Painkillers Add Costs and Delays to Workplace Injuries - NYTimes.com

Workplace insurers are accustomed to making billions of dollars in payments each year, with the biggest sums going to employees hurt in major accidents, like those mangled by machines or crushed in building collapses.

Now they are dealing with another big and fast-growing cost — payouts to workers with routine injuries who have been treated with strong painkillers, including many who do not return to work for months, if ever.

Workplace insurers spend an estimated $1.4 billion annually on narcotic painkillers, or opioids. But they are also finding that the medications, if used too early in treatment, too frequently or for too long, can drive up associated disability payouts and medical expenses by delaying an employee's return to work.

Workers who received high doses of opioid painkillers to treat injuries like back strain stayed out of work three times longer than those with similar injuries who took lower doses, a 2008 study of claims by the California Workers Compensation Institute found. When medical care and disability payments are combined, the cost of a workplace injury is nine times higher when a strong narcotic like OxyContin is used than when a narcotic is not used, according to a 2010 analysis by Accident Fund Holdings, an insurer that operates in 18 states.

"What we see is an association between the greater use of opioids and delayed recovery from workplace injuries," said Alex Swedlow, the head of research at the California Workers Compensation Institute.

The use of narcotics to treat occupational injuries is part of a broader problem involving what many experts say is the excessive use of drugs like OxyContin, Percocet and Duragesic. But workplace injuries are drawing particular interest because the drugs are widely prescribed to treat common problems like back pain, even though there is little evidence that they provide long-term benefits.

Along with causing drowsiness and lethargy, high doses of opioids can lead to addiction, and they can have other serious side effects, including fatal overdoses.

Between 2001 and 2008, narcotics prescriptions as a share of all drugs used to treat workplace injuries jumped 63 percent, according to insurance industry data. Costs have also soared.

In California, for example, workplace insurers spent $252 million on opioids in 2010, a figure that represented about 30 percent of all prescription costs; in 2002, opioids accounted for 15 percent of drug expenditures.

As a result, states are struggling to find ways to reverse the trend, and some of them have issued new pain treatment guidelines, or are expected to do so soon. These states include New York, Colorado, Texas and Washington. Insurers are also trying to influence how physicians prescribe the drugs.

Doctors in four states — Louisiana, Massachusetts, New York and Pennsylvania — appear to be the biggest prescribers of the drugs for workers' injuries, according to a review of data from 17 states by the Workers Compensation Research Institute, a group in Cambridge, Mass.

Painkiller-related costs are also hitting taxpayers, who underwrite coverage for public employees like police officers and firefighters, experts say. In February, one major underwriter, the American International Group, said that it would no longer sell backup coverage to workplace insurers, citing rising pain treatment expenses as one reason.

There is little question that strong pain medications can help some patients return to work and remain productive. But injured workers who are put on high doses of the drugs can develop chronic pain and face years of difficult treatments. It is not clear how, or if, the drugs are involved in the process, but when pain becomes chronic, the cost of a commonplace injury can equal a crippling one, experts said.

"Some of these claims look like someone who fell down an elevator shaft and had multiple injuries," said Dr. Edward J. Bernacki, the director of the division of occupational and environmental medicine at Johns Hopkins University in Baltimore.

For decades, workers' compensation plans, which vary by state, have been plagued by problems like lengthy legal battles over an injury's financial value. But it is in recent years that opioid painkillers have emerged as a major driver of costs, experts said.

Accident Fund Holdings examined its claims and found that the cost of a typical workplace injury — the sum of an employee's medical expenses and lost wage payments — was about $13,000. But when a worker was prescribed a short-acting painkiller like Percocet, that cost tripled to $39,000 and tripled again to $117,000 when a stronger longer-acting opioid like OxyContin was prescribed, said Jeffrey Austin White, an executive with the insurer, which is based in Lansing, Mich.

In a sense, insurers are experiencing the consequences of their own policies. During the last decade, they readily reimbursed doctors for prescribing painkillers while eliminating payments for treatments that did not rely on drugs, like therapy.

Those policies may "have created a monster," said Dr. Bernyce M. Peplowski, the medical director of the State Compensation Insurance Fund of California, a quasi-public agency.

For patients, such policies had consequences.

Dr. Eugenio Martinez, a physician in the Boston area who specializes in rehabilitative medicine, said one patient, a former waitress who hurt her back five years ago in a fall, recently won a court fight to force her insurer to pay for physical therapy. The insurer had cut off those payments five years ago after a few sessions, and the woman, now disabled, had no option but to take strong painkillers, Dr. Martinez said. "It certainly did not help that she was cut off," he said.

Nationwide, data suggests that a vast majority of narcotic drugs used to treat occupational injuries are prescribed by a tiny percentage of doctors who treat injured workers; in California, for example, that figure is just 3 percent. Also, the bulk of such prescriptions go to a relatively small percentage of injured workers, including those who might be addicted to the drugs or those who sell them, experts said.

Several companies, like Accident Fund Holdings and Liberty Mutual, have set up programs in which pain experts contact doctors identified as high prescribers to discuss their practices. The State Compensation Insurance Fund of California has also instituted a policy that requires approval for a doctor to prescribe an opioid for over 60 days.

Insurers say they are making progress in reducing overuse of the drugs. But their ability to influence physicians is limited because workers' compensation plans can allow employees to see any doctor. So several states have or will soon adopt new pain treatment guidelines for doctors who treat workers.

In New York, one proposal would require a doctor to refer a patient who is not improving to a pain specialist when an opioid dose exceeds a certain level, said Dr. Elain Sobol Berger, the associate medical director of the state's workers' compensation board. Washington State has already adopted such a policy.

Dr. Sobol Berger added that the New York rules, which are expected to be proposed this year, will also emphasize nondrug treatments for pain. "We know that there is a significant problem with the management of chronic pain and the use of opioids," she said.

Some insurers, like the California state fund, have also started paying for alternative approaches like specialized psychotherapy or are trying to get addicted workers into treatment. Other companies are also checking on long-disabled workers.

Mark Kulakowski, a 57-year-old former warehouse worker from Peabody, Mass., injured his back more than three decades ago while lifting a box. He has not worked since 1995. Since his injury, he has taken narcotic painkillers and has had a long list of failed treatments.

Recently, his insurer, Liberty Mutual, sought to have a nurse accompany him to his next doctor's appointment, a suggestion he welcomed if it could lead to taking fewer painkillers.

"It just drains everything out of you," he said.

http://www.nytimes.com/2012/06/03/health/painkillers-add-costs-and-delays-to-workplace-injuries.html

Food allergies bring children loneliness, social isolation, researchers say | News | National Post

University of Waterloo

A 17-year old boy who is allergic to peanuts, milk and shellfish drew this sketch of what he feels like when he joins his friends at a pizza lunch. "I feel sad when I can't share in lunch with my friends."

As they talked with youngsters with life-threatening allergies, researchers from the University of Waterloo encountered a repeated theme: Loneliness, social isolation, a persistent stigma.

"[The kids] say 'stay away from me,' I've touched peanuts," 10-year-old Mia said.

These students, who all suffer anaphylaxis — a serious allergic reaction that has a very fast onset and may cause death — are part of the first study of its kind to explore the social implications of having such an allergy. It was released at the Congress of the Humanities and Social Sciences.

"In elementary school and high school, when they see the EpiPen pouch…they think to themselves 'there is something different about you," said Robert, a teen. "Automatically, you are tagged as a person who is different…you are on the outside."

It was a small study involving 20 young people. University of Waterloo public health and health systems professor Nancy Fenton and Susan Elliott, a professor in the applied health sciences department, interviewed 20 children aged 8-18 and found, from their stories, that an allergy can have huge social implications for young people.

University of Waterloo

A 16-year-old boy who is allergic to nuts and some shellfish says he spends most of his time at school in the music room, because food is not allowed in order to protect the instruments.

The study —which is part of a larger work slated for publication in 2013 — was done as an examination of life after Sabrina's Law, which requires staff at Ontario schools be trained on how to recognize and deal with anaphylaxis and have an action plan in place. The law took effect in January, 2006, nearly three years after 13-year-old Sabrina Shannon of Pembroke, Ont. died from eating French fries that were cross-contaminated with dairy.

"Despite the inclusionary policies in place at school through Sabrina's Law, all children and youth, through the interviews, talked about the barriers every day that made them feel excluded," Ms. Fenton said during her presentation on Wilfrid Laurier University campus Wednesday.

Sabrina Shannon certainly felt that isolation, her mother shared during the same presentation. She would get invited to birthday parties at first, but once her food allergy limitations became known, the invitations dried up, said Sara Shannon, who has become an outspoken advocate for anaphylaxis awareness.

"At school, Sabrina was instructed to sit alone, away from all of her classmates at a table, well removed from other students," she said. "Despite showing a brave front and a positive attitude, I believe that this exclusion at a tender age was very harmful and hard on her."

Through their interviews, Ms. Fenton found the isolation affected some students more than others.

"There were a couple participants who didn't eat at school and were anxious about the thoughts of going to university in unregulated environments," she said.

University of Waterloo

A 15-year-old boy who is allergic to nuts depicts his emotions around managing his allergies. Click to enlarge.

And does the social exclusion have an impact on their actual well-being?

"For these kids it had some effect," Ms. Fenton said. "There were also some kids in the study who were really resilient."

As part of their methodology, researchers had the students draw a picture of what it's like to live with a severe food allergy. One teen drew himself in the middle of a food fight —a life-and-death minefield for someone like him. Another drew himself sitting at a table with friends —the only one without a slice of pizza.

Ms. Fenton and her colleagues asked the participants whether things have gotten better post-Sabrina's Law, which also promotes education and awareness in schools. Many students and parents said it had —home was no longer the only safe place for young people with anaphylaxis. School communities began to take more responsibility and students became more aware and sensitive to the dangers as well, she said.

And because the study looked at both younger and older students, who experienced life before the law, there were different perspectives on its impact, she added.

"One of the distinctions between pre and post [law] and because we had that unique sample group, the kids who were younger said 'it's less of a deal,'" she said.

Sabrina's Law was the first of its kind when it was passed in Ontario, and the legislation has received interest from around the world, Sara Shannon said.

"There's a larger circle of responsibility for looking after children's safety at school now," Ms. Fenton said. But students still face these challenges out in the community while they're not in class.

"The results in our study show the events and travel to a restaurant outside of environments at home were still considered very isolating," Ms. Fenton said.

http://news.nationalpost.com/2012/05/31/oh-the-humanities-food-allergies-can-mean-loneliness-social-isolation-for-children-researcher/

For Some, Exercise May Increase Heart Risk - NYTimes.com

Could exercise actually be bad for some healthy people? A well-known group of researchers, including one who helped write the scientific paper justifying national guidelines that promote exercise for all, say the answer may be a qualified yes.

By analyzing data from six rigorous exercise studies involving 1,687 people, the group found that about 10 percent actually got worse on at least one of the measures related to heart disease:blood pressure and levels of insulin, HDL cholesterolortriglycerides. About 7 percent got worse on at least two measures. And the researchers say they do not know why.

"It is bizarre," said Claude Bouchard, lead author of the paper, published on Wednesday in the journal PLoS One, and a professor of genetics and nutrition at the Pennington Biomedical Research Center, part of the Louisiana State University system.

Dr. Michael Lauer, director of the Division of Cardiovascular Sciences at the National Heart, Lung, and Blood Institute, the lead federal research institute on heart disease and strokes, was among the experts not involved in the provocative study who applauded it. "It is an interesting and well-done study," he said.

Others worried about its consequences.

"There are a lot of people out there looking for any excuse not to exercise," said William Haskell, emeritus professor of medicine at the Stanford Prevention Research Center. "This might be an excuse for them to say, 'Oh, I must be one of those 10 percent.' "

But counterbalancing the 10 percent who got worse were about the same proportion who had an exaggeratedly good response on at least one measure. Others had responses ranging from little or no change up to big changes, seen in about 10 percent, where risk factor measurements improved anywhere from 20 percent to 50 percent.

"That should make folks happy," said Dr. William E. Kraus, a co-author of the study who is a professor of medicine and director of clinical research at Duke. He was a member of the committee providing the scientific overview for the Department of Health and Human Services' national exercise guidelines, which advise moderate exercise for at least 150 minutes a week.

The problem with studies of exercise and health, researchers point out, is that while they often measure things like blood pressure or insulin levels, they do not follow people long enough to see if improvements translate into fewer heart attacks or longer lives. Instead, researchers infer that such changes lead to better outcomes — something that may or may not be true.

Some critics have noted that there is no indication that those who had what Dr. Bouchard is calling an adverse response to exercise actually had more heart attacks or other bad health outcomes. But Dr. Bouchard said if people wanted to use changes in risk factors to infer that those who exercise are healthier, they could not then turn around and say there is no evidence of harm when the risk factor changes go in the wrong direction.

"You can't have it both ways," Dr. Bouchard said.

The national guidelines for exercise are based on such inferences and also on studies that compared the health of people who exercised with that of people who did not, a weak form of evidence often said to be hypothesis-generating rather than proof.

"We do not know whether implementing exercise programs for unfit people assures better outcomes," said Dr. Lauer of the heart institute. "That has not been established." And so, he said, "there is a lot of debate over how strong the guidelines should be in light of weak evidence."

Authors of the study say people should continue to exercise as before, but might also consider getting their heart disease risk factors checked on a regular basis. No intervention, including drugs, works for everyone, Dr. Kraus said. So it should not be surprising that exercise does not work for some.

"I am an exercise guy; I believe in exercise for health," Dr. Kraus said. "I would rather have everyone exercise. But you can't ignore the data."

Still, he added, even if someone does not get the expected benefit in some heart risk factors, there are other reasons to exercise: for mental health and to improve physical functioning.

And while the researchers would like to spare people from adverse exercise effects, Dr. Bouchard said, "It is not possible yet to make more specific recommendations because we do not understand why this is happening."

Dr. Bouchard stumbled upon the adverse exercise effects when he looked at data from his own study that examined genetics and responses to exercise. He noticed that about 8 percent seemed to be getting worse on at least one measure of heart disease risk. "I thought that was potentially explosive," he said.

He then looked for other clinical trials that also examined exercise under controlled conditions, making sure that participants actually exercised and did not change their diets, and carefully measuring heart risk factors and how they changed with an exercise program. He found five studies in addition to his own. In all the studies, a proportion of people, about 10 percent, had at least one measurement of heart disease risk that went in the wrong direction.

Then the researchers asked if there was some way of predicting who would have an adverse effect.

They found it was not related to how fit the people were at the start of the study, nor to how much their fitness improved with exercise. Age had nothing to do with it, nor did race or gender. In some studies subjects were allowed to take medications to control their blood pressure or cholesterol levels. In others they were not.

Medication use did not matter. The study subjects exercised at a range of intensities from very moderate to fairly intense. But intensity of effort was not related to the likelihood of an untoward effect. Nothing predicted who would have an adverse response.

Some experts, like Dr. Benjamin Levine, a cardiologist and professor of exercise sciences at the University of Texas Southwestern Medical Center, asked whether the adverse responses represented just random fluctuations in heart risk measures. Would the same proportion of people who did not exercise also get worse over the same periods of time? Or what about seasonal variations in things like cholesterol? Maybe the adverse effects just reflected the time of year when people entered the study.

But the investigators examined those hypotheses and found that they did not hold up.

Dr. Kraus said researchers needed to figure out how to tailor exercise prescriptions to individual needs. For example, people with good cholesterol and insulin levels but worrisome blood pressure would want to know if exercise made their blood pressure rise. A rise in blood pressure would not be compensated by improvements in already good cholesterol or insulin levels.

Dr. Lauer said that if nothing else, the study pointed out the need to know more about what exercise actually does. "If we are going to think of exercise as a therapeutic intervention, like all interventions there will be adverse effects," he said.

He said, "There is a price for everything."

http://well.blogs.nytimes.com/2012/05/30/can-exercise-be-bad-for-you/?

Doctor and Patient: Afraid to Speak Up at the Doctor's Office - NYTimes.com

A friend of mine, a brilliant and accomplished academic in her 70s who once specialized in history and literature, recently phoned to ask for medical advice after being discharged from the hospital for what sounded like a mini-stroke. Ever eager to learn something new, she pressed me on "the latest research" and asked what doctors around the country were doing for her condition.

We discussed a few research studies, diagnostic tests and treatment options, but when I suggested she speak with her primary care doctor and perhaps a neurologist, her end of the line went silent. I wondered if my cellphone had dropped the connection or, for a single harrowing second, if my friend was having another strokelike event.

Doctor and Patient

Dr. Pauline Chen on medical care.

When she finally spoke again, her once-confident voice sounded nearly childlike. "I don't really feel comfortable bringing it up," she said. While her doctor was generally warm and caring, "he seems too busy and uninterested in what I feel or want to say."

"I don't want him to think I'm questioning his judgment," she added. "I don't want to upset him or make him angry at me!"

For over a generation now, efforts to make health care more patient-friendly have focused on getting patients and doctors to work together to make decisions about care and treatment. Numerousresearch papers, conferences and advocacy organizations have been devoted to this topic of "shared decision-making," and even politicians have clambered aboard the train, devoting several provisions in the Affordable Care Act to "preference-sensitive care."

But one thing has been missing in nearly all of these earnest efforts to encourage doctors to share the decision-making process. That is, ironically, the patient's perspective.

Now a study published in the most recent issue of Health Affairs has begun to uncover some of that perspective, and the news is not good. In our enthusiasm for all things patient-centered, we seem to have, as the saying goes, taken the thought of including patient preferences for the deed.

The researchers conducted several focus groups with 48 patients from five primary care physicians in the San Francisco Bay area. First, they showed the patient participants a short video on several equally effective but very different treatment approaches for a heart ailment. Then, they asked them questions about what they did with their own doctors when faced with a choice among several treatment options that might be equally effective but could differ in lifestyle effects, cost or range of complications. Finally, the researchers asked the participants if they were comfortable asking doctors about different treatments, discussing their values and preferences or disagreeing with their doctors' recommendations.

The participants responded that they felt limited, almost trapped into certain ways of speaking with their doctors. They said they wanted to collaborate in decisions about their care but felt they couldn't because doctors often acted authoritarian, rather than authoritative. A large number worried about upsetting or angering their doctors and believed that they were best served by acting as "supplicants" toward the doctor "who knows best." Many also believed that they could depend only on themselves for getting more information about treatments or diseases. Some even said they feared retribution by doctors who could ultimately affect their care and how they did.

The findings fly in the face of previous optimistic assumptions about shared decision-making that were based mostly on studies that examined physicians' intent, but not patient perceptions. "Many physicians say they are already doing shared decision-making," said Dominick L. Frosch, lead author of the new study and an associate investigator in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute in California. "But patients still aren't perceiving the relationship as a partnership."

Interestingly, most participants in this study were over 50, lived in affluent areas and had either attended or completed graduate school. "It's hard to think that people from more disadvantaged backgrounds would find it any easier to question doctors," Dr. Frosch said.

Comment

Do you feel you need to act differently with doctors? Join in the discussion below.

While understanding health care issues and making themselves heard in discussions were not difficult in general for the participants in the study, the skills and confidence they had in other settings appeared to have little relevance once they were in their doctors' offices. They could not speak as easily as they normally did. "People experience a different sense of self in the doctor-patient interaction," Dr. Frosch observed. "The clinical context creates a reluctance to be more assertive."

Dr. Frosch and his colleagues are working on a larger study examining the extent to which patients feel constrained. And they have plans to study whether there are better ways to encourage patient engagement.

Systemic changes to increase shared decision-making must be addressed as well. Care organizations and doctors' practices must be restructured to allow more in-depth conversations; clinicians need to be reimbursed for the time required for more meaningful conversations; and health care systems must adopt rigorous quality standards that measure and value real patient engagement in decisions.

"We urgently need support of shared decision-making that is more than just rhetoric," Dr. Frosch said. "It may take a little longer to talk through decisions and disagreements; but if we empower patients to make informed choices, we will all do much better in the long run."

http://well.blogs.nytimes.com/2012/05/31/afraid-to-speak-up-at-the-doctors-office/?

Anesthesiology News - Cancelled Surgeries Costing Hospitals Millions

Between patient no-shows and cancellations on the day of surgery, hospitals are losing millions in revenue each year, researchers have found. The good news, according to the investigators, is that patients who have a preoperative visit with an anesthesiologist are substantially more likely to keep their appointment in the operating room.

Researchers at Tulane University Medical Center found that in 2009, 327 of 4,876 (6.7%) scheduled elective outpatient surgeries were cancelled, costing the hospital nearly $1 million that year alone. Because surgeries bring in approximately 60% of the hospital's entire revenue, that loss has a major effect on the bottom line, said study author Sabrina Bent, MD, MS, clinical associate professor of anesthesiology and director of research at the Tulane University Department of Anesthesia, in New Orleans.

"People need to recognize that there is a cost to cancelled surgeries that is not insignificant," said Dr. Bent, who presented the findings at this year's American Society of Anesthesiologists Conference on Practice Management (abstract PM23).

The bulk of the cost from cancelled surgery stems from "opportunity costs," Dr. Bent said. When surgeries are cancelled on short notice, hospitals are unable to swap in other procedures that would bring in lost revenue.

Hospitals cancel surgeries at the last minute for various reasons, Dr. Bent noted. More than 30% of patients in her study failed to show up at the time of surgery because of transportation problems, confusion over the date of the procedure, forgetting about the appointment or for other reasons, she said.

Among the minority of cancellations besides no-shows for which the reason was recorded, nearly one-third of the procedures were cancelled because of issues at the hospital itself, such as a lack of beds or equipment. Although it is not in the hospital's interest to cancel planned surgeries, these issues arise, Dr. Bent said. Scheduling errors can occur when one piece of expensive equipment is needed in two operating rooms at once, other equipment fails or the intensive care units happen to be full, leaving no place for patients to recover following procedures.

Dr. Bent and her team found that cancellations were more likely among patients who did not have a preoperative clinic visit with the anesthesiologist—nearly 11% of these surgeries were ultimately cancelled compared with less than 4% of surgeries preceded by a clinic visit.

As a result, Dr. Bent recommended that hospitals ensure all patients receive a preoperative visit to verify patients are medically ready for surgery and that they receive the proper preoperative instructions for the day of the procedure.

"That is a major factor that should be achievable," she told Anesthesiology News. Other ways to reduce cancellations include improving the allocation of equipment and resources, and increasing efficiency to help patients move through the hospital faster, she added. "All of these things are multifactorial and take time, thus are hard to address easily."

Consequently, Dr. Bent recommended that hospitals focus in areas where they could have the most impact. For instance, she and her team found that the cost of cancellation varies with specialty, with the highest loss in neurosurgery and urology (Table). Start with these high-revenue subspecialties, she said, and analyze and develop ways to curb those losses. "Maybe you cannot fix everything right away, but maybe there is something you can do to improve the efficiency and lack of cancellations in specialized groups."

Table. Revenue Loss by Specialty Specialty Total, n Total revenue loss, $ Average revenue loss per case, $ General surgery 102 200,478 1,965 Neurosurgery 7 41,735 5,962 Ophthalmology 16 46,828 2,927 Orthopedics 19 71,807 2,779 Otolaryngology 19 87,840 4,623 Pediatrics 12 15,900 1,325 Plastic surgery 4 9,039 2,260 Radiology 12 33,449 2,787 Thoracic surgery 20 84,160 4,208 Urology 14 66,614 4,758 Total 225 657,850 2,924

The rate of cancellations in the study "makes sense," said David Glick, MD, MBA, associate professor of anesthesia and critical care at the University of Chicago, who conducts similar research. The total cost for Tulane probably exceeded $1 million, however, Dr. Glick said, because the hospital has a relatively small volume and cancelled surgeries also result in a loss of money when disposable equipment is opened and then must be thrown out.

"There can be significant losses to the medical centers when they lose cases because of cancellations," Dr. Glick said. "I think their findings are useful, insofar as they provide justification for greater financial investment by hospitals to decrease cancellations."

For instance, Dr. Glick's own research also showed that patients who have preoperative visits in the anesthesia clinic are less likely to delay or cancel their surgeries (Anesthesiology2005;103:855-859). Although these visits are largely not reimbursed, it may be in the hospital's interest to support them financially. "I think this study suggests that it is reasonable for medical centers to bear a significant cost to maintain the anesthesia preoperative clinic," Dr. Glick said. "It enables them to save more money down the line, when surgeries are not cancelled."

http://www.anesthesiologynews.com/ViewArticle.aspx?d=Policy+&+Management&d_id=3&i=May+2012&i_id=839&a_id=20765

Waking Up to Major Colonoscopy Bills - NYTimes.com

Patients who undergo colonoscopy usually receive anesthesia of some sort in order to "sleep" through the procedure. But as one Long Island couple discovered recently, it can be a very expensive nap.

Both husband and wife selected gastroenterologists who participated in their insurance plan to perform their cancer screenings. But in both cases, the gastroenterologists chose full anesthesia with Propofol, a powerful drug that must be administered by an anesthesiologist, instead of moderate, or "conscious," sedation that often gastroenterologists can administer themselves.

And in both cases, the gastroenterologists were assisted in the procedure by anesthesiologists who were not covered by the couple's insurance. They billed the couple's insurance at rates far higher than any plan would reimburse — two to four times as high, experts say.

Now the couple, Lawrence LaRose and Susan LaMontagne, of Sag Harbor, N.Y., are fending off lawyers and a debt collection agency, and facing thousands of dollars in unresolved charges. All this for a cancer screening test that public health officials say every American should have by age 50, and repeat every 10 years, to save lives — and money.

"Doctors adopt practices that cost more, insurers pay less, and patients get stuck with a tab that in many cases is inflated and arbitrary," said Ms. LaMontagne, whose communications firm, Public Interest Media Group, is focused on health care. "I work on health care access issues every day, so if I'm having a hard time sorting this out, what does that say for other consumers?"

More than 20 million outpatient endoscopy procedures are performed in the United States each year, and the number is growing. A few hardy patients decide that they do not need anesthesia at all. Most receive conscious sedation, a combination of drugs that block pain and help patients relax while remaining conscious; three gastroenterology societies recommend this option as adequate in cases where there are no complications.

Still, a growing number of patients appear to be receiving full anesthesia. Some gastroenterologists say that patients recover more easily after full anesthesia and that the exam is better. But there is no clear scientific evidence to support this, and critics say that an extra pair of hands in the room simply allows the doctor to perform more procedures.

According to a study by the RAND Corporation, published this year in The Journal of the American Medical Association, use of anesthesia administered by an anesthesiologist or nurse anesthetist during outpatient gastroenterology procedures, mostly colonoscopies, has more than doubled in recent years, to more than 30 percent in 2009 from 14 percent in 2003. Most of the increase occurred among low-risk patients who could do without the expensive service. But the practice varies from region to region: Only 13 percent of gastrointestinal procedures in the West involved an anesthesiologist or nurse anesthetist, compared with 59 percent in the Northeast, the study found.

As much as $1.1 billion spent on anesthesia for gastrointestinal procedures each year may not be medically necessary, the researchers concluded. Insurers often foot the bill for full anesthesia, but not always.

Mr. LaRose, 48, said that he did not want to have full anesthesia in the first place. After his first consultation with the doctor, he said, he called his gastroenterologist's office and told a staff member of his preference.

But when he showed up for the colonoscopy on June 24, 2010, his doctor, Dr. Kristin Patrick Naso, told him the procedure is normally done with Propofol, which requires an anesthesiologist. By then Mr. LaRose had already spent 24 hours fasting and going through the unpleasant cleansing preparation, he said.

Mr. LaRose said he relented after the doctors assured him that anesthesiology would be covered. "You're starving and gaseous and you just want to get the whole thing over with," Mr. LaRose said.

In an interview, Dr. Naso said his office provided all patients with a notice saying that the anesthesiologist might not be covered by insurance and providing the anesthesiologist's phone number for more information.

Although Dr. Naso was in network and accepted payment from Mr. LaRose's insurer as payment in full, the anesthesiologist, Dr. Michael Rus, billed $1,600 for the procedure. He was reimbursed $588 by the plan and, after failing to collect the remainder from Mr. LaRose, sent the balance to bill collectors.

Dr. Rus did not respond to requests for comment.

It was a similar situation when Ms. LaMontagne went for her colonoscopy. She said she told Dr. Michael Krumholz in Manhattan about her husband's experience and her concerns about a lack of coverage for full anesthesia. She said she was not told about conscious sedation, which is not available at his practice. Instead, Ms. LaMontagne said, she was told that full anesthesia was standard practice. She went ahead with the procedure in February.

Dr. Krumholz accepted $192 from Ms. LaMontagne's insurance company, Freelancers Insurance Company, which is affiliated with the Freelancers Union. But the insurer rejected the bill from the anesthesiologist, Dr. Joanne Goldman, because she is out of network.

So Dr. Goldman's charge was sent to Ms. LaMontagne: $2,800. She called Dr. Krumholz's office to ask about this charge and any others of which she might be unaware. She said she was told there would also be an additional "facility fee" of $1,800 charged by the endoscopy clinic.

In an interview, Dr. Goldman said she did not do the billing herself and could not address questions about it.

In an e-mail, Dr. Krumholz said that he tells all of his patients about the risks and benefits of colonoscopy, as well as alternatives to the procedure, and of the benefits of and alternatives to anesthesia. He will perform the procedure without anesthesia if the patient so chooses, he said, but his practice does not offer conscious sedation, nor do "most modern endoscopy facilities in New York."

Jordan Fowler, chief executive of Frontier Healthcare and business manager of the endoscopy center where Dr. Krumholz practices, said Ms. LaMontagne "should not lose sleep" over the charges because the anesthesiologists in the group are about to become in-network providers.

Asked whether a $2,800 charge is reasonable for about 30 minutes of anesthesia, he said, "You bill a high fee to negotiate with an insurance company."

Sara Horowitz, founder and executive director of the Freelancers Union, said the trend toward using two doctors for a colonoscopy is "outrageous, when we have another perfectly good kind of anesthesia, twilight sleep, that the GI can do him- or herself."

But there's a bigger problem for consumers here, too. Many physicians who are not the primary contact with patients — like pathologists and radiologists as well as anesthesiologists — do not participate in health insurance plans. When they provide medical services at hospitals or outpatient centers, their charges may not be covered, or may be only partly covered, leaving even well-insured people with large, unexpected bills.

So, what to do if you need a colonoscopy?

CONSIDER ALTERNATIVES Other recommended colon cancer screening methods include the fecal occult blood test, which involves collecting stool samples at home, and sigmoidoscopy, in which a long, flexible tube with a tiny video camera is used to examine the lower colon. Indeed, a study published in The New England Journal of Medicine last week found that patients who underwent sigmoidoscopy had lower rates of colon cancer and lower cancer death rates.

PLAN AHEAD You know when you'll be turning 50, so estimate your costs in advance and put money away in a health savings account, so at least you're not paying taxes on it. (Remember, you may lose the money if you don't use it.)

ASK QUESTIONS When speaking with your gastroenterologist about the procedure, find out what kind of anesthesia will be used and who is going to administer it. If he or she insists on an anesthesiologist or a nurse anesthetist, you have two options: find a gastroenterologist who administers sedation on his or her own, or make sure the anesthesiologist is covered by your plan.

http://well.blogs.nytimes.com/2012/05/28/waking-up-to-major-colonoscopy-bills/

The Prognosis for Medical Innovation - Ezekiel J. Emanuel - NYTimes.com

The sleek, four-armed "da Vinci" robot has been called a breakthrough technology for procedures like prostate surgery. "Imagine," the manufacturer says, "having the benefits of a definitive treatment but with the potential for significantly less pain, a shorter hospital stay, faster return to normal daily activities."

That's just the kind of impressive-sounding innovation that critics of the health care reform act say will be stifled by the new law, with its emphasis on cost control and the comparative effectiveness of new pills and devices. "Instead of encouraging innovation," wrote Senator Ron Johnson, Republican of Wisconsin, in The Wall Street Journal, "it stifles creativity."

The critics are right — if they're talking about innovations like the da Vinci robot, which costs more than a million dollars and yet has never been shown by a randomized trial to improve the outcomes of prostate surgery. Indeed, a 2009 study showed that while patients had shorter hospital stays and fewer surgical complications like blood loss when they underwent this kind of robotic surgery, they later "experienced more … incontinence and erectile dysfunction." Similar problems are occurring with robotic surgery for other cancers.

In other words, this is a pseudo-innovation — a technology that increases costs without improving patients' health.

The Affordable Care Act will not reward this kind of innovation. But by providing incentives for hospitals to reduce infections, errors and readmissions, giving doctors more information on the comparative effectiveness of medical interventions and emphasizing preventive care over expensive services, the act will stimulate a panoply of true medical innovations. These may not be flashy; they might not even be visible to patients. But they will improve health care and lower costs.

For instance: checklists. A 2006 study showed that a five-item checklist — including hand-washing and cleaning a patient's skin — could reduce infection rates from intravenous catheters to nearly zero. According to the study, these infections cost an average of $45,000 per patient, and cause as many as 28,000 deaths among intensive care unit patients each year.

By the end of the decade, we will see many other true innovations — small and large, high-tech and non-tech. Diabetics' smartphone applications could transmit their glucose levels to doctors' offices; wireless home monitoring systems could be installed for patients with congestive heart failure; high-tech caps for drug bottles could alert patients' families if they forget to take their medications. There will also be many innovations in electronic health records. These aren't flashy robots, gleaming scanners or new pills, but there is already evidence that they will save money and improve care.

We have benefited tremendously from medical innovations like M.R.I. scanners, cardiac stents and powerful new drugs, and should celebrate the fact that the United States is the leader in developing medical technologies. But we need to stop glorifying every new technology as an innovation. "New" matters only when it's proved better than what we had before, when it prolongs survival, reduces side effects or improves quality of life — or maintains the current standard of care at a lower cost.

Health care reform may quash pseudo-innovations, but that simply directs capital and creativity away from technologies that don't improve outcomes or lower costs and toward ones that do. That should not be confused with killing innovation.

http://opinionator.blogs.nytimes.com/2012/05/27/in-medicine-falling-for-fake-innovation/?pagemode=print

Medical students learned on the bodies, and now honor the donors - The Washington Post

Nancy Linn attended a memorial service for her husband, Arnold, last week. It was organized by people who never met him or knew his name and yet were connected to him in the most intimate way.

For months, medical and nursing students at Georgetown University had explored his body and those of 64 other donors in the anatomy lab. They searched for nerves, prodded muscles, laid bare major organs. They learned about disease and about complexities of the human body.

Now classes were over and the school was holding its yearly anatomical donor Mass, to say thank you. In a classroom auditorium, about 135 family members watched as a procession of 160 white-coated students walked down the aisles on either side of them. Each placed a glass-held candle on stage with a gentle clink, creating a seemingly endless chain of light.

From Linn's front-row seat, her eyes reddened as she listened to the readings, hymns and remarks by students, a priest, a rabbi and the dean for medical education.

The donors, they said, were the students' first patients. And students were the donors' final caretakers.

"They knew nothing about us, and yet they dedicated their final act on this Earth to share their most intimate possession with us in the hope that we could learn from them," said Mark Norton, 27, class president of the first-year medical students.

"Our donors taught us to celebrate life and to never forget the need for humanity and compassion in medicine — a lesson that could never be explained in any textbook or on any app."

As the Mass drew to a close, the Rev. Salvador Jordan asked family members to step forward. Leaning on her cane, Linn, 75, joined about 20 other people, including a couple with a young boy, in the front of the room. Three students presented them each with a creamy white rose.

Her decision to donate her husband's body had not been difficult — the couple had agreed to be organ donors. But seeing and hearing from the medical students was comforting.

"I feel so much more at ease. . . . ," she said. "I think Arnold would be very pleased."

Introduction to medicine

Each year, 19,000 medical students in the United States dissect cadavers as part of their introduction to medicine. It is one of the most sensitive rites of becoming a doctor because it is often the students' first encounter with death.

Many medical schools hold some type of memorial service at the end of the school year to honor donors. At the George Washington University medical school, family members spoke, and students sang and performed original dance. The service ended with a reading of the donors' first names and a release of butterflies.

"Gross anatomy is a very challenging course in many ways," said Christina Puchalski, director of the university's Institute for Spirituality and Health and one of the speakers. On the science side, students must memorize the location and function of hundreds of anatomical structures. But they also need to acknowledge their emotions.

A challenge in medical education, she said, is to help students achieve competence without losing compassion.

"Gross anatomy is the first place where students start to encounter that tension," she said.

At Georgetown, the formal Mass has been in place for at least 25 years but has grown so large that it is now held in a classroom auditorium instead of the medical school's small chapel.

The Mass is the coda to a year that began in late fall.

Orientation included a video of medical students describing what happens. On the first day of class, before the body bags covering the cadavers were unzipped, 196 students listened to interdenominational prayers. Letters from donors were read aloud.

The time spent on dissection varies by school. Many medical schools supplement the teaching with high-tech virtual simulations or pre-dissected bodies. Georgetown puts a heavier emphasis on students performing their own dissections; they typically spend about 100 hours in the lab. This year, course director Carlos Suarez-Quian added another hands-on component. Students had to pass a table exam after each unit, identifying specific structures on the cadaver within 20 seconds.

He noticed that students in years past were too reliant on perfect drawings they saw in textbooks or on the Web.

"That's not who your patients are going to be," he said.

Most donors are elderly. Disease or age often prevents them from donating organs. This year, one donor was a woman who died of breast cancer in her 40s. Another donor's lungs were pitted black from smoking. Students don't know the names of their donors, only age and cause of death.

Wearing blue scrubs and lab aprons, students worked in groups of five to a table, using the same body for all the labs. They started with the spine, finished with the head and neck. Only the body part being dissected was exposed; the rest was covered with cloth and black plastic, to protect the tissue from drying out. Cadavers in tan body bags meant the family wanted the remains back. Blue signified eventual burial in a common grave. The embalming process drains bodies of blood and other fluids, leaving the skin feeling hard. Students often wear two pairs of blue gloves to protect against contact with the intensely strong-smelling chemical preservatives.

'Deep into the heart'

Class began at the end of October. By early December, they had progressed to the heart.

Instructor Suarez-Quian gave last-minute instructions. Watch out for pacemakers. Cut through the fat around the heart.

Don't rush.

"Put your hand deep into the heart, look at it and feel it before you take the heart out," he said.

At Table 11, students removed an unusually large heart, an indication of disease. It was the size of a small melon. "Look at the size of that aorta," murmured Kate Wagner, 24. Their donor, an 85-year-old man, died from stroke and high blood pressure.

Her tablemate, Liz Harkin, 23, washed the dried blood clotting the internal structures. She held it under running water at a nearby sink. She was focused on her task, but she also realized she was holding a human heart in her hands.

"It's unreal," she said. "It's hard to imagine."

Finding the anatomical structure can be frustrating because every body is different. When Table 13 was looking for a nerve that controls the primary muscle used in breathing — it looks like a yellowish-white flat shoelace — one student used her iPhone, protected in a zippered plastic baggie, to consult an interactive electronic guide. But discovery is exciting.

"You almost gasp," said John Nolan, 23, a first-year student who was also one of nine teaching assistants for the class. "You have that 'aha' moment, and everything starts to click. This artery is leading to here, which gives blood to this part, and you can follow it the whole way."

Discoveries inevitably lead to more questions.

"I'm curious to know how she lived to 102," said Bridget Kaufman, 23, bending over the chest cavity of her table's cadaver. The heart was in good condition. Her lungs "were really clean," she said. No cancer.

Had the woman been rich and led a pampered life, Kaufman wondered, "or did she live so long because of genetics?"

Harder for students to process were the moments when they see glimpses of nail polish, feel a strand of hair, and especially, touch fingers and hands.

Mark Real, 22, became momentarily unnerved when his hand accidently slipped into a handshake with the table's cadaver, a 94-year-old woman. "It felt very familiar," he said. "I stepped back for a second. I had to compose myself."

His tablemate, Mark Mario­renzi, 24, had a similar experience when he touched her hair.

"That's when you realize that it's not an objective lab like we're used to in biochemistry," he said. "You get flooded with emotions, of your own mortality, of loss and sorrow."

Rules for donations

Medical schools don't pay for body donations. Georgetown's medical school gets about 225 requests a year from people who want to donate. Some restrictions apply — no autopsies, no major surgeries, no bodies weighing more than 200 pounds. Also excluded are those outside a 50-mile radius from Georgetown, unless the family can pay for transportation. Bodies are typically used 18 to 24 months after donation. Most donors choose to remain anonymous.

All remains are cremated. About half the families request the ashes. If the families choose, they can receive the remains after the donor Mass, as was the case last week. The others are buried at Mount Olivet Cemetery in Northeast Washington in a section reserved for Georgetown's anatomical donors.

Donors include blue-collar workers and "people of note," said Mark Zavoyna, operations manager for the donor program. Some people choose to donate because their disease was cured and they want to give back to medical science. "They know this is a game changer for students," he said.

Arnold Linn was a carpenter. The longtime Vienna resident was 76 when he died of pancreatic cancer in 2009. His wife, Nancy, a retired Defense Department budget analyst, wanted someone to learn from his disease.

"It's just such a waste to put him in the ground," she told several medical students at a reception last week after the Mass. The family had asked the hospice about body donations. From the list they received, Georgetown was the first place they called.

Impressed by Georgetown's respect for donors and their families, she told the students that she and her youngest son David, 40, had also turned in paperwork that day to become donors.

"Hopefully, we're not over here too soon," she said.

After the service, Linn and David drove to the cemetery to see where the remains would be buried. Section 79 is at the back of the sprawling cemetery, near a wooden fence. An upright granite slab sits in the middle of a grassy patch. In capital letters, it reads: "In Memoriam Those who gave of themselves that others might benefit."

It wasn't the big ornate tombstone that Linn had imagined. But it was very nice, just the same. She stood for several minutes, looking at the spot, between two big pine trees by the back fence. She wanted to remember the landmarks so she could find her way back, after Georgetown buries her husband's remains next month.

http://www.washingtonpost.com/national/health-science/medical-students-learned-on-the-bodies-and-now-honor-the-donors/2012/05/27/gJQAScxJvU_print.html