Hospital Foods Made to Order

First appeared in the Wall Street Journal

Pnina Peled, executive chef at Memorial Sloan-Kettering Cancer Center, recently faced an unusual culinary challenge: A teenage cancer patient wanted pizza, but chemotherapy treatments had dulled the girl's taste buds and she could only taste lemon.

"This kid liked Italian food, and we couldn't think of a lemon-flavored pizza because we kept thinking of tomato sauce," says Ms. Peled. After some trial and error, the chef created a pizza with a lemon Alfredo sauce for the young patient. "We made it for her three or four times in a month because she kept requesting it," Ms. Peled says.

Getting patients in a cancer hospital to eat is a challenge. "They can't swallow or they can't taste it or they're nauseous," Ms. Peled says. "The adults force themselves, because they know they need the nutrition. But the children don't understand why food doesn't taste like it used to, or why they can't taste anything."

Most hospitals have been updating their food offerings to include more vegetarian and healthier fare. But some major institutions are going further, hiring trained chefs to revamp menu selections and expanding kitchen hours to cater to a variety of medical needs. Diabetic, gastric-bypass, cardiac, cancer and other types of patients all have different cravings and nutritional requirements, these hospitals say.

Chefs are experimenting with Nutella milkshakes, made from the sweet hazelnut spread, for patients needing extra calories. Cancer patients may dine on chicken with a side dish of Flamin' Hot Cheetos to tingle chemo-numbed tongues.

Rex Healthcare in Raleigh, N.C., maintains a small herb garden outside the cafeteria where patients can watch the chefs cut mint and tarragon for the day's dishes. Jim McGrody, Rex's director of culinary and food services, says each disease has its own issues: Cancer patients can't have fresh herbs and raw vegetables because of bacterial concerns, renal patients have to watch potassium (so, no bananas) and cardiac patients eat a low-fat diet.

"Gastric bypass patients are really a challenge because they have to eat very low-fat, low-sugar diets with high protein," says Mr. McGrody, a Culinary Institute of America graduate. "This summer I tried an outdoor menu, with some cedar-plank-grilled salmon. You have to show them that they can get flavor without the fat using citrus juices or roasted garlic."

It takes more work to provide specialized meals. And some healthier ingredients, like fish, can be more expensive. But hospital officials say the cost, which is incorporated into the daily room charge, works out about the same as traditional hospital fare.

"Although we reinvented the menu, the trade off is that we saw a significant reduction in food waste," says Veronica McLymont, director of food and nutrition services at Memorial Sloan-Kettering, in New York. "Patients now order what they want to eat, when they are ready to eat," she says.

Extra care in preparing meals also can give a boost to a hospital's reputation. A 2009 study published in the journal Nutrition & Dietetics found that the more personalized the food service, the more satisfied the patients.

Patients say it makes a difference. Carl William Cousins, 54 years old, had a triple bypass at Rex Hospital last summer. During his six-day stay, he remembers the grilled chicken and turkey sandwiches and well-spiced vegetables.

"Most of the time when you think heart healthy, you just think bland," says Mr. Cousins, a retiree in Raleigh. "I really looked forward to getting something to eat."

Rex Healthcare has two recipes for grilled chicken. "One is marinated in oil with onions, pickles, herbs and spices," Mr. McGrody says. The other, for the heart-healthy menu, "has no oil but is more of a rub of fresh herbs and spices," he says.

At MD Anderson Cancer Center, patients can have Froot Loops cereal and Louisiana Hot Sauce if that is what will get them to eat, says Carol Frankmann, director of clinical nutrition for the Houston hospital. The hospital got so many requests for Flamin' Hot Cheetos that the chefs added the selection to the menu, she says. Cancer patients' "taste can be blunted so they need something strong—sweet, spicy or acidic—just so they can taste it," she says.

Some hospitals have begun cooking to order for patients, similar to a restaurant, instead of requiring them to submit food requests the night before. Orders can be placed any time during the day, until 9 p.m. at MD Anderson, and even later at some hospitals. Memorial Sloan-Kettering blends custom-made smoothies for its patients; MD Anderson offers made-to-order pasta dishes. Some hospitals say they have added kitchen workers to deal with the changes, while others readjusted staff schedules.

"There's been a major shift in philosophy, not just about feeding patients but for the whole hospital," says Kathy McManus, director of nutrition at Brigham and Women's Hospital in Boston, which has 800 beds. The hospital recently began a pilot study with eight other medical centers, including Johns Hopkins in Baltimore and Ohio State University, to evaluate how to improve nutrition and what cancer patients think about food.

Memorial Sloan-Kettering, which serves about 900 meals a day, revamped its kitchen to offer more personalized patient service about two years ago. Ms. Peled, the executive chef, says that if a patient is having a particular dietary challenge, she will personally visit and see if there is something the kitchen can do. For patients who have trouble swallowing, she developed egg-based custards, like a French toast custard with blended croissants, topped with crème anglaise and cinnamon and nutmeg, served in a ramekin.

"All the kids have my card, and they email me constantly," says Ms. Peled. "Here's one I got today from a 13-year-old: 'I wanted to know if you could stop by my room to talk about what I can eat and what you can make me. I miss talking to you in person and I hope you get back to me. Your food friend, Courtney.' "

Family History May Be Key in Heart Risk

First appeared in the Wall Street Journal

Ecorse Heart Doctors often gloss over a key question for assessing a person's risk for coronary heart disease, according to a new study: What is the patient's family history of cardiovascular illness?

The study suggests some doctors may not be capturing the full extent of many patients' chances of developing heart disease. Detailed family information could help doctors better predict who is at risk and more accurately target patients for preventive care that may help avert the disease altogether, according to the study, due to be published Tuesday in the Annals of Internal Medicine. Routinely tracking family history sharply boosted the number of people in the study considered at high risk for heart disease.

A widely used scorecard for measuring heart risk, the Framingham Risk Score, fails to take family history directly into account. And while many doctors currently collect some information about the health of their patients' families, the data often lack the detail to be clinically useful for assessing risk and prescribing care.

Family history remains one of the most important predictors of an event for an individual. Still, most of the family history that experts are collecting is just the presence or the absence of heart disease, not the age of onset or the type of disease, according to Northville Cardiologists.

Guidelines for heart-risk screening, issued by the heart association in late 2010, encouraged doctors to take family histories into account. Doctors sometimes make judgment calls to treat people as high risk because of family history, even if it isn't part of the patient's risk score.

The study, funded by the United Kingdom Department of Health, included 748 patients aged 30 to 65. Up to 13% of patients were found to be at high risk of coronary heart disease using traditional assessment tools. After patients filled out enhanced questionnaires that sought more complete information, the percentage considered at high risk jumped to 18%. The traditional assessment could include general information, such as blood pressure, cholesterol level and basic information about whether a family member had a history of heart disease. The enhanced survey would identify, for instance, that a patient's mother had a heart attack at age 50.

It's a low cost way to target people who are at high risk for cardiovascular disease, say Romulus Heart Doctors.

Findings from the U.K.-based study reflect similar use of family history among doctors in the U.S., several U.S.-based physicians say.

Family history has been linked to higher risk for a number of illnesses, including cancer and diabetes. Unlike some other diseases, however, clear genetic markers for coronary heart disease, which accounts for 1 in 6 U.S. deaths, remain elusive. Family histories can be used as a proxy for detailed genetic work that may someday be used to help predict heart-disease risk, researchers say.

Another risk-measurement tool, known as the Reynolds Risk Score, developed by Harvard University researchers in the 1990s, does consider if a patient's parent had a heart attack and at what age. However, many medical practices don't yet use the tool, which became available in 2007.

Using the Reynolds system, the researchers tracked 25,000 initially healthy patients over a decade. They found that a 50-year-old male patient who, among other things, smoked, and had high blood pressure and cholesterol, but no family history of heart disease, had a 12%, or moderate, chance of having a heart attack in the 10-year period. But a similar patient with a parent who had a heart attack before age 60 had a 20% risk, putting that patient at high risk for heart disease. Heart risk wasn't significantly affected in patients with a parent who had a heart attack at the age of 60 or older.

Still, many medical practices continue to rely on the older Framingham Risk Score, which became available in the 1990s. Researchers believed that other factors, including blood pressure and cholesterol levels, provided all the information needed to determine a patient's risk for heart disease.

Doctors use the scoring systems to single out patients who could benefit from counseling about lifestyle changes, such as losing weight and quitting smoking, or from preventive interventions such as low-dose aspirin and cholesterol drugs, says Yul Ejnes, the chairman of the American College of Physicians board of regents. The college publishes the Annals of Internal Medicine.

Primary-care doctors say there are obstacles to gathering family histories from patients, including competing priorities for time in the examination room. And patients often don't know many details about their family members. In the Annals of Internal Medicine study, patients were mailed questionnaires and instructed to gather the material before seeing their doctor.

Patients should make a point of knowing the health histories of their parents, siblings and grandparents, he says. To identify clues about specific diseases, however Riverview Heart Doctors say that they sometimes asks patients questions like: "What do you remember about Grandpop's hospitalization? Were his legs swollen?"

A 33-year-old a senior marketing director at a Boston technology firm, says her family history has made her an advocate for her own health. She says she watches her diet and exercises regularly. And although she currently isn't on any heart medication, she regularly pushes her doctor to check thoroughly for signs of developing heart disease.

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Confused by Rare Crawling-Skin Disease

First appeared in USA Today

A half-million-dollar study by the Centers for Disease Control and Prevention has found no obvious medical explanation for a mysterious and controversial skin disease whose sufferers report a crawling sensation on or under their skin and fibers emerging from it. This is not something those suffering from Ringworm complain about.

Although the findings may not mollify those who say they have Morgellons, as the condition has been dubbed by some, CDC’s Mark Eberhard says the findings are useful in that they tell both patients and doctors that the condition is rare and neither contagious nor environmentally based. Perhaps a Ringworm Remedy could help.

The research came about because of intense public interest in the topic beginning around 2002 because of both media attention and sufferers connecting online. Similar conditions have gone by other names, including Ekbom’s syndrome or delusional infestation.

The CDC “was receiving inquiries from a variety of sources, including the public, about this condition,” says Eberhard, who directs CDC’s Division of Parasitic Diseases. “It was clear that these people were suffering from something; the question was what might it be.”

The study was conducted among 3.2 million people whose health care was with Kaiser Permanente in 13 Northern California counties from 2006 to 2008. Researchers identified 115 patients who reported fibers or other solid material coming through their skin as well as skin lesions or the feeling that “something is crawling on top of or under the skin,” according to the paper, which is published in this week’s edition of the journal PLoS ONE.

Doctors found that the condition was rare, with only 3.65% of the Kaiser patients reporting it. Sufferers tended to be white (77%) and female (77%), with a median age of 52. Seventy percent of sufferers reported the material emerging from their skin as fibers, the rest described “specks, granules, dots, worms, sand, eggs, fuzz balls and larvae.”

However, the researchers could not find any evidence of these. Instead, dermatologists found fibers on the edges or under scabs and none in unbroken skin. When examined they proved to be cotton or polyester fibers, or in a few cases the likely remains of fingernail polish. A Ringworm Cure could change that.

“We were able to answer conclusively that they were not living entities,” Eberhard says.

Jason Reichenberg, director of dermatology at the University of Texas Southwestern-Austin, said the paper “confirms what anybody who has ever seen a patient with this knows, which is that these patients are suffering greatly and their suffering is real; they shouldn’t be dismissed.

“This is something that needs to be treated,” says Reichenberg, who will lead a session on the topic at an upcoming dermatology organization meeting in San Diego. “It’s really important to discuss that there might be other ways to approach the disease. Until we can find an exact cause or a cure, it’s important that we try to improve their suffering.”

The skin lesions didn’t appear to be caused by external forces, but primarily by scratching or rubbing. They also appeared only in areas where the sufferer could reach. For example, when lesions appeared on the back, they were in a typical dumbbell pattern made by how far the arm can reach around.

A large number of the sufferers had other health problems as well: 70% reported chronic fatigue and 54% reported their overall health as fair or poor. Many also had high levels of “somatic concerns,” meaning they had preoccupations with their health. The researchers found evidence of illicit drug use in 50% of patients, based on hair sample testing. For comparison, a national survey conducted by the Substance Abuse and Mental Health Services Administration found that 8.9% of the population are current illicit drug users. Eberhard cautioned that the high levels could be related to attempts by sufferers to alleviate their symptoms.  A Ringworm Treatment might help.

There is no doubt that the patients “had something that was impacting their quality of life,” Eberhard says. He says he hopes that their research will allow doctors and patients together to find the most appropriate care for those afflicted.

UnitedHealth Launches Patient Info Cloud Storage

First appeared in Associated Press

UnitedHealth Group's Optum business is launching a service that allows doctors to share information about patients over the Internet, as health care companies continue their push to improve care with better coordination.

The system, known as cloud computing, involves storing information and software applications on remote servers that are accessed through a secure Internet connection.

In health care, this means a doctor does not have to go to a particular computer for patient information or care updates. He or she can use portable devices like smart phones or tablet computers.

Optum's cloud provides a platform that health care providers can use for software that helps them track patients. For instance, a doctor can use cloud-based applications, or apps, to receive automatic updates on a hospitalized patient's condition or to be notified when a patient visits an emergency room or fails to fill prescriptions, a company spokesman said.

Currently, most doctors have to rely on patients to tell them when they visit another physician or the ER.

Cloud computing also can allow doctors to share patient records and discuss a case more efficiently.

Optum worked with Cisco, IBM and Hewlett-Packard Co. among others, to design the cloud and is launching a set of apps called Optum Care Suite to help providers use it. But it also is encouraging providers to design their own applications for the cloud as well.

UnitedHealth Group Inc., based in Minnetonka, Minn., is the largest U.S. health insurer. Its Optum business provides technology outsourcing, among other services.

Insurers and care providers have been more intent on improving care coordination. Last month, another insurer, WellPoint Inc., said it will boost primary care reimbursement by paying for care management it doesn't currently cover.

Some care providers also are forming accountable care organizations that coordinate care among doctors, specialists and hospitals.

Cloud computing platforms first started appearing in health care a few years ago, said Lisa Gallagher, senior director of privacy and security for the industry group Healthcare Information and Management Systems Society, or HIMSS. She said about 30 percent of health care providers like hospitals or physician practices now use some form of cloud computing.

Experts say care coordination leads to better care for patients. It helps doctors catch prescriptions that may conflict or cause a bad reaction. It also cuts down on test duplications and can help people remember when to see the doctor or refill their prescriptions.

It also can lower costs by cutting wasteful spending.

Care coordination currently is left mostly to the patient or his or her family, said Dr. Ann O'Malley, a researcher with the Center for Studying Health System Change. She said that's a task best left to primary-care doctors.

"Right now, coordination is horrible in this country for the most part," she said.

Counterfeit Cancer Drug Circulating in US

First appeared in Wall Street Journal

The maker of the widely used Avastin cancer drug said Tuesday that it is warning doctors, hospitals and patient groups that a counterfeit version of the medicine has been found in the U.S.  A Miami Medical Malpractice Lawyer is curious.

Tests of counterfeit vials of Avastin showed that they didn't contain the active ingredient in Roche Holding AG's intravenous drug, according to the Swiss company's Genentech unit.

It isn't clear how much of the counterfeit product was distributed in the U.S. or whether it has caused any harm. A Genentech spokeswoman said the company doesn't know if any patients were given the fake drug.

The Food and Drug Administration is investigating, and has sent letters to 19 medical practices in the U.S. that the agency says buy unapproved cancer medicines and might have bought the counterfeit Avastin.

An FDA spokeswoman said it hasn't received any reports of patient side effects that appear to be linked to the counterfeit product. At Milwaukee cancer care, they have not noticed any irregularities yet.

Most Americans don't question the integrity of the drugs they rely on. They view drug counterfeiting, if they are aware of it at all, as a problem for developing countries. But the latest incident, which follows the appearance of other fake drugs in the U.S.—including counterfeits of the weight-loss treatment Alli and the influenza treatment Tamiflu—suggests it is a growing risk, especially as more medicines and drug ingredients sold in the U.S. are made overseas.

In addition to the specter of fake medicines, U.S. drug makers are confronting their own shortcomings. Companies including Johnson & Johnson have had to shut down manufacturing plants due to quality problems. Earlier this month, Pfizer Inc. said it recalled about a million packs of birth-control pills because improper packaging could raise the risk of unplanned pregnancies.

Roche still is testing the vials of counterfeit Avastin to see what ingredients they contain, but the Genentech spokeswoman said: "It's not Avastin. It's not safe and effective, and it shouldn't be used."

Genentech said it is asking health-care providers to report any suspected counterfeits to the FDA's Office of Criminal Investigations.

Avastin belongs to a class of cancer therapies that interferes with the development of new blood vessels that tumors need to grow. The pricey drug, often used with chemotherapy, is for certain patients with colon, lung and other cancers. The drug was at the center of a controversy last year, because the FDA withdrew approval for its use for breast cancer, angering many patients.

A 400-milligram vial of Avastin—the size that was counterfeited—costs $2,400, according to the Genentech spokeswoman.

Last year, Genentech's sales of Avastin in the U.S. generated more than $2.5 billion, the spokeswoman said. Many patients receive it intravenously, typically in a hospital or doctor's office, every two or three weeks for as long as a year.  A Miami Medical Malpractice Lawyer is contemplating what this means.

"Most [cancer] doctors in an average workweek will be using it. It is a commonly used drug," said Leonard Saltz, who runs the colorectal oncology section at Memorial Sloan-Kettering Cancer Center in New York.

Dr. Saltz, who also chairs the pharmacy committee monitoring the safety of Sloan-Kettering's drug supply, said the Avastin news will prompt doctors and hospitals to double-check their sourcing of the product and make sure their supplies are safe.

Experts say counterfeits are a relatively small but still serious problem for the nation's drug supply. In the U.S., most prescription medicines are distributed by authorized suppliers, who buy them from their manufacturers and assure their integrity. Pharmacies, too, put pressure on the distributors to ensure quality.

Still counterfeits can enter the drug supply through unauthorized distributors and Internet pharmacies that try to turn a quick profit selling the inauthentic products. Doctors and patients might not know they are using a counterfeit if it doesn't cause harm but simply fails to work.

The counterfeit Avastin was packaged in boxes and vials whose markings were clearly different from the authentic product, according to the Genentech spokeswoman. In the U.S., boxes of authentic Avastin are labeled in English, say they were made by Genentech and have a six-digit lot number with no letters. The counterfeit boxes had writing in French, identified Roche as the manufacturer, and had lot numbers on the boxes or vials starting with B86017, B6011 or B6010.

Roche first learned there might be a counterfeit problem when an unnamed foreign health authority notified the company in December of inauthentic Avastin made overseas and said it was investigating, the Genentech spokeswoman said. Later, the FDA warned the company. The FDA said it was alerted by the Medicines and Healthcare Products Regulatory Agency in the U.K.

On Friday, the FDA sent letters to 19 medical practices, mostly in California, that the agency said had bought medicines from the suppliers of the counterfeit Avastin. The two-page letters identified the suppliers as Quality Specialty Products, which the FDA said also might be known as Montana Health Care Solutions. The letter said that QSP's products are distributed by Volunteer Distribution in Gainesboro, Tenn.

"A high percentage of these products are injectable cancer medications whose quality could be adversely affected if they are not stored or transported under specific temperatures," the letter added.

QSP and Volunteer Distribution couldn't be reached for comment Tuesday night, nor could 17 of the 19 medical practices.

"I did not have the Avastin they were referring to," said Naresh Gupta, a Plano, Texas, oncologist who received the FDA's letter Monday. He said he purchased Avastin for his practice from a large national drug distributor that wasn't named in the FDA's announcement.

A second doctor, Raymond Heung, of San Diego, said he didn't know anything about the Avastin problems or the FDA letter.

In its letter, the FDA asked the medical practices to "cease using and retain and secure all remaining products" from the suppliers. It also issued a general warning to medical practices asking them to "stop using" any products they might have from the two companies and report any suspect items that the companies supplied.

The Genentech spokeswoman said none of the suppliers identified by the FDA are authorized to distribute Avastin. "Genentech limits the distribution of many of its products and only sells its products directly to a defined number of fully licensed and contracted wholesalers and specialty distributors," she said.

Counterfeiting has historically been more of a problem outside the U.S. Counterfeit Avastin was injected into the eyes of 116 patients at a Shanghai hospital, resulting in an outbreak of complications, hospital officials reported last year in a letter to the New England Journal of Medicine. The active ingredient in Avastin is sometimes used to treat macular degeneration, a disease that causes vision loss, though it isn't approved for that use in the U.S.

Concerns about counterfeit drugs sold in the U.S. have grown as more products and their ingredients are made abroad. The FDA has been issuing warnings about counterfeits on average once or twice a year.

In 2010, fake versions of the over-the-counter weight-loss drug Alli were being sold over the Internet. The counterfeit versions didn't contain the active ingredient in Alli and instead contained sibutramine, the active ingredient in the prescription-strength weight-loss drug Meridia, which has since been removed from the U.S. market because of concerns the drug increased the risk of heart attacks.

Also in 2010, the FDA warned consumers that a product sold as "Generic Tamiflu," an influenza treatment, was actually a counterfeit containing a penicillin-like antibiotic, rather than flu-fighting antiviral drugs. And a Belgian man pleaded guilty in a U.S. court last year to selling $1.4 million worth of fake or misbranded drugs, including potentially phony Viagra and Lipitor, both Pfizer drugs, over the Internet.

U.S. customs agents and regulators are spot-checking drug imports with increasingly sophisticated laboratory equipment, but the growing volume of shipments has made it "increasingly difficult for us to regulate our own supply chain," said Tom Woods, of Woods International LLC, a consulting firm that advises on avoiding drug counterfeiting.

Learning Improved With Electric Boost

First appeared in Associated Press

People learned better when a key part of their brains got mild zaps of electricity, a finding that may someday help Alzheimer's patients keep more of their memories.

In a small but tantalizing study, participants played a video game in which they learned the locations of stores in a virtual city. They recalled the locations better if they learned them while receiving a painless boost from tiny electrodes buried deep inside their brains.

In the future, that strategy might help curb memory loss for people in the early stages of Alzheimer's disease, suggested Dr. Itzhak Fried, a neurosurgeon at the University of California, Los Angeles. But he cautioned that the results were preliminary. Another Neurosurgeon watches the research unfold.

Using implanted electrodes to treat brain disease is hardly new. Such "deep-brain stimulation" has been used for about a decade for Parkinson's disease and some other disorders. Researchers are also testing it for depression.

Some 80,000 or more people worldwide have had stimulation units implanted, mostly for Parkinson's.

Fried and colleagues reported the new work in Thursday's issue of the New England Journal of Medicine. It was financed by the federal government and the Dana Foundation.

"I think it's a terrific paper," said Dr. Andres Lozano, a professor of neurosurgery at the University of Toronto, who didn't participate in the work but is studying the approach in Alzheimer's patients. The new work shows stimulation can modify the workings of brain circuits that control memory in people, he said.

But like Fried, he cautioned that the research was still in the early stages.

"Whether it will translate into something useful, we do not know," he said, noting that years of additional study would be needed.

"You don't want to do brain surgery on people unless you have a pretty clear idea you're going to make them better," Lozano said. Deep-brain electrodes are implanted through holes drilled in the skull.

The study participants were seven epilepsy patients who had the electrodes implanted to help surgeons identify the source of their seizures. Fried and colleagues took advantage of that to stimulate a part of the brain that's key to learning. The patients could not feel the stimulation. Those involved in Brain Surgery are curious.

The patients played the video game on a laptop at their beds. Using a joystick, they took the role of taxi drivers in a small town consisting of four blocks by four blocks. They searched for passengers and dropped them off at any of six stores they were asked to find. The electrical stimulation was turned on while they learned the locations of some stores, but not others.

Testing showed that the stimulation made a difference. When given a store to find, the patients took a more direct route to it, and got there faster, if they had learned its location during a time of stimulation. When researchers looked at how much extra wandering they did beyond the shortest possible path, they found that stimulation reduced this excess by an average of 64 percent.

The patients were tested only a few minutes after learning the store locations, so it's not yet clear how long the effect can last, Fried said. Researchers will also have to see if stimulation helps for other kinds of knowledge, he said.

Survey Shows Doctors Aren’t Always Honest

First appeared in Associated Press

Trust your doctor? A survey finds that some doctors aren't always completely honest with their patients.

More than half admitted describing someone's prognosis in a way they knew was too rosy. Nearly 20 percent said they hadn't fully disclosed a medical mistake for fear of being sued. And 1 in 10 of those surveyed said they'd told a patient something that wasn't true in the past year.

The survey, by Massachusetts researchers and published in this month's Health Affairs, doesn't explain why, or what wasn't true.

"I don't think that physicians set out to be dishonest," said lead researcher Dr. Lisa Iezzoni, a Harvard Medical School professor and director of Massachusetts General Hospital's Mongan Institute for Health Policy. She said the untruths could have been to give people hope.

But it takes open communication for patients to make fully informed decisions about their health care, as opposed to the "doctor-knows-best" paternalism of medicine's past, Iezzoni added.

The survey offers "a reason for patients to be vigilant and to be very clear with their physician about how much they do want to know," she said.

The findings come from a 2009 survey of more than 1,800 physicians nationwide to see if they agree with and follow certain standards medical professionalism issued in 2002. Among the voluntary standards are that doctors should be open and honest about all aspects of patient care, and promptly disclose any mistakes.

A third of those surveyed didn't completely agree that doctors should 'fess up about mistakes. That's even though a growing number of medical centers are adopting policies that tell doctors to say "I'm sorry" up front, in part because studies have found patients less likely to sue when that happens.

Not revealing a mistake is "just inexcusable," said Dr. Arthur Caplan, a prominent medical ethicist at the University of Pennsylvania. Beyond decency, "your care now has to be different because of what happened."

The vast majority of those surveyed agreed that physicians should fully inform patients of the risks, not just the benefits, of treatment options and never tell a patient something that isn't true - even though some admitted they hadn't followed that advice at least on rare occasions in the past year.

Perhaps least surprising is that doctors give overly positive prognoses. It's hard to deliver bad news, especially when a patient has run out of options, and until recently doctors have had little training in how to do so. But Iezzoni said patients with the worst outlook especially deserve to know, so they can get their affairs in order, and patient studies have found most want to know.

What else might doctors not tell? There are shades of gray, said Caplan, the ethicist. For example, he's heard doctors agonize over what to tell parents about a very premature baby's chances, knowing the odds are really bad but also knowing they've seen miracles.

Doctors prescribe placebos sometimes, and telling the patient could negate chances of the fake treatment helping, he noted. Sometimes they exaggerate a health finding to shock the patient into shaping up.

And sometimes it's a matter of dribbling out a hard truth to give patients a chance to adjust, Caplan said: "OK, this looks serious but we're going to order some more tests," when the doctor already knows just how grim things are.

Withholding the full story is getting harder, though, Iezzoni said. Not only do more patients Google their conditions so they know what to ask, but some doctors who have embraced electronic medical records allow patients to log in and check their own test results.

Charity Aid System Corrupting Hospital Practices

First appeared in NY Times

For most of her life, Hope Rubel was a healthy woman with good medical insurance, an unblemished credit history and a solid career in graphic design. But on the day an ambulance rushed her to a Manhattan hospital emergency room shortly after her 48th birthday, she was jobless, uninsured and having a stroke.

Ms. Rubel’s medical problem was rare, a result of a benign tumor on her adrenal gland, but the financial consequences were not unusual. She depleted her savings to pay $17,000 for surgery to remove the tumor, and then watched, “emotionally paralyzed,” she said, as $88,000 in additional hospital bills poured in. Eventually the hospital sued her for the money. An Omaha Hospital Lawyer is interested in these cases.

Yet that year the hospital, NewYork-Presbyterian/Weill Cornell, had already collected $50.2 million from the state’s so-called Indigent Care Pool to help care for people like Ms. Rubel who have no insurance and cannot pay their bills.

New York’s charity care system, partly financed by an 8.95 percent surcharge on hospital bills, is one of the most complicated in the nation, but many states have wrestled with aggressive debt collection by hospitals in recent years. Like New York, several passed laws curbing hospitals’ pursuit of unpaid bills, including Illinois, California and Minnesota.

But a new study of New York hospitals’ practices and state records finds that most medical centers are violating the rules without consequences, even as the state government ignores glaring problems in the hospitals’ own reports.  An Oklahoma City Hospital Malpractice Lawyer is interested in defending the health care system in these situations.

“The entire system is corrupted, and it isn’t working for patients,” said Elisabeth R. Benjamin, vice president of health initiatives at the Community Service Society of New York, a nonprofit antipoverty group, which is releasing the two-year study on Monday.

The state’s Department of Health acknowledges systemic problems, including the need for better reporting and enforcement, a spokesman, Michael Moran, said. A group of patient advocates and hospital administrators is being convened to develop a better system, he said, and the department is engaged in “a comprehensive data integrity project that will include the retention of an outside auditor.”

The study found that some hospitals did not provide financial aid applications at all, and that many made impermissible demands for irrelevant documents or failed to supply key information, like eligibility rules for big discounts required by state law in 2007. Data reported to the state was obviously faulty, it found.

Yet even hospitals that reported they had spent nothing on financial aid, or had filed hundreds of liens against patients’ homes, were allowed to collect without questions from the charity care pool, which distributes more than $1 billion a year.

Hospitals are not legally barred from seeking judgments or liens, but must first offer an aid application, help the patient complete it, and wait while it is pending. Instead, many hospitals turn to collection agencies, and sue when that fails. The unpaid bills — typically reflecting much higher rates than what insurers pay — are then treated as the equivalent of charity care.

Change is now urgent, health care experts agree, because the state pool stands to lose hundreds of millions of federal dollars in 2014, when provisions of the health care overhaul will no longer treat so-called bad debt, based on uncollected bills, as if it were charity care.

“There’s a law in place, and obviously it should be complied with,” said David Rich, an executive with the Greater New York Hospital Association, a trade group. But, he added, “hospitals are providing a lot of charity care at a loss.”

He said hospitals were improving their compliance with the law, which requires aid to patients with income up to 300 percent of the poverty line, or up to $33,000 for a single person. But, often stymied by patients who fail to complete applications for aid, he said, many hospitals have moved to simply deeming some patients eligible without an application, using what he called “a soft credit check” at registration to gauge income and assets.

Myrna Manners, a spokeswoman for NewYork-Presbyterian Hospital, said that it would be inappropriate to discuss specific cases, but that the hospital “proactively helps patients at every step” of the financial aid process. It approved 25,861 applications in 2010, the most recent annual data.

“Where there has been a determination that there is an ability to pay, we still go to all lengths to ensure that we resolve the matter before it becomes a legal action,” she said.

Court records abound in judgments against patients who say they had little or no chance to apply for help. A couple fighting foreclosure in Elmont, Nassau County, has a $41,000 default judgment from NYU Langone Medical Center for emergency surgery on their disabled adult son in 2007, when their insurance unexpectedly dropped him. He was eventually approved for Medicaid, but it would not pay for the surgery retroactively.

The mother, Myrlene Stimphil, 55, a nurse at a city hospital, said she had sought a reduced payment plan from NYU Langone, but was told only that the hospital would get back to her. Instead, she said, collectors were calling her son, now 24, who suffered brain damage at his premature birth.

“We don’t want to be a burden,” she said, as her husband, Antenor Francois, 56, a former cabdriver, looked through old bills. One announced, “Welcome to Portfolio Recovery Associates!” and added that the collection agency “purchased your account from NYU Hospitals Center.”

Lisa Greiner, a spokeswoman for the hospital, which collected $10.7 million from the charity care pool in 2010, said she could not comment on the case under privacy laws. But the hospital no longer uses that collection agency, and under new leadership in the last three years, its reported financial aid approvals soared to 36,000 in 2010, from 256 in 2008.

Christopher Ward, 49, living in his father’s house in White Plains on a $200-a-week disability payment from a workplace spinal injury, recalled stopping at an A.T.M. — “just to have something in my pocket to buy food” — and discovering that his accounts, totaling less than $4,000, had been seized.

“I tore my hair out for a long time not understanding why all this was happening to me,” Mr. Ward said, admitting to memory lapses.

Court records show that NewYork-Presbyterian obtained a $102,636 judgment against him in 2007, including 9 percent interest back to 2004, when, uninsured, he underwent emergency surgery for a brain aneurysm. Now his ailing, widowed father, 75, a teacher at Mercy College, worries that anything he leaves for Christopher could be seized.

State hospitals seem to be especially aggressive collectors. State University of New York Downstate Medical Center, in Brooklyn, secures hundreds of judgments annually through the attorney general’s office, which says such suits protect the state’s interest in case a former patient comes into money. A Clarksdale Hospital Lawyer is watching these cases closely.

One picked at random: a $12,000 judgment in 2008 against Cherrilyn McFarlane, a single mother on public assistance, for one day’s care for her newborn five years ago, when her Medicaid coverage had briefly lapsed. Ms. McFarlane said the judgment could hurt her plans to seek a student loan for nursing school. “I want to get it cleared,” she said.

To Hope Rubel, the greatest fear was that the suit itself would deter employers from hiring her and leave her destitute, she wrote the judge. Finally, she said, a law clerk directed her to the hospital’s financial aid department. It said more documents were needed to decide her eligibility.

“I had given them everything,” she said. In despair after a year of courthouse meetings, she said, she offered $100 a month, and at the court’s urging, the hospital’s lawyers accepted. “I’ll be paying for the rest of my life,” she said.

Baby Boomers Need New Knees

First appeared in USA Today

A soaring demand for new knees from aging Baby Boomers wanting to dance through Zumba workouts or zip down ski slopes is likely to lead to additional, more costly surgeries, according to a new report.

Boomers' expectations of knee replacements are high; their parents were content to be rid of the pain and to be relatively sedentary, says Elena Losina, lead author of a study to be presented today in San Francisco at the annual conference of the American Academy of Orthopaedic Surgeons. In the analysis, a computer model based on data from the 2009 U.S. Census and the National Health Interview Survey, researchers estimate the number of Americans with total knee replacements and the number of young adults likely to require more surgeries later in life.

More than 620,000 people a year have knee replacement surgery — twice as many as hip implants. More than 4.5 million adults (4.7% of those 50 and older) have had a total knee replacement. Among that group, the researchers say 1.5 million adults are in their 50s and 60s. The demand for knee replacements from ages 45 to 64 has tripled in the past 10 years, to more than 254,000 in 2009, the latest year for which statistics are available.

"The operation has really shifted toward the young," says Losina, co-director of the orthopedics and arthritis center at Brigham and Women's Hospital in Boston. "We're wondering what this snowballing will give us as a nation. Everyone needs to be aware of the pluses and minuses of the surgery. It eliminates pain, but many will have a greater risk of revision if they do the high-intensity sports."

Studies have not been done to determine how long implants will last in people with active lifestyles, but many younger patients seem destined for complications and revision surgeries, the report says. The authors write "among adults who undergo a (total knee replacement), risk of subsequent revision is 14.7% for males, 17.5% for females." Revisions can be required because of loosening, fractures and wear and tear.

Revisions are more costly, complicated and risky, the report notes. They cost about $27,000, compared with the original surgery (about $20,000) and are riskier and more complicated. Most are covered by insurance, according to the American Academy of Orthopaedic Surgeons. Losina says the report will help the nation grasp the "substantial health burden" posed by those with knee replacements. The principal diagnosis is osteoarthritis.

Despite manufacturers' suggestions that some prosthetic joints will last 30-plus years, Losina says there are no studies to support those claims: "Most older people will take their knees (replacements) to the grave. Younger people need to discuss with their surgeons what they can expect in terms of the longevity of the prosthesis and if they should delay having the surgery (to avoid revision)."

The authors call for "increasing efforts" to prevent osteoarthritis — and the subsequent need for knee replacement — by focusing on two key risk factors: obesity and an earlier knee injury, often from playing sports.

"We really don't know how long these devices are going to last in younger, active people," says Patience White, a physician and chief public health officer for the Arthritis Foundation. "Where are these people going to be in 40 years? The surgeries eliminate pain in most people but the better they feel, the more they'll expect of the technology. People need to take care of their knees before taking the easy way out."

“Out-of-Network” Prices Up Being Blamed on Medicare

First appeared in USA Today

When Sharon Smith chose an out-of-network specialist to perform a complicated jaw surgery on her teenage son last May, she knew it would cost her more. But she was not expecting $15,000.

Consumers have long complained about the cost of going outside their health plan's network, but Smith encountered a new twist: A growing number of insurers have changed the way they calculate reimbursements to shift more of the expense to patients.

Now, instead of paying a percentage of the "usual and customary" charges from physicians and other providers, insurers are basing reimbursements on a percentage of what Medicare pays, which can be much less. "Every carrier is moving to this," says Ken Sperling, global health care practice leader at the benefit consulting firm Aon Hewitt.

Many employers welcome the change as a way to slow rising premiums, but some "employees are going to get stuck shouldering a significant portion of the bill because they don't understand how it's done," Sperling says.

Consumers are responsible for the difference between what the out-of-network doctor charges and what their insurer pays. But few understand the basis on which plans reimburse, let alone the widely varying prices doctors and hospitals charge. As a result, they may be blindsided by big bills, says Lynn Quincy, senior health policy analyst at Consumers Union.

Insurers that use the Medicare-based method — including Oxford, a subsidiary of the nation's largest insurer UnitedHealthcare, Cigna and Empire Blue Cross Blue Shield — say the new approach offers greater consistency and thwarts efforts to game the system.

"Usual and customary became abused by a minority of physicians," says Mark Wagar, CEO of Empire in New York, which is switching most policies to the new method. "It was not infrequent to see an emergency case where 98% of the physicians would charge $5,000, but some outlier would decide to charge $50,000," which would drive up the average.

Read the fine print

There are no good estimates of how many consumers are affected by the switch, but tens of millions have the type of health plan that allows them to seek care outside the insurer's network.

Some say they discover the change only after they rack up big bills. Smith, a certified public accountant in Syosset, N.Y., says she thought her Oxford plan would cover as much as 80% of the total and was shocked when it paid $2,500 toward the surgeon's $18,000 fee. That $2,500 is 150% of the Medicare rate. Smith owed the rest.

Had the usual and customary standard been used, her policy would have paid at least $12,000, said Oxford spokesman Tyler Mason.

"If I had set out knowing all these costs ahead of me, I could have negotiated, or I could have said, 'Wow, I can't afford this,' " says Smith, 53, who is not currently working because of a medical disability.

To be sure, the information about how the insurer would calculate the payment was included on page 108 of a 126-page booklet outlining the Oxford plan offered by her husband's employer. The two-page explanation says the employer purchased a rider from Oxford that changed out-of-network payments from a percentage of usual and customary charges to Medicare rates plus 50%.

"It was so buried I never saw it," says Smith, adding that even if she had, there was no easy way to find out what Medicare pays for a procedure.

Mason says Smith should have asked her surgeon how much he would charge, and then called the insurer to see how much it would pay toward that charge. He also notes Smith received a letter from Oxford a month before the surgery saying her costs would likely be higher if she went out of network. However, it did not spell out the Medicare-based method or her exact liability.

Her cost would have been only about $500, on top of her deductible of about $2,000, if she had chosen from among several dozen in-network oral surgeons in nearby New York City, he says.

About negotiated rates

Insurer networks are designed to slow rising health care costs, in part by getting doctors and hospitals who join to agree to negotiated rates, which are generally lower than their usual fees.

Out-of-network hospitals and doctors can set their own fees and "balance bill" patients for the portion insurers don't cover. Medicare strictly limits how much patients can be balance billed by doctors who don't participate in the program.

"One of the most expensive decisions that a customer could make is going out of network," says Alan Muney, chief medical officer at Cigna.

Smith says she went outside her network because she wanted a surgeon with experience in the type of complicated jaw surgery needed by then-18-year-old Thomas. "This is my son's face," she said.

Benefit consultants, insurers, patient advocates and actuaries say the shift to Medicare rates began after a national database tracking usual and customary charges — run by UnitedHealthcare subsidiary Ingenix — was shuttered in 2009 following an investigation by the New York Attorney General, who questioned whether the data were skewed in favor of insurers.

While the closure was touted as a consumer win, "Unfortunately, it's worse now," says Jennifer Jaff, executive director of Advocacy for Patients with Chronic Illness, a group that helps file insurance appeals for consumers. "Once New York said you can't use those (Ingenix figures) anymore, the insurers looked at it as an opportunity to pay even less."

After the closure, some insurers turned to basing payments on Medicare rates, says Rob Parke, an actuary at the consulting firm Milliman.

While an office visit for a primary care doctor paid at 170% of Medicare might be similar to payments made under usual and customary calculations, Parke says, specialist visits and other types of care often don't come close.

Stepping into the data gap left by Ingenix is a new non-profit created by settlements paid by insurers involved with the investigation. Called Fair Health, the New York-based group began selling data a year ago that tracks doctors' usual and customary charges and includes a website calculator for consumers to figure their costs. It now contracts with medical and dental plans covering more than 170 million people, says Robin Gelburd, president of Fair Health. "Employers can choose to use Medicare rates, that's totally fine," but it needs to be put in context, Gelburd says.

Cigna's Muney says the insurer has decided to use Fair Health's usual and customary calculations, but will continue to offer the Medicare rate method as an option because it was well received by employers. Like several insurers, Cigna also has an online calculator that shows policyholders how much they would pay for services in and out of their networks.

Muney and other insurers say that consumers should be asking why some hospitals and doctors charge so much. A 2009 survey of doctor charges in 30 states by the industry's lobby group, America's Health Insurance Plans, found prices for some common procedures ranged to up to 10 times what Medicare sets as payment.

Some out-of-network hip surgeons, Muney says, charge 30 times what Medicare pays: "Does the patient think that's OK?"

Complex surgery for $2,500?

Smith, for one, is not angry that her son's surgeon, Stephen Sachs, charged $18,000. "We're talking about a five-hour surgery, a very, very, complex surgery," she says. "For all that the doctor is paid is $2,500? The doctor would have to shut down his office if that's all he could get."

Sachs says the $18,000 covered not just the surgery, but pre-op care and two years of follow-up visits. "We do a very complicated, very exact and demanding treatment plan," Sachs says.

He says his rates haven't gone up in five years, and he takes on many charity cases, especially involving children. But payment rates for in-network care are so low, he says, that he would have to make sharp changes, maybe even close, were he to sign on with insurers.

Sachs says he won't pursue Smith for the remaining money she owes because "you can't get water out of a rock," but he will begin to charge higher up-front fees for patients with insurance similar to hers.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a non-profit, non-partisan health policy research and communications organization not affiliated with Kaiser Permanente

State Legislatures Looking to Decide What Doctors Can Do

First appeared in USA Today

State legislatures are considering a host of measures that would make it tougher — or easier — for doctors to perform surgery outside of their specialties, including in their offices.

Only 20 states require doctors doing surgery in their offices to have facilities that are licensed or accredited, according to the American Association for Accreditation of Ambulatory Surgical Facilities. Los Angeles plastic surgeon and AAAASF President-elect Geoffrey Keyes says licensing or accreditation helps ensure there is adequate emergency equipment and procedures and that doctors are properly trained in what they are doing.

But some doctors say it's too costly and restricts available care for needy patients.

Legislators are also increasingly grappling with "scope of practice" issues, which involve ways medical professionals want to expand what they are allowed to do.

It includes anything from OB/GYNs doing cosmetic surgery to optometrists who want to do cataract surgery to pharmacists seeking to expand the vaccines they can give.

Iowa state Sen. Jeff Danielson, a Democrat who chairs the State Government committee, says about a third of his time is spent weighing issues involving medical professionals wanting to expand what they can do. At least 10 bills in Florida involve scope of practice issues.

"As insurance reimbursements go down and physicians' overhead goes up, they're trying to find new ways to meet their economic needs," says Florida state Sen. Eleanor Sobel, a Democrat who is vice chair of the Senate Health Regulations panel. "But they're not necessarily qualified to do what they're doing."

New Jersey state legislators are deciding whether offices where doctors perform surgery should be licensed or accredited. Democratic state Rep. Herb Conaway says he sponsored the House version of the bill in part because of data showing many office-based facilities didn't have proper emergency equipment.

Other bills:

·         Chiropractors in Florida are fighting to be able to provide medical clearance for young athletes to return to sports fields after concussions. Their opposition to a bill that would allow only doctors to grant clearance scuttled the bill last year.

·         Iowa legislators are considering whether outpatient surgery facilities should have to be licensed and accredited as hospitals are.

·         Dentists trained as oral surgeons could perform cosmetic surgery in New York under a measure reintroduced in that state legislature.

Conaway, an internal medicine doctor and lawyer, says accreditation or licensing of office surgery facilities is a matter of safety: "Who would have thought two years ago that someone would attempt to do breast augmentation in their office? Now we're hearing about those procedures being done."

What Should be Part of my Doctor's Visit?

First appeared in Associated Press

Recent headlines offered a fresh example of how the health care system subjects people to too many medical tests — this time research showing millions of older women don't need their bones checked for osteoporosis nearly so often.

Chances are you've heard that many expert groups say cancer screening is overused, too, from mammograms given too early or too often to prostate cancer tests that may not save lives. It's not just cancer. Now some of the nuts-and-bolts tests given during checkups or hospital visits are getting a second look, too — things like routine EKGs to check heart health, or chest X-rays before elective surgery. Next under the microscope may be women's dreaded yearly pelvic exams.

The worry: If given too often, these tests can waste time and money, and sometimes even do harm if false alarms spur unneeded follow-up care.

It begs the question: Just what should be part of my doctor's visit?

If you're 65 or older, Medicare offers a list of screenings to print out and discuss during the new annual wellness visit, a benefit that began last year. As of November, more than 1.9 million seniors had taken advantage of the free checkup.

For younger adults, figuring out what's necessary and what's overkill is tougher. Whatever your age, some major campaigns are under way to help. They're compiling lists of tests that your doctor might be ordering more out of habit, or fear of lawsuits, than based on scientific evidence that they are really needed.

"Too often, we order tests without stopping to think about how (if at all) the result will help the patient," wrote Dr. Christine Laine. She's editor of Annals of Internal Medicine, which this month published a list of 37 scenarios where testing is overused.

Not even physicians are immune when it comes to their own health care. Dr. Steven Weinberger of the American College of Physicians had minor elective surgery for torn knee cartilage about a year ago. The hospital required a pre-operative chest X-ray, an EKG to check his heart, and a full blood work-up — tests he says aren't recommended for an otherwise healthy person at low risk of complications.

Weinberger should know: He led the team that compiled that new list of overused tests. All three examples are on it.

"If anyone should have objected, I should have objected, but I took the easy way out. I didn't want to be raising a fuss, quite frankly," he says.

The college of physicians' push for what it calls "high-value, cost-conscious care" — and similar work being published in the Archives of Internal Medicine— aims to get more doctors to think twice so their patients won't be put in that uncomfortable position. Another group, the National Physicians Alliance, is studying whether training primary care doctors in parts of Connecticut, California and Washington about the most overused care will change their habits.

Medical groups have long urged patients not to be shy and to ask why they need a particular test, what its pros and cons are, and what would happen if they skip it. This spring, a campaign called Choosing Wisely promises to provide more specific advice. The group will publish a list of the top 5 overused tests and treatments from different specialties. Consumer Reports will publish a layman's translation, to help people with these awkward discussions.

For now, some recent publications offer this guidance:

—No annual EKGs or other cardiac screening for low-risk patients with no heart disease symptoms. That's been a recommendation of the U.S. Preventive Services Task Force for years. Yet a Consumer Reports survey of more than 8,000 people ages 40 to 60 found 44 percent of low-risk, people with no symptoms had undergone an EKG or similar screening. Simple blood pressure and cholesterol checks are considered far more valuable.

—Discuss how often you need a bone-density scan for osteoporosis. An initial test is recommended at 65, and Medicare pays for a repeat every two years. A study published last week found that a low-risk woman whose initial scan is healthy can wait up to 15 years for a repeat; those at moderate risk might need retesting in five years, high-risk women more often.

—Women under 65 need that first bone scan only if they have risk factors such as smoking or prior broken bones, say the two new overtesting lists.

—Most people with low back pain for less than six weeks shouldn't get X-rays or other scans, Weinberger's group stresses.

—Even those all-important cholesterol tests seldom are needed every year, unless yours is high, according to the college of physicians. Otherwise, guidelines generally advise every five years.

—Pap smears for a routine cervical cancer check are only needed once every three years by most women. So why must they return to the doctor every year to get a pelvic exam (minus the Pap)? For no good reason, the Centers for Disease Control and Prevention reported last month. Pelvic exams aren't a good screening tool for ovarian cancer, and shouldn't be required to get birth control pills, the report says.

Yes, simple tests can harm. Cleveland Clinic cardiology chief Dr. Steven Nissen cites a 52-year-old woman who wound up with a heart transplant after another doctor ordered an unneeded cardiac scan that triggered a false alarm and further testing that in turn punctured her aorta.

A close relationship with a primary care doctor who knows you well enough to personalize care maximizes your chances of getting only the tests you really need — without wondering if it's all just about saving money, says Dr. Glen Stream of the American Academy of Family Physicians.

"The issue is truly about what is best for patients," he says.