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Friday, August 28, 2009
Fwd: KMA Legislative Bulletin
Thursday, August 27, 2009
Fwd: AMA HSR Bulletin August 24, 2009
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Aug. 24, 2009
Here's your regular update on efforts by the American Medical Association (AMA) to work with lawmakers in reforming the nation's health care system in a way that provides quality, affordable health care for all.
Senate negotiations continue
The U.S. Senate Finance Committee has been continuing bipartisan negotiations during the August congressional recess in an attempt to reach an agreement on health system reform legislation. Committee Chair Max Baucus (D-Mont.) has publicly stated his hope of reaching consensus on the legislation by Sept. 15, although there are signs that this goal may slip. It is unclear how Baucus and the Democratic leadership will proceed if an agreement is not reached by then.
Potentially complicating those negotiations, Sen. Jon Kyl (R-Ariz.), the minority whip, recently spoke out against the idea of nonprofit insurance cooperatives, which some committee members favor as an alternative to establishing a public plan to compete with private health insurers.
Availability of health IT funds announced
The Department of Health and Human Services (HHS) made a long-awaited announcement last week regarding the availability of $1.2 billion in Health Information Technology for Economic and Clinical Health, or HITECH, Act funding to help physicians and hospitals implement and use electronic health records. During a roundtable discussion on health system reform, Vice President Joe Biden, HHS Secretary Kathleen Sebelius and David Blumenthal, MD, director of the HHS Office of National Coordinator (ONC), provided details about two grant programs—the Health IT Regional Extension Program and the State Health Information Exchange Program.
Under the Health IT Regional Extension Program, HHS will award $598 million in fiscal year 2010 to support the creation of 70 Health IT Regional Extension Centers. These centers will help support physicians and hospitals in their adoption of systems which allow them to become meaningful users of health IT. Learn more about the program. Meantime, the State Health Information Exchange Program will award $564 million to states and qualified "state designated entities" to develop and advance mechanisms for information sharing. Learn more about this program.
Additional information about both programs is available on the ONC Web site.
New AMA resources available
The AMA's new health system reform Web site contains resources for not only physicians but for their patients, too. By selecting the "resources" tab, physicians can download documents about medical liability reform, graduate medical education and the physician work force, and status and procedures for federal health system reform. A frequently updated question-and-answer document about the House health reform legislation, H.R. 3200, is also available. Resources for patients include a flier describing what health system reform would mean for patients, a document containing a list of answers to frequently asked questions by patients, and a resource detailing every component of health system reform for patients, from health insurance market reforms to comparative effectiveness research. And to help debunk some of the myths that patients have about health system reform, the AMA developed a Virtual Town Hall video, in which AMA members answer commonly asked questions. Check out the AMA's Facebook page and Twitter site to get the latest AMA happenings in health system reform via ongoing live updates.
Physician outreach efforts ongoing
AMA leaders continue to conduct a series of regional tele-town hall Physicians' Forums to respond to members' questions about health system reform legislation and the AMA's advocacy efforts. Physicians' Forums are planned through the first week of September, and a schedule of upcoming forums are listed under the "Important dates" section of this newsletter. In addition, AMA Immediate Past President Nancy H. Nielsen, MD, PhD, will share the AMA's perspective on health system reform with physician leaders and the media in Detroit, Lansing and Grand Rapids, Mich., tomorrow, Aug. 25, and Wednesday, Aug. 26, as part of the AMA's National House Call campaign.
Cooperatives' Record Weighed in Health-Care Debate
Cooperatives' Record Weighed in Health-Care DebateBy Steven Mufson
Washington Post Staff Writer
Thursday, August 27, 2009
Sen. Kent Conrad (D-N.D.), a pivotal lawmaker in the health-care debate, wants to deliver coverage to the uninsured by starting up new cooperatives modeled on rural electric cooperatives that were founded during the Great Depression.
But rural electric cooperatives have a mixed track record, experts say. They brought electricity to millions of rural Americans who lacked it in the 1930s and today serve about 14 percent of Americans. But after 75 years, the rural electric cooperatives still rely heavily on federal credit subsidies, have weak balance sheets and, some studies suggest, operate less efficiently than privately-owned utilities.
Over the past three years, some rural electric cooperatives have also come under criticism for excessive payments to executives and for pushing forward with new coal-fired power plants at a time when many people concerned with climate change want to slow down or halt such plants. Yet they remain politically powerful through the National Rural Electric Cooperative Association.
Rep. Jim Cooper (D-Tenn.), a critic of rural electric cooperatives, agrees with Conrad that health-care cooperatives could help provide coverage for the roughly 47 million uninsured Americans. "I want everybody covered and I want it to be affordable," Cooper said. "Co-ops could do that. They are a time-honored mechanism for almost all of rural America. . . . They're kind of an interesting third way, halfway between the public and private sector."
But he warns that the new cooperatives would require close regulation to avoid many of the problems he says afflict rural electric co-ops. "You still have to watch co-ops like a hawk," he said. He said that rural electric cooperatives "became too big for their britches" and "indistinguishable from for-profit firms except that they love government subsidies." In an article in the Harvard Journal on Regulation last year, Cooper argued that rural electric co-ops "turned away from their historic role" and had taken on "deeply troubling anti-consumer behaviors."
Serving Rural Needs
Rural electric cooperatives -- nonprofit organizations owned by their customers -- date back to 1935, when President Franklin D. Roosevelt created the Rural Electrification Administration to bring power to poor and remote farm areas. Rural poverty at the time was captured in the 1939 book of photos by Walker Evans and text by James Agee titled "Let Us Now Praise Famous Men," which Agee opens by describing writing by the light of a coal-oil lamp.
Today, electric lines reach into virtually every household in America, and many of the once-rural areas served by cooperatives have become part of sprawling urban areas, such as Dallas-Fort Worth or Northern Virginia.
Yet they still rely on cheap, subsidized financing from the Rural Utilities Service, part of the Agriculture Department, which provides direct loans and loan guarantees. Co-ops also get financing from the National Rural Utilities Cooperative Finance Corp., a cooperative bank that in turn relies on billions of dollars of low-cost financing from the federal government and the Federal Agricultural Mortgage Corp., a government-sponsored enterprise commonly known as Farmer Mac.
On June 11, Farmer Mac chief executive Michael A. Gerber said in congressional testimony that Farmer Mac had lent the CFC $1.8 billion and that it planned to boost that figure by another $1 billion. He said Farmer Mac planned to pool the loans, turn them into securities, provide guarantees of timely payment and sell them to investors.
"A co-op by definition has several major advantages over private tax-paying corporations," said Ken Glozer, a former Office of Management and Budget official and president of a consulting firm called OMB Professionals. "They don't pay taxes, they borrow all their money from the U.S. government because they because can't raise capital, and they are political as hell because they depend on the government. Over time they will seek and get untold favors that a private company won't be able to get."
Glozer added that cooperatives are "quasi-federal agencies."
Debating the Model
Conrad argues that co-ops can be effective, citing the success of the model at Land O'Lakes, Ace Hardware and Group Health, a health-care co-op with 600,000 members in Washington state, as well as the rural electric co-ops. In a recent opinion piece published in USA Today, he said that co-ops would be "a public-interest alternative, but consumer-controlled and not government-run."
But others have reached different conclusions. In his article on rural co-ops last year, Cooper said: "Co-ops in some regions of the country have been doing a particularly poor job of protecting member interests."
Robert D. Reischauer, president of the Urban Institute and former director of the Congressional Budget Office, said rural electric cooperatives aren't a good model for health insurance regardless of their track record.
"Those were providing a service where no private enterprise wanted to operate because the population density was too low and the capital costs were too high," he said. "And what we're talking about is trying to create a viable insurer that would operate in metropolitan areas and rural areas and suburban areas."
Reischauer added that a firm capable of providing effective health insurance needs to be big, because that would bring economies of scale in administration and market power necessary to bargain with health-care providers. Rural electric cooperatives, by contrast, tend to be local. There are around 800 rural electric cooperatives nationwide, including 16 in Conrad's home state of North Dakota.
"What you want is something that is big and nimble at the same time," Reischauer said.
Wednesday, August 26, 2009
End-of-life care provision stirs angst in health reform debate
By Kevin B. O'Reilly, AMNews staff. Posted Aug. 24, 2009. The public outrage over reimbursement for patient counseling catches doctors by surprise but shows how delicate the discussion over advance-care planning can be.A relatively obscure provision in the House's massive health system reform legislation that would reimburse physicians for counseling Medicare patients about end-of-life care options came under intense fire from conservative opponents in August. The political fallout prompted a group of six senators working on health system reform to drop the idea from ongoing negotiations. The House may follow suit when Congress reconvenes in early September, sources said. But physicians said the controversy shows that despite decades of focus on helping patients choose what -- if any -- interventions they want as they die, end-of-life care remains a political and ethical tripwire. Republicans, conservative commentators and boisterous activists at congressional town hall meetings condemned the provision, Section 1233 of HR 3200, as part of a larger plan to ration medical care. In a post to her Facebook page, 2008 GOP vice presidential candidate Sarah Palin said the measure would place seniors before "death panels" who would decide what care they should receive. 30% of Medicare funds each year are spent on terminal care for 5% of the program's patients. The advance-care consultations eligible for Medicare reimbursement "are part of a bill whose stated purpose is 'to reduce the growth in health care spending,' " Palin wrote. "Is it any wonder that senior citizens might view such consultations as attempts to convince them to help reduce health care costs by accepting minimal end-of-life care?" The American Medical Association, which supports HR 3200, tried to set the record straight. "There has been a lot of misinformation about the advance-care planning provisions in the bill," AMA President J. James Rohack, MD, said in a statement. "Simply put, the bill would create a new Medicare benefit to pay physicians for time spent on advance-care planning consultations with seniors. It would be completely voluntary, and it will allow patients, if they wish, to discuss a broad range of issues, including hospice, living wills, advance directives and appropriate pain care. "These are important discussions everyone should have so they are fully informed and can make their wishes known. That's not controversial, it's plain, old-fashioned patient-centered care." Under the legislation, physicians could bill Medicare for advance-care planning consultations once every five years or when the patient's health conditions change dramatically. In states that have standardized life-sustaining treatment order forms, doctors could counsel patients about their choices and complete that documentation. The bill also calls for consensus standards on how to measure the quality of doctors' and hospitals' performances in carrying out patients' end-of-life care wishes. Doctors dismayedThe political wildfire that flamed over a seemingly innocuous provision left many doctors and end-of-life care experts bewildered and dismayed. "I'm disgusted," said Anthony L. Back, MD, professor of oncology at the University of Washington School of Medicine and an oncologist at the Fred Hutchinson Cancer Center, part of the Seattle Cancer Care Alliance. Dr. Back's research has focused on how to remove barriers that prevent doctors and patients from communicating about end-of-life care decisions. Studies have shown that the 5% of Medicare patients who die each year account for 30% of Medicare's costs, with 78% of last-year-of-life expenses occurring in the month before death. A March 9 Archives of Internal Medicine study of 603 dying cancer patients at seven hospitals, oncology clinics and hospices found that care for patients who had end-of-life discussions with their physicians cost $1,295, compared with $2,780 for patients who did not have such talks. Dr. Back said encouraging physicians to have extended counseling sessions with their patients through the Medicare system could help patients get the care they want at the end of their lives while saving the health system money. 78% of medical expenses during the final year of life occur in the month before death. "But," he added, "I don't see any meaningful public discussion about this going on at all. The whole issue is just politically unsalvageable." Joseph W. Stubbs, MD, president of the American College of Physicians, agreed that the legislation's intent was mischaracterized by its opponents. "The provisions in the HR 3200 legislation providing for payment to physicians for advance-care planning became a hook used by political ideologues," Dr. Stubbs said. "It's basically become an ideological war about what role government should play in terms of the personal lives of individuals and has little to do with advance-care planning." Criticism of the measure has been "completely absurd," said Neil S. Wenger, MD, MPH, professor of medicine and director of the University of California, Los Angeles Health System Ethics Center. He was lead author of an August 2008 report to Congress on advance directives and advance-care planning that influenced the House provision. "Advanced-care planning has been a recommended care process for several decades, especially for the last 10 or 15 years. For there to be concern that it some way violates people's rights, especially the most sick at whom it's actually aimed, is bizarre," Dr. Wenger said. Some physicians, while reticent to echo the "death panel" rhetoric, did voice concern about the end-of-life care measure. "I'm dubious about Congress getting into the specifics of how physicians should interact with their patients and how to plan in the case of someone who's terminally ill," said Mark Schiller, MD, a psychiatrist in the San Francisco Bay area and a board member of the Assn. of American Physicians and Surgeons, which opposes the Democratic reform plans. "That's just not the place of Congress." Overall, though, the controversy signals a more universal problem. Americans are uncomfortable talking about end-of-life care and costs, Dr. Wenger said. "People are so afraid of this discussion that they can't even tolerate this occurring between one doctor and the patient, let alone at the societal level." This content was published online only. ADDITIONAL INFORMATION:Standardizing end-of-life decisionsUnder the House's health system reform plan, doctors in states with standardized forms for life-sustaining treatments would be reimbursed for discussing such interventions with patients as part of an advance-care planning consultation. Eight states currently use the Physician Orders for Life-Sustaining Treatment form, and nearly two dozen others are developing programs to use the standardized order set. POLST documents whether patients or their surrogates want the following interventions under certain end-of-life circumstances:
Source: "Physician Orders for Life-Sustaining Treatment," Oregon Health & Science University Center for Ethics in Health Care (www.ohsu.edu/polst/programs/documents/POLST.JUNE.2009sample.pdf) Weblink"Health care costs in the last week of life: Associations with end-of-life conversations," abstract, Archives of Internal Medicine, March 9 (archinte.ama-assn.org/cgi/content/abstract/169/5/480) "Advance Directives and Advance Care Planning: Report to Congress," U.S. Dept. of Health and Human Services, August 2008 (aspe.hhs.gov/daltcp/reports/2008/adcongrpt.htm) Sample "Physician Orders for Life-Sustaining Treatment" form, Oregon Health & Science University Center for Ethics in Health Care (www.ohsu.edu/polst/programs/documents/POLST.JUNE.2009sample.pdf) |
Tuesday, August 25, 2009
Two state courts, same ruling: Informed consent must include all options
Doctors say the Maryland and Wisconsin decisions could lead to their judgment being second-guessed and undermine patient care.
By Amy Lynn Sorrel, AMNews staff. Posted Aug. 24, 2009.
Separate high court rulings in Maryland and Wisconsin may impose greater liability risks on physicians who fail to tell patients about treatment options.
Doctors must inform patients of all relevant treatment alternatives and the risks, according to unanimous decisions issued separately July 24 by the Maryland Court of Appeals and the Wisconsin Supreme Court. The two courts also clarified that proof of medical negligence is not required for plaintiffs to bring an informed-consent claim.
"The gravamen of an informed consent claim ... is a health care provider's duty to communicate information to enable a patient to make an intelligent and informed choice," the Maryland court said. "The law does not allow a physician to substitute his judgment for that of the patient," judges said, citing a court precedent.
Physicians don't deny their responsibility to advise patients about treatment risks. But they say the rulings could do more harm than good to patient care if they have to give patients too much information or if their judgment is second-guessed.
"This brings doctors closer to having to provide a whole universe of information," said Wisconsin Medical Society General Counsel Ruth Heitz. This can be problematic, "particularly when they may not be specialists in all areas." The WMS was not involved in the case.
"No physician wants a patient who is uninformed. But giving them a whole lot of technical information they can't understand or use doesn't increase choice. It makes the right choice less likely," Heitz said.
Maryland medical liability defense attorney J. Mark Coulson said the ruling there gives plaintiffs another avenue for recovery even when a doctor has met the standard of care.
"This opens up the area of physician judgment to patient override and gives the jury two bites at the apple on liability," said Coulson, an executive committee member of the Maryland Defense Counsel Inc. The trade organization was not tied to the state case. MedChi, the Maryland State Medical Society, was not involved in the case but is monitoring the ruling's impact.
Plaintiff lawyers, on the other hand, view the decisions as a reaffirmation of doctors' existing obligations to continuously involve patients in medical decision-making.
"Why should a doctor decide whether a patient gets a particular therapy, or surgery or nothing?" asked Henry E. Dugan Jr., a plaintiff attorney in the Maryland case. "Any one of those may be acceptable to the medical profession, but not necessarily to the individual patient. So why shouldn't the patient have a say?"
A duty to inform
The Wisconsin case heads back to a trial court to decide if there were other reasonable treatment options for Richard Bubb, who presented in a hospital emergency department in 2001 with stroke-like symptoms. After several tests and an improvement in Bubb's condition, emergency physician William Brusky, MD, discharged him and arranged follow-up care with a neurologist.
Before that appointment, however, Bubb had a large-scale stroke. He alleged that Dr. Brusky had failed to inform him of the option to stay in the hospital for an ultrasound that could have detected the problem more quickly.
Meanwhile, the Maryland decision reinstates a $13 million verdict against ob-gyn Donald Spangler, MD, after a jury found that he failed to offer Peggy McQuitty the option of an immediate C-section when an abnormality was detected in an ultrasound. In 1995, Dr. Spangler counseled the woman, who was 32 weeks pregnant, to continue the pregnancy to prevent the risks of premature delivery, and after monitoring the abnormality, planned to schedule a C-section. Before then, however, McQuitty had a complete placental abruption, requiring an emergency procedure. Her son was born with cerebral palsy.
Juries in both cases found no deficiencies in the doctors' care. The physicians argued that because they adequately informed the patients of the diagnosis and proposed treatment, they should not be held liable.
The Maryland and Wisconsin high courts found that the other treatment options were equally valid under the standard of care and that juries could conclude physicians should have disclosed them to their patients. The courts said informed consent claims depended not on the doctors' actions, but on a patient's right to know.
"These are two separate responsibilities," said Lynn R. Laufenberg, past president of the Wisconsin Assn. for Justice. The trial lawyers organization filed a friend-of-the-court brief in the Wisconsin case.
The Wisconsin Supreme Court reaffirmed that state law requires doctors to tell patients about "all alternate, viable medical modes of treatment, including diagnosis, as well as the benefits and risks of such treatments."
Maryland judges similarly found that doctors could be liable for withholding or failing to provide information relevant to deciding a particular course of treatment. In a rare move, the court concluded that a precedent was interpreted incorrectly as limiting informed consent claims to cases in which a patient underwent a medical procedure and the doctor failed to inform the patient of the risks of that treatment.
How much is enough?
The two courts noted certain limitations on doctors' duties. For example, physicians are required to divulge only those treatment risks and options that a reasonable patient would want to know if faced with the same care decision. Plaintiffs still must prove that another treatment option, if chosen, would have prevented the alleged harm, Laufenberg said.
The Wisconsin court cited other specific exceptions in its statute that do not require disclosure of information beyond what a doctor in a similar field would know, or technical information a patient would not understand.
But the court's decision appears to erode those exceptions, the Wisconsin Medical Society's Heitz said. "As technology advances and there are more and more options, the question is where do you draw the line? And doctors who are not specialists may be left wondering: How much do I need to do?"
Defense attorney Coulson said the Maryland decision similarly expands on doctors' obligations and puts them in the position of having to consult patients on treatment decisions every step of the way.
"Patients should be involved in the conversation, but it's unfair to boomerang all medical decisions back to them when they are not equipped to make calls on a moment-to-moment basis," he said. "At some point, patients have the right to rely on a doctor's expertise, recognizing that [physicians] will be held to the standard of providing reasonable care. That was always the dividing line between informed consent and negligence. Now it's everything with the 20/20 hindsight litigation has."
This content was published online only.
ADDITIONAL INFORMATION:
Cases at a glance
Can patients sue doctors for failing to provide enough information on treatment risks and alternatives?
The Maryland Court of Appeals and Wisconsin Supreme Court said yes, in separate rulings.
Impact: Physicians say the decisions expand their obligations under state informed-consent laws and will harm patient care if doctors have to overexplain their medical judgment. Plaintiff attorneys say the rulings reaffirm patients' rights to be involved in their care.
Dylan McQuitty v. Donald Spangler, MD, Maryland Court of Appeals; Richard Bubb v. William Brusky, MD, Wisconsin Supreme Court
Monday, August 24, 2009
White House redirects health reform spotlight to insurance abuses
An HHS report documents insurance discrimination against members and denials of coverage; insurers counter with report on high out-of-network physician fees.
By Chris Silva, AMNews staff. Posted Aug. 24, 2009.
Backers of health system reform show their support during an Aug. 5 visit by President Obama near Elkhart, Ind. Obama insists that despite some public protests, many Americans still favor reform. [Photo by Sam Riche / Indianapolis Star / Rapport Syndication]
Washington -- President Obama has been crisscrossing the nation to push health system reform this month, conducting his own town hall meetings and placing a new emphasis on overhauling the insurance industry in an attempt to wrest back control of the increasingly incendiary debate.
Lawmakers who support a public health insurance plan option are facing scores of vocal opponents at public events. Protesters accuse reform backers of supporting socialized medicine and government-mandated euthanasia, among other charges. In response to the flak, the Obama administration appears to have shifted gears by attempting to sell health system reform as "health insurance reform" -- a term White House officials began using consistently in early August.
Administration officials have started pointing more frequently to alleged insurance industry abuses as a major reason why it's in the average citizen's best interest to support the broader reform effort. Speaking at a town hall in Grand Junction, Colo., on Aug. 15, Obama immediately addressed insurance companies and discussed "the millions of people denied coverage because of preexisting conditions.""Yesterday, I was in Montana talking about people who've had their insurance policies suddenly revoked, even though they were paying premiums, just because they got sick," Obama said. "And today we're talking about the folks ... who have insurance but are still stuck with huge bills because they've hit a cap on their benefits or are charged exorbitant out-of-pocket fees."
As part of the new strategy, the Dept. of Health and Human Services on Aug. 11 released a report examining the insurance industry's alleged discriminatory practices, including citing preexisting conditions as a reason for denying coverage.
The report highlights a research paper that examined 2007 health care data and concluded that, over a three-year period, 12.6 million nonelderly adults were denied coverage by an insurance company due to preexisting conditions. The paper was published in July by the Commonwealth Fund.
The HHS report also cited statistics on rescission. The term refers to a practice by which insurance companies review a member's application questionnaire after the insured is diagnosed with a costly condition such as cancer, and then retroactively cancel the policy if any preexisting condition was misrepresented. Critics say rescissions occur even if patients were not aware of their medical conditions at the time they applied.
"At least one insurance company has been found to evaluate employee performance based in part on the amount of money an employee saved the company through rescissions," HHS stated. Throughout the release for the report, the department referred to overall health reform as "health insurance reform."
Competing rhetoric
Administration officials are not the only ones turning up the heat on the insurance industry as they attempt to sustain a reform effort that is under stress.
House Speaker Nancy Pelosi (D, Calif.) recently stated publicly that insurers are "almost immoral" and have served as "the villains" in the health system reform debate. Other members of the administration and Congress have suggested that the industry is sponsoring some of the disruptive anti-reform protests that have gained so much publicity during the congressional August recess.
Insurers denied coverage to 12.6 million nonelderly adults in 2007 due to preexisting conditions.
Insurance industry representatives said the new wave of criticism against them is a simple attempt to distract attention away from the declining support for a public plan option.
"An orchestrated, fabricated and irresponsible disinformation campaign is being waged against health plans and their employees," said Robert Zirkelbach, spokesman for America's Health Insurance Plans. AHIP denied that it was behind any of the organized protests.
AHIP also countered the HHS report with its own study looking at the high rates some out-of-network physicians are charging patients. The Aug. 12 report researched by Dyckman & Associates examined the 30 largest states and said some physicians who don't take insurance are charging patients "startling" fees for a variety of services. For example, a physician in one state billed a patient $6,791 for cataract surgery with the insertion of an artificial lens -- more than 11 times what Medicare pays for the same treatment, the AHIP report said.
"As policymakers pursue health care reform, we encourage them to look at how much is being charged for services, particularly since higher charges don't mean high quality of care," said Karen Ignagni, AHIP's president and CEO. She also dismissed charges that insurers are an enemy of reform, noting that AHIP first proposed health insurance reform last year. That proposal would have guaranteed no one is denied coverage because of a preexisting condition, provided the federal government required everyone to obtain insurance.
Physicians respond
The American Medical Association dismissed the AHIP report as a tactic to deflect attention away from insurers as Congress continues its drive to craft health system reform.
"To call this narrowly focused report representative of the physician community is flat-out wrong and insulting to dedicated physicians who provide medical care daily to their patients," said AMA President J. James Rohack, MD. "This is nothing more than an attempt to divert blame for inflated out-of-network charges from where it belongs -- on insurers. This is a grossly misleading report that focuses solely on finding extreme outliers in the billions of health insurance claims filed annually."
Dr. Rohack said the database insurers have used for nearly a decade to determine out-of-network pay rates is flawed, and that a Senate report released June 24 confirms that insurers "shortchange patients to increase their profits." Sen. John Rockefeller (D, W.Va.), chair of the Commerce, Science and Transportation Committee, said his panel's report revealed that "millions of Americans have been forced to pay unjustified extra charges for health insurance coverage when they go out of network."
On the AHIP study, Dr. Rohack went on to say that "the only thing this report proves is that health system reform must include insurance market reforms so that insurance better serves patients."
This content was published online only.
ADDITIONAL INFORMATION:
A tactical strike on insurers
A new Dept. of Health and Human Services report aimed at changing the focus of the health reform debate cites statistics showing that more than 12 million adults with preexisting conditions were denied insurance coverage between 2004 and 2007. Other findings in the Aug. 11 report include:
- 3 large insurers conducted nearly 20,000 rescissions over 5 years, saving them $300 million in medical claims.
- Only 8% of the uninsurable population can afford the high premiums to enroll in high-risk coverage pools.
- All high-risk pools exclude coverage of preexisting conditions for 6 months to a year.
- 1 in 10 people with cancer reports not being able to obtain health coverage because of the diagnosis.
- 9 states still allow insurers to cite a history of domestic violence as a preexisting condition and as grounds for rejecting a coverage application.
Source: HHS Office of Health Reform (www.healthreform.gov/reports/denied_coverage/coveragedenied.pdf)
Saturday, August 22, 2009
Heart attack deaths fall after Medicare guidelines
Tue Aug 18 20:58:34 UTC 2009
WASHINGTON (Reuters) - Clearer U.S. guidelines on how to treat elderly heart attack patients appear to have saved lives, with a marked reduction in heart attack deaths over 10 years, researchers reported Tuesday.
They found a 3 percent drop in the number of patients who died within a month of having a heart attack between 1995 and 2006, after Medicare started applying clearer standards on treatments.
"Among Medicare beneficiaries, for every 33 patients admitted in 2006 compared with 1995, there was 1 additional patient alive at 30 days," Dr. Harlan Krumholz of the Yale University School of Medicine in Connecticut and colleagues wrote in the Journal of the American Medical Association.
They also found a lot less variation in death rates from one hospital to another -- a finding that might support healthcare reform efforts that include more standardized guidelines on patient care.
Krumholz and colleagues studied the records of 2.7 million patients discharged from 4,000 hospitals after having heart attacks between 1995 and 2006.
The patients were over the age of 65, when Medicare, the federal health insurance plan for the elderly, kicks in.
In the past, various hospitals have had highly differing success rates in treating heart attack. Doctors have many choices -- angioplasty to clear out clogged arteries, heart bypasses or drugs to lower cholesterol, reduce clotting and regulate heart beat.
In 1990, the American College of Cardiology and the American Heart Association published joint guidelines on which care was appropriate and when. Medicare followed in 1992.
This appeared to help, said Krumholz. "The 30-day mortality rate decreased from 18.9 percent in 1995 to 16.1 percent in 2006, and in-hospital mortality decreased from 14.6 percent to 10.1 percent," his team wrote.
"Although the cause of the reduction cannot be determined with certainty, this finding may reflect the success of the many individuals and organizations dedicated to improving care during this period."
And the worst hospitals did a lot better. In 1995, 24 percent or more of heart attack patients died within a month after being treated at 39 hospitals.
By 2006 the worst death rate, in 1 percent of hospitals, was 19.5 percent.
"The change resulted from a shift in the entire spectrum of performance among hospitals and a decrease in the variation in performance," Krumholz and colleagues wrote.
Congress is working on healthcare reform, the signature policy of President Barack Obama. Obama has said better quality of care can bring down costs but none of the proposals being considered yet addresses this issue.
A report last week from Thomson Reuters found stressing quality care helped heath systems, with the best-performing 20 percent seeing 25 percent fewer deaths than the 20 percent worst performers.
WASHINGTON (Reuters) - Clearer U.S. guidelines on how to treat elderly heart attack patients appear to have saved lives, with a marked reduction in heart attack deaths over 10 years, researchers reported Tuesday.
They found a 3 percent drop in the number of patients who died within a month of having a heart attack between 1995 and 2006, after Medicare started applying clearer standards on treatments.
"Among Medicare beneficiaries, for every 33 patients admitted in 2006 compared with 1995, there was 1 additional patient alive at 30 days," Dr. Harlan Krumholz of the Yale University School of Medicine in Connecticut and colleagues wrote in the Journal of the American Medical Association.
They also found a lot less variation in death rates from one hospital to another -- a finding that might support healthcare reform efforts that include more standardized guidelines on patient care.
Krumholz and colleagues studied the records of 2.7 million patients discharged from 4,000 hospitals after having heart attacks between 1995 and 2006.
The patients were over the age of 65, when Medicare, the federal health insurance plan for the elderly, kicks in.
In the past, various hospitals have had highly differing success rates in treating heart attack. Doctors have many choices -- angioplasty to clear out clogged arteries, heart bypasses or drugs to lower cholesterol, reduce clotting and regulate heart beat.
In 1990, the American College of Cardiology and the American Heart Association published joint guidelines on which care was appropriate and when. Medicare followed in 1992.
This appeared to help, said Krumholz. "The 30-day mortality rate decreased from 18.9 percent in 1995 to 16.1 percent in 2006, and in-hospital mortality decreased from 14.6 percent to 10.1 percent," his team wrote.
"Although the cause of the reduction cannot be determined with certainty, this finding may reflect the success of the many individuals and organizations dedicated to improving care during this period."
And the worst hospitals did a lot better. In 1995, 24 percent or more of heart attack patients died within a month after being treated at 39 hospitals.
By 2006 the worst death rate, in 1 percent of hospitals, was 19.5 percent.
"The change resulted from a shift in the entire spectrum of performance among hospitals and a decrease in the variation in performance," Krumholz and colleagues wrote.
Congress is working on healthcare reform, the signature policy of President Barack Obama. Obama has said better quality of care can bring down costs but none of the proposals being considered yet addresses this issue.
A report last week from Thomson Reuters found stressing quality care helped heath systems, with the best-performing 20 percent seeing 25 percent fewer deaths than the 20 percent worst performers.
Friday, August 21, 2009
A Nurse’s View of Health Reform
The New York TimesBy Theresa Brown, R.N.
Oncology nurse Theresa Brown is a regular contributor to Well.
I saw a bumper sticker a few days ago that said, “I used up all my sick days so I called in dead.” I liked it because it was absurd, but also because it seemed so apt to the battle raging right now over reforming health care in America.
I could offer a tableau of stories, but instead I will tell just one. A patient we had several months ago was admitted for leukemia treatment. In his 60s, kind and immensely likable, he went through three different rounds of what we call “induction chemo” — the regimen and dose designed to cure. But in trying to cure his leukemia we’d weakened his immune system to such an extent that he no longer had any reserve, and fluids and intravenous antibiotics could not save him from the infection growing in his lungs.
I took care of this patient fairly often, and I got pretty attached to him. I had the privilege of being in his room when he told me, with tears in his eyes, that his first granddaughter had been born that day in a different hospital across town. A Pittsburgh Steelers fan, he hung a “terrible towel” from the TV in his room and grumbled whenever we dislodged it with the I.V. pole. One of his chemo regimens included the drug Topetecan, and the name of this drug led to many jokes: about drinks with little umbrellas called Topetecans, an entire island paradise named Topetecan, even the walks he and his gentle wife took prompted the question, “Are you dancing . . . the Topetecan?”
The dark side of this patient’s visit, in addition to his fight for his life against a very aggressive disease, was that he did not have good health insurance. We talked about it. He was in business for himself selling insurance, but his own personal health insurance was inadequate and didn’t cover all the care he was getting. They were a solidly middle-class family, and he explained that if he had any medical bills in the past he just paid for them out of pocket. Getting leukemia was not part of the plan, and neither was an unexpected six week hospital stay that included thousands of dollars of chemotherapy.
Six weeks is a standard amount of time for new leukemia patients going through their first round of induction chemo. We make them so vulnerable to infection that we keep them in the hospital to ensure quick action if they do get sick. This patient’s six weeks turned into two months, and then three months, as one chemo regimen after another made no headway against his disease.
During periods when he was feeling sort of O.K., he was constantly on the phone and the Internet trying to find a way to pay his mounting hospital bills. He told me, “I know there’s money out there; I just have to find it.” He was confident that he could locate money for his care and that he would “beat” the cancer.
And then I came to work one day, and he was dead as a result of pneumonia. During the fraught and too quick final three months of his life, the cost of his care weighed on him as heavily as his possible death. His wife lost her husband. In addition to mourning him, is she also saddled with a medical debt that will burden her for years to come?
Can we all agree that the worry provoked by any kind of serious illness should not be compounded with the concern that we cannot afford the treatment we need?
I’m a nurse so I’m focused on need, and the treatment required to save someone’s life represents a profound need. It is also a need that is always unanticipated. My patient thought he had planned well for his health care needs. He just never thought he would wake up one day with a diagnosis of leukemia.
But which of us does? And that’s why we need health care reform. My patient was savvy about the business side of health insurance, but not about how cruel and unfair life can be. He was suddenly confronted with an illness, and treatment costs, outside the realm of his imagination. Any of us could wake up tomorrow and find ourselves in the same terrible predicament: really sick, needing treatment we can’t afford.
So I ask the people who oppose health care reform to consider what they would do if they found themselves in my patient’s situation — because they very well could, sooner than they know. Any of us could wake up sick, without the coverage we need, in danger of losing the very job that gives us health insurance. Our lifetime cap on insurance, which we never thought we would approach, can be brought so near that the question of costs cannot be separated from the treatment needed to stay alive.
I have no statistics to support the need for reform; I can only describe what I have seen, because what I have seen brings the discussion of health care reform down to the level of individuals. What do you do when you’ve used up all your sick days and you’re still too sick to go to work? And what if you’ve reached the cap on your health insurance, need a drug that isn’t covered by your plan, or require a scan that you can’t possibly pay for?
Thursday, August 20, 2009
Phys Ed: Does Exercise Reduce Your Cancer Risk?
By Gretchen Reynolds
Finnish researchers recently concluded that, if you wish to ward off lung or gastrointestinal cancer, you might want to spend your leisure time jogging instead of picking berries, mushroom gathering or fishing. In the study, published in late July on the Web site of the British Journal of Sports Medicine, scientists studied the health of a group of 2,560 middle-aged Finns over the course of about 17 years. The subjects, all men living in eastern Finland, kept diaries of their daily activities for a year and then went about them.
Aubrey Jonsson/Getty Images
Finnish researchers recently concluded that, if you wish to ward off lung or gastrointestinal cancer, you might want to spend your leisure time jogging instead of picking berries, mushroom gathering or fishing. In the study, published in late July on the Web site of the British Journal of Sports Medicine, scientists studied the health of a group of 2,560 middle-aged Finns over the course of about 17 years. The subjects, all men living in eastern Finland, kept diaries of their daily activities for a year and then went about them.
At the start of the study, none had cancer. By the end, 181 had died of the disease. Parsing the men’s activity levels, the researchers determined that, after controlling for cigarette smoking, fiber and fat intake, age, and other variables, the most physically active men were the least likely to develop cancer, particularly of the gastrointestinal tract or the lung. Even more striking, the intensity of the exercise was key. The more arduous it was, the more protective it proved. Jogging was the most strenuous activity studied, fishing among the least. The men who jogged or otherwise exercised fairly intensely for at least 30 minutes a day had “a 50 percent reduction in the risk of dying prematurely from cancer,” says Sudhir Kurl, medical director of the School of Public Health and Clinical Nutrition at the University of Kuopio in Finland and one of the study’s authors.
It seems fair and just that conscientiously working out should confer disease-fighting benefits, especially against cancer, and an accreting body of research suggests that under certain conditions and against certain forms of cancer, fitness may be remarkably protective. A major review article published in February on the Web site of the British Journal of Cancer synthesized the results of more than two decades’ worth of studies and concluded that the most active people are 24 percent less likely to develop colon cancer than sedentary people are, regardless of their diets, smoking habits or body weight. Another study, this one presented in May at the annual meeting of the American College of Sports Medicine reported that women over age 30 who defined themselves as “highly competitive” by disposition and who exercised more than the average for the group had much less risk of developing breast cancer than women who worked out for less than 60 minutes per week.
What these recent studies, including the one from Finland, share is the suggestion that, in order to use exercise to reduce the risk of cancer, you must make yourself sweat. In the Finnish study, the most beneficial exercise was both frequent and demanding. The researchers used METs (an acronym for metabolic equivalent of task, a numerical comparison of the oxygen or energy used during an activity versus the amount used at rest) to characterize their subjects’ exercise habits. A MET of 1 is the equivalent of lolling inertly on the couch. In his study, jogging steadily for 30 minutes or so represented a MET of about 10. The men whose METs reached at least 5 almost every day were the least likely to die of cancer, especially of the lung or the gastrointestinal tract. Similarly, in one of the studies included in the colon cancer review, women who walked briskly for five to six hours a week were much less likely to develop colon cancer than those who strolled for 30 minutes per week. And in the bogglingly comprehensive 2008 national Physical Activity Guidelines Advisory Committee report prepared for the secretary of health and human services, which includes a chapter about exercise and cancer, the authors concluded that when it comes to breast cancer, “one hour per day of moderate or vigorous activity produces greater reduction in risk” than the two and a half hours of moderate exercise per week that are currently recommended by the surgeon general.
The Finnish researchers admit that, like other scientists studying activity and cancer, they don’t know just how or why brisk exercise affects risk or why only some types of cancer are affected. Exercise long has been known to speed the emptying of the colon, which may reduce the amount of time that carcinogens linger in the organ, the Finnish scientists point out. Strenuous exercise also affects the production of sex hormones in men and women, and — particularly in the case of estrogen and breast cancer — may by that mechanism reduce cancer formation. Other scientists have posited that the panting involved in strenuous exercise might rapidly move carcinogens out of the lungs. Still other researchers have written that alterations in how a well-trained body handles insulin and some cellular growth factors could lessen the chances of tumors developing.
But it remains difficult to tease out the specific molecular effects of regular, brisk exercise from the generally healthy habits of exercisers. Although the Finnish study controlled for diet, the scientists write that other, unspecified “lifestyle factors” and the luck (good and bad) of genetics may well have affected their results. Still, their findings offer a prescription for potentially reducing your risk of certain cancers that has few obvious, undesirable side effects, except among the intractably lazy. “At least moderately intense physical activity is more beneficial than low intensity physical activity in the prevention of cancer,” the authors conclude. The takeaway, in other words, is that jogging trumps berry picking.Wednesday, August 19, 2009
Health Care Debate Continues in Congress
KMA Principles Would Benefit Kentuckians
On Thursday, July 16, 2009, the US House of Representatives
Ways & Means Committee passed HR 3200, the America’s
Affordable Health Choices Act. It is one of the proposals
currently making its way through the legislative process in
regard to health care reform.
The legislation, as passed by the committee, provides for a
fix to the pending cuts to physician Medicare reimbursement
scheduled January 1, 2010, and contains more favorable
expenditure targets for Medicare physician updates. It also
provides for the creation of a health insurance exchange that
would provide a choice of plans -- including a public plan option
-- as well as a ban on physician-owned hospitals.
It is anticipated that there will be many other proposals for
health care reform in both the House and Senate over the
coming weeks. The KMA has not endorsed any health
reform bill, but does support principles that will provide
changes to the system that will benefit all Kentuckians. These
principles include:
• Repeal of the SGR formula, avoiding the anticipated
20% cut in Medicare reimbursement based on the current
formula, and the creation of a system that more accurately
reflects the cost of operating a physician’s office.
• Meaningful medical liability reform that will reduce the
high cost of defensive medicine.
• Ending health insurance companies’ subsidies under
the Medicare Advantage program and using that money
to fund other proposals, including a fix to the SGR.
• Health insurance reform that reduces the administrative
burden on patients and physicians and reduces the
barriers to obtaining insurance and health care services
for patients.
• Anti-trust relief that allows physicians to negotiate on a
level playing field and allows them to work with others in
the health care delivery system to increase efficiencies in
the delivery of health care that are so badly needed.
KMA urges its members to communicate these principles to
their Congressmen and Senators over the coming days and
weeks as the debate in Congress continues over health care
reform.
Contact Congress During August Recess
The United States Congress has adjourned for its August recess. Now is the time to contact your Congressmen and ask them to support KMA’s priorities for meaningful healthcare reform, which are:
- Repeal of the SGR (Sustainable Growth Rate) formula, averting the pending twenty percent cut in Medicare reimbursement and replacing it with a system that more accurately reflects the cost of operating a physician’s office.
- Meaningful medical liability reform that will reduce the high cost of defensive medicine.
- Ending health insurance companies’ subsidies under the Medicare Advantage program and using that money to fund other proposals, including a fix to the SGR.
- Health insurance reform that reduces the administrative burden on patients and physicians, and reduces the barriers to obtaining insurance and health care services for patients.
- Anti trust relief that allows physicians to negotiate on a level playing field and allows them to work with others in the health care delivery system to increase efficiencies in the delivery of health care that are so badly needed.
KMA urges members to contact their Congressmen using their district office phone numbers provided below.
Senator Mitch McConnell - (502) 582-6304
Senator Jim Bunning - (859) 341-2602
1st District Congressman Ed Whitfield - (270) 885-8079
2nd District Congressman Brett Gurthrie - (270) 842-9896
3rd District Congressman John Yarmuth - (502) 582-5129
4th District Congressman Geoff Davis - (859) 426-0080
5th District Congressman Hal Rogers - (606) 679-8346
6th District Congressman Ben Chandler - (859) 219-1366
Democrats Seem Set to Go It Alone on a Health Bill
By CARL HULSE and JEFF ZELENYTop Democrats said Tuesday that their go-it-alone view was being shaped by what they saw as Republicans’ purposely strident tone against health care legislation during this month’s Congressional recess, as well as remarks by leading Republicans that current proposals were flawed beyond repair.
Rahm Emanuel, the White House chief of staff, said the heated opposition was evidence that Republicans had made a political calculation to draw a line against any health care changes, the latest in a string of major administration proposals that Republicans have opposed.
“The Republican leadership,” Mr. Emanuel said, “has made a strategic decision that defeating President Obama’s health care proposal is more important for their political goals than solving the health insurance problems that Americans face every day.”
The Democratic shift may not make producing a final bill much easier. The party must still reconcile the views of moderate and conservative Democrats worried about the cost and scope of the legislation with those of more liberal lawmakers determined to win a government-run insurance option to compete with private insurers.
On the other hand, such a change could alter the dynamic of talks surrounding health care legislation, and even change the substance of a final bill. With no need to negotiate with Republicans, Democrats might be better able to move more quickly, relying on their large majorities in both houses.
Democratic senators might feel more empowered, for example, to define the authority of the nonprofit insurance cooperatives that are emerging as an alternative to a public insurance plan.
Republicans have used the Congressional break to dig in hard against the overhaul outline drawn by Democrats. The Senate’s No. 2 Republican, Jon Kyl of Arizona, is the latest to weigh in strongly, saying Tuesday that the public response lawmakers were seeing over the summer break should persuade Democrats to scrap their approach and start over.
“I think it is safe to say there are a huge number of big issues that people have,” Mr. Kyl told reporters in a conference call from Arizona. “There is no way that Republicans are going to support a trillion-dollar-plus bill.”
The White House has also interpreted critical comments by Senator Charles E. Grassley of Iowa, the top Republican negotiator in a crucial Finance Committee effort to reach a bipartisan compromise, as a sign that there is little hope of reaching a deal politically acceptable to both parties.
Mr. Grassley, who is facing the possibility of a Republican primary challenge next year, has gotten an earful in traveling around his home state. At one gathering last week, in a city park in the central Iowa town of Adel, a man rose from the crowd and urged him to “stand up and fight” the Democratic plans. If he does not, the man yelled, “we will vote you out!”
The White House, carefully following Mr. Grassley’s activities, presumed he was no longer interested in negotiating with Democrats after he initially made no effort to debunk misinformation that the legislation could lead to “death panels” empowered to judge who would receive care.
Citing a packed schedule, Mr. Grassley has also put off plans for the bipartisan group of Finance Committee negotiators to meet in either Iowa or Maine, the home of another Republican member of the group, Senator Olympia J. Snowe, before Congress resumes.
Further, Mr. Grassley said this week that he would vote against a bill unless it had wide support from Republicans, even if it included all the provisions he wanted. “I am negotiating for Republicans,” he told MSNBC.
In an interview on Tuesday, Mr. Grassley said he had simply been repeating earlier comments that he would not support a measure that did not have significant Republican support. He said that raucous town-hall-style meetings might have made the job of reaching a compromise harder, but that he had not given up.
“It may be more difficult than it was before,” he said. “I am intent on talking. I am intent on seeing what we can do.”
Administration officials, who maintain that Republicans are badly mischaracterizing the legislation that has emerged from three House committees and the Senate health committee, said they had hoped to achieve some level of bipartisan support. But they are becoming increasingly convinced that they will instead have to navigate the complicated politics among varying Democratic factions.
The officials said the White House hoped to make the case to the American people that it was Republicans who had abandoned the effort at bipartisanship. Republicans countered by saying that they simply opposed the legislation and that the public outcry had validated their view and solidified their opposition.
This week’s careful administration maneuvering on whether a public insurance option was an essential element of any final bill was seemingly part of the new White House effort to find consensus among Democrats, since the public plan has been resisted by moderate and conservative Democrats who could be crucial to winning the votes for passage if no Republicans are on board.
For the second time in two days, Mr. Obama did not mention health care on Tuesday, a marked departure from the aggressive public relations campaign he mounted in July and early August. The White House is striving to stay out of the fray, aides said, until the president can get away on vacation this weekend.
Even as the administration showed some flexibility, angering liberal Democrats who consider a public plan essential, Republicans turned their attacks from the public option to the health care cooperative idea being promoted by some Senate Democrats.
In what Democrats regarded as further evidence that Republicans were not serious about negotiating, Mr. Kyl and Representative Eric Cantor of Virginia, the second-ranking House Republican, described a co-op as a public option carrying another name.
The continuing opposition was noted Tuesday by Robert Gibbs, the White House spokesman, who said of Republicans that at best “only a handful seem interested in the type of comprehensive reform that so many people believe is necessary to ensure the principles and the goals that the president has laid out.”Tuesday, August 18, 2009
Here's your regular update on efforts by the American Medical Association (AMA) to work with lawmakers in reforming the nation's health care system in a way that provides quality, affordable health care for all.
AMA clarifies facts on recent examples highlighting amputation and tonsillectomies
The AMA contacted White House staff last night to again express strong concerns with some recent medical treatment examples used by President Obama. We've made it clear that physicians are extremely dedicated and focused—first, foremost and always—on providing care that best serves their patients.
We agree with President Obama on the importance of prevention. However, a recent example used to illustrate his important point was misleading. Surgeons are not paid $30,000 to $50,000 to amputate a diabetic's foot. Medicare pays a surgeon, on average, from $541.72 to $708.71 for one of two procedures involving a foot amputation. It is possible that the total bill, hospital stay, rehabilitation, prosthesis, etc. may approach the larger amount mentioned.
In the case of tonsillectomies, a patient is referred to a surgeon after medication therapy has proven to be ineffective. Actually, the medical profession itself recognized questions about utilization and appropriateness of tonsillectomies and took action by developing clinical guidelines, which has resulted in a sharp decline in the rate of tonsillectomies.
These types of examples create the impression that physicians are motivated by payment levels rather than what is best for patients. The AMA will continue to stress to our elected leaders that physicians are dedicated to putting patients first and optimizing health care quality.
Monday, August 17, 2009
Our Vision for Health System Reform
The AMA Vision for Health System Reform
No one said that achieving meaningful health system reform this year was going to be easy. But tackling the tough challenges is something the American Medical Association (AMA) has been doing for 162 years.
As the nation’s largest organization representing physicians from every state and nearly every medical specialty—and the patients in their care—we are committed to achieving health system reform this year that:
- Protects the sacred relationship between patients and their physicians, without interference by insurance companies or the government
- Provides affordable health insurance for all through a choice of plans and eliminates denials for pre-existing conditions
- Promotes quality, prevention and wellness initiatives
- Repeals the Medicare physician payment system that harms seniors' access to care
- Eases the crushing weight of medical liability and insurance company bureaucracy
Physicians, patients, policymakers and others have found common ground on real health system improvements. Difficult issues must still be resolved. But it’s time for results, not rhetoric. It's time to shift our focus from arguing about differences to working together to resolve them.
The status quo is unacceptable. America's patients and physicians deserve better. The AMA will press on until a better health system is a reality for all Americans.
Sunday, August 16, 2009
Vital Signs Where's That Infection?
I walked into the emergency room and was confronted immediately. “Twenty-year-old woman, vomiting for 12 hours,” Andreas, my ER resident, told me. “Total body pain, fevers, can barely walk.”
He handed over the nursing note. “Chief complaint: chills, fever, nausea, vomiting.” Surprisingly, the patient’s temperature, pulse, and blood pressure were normal.
“Normal vitals and no fever?” I asked. “Can’t be too sick, can she? Gastroenteritis?”
“She looks pretty bad,” Andreas responded. “And there’s something else. Two weeks ago they treated her for a bladder infection. She finished the antibiotics. A few days later the burning and frequency returned.”
“Let’s say hi,” I suggested. Curled into a ball, the young woman barely looked up as we walked in. Her mother stood by her bedside, holding vigil.
“She won’t stop vomiting, doctor.”
“Any belly pain? Fever?”
With great effort, the daughter turned to face us. “I feel so bad” was all she could say.
“Can I examine your abdomen for a moment?” I asked. Grimacing, she slowly straightened out.
“Any pain here?” I asked, gently probing her thin abdomen. “Here?” She shook her head.
“And are you still having urinary symptoms? Burning?” She nodded.
“They took a culture five days ago,” the mother interjected. “The doctor said he would call if there was a problem, but we haven’t heard anything. I assumed it was OK.”
“Can you sit up for me?” I asked the daughter. She heaved herself upright. Gently, I tapped the lower ribs on the right where one kidney lies.
“That OK?”
“Yup.”
I thumped the left. She winced and arched her back. “Ouch. Yes, that hurts.”
I looked at Andreas. “Pyelo?” Pyelonephritis is Latin for “kidney on fire”; in plain English, it means a kidney infection.
“Problem is, she has no fever,” Andreas said, “and the urinalysis showed no white cells.”
That made no sense. Turning back to mother and daughter, I repeated, “For five days you’ve had burning when you urinate, right?” They nodded.
I turned to Andreas. “Dysuria. Flank pain. Vomiting. Should equal pyelo, no?” He gave a shrug, as if to say, “Don’t you know by now that even the simple stuff isn’t simple?”
“She has a kidney infection,” I announced to the mother. “Some parts of the puzzle are missing, but we’re going to start her on antibiotics right away.”
“Please, doctor,” the mother replied, looking relieved. “This has gone on too long.”
I hailed Steve, the young woman’s nurse. “Let’s repeat the temperature and the urinalysis, OK?”
“Coming up.”
The textbooks say high fever and pyelo nephritis go together like mustard on a hot dog. At this point, with no fever and no infection-fighting white cells in the urine, my diagnosis hinged on little more than the young woman’s story and my fist-tap examination of her side.
Steve walked over. “Temp normal. Ninety-eight even.”
“Let’s hang the antibiotics anyway, OK?”
“You got it.”
Bladder infections, or UTIs (urinary tract infections), are like mosquito bites: common, mostly just annoying, but packing the occasional nasty surprise. In toddlers, UTIs can cause high fevers, and—given the impossibility of getting a two-year-old to pee into a cup—they can drive ER doctors nuts waiting for a sample in order to complete a fever workup. More than half of all women will contract a UTI over their lifetime. Some sexually active young women average one every two years.
Why women? It’s a matter of plumbing: The female urethra’s relative proximity to the rectum gives fecal bacteria—especially the always abundant E. coli—easier access to the urinary system than does the male anatomy. Some women even produce specific proteins on their cell surfaces that bacteria can latch onto.
And no, cranberry juice does not cure UTIs.
Treatment in an otherwise healthy woman is a three-day course of a fluoroquinolone antibiotic like ciprofloxacin. Bactrim (also known as Septra) used to be the standard, but over the past decade resistance has soared. In the western United States more than 20 percent of E. coli strains are now resistant—too high for initial use of the drug as empirical therapy.
Because the symptoms of a bladder infection are so specific—and the bacterial culprits are so predictable—a patient’s reported symptoms and a positive urinalysis are generally enough to prompt treatment. Bacterial cultures are not done in most cases because they are both expensive and redundant.
To dismiss UTIs as either simple or trivial would be a big mistake, however.
UTI is a straightforward diagnosis all doctors love to make, but life-threatening abdominal infections can mimic UTIs. Such infections can cause urinary burning and urgency (and a positive urinalysis) when infected intestines abut and inflame the bladder. The bladder, in that respect, is the canary in the abdominal coal mine. So much so that a young man with urinary symptoms and abdominal discomfort most likely has appendicitis, not a UTI.
Left untreated, bacteria can escape the bladder by two routes: via capillaries into the bloodstream or up the ureters into the kidneys. The bloodstream route bedevils older, and especially diabetic, patients, many of whom never feel the telltale symptoms of a bladder infection. Instead they present with full-blown sepsis: fever, confusion, vomiting, and low blood pressure. In younger patients the kidney usually takes the first hit: Flank pain strikes like a baseball bat, with fever and vomiting following close behind.
Years ago pyelonephritis mandated hospitalization, blood cultures, and IV antibiotics—all driven by the fear that recurrent infections can permanently scar the kidney. With the advent of fluoroquinolone drugs, outpatient treatment is now routine: a prescription for oral antibiotics, and presto.
My patient’s second microscopic urinalysis showed white cells in the urine, though not a ton. Fever or no fever, this was definitely pyelo.
“What do you think?” I asked Andreas. “A routine course of cipro at home?”
“Her serum white count’s pretty high,” he replied. “And you can’t take pills if you’re vomiting.”
“OK,” I agreed. “And if the admitting team squawks about no fever, too bad.”
I pulled the mother aside. “She’ll be fine,” I said. “I just want to keep her overnight, give her antibiotics by vein, and make sure the vomiting settles down.”
“Just a day?”
I smiled. “No promises. But most likely yes.”
Two days later I was visiting another patient in the intensive care unit when a familiar form passed by. The mother.
My throat tightened. Only critically ill patients end up in the ICU.
“What happened?” I sputtered.
“Her blood pressure went down the next morning,” she said, her voice raspy and tired. “They rushed her up here. Pumped her full of fluid and more antibiotics. The infection had gotten into her bloodstream.”
I hurried into her room. My patient looked wan but OK. The monitor showed a normal blood pressure—and I started breathing again.
“I feel better today,” the daughter said, wearing the expression survivors of high-speed rollovers get. I racked my brain for what we could have done differently. Andreas had given her plenty of fluid. We’d started antibiotics right away. But apparently the bacteria had begun their invasion of her bloodstream before we even saw her. And I had almost sent her home.
“How do we make sure that this never happens again?” the mother asked.
Glad to change the subject, I explained: “Prevention is key. You should keep antibiotics on hand and start them at the first sign of trouble. You know your body. With UTIs, your symptoms are straightforward. In women who get them very frequently, it’s an accepted practice.”
The mother’s face brightened, knowing that next time she and her daughter could find treatment without having to wait for a doctor’s help.
Tony Dajer is chairman of the department of emergency medicine at New York Downtown Hospital in Manhattan. The cases described in Vital Signs are real, but names and certain details have been changed.
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