27 September 2011


Story first appeared in the Traverse City Record-Eagle.

It took seven years of annual mammograms and a cancer diagnosis for Amy Colton to learn something her doctors had realized for the beginning: Her breast tissue is so dense that it could have masked tumors on earlier exams.

She requested a copy of the report send from her radiologist to her primary care physician, and every single one said, “Patient has extremely dense breast tissue.” The registered labor and delivery nurse was really outraged that she didn’t know this.

About 40 percent of women over 40 have breast tissue dense enough to mask or mimic cancers on mammograms, but many of them don’t know it. Mammogram providers in California will be required to notify those patients, and suggest that they discuss additional screening with their doctors based on their individual risk factor, if Gov. Jerry Brown signs a bill that the Legislature passed this month. Similar laws have passed in Texas and Connecticut in the past two years but no data is available yet from either state on the effect of the legislation.

Researcher studying breast density, a relatively young field, said such requirements may end up causing undo anxiety in millions of women and lead to unnecessary and expensive ultrasound or MRI screening.

The California Medical Association, which represents 35,000 doctors, recommended a public education campaign instead of individual notifications, and said there isn’t enough evidence to support the idea the extra money spent on additional screening will save more lives.

Those test could cost the state more than $1 billion, and may women wouldn’t be able to afford them, said a professor of radiology and chief of breast imaging.

22 September 2011

Database of Physician Discipline and Malpractice Actions Removal

Story first appeared in The New York Times

Three journalism organizations on Thursday protested a decision by the Obama administration to remove a database of physician discipline and malpractice actions from the Web.

The National Practitioner Data Bank, created in 1986, is used by state medical boards, insurers and hospitals. The “public use file” of the data bank, with physician names and addresses deleted, has provided valuable information for many years to researchers and reporters investigating oversight of doctors, trends in disciplinary actions and malpractice awards.

On Sept. 1, responding to a complaint, the Health Resources and Services Administration, an agency of the Department of Health and Human Services, removed the public use file from its Web site, said an agency spokesman, Martin A. Kramer. The agency also wrote a reporter a letter to warn he could be liable for $11,000 or more in civil fines for violating a confidentiality provision of the federal law. Both actions outraged journalism groups.

“Reporters across the country have used the public use file to write stories that have exposed serious lapses in the oversight of doctors that have put patients at risk. Their stories have led to new legislation, additional levels of transparency in various states, and kept medical boards focused on issues of patient safety.”

Two other national journalism organizations, Investigative Reporters and Editors and the Society of Professional Journalists, joined the health reporters’ group in a letter to Mary K. Wakefield, administrator of the federal office. “If anything, the agency erred on the side of physician privacy,” they wrote.

The agency, contacted by a doctor, had become concerned that a Kansas City reporter obtained information from the full data bank, not just its public use file.

That concern and the letter, though, were made moot when the reporter explained that he had been getting information from the public use file.

Nonetheless the agency is reviewing the public use file and may change it to further assure confidentiality before placing it back on the Web, he said, adding that he hoped it would be public again within six months.

“We are going to do everything we can to get the data back up in a public use file as quickly as we possibly can. We want to make sure the public, researchers and reporters have access to all the information that we can legally make available.”

Mr. Kramer said he could not speculate about how the public use file would be changed. He said the agency was still reviewing complaints made by the journalist organizations.

The Kansas City Star, despite the letter to its reporter, published its article on Sept. 3, titled, “Doctors With Histories of Alleged Malpractice Often Go Undisciplined.”

“To see whether other doctors with long malpractice payment histories are practicing in Kansas and Missouri, The Star analyzed thousands of records in the National Practitioner Data Bank,” the article said. It found 21 doctors had at least 10 malpractice payments but had never been disciplined by the states.

Like many others across the country, had performed broad research of courts, state agencies and hospital actions, “allowing them to connect the dots” to individual doctors. But he said the federal database itself did not reveal identities.

Other recent notable articles based partly on the database have appeared in The Duluth News Tribune in Minnesota and The St. Louis Post-Dispatch, which published a series last year titled, “Who Protects the Patients?”

Failure of Metal Hips

Story first appeared in The New York Times

In a troubling development for people with all-metal artificial hips, a registry that tracks orthopedic implants in Britain reported on Thursday that the failure rate of the devices was increasing.

The National Joint Registry for England and Wales said that an all-metal artificial hip once sold by Johnson & Johnson had failed in an estimated one-third of the patients who had been followed for the longest time. The device was recalled by the company last year.

The British registry also found that the early failure rate of some other metal-on-metal hips — ones in which both the ball and the socket components of an artificial joint are made of metal — was significantly higher than for those made from other materials, including a combination of metal and plastic.

While the patients tracked by the British registry are not in the United States, doctors and patients here pay close attention to the registry’s findings because no such body exists in this country, where there is far greater use of artificial hips and knees. Australia also keeps a registry.

There was already heightened concern in the United States about the all-metal hips. In the first six months of this year, the Food and Drug Administration received more reports about problems with the all-metal hips than it had in the previous four years combined, according to an analysis by The New York Times. In May, the F.D.A. took the unusual step of ordering producers of the devices to study how frequently they were failing and to examine the health implications for patients.

While traditional artificial hips typically last 15 years or more before they need to replaced, some of the all-metal models are failing in large numbers of patients within just a few years. Early failure rates for all-metal devices were far higher in women than in men, the British report found.

According to the report, the highest failure rates involved the Johnson & Johnson device, which is known as the Articular Surface Replacement, or the A.S.R. The registry is following about 2,100 patients who received a version of the device that is used as a traditional hip implant. That is also how the A.S.R. was used in this country.

Of those patients in the British group who received the device six years ago, about 29 percent have since had it replaced.

The percentage is slightly lower, about 17 percent, in patients who got the device five years ago, but that number could rise over the next year.

DePuy officials recalled the A.S.R. last year around the time that the previous report of the British registry was released.

Along with a traditional hip model, another version of the device was sold outside this country for use in an alternative hip replacement technique known as “resurfacing.” It was also recalled.

While it is difficult to draw direct comparisons between device failure rates in Britain and in the United States, the new registry findings appear to bode ill for patients here who received an A.S.R. About 40,000 of the 90,000 units sold worldwide were used in this country.

The British data suggests that complaints will continue to grow in the United States in coming years because the A.S.R. was used overseas before its adoption here.

The British data also shows that the failure rate for all-metal devices as a group, even when the A.S.R. is excluded, is accelerating faster than for traditional hip replacements.

Though immediate problems with the hip implants are not life-threatening, some patients have suffered crippling injuries caused by tiny particles of cobalt and chromium that were shed by the metal devices as they wore.

Such debris generation is also believed to be a cause of earlier device failure.

Until a recent sharp decline in their use, all-metal hip implants accounted for nearly one-third of the estimated 250,000 replacements performed in this country each year. According to one estimate, some 500,000 patients in this country have received an all-metal replacement hip.

In the case of devices used for hip resurfacing, which is popular among younger patients, a model known as the Birmingham Hip Resurfacing device had the lowest replacement rate at five years, the registry found.

However, the report noted that further studies needed to be performed to determine whether hip resurfacing conferred true advantages over standard hip replacement.

Coming Together to Make Aging a Little Easier

Story first appeared in The New York Times

LAST summer, Shoya Zichy was about to drop off a prescription at a friend’s house when she tripped and dislocated her elbow in Midtown Manhattan.

As Ms. Zichy lay helpless on the sidewalk, Pam Ramsden came along, on her way to visit the same woman, who was recovering from a traffic accident.

Ms. Ramsden, 67, spent the next 10 hours in a hospital emergency room with Ms. Zichy and accompanied her home in a taxi at 1 a.m.

The women had met once before; both are members of the Caring Collaborative, a program offering volunteer assistance to women with health problems. Started in 2008 by the Transition Network, a New York-based nonprofit group for professional women in or near retirement, the collaborative has 200 volunteers. They provide network members, who pay a small fee, with short-term, nonemergency caregiving, like pet care, Fall Lawn Care, meal and prescription delivery, hospital visits and escorted medical appointments. The network is not organized to help the frail elderly or provide long-term care. A similar program for Senior Health Detroit is being considered.

Members of the Caring Collaborative also meet in neighborhood groups, organized by ZIP code, for confidential discussions of doctors, hospitals and surgical procedures. The collaborative, a pilot program available only to the network’s New York City members, is under consideration at some of the network’s 14 chapters nationwide.

That August night, Ms. Ramsden took on far more than the collaborative’s usual dog-walking or accompanying a recipient home from a colonoscopy. She corralled medical providers, lobbied for more pain medicine and tried to distract Ms. Zichy, who spent hours without food or water on a gurney in the hallway.

Innovative approaches to managing some of the difficulties of aging are bubbling up around the country, often initiated by women who want to stay independent. Women by nature congregate around shared interests, so they are seeing informal networks popping up in church groups, book clubs, unions and lifelong learning programs.

A 65-year-old woman can expect to live at least 20 more years, often alone and in need of help to live independently, yet 40 percent of boomer women don’t know that long-term planning involves complicated decisions about your home, family and community.

The Caring Collaborative was created by Charlotte Frank, a retired executive with the Port Authority of New York and New Jersey and co-founder of the Transition Network. Complications following thyroid surgery a few years ago left her dependent on friends to provide meals, take her to visit the doctor and stay in her Manhattan apartment.

Many New York professional women over age 50 - the core of the Transition Network’s membership - are single or childless and live far from family, “It’s part of the protective armor of being a New Yorker that you don’t get close to your neighbors. So who are you going to ask for help when you need it?”

The program, financed with $144,000 from the New York State Health Foundation, uses software to match caregivers and care recipients. Members can build credits by helping others and later redeem the credit if needed. (There is no need to bank credits - recipients can volunteer later.)

Transition Network chapters on Long Island and in the San Francisco area are interested in adapting the Caring Collaborative model to their geographic requirements, said Ms. Frank. The founders have also prepared three guides to help other organizations create similar networks, peer groups and “vertical villages” in high-rise apartment buildings.

Project Renewment in California, a volunteer organization for professional women in transition from their primary careers, is interested in the Caring Collaborative model. Like the Transition Network, Project Renewment members make friends in small peer groups focused on second career options, volunteering and travel.

The Caring Collaborative is just a first step in resolving older women’s potential vulnerabilities, said Ms. Burns, who heads AARP’s campaign - called “Decide. Create. Share” - aimed at helping older women plan for their later years. “You need to ask difficult questions: ‘Can my home be modified so I can age in place? Does my community have services I might need? Could I afford to hire in-home care? What are my last wishes?’ ”

Ms. Zichy’s accident prompted her to look into a continuing-care retirement community in Philadelphia.

And Ms. Ramsden has given thought to moving near one of her children.

16 September 2011

There is a medical code for “burn due to water-skis on fire?” Why?

Story first appeared in the Wall Street Journal.
Today, hospitals and doctors use a system of about 18,000 codes to describe medical services in bills they send to insurers. Apparently, that doesn't allow for quite enough nuance.
A new federally mandated version will expand the number to around 140,000—adding codes that describe precisely what bone was broken, or which artery is receiving a stent.
It will also have a code for recording that a patient's injury occurred in a chicken coop.
Indeed, health plans may never again wonder where a patient got hurt. There are codes for injuries in opera houses, art galleries, squash courts and nine locations in and around a mobile home, from the bathroom to the bedroom.
Health insurers, doctors and hospitals are bracing for chaos as they prepare to adopt a new federally mandated format for medical billing.
Some doctors aren't sure they need quite that much detail. Brian Bachelder, a family physician in Akron, Ohio want to know what difference does it make where the injury happened…bedroom or bathroom?"
The federal agencies that developed the system—generally known as ICD-10, for International Classification of Diseases, 10th Revision—say the codes will provide a more exact and up-to-date accounting of diagnoses and hospital inpatient procedures, which could improve payment strategies and care guidelines. It's for accuracy of data and quality of care, says Pat Brooks, senior technical adviser at the Centers for Medicare and Medicaid Services.
Billing experts who translate doctors' work into codes are gearing up to start using the new system in two years. They say the new detail is welcome in many cases. But a few aspects are also causing some head scratching.

Some codes could seem downright insulting: R46.1 is "bizarre personal appearance," while R46.0 is "very low level of personal hygiene."
It's not clear how many klutzes want to notify their insurers that a doctor visit was a W22.02XA, "walked into lamppost, initial encounter" (or, for that matter, a W22.02XD, "walked into lamppost, subsequent encounter").
Why are there codes for injuries received while sewing, ironing, playing a brass instrument, crocheting, doing handcrafts, or knitting—but not while shopping, wonders Rhonda Buckholtz, who does ICD-10 training for the American Academy of Professional Coders, a credentialing organization.
Code V91.07XA, which involves a "burn due to water-skis on fire," is another mystery she ponders: "Is it work-related?" she asks. "Is it a trick skier jumping through hoops of fire? How does it happen?"
Much of the new system is based on a World Health Organization code set in use in many countries for more than a decade. Still, the American version, developed by the Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services, is considerably more fine-grained.
The WHO, for instance, didn't see the need for 72 codes about injuries tied to birds. But American doctors whose patients run afoul of a duck, macaw, parrot, goose, turkey or chicken will be able to select from nine codes for each animal, notes George Alex, an official at the Advisory Board Co., a health-care research firm.
There are 312 animal codes in all, he says, compared to nine in the international version. There are separate codes for "bitten by turtle" and "struck by turtle."
U.S. hospitals and insurers are bracing for possible hiccups when the move to ICD-10 happens on Oct. 1, 2013, even though they've known it was coming since early 2009.
Jeremy Delinsky, chief technology officer for athenahealth Inc., which provides billing services to doctors commented that you have millions of transactions flowing in the health-care system and this is an opportunity to mess them all up.
Medicare officials say they believe many big insurers and hospital systems are making preparations, but there may be some issues with smaller ones that won't be ready.
With the move to ICD-10, the one code for suturing an artery will become 195 codes, designating every single artery, among other variables, according to OptumInsight, a unit of UnitedHealth Group Inc. A single code for a badly healed fracture could now translate to 2,595 different codes, the firm calculates. Each signals information including what bone was broken, as well as which side of the body it was on.
Some companies hope to grab business from the shift. One medical-coding website operator, Find A Code LLC, has created a series of YouTube videos with the tagline, "Yeah, there's a code for that." Snow White biting the poisoned apple, the firm says, may be a case of T78.04, "anaphylactic shock due to fruits and vegetables." On April 1, the company posted a document with the secret "X-codes" to describe medical conditions stemming from encounters with aliens.
Other coding cognoscenti spot possible hidden messages in the real codes. The abbreviation some use for the new system itself, I10, is also a code for high blood pressure. Several codes involving drainage devices end in "00Z." Then there are two of the codes describing sex-change operations that end in N0K1 and M0J0. You could see it ripple through the room as people said, “nookie and mojo!” says Kathryn DeVault, who has been teaching ICD-10 classes for the American Health Information Management Association.
Medicare agency's Ms. Brooks, who says the codes are built according to a consistent pattern in which each digit has a meaning not on hidden messages.
Medicare and CDC officials say codes were selected based on years of input from medical experts in various fields. Codes describing the circumstances of injuries are important for public-health researchers to track how people get hurt and try to prevent injuries, they say.
Being able to tabulate risks tied to locations such as chicken coops could be important as far as surveillance activities for public health research, says Donna Pickett, a medical systems administrator at the CDC. She says the current code for a badly healed fracture is so vague it isn't useful.
Another CMS official, Denise M. Buenning, compares ICD-10 to a phone book. She says you are not going to use all the numbers, but all the numbers you need are in there.

Health Of Alpha Males

Story first appeared in the Wall Street Journal.
One evening a week, a group of CEOs meets in a Manhattan psychiatrist's office and engages in an ancient ritual. Ostensibly, it is a support group. Inevitably, it becomes a battle for dominance.
T. Byram Karasu, the veteran psychiatrist who has run the sessions for the past 23 years said whenever you put alpha males together, the most aggressive will overpower the others. The fighting is subtle, but it's vicious. Even giving advice is geared toward lowering the others' self-esteem. Those at the lower end of the group come away doubting themselves, and their testosterone falls. They tell me they can't have sex for three or four days afterward.
Alpha males get the girls, but beta males have fewer stress-related health problems, at least among baboons, according to a recent Princeton study. As Melinda Beck explains, that appears to have health consequences for humans, too.
It isn't easy being an alpha male. Getting to the top and staying there takes a physical toll.
The latest evidence comes from wild baboons in Kenya's Amboseli basin. Researchers from Princeton and Duke universities studied 125 males in five groups over nine years and found that while the alpha males got the best food and the most mates, they experienced far more stress than the beta males just beneath them in the hierarchy, based on the levels of cortisol, a stress hormone, in fecal samples.
The beta males had almost as many mates and got just as much grooming from others, but they didn't have to spend as much time fighting or following females around to keep other males away.
In the human savannah, where smarts matter more than brute strength, alphas run companies, amass fortunes and dominate any meeting they're in. They are ambitious, assertive, confident and competitive.
Masters of the Universe
In the work world, alpha males are ambitious, assertive, confident and competitive. Here's a quiz that helps define who's an alpha male:
Alpha Strengths
• 1. No matter what, I don't give up until I reach my end goal.
• 2. I always say exactly what I think.
• 3. I have no problem challenging people.
• 4. I make the decision I believe is correct, even when I know other people don't agree.
• 5. I seldom have any doubts about my ability to deliver.
Alpha Risks
• 6. I believe that my value is defined by the results I achieve.
• 7. I don't care if my actions hurt people's feelings, if that's what's required to produce results.
• 8. When people disagree with me, I often treat it as a challenge or an affront.
• 9. If I have a good idea and I'm asked to hold off and listen to inferior ideas, I can quickly become visibly annoyed.
• 10. People say I become curt, brusque, or frustrated when I have to repeat myself.
• If all or nearly all of your responses to statements 1 to 5 were "yes," you are probably an alpha with many of the strengths that make alphas such dynamic and influential leaders.
• If all or nearly all of your responses to items 6 to 10 were "yes," you mostly likely have some alpha risks that deserve your attention.
• Don't be confused if you scored high in both categories. Because alpha liabilities are mainly alpha assets taken too far or applied inappropriately, that is to be expected. (The exceptions to the rule are healthy alphas who have worked hard to reduce their negative tendencies.)
While they may appear cool and calm, many human alphas thrive on adrenaline, the hormone that primes the body to fight or flee in times of danger. Those short bursts of power helped our ancestors outrun predators. But if the perceived threat never lets up, the chronic state of alarm increases cortisol, too, and can eventually weaken the immune system, raise blood-pressure, cholesterol and insulin levels, block arteries and spread inflammation.
Some alphas have so-called Type-A personalities, a combination of aggression, impatience and anger first linked to a higher risk of heart disease in the 1960s. Hostility is the main culprit, according to more recent research. A study of 1,750 Canadians in the Journal of the American College of Cardiology last week found that people who displayed signs of hostility—whether they admitted feeling hostile or not—had twice the risk of cardiovascular problems as those who did not. Not all alpha males are Type A, but the combination can be deadly from a health standpoint, Dr. Karasu says.
Women, of course, can be alphas or betas as well, and have the same fight-or-flight response to danger. But some researchers theorize females may experience a tend-and-befriend response as well, pumping out extra oxytocin and prolactin, hormones that enhance nurturing. Shielding offspring and blending into the crowd might have enhanced their chances of survival more than running or fighting, the theory goes. The oxytocin surge has been documented in animal studies, but is unproven in humans.
Many alphas are also dedicated to exercise, which helps burn off excess adrenaline and cortisol. But some alphas take exercise, like everything else, to the extreme. Cardiologists, psychiatrists and executive coaches all say it is critical for alphas to find some way to manage excess stress—be it moderate exercise, sports, yoga, music, meditation, mindfulness training or downtime with family and friends. Some also advise simple deep-breathing exercises, with long exhalations, which can counteract cortisol and increase endorphins, the feel-good brain chemical.
Many alphas find they are happier, healthier and more successful if they learn to temper some of their competitive zeal. Some alphas compete with their own children, says Eddie Erlandson, a former vascular surgeon who now runs an executive coaching company, Worth Ethic Corp., with his wife, Dr. Ludeman.
Some primate studies have found that alpha males that survive longest are those who cultivate friendships. That applies to humans as well with a vengeance
Beta males, by contrast, are nice guys, peacemakers and team players. They make good husbands, fathers and friends. Some experts say they tend to be happier than alphas, since they aren't driven by the need to be on top. Betas can come in many forms—from competent wingmen to extreme introverts who are so determined to avoid conflict they suffer anxiety of their own.
Many observational studies of people and primates have shown that, in general, it's more stressful at the bottom of the social hierarchy than the top. Two long-running studies of British civil-service workers found that people in the lowest ranks had many more health problems and were three times as likely to die as the highest-grade administrators in a 10-year period—even though they all had access to health-care services.
To date, there have been few studies assessing whether human alphas or betas are healthier. But interest is exploding in studying how such social and psychological experiences affect human biology—how they get under our skin, says Richard Suzman, director of Behavioral and Social Research at the National Institute of Aging, which helped fund the baboon research and is studying how social status affects longevity. The National Institute of Mental Health is using brain scans to track how winning and losing changes brain circuits.
Some of the most intriguing questions involve how and when these traits emerge in childhood. Researchers with the National Institute of Child Health and Human Development have observed alpha and beta behavior even in kindergartners and found that the subordinate tots have more cortisol in their saliva.

15 September 2011

Should Hospitals Continue To Be Tax Exempt?

Story first appeared in Bloomberg News.

More than a dozen hospitals in Illinois face the prospect of paying millions of dollars in property taxes or, in some cases, shutting down as a result of a state ruling denying exemptions for three nonprofit healthcare providers, according to a ESOP Lawyer.

The uncertainty has prompted at least one hospital to postpone a $23 million construction bond sale while several others that built facilities say they won’t be able to pay the bill if they lose the break.

Tracy Bauer, chief executive officer of Midwest Medical Center in Galena, a 25-bed hospital that is on the hook for a $2.3 million property tax bill if its nonprofit exemption is revoked said they will go out of business without it.

The challenge to such exemptions comes as Illinois confronts two financial stresses -- the state’s $8 billion in unpaid bills and hospitals struggling with cuts in Medicare and Medicaid payments.

While other states have battled for decades in court over the obligation to treat the poor in exchange for tax breaks, Illinois intensified the fight on Aug. 16 when its Revenue Department denied exemptions for facilities in Chicago, Naperville and Decatur, saying they provided too little charity care.

Windfall for Schools

A reversal of the exemptions would represent a windfall for school districts, which collect the lion’s share of property taxes and have watched state aid shrink and revenue fall during the economic and housing slide.

Pat Schou, executive director of the Illinois Critical Access Hospital Network said there are school districts that are so hungry for this money that there’s a tug and pull in these communities.

The lobbying group for the state’s towns and cities supports the decision to collect the money.

Larry Frang, executive director of the Illinois Municipal League said in a perfect world, everybody ought to pay property taxes.

This is a fight with roots that go back centuries, when the fear of God persuaded governments not to tax churches because they worried about getting struck down by a lightning bolt, Colombo said. Many hospitals gained exemptions because of their religious affiliation or care for the indigent.

‘Poorhouses’ No More

Colombo said hospitals aren’t poorhouses anymore, and that just because they were exempt in 1900 doesn’t mean they should be exempt in 2011.

The Illinois Revenue Department is to rule in the coming months on the tax-exemption status of 15 hospital groups involving hundreds of parcels of property, said spokeswoman Susan Hofer. The Illinois Hospital Association, the industry’s lobbying arm, has asked for a moratorium on decisions until a legislative solution can be worked out, said Danny Chun, a spokesman.

There are no clear statutory guidelines, though the Illinois constitution and a 2010 state Supreme Court ruling provide guidance.
The constitution states that exemptions can be granted when property is used exclusively for charitable purposes.

High Court Ruling

The state’s highest court used that standard in a case involving an Urbana hospital, Provena Covenant Medical Center, which challenged the state’s denial of tax-exempt status. In a March 18, 2010 ruling, the court noted that a mere 302 of the hospital’s 110,000 patients received free care in 2002. Provena failed to meet its burden that the hospital was used exclusively for charitable purposes, the court said.

Although the decision’s immediate impact was confined to Provena, it put other nonprofits on notice. About 75 percent of hospitals in Illinois are nonprofits, according to a 2009 report from the Chicago- based Center for Tax and Budget Accountability.

The center reported that in metropolitan Chicago nonprofit hospitals received $489.5 million in tax exemptions and delivered charity care valued at $175.7 million.

Ralph Martire, executive director of the center, said for the most part, hospitals are very good members of the community, but that doesn’t mean you evade the legal standard. He added that if you’re not doing that in an adequate amount, you lose your exemption.

Jobs Rebuttal

The rebuttal from hospitals is rooted in economics --namely jobs. The Illinois jobless rate in July was 9.5 percent, above the national average of 9.1 percent, and the hospital association said its members provide more to their communities than can be measured by charity care.

Some lawmakers are pushing for a more clearly defined standard. State Senator Iris Martinez, a Chicago Democrat, proposed that hospitals devote 3 1/2 percent of their patient load to charity care as a requirement to receive the tax break. She said the situation cries out for clarity.

Martinez said you have some hospitals that are making big revenues and not doing charity care with billions in revenues without charity.

The hospital association rejects a specific amount and opposes Martinez’s bill, which remains bottled up in a committee.

Hospitals Waiting

Other hospitals are awaiting a decision from the state on their tax- exempt status. Mark Rossi, chief operating officer of Hopedale Medical Complex in Bloomington, said the uncertainty forced the hospital to shelve a $23 million construction bond sale.

Rossi said they were in the process of designing a brand-new hospital, and then this thing happened.If the hospital doesn’t get a tax exemption on the land on which the facility would be built, the annual tax liability would be about $400,000 annually, Rossi said. He said that matches their profits.

At the Midwest Medical Center in Galena, a new $45.5 million replacement hospital would be hit with a $2.3 million total obligation if the facility lost its exemption. Construction for the addition began before the Provena decision.

With high unemployment and governments struggling to provide services, the pressure will build for Illinois lawmakers to broker a compromise that would preserve tax exemptions while boosting charity care, Colombo said.

Poor And Unemployed Targeted For Receiving Improper Payments Totaling Billions

Story first appeared in USA TODAY.
The Obama administration is targeting programs that help the poor and unemployed as it seeks to recover billions of dollars in improper payments.
The effort, part of a government-wide focus on wasteful spending led by Vice President Biden, will get a high-profile boost today when the entire Cabinet meets for the first time on that subject alone.
The latest target for government auditors is Medicaid, the federal-state health care program for the poor and people with disabilities. The Health and Human Services Department will announce an initiative today aimed at recovering $2.1 billion in improper payments over five years.
At the same time, the Labor Department will intensify its partnership with states to reduce improper payments of unemployment insurance. More than half the states have improper payment rates higher than 10%, led by Indiana and Louisiana at more than 40%, according to Labor Department data.
Medicare and Medicaid are considered high-risk programs by the Government Accountability Office because they are prone to high rates of fraud, waste, abuse and improper payments. The GAO estimates that $70 billion was lost through improper payments in 2010 — roughly 10% of their combined federal cost.
The Health and Human Services Department estimated that improper payments in Medicaid alone cost the government $22.5 billion last year.
Government recovery efforts have lagged far behind the problem. Inspector general reports show that $4 billion was recovered last year from improper payments in government health care programs, a figure which has risen steadily from $1 billion in 2007.
The effort to track improper government payments dates to 2002 under the Bush administration and was later expanded to include Medicare and, most recently, Medicaid. Last year's health care law called for about $6 billion in savings by cracking down on waste and fraud.
Past administrations have made similar efforts to reduce waste and audit programs for efficiency and effectiveness. Vice President Al Gore headed President Clinton's Reinventing Government effort, while President George W. Bush created a new method of assessing and rating government programs.
In carrying on the tradition, President Obama brought it under Biden's control and instructed all government agencies to look for wasteful spending, just as he has pushed them to eliminate unneeded regulations.
Outside experts say the effort is worthwhile — but they warn not to expect too much.
Veronique de Rugy, a senior research fellow at George Mason University's Mercatus Center, says past government efforts have proven largely ineffective. She says the federal government is so big at this point that you just can't do proper oversight, unless you're willing to hire an army and give them enforcement powers. She adds, they don't ever seem to get it under control.

Are HPV Vaccines Safe?

Story first appeared in USA TODAY.
Doctors and public health leaders are speaking out to correct misinformation about the safety of HPV vaccines that prevent cervical cancer.
At a time when once-forgotten infectious diseases are making a comeback, health advocates say they're concerned that lifesaving vaccines could become a casuality of the fight to win the Republican presidential nomination. The Food and Drug Administration has approved two vaccines to help prevent cervical cancer, which affects more than 12,000 women each year and kills 4,200.
During Monday's debate, Rep. Michele Bachmann, R-Minn., criticized Texas Gov. Rick Perry's attempt to require the shots for schoolgirls. In TV interviews Tuesday, Bachmann attacked the vaccines themselves as dangerous, relating a conversation with a mother who blames the shots for her daughter's mental retardation.
There's no evidence that the HPV shot — or any other vaccine — causes retardation, says O. Marion Burton, president of the American Academy of Pediatrics.
There is absolutely no scientific validity to this statement, Burton said in a statement. Since the vaccine has been introduced, more than 35 million doses have been administered, and it has an excellent safety record.
Kevin Ault, an associate professor of obstetrics and gynecology at the Emory University School of Medicine in Atlanta, notes that the HPV shot is approved for girls beginning at age 9 and is recommended as part of the normal round of shots that girls receive at age 11 or 12.
Few children with developmental disabilities are diagnosed that late, Ault says.
The Centers for Disease Control and Prevention (CDC) scrutinizes vaccines carefully and has found no sign that the HPV vaccine causes serious side effects, other than a sore arm and occasional fainting, Ault says. Before approval, the HPV shot was tested in more than 30,000 people, Paul Offit, chief of infectious disease at Children's Hospital of Philadelphia says.
In fact, vaccines have been more closely scrutinized than just about any other drug, Offit says. Since approval, the CDC has tracked its safety in two major ways.
First, the CDC monitors reports to the Vaccine Adverse Event Reporting System, a database to which anyone can report a suspected side effect. CDC officials then investigate to see whether reported problems could possibly be caused by vaccines or are simply a coincidence.
Second, the CDC has been following girls who receive the vaccine over time, comparing them with a control group of unvaccinated girls, Ault says. Again, the HPV vaccine has been found to be safe.
Parents also have a choice about vaccinating their kids against HPV. Although Perry tried to require HPV shots with an executive order, he was challenged by the state legislature, and his measure never took effect. Only Virginia and the District of Columbia currently require girls to receive HPV shots, although parents also may opt out, according to the Minnesota-based Immunization Action Coalition.
Although the Food and Drug Administration has approved HPV shots for both girls and boys — both can develop genital warts from HPV — the CDC currently recommends the vaccines only for girls, Offit says. The shots are effective only in people who have never been exposed to HPV, Ault says. Because most people are exposed to the virus in the first year after becoming sexually active, doctors urge parents to vaccinate kids when they're young.
Shots against HPV have been more controversial than others because the disease's association with sex.
Although religious conservatives have opposed mandates, many have supported vaccination. Both Focus on the Family and the Family Research Council say parents should make the decision for themselves, but have described the vaccines as an important advance.
Suspicion of vaccines has helped to fuel outbreaks of a number of infectious diseases in recent years, including measles, mumps and whooping cough, according to the CDC. The CDC has tracked at least 193 cases of measles so far this year — three times more than in all of last year.

Deadly Cosmetic Surgery

Story first appeared in USA TODAY
Her husband says he loved her the way she was, but Kellee Lee-Howard wanted a trimmer body. So she went to a clinic for minimally invasive liposuction.
James Howard woke up on Valentine's Day 2010 to find his wife lying dead on the living room couch.
Along with her husband, Lee-Howard, 32, left behind six children — ages 3 to 14 — and a trail of questions about the doctor here who isn't board certified in any medical specialty but performed a type of liposuction he trademarked and has been teaching other non-plastic-surgeons across the country.
Alberto Sant Antonio, whose office wasn't registered as a surgery center, had done the liposuction a day earlier. According to the autopsy report, Lee-Howard died of an overdose of the painkiller lidocaine from complications after elective cosmetic surgery.
Lee-Howard told her husband she had learned of the Alyne Medical Rejuvenation Institute through an ad and that she'd found a safe way to lose weight by surgery.
After the procedure, she didn't feel well and went to sleep on the couch. The next morning, when their then-10-year-old son tried to ask her if he could play a video game, Howard noticed she wasn't breathing and started screaming her name, trying to wake her.
There was so much lidocaine in Lee-Howard's body that it showed a basic misunderstanding of the principles of pharmacology and patient safety, says Alberto Gallerani, a plastic surgeon here who is an expert witness in the Howard family's lawsuit against Sant Antonio.
Reached at his office, Sant Antonio said he was not at liberty to talk about the case. His attorneys did not return phone calls, but in July they filed a motion seeking to dismiss the case or require the Howard family's attorney to specify how Sant Antonio was negligent
Sant Antonio is one of a soaring number of doctors who trained in other medical specialties, such as vision or obstetrics, but have branched into the more lucrative field of cosmetic surgery. Because state laws governing office-based surgeries often are lax, levels of training vary so widely that some doctors are performing cosmetic procedures after only a weekend observing other doctors. Sant Antonio himself has offered three-day liposuction training at his office for the last few years, according to interviews with doctors who have trained under him.
Some dentists trained in oral surgery now do breast implants; OB/GYNs perform tummy tucks, and radiologists are doing liposuction. The results can be disastrous, according to interviews with scores of victims, plaintiffs' lawyers and plastic surgeons, and a review of lawsuits.
Even so, there's no shortage of patients: An aging — and often overweight — population is willing to spend money on cosmetic procedures, and people often are seeking lower-cost options to board-certified, sometimes higher-priced plastic surgeons.
Lee-Howard was not the only one to die after surgery at Sant Antonio's clinic.
A housekeeper and mother of two, Maria Shortall, 38, died of cardiac arrest after a liposuction and a fat-transfer procedure performed by Sant Antonio in June, according to the Florida Department of Health.
Sant Antonio studied pediatrics briefly before completing a medical residency in general surgery. Although he was never board-certified in any area of medicine, he was able to work as a general surgeon at a Baltimore hospital before moving to the Miami area after settling a medical malpractice claim in 2004, according to Franklin Square Hospital and Florida Board of Medicine records. Franklin Square now requires its doctors to be board-certified.
Sant Antonio fills a niche in the market offering discounted surgery, says Gallerani, who says he sees up to five patients a week whose surgeries were botched by non-plastic-surgeons.
Rohie Kah-Orukotan, in nearby Weston, also died after liposuction by a doctor who wasn't a plastic surgeon. Florida health officials alleged that Omar Brito — whose training was in occupational health — was doing cosmetic surgery without enough training or the proper equipment, according to state medical board records, which show he surrendered his license.
Weston MedSpa, where Kah-Orukotan got manicures and the liposuction procedure that led to her death, wasn't approved for office surgery, according to Florida Health Department records. Kah-Orukotan, 37, was rushed to the hospital and taken off life support about a week later, says lawyer Michael Freedland, who represents Kah-Orukatan's and Shortall's families. Freedland filed a lawsuit against Brito and Weston MedSpa last September; neither have responded to the suit.
The cause of Kah-Orukatan's death, according to the Florida medical examiner, was lidocaine toxicity, an overdose.
Florida state Sen. Eleanor Sobel, a Democrat who is vice chair of the Senate health regulations committee says it is out of control, and it's all about people doing a job they're not qualified to do.
Sobel, who represents nearby Broward County, plans to reintroduce a bill she introduced last year to regulate so-called med-spas as medical clinics, which would subject them to inspection. The bill didn't get traction during the Legislature's last session because it wasn't a priority of the leadership, Sobel says, adding that with the increase in the number of deaths, it should be a priority this year. Sobel also plans to add a requirement that someone trained in anesthesia be present for procedures including liposuction.
Painful and disfiguring
Even when patients survive, botched surgeries can be painful, disfiguring and costly.
Absent regulation, however, any doctor with a license to practice medicine can perform any procedure a patient wants done. Many non-plastic-surgeons have decided to go into areas in which there's limited oversight, more money and little, if any, interference from insurers because elective cosmetic surgery typically isn't covered.
Plastic surgeons had a higher median income — $270,000 — than 12 of the 22 medical specialties, including emergency and family medicine, in the 2010 Medscape survey by WebMD.
The medical field makes a distinction between residency-trained plastic surgeons and cosmetic surgeons, but many consumers aren't aware there's a difference, says Phil Haeck, a Seattle plastic surgeon who heads the American Society of Plastic Surgeons, the oldest of the industry's medical groups. Many of the new cosmetic surgeons are board-certified, just not in plastic surgery, he says.
In medicine, board certification occurs when a doctor has met all of the qualifications required by one of the American Board of Medical Specialties' 24 member boards, which represent the main areas of medicine, including plastic surgery. ABMS sets the standards for the education, lifelong training and testing of doctors.
Residencies — the years-long stints working in hospitals under the guidance of more senior physicians — are required for board certification and are the principal distinction separating plastic and cosmetic surgeons, who typically instead do year-long fellowships or private training.
Insurers and the accrediting bodies for most hospitals, outpatient surgery clinics and doctors' operating rooms look for certification by ABMS member boards and typically require doctors to perform only the procedures for which they are board-certified. It's one of the things that keeps eye doctors from delivering babies and radiologists from treating broken legs.
ABMS' member boards include the American Board of Plastic Surgery but none of the other cosmetic surgery boards, including the similar-sounding American Board of Cosmetic Surgery, that many surgeons say they are certified by.
Boards are assembled so you can say you are board-certified, says Randy Miller, a plastic surgeon who heads the Florida Society of Plastic Surgeons. He says no one is pretending to be a heart surgeon, no one is pretending to be a pediatrician, but everyone's pretending to be a plastic surgeon.
Michael Will, an oral and cosmetic surgeon who is president of the American Board of Cosmetic Surgery, says residencies in plastic surgery are not necessary for doctors — or oral surgeons — who can document their education, experience and training.
If they can, a favorable outcome is certainly possible and likely for the majority of patients, says Will, who trained in general surgery before doing a cosmetic surgery fellowship.
Membership in the American Academy of Cosmetic Surgery increased by 25% during the past five years to 2,600, says AACS President Angelo Cuzalina, an oral surgeon who now does cosmetic surgery full time.
Cuzalina says less than 8% of the group's members are board-certified plastic surgeons. He estimates that 50,000 to 100,000 doctors who aren't board-certified plastic surgeons are doing cosmetic surgery.
Pitches by cosmetic surgeons who aren't board-certified in the field sometimes tout low prices and say the procedures are safe and easy to bounce back from, a review of advertising and websites shows. Some even offer half-price deals on sites including Groupon.
Costs are reduced, in part, when patients are put under local anesthesia rather than intravenous (IV) sedation or general anesthesia. Expenses are much lower when there is no anesthesiologist, hospital or accredited surgical facility.
It may be presented as a way to save money, but sometimes it's the doctors' only option because their lack of training makes them ineligible to practice in accredited facilities.
But Carey Nease, a Chattanooga, Tenn., cosmetic surgeon who is board-certified in facial plastic surgery as well as head and neck surgery, says doctors can be trusted to limit their practices to the procedures they are qualified to do. They can do a fellowship or find training on their own, he says.
It's not a big stretch for OB/GYNs to go from delivering babies to giving patients tummy tucks, says Nease, who conducts training for the American Academy of Cosmetic Surgery. It's up to them to make the right ethical decision to what they feel they're qualified to do.
Too graphic to publish
USA TODAY reviewed dozens of photos — most too graphic to publish — and cases involving fatalities and patients with horrific scars and infections after cosmetic treatments by doctors who were not board-certified to practice plastic surgery. These include third-degree burns across the backs and stomachs of laser liposuction victims; implants protruding out of massively infected breasts; and lumps and wounds in liposuction patients that look like the result of stabbings.
It's difficult to analyze or compare the problems caused by non-certified doctors who perform cosmetic surgeries, or even those caused by board-certified plastic surgeons, because doctors are not required to report complications to medical authorities. In addition, states don't break down deaths by type of doctor involved, and physicians aren't required to report that they are doing surgeries outside their specialties.
In some cases, cosmetic surgeons were trained by other physicians who aren't board-certified in plastic surgery and who critics say are ill-suited for teaching.
Family practitioner Anil Gandhi of Cerritos, Calif., taught himself how to do breast-augmentation surgery after failing eyesight made it impossible for him to do anything other than superficial surgery, he said.
Gandhi, who trains other doctors who aren't plastic surgeons to do cosmetic surgery while patients are awake, said in the deposition that he also does eye lifts, liposuction and tummy tucks. He previously worked as a general surgeon doing procedures including amputations, appendectomies and the treatment of gunshot wounds.
The deposition was taken by Pittsburgh attorney Noah Fardo for a case involving a breast-implant patient of OB/GYN Lei Chen, whom Gandhi trained. The woman, Rhonda Stankavich, has "permanent disfigurement" with scars that were three times the typical size and in the wrong locations, according to the lawsuit filed on her behalf. The suit also claimed she felt significant pain and was administered three times the recommended safe amount of lidocaine.
She says she had the procedure done because she trusted Chen, who was her OB/GYN for more than three years and because his staff said he had done the procedure many times. Instead, she claims in the suit, he was simply trying plastic surgery. The case was settled out of court for an undisclosed amount.
In a legal response to the lawsuit, an attorney for Chen denied the doctor was negligent. Chen no longer practices medicine in the United States.
The Nevada State Board of Medical Examiners filed a formal complaint against another former Gandhi student, family practitioner Sean Su, in September 2009, alleging substandard care of several women and medical malpractice with one. That patient suffered considerable anxiety and pain along with infection after a breast implant was reinserted, the complaint said.
Las Vegas plastic surgeon Warren Tracy Hankins says he helped treat the patient at the emergency room. The woman's breast implant was protruding from her chest even after she had undergone a second procedure to try to sew it back in, he says. A plastic surgeon would have simply removed the implants, he says.
The Nevada medical examiners board's complaint says both procedures took more than eight hours under local anesthesia, which waned in effectiveness, leading to significant ongoing pain and anxiety throughout the procedure.
Under a March 2010 settlement of the complaint, the medical examiners board temporarily revoked Su's medical license but reinstated it as long as he doesn't practice cosmetic surgery and meets other conditions.
In an e-mailed statement, Su said the medical board's allegations were not the facts of the case but that he had to settle "to keep my license to support my family and two young children.
Su declined to comment about specific cases but noted that cosmetic physicians like myself will be criticized for innovative treatments. It is inevitable that we will become the mainstream physicians in aesthetic medicine.
Few legislators and regulators appear willing to put up roadblocks to stop doctors trained in other specialties from performing cosmetic surgery.
Physicians typically are sanctioned only if they botch the procedures — and get caught. Even then, consumer advocates say, the chances are good that overworked and understaffed state boards of medicine won't find out if they are breaking the law until it's too late.
State oversight of negligent doctors is so uneven that doctors doing things without adequate training … will be home scot-free in many states, says Sidney Wolfe, an internal medicine doctor and director of the Health Research Group at advocacy organization Public Citizen. But in a state that does a good job, they're going to get caught even before they've injured and killed someone.
California tightened its laws after rapper Kanye West's mother, Donda West, died following surgery in 2007 by a plastic surgeon who was not board-certified. The state now requires patients to get a physical exam and written clearance from a doctor before cosmetic surgery.
Yolanda Anderson, Donda West's niece, has been trying to persuade other state legislatures to adopt a version of the Donda West Law. Illinois state Sen. Jacqueline Collins, a Democrat, says she is working with her state's Department of Financial and Professional Regulation to see how to adapt the law for Illinois and whether it should be expanded, possibly to cover cosmetic procedures in offices and spas, which is where non-plastic-surgeons typically operate.
We should be looking at how we regulate the industry and get a handle on this before it gets out there too far, says Collins. There should be a happy medium to protect the integrity of the medical profession and the certification process for those providing the service and protection for the safety and well-being of patients.
More states, however, have made it easier for those who aren't plastic surgeons to perform plastic surgery. Sixteen states now allow dentists trained in oral surgery to perform cosmetic surgery on the face, and the New York state legislature is considering a similar bill. New York legislators have been tweaking the laws governing dentists and cosmetic surgery since 2001, according to the National Conference of State Legislatures.
California and Florida are among the few states that require doctors to specify what they are board-certified in, prohibiting them from simply saying they are board-certified.
The doctors who fight efforts to restrict plastic surgery to those board-certified in the area have told state legislators that the plastic surgeons are only trying to quash competition, says plastic surgeon Miller. Those who do cosmetic surgery but haven't completed residencies in plastic surgery say they are just as qualified as plastic surgeons and possibly even more so because their training has focused solely on cosmetic work, not reconstruction after injuries or illness.
The New York State Dental Association contributed more than $2.5 million to New York legislators from 2004 through 2010. California passed a similar bill in 2006; its state dental group contributed more than $5.7 million to legislators from 2003 through 2010. Liz Snow, chief operating officer of the California Dental Association, said in a statement that its contributions are given without regard to any future or pending legislation.
Mark Feldman, an endodontist who is executive director of the New York State Dental Association, says the cosmetic surgery bill is only a very small part of our advocacy agenda, which he says mostly involves things that improve oral health, such as encouraging the use of fluoride. Letting oral surgeons do eye lifts and nose jobs, he says, would increase competition for consumers. The bill would require oral surgeons to have hospital privileges to do the surgeries at hospitals, though he believes the oral surgeons could be trusted to self-regulate.
The debate certainly has the elements of a turf battle. But the plastic surgeons' position that doctors should practice only in the area they are certified has the backing of ABMS.
Public Citizen's Wolfe says residency programs required by ABMS in the areas of medicine practiced are important to ensure doctors "don't wind up practicing on their patients."
An 'emergency restriction'
The Florida Department of Health did take action against Sant Antonio.
In an administrative complaint filed in July, the department charged that Sant Antonio attempted to take out far too much fat from Shortall, didn't have the staff or equipment required by law and didn't take the steps needed to save her life. It issued an emergency restriction on his license that bars him from doing surgery in his office — and he doesn't have hospital privileges, Florida medical records show.
PureLipo, which Sant Antonio trademarked, is a form of tumescent liposuction, which means the painkiller is injected along with saline solution and a drug that slows bleeding into small incisions in the skin. PureLipo has been marketed as less invasive than liposuction done by other doctors.
However, Miami plastic surgeon Adam Rubinstein says virtually all cosmetic surgeons are doing tumescent liposuction; the main difference is the type of anesthesia used. Doctors who aren't allowed to offer general anesthesia sometimes have to use a higher level of local anesthesia, he says, which can lead to lidocaine overdoses.
Lidocaine is a local anesthetic that decreases pain in the area where it is placed. Too much lidocaine can interfere with brain waves, cause seizures and affect the way the heart pumps, leading to potentially life-threatening problems, says Rubinstein.
Liposuction is now the most popular cosmetic surgery procedure in the USA, Cuzalina says.
As early as 1999, however, anesthesiologist Rama Rao wrote in the New England Journal of Medicine that tumescent liposuction should be re-evaluated because of deaths, especially from lidocaine.
Carol Norton, an OB/GYN in Richardson, Texas, says she branched out into cosmetic procedures to have a backup plan, because it's a little precarious where insurance is going with reimbursements for medical care. She started doing Sant Antonio's PureLipo after taking a three-day course he taught here. A trainer from Sant Antonio's company then went to her office to observe her first 30 liposuctions. At least 20 other doctors are touting their PureLipo training online.
Freedland, the plaintiff lawyer who represents Kah-Orukatan's and Shortall's families, says there's a lesson in the liposuction deaths: Consumers need to make sure cosmetic procedures are done in a facility with the equipment to handle an emergency by people who are properly trained to handle that emergency.
James Howard says his wife was always upbeat yet firm with the kids, making it difficult to try to grab the reins on her role. And then there's the challenge of helping his children understand why she died. At 5-foot-5 and 205 pounds, Kellee Lee-Howard was overweight, but when you love a person, that transcends over anything physical, Howard says.
Attorney Philip Freidin, who represents the Howard family, says Howard and his children have asked us to find out what happened to her.

Plastic Surgery Mills

Story first appeared in USA TODAY.
Elsie Soto says she couldn't move her legs after she had liposuction and fat-transfer surgery last year. But instead of sending her to a hospital, a nurse took Soto to her own house. Soto says she has no memory of being taken to the hospital two days later — on her mother's insistence — and needed two blood transfusions when she got there.
A 32-year-old single mother, Soto said she was tired of looking at all the beautifully toned people surrounding her in this popular beach town. She went to three area plastic surgeons before deciding to have her procedures done at Strax Rejuvenation and Aesthetics Institute. It was a simple matter of cost: The other estimates ranged from $10,000 to $12,000; Strax charged $5,000.
But after almost $50,000 in medical bills (including nearly $40,000 for her hospital stay) that insurance won't cover because the procedure was elective, three months out of work and continued pain down her left leg, Soto now says low-cost, high-volume cosmetic surgery clinics are not the way to go.
Strax, which has two locations in South Florida, boasts it is the busiest cosmetic surgery center in the U.S. Soto says that's part of the problem: She thinks she was just another patient whose problems got short shrift in what seemed like an assembly line of patients.
Soto filed a complaint against Strax with The Joint Commission, an independent, not-for-profit organization that accredits most hospitals and many health care facilities, including Strax.
Strax says it is helping consumers by making cosmetic surgery affordable for the masses. Peter Mineo, an outside attorney for Strax, said in an e-mailed statement that Soto suffered a bruise to her sciatic nerve, which he called a rare but well-known potential complication of fat-transfer surgery to the buttocks. He says Soto was told about the risk. The nurse treating Soto was violating company policy when she took Soto to her home, Mineo says, but called it a very kind act. And Strax believes Soto's medical problems were quickly resolved, Mineo says.
A booming business
Critics call it the commoditization of cosmetic surgery. Procedures that once included lengthy consultations with plastic surgeons and trips to the hospital, now often involve meetings in office-park surgery centers with salespeople who tell prospective patients what "work" they need and how little it can cost when performed in their offices, say former patients, other plastic surgeons and plaintiff lawyers. These people often need HIPPA Training.
Elsie Soto says she still often cries herself to sleep because of the pain since her cosmetic surgery.
While these clinics typically employ plastic surgeons who are either board-certified or up for certification, lawyers, victims and other plastic surgeons say these new-style surgery clinics are under so much sales pressure they often don't sufficiently screen patients for medical problems, do inadequate follow-up and persuade patients to undergo procedures that are either unnecessary or unlikely to get good results.
Cosmetic procedures ranging from Botox to buttocks lifts performed by plastic surgeons were up 77% last year, as consumers flock to clinics including Strax, the national chain Lifestyle Lift, and other busy cosmetic surgery centers geared to the budget-minded.
Lifestyle Lift founder David Kent says, there are no guarantees in medicine or surgery, but that the company wants every patient to be satisfied. In a recent recruitment letter to plastic surgeons, Kent said the 39-location company, which advertises heavily on TV, plans to open 40 more clinics nationwide.
With marketers playing a key role at some cosmetic surgery centers, former patients and lawyers say some of the clinics' claims about the low risk, dramatic results and short recuperation time are misstated. Lifestyle Lift's marketing practices, which are under investigation by the Florida attorney general, are backed up by tons and tons of research, says CEO Gordon Quick. Still, Florida's attorney general has more than 60 complaints about the company, including several contesting its claims about fast recoveries, minimal pain and results that take years off one's appearance.
Two years ago, Lifestyle Lift settled a lawsuit by then-New York attorney general Andrew Cuomo charging that the company was writing its own online testimonials for existing websites and at least 10 sites it created to appear consumer-generated.
In its settlement agreement, the attorney general's office revealed internal e-mails, including one directing a Lifestyle Lift employee to "Put your wig and skirt on and tell them about the great experience you had" on the independent site RealSelf.com. Lifestyle Lift says it was simply posting the contents of letters it received from happy patients, although the settlement agreement says evidence shows many of the postings were written entirely by employees.
Jennifer Davis, a spokeswoman for Florida Attorney General Pam Bondi, says its 16-month probe is looking at Lifestyle Lift's advertising of a "facial rejuvenation procedure that is purported by them to be safer and less expensive than other traditional procedures, totally individualized for the client, and offers a quicker recovery time." Investigators, she says, are looking into possible violations of the Florida Deceptive and Unfair Trade Practices Act, which bans commercial practices that deceive consumers.
Left with lopsided ears
Joyce Wooten, 53, of Tampa said her surgeries at Lifestyle Lift ruined her life, in her complaint to the Florida attorney general. She said the healing process was longer and more difficult than she was told and heard in advertising.
Wooten said she began hiding her face everywhere she went because people stared and some gasped. She citing problems including loose flaps of skin on her neck and lopsided ears.
Lifestyle Lift says it did a revision procedure for Wooten at no cost in late 2008, but Wooten says that was only after she threatened a lawsuit. The company says she never returned for her follow-up, which is important for healing.
A happy patient
Lifestyle Lift founder Kent says its centers have performed about 140,000 face-lifts and have only a few people they could not make happy.
Barbara Schmidt, 62, of Plantation, Fla., says she is one of the happy patients. She says she was self-conscious about her chin, which looked like it was "all in one" with her neck. Her Lifestyle Lift procedure, which included liposuction to her neck, made her look so much better, she says.
Aronfeld, who says he fields several calls a day from unhappy Strax patients, has formally requested arbitration — something Strax requires patients to agree in writing to do before suing — on behalf of Soto, the survivors of Lidvian Zelaya, who died in December after having liposuction and fat-transfer surgery, and Barbara Yakin, who was hospitalized after a tummy tuck, thigh lift and liposuction at Strax last September.
Surgery death rates
According to a Denver Wrongful Death Lawyer, Four Strax patients have died in the last two years. The company says three out of the four deaths were unrelated to complications of their surgeries. Zelaya, according to her autopsy, died of an embolism due to complications of liposuction and fat transfer surgery. In a statement, Mineo called the embolism an unavoidable complication of liposuction.
Miami plastic surgeon Alberto Gallerani wrote in an affidavit for the case that the amount of fat transferred and the fact it wasn't done in a hospital unnecessarily increased the risk of a fatal embolism. Roger Gordon, the doctor who performed the surgery, no longer has hospital privileges, according to the Northshore Medical Center FMC Campus and Florida Board of Medicine records.
Another patient died of an overdose of pain medication, the autopsy shows, and Mineo says it was far more than Strax prescribed. The autopsy shows another died of blood poisoning from a wound infection — for which the patient didn't seek timely medical attention, Mineo says. The fourth died of an underlying and very rare disease — Uhl's — that can only be detected through genetic testing or an autopsy, Mineo says.
Mineo maintains that Strax's safety record is second to none. He says Zelaya is Strax's one fatal complication in the universe of 90,000 procedures it has performed. The cosmetic surgery field has a generally accepted level of mortality of one for every 50,000 surgeries, according to widely cited reports. That would give Strax a mortality rate that's about half the accepted level, Mineo says.
But Strax actually has a rate of four deaths in 90,000, which makes Strax's mortality rate almost twice what's considered acceptable in cosmetic surgery, says Miami plastic surgeon Adam Rubinstein. The American Association for Accreditation of Ambulatory Surgery Facilities, which accredits most outpatient surgery centers, mandates in their standards that all deaths occurring within 30 days after a surgery are included in their mortality rates, according to experts including Beverly Hills plastic surgeon Geoffrey Keyes, AAAASF's president-elect. Keyes is the lead author of two peer-reviewed studies of safety and fatalities in outpatient surgery, including one that analyzed more than 6 million procedures and found a death rate of one in 50,000 procedures.
Yakin, 60, says she collapsed when she got home after her Strax procedures, spent two days in intensive care at the hospital and required three more surgeries to correct infected wounds on her thighs and stomach.
Yakin developed a hematoma after the surgery, says Mineo, who called it a well-recognized complication. Yakin was taking blood thinner medication so was cleared by her medical doctor — though not a cardiologist — before the surgery and stopped taking the medicine, Mineo says.
Yakin's doctor, Jeffrey Hamm, was on probation until last September following disciplinary action by Florida's Board of Medicine.
In its complaint, the board charged that Hamm — while working for Strax — failed to meet the standard of care for a patient after he didn't order additional lab tests or consultations when tests showed the person had dangerously elevated blood glucose levels. This earlier patient was hospitalized for almost two months with septic shock, respiratory and renal failure. Mineo says Hamm settled those charges because he was financially broken by the proceedings.
Death after liposuction
In May 2009, Aura Javellana, 28, of Redmond, Wash., died of acute lidocaine intoxication, according to the autopsy report. The day before, she had a liposuction procedure at Sono Bello Body Contouring Center, which has 10 locations in seven states. She took a cab by herself from Sono Bello to a hotel room to recuperate and was found dead by maids the next morning.
A lawsuit against Sono Bello filed by attorney Cydney Campbell Webster on behalf of the Javellana family alleged Javellana was not evaluated by any licensed medical professional — only a company consultant — and didn't meet her doctor until right before the surgery. The lawsuit also charged that the company falsely promoted the procedure as safe, saying it ruled out the complications from traditional liposuction.
The Washington state health department charged that the doctor who performed the surgery, Marco Sobrino, was guilty of unprofessional conduct, which means it believes his conduct met the legal definition of incompetence, negligence or malpractice, says spokesman Gordon MacCracken. A hearing that could result in Sobrino having his license revoked is set for Sept. 27.
Penn Gheen, an attorney representing Sono Bello, says a marketing person who was let go created some materials independently that were given to some patients and probably did downplay the risks more than the official materials. In a response to the suit, Sobrino's attorney denied that he was guilty of wrongful death or medical negligence.
The case was settled out of court in July for about $1.9 million, according to settlement documents filed in the case.
Phil Haeck, a Seattle plastic surgeon who heads the American Society of Plastic Surgeons, says the new approach to cosmetic surgery is especially worrisome when medical professionals are not making the decisions.
Along with the Florida complaints, Lifestyle Lift has a 51% "worth it" rating among 360 reviews on RealSelf.com, a website about cosmetic procedures. The Better Business Bureau has received 19 complaints about the company in the past three years, nearly all about products or services. Of those, 15 complaints were resolved with the assistance of BBB and four couldn't be resolved to the customer's satisfaction.
While these centers typically employ board-certified plastic surgeons, some don't have privileges to treat patients at hospitals, leaving patients to fend for themselves at emergency rooms. Soto says she now wishes she had her procedure performed at a hospital rather than an outpatient surgical center so that if anything happened she was already there.
Awake during surgery
Doing procedures in office surgery centers saves money, something that many consumers, including Wooten, say they found attractive — at least until they realized that it can be traumatic to have surgery under the local anesthesia often used in office settings.
Lifestyle Lift uses only oral sedatives and injections of a painkiller, lidocaine, which is similar to novocaine. Its offices are not accredited by any of the groups that certify hospitals or surgical centers, which rules out even the use of intravenous sedation to put patients into what's known as a partially asleep twilight state.
Kent says the centers have all the emergency equipment accreditation companies would require.
Wooten says that during her Lifestyle Lift procedure, she could tell the doctor was cutting around her ear and hitting it to get it to come loose from her head, according to her complaint to the Florida attorney general.
Wooten says she wishes she had been completely asleep, and the worst part is remembering.
Kent acknowledges that local anesthesia is not for everyone and says the downsides are fully explained to patients.
And some satisfied former Lifestyle Lift patients, whose names were provided by the company, say they wouldn't have it any other way. Beatriz Newnam, 52, of Marco Island, Fla., says she was laughing and telling jokes during her surgery last August, which included an eyelift, face-lift, neck liposuction and lip augmentation.
Orlando plastic surgeon Edward Gross filed a complaint with the Florida Board of Medicine after he provided emergency room services in 2008 for what he called the life threatening condition of a Lifestyle Lift patient.
In the complaint, Gross wrote that the patient was bleeding from the face and needed emergency assistance with breathing and surgery for hematomas. He wrote that the patient, who settled a lawsuit against Lifestyle Lift out of court, was in intensive care on a ventilator and breathing tubes for six days.
He also charged that patient safety was at risk because her doctor didn't have hospital privileges and the facility did not meet the state's standard of care for office surgery.
Lifestyle Lift denied all allegations related to the safety of its facility and doctor, according to its response to a lawsuit Gross filed against the company seeking payment for these services.
Michelle Cordi of Orlando sued Lifestyle Lift last year, charging that she didn't get medical care from the company before her surgery and that the procedure left her with a wound that wasn't treated properly, which led to her hospitalization.
In a response to the suit, Lifestyle Lift denied the allegations and said it was not negligent.
Doctors can earn $1 million a year
Malcolm Paul, a prominent Newport Beach, Calif., plastic surgeon, says that after he saw a Lifestyle Lift plastic surgeon perform a face-lift, he became so convinced of the approach that he is now working as a consultant to the company.
In the recent letter sent to plastic surgeons and reviewed by USA TODAY, Kent said top-performing doctors earn more than $1 million a year in net income and those working two days a week can earn $450,000 a year.
Prendiville, the Fort Myers plastic surgeon, says he's treated several patients who were unhappy with the results they got at Lifestyle Lift. Most had visible, poorly executed face-lift scars with no discernible aesthetic improvement, he says. USA TODAY interviewed six other plastic surgeons who did not want their names used but made similar comments.
Prendiville says Lifestyle Lift's claims aren't based on any studies ever published in surgical journals, and the company uses terms including revolutionary when, he says, their procedure is really just a variant of a quick face-lift that's been done for decades by others.
Kent says the company now does small, medium and large-incision face-lifts and that the larger incisions are for people who have more sagging. Quick says traditional face-lifts are a more invasive process as they go farther under the skin.
As for Soto, she says she still often cries herself to sleep because of the pain since her surgery. And she's changed her view on the competition to look good around her hometown.

07 September 2011

Shorter Recovery For Pitcher’s Elbow Surgery

Story first appeared in USA TODAY.
Stephen Strasburg was back on a major league mound right on schedule, a year and three days after having Tommy John elbow surgery.
That timetable, however, has narrowed significantly from years past.
Pitchers who have the operation are told to expect the rehab to last 12 to 18 months, but most are returning around the one-year mark, thanks to refinements in the surgical technique.
In a study conducted by the American Sports Medicine Institute and published in a trade journal last year, 83% of the 743 athletes (not all professional pitchers) who were contacted reported returning to their previous level of competition or higher within two years of having the surgery. The average return time was 11.6 months.
Research into the careers of active big-league pitchers who have had elbow-reconstruction surgery shows they return to the majors in an average of 394 days, or a year and 29 days, excluding those whose rehab bridged two offseasons because of the timing of the operation.
Recent examples include the Florida Marlins' Josh Johnson (342 days), the Cincinnati Reds' Edinson Volquez (348) and Strasburg's teammate on the Washington Nationals, Jordan Zimmermann (372).
Kevin Wilk, a physical therapist involved in the ASMI study who has worked for 23 years with noted orthopedic surgeon James Andrews of Birmingham, Ala said the rehab is not that complicated per se, the complicated factor is the throwing program and getting your mechanics back in line, getting your velocity back, and obviously the rehab allows you to do that, but what takes the majority of the rehab time is the fine-tuning of the pitching.
Medical experts say surgical adjustments developed in the last decade have helped speed up the recovery while minimizing the risk of complications.
The original procedure, performed in 1974 on John, then a Los Angeles Dodgers left-hander, by pioneering surgeon Frank Jobe, required transposing the ulnar nerve and cutting the elbow muscles off the bone.
Now some surgeons leave the nerve in place, and nearly all split the muscles, which allows for a quicker recovery. Brad Parsons, an orthopedic surgeon at Mount Sinai Medical Center in New York who has performed 30 to 40 elbow reconstructions said it's a little bit less invasive of an approach and the muscles are protected better, and the affixation of the graft into the bone is less invasive, so less trauma is incurred to the elbow.
Strasburg had a 5-3 record, 2.91 ERA and 92 strikeouts in 68 innings during his sensational, though truncated, rookie season, often baffling hitters with a devilish curveball as complement to his 100-mph heat.
He might not get the hook fully back until 2012.
Some pitchers who had Tommy John surgery say they were pleased to see their old fastballs return to their previous standards within a year, but they also point out other aspects of pitching — such as the snap in their breaking pitches and sometimes command — took longer.
Zimmermann said his breaking pitches were not quite as sharp at first, taking 10 months off from throwing, at first it feels like you've never thrown a curve before.
Some of that feeling probably stems from a psychological barrier. The rehab is full of ups and downs, often requiring the athletes to go back a couple of steps in the process, which takes a mental toll.
Lyle Cain, an orthopedic surgeon at ASMI said from a physical aspect, sometimes in eight or nine months they're actually pretty darn good, but having the confidence to really cut loose, to place the ball where they want to and to control all their pitches, it takes a lot longer.
Cain said at some point the rehab time might get further shortened.
But for now the general protocol is about a year, give or take individual variations.
San Francisco Giants right-hander Ryan Vogelsong, who had his elbow reconstructed in 2001, said Tommy John patients need to resist the urge to overdo the rehab on the days they feel good.

06 September 2011


Story first appeared in USA TODAY.
With the touch of a button, Russ Marek's easy chair lifts him to a standing position.
He takes specially fitted crutches and walks down the hallway of his home in Viera, Fla. Then with a slow unsteady gait, but with a sense of accomplishment and smiling, he walks back with the help of only one crutch.
Marek, a staff sergeant, was serving in Iraq with the 4th Battalion, 64th Armor Regiment of the Army's 3rd Infantry Division, when he was critically wounded Sept. 16, 2005, by a roadside bomb. His injuries included the loss of his right leg and right arm, brain injury and burns over 20% of his body.
Marek, 40, said he slowly has learned to compensate and do more for himself. But he still cannot live on his own without assistance.
The Mareks have been approved for the VA's new Family Caregiver program for post-9/11 veterans that provides benefits for the first time to designated family caregivers of eligible severely wounded service members.
In a speech Tuesday to the American Legion Convention, President Obama talked about the caregivers program as part of his plan to help veterans.
He told the Legionnaires that we're giving unprecedented support to our wounded warriors, especially those with a Michigan traumatic brain injury, and thanks to the veterans and caregivers legislation he signed into law, we've started training caregivers so that they can receive the skills and the stipends that they need to care for their loved ones.
The program includes monthly stipends, health insurance and other benefits for the family caregiver. It also provides counseling and travel benefits when the wounded veteran must go for specialized treatment and other services. Quarterly visits from VA social workers help to ensure the veterans are getting appropriate care.
Mearlene Filkins, caregiver support coordinator for the VA Orlando office, which covers several Central Florida counties, including Brevard, said in the past, caregivers had been seen in the shadows of the veteran.
Filkins said that eligible caregivers could receive between $400 and $2,000 per month based on need, whether they provide full-time or part-time care, and based on what it would cost to pay a home healthcare aide in the area.
Since the program started in May, one additional family in Brevard besides the Mareks has been approved for the program and another is awaiting approval. The Orlando area has seen 40 applications, with 21 approved so far, according to the VA.
Of the 2,003 applications the VA received from across the nation as of Aug. 25, 907 have been approved with an average monthly stipend of $1,800.
The program recognizes the efforts of family caregivers, some who have lost income, insurance and other benefits because they left jobs to care for their loved ones. The program helps compensate for that, and allows the veteran to be cared for in the comfort of home by a family member.
Rose Marek, Russ’s mother and caregiver, said the benefits are a great help, especially to younger struggling families.
She and her husband, Paul, have been caring for their son since he was injured about five years ago. The program will help them cover their own insurance and other expenses they incur while caring for their son.
She said it might help her and her husband do something they want to do without putting a strain on their budget. Shee added that to a young couple, it's going to mean everything, if a spouse has to quit work and stay home, it puts a terrible financial strain on that young couple.
Rose Marek said she heard about the new VA Caregiver program from a veterans' organization.
The Mareks take turns, splitting time between their home in Satellite Beach and their son's home in Viera. Though Russ Marek pushes himself to do as much as he can on his own, he needs their help.
Marek walked with crutches to the kitchen cabinets and slowly showed how he could grip a plastic cup with his left hand, which is missing most of his thumb.
Despite the assistance he requires for some basic needs, Russ Marek remains upbeat and accepting of his condition as he struggles to improve. He sometimes pushes to rely less on the walker and crutches to get around.
While many injured veterans are like Marek and require help from caregivers, some resist help with day-to-day activities and can get along without assistance.
John Stearns, a 22-year-old Marine lance corporal who was critically injured on his birthday, Sept. 14, 2010 in Afghanistan when an explosion tore away his right foot and shattered his left leg, doesn't want assistance. He is undergoing treatment and therapy at National Naval Medical Center in Bethesda, Md., and is expected to be there until February.
Stearns, of Palm Bay, was on foot patrol in a field when he stepped on a device that triggered an explosive. He had plans of continuing in the Marine Corps for four years. Now his plans are to attend the University of Central Florida to study radiology, a career he became interested in after undergoing many X-rays while hospitalized. He may be seeking additional assistance from a Chicago brain injury lawyer.
Still in therapy, it will be months before Stearns knows how well he'll do on his own.
Filkins, from the VA, said the needs of each applicant to the program are evaluated.
She said the response she has seen has been very positive, and families have been very happy.


Story first appeared in the Wall Street Journal.
The threat of losing your home is stressful enough to make you ill, it stands to reason. Now two economists have measured just how unhealthy the foreclosure crisis has been in some of the hardest-hit areas of the U.S.
New research by Janet Currie of Princeton University and Erdal Tekin of Georgia State University shows a direct correlation between foreclosure rates and the health of residents in Arizona, California, Florida and New Jersey. The economists concluded in a paper published this month by the National Bureau of Economic Research that an increase of 100 foreclosures corresponded to a 7.2% rise in emergency room visits and hospitalizations for hypertension, and an 8.1% increase for diabetes, among people aged 20 to 49.
Each rise of 100 foreclosures was also associated with 12% more visits related to anxiety in the same age category. And the same rise in foreclosures was associated with 39% more visits for suicide attempts among the same group, though this still represents a small number of patients, the researchers say.
Teasing out cause and effect can be delicate, and correlation doesn't necessarily mean foreclosures directly cause health problems. Financial duress, among other issues, could lead to health problems—and cause foreclosures, too.
The economists didn't find similar patterns with diseases such as cancer or elective surgeries such as hip replacement, leading them to conclude that areas with high foreclosures are seeing mostly an increase of stress-related ailments.
Is the housing crisis making Americans sicker? New economic research suggests just that. The research found a direct correlation between foreclosure rates and the health of residents. Mitra Kalita explains on Lunch Break.
Tuesday brought news of further weakness in the housing market as the closely watched S&P/Case-Shiller home-price index came in 5.9% lower for the second quarter from a year earlier. Continued job losses and economic uncertainty could weigh on home prices and make for another wave of foreclosures, economists say.
It may not just be foreclosure victims arriving at hospitals—but neighbors also grappling with depleting equity in their biggest investment.
Ms Currie said you see foreclosures having a general effect on the neighborhood with everybody being stressed out, and t
here is a connection between people's economic well being and their physical well being."
The situation got so bad for Patricia Graci, a 51-year-old Staten Island, N.Y., resident, that she canceled a recent court appearance related to the foreclosure on her house because she couldn't get out of bed. After her husband lost his job as a painter in 2008, the Gracis relied on savings to pay their mortgage for two years.
She said everything was going downhill, her savings were going down to nothing, and when she realized the money wasn't there anymore, she started getting very anxious and depressed.
She says her lender advised her to default on her mortgage to qualify for a loan modification. Ms. Graci, who was an assistant bank manager and already had rheumatoid arthritis, says she began seeing a therapist and landed in the hospital with difficulty breathing in December 2009. A few weeks later came the foreclosure notice from the bank.
Ms Graci said she was told it was more anxiety and stress that made her wind up in the hospital than the arthritis. After repeatedly missing work due to illness, Ms. Graci went on long-term disability.
The areas that have the highest foreclosure rates also tend to have a large portion of their population unemployed, underemployed or uninsured. Ms. Currie says the research accounted for this by instituting controls for persistent differences among areas, such as poverty rates, as well as for county-level trends. Much of the 2005-2009 period examined came before unemployment peaked, too, she says. The researchers examined hospital-visit numbers and foreclosure rates in all ZIP Codes that had those data available.
The areas that have the highest foreclosure rates also tend to have a large portion of their population unemployed, underemployed or uninsured. Ms. Currie says the research accounted for this by instituting controls for persistent differences among areas, such as poverty rates, as well as for county-level trends. The time period examined, 2005 to 2007, was before unemployment peaked, she says. The researchers examined hospital-visit numbers and foreclosure rates in all ZIP Codes that had those data available.
They found that areas in the top fifth of foreclosure activity have more than double the number of visits for preventable conditions that generally don't require hospitalization than the bottom fifth.
At the local hospital in Homestead, Fla., a city of mostly single-family, middle-class homes about 30 miles from Miami, the emergency room has been bustling. Emergency visits to the hospital in 2010 more than doubled from 10 years earlier to about 67,000, and emergency department medical director Otto Vega says they will surpass 70,000 this year. Homestead has the highest rate of mortgage delinquencies in the U.S.—in June, 41% of mortgage holders in the hardest-hit ZIP Code of Homestead were 90 days or more past due on payments, according to real-estate data firm CoreLogic Inc.
While the most common ailments are respiratory problems and pneumonia, Dr. Vega notes an increase in psychosomatic disorders, such as patients with chest pain and shortness of breath, and others who feel suicidal. He said when a lot of young people, less than 50 years old, have chest pain, then you know it's anxiety.
Nationwide, overall emergency-room visits have also been rising, growing 5% from 2007 to 127.3 million in 2009, according to the American Hospital Association. But inpatient stays have largely kept pace with population growth over the last decade, says Beth Feldpush, a vice president for policy and advocacy at the National Association of Public Hospitals.
The number of people covered by employer-sponsored insurance has been falling, she says. When people don't have insurance, they put off seeking care for too long and end up in the emergency room.
And some of those seeking treatment had medical conditions before foreclosure—but the stress of losing their homes has exacerbated their ailments.
In 2008, Norman Adelman of Freehold, N.J., called his lender to ask for a forbearance of three or four months, saying he was about to undergo knee-replacement surgery. The lender complied and Mr. Adelman, who runs a home-energy business, says he began scaling back his work. He underwent needed tests and doctor visits.
After two months of not paying his mortgage, he successfully applied for a loan modification, taking his monthly payment from $2,700 to $1,900. But then the loan was sold—and a new servicer didn't recognize the terms of the arrangement, he says.
Mr. Adelman is fighting the new lender but says he has been in and out of the hospital for the last two years. He never had his knees replaced and is now on antidepressants and antianxiety medication.
Earlier this month, after working with the nonprofit Staten Island Legal Services, Ms. Graci received a trial loan modification. She may be happy about this, however she is still scared because it is not a permanent solution.