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.

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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.

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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

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.

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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.

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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)

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.

A Nurse’s View of Health Reform

The New York Times

By 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?

Phys Ed: Does Exercise Reduce Your Cancer Risk?

By Gretchen Reynolds

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.

Related

• More Phys Ed columns
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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.

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:

1. 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.
2. Meaningful medical liability reform that will reduce the high cost of defensive medicine.
3. Ending health insurance companies’ subsidies under the Medicare Advantage program and using that money to fund other proposals, including a fix to the SGR.
4. 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.
5. 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