Conflicts of Interest Between Doctors, Hospitals, and Patients Result in Harmful Treatment

OK, I was going to write about the new social caste-system determining how you pay for your health care, but the New York Times article about the errant Dr. Ghandi from Indiana (I kid you not) and his over zealous love of invasive cardiac treatments is too good to pass up. First of all, the full color photo in the New York Times of this woman's scarred chest is a shock. The sleeveless pink floral top (not enough of it to merit calling it a blouse) is the standard rag you find so many many American woman wearing to places they should not. I mean really, this is what you wore for an interview with the New York Times? One could make a case that the cardiac chest-crack surgical scar is more aesthetic than that mom tattoo. I thought you were supposed to put your kids names on your body, not the word mom, isn't that reserved for sailors? Read on to find out how this all went wrong in the midwest.
 Malpractice and Medicare Rip-offs
The woman in the New York Times photo had been treated by Dr. Ghandi for thirty years, originating from the irregular heartbeat diagnosis and devolving into multiple surgeries involving stents,  and other invasive procedures. This plucky female did say no to Dr. Ghandi's insistence on getting a pacemaker (smart move sister) but she was pummeled into the insertion of a heart monitor. Unbeknownst to her, this monitor was linked directly to Dr. Ghandi's bank account. At last count, 293 patients have sued this doctor for installing unnecessary pacemakers, stents, and other cardiac devices. Thanks to Dr. Ghandi and his co-conspirators, little Munster (not to be confused with Muncie), Indiana placed within the top 10% for cardiac defibrillator implants (pacemakers) according to Medicare, which is also investigating. Munster is a town of 23,270 people, so it is pretty difficult to imagine they have that many defective tickers. But please remember, Indiana is pretty close to Wisconsin, where most of the world's cardiac devices are manufactured, so maybe they were being neighborly. However, here is where the story takes an even more twisted turn.
Hospital Administration Conflict of Interest
The hospital administrators knew that Dr. Ghandi and others in his cardiac practice were performing invasive medically unnecessary procedures and they did nothing to stop it. Lest you think this was a for-profit hospital, you'd be wrong. In fact, a nonprofit community hospital, much like any local hospital, such as  Harrison, in Kitsap County, made the decision to ignore the professional complaints brought by Dr. Mark Dixon, whom also practiced at the hospital. The hospital's chief benefactor it seems was a long time patient of  Dr. Ghandi's for his cardiac care, so no conflict there at all. Specifically, Dr. Dixon's complaint was unqualified people were installing some of these cardiac devices and Dr. Ghandi's patients did not meet the medical necessity requirements for some of the treatments.  So, why would the hospital ignore these concerns-because cardiac care is very lucrative and brings in lots of money for the facility. In fact, in hospital administration parlance, this is referred to as a service line, it isn't even called health care. And yes, in hospitals, the doctors who bring in the most money are treated with deference.
What You Can Do
Hold the phone-this is the lesson for all persons reading this article-(1.) ask questions about training and board certification before you consent to any surgery and (2.) get a second opinion. Sure Munster is a small town, but you do not have to have your treatment there, you can go to a bigger city, like Indianapolis or Chicago, or if you are really smart, the Mayo Clinic in Minnesota. Further, if you cannot commute to these locations, you can go to the following web sites to get information which is reliable on cardiac care:
 http://www.mayoclinic.org/departments-centers/cardiovascular-diseases/home/orc-20121930
 http://www.mayoclinic.org/diseases-conditions/heart-murmurs/basics/definition/con-20028706
 http://www.cdc.gov/heartdisease/materials_for_patients.htm
http://my.clevelandclinic.org/services/heart/disorders

Tip of the Iceberg
Lest you think this scenario of over diagnosis and money making through unnecessary medical procedures is an anomoly, it is one of the biggest problems in the U.S. healthcare system. Thankfully, in the last decade, better information has become available to consumers through websites and other resources, which make it easier for the average person to double-check the facts before submitting to a procedure.  The truth is you can't always trust what your community hospital is telling you, nor can the same be said for every doctor. The responsibility is on the patient and their advocate to ferret out all necessary information and make an informed decision. The Lown Care organization is in the midst of its' Right Care Campaign and that is one example of a collective effort of clinicians to curtail abusive practices in healthcare. I have written about health care scenarios and policies for the past eight years, and in 2013, I specifically targeted the layperson in my book, Unraveling U.S. Healthcare-A Personal Guide, of which five chapters were devoted to figuring out how to gauge health care quality.

Stay healthy by choosing wisely and this is the healthpolicymaven signing off, encouraging you to share this article widely. Roberta E. Winter is a graduate of the University of Washington School of Public Health and the University of Washington Evans School of Public Affairs and publishes under the trademark healthpolicymaven.
1. http://www.nytimes.com/2015/10/18/business/a-small-indiana-town-scarred-by-a-trusted-doctor.html?smprod=nytcore-iphone&smid=nytcore-iphone-share&_r=1
2.  http://www.rightcaredeclaration.org/
3. http://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

Affordable Care Act Program Shows Reduced Medical Costs Through House Calls

The Affordable Care Act funded the Shared Savings Program which financially rewards health care organizations for reaching targets for patient care, such as reductions in hospital re-admissions, and thereby reduces plan costs. One of the most compelling projects from this pay-for-performance program has been a resurgence in house calls by doctors to vulnerable Medicare patients. The Wall Street Journal recently featured an article on this phenomena and found the "Independence at Home" Medicare demonstration project has shown a 25 million dollar savings for Medicare in the first year of the program. (1) This article reveals more about how this program works, who participates, and what it might mean for health care plans. Here are the creative health care organizations which elected to participate in this three year initiative (sans the LLC, Inc, or other corporate modifiers): Boston Medical Center, Christiana Health Care Services, Cleveland Clinic Home Care Services, Comprehensive Geriatric Medicine, Doctors Making Housecalls, Housecall Providers, MD2U, Medical House Call Program at Medstar Washington, National House Call Practitioner Group, North Shore Long Island Jewish Health Care, RMED, Schnabel In-Home Care,Virginia Commonwealth University, and Visiting Physicians Association (locations in 4 states). (2)
Awarding Value-Based Payments
As a part of the value-base care initiative, participating practices were able to reduce emergency room re-admission costs by 16.4%. In order to receive a shared savings reward, the organization had to meet the following clinical targets for qualified Medicare patients:

• Have fewer hospital re-admissions within 30 days of discharge
• Have follow-up contact from their provider within 48 hours of a hospital admission, hospital discharge, or emergency department visit
• Have their medications identified by their provider within 48 hours of discharge from the hospital
• Have their preferences documented by their provider
• Use inpatient hospital and emergency department services less for conditions such as diabetes, high blood pressure, asthma, pneumonia, or urinary tract infection.

This pay for performance effort resulted in incentive payments for four group practices and one consortium of health care practices. The top three shared savings recipients for this program were; Visiting Physicians Association capturing the lions share of the compensation, totaling 7.8 million, followed by the Mid-Atlantic Consortium, which includes Medical House Call Program at Medstar, Schnabel In-Home Care, and Virginia Commonwealth,  receiving 1.8 million, and  Portland, Oregon, Home Care Services, getting 1.2 million dollars in incentive pay.(2) It is pretty obvious that the health practices which were exclusively organized to provide home health care had an advantage for the first year of this program, based on the results achieved. However, the other groups may catch up in the three year period, as Medicare has stated it wants to tie 30% of all CMS reimbursements for patient care to incentive plans by 2016 and increase that to 50% by 2018. (3)  I am skeptical these results are possible, nor are all health care organizations going to be able to achieve this outcome, especially smaller practices, so there will be some fall-out on these bold goals. Finally, there is some concern that the focus on health metrics has gotten in the way of patient care, as so much of the clinical day is now devoted to completing forms and reports.

Today's house calls can include portable MRI machines for imaging as well as on-the-spot blood draws and testing, which enable clinicians to gauge the health of especially frail patients more closely. For a vulnerable Medicaid patient who is just out of the hospital, being able to remain at home, and not risk travel or hospital acquired infections could be a plus. However, all you have to do is walk your rounds in today's hospitals to see who the patients are, frail elderly people, who are often without family to look after them, so the house call bonanza won't apply to the entire population.

This article was written by Roberta Winter, a healthcare advocate who has published under the trademark, healthpolicymaven since 2007, and may be shared virally. For more straight talk on health care programs and policy you can follow me on twitter at:.https://twitter.com/healthpolicymav
 
Roberta Winter is the author of: Unraveling U.S. Healthcare-A Personal Guide, which may be found at http://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972





(1) Laura Landro, "How House Calls Cut Medical Costs", Wall Street Journal, September 27, 2015
http://www.wsj.com/articles/how-house-calls-can-cut-medical-costs-1443407612
(2) Innovation Projects, Centers for Medicare and Medicaid, Independence at Home, Year One Results  http://innovation.cms.gov/Files/x/iah-yroneresults.pdf
(3) Centers for Medicare and Medicaid, Media Release, June 18, 2015
 https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-06-18.html

Medical Evidence and Getting the Right Care

Choosing Medical Treatments Wisely

The spate of media articles on unnecessary procedures and treatments which do not improve health and can harm patients is a sentinel cry to the public. This article addresses the types of questions patients and their families need to ask when faced with health care decisions and where to get answers.

Understand the Disease Evidence

One of the statistical principles which patients should understand is that an increase in the incidence (precursor) of a disease does not mean an increase in the invasiveness or death from the disease. A good example of this is thyroid cancer, here-to-for a relatively obscure disease which has now hurtled into 9^th place in the cancer lexicon, as elucidated by Dr. R. Michael Tuttle in Medscape Oncology. [1]What this phenomena means to the general public as well as clinicians is the surveillance and testing for this condition has increased in specificity and volume. This does not in fact mean that there are more invasive thyroid cancers or that more people are dying from it, merely that smaller nodules are being found because of the improvement in imaging. The same can be said for the explosion in breast cancer in the U.S. where conditions which are pre-cancerous are lumped into the cancer milieu, causing an increase in prophylactic breast amputations.

 Before you consent to a medical procedure, whether it involves radiology (radiation transmitted into your body), treatment with drugs, or an invasive surgical procedure, there are questions you should ask.  I am citing Dr. Nortin Hadler’s prolific publishing and seminal work at the University of North Carolina, as the expert in debunking the medicalization mythology. Dr. Hadler states, “The best we can do today is to impose rationality on the current (healthcare) system- iron clad, science supported, and patient-driven rationality with the goal of assuring health and providing recourse when that assurance falls short.” [2]

Rational Questions for Patients and Families

Does the lab test contribute to an increased cancer risk?

What are the risks and side effects of the procedure or the prescription?

Are there other treatment options such as watchful-waiting?

Organizations Which Can Help Inform Your Medical Decisions

The ABIM Foundation, which is a physician driven nonprofit working to discern and promote methods to provide high value health care, has created the Choosing Wisely Campaign which aims to focus on reducing the overuse of tests and treatments.[3]The ABIM Foundation has come up with a list of 70 procedures that physicians and patients should question.[4]Here is my short list, but follow the link in the footnotes to find all 70: 

1. Colonoscopy is often done too frequently- Unless you have an irregular test (polyps or other cancer risk factors), this test need only be done every 5 or even 10 years. This is a baseline test folks, not part of your “annual physical” and it is a very expensive test, running over $2,000 (U.S.) and requiring the use of anesthesia, which has other risks.
2.  Screening tests regardless of health condition- These ubiquitous “fishing” tests are often promoted by “special clinics” or at “shopping malls” and offer full body scans, which are unnecessary and not shown to improve health or extend life. Again, it is best to avoid the extra doses of radiation when you can. Yes, a full body scan may find something wrong with you, but this information won’t necessarily impede your health or hasten your death.
3.    Prescribing Opioids for chronic pain-In laypersons terms these drugs are known as Vicodin, OxyContin, or Percocet which are designed to work in the short term (following surgery) and over time they become less effective for pain relief. Also, one fourth of all patients who use these medications become addicted and they can cause death. Other side effects include world class constipation, nausea, confusion, mental disturbance, and if that isn’t enough, liver damage if you take enough of the stuff.
4.  Medical tests administered at the end stages of life-For example after your cancer has spread to Stage V, it is wise to start asking quality of life questions, such as: Will the treatment help you live longer or What are the side Affects and Risks? Ask about palliative care, which does improve your life. These same questions can and should be asked by all octogenarians. In other words, how is the test or treatment going to improve your life? 
5.  Ubiquitous testing for urinary tract infections- This is a test frequently given when no symptoms exist and results in an over use of antibiotics. Taking antibiotics kills friendly bacteria which your body needs to fight infections and over use causes super bugs which are resistant to treatment. 

Initiatives to Help Patients Make Informed Decisions

Currently, there are a number of medical initiatives in the Unites States, which are researching how to create and test patient and doctor shared decision making tools.  The Centers for Medicare and Medicaid provided $9,332,545 to a Texas initiative called Med Expert International, which is testing a shared decision making process. This award is a collaborative effort with California, Idaho, Texas, and Washington State.[5]

Things you can Read to Improve Your Health Care IQ

Dr. Nortin Hadler has been a persistent voice for clarity in how we much waste we have in U.S. healthcare and his most recent book, The Citizen Patient, published by the University of North Carolina Press, in 2013, reveals critical information about hospitals, interpreting scientific findings, and health care procedures which are more about revenue than enhancing health. [6]Dr. Nortin Hadler has also written, “Aging: Growing Old and Living Well in an Over Treated Society”, University of North Carolina Press.[7]

Roberta Winter is the author or Unraveling U.S. Healthcare-A Personal Guide
http://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972
 And this is the healthpolicymaven signing off encouraging you to share this article with anyone whom may benefit. "healthpolicymaven" is a trademark of Roberta E. Winter, a graduate of the University of Washington School of Public Health and Community Medicine and the Daniel Evans School of Public Affairs. This article in no way provides medical advice.

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[1]Overdiagnosis in Thyroid Cancer: The Case for Observation, Medscape Multispecialty, Gabriel Miller, August 25, 2015

 http://www.medscape.com/viewarticle/849893

[2]Nortin M. Hadler, M.D. The Citizen Patient-Reforming Health Care for the Sake of the Patient, Not the System, University of North Carolina Press, 2013, p. 182

 http://www.amazon.com/The-Citizen-Patient-Reforming-Lillian/dp/1469607042

[3] http://www.choosingwisely.org/new-grantees-will-focus-on-reducing-overuse/

[4] http://www.choosingwisely.org/patient-resources/

[5] http://innovation.cms.gov/initiatives/Health-Care-Innovation-Awards/California.html

[6] http://www.amazon.com/The-Citizen-Patient-Reforming-Lillian/dp/1469607042

[7] http://www.amazon.com/Rethinking-Aging-Growing-Overtreated-Society/dp/0807835064

Cancer Drugs-Cost Versus Benefit the New Paradigm

Recently, both the New York Times and the Los Angeles Times have published articles about oncologists' new consumer tool to gauge the effectiveness of cancer drugs. This effort was spurred after harsh rebukes of the pharmaceutical industry from clinicians at the Mayo Clinic and Harvard Medical School.  Both of the "Times" articles cite information from the Journal of the American Medical Association (JAMA) article, which ranked cancer fighting drugs from 2009 through 2013 for effectiveness and cost. (1) Oncologists have embraced this new consumer decision aide as it provides health care purchasers and their families with another basis for decision making. And, as it often turns out, the most expensive medication is not necessarily the most effective. Using a scale of 0 to 130 rating system, the cancer drug treatments are ranked for efficacy. Here are the most expensive oncology medications, based on the analysis of experts at JAMA in this study, costs are expressed annually and their effectiveness ranking is listed below:
       RX Ranking by cost-

1. Omacetaxine for chronic myeloid lukemia-$168,366
2. Ibrutinib for mantle cell lymphoma-$157,440
3. Crizotinib for non-small cell lung cancer-$156,544
4. Pomalydomide for multiple myeloma-$150,408
5. Sorafenib for papillary thyroid cancer-$141,984
6. Regorafenib for colorectal cancer-$141,372
7. Ponatinib for chronic myeloid lukemia-$137,592
8. Trametinib for malignant melanoma-$125,280
9. Lenalidomide for mantle cell lymphoma-$124,870
10. Cabozantinib for medulliary thyroid cancer-$118,800

      Same RX showing effectiveness and extended life expectancy due to drug observed response
     Note that some of the drugs lack a proportional effectiveness ranking, this is not an omission.
     Observed effects are quoted from the JAMA article findings.

1. Omacetaxine for chronic myeloid lukemia-14.3% effectiveness, 12.5 months median observed effect
2. Ibrutinib for mantle cell lymphoma-66% effectiveness, 17.5 months median observed effect
3. Crizotinib for non-small cell lung cancer-7.7 months median observed effect versus 3 months on other treatment
4. Pomalydomide for multiple myeloma-29% effectiveness,7.4 months median observed drug effect
5. Sorafenib for papillary thyroid cancer-10.8 months median observed effect versus 5.8
6. Regorafenib for colorectal cancer-2 months median observed drug effect versus 1.7 for other
7. Ponatinib for chronic myeloid lukemia-54% effectiveness, 3.2 to 9.5 months median observed drug effect
8. Trametinib for malignant melanoma-4.8 months versus 1.5 median observed effect
9. Lenalidomide for mantle cell lymphoma-26% effectiveness, median observed effect 16.6 months
10. Cabozantinib for medulliary thyroid cancer-11.2 months median observed effect versus 4 months

As you can see, a high price tag does not assure a fantastic response rate, especially when compared to plain old chemotherapy. Or for example, the non-small cell lung cancer drug, Erlotinib (Tarceva) scored a 44% effectiveness rate and costs $4,600 per month versus the outrageously priced Crizotinib at more than twice that price. Also in comparison, the widely marketed Avastin drug for lung cancers scored only a 16% effectiveness ranking, and it costs $12,000 a month. (2)

Oncologists have banded together to create a Value Framework (3) from which patients and their families can assess the total efficacy of a cancer drug, including cost, response to drug, and a comparison to other treatments. This welcome tool is called a decision aide and it is the latest trend in getting health care quality and purchasing information to the individual patients.

Concern for the efficacy of health care treatments is being expressed by governments as well, with multiple states passing laws requiring drug companies to share their development cost data and not just the drug price. California, Massachusetts, North Carolina, Oregon, and Pennsylvania all have bills pending for pharmaceutical transparency and disclosure. (4) This is all part of the increased effort for greater transparency in health care, driven to the consumer, who actually has to pay for the insurance, the treatments, or the taxes for all of the above.  Although the pharmaceutical pricing model is price-to-whatever-the-U.S.-market-will-bear, this is increasingly becoming a free fall for the consumer who can't afford the treatment and for publicly funded health care programs which are balking at the price gouging.

In 2013, in my book, http://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972 I wrote about discerning quality in health care services and this is one more step in empowering patients and their families to make better decisions for their health treatments. To increase your health purchasing IQ continue to read what the healthpolicymaven has to say.  Other articles which may be of interest include:
http://healthpolicymaven.blogspot.com/search/label/cost%20of%20health%20care
http://healthpolicymaven.blogspot.com/2010/11/state-by-state-analysis-of-patient.html

And this is the healthpolicymaven signing off. This article does not offer medical advice and may be shared virally, with appropriate attribution to the writer of course. The healthpolicymaven is a graduate of the University of Washington School of Public Health and Community Medicine and the Daniel Evans School of Public Affairs.

(1) Sham Mailankody, MB BS¹; Vinay Prasad, MD, MPH,  Five Years of Cancer Drug Approvals, Innovation, Efficiency, and Costs, JAMA, July 2015, Volume 1 No. 4
http://oncology.jamanetwork.com/article.aspx?articleid=2212206&utm_source=google_plus_page&utm_medium=sohttp://oncology.jamanetwork.com/article.aspx?articleid=2212206&utm_source=google_plus_page&utm_medium=so

(2) Melissa Healy, Cancer Drugs get a new consumer's guide, Science Now, The Los Angeles Times, June 22, 2015
http://www.latimes.com/science/sciencenow/la-sci-sn-cancer-drugs-consumers-guide-20150622-story.html#page=1

(3)   Lowell E. Schnipper, Nancy E. Davidson, Dana S. Wollins, et, al. American Society of Clinical Oncology Statement: A Conceptual Framework to Assess the Value of Cancer Treatment Options,
American Society of Clinical Oncology, August 2015
http://jco.ascopubs.org/content/early/2015/07/08/JCO.2015.61.6706http://jco.ascopubs.org/content/early/2015/07/08/JCO.2015.61.6706

 (4) Andrew Pollack, Drug Prices Soar, Prompting Calls for Justification, The New York Times, July 23, 2015
http://www.nytimes.com/2015/07/23/business/drug-companies-pushed-from-far-and-wide-to-explain-high-prices.html?_r=0

Cutting Clinician Compensation for Primary Care Is Not the Answer-A Closer Look at Federal Programs

Centers for Medicare and Medicaid Physician Pay Cuts
Cutting Medicare and Medicaid payments to doctors will not engender more support for primary care, which is the weakest link in the chain in U.S. health care. This article examines federal programs established to create an improved healthcare system which have unintended consequences. Under the Budget Control Act of 2007, the Centers for Medicare and Medicaid (CMS) have been required to assess certain health care quality factors and integrate that data into clinician compensation. Initially, doctors were given incentives to show the quality of their care, but now the penalty phase has started. Also, please note, this law has nothing to do with the Affordable Care Act, so those of you with that myopathy, don't get your shorts in a bunch. Based on the Physician Quality Reporting System (PQRS) (1.) results from CMS, 470,000 doctors will get a 1.5% haircut, which is in addition to the overall budget reduction of 2% due to sequestration. (2.) So, in plain English, even the doctors whom managed to qualify for the PQRS quality bonuses, will not see that money, because the federal budget reduction exceeds that value.
Impact on Access to Care
Compensation is an important aspect of the U.S, healthcare system and the levels of reimbursement drive patient care and services. About half the doctors in the United States will not treat Medicaid patients because they cannot afford to do it. (3.) The expansion of Medicaid under the Affordable Care Act in 2010, is a lynch pin in the expansion of health insurance coverage and responsible for increasing access to basic health services for low-income people.
The idea of giving some programs budget restrictions while others are spending according to the  marketplace (private sector insurance plans) won't work. Healthcare budgets only work if everyone in the system is subject to the same constraints, incentives, and rules. In the U.S., our healthcare system is a series of separate systems tethered only by some government regulations and CMS reimbursements. Health care providers cannot afford to overlook Medicare patients, because that group represents 16% of the national population. (4.)  Of that figure, 20% of all health care services are for Medicare recipients and another 15% for Medicaid. However, health care providers do decline to accept new Medicare patients if they lack private Medicare supplement insurance. And of course many providers will not accept Medicaid patients at all.
How Can We Spend So Much and Still Have Poor Access?
 In 2013, the U.S. spent $9,255 per person, still vastly in first place for over spending on dubious health care results. In 2012, the Commonwealth Fund Mirror Mirror On the Wall Health Systems Comparison, shows the U.S. spent $8,508 per capita on health care.

The next largest per capita health care spend was in Norway at $5,669, still one third less than the U.S.A. (5.)  For those readers who may not be math wizards, the per capita measure is the great equalizer, as a country with a smaller population can be compared to a larger one based on this criteria. Some of my readers have complained that it isn't fair to compare smaller countries to the U.S. for health care, so here is a larger country comparison, France spent $4,118 per person in the same time period and it has a population of 68 million. Germany spent $4,495 and it has a population of 80 million. The U.S. population in 2013 was 316 million. However, just for giggles, I took most of the population of Europe and it's health care spend and compared that to the United States.  The combined annual per capita heath services spend was $4,407, after adjusting for proportion of population and national health care spend in this group of European nations comprising 339,789,381 people. (6.) This information was drawn from 10 large European countries with current 2013 health care spending information, expressed in U.S. dollars. So, even when you size up the included European country populations to an aggregate comparable to the USA, Europe still spends about half of what the U.S. does on health care for it's citizens. Europeans spend much less than the U.S. on health care because they have national health care systems, which have been shown to be highly effective in reducing waste, delivering sound primary health care, and serving everyone. They also use a fraction of what the U.S. does to administer their health care programs.
Current State of Affairs
CMS reports that hospital spending has decreased for all health care sectors, public and private. However, this means inpatient treatment, not necessarily stand alone or ambulatory facilities owned by hospitals has been reduced. Many procedures for orthopedic surgery, cardiac care, and chemo therapy are done on an outpatient basis now, so this accounts for some of the reduction of inpatient services. As in basic rules of economics, pressure or restriction in one economic sector will cause a corresponding change elsewhere in the system. In the case of Medicare we are seeing increased cost sharing on the part of Medicare enrollees, increased prescription drug costs, and an antiquated benefit design for basic Medicare coverage.
Suggestions for Improvement
Rather than punishing individual doctors for their onerous work loads and efforts to serve low-income patients, why not look at ways to make it easier for them to do so? Here are some ideas worth considering:

• For clinicians who demonstrate they have met the PQRS standard for 2 out of the preceding 3 years, why not give them a reporting waiver, and only audit them every other year?
• Look at ways to reduce the burden of paperwork within CMS and other regulatory agencies which would certainly provide relief to clinicians, and allow them more time to spend with patients.
• Rather than demanding an insurance wellness plan, why not allow firms to come up with creative approaches? For example, massage has been shown to have health benefits and could be provided to people before they experience restriction in movements and are in need of physical therapy. In our increasingly sedentary society we need to look at ways that inspire low-risk movement. Maybe a roving masseuse who gives chair massages in the office will prevent injuries, so why can't this be covered under preventive services?
• Annual physicals are considered the holy grail of wellness, but they can add to unnecessary medical tests which increase patient anxiety and have not been shown to extend life. I am thinking in particular of the numerous scans and imaging tests. Of course a high resolution MRI can find something wrong with you, but the question is, will it change your life expectancy?
• Automatic treatment protocols, such as the use of statins for lowering cholesterol have not been proven to prevent heart failure, but have been shown to be harmful to the kidneys and liver. The government needs to tread lightly on rewarding protocols as opposed to patient results, such as reduced emergency room admissions, or hospital re-admissions.And at the end of the day, the clinician does not have complete control over the patient's health.

The bi-partisan effort of Congress to scrap the current physician payment formula and find a more equitable and effective method to reward clinician work is a recognition of these problems.(7.) Can you believe it, House Speaker, John Boehner and Democratic Leader, Nancy Pelosi actually worked together on something!

Sources and Citations
(1.) Centers for Medicare and Medicaid
 http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2013MLNSE13__AvoidingPQRSPaymentAdjustment_083013.pdf
(2.)  Medscape.com
http://www.medscape.com/viewarticle/843815?src=wnl_edit_medn_wir&spon=34
(3.) Bloomberg News.com
http://www.bloomberg.com/bw/articles/2014-12-18/more-medicaid-patients-less-money-for-doctors
(4.) Kaiser Family Foundation.org
http://kff.org/medicare/state-indicator/medicare-beneficiaries-as-of-total-pop/
(5.) Commonwealth Fund Publications
.http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror
(6.) Office of Economic Development
OECD (2014), "Total expenditure on health per capita", Health: Key Tables from OECD, No. 2.
DOI: http://dx.doi.org/10.1787/hlthxp-cap-table-2014-1-en

(7.) Kaiser Health News.org

 http://kaiserhealthnews.org/news/faq-could-congress-be-ready-to-fix-medicare-pay-for-doctors-2/

Healthpolicymaven is a trademark of Roberta E. Winter and has been used continuously since 2007. This article reflects her views and if you find them compelling, feel free to share it virally, with appropriate attribution of course.

What is Global Warming?

Every time we drive a car, use electricity from coal-fired power plants, or cool or heat our homes with oil or natural gas, we release carbon dioxide (CO2) and other heat-trapping gases to the atmosphere. These gases act like a blanket, trapping heat and warming the Earth’s surface. The more of these gases we release, the thicker the blanket becomes.
Since the mid-1800s, our emissions of carbon dioxide have skyrocketed. There is more CO2 in the atmosphere now than there has been in the last 650,000 years. The burning of fossil fuel alone accounts for about 75% of the increase in CO2. Deforestation—the cutting and burning of forests that trap carbon—accounts for another 20%.
This heat-trapping blanket has warmed the Earth about 1°F during the past century. The last two decades are the warmest on record. Earth has not experienced such a rapid change in temperature in thousands of years. Unless we reduce the pollution that causes global warming, the world’s top scientists predict that temperatures could climb between 2.0° to 11.5°F this century.

Corporate CEO's Speak Out

In an open letter, published in Financial Times, 43 international CEO's from major corporations called upon world leaders to act on climate change. This is very good news. If we can get people other than scientists to urge action, especially powerful, influential people, then we might be able to get something done.

This letter was in the lead-up to the meeting that will be taking place in Paris this December to work on a climate change treaty. Let's hope enough pressure will be put on the world leaders they will find a way to get something meaningful done.

However, I believe we need to brace ourselves. The global warming deniers managed to spring some dirty tricks right before the last two conferences in an attempt to sabotage them. It is not unreasonable to expect them to do it again.