Continuity of Care Threatened by Deteriorated Communication Between Hospital-Based & Community-Based Physicians

Medicine in my area of the country has morphed into physicians who care for patients while they are in the hospital  as “in patients” or “ observational status” and outpatients.  Very few primary care physicians admit their patients to a hospital and then care for them while hospitalized. There are numerous reasons for this, mostly economic and initiated by hospital administrations and insurers, but that will be the topic of a future discussion.

In today’s healthcare environment, most hospitalized patients are cared for by hospitalists. These are physicians, nurse practitioners and physician assistants either employed directly by the hospital or employed by a group practice that is contracted to provide services at that facility.

My role as a primary care physician is to present the hospitalists with the reason why the patient is at the emergency department with past records and to provide them with the perspective needed to provide continuity of care. If I know my patient is going to the Emergency Department, I phone the ER charge nurse , review the patient’s case and ask to speak to the physician who will be evaluating them. After I have completed those two calls I send over the records via fax. 

Sadly, the ER physician I have spoken to is often not the ER physician who sees the patient. Also, the records I fax to the ER frequently are not added to the patient’s chart nor are they provided to the ER physician even though I have received electronic confirmation that they were received.

I have arranged to have one coverage team of hospitalists see my patients requiring hospital admission. I text or call that physician to alert them that a patient is on the way.  Unfortunately, the Emergency Department doesn’t always call that doctor to see the patient. In those instances, they admit the patient to the hospitalists resident team instead. I have had numerous phone calls and meetings with the hospital CEO, hospital chief medical officer, the physician leader of the emergency medicine group employed by the hospital and the head nurse in the ER regarding these issues.  My name and the covering physician’s name are clearly listed in their computers and they discuss it at staff meetings but somehow patients frequently end up on the wrong team.

As part of the hospital admission process, the patient’s primary care doctor in the community, and specialists, are usually mentioned in the information obtained upon arrival. That information is certainly included in the documents I send over to the facility. Despite this, it is rare to see a patient admitted to the resident program hospitalists program actually notify those specialists or ask them to see their patient. I call those specialists to make them aware of our mutual patient’s hospital admission so they know to stop by and check on the progress of our patients. 

I use the computer portal daily to follow the evaluation and treatment of these patients. If I have questions or concerns, I speak to the hospitalist physician about it. Upon a patient’s discharge from the hospital, I receive a fax notification from hospital administration notifying me that the patient has been sent home.  I access the discharge summary, print it out and place it in the patient’s office chart and update the medication list if changes have been made in the hospital. For this to be thorough and complete the process requires the hospitalist dictating the summary to be thorough and complete. Sometimes this occurs.

Take the case of Kathy, a 63-year-old woman born with cerebral palsy and suffering seizures.  Since her parents died, she is living with a caregiver supervised by a family member who makes all the medical, legal and financial decisions with the patient supported by funds set aside by her late parents. For unknown reasons, she tragically has had a series of uncontrolled seizures and is taken to a hospital not in my service area. To control her seizures required sedating her, intubating her and putting her on a ventilator to breathe while sedated. While unconscious from sedation she had an arrhythmia requiring starting a new medication to control the rhythm and an anticoagulant to prevent a clot from forming in her heart and traveling to her brain causing a stroke.  Her neurologist and heart specialist were never notified by that facility’s hospitalists even though they had partners who routinely visited that facility. 

Upon discharge, the hospitalist prescribed two days of the amiodarone for the new rhythm and two days of the anticoagulant Eliquis.  They suggested seeing the cardiologist for follow up but the soonest his office could see her was five weeks away.  The discharge summary made no mention of the arrhythmia. The discharge summary did not list the amiodarone or Eliquis.   

The patient’s legal guardian called me to ask about the lack of medications prescribed and basically to have someone explain to him what had occurred. To clarify the situation, my staff contacted the medical records department of the hospital and faxed them a signed authorized medical release of records . We obtained all the daily progress notes and consultation reports. These documents provided the name of the cardiologist who saw her.  It took several attempts by phone before we reached him and he explained what had occurred and clarified what dosage of amiodarone and what length of treatment he preferred and why.   

This research and clarification took hours of non-compensated time.  It was an absolute necessity to insure safe care for the patient. General internists, family practitioners, pediatricians do this daily attempting to coordinate patient care . The lack of interest by hospital administration and overworked employed hospital physicians and staff make being successful increasingly difficult.  The lack of outrage over these incomplete and lazy handoffs is infuriating.

The same families that are furious at the care they receive donate charitable funds to these institutions with few, if any, strings attached about where the money is needed and should go. With for-profit hospital and medical facilities behaving no differently than non-profit facilities and medical groups, and no pressure from the IRS, Center for Medicare Services or insurers, I see no hope for a more professional and thorough handoff of care between the community physicians and hospital-based care.

I Didn’t Make the Cut!

I have been seeing my current internal medicine physician for well over a decade. Years ago, he sold his practice to a large hospital chain and continued to practice as an employee of that entity. My relationship with this younger colleague was both professional and personal. I admired his work ethic, his diligence, his willingness to teach students and young physicians and just the fact that he was a fine and sweet human being.  Several months ago, I saw him for a checkup and then a follow-up visit and we set realistic lifestyle and health goals for me to achieve.

Over the years I have seen him take on administrative and corporate responsibilities for the large health care system that employs him, adding time and workload to his day. We have not always agreed on his decisions as an administrator, but I completely understood that policy decision-making is dictated by his corporate employers.

Last week to my surprise I received a form letter from the corporation announcing that as of January 1, 2024, he would no longer be a part of their corporate health system. The letter outlined that there would be new physicians in the office to see patients but if I wanted to change physicians, they had enclosed a release of records form for me to submit to them. The letter was signed by the local hospital’s new chief medical officer, a former surgeon I had worked with many times over many years.  My wife received the same letter as did close friends who are patients as well. My first thought was why is a youngish physician leaving practice? Is he ill? Is he moving closer to family? Is he retiring?

Since we are both busy actively seeing patients daily over the years for non-personal health reasons, we initiate communication by text message and then talk when we both have a free moment. He replied to my text by saying that he was healthy and remaining with the corporate health organization he was currently under contract with but at a new location closer to the hospital as a “concierge physician”.  He said his patient practice rosters are currently full and closed.

I wished him the best of luck but asked when he would be sending out information about joining the new practice. He responded that no information would be distributed to existing patients because the practice already had enough to close his panel. He said that one week ago a corporate employee had phoned each existing patient in his practice and told them about the new practice and the fee. When they reached the desired panel size, they stopped making phone calls. I reminded him that my wife and I had not received any such phone call. He responded that he thinks they called my wife and could not reach her. I responded by asking if we had to find a new physician and he responded that his panel was full, so “yes”.

Twenty years earlier when I converted my traditional practice to a concierge practice the health care attorneys we consulted from the American Medical Association and the largest health care firm in Florida required us to take a different path. We were required to contact each patient individually and set up a meeting with them to discuss the new practice. We were required to interview and find half a dozen internists locally who would agree to receive our patients as theirs. We were asked to copy the patients’ records at our cost and give them to the patients choosing not to stay with the new concierge practice. They required us to send out a notice informing all the patients of the new practice, how it worked and when we would begin accepting applications for patients to join the new practice.

The attorneys said failure to follow these steps would leave us in a position of being charged by the Florida Board of Medicine with abandoning our patients. Any patient who did not respond by the deadline and did not find a new physician was seen by the new practice until they were safely being followed by another physician.

I called that law firm yesterday and asked them about my current experience, and they said it was a clear-cut violation of the state professional practice guidelines and should be reported to the Florida Board of Medicine as abandonment. I will not do that to a colleague working as an employee of a mammoth health care system. I will find a new physician and try and get over just how hurt and disappointed I am at being treated so callously by a peer in my profession.

Some will say it is “kismet” or “karma” that a concierge physician is now forced to face having his own physician disown him by going into concierge medicine. I don’t feel that way at all and hope he enjoys his new practice style. I just feel the methods employed were inconsiderate and clearly violated the professional standards we are supposed to be upholding when we discontinue care for a patient. I also felt that our relationship was more than a name and number of an electronic chart and I am hurt learning that I was wrong. I can only imagine how his other patients who also “missed the cut”, and are not professional peers, must feel!

Nurse To Patient Staffing Ratios are Important for Safety and Outcomes

There is a battle ongoing between nursing associations and hospital leadership. The main issue is that experienced nurses believe there are only so many patients one nurse can care for in a hospital inpatient location before the health and safety of the patients are put at risk.

When I started practicing medicine in a large public hospital in Dade County, Florida the ratio of nurses to patients on the medical floors was 1:4.  Illness and emergency situations often led to a ratio of 1:5 or even 1:6 patients but the additional patients were usually relatively healthy individuals requiring far less attention.

At that time, the ratio of nurses to patients in the critical care areas such as the intensive care unit, cardiac care unit or surgical intensive care unit was usually 1:1.  Staff illness and emergencies rarely led to a ratio of 1:2 but that second patient usually was well enough to require less attention. Only the more experienced critical care nurses were assigned to that second patient. 

There were times when nursing shortages led to the unit’s charge nurse closing beds in critical care areas rather than bringing in patients who could not receive the attention they required. As a clinician and physician let me make this perfectly clear, the quality of the care was directly proportional to the quality and skill of the nursing staff. Good hospitals with good outcomes had great nurses.  In those days the head nurse or charge nurse on a particular floor or ward was usually experienced and had overseen that area for years.  As a physician you quickly learned that if you wanted your patients well cared for, you followed the rules that the charge nurse on that ward or floor  established. There were other differences such as the same nurse cared for the same patient on the same shift daily until that patient was discharged.

In today’s hospital world there is a post pandemic shortage of experienced nurses. Continuity of nursing care doesn’t exist in most places. The ratio of nurses to patients has dramatically increased.  Hospital administrators cite cost constraints and new technology permitting nurses to care for more patients as the reason ratios are climbing above 1:5 today.

Linda Aiken, PhD, RN of the University of Pennsylvania School of Nursing’s Center for Health Outcomes and Policy Research is a firm believer in keeping the ratios of nurses to patients low.  The best staffed hospitals in her study maintain a 1:4 ratio while some corporate facilities have a 1:11 ratio.  Her research from a 2002 study reveals that there is a 7% patient death rate increase for each additional patient a hospital nurse is assigned.  The State of California is one of the few states that passed legislation limiting the ratio to one licensed nurse per five patients. Other states have tried but they have run into a lobbying roadblock from none other than hospital administrators and corporate owners.

The quality of the care one receives in the hospital is directly related to the quality of the nursing care and the availability of the nurses to assess the patient and respond to their health needs. A ratio of one nurse caring for four patients should be the goal. 

In my community, for the last decade or more, our local community hospital has behaved and billed no different than the for-profit corporate facilities.  The community is affluent and fund-raising campaigns at extraordinarily wealthy country clubs and oceanside and golf course condominiums raise hundreds of thousands of dollars for the local facility. I ask these charitable groups, “Do you know what the money is being used for?”   The answer is always, “No.” When I suggest that they use the charitable funds to sponsor another nurse on each floor to reduce the ratio of patients to nurses they look at me like I am insane. I stand by my suggestion. 

Ask what the ratio of nurses to patients is at your facility. Ask if the same nurse cares for the same patient on the same shift daily.

If you are generous enough to donate and raise funds for your local hospital, sponsor an extra nurse per shift per floor! It could save your life or someone you love!

Has the Business of Medicine Ruined Health Care?

Early in my career if I had an elderly patient recovering from an illness or surgical procedure and their condition required an extra inpatient hospital day, I just looked at the chart and found some chronic condition still not “normal” . I wrote a note in the chart documenting it and the patient stayed put. Most of the time the reason was medical. Sometimes it was logistical, such as a family member flying in to be the caregiver and unexpectedly delayed. Sometimes it was about a hospital bed or wheelchair or nebulizer unavailable until the next day. I deferred to caring and compassion.

As we moved into the 1980’s and 1990’s, and managed care evolved, a new hospital employee position replaced the “social worker” called a “ case manager”. They would discuss “ Length of Stay or LOS” and tell us reckless spenders how much we were costing the hospital. This didn’t jive ever with the annual financial report card I received from that facility  in the first quarter of each year on patients I cared for while hospitalized. There was not a year where I had not made the facility at least $250,000 in profit and that was only from the inpatient data. I kept a copy of that report with me when I made rounds and, as an independent practitioner not employed by the institution, I had the ability to put my patient first and remind administration each time they complained.

I bring this up because I read an article in the New England Journal of Medicine this week written by a young physician complaining about how the hospital employed physicians discharged patients routinely before their evaluations were complete. He cited examples of how this practice delayed the diagnosis and life span of the patients. The author felt great compassion for the patient and the hospital based employed  physicians who are under tremendous contractual pressure to discharge quickly and keep the admission profitable. This is occurring in for-profit hospitals as well as in  not-for-profit hospitals.

At the same reading session, I read an article discussing the problems that occur when an older adult is admitted to the hospital for an illness which the authors, in retrospect, believe could have been handled while the patient stayed at home. In 40 years of practice, I know of no situation where a patient who could safely stay at home was hospitalized for physician profit.

Do you have any idea how inconvenient, inefficient and cost ineffective it is  for a physician with an office-based practice to care for a hospitalized patient ? You have to get there before daily office hours, return after office hours and handle dozens of phone calls from nurses, aides, pharmacy staff and physical therapists – not to mention family members.

“The suits”, business investors, insurers and employers, plus CMS and our elected Congressional officials, have cut the heart and caring out of medicine. I stopped going to the hospital at the  start of the pandemic when hospital officials limited who could see patients as a means to slow the spread of infection. When it was considered safe to return to the hospital, the control of administrators over care decisions had expanded so much that it was clearly uncomfortable to work there.

My physician partner, who covered my practice when I was out of town or ill, refused to  return to hospital care for just this reason. It left me without backup.  I explored returning but the care and concern by hospital staff were so different and so robotic I felt that if I returned I would end up in a shouting match trying to advocate for my patients and lose my credentials anyway.            

My local hospital was built because emergency care was not available for two youngsters who died enroute to a distant hospital in the early 1960’s. The facility was built by the community and recently sold to a major not-for-profit chain. Just prior to the sale, they  closed its pediatric unit because it  was not  profitable. However, they continue to have a profitable labor and delivery program and continue to deliver babies. If those newborns become ill they are sent to hospitals 35 – 40 minutes away. If a child is brought to the Emergency Room and requires admission to the hospital, they too are transferred to a pediatric unit in Broward County or the one in Palm Beach. This is what occurs when financial people run healthcare.

The influence of ‘ business” on medicine has even infiltrated into medical schools where students are encouraged to become employees and work shifts for balance of life reasons rather than enter their own private practice and develop lifelong professional relationships with patients.

An article from Canada talked about the importance of primary care in treating chronic illnesses. With an aging population of baby boomers, preventing and controlling chronic problems is essential to the health of the citizens and the financial health of the country. 

In Canada, with a national health system, less than 1% of the caregivers are nurse practitioners or physician assistants. You are evaluated by and treated by a physician. Hospitalists( hospital-based and employed physicians) were the creation of a bunch of residents at University of California San Francisco who, upon completing their training, had no idea what to do with their careers. Their mentors in academia detested their time away from their research while out on the wards supervising the care and training of internal medicine physicians. They hired these doctors to perform their clinical duties and responsibilities so they could continue to teach and conduct research. Hospital administrators loved the concept because by employing them and making it difficult for community based independent physicians to come to the hospital, they had a mechanism to control costs and length of stay. Insurers and employers loved them for the same reason. Nurse practitioners and physician assistants were adored for the same reason.

Hiring a “mid-level” provider is far less expensive than hiring a physician. The original wave of NPs and PAs came from experienced nurses with years of  experience in the field. Bringing them back to school for training and then supervising their postgraduate clinical experiences produced some outstanding clinicians. The new breed of mid-level providers come from students with two years of experience only. While a physician in training is supervised for a minimum of 144,000 hours, the oversight on mid-level providers is far less. Asking them to be the chronic care supervisors in the USA may help the bottom line of insurers, employers and hospital systems but it does little for senior citizens.

My advice to patients is simple.  Find yourself a well-trained independent physician who actually sees patients. Stay away from HMO plans unless it is a superior product like Kaiser Permanente. Stay away from Medicare Advantage plans. They are not the same as traditional Medicare. They cost less for patients but the price you pay if you get ill in terms of choice of physicians to care for you and facilities can be very limited.

If you can afford a concierge physician or direct pay physician with a small practice it is well worth it.  If you get hospitalized you need a savvy advocate who knows health care to be there with you.  Write your Congressman and advocate  against Medicare Advantage plans which actually cost more per patient now than traditional Medicare. If your care is switched to a mid-level provider, ask that provider how much clinical experience they had in nursing prior to entering NP or PA programs. Scrutinize them the same way you would view the credentials of a perspective physician. Lastly, ignore their online reviews. In general, online reviews are written by patients who are dissatisfied and don’t necessarily represent the overall sentiment the majority have of the provider.

COVID-19 & Public Health Departments

I received an email from the Florida Department of Public Health saying a Federal Judge from Missouri had struck down the necessity for health care workers to be vaccinated against COVID or risk losing their jobs. The suit was brought by several states and, while Florida was not part of this particular lawsuit, was part of other lawsuits which are ongoing.  My immediate thought is that the Florida Department of Public Health should have more important things to do such as providing public health! 

I contrast this with a story told to me by a reliable source – a 66-year-old New Yorker. He lives in the Upper West Side of Manhattan with his 63-year-old wife and spends winters at a home on the West Coast of Florida. 

They packed up their car and, for the first time, hired a professional driver to transport it plus some belongings down to their Florida winter home . They were scheduled to board a flight to Sarasota on December 2^nd until the husband received a text message from the NY City Department of Health.  The message said that using cell phone location tracking data they have discovered that the husband was within six feet of an individual who tested positive for COVID-19.  They provided contact information and requested he call the number to receive precautionary recommendations.

When he called, they advised that if he was vaccinated and had no symptoms of COVID he should be tested in four to seven days but remain masked and quarantined until then. The husband stays home most days, except for a daily morning bicycle ride along the Hudson River down to Battery Park where he rents out a gym for a private 90-minute workout with a vaccinated masked trainer who is the only other individual in the facility.  He then bikes home along the Hudson River stopping at a food truck on sunny days to purchase a cup of coffee which he drinks alone on a bench overlooking the river. He and his wife mask, maintain safe distances from others and avoid indoor facilities.

The couple decided to follow the advice of the Health Department. They separated within their home staying masked indoors. They rescheduled their flights for the following week. They have appointments to have nasal PCR tests on day 7 after exposure.

Wouldn’t it be lovely if we had a public health department in Florida that actually practiced public health along with citizens who respected the health of others by following recommendations to prevent transmission of the disease?

American College of Physicians Breast Cancer Screening Guidance

The American College of Physicians released four guidance statements on detection of breast cancer in women with average risk and no symptoms of breast cancer.

1. Doctors should discuss with their patients the pros and cons of screening with mammography for breast cancer in asymptomatic women with a modest risk of disease between ages 40- 49 years. The potential risks of screening are felt to outweigh the benefits.
2. Clinicians should screen average risk women aged 50-74 years for breast cancer with mammography every other year.
3. Clinicians should discontinue breast cancer screening in women aged 75 years or greater with an average risk of breast cancer and a life expectancy of 10 years or less.
4. Clinical breast examinations SHOULD NOT be used to screen for breast cancer of average risk women of all ages.

These guidance statements DO NOT APPLY to women with a higher risk of breast cancers including those with abnormal screening results in the past, a personal history of breast cancer or a mutation in the BRCA1 or BRCA2 gene.

At the same meeting, data was presented discussing the problems with supplemental whole breast ultrasound in women with dense breasts.  The concern is that all this testing leads to invasive biopsies, over diagnosis and treatment of breast cancer in 1 in 5 patients and complications and increased cost to patients and insurers.  Like most recommendations on breast cancer, and prostate cancer in men, the results and conclusions from following these guidelines will not be apparent until 10 to 15 years from now.

Today’s adult women will either benefit from these suggestions, which have even included no longer teaching adult women how to perform breast self-exam, or they will be the unsuspecting research victims of cost containment. I question the competence of physicians in examining problematic breast disease if they are not being trained how to evaluate a breast and following that with clinical exams. In surgery we usually do not feel a clinician is competent and fully aware of the pitfalls of a procedure until the surgeon has done 200 or more. We additionally know that doing the procedure frequently results in better results than performing a procedure infrequently.

How will that apply if young physicians no longer examine breasts routinely?  How many, and how often, will they need to do an adequate exam to be able to perform when there is a real issue?  Do we actually wish to create a narrow panel of breast experts only at Centers of Excellence who actually know how to examine a breast and use the available imaging modalities safely and effectively?  It seems these ACP recommendations move in that direction.

For several years now I have been a supporter and champion of our community’s Women’s’ Center associated with Boca Raton Regional Hospital. Run by astute future thinking clinicians and researchers, and stocked with state of the art imaging equipment, it provides an option to meet with a counselor, assess your breast cancer risk and enter a screening pathway most individually suited to your personalized needs.  I will continue to support that choice.

“They Paved Paradise, Put in a Parking Lot”

My local hospital has been petitioning the local city zoning board for permission to build an on-site parking garage for years now.  The city zoning board is very strict about the height of buildings and has turned the requests down repeatedly.

This past fall, the hospital administration announced that it needed a capital partner to expand and stay solvent.  Most of the members of the hospital medical staff have absolutely no idea if this is true and accurate or not.  We do know that several weeks after agreeing to a relationship with a well-respected health care system as a capital partner, they received permission to build that garage.

Construction is set to begin in March so it was no surprise to receive a three page email announcement that the physician hospital parking has been moved from adjacent to the hospital to an area that will make it significantly easier for me to get my daily 10,000 steps in. The construction will take a year. Florida’s sudden onset of torrential downpours will present a challenge but, that’s what umbrellas are for.

I bring this up after making rounds on my affluent patient, whose hospital identification information identifies him as a VIP Benefactor with a yellow star, upstairs in the spectacular VIP section known as the Rockwell Suites.  The operators have gotten used to us staff members calling in and asking the operator to connect us to the nursing station at the Rock and Roll Suites.

His room is the size of three to four rooms with dark wood paneled floors and walls. There are three big screen TVs in this room along with two computer screens. The floor has its own chef available to make a meal for a patient or family member anytime of the day or night.  There is a surcharge for this type of room not covered by insurance.

When I left this patient’s room, and had adjusted his medications at the nursing station, I went downstairs to the general medical telemetry floor.  My patient on that floor also is a benefactor but is in a semiprivate room being evaluated for a fainting episode.  I reached up behind his bed for a blood pressure cuff to check his blood pressure in various positions and there was none. I walked out to the nursing desk and asked the charge nurse for a blood pressure cuff and, after five minutes of going from room to room, she found one that didn’t hold the pressure load and was not working very well.   A digital one was finally located so I could measure the patient’s blood pressure myself.

My community hospital was built by neighbors and philanthropic donations after two young children died of a poison ingestion and there was no local hospital to bring them to. It was controlled by a lay community board, a community medical staff that represented the patient’s through the physician staff and a separate administration.  Addition of new doctors to the staff required the approval of a lay community council that first looked at the need for that specialty based on the population and the number of existing doctors already here practicing that specialty.  They were concerned that too many doctors would lead to many unnecessary tests because everyone needed to generate income.

That community hospital is now a “regional “hospital with a board filled by CEOs of Fortune 500 companies and doctors who are employed by the hospital. The pediatrics wing has been closed down because it lost money.  There is no geriatrics wing despite a plethora of senior citizens. There is little or no relationship with the student health programs at the two local universities.  There are no blood pressure cuffs in most rooms and no otoscopes or ophthalmoscopes in most rooms in the emergency department.  But, there are three big screen TVs in the Rock and Roll Suites and a parking garage in the works.

I wonder who now represents the health and medical needs of our community?

Medicare Will Not Pay For Bone Marrow or Umbilical Cord Blood Transplants

Treatment of blood disorders, leukemia and lymphomas today includes the use of life saving transplants of bone marrow from genetically similar donors and use of newborn childrens’ umbilical cord blood containing stem cells.  The National Marrow Donor Program (NMDP), Be the Match, is the organization which operates the national match registry and has worked for the last 30 years to find 13.6 million adult bone marrow volunteer donors and 225,000 units of fetal cord blood for use. The NDMPs relationship with similar organizations across the globe creates a pool of 24.5 million potential marrow donors and 609,000 units of cord blood.

There are people who need these vital products and cannot find a match but, fortunately, that number is declining. The real problem in men and women 65 years of age or older is that outdated Medicare reimbursement policies do not pay for these products and services and the cost is too expensive for many to bear themselves. The Centers for Medicare & Medicaid Services (CMS) has created barriers to Medicare age recipients being covered for these products resulting in financial uncertainty for the patient. The actual cost is beyond the means of most working individuals to bear.

While private insurers cover more than 70 diseases and conditions, Medicare covers less than a dozen.  The US Department of Health and Human Services calculated that almost 20,000 people in the U.S. could benefit from life-saving marrow or cord blood transplant each year but do not receive them because CMS policy does not cover them.   Where Medicare covers the conditions, the rate of reimbursement is often insufficient to cover the costs.  As Baby Boomers become eligible for Medicare the problem will intensify.

Dr Fred LeMaistre, M.D., director of the Sarah Cannon Blood Cancer Network authored an editorial and appeal to the physician community to lobby for better coverage of marrow and cord blood transplants as a life saving measure.

I for one was stunned to realize just how poor the coverage has remained for these services and find it disgraceful that Sarah Palin’s predicted death panels have now materialized in the form of accepted lifesaving technology not being covered after age 65.  If you are as surprised as I am write to your Congressional representatives and demand appropriate reimbursement for bone marrow and cord blood transplants to save lives!

High Disability and Death Rates in Bleeds Associated with New Oral Anticoagulants

In the trailer for the movie Jaws 2 they show a swimmer in the ocean with a deep voice saying, “Just when you thought it was safe to go back into the water…” followed by the classic music associated with a shark attack and a big fin approaching the unsuspecting swimmer. I feel much the same way upon reading a Medpage Today online journal review of an article in JAMA Neurology published on December 14, 2015. Jan C. Purrucker, MD and colleagues looked at 61 consecutive patients with non-trauma related cerebral hemorrhages due to the newer oral anticoagulants Pradaxa, Xarelto and Eliquis. Overall there was a death rate of 28% at three months and “two out of 3 survivors had an unfavorable outcome.”

In October of 2015 the FDA approved the use of the antibody fragment idarucizumab (Praxbind) to reverse anticoagulation in patients bleeding from the administration of the oral anticoagulant Pradaxa. There are currently no medications to reverse the bleeding from the drugs Xarelto or Eliquis but we are promised that new products are in development. The article goes on to discuss how physicians have been forced to improvise when patients on these medications show up bleeding. They have tried fresh frozen plasma, 3-factor, 4-factor and activated prothrombin complex concentrates prothrombin complex concentrates, recombinant factor VIIa and cryoprecipitate alone or in combination with marginal success at best.

Despite there being no antidote to these blood thinners, the massive direct to consumer advertising continues on television prime time and magazines as if the products are no more dangerous than an antacid for heartburn. Coumadin or warfarin is the prototype anticoagulant working by inhibiting vitamin K dependent clotting factors. Its effects are reversible with administration of Vitamin K and clotting factors if bleeding occurs. Coumadin requires periodic blood tests (INR) to check on its efficacy and there is a long list of medications and foods that need to be avoided or adjusted while taking it. It is less convenient but safer in the sense that its effects can be reversed with medication.

The newer oral anticoagulants were championed by several studies that suggested that they were more effective in preventing embolic strokes in patients with the heart rhythm atrial fibrillation. Many experts in the field felt that those conclusions were flawed because the Coumadin group was not tightly regulated to keep their INR in a therapeutic non-clotting range thus unfairly biasing the results in favor of the newer agents.

There is no question that the newer agents are more convenient than warfarin treatment, but until there are readily available antidotes, complications seem to be more difficult to limit and control.

Does Not Testing the PSA Lead to More Advanced Prostate Cancer?

Mortality from prostate cancer has diminished by almost 40% since the introduction of the PSA test in the late 1980’s. Much of this is due to the use of the PSA blood test for screening purposes. In 2011 The US Preventive Screening Task Force strongly condemned the use of PSA screening. They felt that we were finding too many inconsequential early malignancies that would not lead to death and were being over treated. In their eyes, prostate cancer treatment with surgery and or radiation carried a high price tag with multiple long term complications and the benefit of screening was not worth the risk. Prior to the USPSTF”s 2011 recommendation against screening for prostate cancer with a PSA there were 9000 – 12,000 new cases of prostate cancer diagnosed per month. In the month following the USPSTF recommendation not to screen with PSA the number of new cases dropped by almost 1400 a month or over 12%. Over the next year the decline in prostate cancer diagnosis was 37.9 % for low-risk prostate cancer, 28.1% for intermediate risk, 23.1 5 for high risk and 1.1% for non-localized cancer. Clearly if you do not look for a disease you will not find it.

In the December issue of the Journal of Urology, Daniel Barocas, MD, of Vanderbilt University and colleagues discussed the PSA testing controversy. They too noted that the consequences of not screening for intermediate and high risk prostate cancer by performing the PSA test may lead to individuals presenting with far more advanced disease that is more difficult to treat, has more complications and ultimately leads to disease related deaths. His position was debated by two major urologists in the editorial section of the journal with no firm conclusion being reached.

In an unrelated article, the Center for Medicare Services or CMS announced that it is considering penalizing physicians who test the PSA for screening in Medicare patients beginning in 2018 as part of their paying for value and quality. They said that physicians need to present their patients with an ABN (advanced beneficiary notice) stating that Medicare will not pay for this test, before the blood is drawn or face fines and penalties.

Men in their forties and older have been put in an uncomfortable and inappropriate position by health policy leaders. The truth is we are currently unsure how and when to test for prostate cancer in men with a normal digital rectal exam (DRE). The consequences of not paying for screening will not be known or understood for easily ten to fifteen years. It is clear that early stage disease has the option to be observed for progression with minimal consequences in the short term. Not enough time has elapsed for anyone to know the long term effects of this policy change. Unfortunately, men in this age group are all guinea pigs in the public health policy laboratory while the data to reach a firm scientific conclusion is assembled. The predominant policy today is spending less and doing less. With this in mind, it is best for men to see their doctor, have an annual digital rectal exam, discuss their family history of prostate disease and reach an individual decision on PSA screening appropriate for their unique situation rather than one based on large population policy.