When she was diagnosed with multiple sclerosis, a Minnesota woman thought that her carefully chosen neurologist had her best interests in mind when prescribing initial treatments to modify the disease. That was before a little detective work uncovered the real motivation for her physician’s patterns of prescribing that left her even more debilitated than when she was initially showing symptoms.

It worried me that none of them ever suggested that I discontinue treatment—or switch to another treatment—even after I reported that my injection site reactions were affecting my quality of life. Despite the fact that my neurologist insisted that I begin disease-modifying therapy, I was never contacted by him, his nurse, or anyone else in the neurology clinic with questions about how my Copaxone injections were going.

The patient, a U of M philosophy graduate student, puts into her own words the ethical issue she gradually uncovered while under the specialist’s care. Just how influential are pharma companies’ financial compensations for physicians who choose to prescribe their products? Just how willing are they to prescribe knowingly untested medications without concern as to their problematic and potentially lethal adverse effects? Her answer came at her next appointment, after enduring months of increasingly debilitating pain and enfeebling function from the trial with the first drug.

[M]y neurologist informed me that I’d begun to develop lesions inside my brain stem. He explained that this was a very bad place to have lesions, occupied as it is with regulating some of the body’s basic functions, such as breathing. He strongly recommended that I go back on MS treatment, suggesting this time a drug called Tysabri (natalizumab), which had worked wonders for some of his patients but also carried some amount of risk. Worried about the new lesions, but knowing little about the drug he was advising, I told him I’d think about it. I needed to be convinced through my own investigations that this drug would be worth taking.

Her investigations were not only telling, but they are also indicative of an all-to-familiar refrain for patients of (mostly specialist) physicians who pocket major coin from pharma companies to get these ridiculously expensive agents to the marketplace, at the risk of patient harm. In Minnesota, the patient was assisted by a database which lists pharmaceutical third parties with which a prescribing physician has a financial interest. She makes little doubt of her eagerness for this requirement to spread nationally as the result of the reform law. | PDF LINK

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One axiom is certain in medicine: there is always room for controversy. And that’s good, because it spurs further scholarly thought and research — both qualities can only help patients and providers in the long run. With the current discussion in the media regarding the utilization of the PSA in determining the course of action in prostate cancer screening, so many fundamental issues surrounding patient informed consent, unnecessary treatments, and the potential harms from treatments — can serve as valuable teaching points for patients and current and future physicians alike. The discussion — highlighted in the current NEJM — really brings this point home.

Watchful waiting and active surveillance may help prevent the conversion of overdiagnosis to overtreatment, mitigating the harms of screening that are so accurately portrayed by the task force. … we primary care clinicians must ensure there is no more routine, indiscriminate PSA screening — and no washing our hands of responsibility once the patient is referred to a specialist for prostate-cancer treatment. We owe it to our patients to provide them with the kind of guidance about this screening test that they need and deserve…

LINK | USPSTF guidelines on PSA screening here

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A new study out of Harvard finds that approximately a third of all Medicare beneficiaries in the last year of life chose to have a major surgical procedure. The operative (excuse the pun) issue here is whether such timed, elective surgeries are necessary — implying a possible increase in life expectancy. Problem is, no one knows when the beneficiary will die.

By analyzing Medicare claims data the study authors found that, in a group of almost 2 million elderly beneficiaries, all of whom died in 2008, almost one-third had inpatient surgery in the year before they died, almost one in five in the last month of their lives and almost one in 10 in the week before they took their last breath.

The study itself is a good lesson in who exactly “benefits” in these cases. As futile as these findings may sound, there is no question that any procedure done within FFS Medicare coverage remains a reimbursement cache for the provider and hospital, crudely suggesting a financial incentive. While this scenario is entirely possible, it really doesn’t seem to be the impetus for the study’s findings, in my humble opinion. Besides being reflective of a cynical and laconic way of approaching the study’s results, it really makes no sense in a healthcare delivery system increasingly focused on positive outcomes (read: anything but mortality or unacceptable morbidity). The study, however, does usher in the need to discuss the perennial issue of quality of life versus the “appropriateness” of acute surgical treatment among consenting patients with significant chronic illness.

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Sign of the times: social media’s use in increasing interaction among patients with dementia. A researcher, part of a team, is busy at work on a web-based app based upon Facebook for utilization among cognitively impaired elders. She states:

“We have already carried out some practical testing of other web-based communications systems. Among other things, we have tested a “digital diary” and a “scrapbook” containing personal photos, newspaper cuttings and information found online.”

What is both curious and puzzling at the same time regarding this research is that it is being conducted in Norway, of all places. Why not here in the good ol’ U.S. of A? Innovation of this type began and germinated here. Social media’s global function of “keeping one in the loop”, including the elderly, can not be understated in its potential in non-pharmacologic dementia research. Here’s to hoping it gains ground on these shores.

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Alzheimer dementia continues to be among the most heavily researched and funded chronic diseases in medical science today. The increased awareness, brought into the spotlight and “modernized” more than 20 years ago following the high profile revelations of celebrites and politicians afflicted with the disorder, has led to increased patient education, public policy initiatives, and, of course, greater research monies in the effort to not only treat symptoms, but also to find a cure.

An international advocacy group is now asking municipalities to take awareness a notch higher with the commitment to even greater awareness of the disorder — addressing what it calls a “treatment gap”, hampering any gains on detection of the disorder at its earlier stages. Here in the U.S., the Obama admin is apparently hard at work in developing the country’s first-ever national anti-Alzheimer strategy aimed at sharply cutting the enormous healthcare costs associated with ancillary treatment .

The National Alzheimer’s Project: From Act to Action is an effort to support a committed and effective implementation of the National Alzheimer’s Project Act (NAPA). Information collected from individuals living with the disease, caregivers, providers and other stakeholders will be shared with the U.S. Department of Health and Human Services, which is responsible for creating a national strategy to address the crisis and coordinate across government agencies. This project is facilitated and supported by the Alzheimer’s Association.

Consider this effort an amalgam of citizen awareness and discussion (townhalls) and legislation (congressional passage of the National Alzheimer Project Act) garnering bipartisan^[1] support to fight a scourge that can leave heavy financial tolls on caregivers, families, and the healthcare delivery system itself.^[2] A daunting task, to be sure — but one that is sorely needed. Here’s looking forward to December — the date when the president makes his plans for these initiatives very public. | LINK

1. Just how bipartisan? In 2007, Newt Gingrich co-authored an article in Alzheimer’s and Dementia: The Journal of the Alzheimer’s Association, making the case for the creation of a federal Alzheimer strategy.
2. Alzheimer’s Association advocates sent more than 15,000 email messages to the White House asking the President to sign the National Alzheimer’s Project Act into law; on 1/4/11, he did — making this action the most significant legislative action with respect to Alzheimer funding intiatives up to this point.

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After more than a century of service (102 years, to be exact), Walter Reed Hospital in DC is closing its doors. This seemed to be an inevitability, especially after the facility had a difficult time separating itself from its healthcare delivery scandals during the George W Bush administration.

The Walter Reed Army Medical Center in Washington, D.C., closed its doors for the final time Aug. 27 as the remaining 18 patients were moved to the National Naval Medical Center in Bethesda, Md., one day ahead of schedule, thanks to the approach of Hurricane Irene. Walter Reed had provided medical care to military service members for 102 years.

While the beacon of military medicine is shutting its doors, the Reed moniker will still be intact, as those final 18 patients are transferred to the Bethesda National Military Medical Center — which will now be known as the Walter Reed National Military Center. | LINK

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Much has been written of late regarding the initial media presentations of the virus that causes AIDS and the de rigueur comparisons to how far awareness, activism, and innovation have propelled its discussion to every corner of the planet in 2011. Its chilling descriptions more than thirty years ago cannot belie the fact that, in spite of advances, there is still much to be done on the road to eradication and cure. Within this paradigm is the notion that an entire generation or two have witnessed how the existence of HIV/AIDS has shaped healthcare policy in this country and worldwide.

Here in the U.S., the specter of the aging patient with this now “manageable chronic disease”, the numbers of patients this will represent, and the availability of physicians knowledgeable enough to not only treat chronic HIV disease but also its unknown effects in the increasingly “geriatric” patient — are gaining consideration and acknowledgement in policy circles. Discussion almost always leads to the role of the primary care physician in not only screening but also becoming an active treatment provider.

In 2009, a record 82.9 million American adults were tested for HIV. [...] By 2015, the IOM estimates that half of Americans living with HIV/AIDS will be older than 50. For primary care doctors, this means a growing number of their patients will need care for chronic diseases as well as HIV.

Today’s generation of physicians has inhereted the mantle of providing care for a disease whose spurred innovations ranks as one of the greatest medical achievements of the last century. It is time to consider the primary care approach to chronic HIV disease as another fundamental skill set as reform redefines healthcare delivery in the 21st century. | LINK

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Getting the word out about all the preventive services available to Medicare beneficiaries is about as easy as wiping out fraud within CMS completely. But that’s not stopping HHS from pulling out all the stops in an effort to curtail future spending on preventable medical problems.

On Monday, HHS Secretary Kathleen Sebelius announced that the agency was launching a publicity campaign, known as “Share the News, Share the Health” to alert Medicare patients, their doctors and their relatives that the services are available at no charge. “Our job is to make sure every single Medicare beneficiary in the country knows,” Sebelius said.

Chalk it up to a (political) campaign by the federal government to get patients knowledgeable and accepting of the benefits afforded them under the reform law. Overall, this effort is a good thing. At its most superficial, it is a way to catch disease earlier, implement higher quality care delivery for less ill patients sooner, and it represents a time saver for the primary care physician, freeing him from informing the beneficiary in order to make the most of the covered physician service/visit. More profound, however, is the stark effect this initiative could have on patient empowerment — as only slightly more than 10 percent of beneficiaries takes advantage of at least one of the covered preventive medical screenings and services.

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President Obama has issued policy guidance on the extension of healthcare benefits under Medicaid for gay couples.

Under the new guidance, dated June 10, states have the option to allow healthy partners in a same-sex relationship to keep their homes while their partners are receiving support for long-term care under Medicaid, such as care in a nursing home.

This is significant, because, as the article states, states have the ability to seize property to pay for overdue medical charges once a beneficiary’s ability to pay is exhausted. The presence of a spouse in a married relationship living on that property would prevent liens and seizures from taking place, allowing Medicaid benefits to kick in. The same-sex partner living in the home would abort any power the state would have in realizing payments under those alternative conditions for beneficiaries receiving long term care services.

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Recent concerns of two members of congress have upped the ante in the war against a key provision of the ACA: the development of an independent payment advisory board^[1] for the purpose of overseeing payments made by Medicare in the event of rapid spending growth in the healthcare delivery sector. It’s just the latest argument in the ongoing saga to balance the major deficit facing the federal government in the wake of world crises, skyrocketing fuel prices, and the controversial Ryan plan.

[This board differs from the current Medicare Payment Advisory Commission (MedPAC), in which recommendations to Congress do not have to be acted upon. If fact they can be ignored.]

Essentially, the panel would have total control over the direction of Medicare spending once it hits the regulatory criterion in comparison to overall government spending. Championed by Kathleen Sebelius and Sen. Jay Rockefeller, the provision for board oversight would “ensure that health costs are reduced” at the discretion of “experts, using evidence, not by the undue influence of special interests”.

The GOP are fearing regulation under the guise of a presumptive non-partisan body (appointed by the president) and don’t like it one bit. Cries of the potential for “rationing boards” and interference in market forces by third parties that contract with Medicare to provide payments to healthcare providers at the hands of non-vetted “bureaucrats” are representative of that party’s concerns.

Perhaps what is a little surprising is the lukewarm reaction by many advocacy lobbies — from the AARP to the American Health Care Association — to Obama’s provisions. The focus on setting Medicare spending policy by unelected officials and the strong potential for policy decisions to be made by unaccountable and seemingly dispassionate arbiters of oversight and governance is of grave concern to these and other groups whose core constituencies (mainly those in long term care and chronic healthcare delivery to seniors) are directly affected by such decisions. The lobby groups allege the legislation of healthcare benefits to seniors by bypassing lawmakers’ authority would result in adverse consequences to coverage and access.

Appointees to the commission are chosen by President Obama and would require Senate confirmation. Currently, Democrats have slim control of the balance of power in that body.

1. Under the PPACA provision, the board cannot make recommendations to ration healthcare delivery, raise revenues or increase beneficiaries’ premiums, deductibles or co-payments. Recommendations of the board will become law unless the House and the Senate each adopt, by a 3/5 majority, a resolution to block them.

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