Friday, June 11, 2010

Why Patients Aren’t Getting the Shingles Vaccine -

Four years ago at age 78, R., a retired professional known as much for her small-town Minnesotan resilience as her commitment to public service, developed a fleeting rash over her left chest. The rash, which turned out to be shingles, or herpes zoster, was hardly noticeable.

But the complications were unforgettable.

For close to a year afterward, R. wrestled with the searing and relentless pain in the area where the rash had been. "It was ghastly, the worst possible pain anyone could have," R. said recently, recalling the sleepless nights and fruitless search for relief. "I've had babies and that hurts a lot, but at least it goes away. This pain never let up. I felt like I was losing my mind for just a few minutes of peace."

Shingles and its painful complication, called postherpetic neuralgia, result from reactivation of the chicken pox virus, which remains in the body after a childhood bout and is usually dormant in the adult. Up to a third of all adults who have had chicken pox will eventually develop one or both of these conditions, becoming debilitated for anywhere from a week to several years. That percentage translates into about one million Americans affected each year, with older adults, whose immune systems are less robust, being most vulnerable. Once the rash and its painful sequel appear, treatment options are limited at best and carry their own set of complications.

While the search for relief costs Americans over $500 million each year, the worst news until recently has been that shingles and its painful complication could happen to any one of us. There were no preventive measures available.

But in 2006, the Food and Drug Administration approved a new vaccine against shingles. Clinical trials on the vaccine revealed that it could, with relatively few side effects, reduce the risk of developing shingles by more than half and the risk of post-herpetic neuralgia by over two-thirds. In 2008, a national panel of experts on immunizations at the Centers for Disease Control and Prevention went on to recommend the vaccine to all adults age 60 and older.

At the time, the shingles vaccine seemed to embody the best of medicine, both old school and new. Its advent was contemporary medicine's elegant response to a once intractable, age-old problem. It didn't necessarily put an end to the spread of disease, in this case chicken pox; but it dramatically reduced the burden of illness for the affected individual. And, most notably, its utter simplicity was a metaphoric shot-in-the-arm for old-fashioned doctoring values. Among the increasingly complex and convoluted suggestions for health care reform that were brewing at that moment, here was a powerful intervention that relied on only three things: a needle, a syringe and a patient-doctor relationship rooted in promoting wellness.


In the two years since the vaccine became available, fewer than 10 percent of all eligible patients have received it. Despite the best intentions of patients and doctors (and no shortage of needles and syringes), the shingles vaccine has failed to take hold, in large part because of the most modern of obstacles. What should have been a widely successful and simple wellness intervention between doctors and their patients became a 21st century Rube Goldberg-esque nightmare.

Last month in The Annals of Internal Medicine, researchers from the University of Colorado in Denver and the C.D.C. surveyed almost 600 primary care physicians and found that fewer than half strongly recommended the shingles vaccine. Doctors were not worried about safety — a report in the same issue of the journal confirmed that the vaccine has few side effects; rather, they were concerned about patient cost.

Although only one dose is required, the vaccination costs $160 to $195 per dose, 10 times more than other commonly prescribed adult vaccines; and insurance carriers vary in the amount they will cover. Thus, while the overwhelming majority of doctors in the study did not hesitate to strongly recommend immunizations against influenza and pneumonia, they could not do the same with the shingles vaccine.

"It's just a shot, not a pap smear or a colonoscopy," said Dr. Laura P. Hurley, lead author and assistant professor of medicine at the University of Colorado in Denver. "But the fact is that it is an expensive burden for all patients, even those with private insurance and Medicare because it is not always fully reimbursed."

Moreover, many private insurers require patients to pay out of pocket first and apply for reimbursement afterward. And because the shingles vaccine is the only vaccine more commonly given to seniors that has been treated as a prescription drug, eligible Medicare patients must also first pay out of pocket then submit the necessary paperwork in order to receive the vaccine in their doctor's office. It's a complicated reimbursement process that stands in stark contrast to the automatic, seamless and fully covered one that Medicare has for flu and pneumonia vaccines.

Despite this payment maze, some physicians have tried to stock and administer the vaccine in their offices; many, however, eventually stop because they can no longer afford to provide the immunizations. "If you have one out of 10 people who doesn't pay for the vaccine, your office loses money," said Dr. Allan Crimm, the managing partner of Ninth Street Internal Medicine, a primary care practice in Philadelphia. Over time, Dr. Crimm's practice lost thousands of dollars on the shingles vaccine. "It's indicative of how there are perverse incentives that make it difficult to accomplish what everybody agrees should happen."

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Bringing Comparison Shopping to the Doctor’s Office -

Americans comparison-shop for items as small as groceries and as big as cars. But they rarely compare prices on their health care. When a doctor recommends a test or a procedure, most patients simply go where the doctor tells them to go.

Even if a patient does want to comparison-shop, there is no easy way to obtain complete and useful information. It is a hole in the market that some companies see as an opportunity, especially because many Americans will soon have to pay more attention to what they are paying for, rather than count on insurance to cover everything.

But there has been no easy way for consumers to shop for the best deal on a colonoscopy or blood test. A start-up financed by prominent venture capitalists and the Cleveland ClinicCastlight Health, aims to change that by building a search engine for health care prices. Patients using Castlight could search for doctors that offer a service nearby and find out how much they will charge, depending on their insurance coverage.

A few others are starting to publish health care prices, including Thomson Reuters, a Tennessee start-up called Change:healthcare, the New Hampshire government, which created a comparison shopping tool for residents, and health insurers. Aetna, for instance, has built tools to help patients estimate prices and may build more advanced tools, said Lonny Reisman, Aetna's chief medical officer.

Price transparency could significantly change the way health care is bought in the United States. The notion "seems ridiculously simple and obvious, and in any other industry, you would say, 'Duh, we already have that.' But in health care, it's revolutionary," said Alan M. Garber, a professor of medicine and the director of the center for health policy at Stanford, as well as an investor in Castlight.

The lack of price information in health care has been a big driver of ballooning health care costs, analysts say, because costs are opaque to patients and heavily subsidized by employers. The patient has no incentive or responsibility to keep costs down. But many employers are switching to health plans that require patients to pay more out of their own pockets.

"Since Americans started having employer-sponsored health care, people are paying with someone else's credit card, so we created a very inefficient market," said Giovanni Colella, chief executive and a founder of Castlight. "Creating the right incentives changes the way people behave, and that's where our company comes in."

Dr. Colella started RelayHealth, which connects patients and doctors over the Web and was bought by McKesson in 2006. He founded Castlight with Todd Park, a founder of Athenahealth and chief technology officer of the federal Department of Health and Human Services.

On Thursday, Castlight announced that it raised $60 million from investors, in addition to the $21 million it previously raised. Safeway, the grocery chain, with 200,000 employees, has signed on as its first customer.

Castlight has received money from investment firms including Venrock, Maverick Capital, Oak Investment Partners and from an unlikely source, the Cleveland Clinic. Hospitals' business models could be turned upside-down by price transparency.

Several studies and pilot projects suggest that the more patients know about prices, the more money they save. A study published last month by Mercer, a human resources consulting firm, found that people on high-deductible health plans, with more exposure to the prices of doctor visits, spent less. Indiana adopted high-deductible health plans, and the average expense in 2009 for patients on one of these plans was $6,393, compared with $8,570 for patients on a more traditional health maintenance organization plan.

"A lot of it is to understand the driver of costs and how they can start to control that, and encouraging that debate to happen while in the physician's office," Dr. Colella said. Castlight is working on a mobile version of the service to introduce next year so people can access the information from the exam table.

Health care pricing became part of the national conversation during the debate over health care reform. Prices will be important for the 30 million to 40 million people expected to join exchanges, which will encourage comparison shopping.

But so far, prices have been very difficult to find because health insurance providers and doctors negotiate rates and often agree not to reveal those numbers for competitive reasons. The Cleveland Clinic, for example, has about a hundred different contracts with insurance carriers, each with a different rate for a given procedure.

Ideally, transparency in health care pricing could lead to higher-quality, lower-cost health care, and more patient involvement in buying health care, said Delos Cosgrove, chief executive of the Cleveland Clinic. "Because they begin to realize that a trip to the doctor is not free, they might stay home and take the aspirin instead of getting the neurologic work-up."

Castlight sells its service to employers and charges by employee per month. (It plans to eventually introduce a Web site for anyone to use.) Employees log on to a search portal, where they enter something like "colonoscopy" to find a list of doctors nearby and how much they charge.

Some insurers have shared pricing with Castlight, but the company gleans most of the information from the explanation-of-benefits forms that patients receive after a doctor visit. Castlight developed a way to pull the information from the millions of forms provided to it by employers.

Anyone who has read an explanation of benefits knows that it often raises more questions than answers, and Castlight says it wants to provide health education in addition to price information. The site explains why a patient has to pay a certain amount and the standard number of tests that a doctor would order for a particular problem.

Safeway has been experimenting with ways to cut health costs, including by using Castlight. "I'm a big believer in trying to create market forces wherever you can and then let personal accountability really drive the result," said Steven A. Burd, the chief executive of Safeway.

For instance, Safeway pays up to $1,200 for its employees' colonoscopies, a preventative procedure to detect cancer. If employees wish to go to a doctor who charges more, they must pay the difference. According to Castlight, colonoscopies in the Bay Area, where Safeway is based, range from $500 to $3,000, and sometimes a doctor charges different rates at different hospitals.

Castlight plans to add quality measurements to its price information. There are already several providers of that information, though there is no standard set of quality measurements in medicine. But even with quality ratings, there are many procedures for which Castlight's service is not applicable. Someone suffering a heart attack is not going to check the Web before calling the ambulance, and a patient who discovers he needs emergency brain surgery is likely to prioritize quality above all else.

Even for more basic services, pricing is not always cut-and-dried. The delivery of a baby, for example, includes the hospital stay and the obstetrician's fees, but could also include fees for a pediatrician, an anesthesiologist and specialists if there are complications.

At this stage, Castlight works best for big companies that are self-insured and for outpatient doctor visits for which quality does not vary greatly.

Tuesday, June 8, 2010

Personalizing the M.D. - Inside Higher Ed

A hundred years after the release of the Flexner Report, which set many of the standards that still guide North American medical education, a report being published today aims to stimulate reforms to reshape medical schools and residency programs for the next century.

Commissioned by the Carnegie Foundation for the Advancement of Teaching -- the same group that sponsored Abraham Flexner's early-20th century examination of all 155 medical schools in the United States and Canada -- the new report lays out the case for drastic reconsideration of how North American medical education works. Published in book form as Educating Physicians: A Call for Reform of Medical School and Residency (Wiley), the study is the culmination of four years of research and site visits to medical schools and teaching hospitals. It calls for major change and innovation -- "new approaches to shaping the minds, hands and hearts of physicians."

As the U.S. health care system has changed, a need has emerged for the medical profession to "rethink how we do education all over again," said one of the report's co-authors, David M. Irby, vice dean for education and a professor of medicine at the University of California at San Francisco School of Medicine. "The report speaks to both specific and general ways in which teaching and learning can be enhanced. But our intent here is to stimulate reform and to encourage innovation and creativity, and is less about specific requirements or changes we'd like to see."

Central to the report's recommendations is a shift away from the regimentation and regulation that created the four-year Doctor of Medicine degree and two-to-four-year residency toward a more flexible model that could adapt to students' interests and learning styles. For some students, that shift might translate into shorter time to degree or a briefer residency period.

"Medical school and residency need to shift from one-size-fits-all to a much more individualized program," said Molly Cooke, another co-author and a professor of medicine at the UCSF School of Medicine. "Students bring different dispositions, talents, career interests -- and medical education ought to support that." The report's third author, Bridget C. O'Brien, is an assistant professor of medicine at UCSF and a researcher in the university's Office of Medical Education.

Individualization, Irby acknowledged, "would be a huge challenge for the accrediting, licensing and certifying agencies who find it much more reassuring to focus on the number of weeks or months of training." But, he added, "by focusing on competencies -- the milestones at each level of training -- we can ensure that physicians are capable of doing what we'd like them to be able to do."

There would still be a core of skills and knowledge that all students would need to master, Cooke said, cautioning that individualization wouldn't translate into "people can go to medical school and just learn whatever." But it would be balanced with a "flexible component" aligned with students' professional interests, whether to become a bench researcher or a community health advocate.

By shifting to competency-based assessments, medical education could become more self-paced and less tied to how much time a student spends doing any one thing.

For some students, Cooke said, that might translate into a degree that takes fewer than four years to complete. For others, it might take longer. "It ought to take as long as it takes, but eight or nine years to get a doctorate, as is the case in some Ph.D. programs, that's a step in the wrong direction."

Texas Tech University said in March that it would begin offering a three-year primary care M.D., squeezing some of the traditional third-year clinical work into the second year of study and some of the fourth-year work into the third. At the time of the announcement, Irby told Inside Higher Ed that the move was well-aligned with the report's objectives. Less time to degree, he said, "ought to be an option for every student -- regardless of specialty."

But both he and Cooke stressed that they were not calling for a drop in standards. "We'd just be changing from specified time to specified quality of performance," Cooke said. "And in no way am I comfortable saying every degree should be reduced from four years to three years."

So far, Cooke said, feedback on the report has been mixed. When presenting before professors, deans and presidents last fall at a meeting of the Association of American Medical Colleges, "people were very enthusiastic."

But the groups that sponsor the United States Medical Licensing Examination, for instance, are likely to be less enthusiastic. "The oversight of medical education is very complicated and nobody means to be doing a bad job or to be a retrogressive influence, so to the extent that we say that the content of the three USMLE exams is not particularly helpful, that frankly tends to offend those groups," Cooke said. "But if we didn't stir things up a bit and really point out where we thought there were opportunities to significantly improve this enterprise, I don't think we'd be doing what we set out to do."

Matthew Stull, a recent graduate of the University of Pittsburgh School of Medicine who has put his residency on hold for a year to work as the American Medical Student Association's education and research fellow, said that just as "the Flexner Report was such a monumental wake-up call," the new report was "likely to be a very big deal in medical education."

The curricular flexibility the report calls for, he added, "was the most innovative thing" he had identified in the report and would, he thought, be well-received by medical students.

Sunday, June 6, 2010

Obese Mothers a Burden on Hospital Resources -

As Americans have grown fatter over the last generation, inviting more heart disease, diabetes and premature deaths, all that extra weight has also become a burden in the maternity ward, where babies take their first breath of life.

About one in five women are obese when they become pregnant, meaning they have a body mass index of at least 30, as would a 5-foot-5 woman weighing 180 pounds, according to researchers with the federal Centers for Disease Control and Prevention. And medical evidence suggests that obesity might be contributing to record-high rates of Caesarean sections and leading to more birth defects and deaths for mothers and babies.

Hospitals, especially in poor neighborhoods, have been forced to adjust. They are buying longer surgical instruments, more sophisticated fetal testing machines and bigger beds. They are holding sensitivity training for staff members and counseling women about losing weight, or even having bariatric surgery, before they become pregnant.

At Maimonides Medical Center in Brooklyn, where 38 percent of women giving birth are obese, Patricia Garcia had to be admitted after she had a stroke, part of a constellation of illnesses related to her weight, including diabetes and weak kidneys.

At seven months pregnant, she should have been feeling the thump of tiny feet against her belly. But as she lay flat in her hospital bed, doctors buzzing about, trying to stretch out her pregnancy day by precious day, Ms. Garcia, who had recently weighed in at 261 pounds, said she was too numb from water retention to feel anything.

On May 5, 11 weeks shy of her due date, a sonogram showed that the baby's growth was lagging, and an emergency Caesarean was ordered.

She was given general anesthesia because her bulk made it hard to feel her spine to place a local anesthetic. Dr. Betsy Lantner, the obstetrician on call, stood on a stool so she could reach over Ms. Garcia's belly. A flap of fat covered her bikini line, so the doctor had to make a higher incision. In an operation where every minute counted, it took four or five minutes, rather than the usual one or two, to pull out a 1-pound 11-ounce baby boy.

Studies have shown that babies born to obese women are nearly three times as likely to die within the first month of birth than women of normal weight, and that obese women are almost twice as likely to have a stillbirth.

About two out of three maternal deaths in New York State from 2003 to 2005 were associated with maternal obesity, according to the state-sponsored Safe Motherhood Initiative, which is analyzing more recent data.

Obese women are also more likely to have high blood pressure, diabetes, anesthesia complications, hemorrhage, blood clots and strokes during pregnancy and childbirth, data shows.

The problem has become so acute that five New York City hospitals — Beth Israel Medical Center and Mount Sinai Medical Center in Manhattan, Maimonides in Brooklyn and Montefiore Medical Center and Bronx-Lebanon Hospital Center in the Bronx — have formed a consortium to figure out how to handle it. They are supported by their malpractice insurer and the United Hospital Fund, a research group.

One possibility is to create specialized centers for obese women. The centers would counsel them on nutrition and weight loss, and would be staffed to provide emergency Caesarean sections and intensive care for newborns, said Dr. Adam P. Buckley, an obstetrician and patient safety expert at Beth Israel Hospital North who is leading the group.

Very obese women, or those with a B.M.I. of 35 or higher, are three to four times as likely to deliver their first baby by Caesarean section as first-time mothers of normal weight, according to a study by the Consortium on Safe Labor of the National Institutes of Health.

While doctors are often on the defensive about whether Caesarean sections, which carry all the risks of surgery, are justified, Dr. Howard L. Minkoff, the chairman of obstetrics at Maimonides, said doctors must weigh those concerns against the potential complications from vaginal delivery in obese women. Typically, these include failing to progress in labor; diabetes in the mother, which can lead to birth complications; and difficulty monitoring fetal distress. "With obese women we are stuck between Scylla and Charybdis," Dr. Minkoff said.

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A Cancer Scare, a Scar, a Silver Lining - NICHOLAS D. KRISTOF -

My doctor's call came early last month just as I was completing a column noting that 41 percent of Americans come down with cancer. That statistic felt as remote as a puff of cloud in the stratosphere — until my physician, Gary Raizes, gently began to break the news to me that I had a tumor in my right kidney.

The result was a grim monthlong whirlwind of doctors' visits, medical tests and furrowed brows. The doctors agreed that the odds were 10 percent that my tumor was benign, 90 percent that it was malignant. I had no option: surgery was essential.

My built-in optimism was shaken when I read that five-year survival rates for kidney cancer are less than 50 percent.

Ten days ago, I had a three-hour operation. I lost 10 percent of my right kidney, along with a tumor a bit more than an inch long. Afterward, I felt as if I'd been hit by a truck, and I gained a six-inch scar that won grudging admiration from my hard-to-impress teenage kids.

And, boy, did I feel lucky!

The main reason that kidney cancers are so deadly is that they are typically discovered late. My tumor was discovered early only by accident, through a CT scan ordered for another reason entirely. I confess that I had been committing thought crimes against the physician who ordered the scan, Mark Fialk, wondering if it was an example of out-of-control testing — and now I felt that Dr. Fialk might have saved my life.

But I also felt lucky in another way.

This is trite but also so, so true: A brush with mortality turns out to be the best way to appreciate how blue the sky is, how sensuous grass feels underfoot, how melodious kids' voices are. Even teenagers' voices. A friend and colleague, David E. Sanger, who conquered cancer a decade ago, says, "No matter how bad a day you're having, you say to yourself: 'I've had worse.' "

Floyd Norris, a friend in The Times's business section, is now undergoing radiation treatment for cancer after surgery on his face and neck. He wrote on his blog: "It is not fun, but it has been inspiring. In a way, I am happier about my life than at any time I can remember."

I don't mean to wax lyrical about the joys of tumors. But maybe the most elusive possession is contentment with what we have. There's no better way to attain that than a glimpse of our mortality.

My surgeon, Douglas Scherr, said that his patients frequently derive additional satisfaction from life after a cancer diagnosis, and at least for a time are more focused on what feels more important — like families.

In contrast, none of us want this for an epitaph: "He sweated many weekends at the office, ignoring his family but earning a huge bonus."

As regular readers know, I've written frequently about suspected links between chemicals and health. In my own case, I can't help wondering if there might not be a connection as well.

I grew up on a sheep and cherry farm in Oregon, and as a kid I helped mix the pesticides in the sprayer. Dogs on the farm have often died from cancer, and some have had unusual kidney cysts and deformities. Could the orchard pesticides perhaps have some impact on kidneys? Nobody knows.

After four days in the hospital, I spent a week recovering at home from the surgery. As I was finishing up this column, the pathologist's report on my tumor finally came back. Dr. Scherr told me that my tumor turned out to be an oncocytoma, which is benign. Astonishingly, against all odds and expectations, I hadn't had cancer after all. My wife tells me she no longer feels sorry for me, and I'm beaming.

So today I have an impressive scar, a bit less kidney, a big bellyache, and far more appreciation for the glory of life.

My hope is that when you put this column down, you'll think about what you can do to reduce the risk of getting an ominous doctor's call like mine last month:

Stop smoking and avoid secondhand smoke. Slather on sunscreen and avoid tanning salons. Avoid charred meats. Check yourself over for lumps, changes or irregularities, whether in breasts or testicles or skin, and consult a doctor if you have doubts. Try to microwave food in glass or ceramic containers rather than plastic. Toss out plastic food containers that are marked 3, 6 or 7 at the bottom (unless they say "BPA-free"). Buy a radon detector to check radon levels around your house.

And, believe me, it's never too early — cancer or no cancer — to start appreciating our wondrous world, instead of disparaging its imperfections.