Thursday, May 7, 2015

America’s Epidemic of Unnecessary Care - The New Yorker

It was lunchtime before my afternoon surgery clinic, which meant that I was at my desk, eating a ham-and-cheese sandwich and clicking through medical articles. Among those which caught my eye: a British case report on the first 3-D-printed hip implanted in a human being, a Canadian analysis of the rising volume of emergency-room visits by children who have ingested magnets, and a Colorado study finding that the percentage of fatal motor-vehicle accidents involving marijuana had doubled since its commercial distribution became legal. The one that got me thinking, however, was a study of more than a million Medicare patients. It suggested that a huge proportion had received care that was simply a waste.

The researchers called it "low-value care." But, really, it was no-value care. They studied how often people received one of twenty-six tests or treatments that scientific and professional organizations have consistently determined to have no benefit or to be outright harmful. Their list included doing an EEG for an uncomplicated headache (EEGs are for diagnosing seizure disorders, not headaches), or doing a CT or MRI scan for low-back pain in patients without any signs of a neurological problem (studies consistently show that scanning such patients adds nothing except cost), or putting a coronary-artery stent in patients with stable cardiac disease (the likelihood of a heart attack or death after five years is unaffected by the stent). In just a single year, the researchers reported, twenty-five to forty-two per cent of Medicare patients received at least one of the twenty-six useless tests and treatments.

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NYTimes: Company Creates Bioethics Panel on Trial Drugs

Johnson & Johnson has appointed a nationally known bioethicist to create a panel that will make decisions about patients' requests for lifesaving medicine, responding to an emotional debate over whether companies should allow desperately ill people to have access to the drugs before they are approved.

The move, to be announced by the company on Thursday, is believed to be the first of its kind in the industry and, given the size and influence of the drug maker, could inspire other companies to follow suit. It comes as a small but growing number of patients with terminal illnesses have sought the right to obtain drugs still in the testing phase that show promise for treating their diseases.

Some of the requests have become highly publicized cases on social media, where family members and advocates have lobbied the companies on patients' behalf — often to no avail because drug makers fear that doing so would interfere with clinical trials, or, in the case of the Ebola outbreak, that they have too little available. The issue, which involves fundamental questions of fairness and equal access to care, has become so intense that more than a dozen states have taken up legislation to speed the process.

Johnson & Johnson said the bioethicist, Arthur L. Caplan of New York University, who has written extensively about the issue of experimental drug availability — known as "compassionate use" — would oversee an independent panel of doctors, ethicists and patient advocates that will review requests for access to a limited array of experimental medicines and decide how Johnson & Johnson should respond.

The pilot program will be funded by the company but will have no influence on the panel's decisions, Johnson & Johnson said, adding that payments will go directly to the university. Dr. Caplan will not be paid in his work in the program.

Dr. Caplan, who has argued that the industry needs a fairer, more consistent system for deciding whose requests should be granted, said he was intrigued when company executives approached him about the idea. "If we could structure this right, this would be a chance to not just complain about what's wrong, but maybe to suggest a way forward," he said in an interview.

Drug companies have been granting emergency access to their unapproved drugs since the AIDS epidemic of the 1980s, when the Food and Drug Administration set up a process to help desperate patients get experimental treatments. The F.D.A. typically signs off on use of unapproved drugs, but not until the company agrees.

But saying yes is not so simple: Manufacturers often have a limited supply of such treatments, leading to anguished decisions over who should be given the products. The unproved drugs also might not work, or could even cause harm. And the time and resources involved in granting access to such drugs could delay efforts to get them approved for a much wider population of needy patients, especially at smaller companies. In the case of the Ebola epidemic, last year the F.D.A. allowed the makers of ZMapp, an experimental treatment, to be used on a handful of patients, but the company quickly exhausted its limited supply.

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Johnson & Johnson named the bioethicist Arthur L. Caplan to create a panel to decide on patients' requests for lifesaving medicines before they are approved.

Wednesday, May 6, 2015

Despite numerous risk factors that should shorten their lives, Hispanics in the United States are generally healthier than non-Hispanic whites, the Centers for Disease Control and Prevention reported Tuesday in its first comprehensive report on the health of that large and growing ethnic group.

Despite being poorer and having less access to health insurance and health care, Hispanics suffer 35 percent less heart disease and 49 percent less cancer than whites, and according to another study cited in Tuesday's report, live about two years longer. They also have lower rates of Alzheimer's disease, cerebrovascular disease, flu, pneumonia and other common killers of Americans.

"For many years there has been a description of the Hispanic Paradox, that despite … lower socioeconomic status they live longer," Tom Frieden, director of the CDC, said at a telephone news conference Tuesday. "Recent data corroborates that most of that may relate to smoking rates." In surveys, just 13.5 percent of Hispanics said they smoked, compared with 23.8 percent of whites.

Another possible factor, according to the report, is that the healthier members of Hispanic countries tend to be the ones who immigrate to the United States. And on average, Hispanics here are 15 years younger than whites.

But Hispanics' health advantages are not universal. Hispanics have higher death rates from diabetes, chronic liver disease and cirrhosis of the liver, hypertension and homicide than whites. More of them are obese and have diabetes when compared to whites.

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Sunday, May 3, 2015

NYTimes: The Medical Bill Mystery

I CONFESS I filed this column several weeks late in large part because I had hoped first to figure out a medical bill whose serial iterations have been arriving monthly like clockwork for half a year.

As medical bills go, it's not very big: $225, from a laboratory. But I don't really want to pay it until I understand what it's for. It's not that the bill contains no information — there is lots of it. Test codes: 105, 127, 164, to name a few. CPT codes: 87481, 87491, 87798 and others. It tells me I'm being billed $29.90 for each of nine things, but there is an "adjustment" to one of $14.20.

At first, I left messages on the lab's billing office voice mail asking for an explanation. A few months ago, when someone finally called back, she said she could not tell me what the codes were for because that would violate patient privacy. After I pointed out that I was the patient in question, she said, politely: "I'm sorry, this is what I'm told, and I don't want to lose my job."

I have spent the last two and a half years reporting and writing about medical costs, and during that time I have pored over hundreds of patients' bills. And while I've become pretty adept at medical bill exegesis, I continue to be baffled by how we've come to tolerate the Kafkaesque stream of nonexplanations that follow health encounters.

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