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Overkill

Annals of Health CareMay 11, 2015 Issue
Source: The New yorke

An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it?

By Atul Gawande May 4, 2015
Photo(s) Source: The New yorker

  • It was lunchtime before my afternoon surgery clinic, which meant that I was at my desk, eating a ham-and-cheese sandwich and clicking through medical articles. Among those which caught my eye: a British case report on the first 3-D-printed hip implanted in a human being, a Canadian analysis of the rising volume of emergency-room visits by children who have ingested magnets, and a Colorado study finding that the percentage of fatal motor-vehicle accidents involving marijuana had doubled since its commercial distribution became legal. The one that got me thinking, however, was a study of more than a million Medicare patients. It suggested that a huge proportion had received care that was simply a waste.
Millions of Americans get tests drugs and operations that wont make them better may cause harm and cost billions.
Millions of Americans get tests, drugs, and operations that won’t make them better, may cause harm, and cost billions.Illustration by Anna Parini

The researchers called it “low-value care.” But, really, it was no-value care. They studied how often people received one of twenty-six tests or treatments that scientific and professional organizations have consistently determined to have no benefit or to be outright harmful. Their list included doing an EEG for an uncomplicated headache (EEGs are for diagnosing seizure disorders, not headaches), or doing a CT or MRI scan for low-back pain in patients without any signs of a neurological problem (studies consistently show that scanning such patients adds nothing except cost), or putting a coronary-artery stent in patients with stable cardiac disease (the likelihood of a heart attack or death after five years is unaffected by the stent). In just a single year, the researchers reported, twenty-five to forty-two per cent of Medicare patients received at least one of the twenty-six useless tests and treatments.

Could pointless medical care really be that widespread? Six years ago, I wrote an article for this magazine, titled “The Cost Conundrum,” which explored the problem of unnecessary care in McAllen, Texas, a community with some of the highest per-capita costs for Medicare in the nation. But was McAllen an anomaly or did it represent an emerging norm? In 2010, the Institute of Medicine issued a report stating that waste accounted for thirty per cent of health-care spending, or some seven hundred and fifty billion dollars a year, which was more than our nation’s entire budget for K-12 education. The report found that higher prices, administrative expenses, and fraud accounted for almost half of this waste. Bigger than any of those, however, was the amount spent on unnecessary health-care services. Now a far more detailed study confirmed that such waste was pervasive.

I decided to do a crude check. I am a general surgeon with a specialty in tumors of the thyroid and other endocrine organs. In my clinic that afternoon, I saw eight new patients with records complete enough that I could review their past medical history in detail. One saw me about a hernia, one about a fatty lump growing in her arm, one about a hormone-secreting mass in her chest, and five about thyroid cancer.

To my surprise, it appeared that seven of those eight had received unnecessary care. Two of the patients had been given high-cost diagnostic tests of no value. One was sent for an MRI after an ultrasound and a biopsy of a neck lump proved suspicious for thyroid cancer. (An MRI does not image thyroid cancer nearly as well as the ultrasound the patient had already had.) The other received a new, expensive, and, in her circumstances, irrelevant type of genetic testing. A third patient had undergone surgery for a lump that was bothering him, but whatever the surgeon removed it wasn’t the lump—the patient still had it after the operation. Four patients had undergone inappropriate arthroscopic knee surgery for chronic joint damage. (Arthroscopy can repair certain types of acute tears to the cartilage of the knee. But years of research, including randomized trials, have shown that the operation is of no help for chronic arthritis- or age-related damage.)

Virtually every family in the country, the research indicates, has been subject to overtesting and overtreatment in one form or another. The costs appear to take thousands of dollars out of the paychecks of every household each year. Researchers have come to refer to financial as well as physical “toxicities” of inappropriate care—including reduced spending on food, clothing, education, and shelter. Millions of people are receiving drugs that aren’t helping them, operations that aren’t going to make them better, and scans and tests that do nothing beneficial for them, and often cause harm.

Why does this fact barely seem to register publicly? Well, as a doctor, I am far more concerned about doing too little than doing too much. It’s the scan, the test, the operation that I should have done that sticks with me—sometimes for years. More than a decade ago, I saw a young woman in the emergency room who had severe pelvic pain. A standard X-ray showed nothing. I examined her and found signs of pelvic inflammatory disease, which is most often caused by sexually transmitted diseases. She insisted that she hadn’t been sexually active, but I didn’t listen. If I had, I might have ordered a pelvic CT scan or even recommended exploratory surgery to investigate further. We didn’t do that until later, by which time the real source of her symptoms, a twisted loop of bowel in her pelvis, had turned gangrenous, requiring surgery. By contrast, I can’t remember anyone I sent for an unnecessary CT scan or operated on for questionable reasons a decade ago. There’s nothing less memorable.

It is different, however, when I think about my experience as a patient or a family member. I can readily recall a disturbing number of instances of unnecessary care. My mother once fainted in the Kroger’s grocery store in our Ohio home town. Emergency workers transported her to a hospital eighty miles away, in Columbus, where doctors did an ultrasound of her carotid arteries and a cardiac catheterization, too, neither of which is recommended as part of the diagnostic workup for someone who’s had a fainting episode, and neither of which revealed anything significant. Only then did someone sit down with her and take a proper history; it revealed that she’d had dizziness, likely from dehydration and lack of food, which caused her to pass out.

I began asking people if they or their family had been subject to what they thought was unnecessary testing or treatment. Almost everyone had a story to tell. Some were appalling.

My friend Bruce told me what happened when his eighty-two-year-old father developed fainting episodes. His doctors did a carotid ultrasound and a cardiac catheterization. The tests showed severe atherosclerotic blockages in three coronary arteries and both carotid arteries. The news didn’t come as a shock. He had smoked two packs of cigarettes a day since the age of seventeen, and in his retirement years was paying the price, with chronic lung disease, an aortic-aneurysm repair at sixty-five, a pacemaker at seventy-four, and kidney failure at seventy-nine, requiring dialysis three days a week. The doctors recommended doing a three-vessel cardiac-bypass operation as soon as possible, followed, a week or two later, by surgery to open up one of his carotid arteries. The father deferred the decision-making to the son, who researched hospitals and found a team with a great reputation and lots of experience. The team told him that the combined procedures posed clear risks to his father—for instance, his chance of a stroke would be around fifteen per cent—but that the procedures had become very routine, and the doctors were confident that they were far more likely to be successful than not.VIDEO FROM THE NEW YORKERHow Will Americans Vote During a Crisis?

It didn’t occur to Bruce until later to question what the doctors meant by “successful.” The blockages weren’t causing his father’s fainting episodes or any other impairments to his life. The operation would not make him feel better. Instead, “success” to the doctors meant reducing his future risk of a stroke. How long would it take for the future benefit to outweigh the immediate risk of surgery? The doctors didn’t say, but carotid surgery in a patient like Bruce’s father reduces stroke risk by about one percentage point per year. Therefore, it would take fifteen years before the benefit of the operation would exceed the fifteen-per-cent risk of the operation. And he had a life expectancy far shorter than that—very likely just two or three years. The potential benefits of the procedures were dwarfed by their risks.

Bruce’s father had a stroke during the cardiac surgery. “For me, I’m kicking myself,” Bruce now says. “Because I remember who he was before he went into the operating room, and I’m thinking, Why did I green-light an eighty-something-year-old, very diseased man to have a major operation like this? I’m looking in his eyes and they’re like stones. There’s no life in his eyes. There’s no recognition. He’s like the living dead.”

A week later, Bruce’s father recovered his ability to talk, although much of what he said didn’t make sense. But he had at least survived. “We’re going to put this one in the win column,” Bruce recalls the surgeon saying.

“I said, ‘Are you fucking kidding me?’ ”

His dad had to move into a nursing home. “He was only half there mentally,” Bruce said. Nine months later, his father died. That is what low-value health care can be like.

I’m a fan of the radio show “Car Talk” (which ceased taping in 2012 but still airs in reruns), and a regular concern of callers who sought the comic but genuine advice of its repair-shop-owning hosts, Tom and Ray Magliozzi, was whether they were getting snookered by car mechanics into repairs they didn’t need.

“There’s no question we have considerable up-selling in the industry,” Ray told me when I reached him by phone. “Quickie-lube places are the worst for this. I won’t name names, but they tend to have the word ‘lube’ in them.” He let out that nyuk-nyuk-nyuk laugh he has. “You can’t make money on a $29.95 oil change. So they try to sell you on a lot of stuff. First level, they sell you something you don’t need but at least doesn’t hurt. Second level, they do some real damage mucking around.”

Even reputable professionals with the best intentions tend toward overkill, he said. To illustrate the point, he, too, had a medical story to tell. Eight months earlier, he’d torn a meniscus in his knee doing lunges. “Doing lunges is probably something a sixty-five-year-old should not be doing to begin with,” he admitted. He was referred to an orthopedic surgeon to discuss whether to do physical therapy or surgery. “Very good guy. Very unassuming. I had no reason not to trust the guy. But I also know he’s a surgeon. So he’s going to present surgery to me.”https://8cda257c87e858baee5380cc65ab1ba3.safeframe.googlesyndication.com/safeframe/1-0-37/html/container.htmlADVERTISEMENT

Sure enough, the surgeon recommended arthroscopic knee surgery. “This is going to fix it,” Ray recalled him saying. “In by nine, out by noon.”

Ray went for a second opinion, to a physical therapist, who, of course, favored physical therapy, just as the surgeon favored surgery. Ray chose physical therapy.

“How’d it turn out?” I asked.

“Amazingly well,” he said. “I feel pretty darn good right now.”

“What did the surgeon say when you told him you weren’t going to do the surgery?”

“He said, ‘No problem, go to P.T., and when that doesn’t work we can schedule the surgery,’ ” Ray recalled. “Who knows? Maybe I will end up having to go back. He wasn’t trying to pull the wool over my eyes. But he believed.”

What Ray recommended to his car-owning listeners was the approach that he adopted as a patient—caveat emptor. He did his research. He made informed choices. He tried to be a virtuous patient.

The virtuous patient is up against long odds, however. One major problem is what economists call information asymmetry. In 1963, Kenneth Arrow, who went on to win the Nobel Prize in Economics, demonstrated the severe disadvantages that buyers have when they know less about a good than the seller does. His prime example was health care. Doctors generally know more about the value of a given medical treatment than patients, who have little ability to determine the quality of the advice they are getting. Doctors, therefore, are in a powerful position. We can recommend care of little or no value because it enhances our incomes, because it’s our habit, or because we genuinely but incorrectly believe in it, and patients will tend to follow our recommendations.

Another powerful force toward unnecessary care emerged years after Arrow’s paper: the phenomenon of overtesting, which is a by-product of all the new technologies we have for peering into the human body. It has been hard for patients and doctors to recognize that tests and scans can be harmful. Why not take a look and see if anything is abnormal? People are discovering why not. The United States is a country of three hundred million people who annually undergo around fifteen million nuclear medicine scans, a hundred million CT and MRI scans, and almost ten billion laboratory tests. Often, these are fishing expeditions, and since no one is perfectly normal you tend to find a lot of fish. If you look closely and often enough, almost everyone will have a little nodule that can’t be completely explained, a lab result that is a bit off, a heart tracing that doesn’t look quite right.

Excessive testing is a problem for a number of reasons. For one thing, some diagnostic studies are harmful in themselves—we’re doing so many CT scans and other forms of imaging that rely on radiation that they are believed to be increasing the population’s cancer rates. These direct risks are often greater than we account for.

What’s more, the value of any test depends on how likely you are to be having a significant problem in the first place. If you have crushing chest pain and shortness of breath, you start with a high likelihood of having a serious heart condition, and an electrocardiogram has significant value. A heart tracing that doesn’t look quite right usually means trouble. But, if you have no signs or symptoms of heart trouble, an electrocardiogram adds no useful information; a heart tracing that doesn’t look quite right is mostly noise. Experts recommend against doing electrocardiograms on healthy people, but millions are done each year, anyway.

Resolving the uncertainty of non-normal results can lead to procedures that have costs of their own. You get an EKG. The heart tracing is not completely normal, and a follow-up procedure is recommended. Perhaps it’s a twenty-four-hour heart-rhythm monitor or an echocardiogram or a stress test or a cardiac catheterization; perhaps you end up with all of them before everyone is assured that everything is all right. Meanwhile, we’ve added thousands of dollars in costs and, sometimes, physical risks, not to mention worry and days of missed work.

Overtesting has also created a new, unanticipated problem: overdiagnosis. This isn’t misdiagnosis—the erroneous diagnosis of a disease. This is the correct diagnosis of a disease that is never going to bother you in your lifetime. We’ve long assumed that if we screen a healthy population for diseases like cancer or coronary-artery disease, and catch those diseases early, we’ll be able to treat them before they get dangerously advanced, and save lives in large numbers. But it hasn’t turned out that way. For instance, cancer screening with mammography, ultrasound, and blood testing has dramatically increased the detection of breast, thyroid, and prostate cancer during the past quarter century. We’re treating hundreds of thousands more people each year for these diseases than we ever have. Yet only a tiny reduction in death, if any, has resulted.

My last patient in clinic that day, Mrs. E., a woman in her fifties, had been found to have a thyroid lump. A surgeon removed it, and a biopsy was done. The lump was benign. But, under the microscope, the pathologist found a pinpoint “microcarcinoma” next to it, just five millimetres in size. Anything with the term “carcinoma” in it is bound to be alarming—“carcinoma” means cancer, however “micro” it might be. So when the surgeon told Mrs. E. that a cancer had been found in her thyroid, which was not exactly wrong, she believed he’d saved her life, which was not exactly right. More than a third of the population turns out to have these tiny cancers in their thyroid, but fewer than one in a hundred thousand people die from thyroid cancer a year. Only the rare microcarcinoma develops the capacity to behave like a dangerous, invasive cancer. (Indeed, some experts argue that we should stop calling them “cancers” at all.) That’s why expert guidelines recommend no further treatment when microcarcinomas are found.

Nonetheless, it’s difficult to do nothing. The patient’s surgeon ordered a series of ultrasounds, every few months, to monitor the remainder of her thyroid. When the imaging revealed another five-millimetre nodule, he recommended removing the rest of her thyroid, out of an abundance of caution. The patient was seeing me only because the surgeon had to cancel her operation, owing to his own medical issues. She simply wanted me to fill in for the job—but it was a job, I advised her, that didn’t need doing in the first place. The surgery posed a greater risk of causing harm than any microcarcinoma we might find, I explained. There was a risk of vocal-cord paralysis and life-threatening bleeding. Removing the thyroid would require that she take a daily hormone-replacement pill for the rest of her life. We were better off just checking her nodules in a year and acting only if there was significant enlargement.

H. Gilbert Welch, a Dartmouth Medical School professor, is an expert on overdiagnosis, and in his excellent new book, “Less Medicine, More Health,” he explains the phenomenon this way: we’ve assumed, he says, that cancers are all like rabbits that you want to catch before they escape the barnyard pen. But some are more like birds—the most aggressive cancers have already taken flight before you can discover them, which is why some people still die from cancer, despite early detection. And lots are more like turtles. They aren’t going anywhere. Removing them won’t make any difference.ADVERTISEMENT

We’ve learned these lessons the hard way. Over the past two decades, we’ve tripled the number of thyroid cancers we detect and remove in the United States, but we haven’t reduced the death rate at all. In South Korea, widespread ultrasound screening has led to a fifteen-fold increase in detection of small thyroid cancers. Thyroid cancer is now the No. 1 cancer diagnosed and treated in that country. But, as Welch points out, the death rate hasn’t dropped one iota there, either. (Meanwhile, the number of people with permanent complications from thyroid surgery has skyrocketed.) It’s all over-diagnosis. We’re just catching turtles.

Every cancer has a different ratio of rabbits, turtles, and birds, which makes the story enormously complicated. A recent review concludes that, depending on the organ involved, anywhere from fifteen to seventy-five per cent of cancers found are indolent tumors—turtles—that have stopped growing or are growing too slowly to be life-threatening. Cervical and colon cancers are rarely indolent; screening and early treatment have been associated with a notable reduction in deaths from those cancers. Prostate and breast cancers are more like thyroid cancers. Imaging tends to uncover a substantial reservoir of indolent disease and relatively few rabbit-like cancers that are life-threatening but treatable.

We now have a vast and costly health-care industry devoted to finding and responding to turtles. Our ever more sensitive technologies turn up more and more abnormalities—cancers, clogged arteries, damaged-looking knees and backs—that aren’t actually causing problems and never will. And then we doctors try to fix them, even though the result is often more harm than good.

The forces that have led to a global epidemic of overtesting, overdiagnosis, and overtreatment are easy to grasp. Doctors get paid for doing more, not less. We’re more afraid of doing too little than of doing too much. And patients often feel the same way. They’re likely to be grateful for the extra test done in the name of “being thorough”—and then for the procedure to address what’s found. Mrs. E. was such a patient.

Mrs. E. had a turtle. She would have been better off if we’d never monitored her thyroid in the first place. But, now that we’d found something abnormal, she couldn’t imagine just keeping an eye on it. She wanted to take her chances with surgery.

The main way we’ve tried to stop unnecessary treatments has been through policing by insurers: they could refuse to pay for anything that looked like inappropriate care, whether it was an emergency-room visit, an MRI scan, or an operation. And it worked. During the nineteen-nineties, the “Mother, may I?” strategy flattened health-care costs. But it also provoked a backlash. Faceless corporate bureaucrats second-guessing medical decisions from afar created an infuriating amount of hassle for physicians and patients trying to orchestrate necessary care—and sometimes led to outrageous mistakes. Insurance executives were accused of killing people. Facing a public outcry, they backed off, and health-care costs resumed their climb. A decade and a half later, however, more interesting approaches have emerged.

Consider the case of Michael Taylor. A six-foot-tall, fifty-five-year-old optician from Ogden, Utah, Taylor threw his back out a year ago, while pulling weeds from his lawn. When he tried to straighten up, pain bolted from his lower back through his hips and down both thighs. He made his stooped way up his front-porch steps, into his house, and called his wife, Sandy, at work.

“For him to call meant it was really bad,” she said later.

Taylor was a stoic guy who had had back issues for a long time. By his early thirties, he had already undergone two spine operations: the fusion of a vertebra in his neck, which was fractured in a car accident, and the removal of a ruptured disk in his lower back that had damaged a nerve root, causing a foot drop—his left foot slapped when he walked. He’d had periodic trouble with back spasms ever since. For the most part, he managed them through stretches and exercise. He had been a martial artist since the age of thirteen—he’d earned a third-degree black belt—and retained tremendous flexibility. He could still do splits. Occasionally, if an attack was bad, he saw a pain specialist and got a spinal injection of steroids, which usually worked for a while. This episode, however, was worse than any before.

“He could hardly walk,” Sandy said. He tried sleeping in a recliner and waiting out the pain. But it didn’t go away. He called his primary-care physician, who ordered an MRI. It showed degenerative disk disease in his lumbar spine—a bulge or narrowing of disk space between two of the vertebrae in his lower back. The doctor prescribed muscle relaxants and pain medications, and said that Taylor might need spinal surgery. She referred him to a local neurosurgeon.

Taylor put off making the appointment. He did his lower-back stretches and range-of-motion exercises, and worked on losing weight. These measures helped a little, but he still couldn’t sleep in his bed or manage more than a shuffling walk. After four weeks with no improvement, he finally went to see the surgeon, who recommended fusing Taylor’s spine where his disk was bulging. Taylor would lose some mobility—his days of spinning kicks were over—and success was not guaranteed, but the doctor thought that it was the best option.

“He said the surgery would be, like, a fifty-fifty thing,” Taylor recalled. “Half of people would see great success. The other half would see little or no difference. And there’d be a few who find it makes the pain worse.” There was also the matter of cost. The vision center he managed was in a Walmart superstore, and the co-payments and deductibles with the company insurance plan were substantial. His bills were likely to run past a thousand dollars.

But Taylor had heard about a program that Walmart had launched for employees undergoing spine, heart, or transplant procedures. Employees would have no out-of-pocket costs at all if they got the procedure at one of six chosen “centers of excellence”: the Cleveland Clinic; the Mayo Clinic; Virginia Mason Medical Center, in Washington; Scott and White Memorial Hospital, in Texas; Geisinger Medical Center, in Pennsylvania; and Mercy Hospital Springfield, in Missouri. Taylor learned that the designated spine center for his region was Virginia Mason, in Seattle. He used to live in Washington, and the back surgery he’d had when he was younger was at the same hospital. He trusted the place, and it had a good reputation. He decided to proceed.

The program connected him to the hospital, and its staff took care of everything from there. They set up his appointments and arranged the travel for him and his wife. All expenses were covered, even their food and hotel costs.

“They flew us from Salt Lake City and picked us up at the airport in a town car,” Taylor said. He said he felt like royalty.

Walmart wasn’t providing this benefit out of the goodness of its corporate heart, of course. It was hoping that employees would get better surgical results, sure, but also that the company would save money. Spine, heart, and transplant procedures are among the most expensive in medicine, running from tens of thousands to hundreds of thousands of dollars. Nationwide, we spend more money on spinal fusions, for instance, than on any other operation—thirteen billion dollars in 2011. And if there are complications the costs of the procedure go up further. The medical and disability costs can be enormous, especially if an employee is left permanently unable to return to work. These six centers had notably low complication rates and provided Walmart a fixed, package price.

Two years into the program, an unexpected pattern is emerging: the biggest savings and improvements in care are coming from avoiding procedures that shouldn’t be done in the first place. Before the participating hospitals operate, their doctors conduct their own evaluation. And, according to Sally Welborn, the senior vice-president for benefits at Walmart, those doctors are finding that around thirty per cent of the spinal procedures that employees were told they needed are inappropriate. Dr. Charles Nussbaum, until recently the head of neurosurgery at Virginia Mason Medical Center, confirmed that large numbers of the patients sent to his hospital for spine surgery do not meet its criteria.

Michael Taylor was one of those patients. Disk disease like the kind seen on his MRI is exceedingly common. Studies of adults with no back pain find that half or more have degenerative disk disease on imaging. Disk disease is a turtle—an abnormality that generally causes no harm. It’s different when a diseased disk compresses the spinal cord or nerve root enough to cause specific symptoms, such as pain or weakness along the affected nerve’s territory, typically the leg or the arm. In those situations, surgery is proved to be more effective than nonsurgical treatment. For someone without such symptoms, though, there is no evidence that surgery helps to reduce pain or to prevent problems. One study found that between 1997 and 2005 national health-care expenditures for back-pain patients increased by nearly two-thirds, yet population surveys revealed no improvement in the level of back pain reported by patients.

There are gray-zone cases, but Taylor’s case was straightforward. Nussbaum said that Taylor’s MRI showed no disk abnormality compressing his spinal cord or nerve root. He had no new leg or foot weakness. His pain went down both legs and not past the knee, which didn’t fit with disk disease. The symptoms were consistent with muscle spasms or chronic nerve sensitivity resulting from his previous injuries. Fusing Taylor’s spine—locking two vertebrae together with bolts and screws—wouldn’t fix these problems. At best, it would stop him from bending where it hurt, but that was like wiring a person’s jaw shut because his tooth hurts when he chews. Fusing the spine also increases the load on the disks above and below the level of fusion, making future back problems significantly more likely. And that’s if things go well. Nussbaum recommended against the surgery.https://8cda257c87e858baee5380cc65ab1ba3.safeframe.googlesyndication.com/safeframe/1-0-37/html/container.htmlADVERTISEMENT

This was not what Taylor’s wife wanted to hear. Had they come all this way for nothing? “I got kind of angry,” Sandy told me later. She wanted his back problem solved.

He did, too. But he was relieved to hear that he wouldn’t have to undergo another back operation. Nussbaum’s explanations made sense to him, and he had never liked the idea of having his spine fused. Moreover, unlike most places, the Virginia Mason spine center had him seen not only by a surgeon but also by a rehabilitation-medicine specialist, who suggested a nonsurgical approach: a spinal injection that afternoon, continued back exercises, and a medication specifically for neuropathic pain—chronic nerve sensitivity.

“Within a couple of weeks, I was literally pain free,” Taylor said. It was six months after his visit to Seattle, and he could do things he hadn’t been able to do in decades.

“I was just amazed,” Sandy said. “The longer it’s been, the better he is.”

If an insurer had simply decreed Taylor’s back surgery to be unnecessary, and denied coverage, the Taylors would have been outraged. But the worst part is that he would not have got better. It isn’t enough to eliminate unnecessary care. It has to be replaced with necessary care. And that is the hidden harm: unnecessary care often crowds out necessary care, particularly when the necessary care is less remunerative. Walmart, of all places, is showing one way to take action against no-value care—rewarding the doctors and systems that do a better job and the patients who seek them out.

Six years ago, in “The Cost Conundrum,” I compared McAllen with another Texas border town, El Paso. They had the same demographics—the same levels of severe poverty, poor health, illegal immigration—but El Paso had half the per-capita Medicare costs and the same or better results. The difference was that McAllen’s doctors were ordering more of almost everything—diagnostic testing, hospital admissions, procedures. Medicare patients in McAllen received forty per cent more surgery, almost twice as many bladder scopes and heart studies, and two to three times as many pacemakers, cardiac bypass operations, carotid endarterectomies, and coronary stents. Per-capita spending on home-health services was five times higher than in El Paso and more than half of what many American communities spent on all health care. The amount of unnecessary care appeared to be huge.

What explained this? Our piecework payment system—rewarding doctors for the quantity of care provided, regardless of the results—was a key factor. The system gives ample reward for overtreatment and no reward for eliminating it. But these inducements applied everywhere. Why did McAllen succumb to them more than other medical communities did? Doctors there described a profit-maximizing medical culture. Specialists not only made money from the services they provided; many also owned stakes in home-health-care agencies, surgery and imaging centers, and the local for-profit hospital, which brought them even bigger returns from health-care overuse.

The test of health-care reform, I wrote, was whether McAllen or El Paso would become the new norm. Would McAllen’s costs come down or El Paso’s go up? Now that it has been five years since the passage of the Affordable Care Act, I thought I’d find out. I returned to the economist Jonathan Skinner, of the Dartmouth Institute for Health Policy and Clinical Practice, who had provided the earlier analysis of the Medicare data, and worked with him to get a sense of what recent data reveal. As it turns out, the cost of a Medicare patient has flattened across the country, El Paso included. U.S. health-care inflation is the lowest it has been in more than fifty years. Most startling of all, McAllen has been changing its ways. Between 2009 and 2012, its costs dropped almost three thousand dollars per Medicare recipient. Skinner projects the total savings to taxpayers to have reached almost half a billion dollars by the end of 2014. The hope of reform had been to simply “bend the curve.” This was savings on an unprecedented scale.

Skinner showed me the details. In-patient hospital visits dropped by about ten per cent—and physicians reduced the mad amounts of home-health-care spending by nearly forty per cent. McAllen’s spending on ambulance rides—previously the highest in the country—dropped by almost forty per cent, too.

I followed up with doctors there to find out how this had happened. I started with Lester Dyke, a cardiac surgeon who was one of many doctors troubled by what they were seeing, but the only one to let me quote him by name in my McAllen piece. (“Medicine has become a pig trough here,” he had told me. “We took a wrong turn when doctors stopped being doctors and became businessmen.”) After it was published, television crews descended on the town. Texas newspapers did follow-up investigations.

“The reaction here was fierce, just a tremendous amount of finger-pointing and yelling and screaming,” Dyke recently told me. The piece infuriated the local medical community, which felt unfairly singled out. And Dyke paid a steep price: “I became persona non grata overnight.” Colleagues said that he would be to blame if they lost money. Cardiologists stopped sending him patients. “My cases went down by ninety per cent,” he told me. He had to give up his practice at Doctors Hospital at Renaissance, the for-profit hospital, after it became clear that he wasn’t welcome there, but he was able to continue doing some surgery at two other hospitals. When I talked to Dyke in the first months afterward, he’d sounded low. The few friends who voiced support didn’t want to be seen in public with him. He thought he might be forced to retire.

Yet he insisted that he had no regrets. Two of his children went into medicine, and in a medical-ethics class his son was assigned the article. The professor asked whether he was related to the Dr. Dyke quoted in it.

“Yes, I am,” he said proudly. “That’s my crazy dad.”

“I don’t think you often get a chance in life to stand up to all the badness,” Dyke told me.

With time, the anger of colleagues subsided. Many of them resumed sending him patients. Within a couple of years, he was back to an annual caseload of three hundred open-heart operations. Meanwhile, it got harder for McAllen physicians to ignore the evidence about unnecessary care. Several federal prosecutions cracked down on outright fraud. Seven doctors agreed to a twenty-eight-million-dollar settlement for taking illegal kickbacks when they referred their patients to specialty medical services. An ambulance-company owner was indicted for reporting six hundred and twenty-one ambulance rides that allegedly never happened. Four clinic operators were sent to jail for billing more than thirteen thousand visits and procedures under the name of a physician with dementia. The prosecutions involved only a tiny fraction of the medical community. But Dyke thought it led doctors to say to themselves, “Hey, we’re under the magnifying glass. We need to make sure we’re doing things strictly by the book.”

Jose Peña, an internist, was a board member at Doctors Hospital at Renaissance in 2009. When we spoke recently, he didn’t hesitate to tell me the immediate reaction his colleagues had to what I’d written. “We hated you,” he said. The story “put us in a spotlight, in a bad way,” but, he added, “in a good way at the same time.” They hadn’t known that they were one of the most expensive communities in the country, he maintained. They knew there were problems, “but we did not know the magnitude.” His hospital did its own analysis of the data and reluctantly came to the same conclusion that the article did: inappropriate and unnecessary care was a serious problem.

The major overuse of home-health-care services proved particularly embarrassing. “We didn’t know that home health was a thousand dollars a month” for each patient, Peña said. People in the medical community had never paid attention to how much of it they were ordering or how little of it was really needed. He led monthly staff meetings with more than four hundred local physicians and began encouraging them to be more mindful about signing home-health-care orders. Within a year, home-health-care agencies started going out of business.

But more interesting was how broad and enduring the cost decline has been. E.R. visits, hospital admissions, tests, and procedures all fell from the Texas stratosphere. And, years after the attention and embarrassment had passed, the costs continued to fall. Bad publicity, a few prosecutions, and some stiffened regulatory requirements here and there couldn’t explain that. I probed for months, talking to local doctors and poring over data. And I’ve come to think that a major reason for the change may be a collection of primary-care doctors who don’t even seem to recognize the impact of what they’ve been doing.

Armando Osio is a sixty-three-year-old family physician in McAllen. In 2009, when the article came out, he did not own part of an imaging center or sleep-testing center or hospital or any other medical money-making venture. He didn’t have any procedures or tests that he made big money from. He was just a primary-care doctor doing what primary-care doctors do—seeing patient after patient every twenty to thirty minutes, for about sixty dollars a visit. That’s what Medicare paid; private insurance paid more, and Medicaid or the uninsured paid less. He earned nothing like the income of the specialists that I’d written about.

Then, later that year, officials at a large medical group called WellMed contacted Osio. They wanted to establish a practice in McAllen, catering to Medicare patients, and asked whether he’d join them. WellMed had contracted with Medicare H.M.O. plans to control their costs. Its pitch to clinicians was that, if a doctor improved the quality of care, this would save on costs, and WellMed would share those savings with the doctor in the form of bonuses. That meant Osio would have to see fewer patients, for longer visits, but WellMed assured him that, if he could show measurable quality improvements, he’d actually make more money.

Osio was skeptical, but he agreed to see some of WellMed’s patients. When he was in training, he’d been interested in geriatrics and preventive medicine. In practice, he hadn’t had time to use those skills. Now he could. With WellMed’s help, Osio brought on a physician assistant and other staff to help with less complex patients. He focussed on the sicker, often poorer patients, and he found that his work became more satisfying. With the bonuses for higher patient satisfaction, reducing hospital admissions, and lowering cardiology costs, his income went up. This was the way he wanted to practice—being rewarded for doing right rather than for the disheartening business of churning through more and more people. Within a year, he’d switched his practice so that he was seeing almost entirely WellMed patients.

He gave me an example of one. That day, he’d seen an elderly man who had taken a bad spill two or three weeks earlier, resulting in a contused kidney and a compression fracture of his lower spine. After a couple of days in the hospital, he’d been sent home. But the pain remained unmanageable. He called Osio’s office seeking help.

If the man had called five years ago, a receptionist would have told him that the schedule was full for days and sent him to an emergency room. There, he would have waited hours, been seen by someone who didn’t know his story, been given a repeat CT or MRI, and then likely have been kept for another hospital stay. Once the doctors were sure that the situation wasn’t dangerous, he would finally have been sent home, with pain medicine and instructions to see his primary-care doctor. Cost: a few thousand dollars.ADVERTISEMENT

Now when the man called, the receptionist slotted him to see Osio that afternoon. The doctor examined him and, being familiar with his case, determined that he had no worsening signs requiring imaging. He counselled patience and offered reassurance, gave him pain medication, and sent him home, with a plan for his nurse to check on him the next day. Cost: at most, a hundred dollars. And the patient got swifter, better care.

I spoke to Carlos Hernandez, an internist and the president of WellMed. He explained that the medical group was founded twenty-five years ago, in San Antonio, by a geriatrician who believed that what the oldest and sickest most needed in our hyper-specialized medical system was slower, more dedicated primary care. “Our philosophy is that the primary-care physician and patient should become the hub of the entire health-care-delivery system,” Hernandez said. He viewed the primary-care doctor as a kind of contractor for patients, reining in pointless testing, procedures, and emergency-room visits, coördinating treatment, and helping to find specialists who practice thoughtfully and effectively. Our technology- and specialty-intensive health system has resisted this kind of role, but countries that have higher proportions of general practitioners have better medical outcomes, better patient experiences, and, according to a European study, lower cost growth. WellMed found insurers who saw these advantages and were willing to pay for this model of care. Today, WellMed has more than a hundred clinics, fifteen hundred primary-care doctors, and around a quarter of a million patients across Texas and Florida.

There’s a reason that WellMed focussed on these two states. They are among the nation’s most expensive states for Medicare and are less well-supplied with primary care. An independent 2011 analysis of the company’s Texas clinics found that, although the patient population they drew from tended to be less healthy than the over-all Medicare population (being older and having higher rates of diabetes and chronic lung disease, for instance), their death rates were half of the Texas average.

This last part puzzled me. I had started to recognize how unnecessary care could crowd out necessary care—but enough that dedicated primary care could cut death rates in half? That seemed hard to believe. As I learned more about how Dr. Osio’s practice had changed, though, I began to grasp how it could happen.

He told me, for instance, about a new patient he’d seen, a sixty-five-year-old man with diabetes. His blood-sugar level was dangerously high, at a level that can signify a full-blown diabetic crisis, with severe dehydration, rising acid levels in the blood, and a risk of death. The man didn’t look ill, though. His vital signs were normal. Osio ordered a urine test, which confirmed that the man was not in crisis. That was, in a way, a bad sign. It meant that his diabetes was so out of control that his body had developed a tolerance to big spikes in blood sugar. Unchecked, his diabetes would eventually cause something terrible—kidney failure, a heart attack, blindness, or the kind of wound-healing problem that leads to amputation.

Previously, Osio would not have had the time or the resources to do much for the man. So he would have sent him to the hospital. The staff there would have done a battery of tests to confirm what Osio already knew—that his blood sugar was way too high. They would have admitted him, given him insulin, and brought his blood sugar down to normal. And that would have been about it. The thousands of dollars spent on the hospital admission would have masked a galling reality: no one was addressing the man’s core medical problem, which was that he had a chronic and deadly disease that remained dangerously out of control.

But now WellMed gave Osio bonuses if his patients’ diabetes was under better control, and helped him to develop a system for achieving this. Osio spent three-quarters of an hour with the man, going over his pill bottles and getting him to explain what he understood about his condition and how to treat it. The man was a blue-collar worker with limited schooling, and Osio discovered that he had some critical misunderstandings. For instance, although he checked his blood-sugar level every day, he wrongly believed that if the level was normal he didn’t need to take his medicine. No, Osio told him; his diabetes medication was like his blood-pressure medication—he should never skip a dose unless the home measurements were too low.

Osio explained what diabetes is, how dangerous it can be, how insulin works. Then he turned the man over to an office nurse who had taken classes to become certified as a diabetes educator. She spent another forty-five minutes having him practice how to draw up and take his insulin, and how to track his sugar levels in a logbook. She set a plan to call him every other day for a week and then, if necessary, bring him back for another review. This would continue until his disease was demonstrably under control. After that, she’d check on him once a month by phone, and Osio would see him every three to four months. The nurse gave him her direct phone number. If he had any problems or questions, she told him, “Llámame”—call me.

Step by deliberate step, Osio and his team were replacing unnecessary care with the care that people needed. Since 2009, in Hidalgo County, where McAllen is situated, WellMed has contracted with physicians taking care of around fourteen thousand Medicare patients. According to its data, the local WellMed practices have achieved the same results as WellMed has elsewhere: large reductions in overuse of care and better outcomes for patients. Indeed, for the past two years, the top-ranked primary-care doctor out of WellMed’s fifteen hundred—according to a wide range of quality measures, such as the percentage of patients with well-controlled blood pressure and diabetes, rates of emergency-room visits and hospital readmissions, and levels of patient satisfaction—has been a McAllen physician.

I spoke to that doctor, Omar Gomez. He said that he’d set about building a strong team around his patients, and that team included specialists such as cardiologists and surgeons. He encouraged his patients to shift to the ones who, he noticed, didn’t subject them to no-value care. He sat with the specialists, and, he said, “I told them, ‘If my patient needs a cardiac cath—by all means, do it. But if they don’t, then don’t do it. That’s the only thing I ask.’ ”

The passage of the Affordable Care Act, in 2010, created opportunities for physicians to practice this kind of dedicated care. The law allows any group of physicians with five thousand or more Medicare patients to contract directly with the government as an “accountable-care organization,” and to receive up to sixty per cent of any savings they produce. In McAllen, two primary-care groups, with a total of nearly thirteen thousand patients, formed to take advantage of the deal. One, as it happens, was led by Jose Peña, the Doctors Hospital at Renaissance internist. Two years later, Medicare reported that Peña’s team had markedly improved control of its patients’ diabetes; patients also had dramatically lower emergency-room visits and hospital admissions. And the two McAllen accountable-care organizations together managed to save Medicare a total of twenty-six million dollars. About sixty per cent of that went back to the groups. It wasn’t all profit—achieving the results had meant installing expensive data-tracking systems and hiring extra staff. But even after overhead doctors in one group took home almost eight hundred thousand dollars each (some of which they shared with their mid-level staff). It was proving to be a very attractive way to practice.

McAllen, in large part because of changes led by primary-care doctors, has gone from a cautionary tale to something more hopeful. Nationwide, the picture is changing almost as fast. Just five years after the passage of health-care reform, twenty per cent of Medicare payments are being made to physicians who have enrolled in alternative-payment programs, whether through accountable-care organizations like those in McAllen or by accepting Walmart-like packaged-price care—known as bundled payment—for spine surgery, joint surgery, and other high-cost procedures. If government targets are met, these numbers will reach thirty per cent of Medicare payments by 2016. A growing number of businesses are also extending the centers-of-excellence approach to their employees, including Boeing, Kohl’s, Lowe’s, and PepsiCo. And a nonprofit in California, the Pacific Business Group on Health, now offers to provide a similar network to any health-care purchaser in the country.

Could a backlash arrive and halt the trend? It’s a concern. No one has yet invented a payment system that cannot be gamed. If doctors are rewarded for practicing more conservative medicine, some could end up stinting on care. What if Virginia Mason turns away a back-pain patient who should have gone to surgery? What if Dr. Osio fails to send a heart patient to the emergency room when he should have? What if I recommend not operating on a tiny tumor, saying that it is just a turtle, and it turns out to be a rabbit that bounds out of control?

Proponents point out that people can sue if they think they’ve been harmed, and doctors’ groups can lose their contracts for low-quality scores, which are posted on the Web. But not all quality can be measured. It’s possible that we will calibrate things wrongly, and skate past the point where conservative care becomes inadequate care. Then outrage over the billions of dollars in unnecessary stents and surgeries and scans will become outrage over necessary stents and surgeries and scans that were not performed.

Right now, we’re so wildly over the boundary line in the other direction that it’s hard to see how we could accept leaving health care the way it is. Waste is not just consuming a third of health-care spending; it’s costing people’s lives. As long as a more thoughtful, more measured style of medicine keeps improving outcomes, change should be easy to cheer for. Still, when it’s your turn to sit across from a doctor, in the white glare of a clinic, with your back aching, or your head throbbing, or a scan showing some small possible abnormality, what are you going to fear more—the prospect of doing too little or of doing too much?ADVERTISEMENT

Mrs. E., my patient with a five-millimetre thyroid nodule that I recommended leaving alone, feared doing too little. So one morning I took her to the operating room, opened her neck, and, in the course of an hour, removed her thyroid gland from its delicate nest of arteries and veins and critical nerves. Given that the surgery posed a greater likelihood of harm than of benefit, some people would argue that I shouldn’t have done it. I took her thyroid out because the idea of tracking a cancer over time filled her with dread, as it does many people. A decade from now, that may change. The idea that we are overdiagnosing and overtreating many diseases, including cancer, will surely become less contentious. That will make it easier to calm people’s worries. But the worries cannot be dismissed. Right now, even doctors are still coming to terms with the evidence.

Other people of a more consumerist bent will be troubled not that I gave her the choice but that she paid virtually none of the expenses incurred by it. The nature of her insurance coverage guaranteed that. Her employer had offered her two options. One was a plan with a high deductible and a medical savings account that would have made her pay a substantial portion of the many-thousand-dollar operation. And this might have made her think harder about proceeding (or, at least, encouraged her to find someone cheaper). But, like many people, she didn’t want to be in that situation. So she chose the second option, which provided full coverage for cases like this one. She found it difficult enough to weigh her fears of the cancer against her fears of the operation—with its risks of life-threatening bleeding and voice damage—without having to put finances into the equation.

Two hours after the surgery, Mrs. E.’s nurse called me urgently to see her in the recovery room. Her neck was swelling rapidly; she was bleeding. We rushed her back to the operating room and reopened her neck before accumulating blood cut off her airway. A small pumping artery had opened up in a thin band of muscle I’d cauterized. I tied the vessel off, washed the blood away, and took her back to the recovery room.

I saw her in my office a few weeks later, and was relieved to see she’d suffered no permanent harm. The black and blue of her neck was fading. Her voice was normal. And she hadn’t needed the pain medication I’d prescribed. I arranged for a blood test to check the level of her thyroid hormone, which she now had to take by pill for the rest of her life. Then I showed her the pathology report. She did have a thyroid cancer, a microcarcinoma about the size of this “O,” with no signs of unusual invasion or spread. I wished we had a better word for this than “cancer”—because what she had was not a danger to her life, and would almost certainly never have bothered her if it had not been caught on a scan.

All the same, she thanked me profusely for relieving her anxiety. I couldn’t help reflect on how that anxiety had been created. The medical system had done what it so often does: performed tests, unnecessarily, to reveal problems that aren’t quite problems to then be fixed, unnecessarily, at great expense and no little risk. Meanwhile, we avoid taking adequate care of the biggest problems that people face—problems like diabetes, high blood pressure, or any number of less technologically intensive conditions. An entire health-care system has been devoted to this game. Yet we’re finally seeing evidence that the system can change—even in the most expensive places for health care in the country. ♦Published in the print edition of the May 11, 2015, issue.

Source: The New yorker
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Atul Gawande is a surgeon, a public-health researcher, and the chairman of the health-care venture Haven. His four books include “Being Mortal” and “The Checklist Manifesto.”

What did you learn from this article? What is your prospective as a patient? Why?

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GP stalked patient after accessing her medical records to get phone number, tribunal hears

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14 JANUARY 2019 • 12:25PM 

AGP was accused of stalking a patient after accessing her medical records so he could obtain her mobile phone number, a medical tribunal heard.

Dr Chika Mbah, 37, allegedly sent a stream of WhatsApp messages asking the woman out for a date and turned up once outside her home after signing her off work for work-related stress.

The woman repeatedly declined his invitation but father-of-two Mbah, who called himself ‘Dr Sandy’, kept calling her and left messages saying: “How are you stranger? – don’t you remember, it’s me, Dr Sandy?,’ the tribunal heard.

The patient, who was not named and known as Patient A, was grieving at the time Mbah contacted her following the death of her grandparent. 

She was said to be so uncomfortable as a result of his advances that she refused to attend his surgery for an urgent check up over a stomach problem.

Mbah was suspended from medical practice for three months after he was found guilty of misconduct when he admitted pursuing an improper relationship with the patient. 

But he denied allegations of illicitly accessing her medical records and the panel found no evidence of “any predatory behaviour”.

In a statement read out at the Medical Practitioners Tribunal Service in Manchester, the woman said: “During many messages, he asked me out for a drink which I did not go to and I received the odd phone call for a chat.

Health care fraud comes in many forms. Would you recognize it if you saw it? What does it look like? What are the costs?

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Yes, Google’s using your healthcare data – and it’s not alone

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There’s a multi-billion dollar industry built around collecting healthcare data and anonymizing it so it can be used for research; it’s perfectly legal.

Source: Computer World
By Lucas Mearian
Senior Reporter, Computerworld | NOV 15, 2019 9:49 AM PST
Featured Photo Source: Unsplash, Mitchell Luo

Google is working with one of the largest healthcare systems in the U.S. to collect patient data on millions of Americans in 21 states and across 2,600 hospitals or clinics in order to analyze it and come up with advice for better patient care and cost cutting measures.

The project was reportedly revealed by a whistleblower who said the program, dubbed “Project Nightingale,” involved Ascension – the largest Catholic health system in the world – and up to 50 million private medical records from healthcare providers.

It wasn’t Google’s only public controversy this week. Shortly after its deal with Ascension became public, The Washington Post reported that the National Institutes of Health (NIH) stopped the tech giant from posting more than 100,000 human chest x-rays.

Although the x-rays were part of a 2017 joint project with the NIH, the government agency discovered some of the images contained personally identifiable information of patients.

As for its deal with Ascension, Google said it had revealed plans to use its cloud data analytics to cull information from Ascension’s patient data during a Q2 earnings call in July, though “Project Nightingale” was never mentioned during that call. “We announced ‘Google Cloud’s AI and ML solutions are helping healthcare organizations like Ascension improve the healthcare experience and outcomes,'” Google Cloud President Tariq Shaukat said in a blog post.

“Our work with Ascension is exactly that – a business arrangement to help a provider with the latest technology, similar to the work we do with dozens of other healthcare providers, Shaukat wrote. The list of care providers and healthcare records tech  companies includes the Cleveland Clinic, the American Cancer Society, McKesson and Athena.

Shaukat said Google has a Business Associate Agreement (BAA) with Ascension, which governs access to Protected Health Information (PHI) for the purpose of helping providers support patient care.

“This is standard practice in healthcare, as patient data is frequently managed in electronic systems that nurses and doctors widely use to deliver patient care,” Shaukat said.

No matter how well intentioned the project’s overseers say it is, the collection of private medical data has raised the ire of patients and lawmakers who have called for a federal inquiry into the practice.

The Office for Civil Rights in the Department of Health and Human Services “will seek to learn more information about this mass collection of individuals’ medical records to ensure that HIPAA protections were fully implemented,” the office’s director, Roger Severino, said in a statement.

Third parties compiling patient data is not only common among healthcare providers and analytics tech firms, it’s perfectly legal – as long as patients have given consent by signing a common HIPAA form. And, wittingly or not, most have done so, according to Cynthia Burghard, a research director at IDC.

“Databases of this size are not uncommon,” Burghard said. “On face value, I don’t see an issue. They [Google] signed the HIPAA compliant document for business associate arrangements. So, they complied with the law there. When you go to a healthcare provider’s office as a patient, you sign a HIPAA release form, which allows the institutions to use your data for medical research or improved care management; so there is patient consent there.

“That said, long term can you trust Google or any high-tech company … who’s used to monetizing assets to not do something bad?” Burghard said.

Many healthcare providers are storing patient data for analytics purposes in a cloud somewhere, whether it’s Amazon Web Services, Microsoft’s Azure or Google Cloud.

In September, controversy around patient privacy erupted when Google acquired the health division of London-based AI firm DeepMind, which built a healthcare app used to give clinicians at National Health Service [NHS] hospitals easy access to medical records. DeepMind’s Streams app was already controversial after a UK privacy watchdog found the NHS had illegally handed 1.6 million patient records to DeepMind as part of a trial.

Last year, Amazon, JPMorgan and Berkshire formed a partnership to create a private healthcare company aimed at lowering the cost of care.

According to Adam Tanner, author of the book “Our Bodies, Our Data: How Companies Make Billions Selling Our Medical Records,” businesses that have nothing to do with medical treatment are allowed to buy and sell healthcare data, provided they remove certain fields of information, including birth date, name and Social Security number.

The guidelines, outlined in U.S. HIPAA rules, have allowed a multi-billion-dollar market  in anonymized patient data to emerge in recent years, with data-mining firms collecting dossiers on hundreds of millions of patients, according to Tanner. A growing number of data scientists and healthcare experts say the same computing advances that allow the aggregation of millions of anonymized patient files into a dossier also make it increasingly possible to re-identify those files — that is, to match identities to patients.

An earlier study by Carnegie Mellon University showed how anonymized U.S. Census data could uniquely, or nearly uniquely, identify some individuals simply by combining a few characteristics found in populations.

“Clearly, data released containing such information about these individuals should not be considered anonymous. Yet, health and other person-specific data are publicly available in this form,” said Latanya Sweeney, the report author and director of the Data Privacy Lab at Carnegie Mellon University.

The healthcare information, stripped of basic personal identifiers is sold off to researchers, drug developers, marketers and others. Medical informatics companies, such as Iqvia (IMS Health), Optum, and Symphony Health reap the profits of selling the healthcare data while the people from whom it’s collected have no control over how it’s used. Nor do they get any compensation for it.

Last year, start-up Hu-manity.co partnered with IBM to develop a blockchain-based electronic ledger that gives consumers the cryptographic key to their personal data, even allowing patients or others to control the specific purpose for which it’s used, while also allowing them to eventually profit from it.

In 2015, IBM launched its Watson Health global analytics cloud to enable healthcare providers and researchers to upload and analyze patient data for greater insights into trends and to “improve individual and overall patient outcomes.” The next year, IBM bought Truven Health Analytics for $2.6 billion, adding a trove of previously amassed patient data to its collection. It was IBM’s fourth major health data-related acquisition since launching the Watson Health unit.

At the time of the Truven buyout, IBM Health announced it had healthcare data on “approximately 300 million patient lives,” most from the U.S.

When IBM bought Truven, it got tens of millions of records and years of [health insurance] claims data “they could monetize by selling analysis and reports and access to your claims data,” Burghard said.

In the same way, Google’s cloud analytics platform uses AI and machine learning to process patient data and deliver potential best practices for care and cost savings.

Amazon, Apple, Microsoft and other tech giants are also entering the healthcare arena, either with applications that enable access to patient electronic healthcare records, or with their own in-house healthcare programs.

Earlier this year, pharmacy giant CVS and its healthcare insurance subsidiary, Aetna, released an app that lets members opt-in to sharing their EMRS with Apple’s health service; in turn, Apple will offer Apple Watch wearers personalized fitness and health goals.Related: 

Senior Reporter Lucas Mearian covers financial services IT (including blockchain), healthcare IT and enterprise mobile issues (including mobility management, security, hardware and apps).Follow

Copyright © 2019 IDG Communications, Inc.

Should health care providers disclose and ask how you would like your health care information shared? What do you think about your health care information being monetized? What do you think about your health care information being used without your permission.

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Patients voice concerns after Chesapeake doctor arrested for health care fraud

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Source: WAVY News 10 | 11-09
Featured Photo Source: Unsplash, Sharon Mccutcheon

CHESAPEAKE, Va. (WAVY) — A Chesapeake doctor was arrested on Friday for alleged health care fraud and false statements related to health care matters. Court documents say the Federal Bureau of Investigation started investigating 69-year-old Javaid Perwaiz in September 2018, when they received a tip from a hospital employee who suspected he was performing unnecessary surgeries on unsuspecting patients.

Would you recognize health care fraud if you saw it? Would you know if you were taking unnecessary medicine or had an unnecessary procedure? What would it look like?

Share your comments with the community by posting them below. Share the wealth of health with your friends and family by sharing this article with 3 people today. As always you are the best part of what we do. Keep sharing!

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Psychiatrist Sentenced to Prison for Healthcare Fraud Scheme – Norfolk, VA

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FOR IMMEDIATE RELEASE Thursday, January 16, 2020

Source: US Department of Justice
NORFOLK, Va. – A Virginia Beach doctor was sentenced today to 27 months in prison for defrauding Medicare, Medicaid, and Tricare, and other health care benefits programs out of hundreds of thousands of dollars.

Additionally, Udaya K. Shetty, 64, agreed to pay over $1 million to settle related civil claims.

According to court documents, was a licensed psychiatrist practicing medicine at his own practice, Behavioral & Neuropsychiatric Group. Beginning in 2013, Shetty created a scheme by which he could overbill healthcare benefit programs by seeing patients for only five to 10 minutes, but then billing for services that were on average 41 to 63 minutes long. Shetty instructed his staff to often double, triple, or even quadruple book appointment times. The fraud became apparent when investigators discovered that on dozens of instances Shetty would need more than 24 hours a day of working to perform the services for which he billed. 

In 2017, Shetty closed his own practice and joined another psychiatric practice, Quietly Radiant Psychiatric Services. While there Shetty, and one of his former employees, Mary Otto, engaged in a similar scheme. Although other Quietly Radiant staff members were responsible for billing, Shetty directed Otto to access the billing system and change all of his billing data to a higher billing rate.  Otto complied and changed the data without the knowledge of Quietly Radiant’s staff. As a result of their actions, Shetty and Otto defrauded various healthcare benefit programs of more than $450,000. Otto pled guilty for her role in the scheme and was sentenced to 15 months in prison on January 10.

In regards to the civil settlement, Shetty agreed to pay $1,078,000 to the United States and the Commonwealth of Virginia to resolve his liability under the False Claims Act and the Virginia Fraud Against Taxpayers Act for submitting or causing the submission of false claims to the Medicare, Medicaid, and TRICARE programs.

G. Zachary Terwilliger, U.S. Attorney for the Eastern District of Virginia; Martin Culbreth, Special Agent in Charge of the FBI’s Norfolk Field Office; Robert E. Craig, Special Agent in Charge for the Defense Criminal Investigative Service’s (DCIS) Mid-Atlantic Field Office; Maureen R. Dixon, Special Agent in Charge of the Office of Inspector General for the U.S. Department of Health and Human Services (HHS); and Mark R. Herring, Attorney General of Virginia, made the announcement after sentencing by U.S. District Judge Rebecca Beach Smith. Assistant U.S. Attorney Joseph L. Kosky prosecuted the criminal case. Assistant U.S. Attorney Clare P. Wuerker handled the civil case.

A copy of this press release is located on the website of the U.S. Attorney’s Office for the Eastern District of Virginia. Related court documents and information are located on the website of the District Court for the Eastern District of Virginia or on PACER by searching for Case No. 2:19-cr-089.

Some patients often start off with private health care and end up with Medicaid, Medicare or Tricare because these government health insurance or more advantageous for those medical ‘professionals’ seeking to defraud patients and insurance providers. Would you recognize health care fraud if you see it? What does it look like? Have you been a victim of health care fraud?

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HHS Turning up the HEAT on Healthcare Fraud Charges

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Source: Policy Med

HEALTHCARE REFORMHHS-OIG By Thomas Sullivan Last Updated May 5, 2018

Since the health care reform debate began almost two years ago, the Obama Administration has identified fighting fraud committed against public health care programs as a top priority. Both the Recovery Act and Affordable Care Act include significant provisions to fight health care fraud. Among many other changes, the ACA amended the False Claims Act’s public disclosure provision and strengthened the provisions of the federal health care Anti-Kickback Statute.

One of the main reasons for this is because the Obama Administration largely asserted during the debate that significant reductions in health care fraud and abuse could help pay for part of the health care reform legislation.

These goals were further expressed in President Obama’s FY 2011 budget, which included $561 million in discretionary resources to the Department of Health and Human Services (HHS), an increase of $250 million. HHS Secretary Kathleen Sebelius acknowledged that this increase would strengthen the Medicare and Medicaid program integrity activities, with a particular emphasis on fighting health care fraud in the field, increasing Medicaid audits, and strengthening program oversight while reducing costs. 

Such an investment against fraud and abuse claims to help save $9.9 billion over ten years. According to HHS, the additional funding will better equip the Federal government to minimize inappropriate payments, pinpoint potential weaknesses in program integrity oversight, target emerging fraud schemes by provider and type of service, and establish safeguards to correct programmatic vulnerabilities.

Additionally, the HHS budget will install a set of new program integrity proposals that will give HHS the necessary tools to fight fraud by enhancing provider enrollment scrutiny, increasing claims oversight, improving Medicare’s data analysis capabilities, and reducing over-utilization of Medicaid prescription drugs. These proposals will claim to save approximately $14.7 billion over 10 years.

Consequently, the Department of Justice (DOJ) has been busy trying to reach that goal, securing more than $3 billion in civil settlements and judgments in cases involving fraud against the government in the fiscal year ending Sept. 30, 2010. Announcing this accomplishment, Tony West, Assistant Attorney General for the Civil Division, announced in a press release that this total includes $2.5 billion in health care fraud recoveries—the largest in history—and represents the second largest annual recovery of civil fraud claims.

West also mentioned that the amounts recovered under the False Claims Act since January 2009 have eclipsed any previous two-year period with $5.4 billion in taxpayer dollars returned to federal programs and the Treasury. Of that total, $4.6 billion were under the False Claims Act from health care providers and others in the industry, a two-year health care fraud record. DOJ also secured 25 criminal convictions. Since 1986, when Congress substantially strengthened the civil False Claims Act, recoveries now total more than $27 billion.RELATED POSTS

The largest fiscal year 2010 False Claims Act recoveries came from the pharmaceutical and medical device industries, which accounted for $1.6 billion in settlements, including the $669 million from Pfizer Inc., $302 million from AstraZeneca, and $192.7 from Novartis Pharmaceutical Corporation. These numbers may appear to be deceptive however, as some have predicted that the era of big pharma settlements may be ending. For example, many companies such as Pfizer have entered into lengthy corporate integrity agreements that span over the next several years.

While it is certainly important for revenue purposes that DOJ continues to successfully prosecute wrongful acts of companies, the agreements these companies have entered into require more of an oversight role than investigative, to ensure compliance with the agreement. Without large settlements, the DOJ might not be able to sustain its ‘profitability’ of fraud collections. For example, without a large settlement like Pfizer’s, DOJ’s claims may not cover the $500 million plus the government put in. In other words, if the administration is to continue such efforts, they will first have to recover $500 million to break even.

Much of the success for recovering this money stems from the Department of Health and Human Services (HHS) creation of a new interagency task force, the Health Care Fraud Prevention and Enforcement Action Team (HEAT). On May 20, 2009, Attorney General Eric Holder and HHS Secretary Kathleen Sebelius created HEAT to increase coordination and optimize criminal and civil enforcement, which they argue results in higher quality health care at a more reasonable price. DOJ and HHS also assert that HEAT is used as a tool to protect the Medicare Trust Fund for seniors and the Medicaid program for the country’s neediest citizens.

West further acknowledged the role of HEAT by recognizing that Since January 2009, the Civil Division, together with the U.S. Attorneys’ offices, commenced more health care fraud investigations, secured larger fines and judgments, and recovered more taxpayer dollars lost to health care fraud than in any other two-year period.” Most of the cases resulting in recoveries were brought to the government by whistleblowers under the False Claims Act, the federal government’s primary weapon in the battle against fraud.

In 1986, Senator Charles Grassley and Representative Howard Berman led successful efforts in Congress to amend the False Claims Act to revise the statute’s qui tam (or whistleblower) provisions, which encourage whistleblowers to come forward with allegations of fraud. Since 1986, recoveries in qui tam cases have exceeded $18 billion, and relators (whistleblowers) have obtained more than $2.8 billion in awards. They were awarded $385 million in 2010.

Impact of Settlements

Ultimately, while the success of the DOJ is clear, how much this will continue down the road depends on a number of factors. Nevertheless, it is important that the DOJ and HHS continue to work with companies on solutions to prevent fraud, waste and abuse to reduce costs and improve efficiency in the health care system. While the recoveries may help to pay for some of the provisions in health care reform, it is more important that the companies maintain their trust and integrity with the public by adhering to their agreements and making a concerted effort to prevent fraud and abuse.

How much of your tax dollars do you think go towards health care fraud (unnecessary procedures, over billing etc.? How much of your health insurance premium dollars do you think goes towards paying for fraudulent procedures and over billing? Do you look at your insurance bill? Does your insurance company send you a copy of your medical charges?

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US coronavirus stimulus went to some healthcare providers facing criminal inquiries

Source: CNBC
PUBLISHED SAT, MAY 2 2020 6:07 AM EDT

The exterior of the U.S. Department of Health and Human Services in Washington, DC.

Eager to bolster the healthcare system during the coronavirus pandemic, the U.S. government last month sped $30 billion in stimulus payments to most healthcare providers that billed Medicare last year.

That speed resulted in taxpayers’ money flowing to some companies and people facing civil or criminal fraud investigations, according to defense lawyers and others representing more than a dozen firms and people facing such inquiries.

The disclosures about such payments have prompted outrage among some congressional Democrats, who say they highlight the problems with how stimulus funds have been distributed.

“I have an enormous amount of frustration with the way the Trump administration is distributing these dollars, and examples like these magnify the consequences of the White House’s efforts to limit transparency and stonewall oversight,” Senator Ron Wyden, ranking member of the Senate Finance Committee, told Reuters.

Henry Connelly, a spokesman for House of Representatives Speaker Nancy Pelosi, added: “It is alarming to see the Trump administration giving precious taxpayer dollars to unscrupulous entities while so many hospitals and health care workers on the frontlines of the battle against coronavirus are desperate for resources.”

The Department of Health and Human Services, which sent the payments, told Reuters it transmitted funds to all medical providers who submitted billings in 2019 to Medicare, the federal health insurance program for elderly and disabled Americans, unless they had already been excluded from participating.

It declined to respond to the criticism from Wyden and Pelosi’s office and did not respond to specific questions from Reuters about the payments.

Katherine Harris, a spokeswoman for the HHS Office of the Inspector General, said her office oversees the program but declined to comment on the specific distribution of funding.

“While we cannot comment specifically on any work other than what has been publicly announced, I can tell you that we regularly perform reviews of the department’s administration of programs, including the distribution of funding,” Harris said.

Reuters was unable to independently determine what portion of the stimulus payments went to entities and individuals involved in civil and criminal actions with Medicare.

In an email to funding recipients seen by Reuters, HHS asked providers to sign a lengthy attestation that stipulates they have been or will be treating patients suffering from COVID-19, the disease caused by the new coronavirus.

If providers do not respond within 30 days, HHS said it will assume they have accepted the government’s terms and conditions. It said in a statement it “has mechanisms in place to recoup funds and address fraudulent activity.”WATCH NOWVIDEO05:53CARES Act, Fed response insufficient given headwinds: Chief economist

The funds came from the $2.3 trillion CARES Act passed by Congress to blunt the economic toll of the pandemic, which has killed more than 64,000 Americans and thrown at least 30 million people out of work.

Unlike the portions of that package intended to help small businesses, which required companies to apply for it, some of the healthcare funding was initiated by the U.S. Department of Health and Human Services and showed up as a surprise in the bank accounts of many healthcare providers.

Reuters interviewed six defense lawyers and others representing more than a dozen healthcare providers facing civil or criminal inquiries who received the money, including a pain medicine doctor who recently settled a civil false claims case, and an operator of an assisted living facility who is planning to plead guilty to healthcare fraud.

“The left hand does not know what the right hand is doing,” said Joel Hirschhorn, an attorney who represents the pain medicine doctor and the operator of the assisted living facility.

The lawyers who spoke to Reuters declined to identify their specific clients, citing confidentiality rules.

The surprise deposit of funds has led attorneys to scramble to warn clients to be ready to return the money.

“There is no such thing as a windfall from the government,” said Sam J. Louis, a former prosecutor who is now a partner with the law firm Holland & Knight, whose law firm issued an alert to clients warning them of the potential of legal liability in taking the funds.

Some former federal prosecutors say it would not have been difficult for HHS to weed out these providers first.

“If fraudulent providers, either convicted or under investigation, are receiving CARES Act bail-outs automatically, without any vetting, then shame on the government,” said Paul Pelletier, one former prosecutor.

However, defense lawyers stressed that people charged with crimes are innocent until proven guilty, and they are not usually barred from billing Medicare until well after they are convicted of a crime. People facing criminal healthcare charges usually agree to stop billing Medicare as a condition of their bond, they added.

Another pool of practitioners eligible for the cash infusions include doctors who have lost their medical licenses or licenses to prescribe highly addictive drugs, said Ron Chapman, a lawyer in Miami.

HHS declined to say what portion of the $30 billion went to providers facing criminal or civil inquiries.

It said it distributed funds to more than 315,000 provider billing organizations reaching over 1.5 million healthcare providers.

In fiscal year 2019, investigations by the HHS inspector general’s office led to 747 criminal actions and 684 civil actions.

In the midst of the pandemic health care fraud is alive and prevalent while many suffer economically across the globe. How has the pandemic effected you financially? Do you think pandemic aid could have been better spent? How many people do you think lost or missed work? How many industries and small business have been impacted or closed due to COVID 19?

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10. The Stanford Prison Experiment

Source: Mental Floss
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In 1971, Philip Zimbardo of Stanford University conducted his famous prison experiment, which aimed to examine group behavior and the importance of roles. Zimbardo and his team picked a group of 24 male college students who were considered “healthy,” both physically and psychologically. The men had signed up to participate in a “psychological study of prison life,” which would pay them $15 per day. Half were randomly assigned to be prisoners and the other half were assigned to be prison guards. The experiment played out in the basement of the Stanford psychology department where Zimbardo’s team had created a makeshift prison. The experimenters went to great lengths to create a realistic experience for the prisoners, including fake arrests at the participants’ homes.

The prisoners were given a fairly standard introduction to prison life, which included being deloused and assigned an embarrassing uniform. The guards were given vague instructions that they should never be violent with the prisoners, but needed to stay in control. The first day passed without incident, but the prisoners rebelled on the second day by barricading themselves in their cells and ignoring the guards. This behavior shocked the guards and presumably led to the psychological abuse that followed. The guards started separating “good” and “bad” prisoners, and doled out punishments including push ups, solitary confinement, and public humiliation to rebellious prisoners.

Zimbardo explained, “In only a few days, our guards became sadistic and our prisoners became depressed and showed signs of extreme stress.” Two prisoners dropped out of the experiment; one eventually became a psychologist and a consultant for prisons. The experiment was originally supposed to last for two weeks, but it ended early when Zimbardo’s future wife, psychologist Christina Maslach, visited the experiment on the fifth day and told him, “I think it’s terrible what you’re doing to those boys.”

Despite the unethical experiment, Zimbardo is still a working psychologist today. He was even honored by the American Psychological Association with a Gold Medal Award for Life Achievement in the Science of Psychology in 2012.

Does this occur in prisons? Did it begin to occur before or after such experiments? Is any of this behavior acceptable and to be considered real health care?

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5 Unethical Unauthorized Medical Experiments

Five worst medical experiments in history - This is Genius

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5 Worst Medical Experiments
Source: This is genius
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What are the worst medical experiments you know of? Why do you think these medical experiments occur? What should be the consequences for such experiments?

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Feds accuse Chesterfield psychiatrist of $15M in health care fraud

ST. LOUIS — A psychiatrist from Chesterfield and his business partner have been indicted on federal charges for their involvement in what prosecutors said Thursday was $15 million in health care fraud.

Prosecutors said Dr. Franco Sicuro and Carlos Himpler, of Baton Rouge, Louisiana, owned Genotec DX and Midwest Toxicology Group, which received over $15 million for performing drug tests. But prosecutors said the companies didn’t have the equipment required to perform the urine tests. Instead, they paid other labs $125 per sample, then billed Medicare and private insurance companies thousands of dollars per sample as if they had done the work themselves, authorities said.

To pull off the scheme, the two companies billed as if they had performed multiple tests on the same sample, and submitted them on different days with different billing codes.

One of the victims was a local union, United Food and Commercial Workers local 655, which paid Genotec DX $1 million for urine drug tests for seven union members from January to October 2015, and paid $150,000 to Midwest Toxicology Group, prosecutors said.

Prosecutors are seeking the forfeiture of cash, investments accounts, real estate and luxury vehicles owned by both men. 

Sicuro is facing 19 charges in U.S. District Court in St. Louis and Himpler was named in 21 counts, including charges of conspiracy, health care fraud and money laundering. No lawyers are listed for either man in online court records, and a call to Sicuro’s Chesterfield office was not immediately returned.

Himpler is a former St. Louis-area resident who started several businesses here, the indictment says. 

Source: St. Louis Post Dispatch

Has your insurance ever been over billed? Do you look at your insurance bill? Would you recognize health care if you see it? Share your comments with the community by posting them below. Share the wealth of health with your friends and family by sharing this article with 3 people today. As always you are the best part of what we do. Keep sharing!

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