Saturday, February 13, 2010

Though Results Are Unproved, Robotic Surgery Wins Converts -

At age 42, Dr. Jeffrey A. Cadeddu felt like a dinosaur in urologic surgery. He was trained to take out cancerous prostates the traditional laparoscopic way: making small incisions in the abdomen and inserting tools with his own hands to slice out the organ.

But now, patient after patient was walking away. They did not want that kind of surgery. They wanted surgery by a robot, controlled by a physician not necessarily even in the operating room, face buried in a console, working the robot's arms with remote controls.

"Patients interview you," said Dr. Cadeddu, a urologist at the University of Texas Southwestern Medical Center at Dallas. "They say: 'Do you use the robot? O.K., well, thank you.' " And they leave.

On one level, robot-assisted surgery makes sense. A robot's slender arms can reach places human hands cannot, and robot-assisted surgery is spreading to other areas of medicine.

But robot-assisted prostate surgery costs more — about $1,500 to $2,000 more per patient. And it is not clear whether its outcomes are better, worse or the same.

One large national study, which compared outcomes among Medicare patients, indicated that surgery with a robot might lead to fewer in-hospital complications, but that it might also lead to moreimpotence and incontinence. But the study included conventional laparoscopy patients among the ones who had robot-assisted surgery, making it difficult to assess its conclusions.

It is also not known whether robot-assisted prostate surgery gives better, worse or equivalent long-term cancer control than the traditional methods, either with a four-inch incision or with smaller incisions and a laparoscope. And researchers know of no large studies planned or under way.

Meanwhile, marketing has moved into the breach, with hospitals and surgeons advertising their services with claims that make critics raise their eyebrows. For example, surgeons in private practice at the New Jersey Center for Prostate Cancer and Urology advertise on their Web site that robot-assisted surgery provides "cancer cure equally as well as traditional prostate surgery" and "significantly improved urinary control."

Robot-assisted prostate surgery has grown at a nearly unprecedented rate.

Last year, 73,000 American men — 86 percent of the 85,000 who had prostate cancer surgery — had robot-assisted operations, according to the robot's maker, Intuitive Surgical, the only official source of such data. Eight years ago there were fewer than 5,000, Intuitive says.

Dr. Sean R. Tunis, director of the Center for Medical Technology Policy, a nonprofit organization that evaluates medical technology, said few other procedures had made such rapid inroads in medicine.

Medical researchers say the robot situation is emblematic of a more general issue. New technology has sometimes led to big advances, which can justify extra costs. But often, technology spreads long before investigators know whether it is worthwhile.

With drugs, the Food and Drug Administration requires extensive tests to determine safety and efficacy. But surgeons are free to innovate, and few would argue that surgery can or should be held to the same standards as drugs. Still, a situation like robot-assisted surgery illustrates how patients may end up making what can be life-changing decisions based on little more than assertive marketing or the personal prejudices of their surgeon.

"There is no question there is a lot of marketing hype," said Dr. Gerald L. Andriole Jr., chief of urologic surgery at Washington University. Dr. Andriole does laparoscopic prostate surgery, and although he tried the robot, he went back to the old ways.

"I just think that in this particular instance, with this particular robot," he said, "there hasn't been a quantum leap in anything."

Evaluating technology is complicated. As often happens in surgery, doctors can become enthusiasts without rigorous studies ever being done.

And with prostate cancer, more is at stake than just an academic dispute, said Dr. Jason D. Engel, director of urologic robotic surgery at George Washington University Medical Center in Washington. One in six American men develop prostate cancer in their lifetime. Treatment options include radiation and watchful waiting, but the most popular is surgery.

"With the stream of prostate cancer patients that come through," Dr. Engel said, "this is a big, big business."

Dr. Michael J. Barry, a professor of medicine at Massachusetts General Hospital in Boston, said that once a hospital invests in a robot — $1.39 million for the machine and $140,000 a year for the service contract, according to Intuitive — it has an incentive to use it. Doctors and patients become passionate advocates, assuming that newer means better.

"Doctors and medical centers advertise it, and patients demand it," Dr. Barry said, creating a "folie a deux."

The robot's ability to reach into small spaces comes with tradeoffs. Ordinarily, doctors can feel how forcefully they are grabbing tissue, how well they are cutting, how their stitches are holding. With the robot, that is lost. And the robot is slow; it typically takes three and a half hours for a prostate operation, according to Intuitive, twice as long as traditional surgery.

A few highly experienced doctors are much faster. Dr. Vipul Patel, for example, at Florida Hospital in Celebration, Fla., has done more than 3,500 robot-assisted prostate surgeries. He often does six a day, taking about one and a half hours for each.

"From Day 1, when I sat down at that robotic console, I knew we would give patients a better outcome," Dr. Patel said. "I have not seen anyone who has done a good amount of robotic surgery go back."

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Thursday, February 11, 2010

Less-Invasive Hip Surgery That Speeds Recovery -

Hip replacement is one of the most successful operations in all of medicine, which prompts many orthopedic surgeons to think, as one leader in the field put it, "Why change something that doesn't need fixing?"

But that leader, Dr. Robert Berghoff; his colleagues at Arizona Orthopedic Associates in Phoenix; and other orthopedic surgeons around the country believed that improvements were possible, especially with regard to reducing complications and speeding recovery.

The technique these surgeons use is called anterior hip replacement, one of several minimally invasive operations that are associated with a shorter hospital stay, smaller incision, less trauma to muscles, less pain and blood loss, reduced risk of dislocation after surgery, faster healing and a quicker return to normal activities.

"The morning after surgery I was able to walk without a walker or even a cane and could put my full weight on the operated side," Jack White, a 71-year-old personal trainer from Paradise Valley, Ariz., said in an interview. "The next day I walked 50 yards without a limp and was able to go home, where I did physical therapy five days a week for two weeks. On Day 5, I walked a mile and a half, and in Week 4, I taught my aerobics class and played 18 holes of golf with no pain and no problem."

The operation was introduced in the United States more than two decades ago by Dr. Joel M. Matta of the St. John's Health Center in Santa Monica, Calif., who also helped design a special operating table to simplify the procedure.

Another minimally invasive form of hip replacement, the PATH technique, was developed by a Los Angeles orthopedist, Dr. Brad L. Penenberg.

Dr. Patrick Meere of New York University Langone Medical Center and the Hospital for Joint Diseases in New York tells me this method has the same advantages as the anterior approach, results in no activity limitations and also offers a safety net: If anything goes wrong during the procedure, the problem can be repaired without having to do a more extensive operation.

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Revising Book on Disorders of the Mind -

Far fewer children would get a diagnosis of bipolar disorder. "Binge eating disorder" and "hypersexuality" might become part of the everyday language. And the way many mental disorders are diagnosed and treated would be sharply revised.

These are a few of the changes proposed on Tuesday by doctors charged with revising psychiatry's encyclopedia of mental disorders, the guidebook that largely determines where society draws the line between normal and not normal, between eccentricity and illness, between self-indulgence and self-destruction — and, by extension, when and how patients should be treated.

The eagerly awaited revisions — to be published, if adopted, in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, due in 2013 — would be the first in a decade.

For months they have been the subject of intense speculation and lobbying by advocacy groups, and some proposed changes have already been widely discussed — including folding the diagnosis of Asperger's syndrome into a broader category, autism spectrum disorder.

But others, including a proposed alternative for bipolar disorder in many children, were unveiled on Tuesday. Experts said the recommendations, posted online at for public comment, could bring rapid change in several areas.

"Anything you put in that book, any little change you make, has huge implications not only for psychiatry but for pharmaceutical marketing, research, for the legal system, for who's considered to be normal or not, for who's considered disabled," said Dr. Michael First, a professor of psychiatry at Columbia University who edited the fourth edition of the manual but is not involved in the fifth.

"And it has huge implications for stigma," Dr. First continued, "because the more disorders you put in, the more people get labels, and the higher the risk that some get inappropriate treatment."

One significant change would be adding a childhood disorder called temper dysregulation disorder with dysphoria, a recommendation that grew out of recent findings that many wildly aggressive, irritable children who have been given a diagnosis of bipolar disorder do not have it.

The misdiagnosis led many children to be given powerful antipsychotic drugs, which have serious side effects, including metabolic changes.

"The treatment of bipolar disorder is meds first, meds second and meds third," said Dr. Jack McClellan, a psychiatrist at the University of Washington who is not working on the manual. "Whereas if these kids have a behavior disorder, then behavioral treatment should be considered the primary treatment."

Some diagnoses of bipolar disorder have been in children as young as 2, and there have been widespread reports that doctors promoting the diagnosis received consulting and speaking fees from the makers of the drugs.

In a conference call on Tuesday, Dr. David Shaffer, a child psychiatrist at Columbia, said he and his colleagues on the panel working on the manual "wanted to come up with a diagnosis that captures the behavioral disturbance and mood upset, and hope the people contemplating a diagnosis of bipolar for these patients would think again."

Experts gave the American Psychiatric Association, which publishes the manual, predictably mixed reviews. Some were relieved that the task force working on the manual — which includes neurologists and psychologists as well as psychiatrists — had revised the previous version rather than trying to rewrite it.

Others criticized the authors, saying many diagnoses in the manual would still lack a rigorous scientific basis.

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BlueCross BlueShield of Texas' blueprint for denying health policies. - By Timothy Noah - Slate Magazine

It's difficult to appreciate the stakes in health care reform if you receive health insurance through your employer. About 59 percent of Americans do, and while they are paying more and more for fewer and fewer benefits, in the larger scheme of things they're the lucky ones. Although they could certainly use some help from Washington, Obamacare won't give them much.

The people who most urgently need Congress to pass health care reform belong to a different group. They're the 9 percent of Americans who purchase health care for themselves or their families in the so-called "nongroup market," which is where most of the horror stories you've heard about health insurance tend to occur. On second thought, that's not quite right. The people who most urgently need health reform are those who aspire to join the 9 percent, but can't, either because no nongroup insurer will take them or because any nongroup insurer that will take them has priced its policy sky-high to offset some medical risk or another. Neither wealthy enough to pay for nongroup insurance nor poor enough to qualify for Medicaid, these spurned customers end up among the 15 percent of Americans who receive no health insurance at all. Should you lose your job and fail to find another, expect to purchase nongroup insurance or, worse, not purchase it. Together, these two groups represent one-quarter of the population.

A lot has been written about what health reform would do for this 25 percent. It would create a new marketplace (the "exchange") to sell private health insurance to people who aren't insured through their employer or the government. Insurance companies that sold through the exchange would not be allowed to reject customers based on pre-existing conditions, and their ability to charge different people different rates would be sharply reduced. Everyone would be required to have health insurance (to prevent customers from gaming the system by not purchasing insurance until they got sick), and to help make such purchases possible the government would offset some of the cost for most customers in the exchange.

How badly are these reforms needed? To find out, I read through a 2009 document that BlueCross BlueShield of Texas provided its agents to guide them about who may and may not purchase a policy, and on what terms. The underwriting guidelines are quite draconian, though not dramatically worse than others that have leaked out; similar documents are online for BlueCross BlueShield of Florida (2009), Health Net of California (2006), BlueShield of California (2006), BlueCross of California (2004), and Pacificare of California (2003). BlueCross BlueShield of Texas is of interest because it's the largest health insurer in the state and because Texas has the nation's highest percentage of people without health insurance (25 percent). Also, the document happened to get leaked to me. BCBSTX did not return my call asking for comment.

The first hurdle to clear concerns weight. BlueCross BlueShield of Texas isn't too strict on this score. At 5 feet 8 inches, I'm 15 to 20 pounds heavier than I really ought to be, but I still fit comfortably within BCBSTX's required range of 115-193 for anyone receiving a "preferred" (i.e., lower) rate. Let the scales tilt to 194, though, and I'd have to pay the "standard" (higher) rate. If, during the past year, I'd been over the 194-pound limit but, through exercise or diet or medication, managed to drop my weight to 193 or lower, my insurance agent would add to my weight half the amount I lost in calculating my eligibility. Keep the weight off for a year, though, and I'd be scored like everyone else.

The next hurdle is much higher. It's called (with a refreshing absence of euphemism) the Automatic Decline List, and it consists of 143 diseases, from Addison's Disease to periarteritis nodosa, that will immediately disqualify you for coverage. It's "not all inclusive," we are warned, but if a potential customer has any of these then the agent must show him the door. Hemophilia? Disqualified. Penile implant? Get lost, you sissy! Pregnant? Begone, slattern, until after your post-partum checkup. Organ transplant? Unless it was your cornea, we got nothing to talk about.

Nine years ago I was misdiagnosed, by an emergency-room doctor of dubious competence, as having suffered a transient ischemic attack, a sort of mini-stroke that, in one-third of all cases, presages a full-scale stroke "some time in the future," according to the National Institute of Neurological Disorders and Stroke. That prognosis struck me as a little vague, considering stroke is the third leading cause of death in the United States, but in the end it didn't matter. Further investigation (by me) determined that in fact I had accidentally popped three Ambiens. (Long story.) The emergency room didn't draw any blood, which would have identified the problem instantly. Instead it took me at my word (I don't remember this; I was stoned out of my gourd) that, no, I hadn't taken any drugs that day. Did the paperwork ever catch up with my after-the-fact gumshoeing? I'm not sure, but I hope it did, because if I lived in Texas and was in the market for nongroup health insurance, my purported TIA would instantly disqualify me from buying any from BCBSTX.

Moving on to the Standard Rate Condition List of things that disqualify you for the preferred (but not standard) rate, I see "Anxiety/depression" (I'm busted), "GERD (acid reflux)," "Headache" (presumably that means more than the usual kind), "Herpes," "Temporomandibular Joint Disorder" (formerly known as lockjaw), "Tobacco use" (that's fair), and "Tourette's Syndrome" (the handbook offers no guidance about what a Tourette's sufferer is likely to say once he's been broken the bad news). Quit smoking for a year and you become eligible for the premium rate, provided you're no longer using a "cessation aid" or "nicotine substitution product."

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Wednesday, February 10, 2010

Interview with Angela Braly: 'A Wasted Opportunity' -

Angela Braly is in good spirits considering that her company seems to have narrowly avoided being converted into a public utility, if not destroyed outright. One gets the sense that she'salways in good spirits. After years of sustained political assault, the power of positive thinking probably helps.

Mrs. Braly is the CEO and president of WellPoint, the largest U.S. commercial health insurer by membership. Her company's affiliated health plans in 14 states cover 34 million people—or roughly one out of nine Americans. It contracts with 82% of the nation's primary-care physicians, 84% of specialists, and 94% of hospitals. That scale lands her on the most-wanted list in President Obama's Washington, though it's tough to imagine a less likely villain than the very Midwestern Mrs. Braly.

"It's just not clear where we go from here," says the highest ranking woman in the Fortune 500, sounding as astonished as anyone about Scott Brown's victory. Merely days before this interview in WellPoint's lower Manhattan offices at the edge of Ground Zero, Massachusetts voters effectively sent ObamaCare to its own death panel. The reflexive liberal response was to castigate the likes of Mrs. Braly. "I mean, to be fair, the status quo is working for the insurance industry, but it's not working for the American people," Mr. Obama said recently.

To actually be fair, the insurance industry was a cheerleader for the plan, at least until the policy substance congealed sometime in September. "Obviously, we've been involved in this discussion for a while—more than a year—and if you think about it we came to the table early, early on and said we're going to be advocates for responsible, sustainable health-care reform done right," Mrs. Braly says. "We really do have to get at the underlying question of health-care costs."

That was the core promise of ObamaCare. Overall health costs for people insured by WellPoint increased by 8.9% in 2009 alone, and arresting this climb was the reason so many industry groups, not only the insurers, joined with the White House and Democrats. Nobody thinks the status quo is a success. But as Mrs. Braly notes ruefully, "The nature of health care is very complex, and sometimes the nature of politics is very simple."

The tragedy, as she sees it, is what "a wasted opportunity" it all turned out to be. "Health-care reform" soon became "health-insurance reform" exclusively. "It was a pivot that was—unfortunate," she says, "because it is not going to solve the longer-term problem."

It's hard to see how WellPoint could be to blame for surging health spending, Mrs. Braly says, when 85 cents out of every premium dollar or more "is paid out in the actual cost of care, doctors, hospitals, suppliers, drugs, devices." Confiscating the 2009 profits of the entire insurance industry would pay for two days of U.S. health care.

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Sunday, February 7, 2010

Fighting Denied Claims Requires Perseverance -

MARIA CARR, a 43-year-old school administrator from Tulare, Calif., could not believe it when her insurer, UnitedHealth, denied coverage for arthroscopic surgery she underwent last year to treat a bone spur on her hip.

Her doctor told Ms. Carr he had successfully performed this procedure for eight other UnitedHealth patients suffering from the same ailment in the same year. To Ms. Carr's mind, arthroscopyseemed a much less invasive and cheaper way to treat the problem than open hip surgery, the traditional treatment for bone spurs.

"When the denial came I was shocked," Ms. Carr said, "but I figured I'd just have to find a way to pay." The total bill for the hospital and surgeon fee was $21,225.

Ms. Carr's form of shock is all too common. The Department of Labor estimates that each year about 1.4 billion claims are filed with the employer-based health plans the department oversees.

Of those, according to data collected from health insurance industry sources, 100 million are initially denied. In simpler numbers, that is one of every 14 claims.

But Ms. Carr, whose hip pain ceased after the arthroscopic surgery, did not give up on the reimbursement. And neither should you. When Ms. Carr, a special education administrator at a localcharter school, read her explanation of benefits statement more carefully, she spotted some instructions on how patients can appeal denied claims.

"I decided I would fight," she said. "After all, what did I have to lose?"

Ms. Carr researched medical journals and other publications to find proof that her procedure was a bona fide and safe treatment. She then wrote a formal letter to her insurer making her case and including copies of the research she had found. Her doctor backed her up with a thorough letter of his own.

The appeal was initially denied, but Ms. Carr kept fighting. She took her case to her insurer's external review board, where an impartial medical expert weighed the evidence.

The expert agreed with Ms. Carr, saying UnitedHealth had to pay the claim. "The expert felt UnitedHealth couldn't call the procedure experimental if it paid for other patients to have it," Ms. Carr said.

UnitedHealth ended up paying $12,282 for Ms. Carr's claim — at a rate the insurer negotiated with the doctor and hospital. Ms. Carr's share was about $500.

"That's what the appeals process is there for," said Cheryl Randolph, a spokeswoman for the insurer. "We're glad it worked for her, and we encourage members to exercise their right to appeal whenever they need to."

Not that UnitedHealth now happily pays all such claims. Soon after Ms. Carr's successful appeal, the insurer revised its policy to stipulate that it did not cover that type of hip procedure — although Ms. Randolph says the company is now rethinking things once again because of "the changing landscape of medical literature" about the procedure.

Whatever the treatment or procedure a patient receives or is contemplating, a variety of things can prompt a claims denial. It might be a simple clerical error, like an incorrect address, or a doctor's use of the wrong diagnostic or treatment code for your treatment.

Then there are the more serious causes — as when a treatment is specifically excluded from your policy, for example, or, as in Ms. Carr's case, when the insurer deems a procedure experimental and therefore ineligible for reimbursement. Other frequently denied claims involve emergency room visits, especially those at out-of-network hospitals and clinics.

Another big category involves chronically ill patients, who often must try several medicines and treatments to find the one that works best for them. Such patients can become all too familiar withinsurance denials, says Jennifer C. Jaff, founder of Advocacy for Patients with Chronic Illness.

But as Ms. Carr discovered, if you are denied coverage you have a right to appeal. And in most cases, experts advise you to do just that. Approximately half of all appeals are successful, according to anecdotal evidence from patient advocacy groups and data from individual states.

"About 53 percent of appeals work in our state," said the Kansas insurance commissioner, Sandy Praeger. "That demonstrates that the process works."

Use the following advice to increase your chances of success in appealing a health insurance denial. As you'll see below, expert help may be available. And if you feel in over your head, and a significant amount of money at stake, it may even be worth hiring a type of specialist known as a billing advocate.

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Texas Nurse to Stand Trial for Reporting Doctor -

KERMIT, Tex. — It occurred to Anne Mitchell as she was writing the letter that she might lose her job, which is why she chose not to sign it. But it was beyond her conception that she would be indicted and threatened with 10 years in prison for doing what she knew a nurse must: inform state regulators that a doctor at her rural hospital was practicing bad medicine.

"It was surreal," said Mrs. Mitchell, 52, the wife of an oil field mechanic and mother of a teenage son. "I said how can this be? You can't go to prison for doing the right thing."

But in what may be an unprecedented prosecution, Mrs. Mitchell is scheduled to stand trial in state court on Monday for "misuse of official information," a third-degree felony in Texas.

The prosecutor said he would show that Mrs. Mitchell had a history of making "inflammatory" statements about Dr. Rolando G. Arafiles Jr. and intended to damage his reputation when she reported him last April to the Texas Medical Board, which licenses and disciplines doctors.

Mrs. Mitchell counters that as an administrative nurse, she had a professional obligation to protect patients from what she saw as a pattern of improper prescribing and surgical procedures — including a failed skin graft that Dr. Arafiles performed in the emergency room, without surgical privileges. He also sutured a rubber tip to a patient's crushed finger for protection, an unconventional remedy that was later flagged as inappropriate by the Texas Department of State Health Services.

Charges against a second nurse, Vickilyn Galle, who helped Mrs. Mitchell write the letter, were dismissed at the prosecutor's discretion last week.

The case has been infused with the small-town politics of this wind-whipped city of 5,200 in the heart of the Permian Basin, 10 miles from the New Mexico border. The seeming conflicts of interest are as abundant as the cattle grazing among the pump jacks and mesquite.

When the medical board notified Dr. Arafiles of the anonymous complaint, he protested to his friend, the Winkler County sheriff, that he was being harassed. The sheriff, an admiring patient who credits the doctor with saving him after a heart attack, obtained a search warrant to seize the two nurses' work computers and found the letter.

Both sides acknowledge that the case has polarized the community, and the judge has moved the trial to a neighboring county.

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