lives in New Orleans and is a frequent contributor to The New York Review of Books and The Atlantic. ..."
Rob Bilott was a corporate defense attorney for eight years. Then he took on an environmental
suit that would upend his entire career - and expose a brazen, decades-long history of chemical pollution.
By NATHANIEL RICH
Just months before Rob Bilott made partner at Taft Stettinius & Hollister, he received a call
on his direct line from a cattle farmer. The farmer, Wilbur Tennant of Parkersburg, W.Va., said that
his cows were dying left and right. He believed that the DuPont chemical company, which until recently
operated a site in Parkersburg that is more than 35 times the size of the Pentagon, was responsible.
Tennant had tried to seek help locally, he said, but DuPont just about owned the entire town. He
had been spurned not only by Parkersburg's lawyers but also by its politicians, journalists, doctors
and veterinarians. The farmer was angry and spoke in a heavy Appalachian accent. Bilott struggled
to make sense of everything he was saying. He might have hung up had Tennant not blurted out the
name of Bilott's grandmother, Alma Holland White.
White had lived in Vienna, a northern suburb of Parkersburg, and as a child, Bilott often visited
her in the summers. In 1973 she brought him to the cattle farm belonging to the Tennants' neighbors,
the Grahams, with whom White was friendly. Bilott spent the weekend riding horses, milking cows and
watching Secretariat win the Triple Crown on TV. He was 7 years old. The visit to the Grahams' farm
was one of his happiest childhood memories.
When the Grahams heard in 1998 that Wilbur Tennant was looking for legal help, they remembered
Bilott, White's grandson, who had grown up to become an environmental lawyer. They did not understand,
however, that Bilott was not the right kind of environmental lawyer. He did not represent plaintiffs
or private citizens. Like the other 200 lawyers at Taft, a firm founded in 1885 and tied historically
to the family of President William Howard Taft, Bilott worked almost exclusively for large corporate
clients. His specialty was defending chemical companies. Several times, Bilott had even worked on
cases with DuPont lawyers. Nevertheless, as a favor to his grandmother, he agreed to meet the farmer.
''It just felt like the right thing to do,'' he says today. ''I felt a connection to those folks.''
The connection was not obvious at their first meeting. About a week after his phone call, Tennant
drove from Parkersburg with his wife to Taft's headquarters in downtown Cincinnati. They hauled cardboard
boxes containing videotapes, photographs and documents into the firm's glassed-in reception area
on the 18th floor, where they sat in gray midcentury-modern couches beneath an oil portrait of one
of Taft's founders. Tennant - burly and nearly six feet tall, wearing jeans, a plaid flannel shirt
and a baseball cap - did not resemble a typical Taft client. ''He didn't show up at our offices looking
like a bank vice president,'' says Thomas Terp, a partner who was Bilott's supervisor. ''Let's put
it that way.''
Terp joined Bilott for the meeting. Wilbur Tennant explained that he and his four siblings had
run the cattle farm since their father abandoned them as children. They had seven cows then. Over
the decades they steadily acquired land and cattle, until 200 cows roamed more than 600 hilly acres.
The property would have been even larger had his brother Jim and Jim's wife, Della, not sold 66 acres
in the early '80s to DuPont. The company wanted to use the plot for a landfill for waste from its
factory near Parkersburg, called Washington Works, where Jim was employed as a laborer. Jim and Della
did not want to sell, but Jim had been in poor health for years, mysterious ailments that doctors
couldn't diagnose, and they needed the money.
DuPont rechristened the plot Dry Run Landfill, named after the creek that ran through it. The
same creek flowed down to a pasture where the Tennants grazed their cows. Not long after the sale,
Wilbur told Bilott, the cattle began to act deranged. They had always been like pets to the Tennants.
At the sight of a Tennant they would amble over, nuzzle and let themselves be milked. No longer.
Now when they saw the farmers, they charged.
Wilbur fed a videotape into the VCR. The footage, shot on a camcorder, was grainy and intercut
with static. Images jumped and repeated. The sound accelerated and slowed down. It had the quality
of a horror movie. In the opening shot the camera pans across the creek. It takes in the surrounding
forest, the white ash trees shedding their leaves and the rippling, shallow water, before pausing
on what appears to be a snowbank at an elbow in the creek. The camera zooms in, revealing a mound
of soapy froth.
''I've taken two dead deer and two dead cattle off this ripple,'' Tennant says in voice-over.
''The blood run out of their noses and out their mouths. ... They're trying to cover this stuff up.
But it's not going to be covered up, because I'm going to bring it out in the open for people to
see.''
The video shows a large pipe running into the creek, discharging green water with bubbles on the
surface. ''This is what they expect a man's cows to drink on his own property,'' Wilbur says. ''It's
about high time that someone in the state department of something-or-another got off their cans.''
At one point, the video cuts to a skinny red cow standing in hay. Patches of its hair are missing,
and its back is humped - a result, Wilbur speculates, of a kidney malfunction. Another blast of static
is followed by a close-up of a dead black calf lying in the snow, its eye a brilliant, chemical blue.
''One hundred fifty-three of these animals I've lost on this farm,'' Wilbur says later in the video.
''Every veterinarian that I've called in Parkersburg, they will not return my phone calls or they
don't want to get involved. Since they don't want to get involved, I'll have to dissect this thing
myself. ... I'm going to start at this head.''
The video cuts to a calf's bisected head. Close-ups follow of the calf's blackened teeth (''They
say that's due to high concentrations of fluoride in the water that they drink''), its liver, heart,
stomachs, kidneys and gall bladder. Each organ is sliced open, and Wilbur points out unusual discolorations
- some dark, some green - and textures. ''I don't even like the looks of them,'' he says. ''It don't
look like anything I've been into before.''
Bilott watched the video and looked at photographs for several hours. He saw cows with stringy
tails, malformed hooves, giant lesions protruding from their hides and red, receded eyes; cows suffering
constant diarrhea, slobbering white slime the consistency of toothpaste, staggering bowlegged like
drunks. Tennant always zoomed in on his cows' eyes. ''This cow's done a lot of suffering,'' he would
say, as a blinking eye filled the screen.
''This is bad,'' Bilott said to himself. ''There's something really bad going on here.''
Bilott decided right away to take the Tennant case. It was, he says again, ''the
right thing to do.'' Bilott might have had the practiced look of a corporate lawyer - soft-spoken,
milk-complected, conservatively attired - but the job had not come naturally to him. He did not have
a typical Taft résumé. He had not attended college or law school in the Ivy League. His father was
a lieutenant colonel in the Air Force, and Bilott spent most of his childhood moving among air bases
near Albany; Flint, Mich.; Newport Beach, Calif.; and Wiesbaden, West Germany. Bilott attended eight
schools before graduating from Fairborn High, near Ohio's Wright-Patterson Air Force Base. As a junior,
he received a recruitment letter from a tiny liberal-arts school in Sarasota called the New College
of Florida, which graded pass/fail and allowed students to design their own curriculums. Many of
his friends there were idealistic, progressive - ideological misfits in Reagan's America. He met
with professors individually and came to value critical thinking. ''I learned to question everything
you read,'' he said. ''Don't take anything at face value. Don't care what other people say. I liked
that philosophy.'' Bilott studied political science and wrote his thesis about the rise and fall
of Dayton. He hoped to become a city manager.
But his father, who late in life enrolled in law school, encouraged Bilott to do the same. Surprising
his professors, he chose to attend law school at Ohio State, where his favorite course was environmental
law. ''It seemed like it would have real-world impact,'' he said. ''It was something you could do
to make a difference.'' When, after graduation, Taft made him an offer, his mentors and friends from
New College were aghast. They didn't understand how he could join a corporate firm. Bilott didn't
see it that way. He hadn't really thought about the ethics of it, to be honest. ''My family said
that a big firm was where you'd get the most opportunities,'' he said. ''I knew nobody who had ever
worked at a firm, nobody who knew anything about it. I just tried to get the best job I could. I
don't think I had any clue of what that involved.''
The road to one of the Tennant farms. Credit Bryan
Schutmaat for The New York Times
At Taft, he asked to join Thomas Terp's environmental team. Ten years earlier, Congress passed
the legislation known as Superfund, which financed the emergency cleanup of hazardous-waste dumps.
Superfund was a lucrative development for firms like Taft, creating an entire subfield within
environmental law, one that required a deep understanding of the new regulations in order to guide
negotiations among municipal agencies and numerous private parties. Terp's team at Taft was a
leader in the field.
As an associate, Bilott was asked to determine which companies contributed which toxins and hazardous
wastes in what quantities to which sites. He took depositions from plant employees, perused public
records and organized huge amounts of historical data. He became an expert on the Environmental Protection
Agency's regulatory framework, the Safe Drinking Water Act, the Clean Air Act, the Toxic Substances
Control Act. He mastered the chemistry of the pollutants, despite the fact that chemistry had been
his worst subject in high school. ''I learned how these companies work, how the laws work, how you
defend these claims,'' he said. He became the consummate insider.
Bilott was proud of the work he did. The main part of his job, as he understood it, was to help
clients comply with the new regulations. Many of his clients, including Thiokol and Bee Chemical,
disposed of hazardous waste long before the practice became so tightly regulated. He worked long
hours and knew few people in Cincinnati.
... ... ...
The Tennant case put Taft in a highly unusual position. The law firm was in the business of representing
chemical corporations, not suing them. The prospect of taking on DuPont ''did cause us pause,'' Terp
concedes. ''But it was not a terribly difficult decision for us. I'm a firm believer that our work
on the plaintiff's side makes us better defense lawyers.''
... ... ...
Bilott filed a federal suit against DuPont in the summer of 1999 in the Southern
District of West Virginia. In response, DuPont's in-house lawyer, Bernard Reilly, informed him that
DuPont and the E.P.A. would commission a study of the property, conducted by three veterinarians
chosen by DuPont and three chosen by the E.P.A. Their report did not find DuPont responsible for
the cattle's health problems. The culprit, instead, was poor husbandry: ''poor nutrition, inadequate
veterinary care and lack of fly control.'' In other words, the Tennants didn't know how to raise
cattle; if the cows were dying, it was their own fault.
This did not sit well with the Tennants, who began to suffer the consequences of antagonizing
Parkersburg's main employer. Lifelong friends ignored the Tennants on the streets of Parkersburg
and walked out of restaurants when they entered. ''I'm not allowed to talk to you,'' they said, when
confronted. Four different times, the Tennants changed churches.
Wilbur called the office nearly every day, but Bilott had little to tell him. He was doing for
the Tennants what he would have done for any of his corporate clients - pulling permits, studying
land deeds and requesting from DuPont all documentation related to Dry Run Landfill - but he could
find no evidence that explained what was happening to the cattle. ''We were getting frustrated,''
Bilott said. ''I couldn't blame the Tennants for getting angry.''
With the trial looming, Bilott stumbled upon a letter DuPont had sent to the E.P.A. that mentioned
a substance at the landfill with a cryptic name: ''PFOA.'' In all his years working with chemical
companies, Bilott had never heard of PFOA. It did not appear on any list of regulated materials,
nor could he find it in Taft's in-house library. The chemistry expert that he had retained for the
case did, however, vaguely recall an article in a trade journal about a similar-sounding compound:
PFOS, a soaplike agent used by the technology conglomerate 3M in the fabrication of Scotchgard.
Bilott hunted through his files for other references to PFOA, which he learned was short for perfluorooctanoic
acid. But there was nothing. He asked DuPont to share all documentation related to the substance;
DuPont refused. In the fall of 2000, Bilott requested a court order to force them. Against DuPont's
protests, the order was granted. Dozens of boxes containing thousands of unorganized documents began
to arrive at Taft's headquarters: private internal correspondence, medical and health reports and
confidential studies conducted by DuPont scientists. There were more than 110,000 pages in all, some
half a century old. Bilott spent the next few months on the floor of his office, poring over the
documents and arranging them in chronological order. He stopped answering his office phone. When
people called his secretary, she explained that he was in the office but had not been able to reach
the phone in time, because he was trapped on all sides by boxes.
''I started seeing a story,'' Bilott said. ''I may have been the first one to actually go through
them all. It became apparent what was going on: They had known for a long time that this stuff was
bad.''
Bilott is given to understatement. (''To say that Rob Bilott is understated,'' his colleague Edison
Hill says, ''is an understatement.'') The story that Bilott began to see, cross-legged on his office
floor, was astounding in its breadth, specificity and sheer brazenness. ''I was shocked,'' he said.
That was another understatement. Bilott could not believe the scale of incriminating material that
DuPont had sent him. The company appeared not to realize what it had handed over. ''It was one of
those things where you can't believe you're reading what you're reading,'' he said. ''That it's actually
been put in writing. It was the kind of stuff you always heard about happening but you never thought
you'd see written down.''
The story began in 1951, when DuPont started purchasing PFOA (which the company
refers to as C8) from 3M for use in the manufacturing of Teflon. 3M invented PFOA just four years
earlier; it was used to keep coatings like Teflon from clumping during production. Though PFOA was
not classified by the government as a hazardous substance, 3M sent DuPont recommendations on how
to dispose of it. It was to be incinerated or sent to chemical-waste facilities. DuPont's own instructions
specified that it was not to be flushed into surface water or sewers. But over the decades that followed,
DuPont pumped hundreds of thousands of pounds of PFOA powder through the outfall pipes of the Parkersburg
facility into the Ohio River. The company dumped 7,100 tons of PFOA-laced sludge into ''digestion
ponds'': open, unlined pits on the Washington Works property, from which the chemical could seep
straight into the ground. PFOA entered the local water table, which supplied drinking water to the
communities of Parkersburg, Vienna, Little Hocking and Lubeck - more than 100,000 people in all.
Bilott learned from the documents that 3M and DuPont had been conducting secret medical studies
on PFOA for more than four decades. In 1961, DuPont researchers found that the chemical could increase
the size of the liver in rats and rabbits. A year later, they replicated these results in studies
with dogs. PFOA's peculiar chemical structure made it uncannily resistant to degradation. It also
bound to plasma proteins in the blood, circulating through each organ in the body. In the 1970s,
DuPont discovered that there were high concentrations of PFOA in the blood of factory workers at
Washington Works. They did not tell the E.P.A. at the time. In 1981, 3M - which continued to serve
as the supplier of PFOA to DuPont and other corporations - found that ingestion of the substance
caused birth defects in rats. After 3M shared this information, DuPont tested the children of pregnant
employees in their Teflon division. Of seven births, two had eye defects. DuPont did not make this
information public.
In 1984, DuPont became aware that dust vented from factory chimneys settled well beyond the property
line and, more disturbing, that PFOA was present in the local water supply. DuPont declined to disclose
this finding. In 1991, DuPont scientists determined an internal safety limit for PFOA concentration
in drinking water: one part per billion. The same year, DuPont found that water in one local district
contained PFOA levels at three times that figure. Despite internal debate, it declined to make the
information public.
(In a statement, DuPont claimed that it did volunteer health information about PFOA to the E.P.A.
during those decades. When asked for evidence, it forwarded two letters written to West Virginian
government agencies from 1982 and 1992, both of which cited internal studies that called into question
links between PFOA exposure and human health problems.)
By the '90s, Bilott discovered, DuPont understood that PFOA caused cancerous testicular, pancreatic
and liver tumors in lab animals. One laboratory study suggested possible DNA damage from PFOA exposure,
and a study of workers linked exposure with prostate cancer. DuPont at last hastened to develop an
alternative to PFOA. An interoffice memo sent in 1993 announced that ''for the first time, we have
a viable candidate'' that appeared to be less toxic and stayed in the body for a much shorter duration
of time. Discussions were held at DuPont's corporate headquarters to discuss switching to the new
compound. DuPont decided against it. The risk was too great: Products manufactured with PFOA were
an important part of DuPont's business, worth $1 billion in annual profit.
But the crucial discovery for the Tennant case was this: By the late 1980s, as DuPont became increasingly
concerned about the health effects of PFOA waste, it decided it needed to find a landfill for the
toxic sludge dumped on company property. Fortunately they had recently bought 66 acres from a low-level
employee at the Washington Works facility that would do perfectly.
By 1990, DuPont had dumped 7,100 tons of PFOA sludge into Dry Run Landfill. DuPont's scientists
understood that the landfill drained into the Tennants' remaining property, and they tested the water
in Dry Run Creek. It contained an extraordinarily high concentration of PFOA. DuPont did not tell
this to the Tennants at the time, nor did it disclose the fact in the cattle report that it commissioned
for the Tennant case a decade later - the report that blamed poor husbandry for the deaths of their
cows. Bilott had what he needed.
In August 2000, Bilott called DuPont's lawyer, Bernard Reilly, and explained
that he knew what was going on. It was a brief conversation. The Tennants settled. The firm would receive its contingency fee. The whole business might have
ended right there. But Bilott was not satisfied.
''I was irritated,'' he says.
DuPont was nothing like the corporations he had represented at Taft in the Superfund cases. ''This
was a completely different scenario. DuPont had for decades been actively trying to conceal their
actions. They knew this stuff was harmful, and they put it in the water anyway. These were bad facts.''
He had seen what the PFOA-tainted drinking water had done to cattle. What was it doing to the tens
of thousands of people in the areas around Parkersburg who drank it daily from their taps? What did
the insides of their heads look like? Were their internal organs green?
Bilott spent the following months drafting a public brief against DuPont. It was 972 pages long,
including 136 attached exhibits. His colleagues call it ''Rob's Famous Letter.'' ''We have confirmed
that the chemicals and pollutants released into the environment by DuPont at its Dry Run Landfill
and other nearby DuPont-owned facilities may pose an imminent and substantial threat to health or
the environment,'' Bilott wrote. He demanded immediate action to regulate PFOA and provide clean
water to those living near the factory. On March 6, 2001, he sent the letter to the director of every
relevant regulatory authority, including Christie Whitman, administrator of the E.P.A., and the United
States attorney general, John Ashcroft.
DuPont reacted quickly, requesting a gag order to block Bilott from providing the information
he had discovered in the Tennant case to the government. A federal court denied it. Bilott sent his
entire case file to the E.P.A.
''DuPont freaked out when they realized that this guy was onto them,'' says Ned McWilliams, a
young trial lawyer who later joined Bilott's legal team. ''For a corporation to seek a gag order
to prevent somebody from speaking to the E.P.A. is an extraordinary remedy. You could realize how
bad that looks. They must have known that there was a small chance of winning. But they were so afraid
that they were willing to roll the dice.''
With the Famous Letter, Bilott crossed a line. Though nominally representing the Tennants - their
settlement had yet to be concluded - Bilott spoke for the public, claiming extensive fraud and wrongdoing.
He had become a threat not merely to DuPont but also to, in the words of one internal memo, ''the
entire fluoropolymers industry'' - an industry responsible for the high-performance plastics used
in many modern devices, including kitchen products, computer cables, implantable medical devices
and bearings and seals used in cars and airplanes. PFOA was only one of more than 60,000 synthetic
chemicals that companies produced and released into the world without regulatory oversight.
''Rob's letter lifted the curtain on a whole new theater,'' says Harry Deitzler, a plaintiff's
lawyer in West Virginia who works with Bilott. ''Before that letter, corporations could rely upon
the public misperception that if a chemical was dangerous, it was regulated.'' Under the 1976 Toxic
Substances Control Act, the E.P.A. can test chemicals only when it has been provided evidence of
harm. This arrangement, which largely allows chemical companies to regulate themselves, is the reason
that the E.P.A. has restricted only five chemicals, out of tens of thousands on the market, in the
last 40 years.
It was especially damning to see these allegations against DuPont under the letterhead of one
of the nation's most prestigious corporate defense firms. ''You can imagine what some of the other
companies that Taft was representing - a Dow Chemical - might have thought of a Taft lawyer taking
on DuPont,'' Larry Winter says. ''There was a threat that the firm would suffer financially.'' When
I asked Thomas Terp about Taft's reaction to the Famous Letter, he replied, not quite convincingly,
that he didn't recall one. ''Our partners,'' he said, ''are proud of the work that he has done.''
Bilott, however, worried that corporations doing business with Taft might see things differently.
''I'm not stupid, and the people around me aren't stupid,'' he said. ''You can't ignore the economic
realities of the ways that business is run and the way clients think. I perceived that there were
some 'What the hell are you doing?' responses.''
The letter led, four years later, in 2005, to DuPont's reaching a $16.5 million settlement with
the E.P.A., which had accused the company of concealing its knowledge of PFOA's toxicity and presence
in the environment in violation of the Toxic Substances Control Act. (DuPont was not required to
admit liability.) At the time, it was the largest civil administrative penalty the E.P.A. had obtained
in its history, a statement that sounds more impressive than it is. The fine represented less than
2 percent of the profits earned by DuPont on PFOA that year.
Bilott never represented a corporate client again.
The obvious next step was to file a class-action lawsuit against DuPont on behalf
of everyone whose water was tainted by PFOA. In all ways but one, Bilott himself was in the ideal
position to file such a suit. He understood PFOA's history as well as anyone inside DuPont did. He
had the technical and regulatory expertise, as he had proved in the Tennant case. The only part that
didn't make sense was his firm: No Taft lawyer, to anyone's recollection, had ever filed a class-action
lawsuit.
It was one thing to pursue a sentimental case on behalf of a few West Virginia cattle farmers
and even write a public letter to the E.P.A. But an industry-threatening class-action suit against
one of the world's largest chemical corporations was different. It might establish a precedent for
suing corporations over unregulated substances and imperil Taft's bottom line. This point was made
to Terp by Bernard Reilly, DuPont's in-house lawyer, according to accounts from Bilott's plaintiff's-lawyer
colleagues; they say Reilly called to demand that Bilott back off the case. (Terp confirms that Reilly
called him but will not disclose the content of the call; Bilott and Reilly decline to speak about
it, citing continuing litigation.) Given what Bilott had documented in his Famous Letter, Taft stood
by its partner.
A lead plaintiff soon presented himself. Joseph Kiger, a night-school teacher in Parkersburg,
called Bilott to ask for help. About nine months earlier, he received a peculiar note from the Lubeck
water district. It arrived on Halloween day, enclosed in the monthly water bill. The note explained
that an unregulated chemical named PFOA had been detected in the drinking water in ''low concentrations,''
but that it was not a health risk. Kiger had underlined statements that he found particularly baffling,
like: ''DuPont reports that it has toxicological and epidemiological data to support confidence that
exposure guidelines established by DuPont are protective of human health.'' The term ''support confidence''
seemed bizarre, as did ''protective of human health,'' not to mention the claim that DuPont's own
data supported its confidence in its own guidelines.
Still, Kiger might have forgotten about it had his wife, Darlene, not already spent much of her
adulthood thinking about PFOA. Darlene's first husband had been a chemist in DuPont's PFOA lab. (Darlene
asked that he not be named so that he wouldn't be involved in the local politics around the case.)
''When you worked at DuPont in this town,'' Darlene says today, ''you could have everything you wanted.''
DuPont paid for his education, it secured him a mortgage and it paid him a generous salary. DuPont
even gave him a free supply of PFOA, which, Darlene says, she used as soap in the family's dishwasher
and to clean the car. Sometimes her husband came home from work sick - fever, nausea, diarrhea, vomiting
- after working in one of the PFOA storage tanks. It was a common occurrence at Washington Works.
Darlene says the men at the plant called it ''Teflon flu.''
States of Uncertainty
No one knows for certain how much PFOA is safe to drink. Rob Bilott's lawsuit against DuPont in
West Virginia included anyone whose drinking water had levels above 0.05 parts per billion. But last
June, based on a comprehensive review of previous health studies, Philippe Grandjean of the Harvard
School of Public Health and Richard Clapp of the University of Massachusetts-Lowell named an ''approximate''
safe level of 0.001 p.p.b. Soon thereafter, the nonprofit Environmental Working Group analyzed two
years of E.P.A. survey data to find that this threshold had been exceeded - in some cases by factors
of 100 or more - in 94 water systems across 27 states. Below, the estimated number of people in each
state whose drinking water is affected.
Alabama
312,522
Arizona
217,218
California
1,441,298
Colorado
67,348
Delaware
320,484
Florida
971,913
Georgia
94,874
Illinois
135,763
Kentucky
730,611
Massachusetts
103,762
Maryland
104,567
Minnesota
143,637
New Hampshire
53,000
New Jersey
1,334,413
New York
174,000
North Carolina
225,262
Ohio
79,337
Oklahoma
20,307
Pennsylvania
221,121
Rhode Island
21,900
South Carolina
24,904
Tennessee
139,110
Texas
11,489
Virginia
47,574
Washington
109,527
West Virginia
34,251
Wisconsin
30,100
In 1976, after Darlene gave birth to their second child, her husband told her that he was not
allowed to bring his work clothes home anymore. DuPont, he said, had found out that PFOA was causing
health problems for women and birth defects in children. Darlene would remember this six years later
when, at 36, she had to have an emergency hysterectomy and again eight years later, when she had
a second surgery. When the strange letter from the water district arrived, Darlene says, ''I kept
thinking back to his clothing, to my hysterectomy. I asked myself, what does DuPont have to do with
our drinking water?''
Joe called the West Virginia Department of Natural Resources (''They treated me like I had the
plague''), the Parkersburg office of the state's Department of Environmental Protection (''nothing
to worry about''), the water division (''I got shut down''), the local health department (''just
plain rude''), even DuPont (''I was fed the biggest line of [expletive] anybody could have been fed''),
before a scientist in the regional E.P.A. office finally took his call.
''Good God, Joe,'' the scientist said. ''What the hell is that stuff doing in your water?'' He
sent Kiger information about the Tennant lawsuit. On the court papers Kiger kept seeing the same
name: Robert Bilott, of Taft Stettinius & Hollister, in Cincinnati.
Bilott had anticipated suing on behalf of the one or two water districts closest
to Washington Works. But tests revealed that six districts, as well as dozens of private wells, were
tainted with levels of PFOA higher than DuPont's own internal safety standard. In Little Hocking,
the water tested positive for PFOA at seven times the limit. All told, 70,000 people were drinking
poisoned water. Some had been doing so for decades.
But Bilott faced a vexing legal problem. PFOA was not a regulated substance. It appeared on no
federal or state list of contaminants. How could Bilott claim that 70,000 people had been poisoned
if the government didn't recognize PFOA as a toxin - if PFOA, legally speaking, was no different
than water itself? In 2001, it could not even be proved that exposure to PFOA in public drinking
water caused health problems. There was scant information available about its impact on large populations.
How could the class prove it had been harmed by PFOA when the health effects were largely unknown?
The best metric Bilott had to judge a safe exposure level was DuPont's own internal limit of one
part per billion. But when DuPont learned that Bilott was preparing a new lawsuit, it announced that
it would re-evaluate that figure. As in the Tennant case, DuPont formed a team composed of its own
scientists and scientists from the West Virginia Department of Environmental Protection. It announced
a new threshold: 150 parts per billion.
Bilott found the figure ''mind-blowing.'' The toxicologists he hired had settled upon a safety
limit of 0.2 parts per billion. But West Virginia endorsed the new standard. Within two years, three
lawyers regularly used by DuPont were hired by the state D.E.P. in leadership positions. One of them
was placed in charge of the entire agency. ''The way that transpired was just amazing to me,'' Bilott
says. ''I suppose it wasn't so amazing to my fellow counsel in West Virginia who know the system
there. But it was to me.'' The same DuPont lawyers tasked with writing the safety limit, Bilott said,
had become the government regulators responsible for enforcing that limit.
ilott devised a new legal strategy. A year earlier, West Virginia had become one of the first
states to recognize what is called, in tort law, a medical-monitoring claim. A plaintiff needs
to prove only that he or she has been exposed to a toxin. If the plaintiff wins, the defendant
is required to fund regular medical tests. In these cases, should a plaintiff later become ill,
he or she can sue retroactively for damages. For this reason, Bilott filed the class-action suit
in August 2001 in state court, even though four of the six affected water districts lay across
the Ohio border.
Meanwhile the E.P.A., drawing from Bilott's research, began its own investigation into the toxicity
of PFOA. In 2002, the agency released its initial findings: PFOA might pose human health risks not
only to those drinking tainted water, but also to the general public - anyone, for instance, who
cooked with Teflon pans. The E.P.A. was particularly alarmed to learn that PFOA had been detected
in American blood banks, something 3M and DuPont had known as early as 1976.
By 2003 the average
concentration of PFOA in the blood of an adult American was four to five parts per billion. In 2000,
3M ceased production of PFOA. DuPont, rather than use an alternative compound, built a new factory
in Fayetteville, N.C., to manufacture the substance for its own use.
... ... ...
As part of its agreement with the E.P.A., DuPont ceased production and use of PFOA in 2013.
The five other companies in the world that produce PFOA are also phasing out production. DuPont,
which is currently negotiating a merger with Dow Chemical, last year severed its chemical businesses:
They have been spun off into a new corporation called Chemours. The new company has replaced PFOA
with similar fluorine-based compounds designed to biodegrade more quickly - the alternative considered
and then discarded by DuPont more than 20 years ago. Like PFOA, these new substances have not come
under any regulation from the E.P.A. When asked about the safety of the new chemicals, Chemours replied
in a statement: ''A significant body of data demonstrates that these alternative chemistries can
be used safely.''
Last May, 200 scientists from a variety of disciplines signed
the Madrid Statement, which expresses concern about
the production of all fluorochemicals, or PFASs, including those that have replaced PFOA. PFOA and
its replacements are suspected to belong to a large class of artificial compounds called endocrine-disrupting
chemicals; these compounds, which include chemicals used in the production of pesticides, plastics
and gasoline, interfere with human reproduction and metabolism and cause cancer, thyroid problems
and nervous-system disorders. In the last five years, however, a new wave of endocrinology research
has found that even extremely low doses of such chemicals can create significant health problems.
Among the Madrid scientists' recommendations: ''Enact legislation to require only essential uses
of PFASs'' and ''Whenever possible, avoid products containing, or manufactured using, PFASs. These
include many products that are stain-resistant, waterproof or nonstick.''
When asked about the Madrid Statement, Dan Turner, DuPont's head of global media relations, wrote
in an email: ''DuPont does not believe the Madrid Statement reflects a true consideration of the
available data on alternatives to long-chain perfluorochemicals, such as PFOA. DuPont worked for
more than a decade, with oversight from regulators, to introduce its alternatives. Extensive data
has been developed, demonstrating that these alternatives are much more rapidly eliminated from the
body than PFOA, and have improved health safety profiles. We are confident that these alternative
chemistries can be used safely - they are well characterized, and the data has been used to register
them with environmental agencies around the world.''
Every year Rob Bilott writes a letter to the E.P.A. and the West Virginia D.E.P.,
urging the regulation of PFOA in drinking water. In 2009, the E.P.A. set a ''provisional'' limit
of 0.4 parts per billion for short-term exposure, but has never finalized that figure. This means
that local water districts are under no obligation to tell customers whether PFOA is in their water.
In response to Bilott's most recent letter, the E.P.A. claimed that it would announce a ''lifetime
health advisory level for PFOA'' by ''early 2016.''
This advisory level, if indeed announced, might be a source of comfort to future generations.
But if you are a sentient being reading this article in 2016, you already have PFOA in your blood.
It is in your parents' blood, your children's blood, your lover's blood. How did it get there? Through
the air, through your diet, through your use of nonstick cookware, through your umbilical cord. Or
you might have drunk tainted water. The Environmental Working Group has found manufactured fluorochemicals
present in 94 water districts across 27 states (see sidebar beginning on Page 38). Residents of Issaquah,
Wash.; Wilmington, Del.; Colorado Springs; and Nassau County on Long Island are among those whose
water has a higher concentration of fluorochemicals than that in some of the districts included in
Rob Bilott's class-action suit. The drinking water in Parkersburg itself, whose water district was
not included in the original class-action suit and has failed to compel DuPont to pay for a filtration
system, is currently tainted with high levels of PFOA. Most residents appear not to know this.
Where scientists have tested for the presence of PFOA in the world, they have found it. PFOA is
in the blood or vital organs of Atlantic salmon, swordfish, striped mullet, gray seals, common cormorants,
Alaskan polar bears, brown pelicans, sea turtles, sea eagles, Midwestern bald eagles, California
sea lions and Laysan albatrosses on Sand Island, a wildlife refuge on Midway Atoll, in the middle
of the North Pacific Ocean, about halfway between North America and Asia.
''We see a situation,'' Joe Kiger says, ''that has gone from Washington Works, to statewide,
to the United States, and now it's everywhere, it's global. We've taken the cap off something here.
But it's just not DuPont. Good God. There are 60,000 unregulated chemicals out there right now. We
have no idea what we're taking.''
Bilott doesn't regret fighting DuPont for the last 16 years, nor for letting PFOA consume his
career. But he is still angry. ''The thought that DuPont could get away with this for this long,''
Bilott says, his tone landing halfway between wonder and rage, ''that they could keep making a profit
off it, then get the agreement of the governmental agencies to slowly phase it out, only to replace
it with an alternative with unknown human effects - we told the agencies about this in 2001, and
they've essentially done nothing. That's 14 years of this stuff continuing to be used, continuing
to be in the drinking water all over the country. DuPont just quietly switches over to the next substance.
And in the meantime, they fight everyone who has been injured by it.''
Bilott is currently prosecuting Wolf v. DuPont, the second of the personal-injury cases filed
by the members of his class. The plaintiff, John M. Wolf of Parkersburg, claims that PFOA in his
drinking water caused him to develop ulcerative colitis. That trial begins in March. When it concludes,
there will be 3,533 cases left to try.
"... The proof is in how there is one premium cost if the medical provider is on their own and magically it is cheaper if they are part of a group or hospital.. Same doctor…same practices…lower rates…prima facia evidence of insurance company rate fraud… ..."
"... One of my faculty mentors, a student of Engel's and editor of the Merck Manual, repeatedly emphasized that the most powerful diagnostic and therapeutic tool at the physician's disposal was their relationship with the patient. ..."
"... What this woman didn't realize was that my mom had bent over backwards for years for her patients, regularly putting in 90+ hour weeks and not reducing the quality of care despite not being paid well for it. My dad calculated she made less per hour than her secretary. ..."
Not mentioned in regard to doctors is the issue of capital intensity.
Using federal regulation, the health care cartel (hospitals, insurers, Big
Pharma) is increasing regulatory overhead to the point that individual
practitioners are no longer viable.
As one example, federal regulations requiring increasing "meaningful use"
of electronic health records have caused some individual practitioners with
most of their career behind them to say "screw it, I'm retiring."
Big Biz has an agenda, and it's about regulating small business out of
existence with compliance burdens that only capital-intensive
mega-corporations can shoulder.
I think you've misinterpreted both motive and causality in this
assessment. First, medium and large corporations are also struggling to
deal with increasing regulation so it's inaccurate to assert that only
small business can't cope. There is plenty of painful flailing happening
inside every company in the world. The only reason people get to the top
is the manage that confusion with an unending stream of happy horseshit
and a good sales pitch. But they sure as shit are not "managing" anything
besides their retirement packages.
Then there is the matter of lobbying and political corruption to stem
the tide of regulation. But regulation always follows some egregious
abuse. There is no law on the books that addresses a crime that has not
already been committed by someone somewhere somewhen. Similarly, there
are no regulations disincenting smart, compassionate behaviors. That's
unattractive because everyone thinks they have a god given right to be
rich. Society has confused the measure with the value.
Too, regulation is often written by an administrative bureaucracy
charged with interpreting legislative intent. Given the constant pressure
on "costs," the mind numbing nature of bureaucracy, and the itinerant
mediocrity, well you can see where this is going.
Or you might be witnessing attrition from enforcement actions which
naturally fall on the small and weak because ambitious young prosecutors
a) want the job at wall street or DC, so can't make enemies, and b) don't
have the budgets to take on big companies.
Capitalism is antithetical to Democracy, Democracy is not "business"
it is civil society.
When it comes to "healthcare", that's really now "insurance" and the
provision of medical services is a commodity, just like hair clips and
reality TV shows. Pine for the old fashioned ways all you want, and take
cheer in knowing the food shortages that'll start cropping up in a few
years will make all of this seem pretty silly.
You nailed it on medical professionals…would like to add, that at
least here in flori duh there seems to be massive pricing fraud by
malpractice and liability insurance providers which state regulators
allow to continue to force small or single practitioners to join
groups by financial obliteration…at least in floriduh, there is the
usual massive distortion suggesting insurance companies are paying out
huge amounts when there in fact seems to be collusion amongst
insurance companies neglecting the legal requirement to try to settle
on good faith and end up forcing people to settle for pennies on the
dollar…yet the insurance companies keep picking the pockets of medical
professionals
The proof is in how there is one premium cost if the medical
provider is on their own and magically it is cheaper if they are part
of a group or hospital.. Same doctor…same practices…lower rates…prima
facia evidence of insurance company rate fraud…
I have read this site daily for many years but have refrained from
commenting, either from knowing too little [most of the time] or more than I
felt comfortable trying to articulate. I spent my family residency in a high
quality, reform/radically oriented program in the late 1970's. The ideal was to
revivify the art of diagnosing and caring for other people by teaching out of
the biopsychosocial model articulated be George Engel at the University of
Rochester.
One of my faculty mentors, a student of Engel's and editor of the
Merck Manual, repeatedly emphasized that the most powerful diagnostic and
therapeutic tool at the physician's disposal was their relationship with the
patient.
It took me years of real world experience in private practice followed
by a long stint in rural Honduras and AIDS and poverty clinic work to realize
the truth of that claim. At least at the primary care level corporate
employment has almost completely effaced this truth and it's associated ethic.
To paraphrase Wittgestein, the misuse of words easily beguiles our
intelligence. The authors of this travesty use references to medicine and
doctors without regard to their historic usage, to obscure and invert their
meaning and they and their masters have largely prevailed in this unhappy
country.
Ditto, great comment. All I could think of while reading this was, "why
would I go to doctors that follow checklists like that?"
My mother used to co-run an independent medical practice as an MD. Then
she joined MDVIP and had to get her patients to signup with a chunk of
change each year (~$1600) which was revenue in addition to insurance
payouts. My mom told me of one quite well-off (financially) patient who
balked at the expense and left with her husband for another practice.
What this woman didn't realize was that my mom had bent over backwards
for years for her patients, regularly putting in 90+ hour weeks and not
reducing the quality of care despite not being paid well for it. My dad
calculated she made less per hour than her secretary.
This woman went to another doctor, saw the sort of treatment she
received, including minimal time and attention, and then snuck into my mom's
office without seeing her, wrote a check, dropped it at the secretary's
desk, and left, and is now a happy patient again.
My mom followed her longtime doctor to MDVIP. Her doctor sees far
fewer patients than she did. There is a tradeoff: she no longer has
hospital privileges, but fortunately, in part because of this GP's
excellent care, my mom stays out of the hospital. We are usually the only
people in the office when she goes in for checkups.
Actually the idea of the outpatient physician also doing hospital
treatment as well is going away.
The Hospitalist has taken over the
hospital part of treatment. Note that this does imply that for a lot
of outpatient things physicians are drastically overtrained (due to
extending residency compared to 50 years ago for example). By doing
this you can bring in the nurse practicioner/physicians assistant at
the outpatient clinic, as well as having nurse practioners etc with
specific training for hospitals.
And you wonder why doctors have high suicide rates. Your mother sounds
like an absolute Mensch, however, we shouldn't accept a system that
shoves people into this saint/worker drone paradigm. What bothers me is
how these austerity practices grind people down…the people who really
care, deeply, and want to help have to choose between being heroes or to
accept the system "is what it is," which is its own sort of moral death.
The Last but not LeastTechnology is dominated by
two types of people: those who understand what they do not manage and those who manage what they do not understand ~Archibald Putt.
Ph.D
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Loan Eby says:
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