E-cigs: Cute But Still As Addictive

An insidious new campaign to capture new smokers at the youngest ages has started. Make no mistake, Big Tobacco companies are much more savvy than any consumer group out there. They know exactly what it takes to capture an entirely new segment of consumers before the individuals even know that they are consumers.

E-cigarettes may look cute and not have the typical and readily-identifiable noxious smell of "real" tobacco, but nicotine-delivery is just as efficient. Addiction is therefore assured and incumbent health risks remain ever-present.

As reported in Bloomberg-Businessweek: "As e-cigarettes become more popular, the federal government is looking for ways to regulate their use, especially among teens. A March study in the journal JAMA Pediatrics reported that 3.3% of 6th to 12th graders said they'd tried e-cigarettes in 2011. In 2012 the number more than doubled, to 6.8%. Using data from the CDC and Prevention, the study found kids who tried e-cigarettes were more likely to try real cigarettes than those who hadn't."

Message to Congress: Please Repeal The Flawed SGR Now!

I can't tell you how dissatisfied I am to now be an unwilling part of the Republican agenda to overturn and/or dismantle the Affordable Care Act. In my opinion, and I believe most physicians would agree, the law needs to be improved, not dismantled. Attempting to repeal or dismantle it is counterproductive and time wasting. Hence, the recent House Republican push to bundle the SGR repeal bill with an attempt to further delay individual mandate of the ACA is unfortunate.

Read below for an email I received:


House Republications Expected to Propose SGR Repeal Funded by Delaying Individual Mandate

Posted on March 11, 2014 by Geoff Cockrell

Republicans in the House are expected to vote this week on legislation that would permanently repeal the sustainable growth rate (SGR) Medicare physician payment formula.

To pay for the SGR fix, the legislation is expected to propose a delay or repeal of the Affordable Care Act's individual mandate, according to multiple news reports including a Modern Healthcare report.

If the SGR fix legislation is bundled with a bill that would call for the delay or repeal of the individual mandate, the Senate is not expected to approve the merged legislation.

The deadline for the next doc fix is March 31. If a temporary or permanent fix is not in place by then, Medicare physician payments under the SGR will be cut by about 24%.


White Noise Machines - Not So Infant Soothing?

For any new parents out there, please read these excerpts and do some research. It seems the white noise sleep monitors may not be easy on your child's ears after all. There are reasons for and against using these devices, not the least is that they are probably not necessary. I mean, isn't a baby supposed to get used to some ambient noise? I always thought it made for better sleepers as they get older.

AMA excerpts as follows:

Noise machines may put infants at risk of developing hearing loss. USA Today (3/3, Healy) reports that research published online in Pediatrics suggests that “parents should be cautious with” infant sleep machines “because they can generate sound levels that could place infants at risk of developing noise-induced hearing loss.” These “machines – which can be used to mask environmental noises or provide ambient noise designed to soothe an infant during sleep – ‘are capable of producing levels that may be damaging to babies’ hearing,’ says Blake Papsin...senior author of the study.” The New York Times (3/3, Louis, Subscription Publication) reports that according to Dr. Gordon B. Hughes, the program director of clinical trials for the National Institute on Deafness and Other Communication Disorders, “Unless parents are adequately warned of the danger, or the design of the machines by manufacturers is changed to be safer, then the potential for harm exists, and parents need to know about it.” Dr. Hughes was not involved in the study. On its website, NBC News (3/3, Mantel) reports that in the study, investigators “tested 14 widely available machines that play white noise and other soothing sounds.” The researchers found that “at one foot away, three of the machines produced such intense sound levels at maximum volume that, if played through the night, they would exceed allowable noise limits for adults at work.” Also covering the story are CNN (3/3, Landau) and Reuters (3/3, Seaman).

Unintended consequences of genetic manipulation

Scientific advances must be viewed from all angles as we attempt to understand the ramifications of progress. So it comes as no surprise to read the following excerpts from the daily AMA communication.

Scientists are now able to manipulate genes in order to eliminate some genetic diseases. On its surface, this development is favorable. But the unintended consequences include something on the lines of "I'll have a blue-eyed, blond-haired genius boy please and leave out the Tay-Sachs disease."

From that possibility, we must proceed cautiously.


FDA panel considers controversial fertility procedure. CBS Evening News (2/25, story 7, 1:35, Pelley) reported in its broadcast that an FDA panel “began two days of meetings” on Tuesday and Wednesday “about a controversial medical procedure that critics believe could lead to designer babies.” CBS’ Dr. Jon Lapook said, “It’s controversial because in addition to the DNA of the mother and the father, material from a third person is used in the process.” Lapook noted that the concerns over the procedure range from technical issues such as how to make it “safe and effective” to ethical issues of creating “designer babies.” The New York Times (2/26, Tavernise, Subscription Publication) noted that the agency has asked an expert committee “to summarize current science to determine whether the approach – which has been performed successfully in monkeys by researchers in Oregon and in people more than a decade ago – is safe enough to be used again in people.” The paper pointed out the meeting is “meant to address the scientific issues around the procedure, not the ethics.” Specifically, the scientists have been asked to discuss “the risks to the mother and the potential child and how future studies should be structured, among other issues.” The Washington Post (2/26, Cha, Somashekhar) noted that the FDA’s disclosure “several months ago” about its intention to hold a public hearing on the matter “elicited an outcry from scientists, ethicists and religious groups, who say the technology raises grave safety concerns and could open the door to creating ‘designer’ babies, whose eye color, intelligence and other characteristics are selected by parents.” Marcy Darnovsky, executive director of the Center for Genetics and Society and a vocal critic of the procedure, “said human trials would mark the first time the FDA had approved a gene-modification technique whose effect is transmitted to a person’s descendants,” according to the Post. Reuters (2/26, Begley) provided background information, noting that during the in-vitro fertilization, the father would donate the sperm while the mother would provide her egg and its nucleus. However, if the mother is a carrier of harmful genetic mutations in the cell’s mitochondria, scientists will replace that with a healthy mitochondria from the second woman, so the child will not have any harmful mitochondrial disease. In an editorial, the Los Angeles Times (2/26) argued that “manipulation of human genes could provide huge advances in our ability to cure or prevent terrible diseases.” Still, the paper suggested, “it is vital to proceed with extreme caution on research that involves possible permanent changes in the human genome.” The news was also covered by the AP (2/26, Perrone),MedPage Today (2/26), HealthDay (2/26) and Bloomberg News (2/25).

The State of Healthcare in America??

Is this the state of healthcare in America??

Recently I read a CT scan and identified large clots in the right and left main pulmonary arteries. ("Bilateral pulmonary emboli") As summarized here, studies have "estimated that more than 1,000,000 people in the United States are affected by pulmonary emboli each year, with 100,000 to 200,000 of these events being fatal."

When I finally, after 15 minutes of trying, reached the nurse practitioner on call for the hospitalist group caring for this patient, she asked me, "Is that critical? Do I need to call the ICU?"


Holding back a bit, I politely replied, "Although that decision is up to you taking care of the patient, this is a life-threatening emergency. I would do so if I were taking care of her."

I have several friends who are excellent hospitalists. It's not an issue whether the hospitalist is good or bad, though that of course is important to note. But it is very important that we recognize that care by hospitalists is fragmented unless said hospitalist is on duty on a more continuous basis. There are solo hospitalist practitioners who care for their patients on a daily basis and have more exclusive practices than others. But hospitalist groups tend toward more shift work and I think that is a major failing of the current method of inpatient care.

Oh, and by the way, in Florida, there is a bill being pushed in the Florida House and Senate to allow nurse practitioners to care for patients independently. I know several excellent nurse practitioners. But it's the overall system failing I am pointing out to inform and educate so that patients are aware of what is happening. Nurse practitioners work best in concert with physicians. Nurse practitioners and physicians train differently and gather differing experiences. They are best when working together and complement each other. Hospitalists best know their patients when they are not on-off-on-off shift workers. I know several hospitalists who only care for certain issues, or who work in a small group or solo, allowing for a continuity of care that large hospitalist groups can absolutely not match. Those are important distinctions that are being overlooked thanks to meaningless discussions about slow websites!

Use Appropriateness Criteria When Ordering CT Scans

Following excerpt is from my AMA daily email. I have often opined on the same subject. It is imperative that the public and caretakers alike understand the risks and benefits of medical imaging. As a radiologist, I know too well the number of scans I see daily. Most of the scans I read and see in a day are hopefully helpful to the physicians and caretakers ordering them. But there are studies that cross my path that make one question. Appropriateness criteria assist ordering physicians and caretakers in hopefully decreasing the number of inappropriate studies being ordered.


Physicians point to health risks associated with CT use.

"In a strongly-worded New York Times (1/31, A27, Redberg, Subscription Publication) op-ed, cardiologist Rita F. Redberg and radiologist Rebecca Smith-Bindman discuss the increased cancer risk associated with medical imaging. In particular, they decry the overuse of CT scans, and argue that the scans are not always performed as safely as they should be. Redberg and Smith-Bindman say that medical professionals have taken steps to combat the problem; they point out, for instance, that “the American College of Radiology and the American College of Cardiology have issued ‘appropriateness criteria’ to help doctors consider the risks and benefits before ordering a test,” but the authors contend that “we need clear standards, published by professional radiology societies or organizations like the Joint Commission or the FDA.” The authors conclude that “we need to find ways to use” CT scans “without killing people in the process.”"

PET Scans - Not All "Hot Spots" Mean Cancer!

As a radiologist, a challenge is to clearly explain the limitations of the imaging modalities we use to diagnose disease. For instance, people think of a PET scan as the best way to diagnose a cancer. If a "spot" is "bright," i.e. "hot," it must be cancer right?


Here is an excerpt from "Radiologic Clinics of North America: PET/CT," September 2013, which nicely sums up the limitations of PET scans for "patients with known or suspected lung cancer:"

"Information can mimic malignant tissue on FDG-PET, and this must always be kept in mind. For example, small spiculated nodules can because by pneumonitis, and present a management dilemma as they are not generally suitable for biopsy. Radiation pneumonitis can be FDG-PET positive, making it difficult to assess possible residual or recurrent lung cancer after radiation treatment. A pulmonary abscess can be indistinguishable from a pulmonary cancer based on CT and FDG-PET findings. Not all malignant neoplasms are FDG avid, and, in the lungs, well-differentiated adenocarcinoma and carcinoid tumors can be minimal or essentially negative on FDG-PET images. Small foci of FDG tracer activity in the skeleton can be caused by degenerative joint changes or healing fractures, or even Schmorl's nodes and vertebral body end plates and mimic small metastatic deposits. Benign adrenal adenomas can present modest FDG uptake. In contrast, certain benign tumors such as Warthin's tumor in the parotid gland or pituitary adenomas at the skull base can be very FDG avid and be mistaken for distant metastases based on the PET images alone. Patients with lung cancer can have additional unrelated neoplasms, and incidental thyroid and early colon cancers are commonly seen on FDG-PET images."

So if you or a loved one or a friend needs or has undergone a PET scan, please make sure you understand the findings and discuss them fully with either your doctor or, if possible, the radiologist who interpreted the study.

UnitedHealthcare Drops Providers - Patient Access Nightmares Will Ensue

Below is a forwarded email that comments on the UnitedHealthcare activity. This major insurer has been dropping doctors from its networks across the country, resulting in major disruptions to the access to care of thousands of patients just like you. Stay tuned, the final chapters have not been written on this insidious activity, all done under the guise of quality improvement, when in reality it is absolutely nothing more than cost-cutting at its worst.

Read on and stay informed:


The ruling only affects members of the Hartford County Medical and Fairfield County Medical associations. The ruling does not cover the state’s other medical associations, including the Connecticut State Medical Society and its members. - See more at: http://medicaleconomics.modernmedicine.com/medical-economics/news/federal-judge-grants-temporary-injunction-against-unitedhealthcare#sthash.pkr1lnch.dpuf



Federal judge slaps UnitedHealthcare with injunction hours before dropping thousands of physicians from Medicare Advantage network

Two Connecticut medical associations won a temporary injunctive order against UnitedHealthcare in federal court hours before the insurer was set to drop hundreds of doctors and thousands of patients from its rolls

Publish date: DEC 06, 2013



By: Keith Griffin

Two Connecticut medical associations won a temporary injunctive order against UnitedHealthcare in federal court hours before the health insurer was set to drop thousands of physicians and patients from its rolls. The order prevents the insurer from removing any of the doctors until the court can rule on the merits of the case.

U.S. District Court Judge Stefan Underhill ruled Friday, December 6, that the Hartford County Medical Association and Fairfield County Medical Association "met their burden of demonstrating that they will suffer harm that is imminent and cannot be adequately compensated through damages."

The associations sought a temporary restraining order preventing UnitedHealthcare from removing the physicians, approximately 20% of the UnitedHealthcare provider panel, from its Medicare Advantage networks. Anywhere from 20,000 to 30,000 patients could be affected, the medical groups say.

The injunction forces UnitedHealthcare to start proceedings from the beginning and “do it the right way,” says Roy Breitenbach, JD, legal counsel for the medical associations.

“[The decision] levels the playing field, and we're prepared to go forward,” contends Breitenbach, a partner/director of Garfunkel Wild PC in Great Neck, New York. “If they start from scratch and follow the termination proceedings, there are certain rights to follow the termination."

UnitedHealthcare intends to immediately appeal the decision, the company says in an e-mailed statement.

“We believe the court’s ruling will create unnecessary and harmful confusion and disruption to Medicare beneficiaries in Connecticut,” says Terry O'Hara, of UnitedHealthcare Group. “We know that these changes can be concerning for some doctors and customers, and supporting our customers is our highest priority. United Healthcare will continue to stay focused on the people we serve.”

The ruling only affects members of the Hartford County Medical and Fairfield County Medical associations. The ruling does not cover the state’s other medical associations, including the Connecticut State Medical Society and its members. The majority of the affected 2,200-plus physicians are reported to be in Hartford, New Haven, and New London counties.

The judge's ruling boiled down to evidence that UnitedHealthcare appears to have breached its contract with the physicians by removing them without cause or explanation, in apparent violation of Medicare regulations. Bollepalli Subbarao, MD, president of the Hartford County Medical Association, characterized those actions by United Healthcare as "pure abuse."

Underhill wrote: "At oral argument, United suggested that it routinely amends [the contract] without the consent of participating physicians as a way of removing physicians from participation in a particular plan." But the judge noted the insurer provided no evidence of that in follow-up documents and, in fact, only used the amendment "to add physicians to the network, not delete them."

According to Rick Fiorentino, executive director of the Hartford County Medical Association, the two associations were willing to go to mediation to resolve the dispute. He said United Healthcare opposed this move, which would have delayed implementation for a year, and took its chances on the court ruling. "The judge was angry that (the company) wouldn't go to mediation," Fiorentino said.

Both medical associations took strong advocacy roles against United Healthcare once the cuts were announced in October, as reported by Medical Economics. In addition to the court filings, the two associations organized a November "townhall-like meeting" for those providers and patients impacted by the UnitedHealthcare Group action in Westport, Connecticut and West Hartford, Connecticut. The two groups also hosted a press conference December 5, 2013, at Connecticut's Legislative Office Building on future steps that will be taken to prevent similar actions by insurance companies.

Here are links to other coverage related to this developing story:

Physicians gather to fight UnitedHealthcare's cancellations

AMA, medical societies fight mass physician cancellations

UnitedHeathcare cuts thousands of physicians from network

- See more at: http://medicaleconomics.modernmedicine.com/medical-economics/news/federal-judge-grants-temporary-injunction-against-unitedhealthcare#sthash.pkr1lnch.dpuf

UnitedHealthcare - The Tip of The Iceberg?

Please see the letter below, explaining the potential steps to come from the recent injunction that temporarily stopped UnitedHealthcare in Connecticut from terminating 2,200 physicians from its network. Such a change would drastically affect the access to care of thousands of patients. While the insurers attempt to maneuver to meet the demands of the ACA, aka Obamacare, patient care is being adversely affected. Hopefully, with continued focus on this issue, insurers will be forced to adjust their behavior and maintain their networks so that patients can continue to receive high quality care from dedicated physicians across the country.


Judge's Medicare Advantage Order Could Have National Impact


By Susan Jaffe

DEC 06, 2013

In a decision that could have national implications, a federal judge in Connecticut temporarily blocked UnitedHealthcare late Thursday from dropping an estimated 2,200 physicians from its Medicare Advantage plan in that state.

While the judge’s decision affects only the physicians in Fairfield and Hartford Counties who brought suit, several other medical groups are considering filing similar actions.

“This is very good news from Connecticut,” said Dr. Sam L. Unterricht, president of the Medical Society of the State of New York.  “We will definitely seriously consider filing a suit in New York as well.”

The Ohio State Medical Association is also reviewing the decision, said Todd Baker, a spokesman for the Ohio State Medical Association.


The preliminary injunction issuedby U.S. District Court Judge Stefan Underhill comes less than 48 hours before a deadline at midnight tomorrowfor seniors to choose a Medicare Advantage or drug plan for next year. Medicare officials said they don’t plan to extend the deadline for beneficiaries affected by the terminations, but will continue to monitor the situation. After the deadline, Medicare Advantage members are allowed to make one change from Jan. 1 through Feb. 14 -- they can leave their plan and rejoin traditional Medicare.

UnitedHealthcare is the largest Medicare Advantage insurer in the country, with nearly 3 million members and is reducing its network of physicians in at least nine other states  More than 14 million older or disabled Americans are enrolled in Medicare Advantage plans, a managed care version of Medicare. Generally, it is an alternative to traditional Medicare that offers medical and usually drug coverage but members have to use the plan’s providers.  

“We disagree with the ruling and intend to appeal it immediately,” said UnitedHealthcare spokesman Terry O’Hara.  However, the company will comply with the order, while the appeal is underway.  

The judge criticized the strategy to terminate the doctors: unilaterally amending the doctors’ contracts with a provision that canceled them.  “United’s argument that it has a unilateral right to terminate participating physicians from participation in the Medicare Advantage plan by amendment of that plan is not supported by the language of the contract or the parties’ experience under it,” Underhill wrote.

The Centers for Medicare & Medicaid Services, which oversees the Medicare Advantage program, is reviewing the provider changes by UnitedHealthcare to determine whether its plans have sufficient doctors to meet federal requirements.

Neither the agency nor the insurer would discuss that review, but the Connecticut doctors argued in court that the changes would harm patients.  

“We won’t let UnitedHealthcare get away with interfering with the doctor-patient relationship,” said Dr. Robin Oshman, president of the Fairfield County Medical Association in a written statement.  The lawsuit was brought by that and the Hartford County Medical Association.

Seniors advocates welcomed the ruling.

 “Judge Underhill’s decision, at a minimum, shows private Medicare plans that they do not have unfettered license,” said Judith Stein, executive director of the Connecticut-based Center for Medicare Advocacy. “Federal courts have jurisdiction over Medicare Advantage actions to ensure the beneficiary rights are protected.”

Unterricht said he hopes UnitedHealthcare will reconsider the doctors’ terminations.

“This patient population is very fragile and requires stable medical care from physicians who know them and whom they know,” he said.


This article was produced by Kaiser Health News with support from The SCAN Foundation.

Smoking Ban Should Include E-Cigs

Of late, I have been amazed when I see people toking on their e-cigarettes. They hold them as if they were marijuana joints. They puff on them secretively with furtive glances. For health reasons, there remains an appropriate stigma on smoking in public. Rightfully so, the public has become aware of the carcinogenic effects of smoking. Therefore, the following excerpt from the AMA daily email, which notes that New York may soon ban e-cigarette smoking in public places, is welcome. I urge you to consider e-cigarettes to be just as hazardous as traditional forms of tobacco, despite the fact that there is no actual "smell." Obviously, there are differences between traditional tobacco products and the electronic counterparts. But make no mistake, these products are also addictive and carry a risk of cancer.


Excerpt as follows:

New York City considering adding e-cigarettes to current public smoking ban. New York City-area newspapers and one major wire source cover how yesterday, the New York City Council heard testimony on a proposal to add electronic cigarettes to the public smoking ban already in effect. The New York Times (12/5, A33, Hartocollis, Subscription Publication) features coverage of some of the “theatrical provocateurs” demonstrating the “innocuous” safety of the devices. The article notes that New York’s health commissioner Dr. Thomas Farley was hesitant to say if e-cigarettes are or are not as harmful as traditional cigarettes. According to the bill’s primary sponsor, Councilman James Gennaro, however, this is the time for the regulation. Explaining why the city should act now, Gennaro said, “I’m just not willing to wait for Big Tobacco to completely take over the electronic cigarette industry, and then you’ll get nothing out of Washington, because people are bought and paid for.” Furthermore, if the bill fails this month, the New York Times reports that “several of its strongest advocates...will be out of office,” putting the measure in jeopardy. The AP (12/4) report puts Dr. Farley more firmly on the side of regulation, noting that he did say, “Waiting to act could jeopardize the progress we’ve made in the last 12 years.”

Nicotine is Addictive? What A Revelation

Smoking is bad for you. It causes cancer. And, if you smoke traditional products like cigarettes, you smell like an ash tray and no one except another smoker wants to kiss an ash tray.

But then come e-cigarettes and smoking is now good for you, right? Wrong.

Nicotine is addictive (anyone remember that fact?). And, according to the following excerpt, research proves it once again.

Please don't smoke. It just increases the chances that you will become a patient and need the services of someone like me so that I can biopsy your lung cancer or perhaps stent or balloon a blockage in your arteries.

I'd rather not smoke and decrease my chances of needing to visit a doctor. But that's just me.


Excerpted from the AMA daily email: Study: E-cigarettes appear to be addictive.

The San Francisco Chroniclehttp://mailview.bulletinhealthcare.com/mailview.aspx?m=2013120401ama&r=5642645-a3d3&l=03a-b89&t=c (12/4, Lee, Allday) reports that, according to a study published last week in the Journal of Adolescent Health, e-cigarettes “may only serve as a new route to nicotine addiction among adolescents.” An analysis in South Korea, where e-cigarettes are sold similarly to how they are sold in the US, showed about 80% of South Korean adolescents using e-cigarettes also smoked tobacco cigarettes and that young e-cigarette smokers were more likely to have tried quitting smoking, indicating a belief that e-cigarettes can help with smoking cessation. Ultimately, researchers found links between e-cigarette use and heavier conventional cigarette use, leading to the conclusion that “the nicotine in e-cigarettes is addictive.”

Cutting Providers From Insurance Networks Is Wrong

This is just wrong. Patient access to care is being adversely affected.

Excerpt from the AMA:

"UnitedHealthcare cuts physicians from Medicare Advantage. USA Today (11/29, Jaffe) reported that UnitedHealthcare, “the largest Medicare Advantage insurer in the country, with nearly 3 million members,” has cut many physicians from its Medicaid Advantage coverage. The company issued a statement on the cuts: “While these changes can be difficult for patients and their doctors, they are necessary to meet rising quality standards, slow the increase in health costs and sustain our plans in an era of Medicare Advantage funding cuts.” Several medical associations, including the American Medical Association, are asking the Federal government address the situation."

Hospital Bonuses To Physicians May Violate Stark Laws

Fascinating stuff. After being employed by hospitals, the risk to physicians and the hospital entity actually increases. Innocuous-seeming bonuses for enhanced productivity are violations of the Stark Law.


The Health Care Investor - Physician Compensation by Hospitals Drawing Increased Legal Attention


Physician Compensation by Hospitals Drawing Increased Legal Attention

Posted: 02 Dec 2013 05:19 PM PST

We are increasingly seeing attention on physician compensation issues, especially in light of the increased consolidation of physician practices into hospital systems. Setting appropriate compensation is a critical compliance issue for the hospital and physicians. The recent ruling by the U.S. District Court in the Middle District of Florida regarding Halifax Hospital Medical Center's compensation of employed oncologists highlights the Stark law issues inherent in compensation methodologies.

A federal judge in the case, United States et al. v. Halifax Hospital Medical Center et al., ruled that Halifax Hospital in Daytona Beach, Fla., gave bonuses to six oncologists that increased as the physicians directed more patients to the hospital for treatment, according to a Modern Healthcare report. The court ruled that this "incentive bonus" violated the Stark law's prohibition on paying physicians in such a manner that encourages referrals of Medicare patients.

The case is now scheduled to go to trial next spring, with a jury tasked with determining how much Medicare oncology revenue was at issue and whether Halifax Hospital's conduct also violated the False Claims Act. If the jury rules in favor of the government on its False Claims Act claims, Halifax Hospital's damages could exceed $1 billion.

The court's order can be found by clicking here (pdf).

Interventional Radiology Can Help Fight Obesity

THIS is what makes Interventional Radiology such a cool field - the constant innovative thinking-outside-the-box of interventional radiologists! The concept, discussed in this article, needs a bit more research to ensure patient safety, but there will come a day when I will offer left gastric artery embolization to treat obesity. In conjunction with dietary specialists, primary care physicians and bariatric surgeons, this kind of procedure adds to the available options to help people. Very exciting.

Don't Let Your Access To Care Be Limited

"The concept is to funnel a larger volume of patients to fewer, quality-selected providers, sometimes in exchange for lower reimbursement rates." - A quote from a recent Modern Healthcare article regarding a major, yet poorly-publicized access-to-care issue, discussing how "insurers [are] offering health plans on the public exchanges that feature narrow provider networks." 

The true reason for the narrowing of provider networks is that hospitals are vying for position at the reimbursement table, cutting off providers that they deem out of network, typically solely because those providers are not currently employed by said hospital. This issue threatens to become a major political battle between hospitals and providers. 

Patients are rapidly losing choices and reasonable access to care as the insurance networks become squeezed by what could be seen as collusion between hospitals and insurance companies. Pay attention people. Please be aware. The doctors that are in your network are not necessarily there because of "quality."

Case in point - until recently, there is one established neurointerventionalist in my town, Dr M. He is a doctor who treats brain aneurysms. It is a highly specialized field and he has been treating people for around 15 years with very good results. Recently, I received a request from a patient asking me if there are any other doctors in town who do what he does. Not being aware of any, I told her so and asked her what was the reason she doesn't go see Dr M? Her response - he's no longer in her network.

The same week, another patient asked me if there was a vascular surgeon in town who treats a certain kind of vascular problem. Not all vascular surgeons treat all ailments and this problem was more specialized than usual. I know of two of the six vascular surgeons in town who could help - both of them are "out of network" for this patient.

As these networks are squeezed by hospitals and insurers, access to care is being detrimentally affected. It is a subtle, insidious change that flies well under the radar of the well-publicized health care changes we are seeing in the media. The healthcare.gov website debacle is but one tiny facet of the overall changing face of healthcare. 

Stay informed. Be aware. 

Choose Your Radiology Appropriately

Most of us are aware that radiology imaging studies such as CT scans, mammograms, and x-rays use ionizing radiation to capture images and allow our radiologists and treating physicians to see what ails us.

But how many of us ask our doctor whether the test he/she is ordering is "appropriate?" The word "appropriate" doesn't just have the benign connotation of whether the study is indicated. In fact, there is a whole set of criteria, "Appropriateness criteria," that are determined by groups of 20 or more physicians and revised every three years as needed.

These ACR Appropriateness Criteria can give you the peace of mind that your doctor is following the evidence and recommendations that are necessary to ensure your safety. Too much ionizing radiation can cause cancer. Imaging studies must therefore be relevant and necessary in order to do maximal benefit and minimal harm.

When your doctor orders an imaging study, ask him/her if they have reviewed the Appropriateness Criteria. If they have not, consider a second opinion before you agree to undergo the ordered study. If they are aware of the criteria, thank them and ask them to explain the recommendations.

Become aware. Stay informed. Your health depends on it.

E-cigarettes - New Ploy, Same Cancer

E-cigarettes are all the rage now. I have to tell you though, smoking still isn't cool. You see people holding these "neat" looking little "crack pipes," although presumably smoking legal stuff. But I just don't see how there isn't an outcry about this obvious ploy to hook more people on smoking. Sure, there are fewer carcinogens with E-cigarettes then with the traditional forms of tobacco usage. But carcinogens remain nevertheless. There are catchy names designed for maximal marketing as well. Names like bubble gum and cotton candy. I don't understand how this obvious a marketing ploy is permitted. Obviously it's not illegal, but they should be the same kind of negative press on this as there has been on smoking in general for decades.

Here's a bit more on the subject, as reported by the AMA daily email:

CDC: Teen smoking down but use of cigars, e-cigarettes up. The Wall Street Journal (11/14, Esterl, Subscription Publication, 5.91M) is part of the group of US national media outlets reporting on new findings from the US Centers for Disease Control and Prevention that were published yesterday. Though the CDC revealed that cigarette use among minors in the US is dropping over last year, the use of alternative tobacco products, such as miniature cigars, electronic cigarettes, and hookah, has risen. The Wall Street Journal focuses on the first of that group, cigarillos and little cigars, as being the second most used tobacco product among teenagers. Virtually every other source reporting paid more attention to the CDC’s findings regarding hookahs and e-cigarettes in particular, with USA Today (11/15, Koch, 5.82M) saying that the CDC’s 2012 National Youth Tobacco Survey among middle- and high-school students in the US “found a notable increase” in the number of respondents saying they have used hookahs and e-cigarettes, “both of which aren’t federally regulated and taxed as are cigarettes.” On its website, NBC News (11/15, Aleccia, 6.79M) reports that the CDC report said, “The increase in use of electronic cigarettes and hookah tobacco could be attributed to low price, an increase in marketing, availability and visibility of these products, and the perception that these products might be ‘safer’ alternatives to cigarettes.” The article clarifies that even if the number of middle-school and high-school students using e-cigarettes is “a tiny proportion of kids,” the rate of minors who have used the devices “in the past 30 days jumped more than 83 percent among middle-school youth and 86 percent among high-schoolers between 2011 and 2012.” The Time (11/15, Nicks, 13.4M) “Healthland” blog notes that the US Food and Drug Administration is considering increased regulation on products like e-cigarettes and little cigars, although there is little to report besides the agency’s intentions to act. The director of the US Centers for Disease Control and Prevention, Tom Frieden, MD, MPH, in a special blog post for the website of the Huffington Post (11/15, 11.54M), singles out “the use of emerging tobacco products such as electronic cigarettes and hookahs” as the problem, given the fact that their use among teenagers is going up while “there’s been no change in cigarette use.” Frieden ends up directing most of his focus on the fact that “kids are the primary target” of the other group of “new products,” that is, miniature cigars.

President Obama Apologizes to America

From the AMA: Amid criticism, Obama apologizes to Americans losing health insurance. President Obama gave an interview to NBC’s Chuck Todd on Thursday in which he effectively apologized for an aspect of the Affordable Care Act which has garnered extensive media coverage of late: that millions of Americans are receiving insurance cancellation notifications despite his repeated assurances that “if you like your policy, you can keep it.” His deference to this criticism dominated headlines, taking up nearly five minutes of nightly news airtime and making the front page of two major national newspapers. Indeed, nearly every report on the President’s interview includes some variation of the words “apology” or “sorry” in their headlines. At the opening of NBC Nightly News, Brian Williams said, “We are all about to hear the President of the United States apologize...for the fact that his promise to the American people that if they like their current health insurance they can keep it has not held true for all.” Chuck Todd went on to report that “the President’s apparent broken promise about folks keeping the plans they like has been weighing heavily on the entire White House, so it was a chastened commander in chief that I spoke with.” President Obama was shown saying, “We’re talking about five percent of the population who are in what’s called the individual market,” and “even though it only affects a small amount of the population, it means a lot to them, obviously, when they get this letter [informing them that their health insurance has been] cancelled – and I am deeply concerned about it and I’ve assigned my team to see what can we do.” Asked, “Do you feel like you owe these folks an apology for misleading them,” President Obama replied, “I regret very much that what we intended to do...that we weren’t as clear as we needed to be in terms of the changes that were taking place. ... And I am sorry that they are finding themselves in this situation based on assurances they got from me.” Scott Pelley, on the CBS Evening News, said the President “apologized for one of the biggest emerging problems with the Affordable Care Act.” According to Pelley, “More than three million Americans have been told that they will lose their health insurance plans, even though the President has repeated for years that Americans who liked their plans could keep them.” Nearly every report on the President’s interview includes some variation of the words “apology” or “sorry” in their headlines. The New York Times (11/8, Shear, Subscription Publication, 9.61M), in an article titled, “Apologizing, Obama Yields to Criticism of Health Law,” reports that in an interview with Chuck Todd Thursday night, President Obama “bowed...to mounting criticism that he had misled the American people about the health care law, apologizing to people who were forced off their health insurance plans by the Affordable Care Act despite ‘assurances from me.’” The Times says the President’s “decision to apologize...reflects the increasingly dire political position that the president is in.” Under the headline, “President Obama Apologizes To Americans Who Are Losing Their Health Insurance,” theWashington Post (11/8, A1, Eilperin, 4.28M) reports on its front-page that Thursday’s interview represented an “unusual act of contrition for a president who has come under heavy criticism for misleading the public.” According to the Post, “presidents rarely say ‘I’m sorry’ in public, even when acknowledging missteps,” and, on Thursday, President Obama “only did so after Chuck Todd...pressed him on the point.” Under the headline, “Obama Says He’s Sorry Americans Losing Insurance,” the AP (11/8, Pace) reports that while the President “says he’s sorry Americans are losing health insurance plans he repeatedly said they could keep,” he “stopped short of apologizing for making those promises in the first place.” The AP adds that “critics” of the President “have accused him of misleading the public about changes that were coming under the law, which remains unpopular with many Americans.” On its front page, USA Today (11/8, A1, Madhani, 5.82M) says the President was responding to “a steady stream of criticism as millions of Americans on the individual insurance market received notices that their plans do not meet the minimum benefit requirements set under the ACA and will be canceled.” USA Today says the President’s apology “mark[s] a significant change in tone following more than a week of his aides resisting suggestions that the president misled Americans.” USA Today notes that Senate Minority Leader Mitch McConnell “dismissed the apology, and called on Obama to embrace a bipartisan legislative effort in the Senate that would allow those getting cancellation notices to retain their coverage.” McConnell is quoted as saying, “If the president is truly sorry for breaking his promises to the American people, he’ll do more than just issue a half-hearted apology on TV.”

FMA to Florida Congress: Investigate UnitedHealth Terminations


Message from the President: FMA addresses UHC terminations  

Dear Friends and Colleagues,

As most of you are aware, hundreds of thousands of Floridians have received termination letters from their current health insurers for individual policies for the upcoming year. The majority of these policies fail to have all of the required elements of health insurance policies as required by the Affordable Care Act (ACA or "Obamacare"). This was widely anticipated by those of us who understood the details of the exchanges and the various levels of insurance products that could be offered in 2014. However, this came as a shock to millions of individuals nationwide, as this information was not adequately broadcast by Washington. The public had focused on the earlier message: "If you like your health care policy, you can keep it." So much for transparency.

You may also recall another promise: "If you like your doctor, you can keep your doctor." As most of you also know, United Healthcare is now involved in the process of terminating approximately 7,000 Florida physicians who care for their Medicare Advantage patients. In response to this alarming trend, I sent a letter this week to Florida's congressional delegation to express the FMA's concern about the negative impacts of these terminations on the patients we serve. I will go to Washington, D.C., on Nov. 14, 2013, to directly visit with those congressional offices that are receptive to my requests to directly discuss these and related issues.

The terminations are taking place nationwide, but they are particularly troubling in Florida, where a larger population of elderly residents accesses medical care through Medicare Advantage plans. The full letter follows this report. As you know, the FMA strongly supports patients' rights to choose their physicians. We will continue to be an aggressive advocate for patients.

W. Alan Harmon, M.D., FACP


Click here to read the full letter.

Insurers dropping providers without cause

Something insidiously unsettling is happening to health care, and I'm not even getting into a political commentary about the pros or cons of the ACA, aka Obamacare. Insurers are dropping providers from their networks without any apparent cause. Patient care may be drastically affected. For perspective, the only medical oncologists in the entire Southwest Florida region are  Florida Cancer Specialists. Eliminating the entire group from a network forces patients in those plans to have to drive hundreds of miles, possibly, to find a similar physician.

Read the following article from Naples News:

Humana dropping Florida Cancer Specialists as covered practice By LIZ FREEMAN

Saturday, November 2, 2013

NAPLES — Brenda Wallace finished chemotherapy for breast cancer at Florida Cancer Specialists a year ago this month.

The Naples grandmother counts herself lucky — for the successful outcome and because the large group practice operates in Southwest Florida.

“I still go for testing every couple of months,” the 68-year-old said.

But her insurer, Humana, is dropping the cancer group from its network of providers effective March 15, 2014, said Dr. William Harwin, who founded the group in 1984.

The Louisville-based Humana sent the practice a cancellation notice in September. It applies to all Humana plans, the Louisville-based insurer confirmed.

“No reason was given,” Harwin said. “It was without cause.”

Patients are getting notices from Humana and are upset, he said, adding that the insurer will allow current patients to continue getting treatment with his group, even after the termination takes effect.

“They have to allow us (to continue) until the treatment is over,” he said. “Our first priority is to take care of our patients.”

In Collier, the cancer group is the only outpatient provider of chemotherapy services, said Sarah Cevallos, vice president of payer contracting for the cancer group.

The termination letter said it’s due to a change in Humana’s business model and conflicting views of Humana policies and procedures.

“I have no idea what that means,” Harwin said. “We have made many efforts to try and resolve the situation.”

The cancer group has 162 physicians and extensive support staff in 80 practice locations in Florida serving 12,000 Humana-insured patients, Harwin said.

Nancy Hanewinckel, Humana’s regional spokeswoman, confirmed the cancer group is being terminated.

No other provider groups in Southwest Florida are being terminated, she said.

“Humana must sometimes make difficult business decisions regarding providers in our participating networks and, when this happens, our goal is to reduce disruption to our members as possible,” she said in an email. “Members in current treatment will continue care with their current (cancer group) provider.”

Hanewinckel said Humana nurses are reaching out to members undergoing treatment to answer any questions about continuing care.

Humana intends to have several established oncology groups in its network in Collier by next March when its relationship ends with the cancer group, she said.

Cevallos, with the cancer group, said there’s been no indication yet that Humana is aligning with another group to provide chemotherapy services.

Officials at 21st Century Oncology, which provides radiation services in Lee and Collier, couldn’t be reached for comment.

Harwin said he has a meeting scheduled for Nov. 11 with Humana officials to try to get the decision reversed. In addition, he has filed an appeal, which gets reviewed by a physician review panel.

Harwin doesn’t believe Humana’s decision is based on any medical malpractice claim or that it’s being done to get an upper hand on contract negotiations.

Wallace, the breast cancer survivor treated last year in Naples by the cancer group, hopes there’s a change of heart by Humana. She has Humana’s Medicare Advantage plan now but is switching to traditional Medicare starting in the new year.

“You do develop a relationship with your doctor who has your life in his hands,” she said.

  © 2013 Scripps Newspaper Group — Online