Princess Health andUp to 1/3 of rural hospitals in poor financial shape, auditor finds, calling report a baseline for local decisions that could be tough.Princessiccia

Princess Health andUp to 1/3 of rural hospitals in poor financial shape, auditor finds, calling report a baseline for local decisions that could be tough.Princessiccia

health reform hospitals managed care Medicaid Medicare obamacare state government

Gusty 17:34 Add Comment

By Melissa Patrick and Al Cross
Kentucky Health News
For a video of Edelen's press conference, click here. For a cn|2 report with video, go here.

FRANKFORT, Ky. -- As many as one-third of Kentucky's rural hospitals are in poor financial shape, and the survival of some will likely depend on their willingness to adopt new business models, state Auditor Adam Edelen said Monday.

Unveiling a nine-month study, Edelen said 15 of the 44 hospitals examined were in "poor financial health," and warned, "Closure may be an unfortunate reality for some."

Rural hospitals in purple declined to make useful financial information available to the auditor's office.

The study did not include 22 of the 66 Kentucky hospitals that are located outside metropolitan areas, which declined to participate or didn't provide the type of information requested. Edelen said those hospitals are mainly privately owned. If they had been included, Kentucky Hospital Association CEO Michael Rust said, the financial picture "would be better, but I don't think they would be substantially different."

Gov. Steve Beshear said the report was "a dated snapshot" because its most recent data was from 2013, before federal health reform was fully implemented. "Conditions are no longer the same," Beshear said in a news release. "Hospitals received more than $506 million in 2014 through new Medicaid expansion payments, while seeing significant reductions in uncompensated care costs.  Those are huge changes to hospitals� bottom lines that are not shown here."

Edelen, who was Beshear's first chief of staff, said the full effect of federal health reform isn't certain. His report noted that Kentucky hospitals have had higher-than-average penalties from Medicare for readmitting patients within 30 days, a newly implemented feature of the law. Forty of the 63 hospitals penalized were rural, and nine of the 39 in the U.S. that got the maximum penalty were in Kentucky.

"This report doesn't speak to causation" by the reform law or the state's relatively new managed-care system for Medicaid, Edelen said, it is "not a rebuke" of either, but provides "a baseline for monitoring" by policymakers at the state and local levels.

The report says that to survive, rural hospitals must adapt to new business models, such as merging with larger hospitals or hiring them as managers, forming coalitions with other rural hospitals, or finding a health-care niche that hasn't been served.

Edelen cited Rockcastle Regional Hospital, which has become a niche provider of ventilator dependent care and the coalition formed by Morehead's St. Claire Regional Medical Center and Highlands Regional Hospital in Paintsville to provide more efficient care, improve patient access and adapt to changes under the reform law.

Adaptations might be a hard pill to swallow for many rural hospitals because they call for yet more change in the rapidly changing health-care landscape of electronic health records, managed care, Medicaid expansion and full implementation of the Patient Protection and Affordable Care Act.

Edelen said adaptation is important for rural communities, for whom "the importance of rural hospitals cannot be understated. They provide health care to 45 percent of Kentuckians and in every community they serve they act as one of the larger employers, paying a significantly higher wage than the average the community experiences."

He also cited the many small hospitals that have formed relationships with larger networks to relieve the increased administrative burden associated with the three-year-old managed-care system. The report says half the hospitals studied have reported an increase in hours spent on administration.

The report suggested that the state Cabinet for Health and Family Services negotiate better contracts with managed-care organizations, partly to streamline MCO rules and paperwork to reduce the administrative burden. "We are optimistic that the current work of the cabinet to improve those contracts is going to bear real fruit," Edelen said.

The new contracts will start July 1. In an interview, cabinet Secretary Audrey Haynes sounded optimistic about them but said she couldn't give details.

Haynes has been saying since she became secretary three years ago that many hospitals must change the way they do business. She said in an interview that the readmission penalties have forced hospitals to change by providing better discharge planning, and utilizing outpatient services like home health, nursing homes and rehabilitation.

One Kentucky hospital, in Nicholas County, has closed in the last year. Haynes said the cabinet is working with Fulton County, whose hospital is scheduled to close March 31, to explore how to continue providing care at the facility, such as an emergency room or an ambulatory surgical center.

Haynes recommended in the interview that all nonprofit hospitals put audited financial records and their tax returns on their websites and adhere to open-meeting laws.

In a lengthy response, included in the report, Haynes rejected Edelen's suggestion that her cabinet regularly monitor the fiscal strength of rural hospitals. She said in the interview that would pose a conflict of interest, since the cabinet regulates the hospitals.

Edelen's analysis of hospitals' financial health was based on percentage of revenue kept as profit, number of days of cash on hand, debt financing and depreciation. It found that the financial condition of 68 percent of Kentucky�s rural hospitals scored below the national average.

Edelen's office also surveyed rural hospital administrators, held 11 public hearings and met with representatives of all five Medicaid managed-care companies. His report found that:

• Rural hospitals that were geographically well-positioned, such as Pikeville Medical Center, scored high while geographically-isolated hospitals, like those in Clinton and Wayne counties, scored low. The Clinton County Hospital is in bankruptcy to restructure debt incurred for an expansion and modernization.
• The Pikeville hospital, formerly Pikeville Methodist, was one of only three judged to be in excellent financial health. The others were critical-access hospitals in Franklin and Morganfield.
• Critical-access hospitals, which limit their beds, services and patient stays to qualify for federal reimbursement at 101 percent of cost, scored better than regular acute-care hospitals. They accounted for seven of the 14 that were above the national average and thus were rated "good."
• Fifteen hospitals were rated "fair" and 15 were rated "poor." Westlake Regional Hospital in Columbia, which is in bankruptcy, was at the bottom, far worse than the next highest, St. Joseph Mount Sterling.
• The number of health-care providers across the state � particularly in rural Kentucky � dropped significantly between 2013 and 2014. The cabinet disputed that finding, based on different measurements.

Here are the rankings (click on the image for a slightly larger version):

Princess Health and Times: American boards are exceptional--and not necessarily in a good way. Princessiccia

Princess Health and Times: American boards are exceptional--and not necessarily in a good way. Princessiccia

Gusty 10:44 Add Comment

The recent New York Times piece on the behavior of (mainly for-profit, but by extension...) US organizations' boards of directors, goes some way toward explaining the anechoic effect.

The redoubtable Gretchen Morgenson reports on the gulf between company directors' approach to transparency in the United States when compared, say, with a lot of boards in the UK, Holland, and the Scandinavian countries.

The novel idea of taking shareholders' views into account seems to be far more common on the other side of the pond. When it comes to for-profit entities, of course, investors' expectations come into play--you'd think this would be an easier case.

One would think that directors would take their fiduciary responsibilities seriously, and at least listen. In the US, however, there seems to be a systematic process of hiving off the directors in a sort of anechoic chamber. Two-thirds of board members in one survey didn't communicate at all with the outside world. Over half hadn't even had a discussion about their organizational communications policies!

Non-profits--and health care spans both types--don't have investors per se. But they have lots of stake-holders. Health Care Renewal's editor and lead blogger, Dr. Poses, has reported in these pages early and often about the lack of transparency on both sides of this rather artificial divide. It's a bit surprising, then, to hear that accountability is more highly valued in Europe than in these democratic United States.

My own experience with boards has been highly consonant with this insular approach. Directors seem mostly there to prop up management. Rubber stamps are the most important tools. Fat wallets also help. Circling the wagons is the most important skill set. Board members in health care organizations, including those that are not-for-profit, either don't talk about what they see lacking, or, scarier still, it's nicely hidden from them. Probably both. I've heard chairpersons publicly excoriate directors, in front of their peers, for "free-lancing" when they engaged in responsible outside communication.

These boards, and especially their chars, almost invariably defer to management. Non-profits wait until their top management do something not merely execrable but illegal and humiliating before they remove them. Is this laziness or selling-out? Unclear. Maybe both.

If this is the kind of American Exceptionalism our organizations subscribe to, they might want to try being a bit more unexceptional!

Princess Health andResearchers discuss physical activity as a way of maintaining or improving health; daily walking is still the best exercise .Princessiccia

Princess Health andResearchers discuss physical activity as a way of maintaining or improving health; daily walking is still the best exercise .Princessiccia

child obesity childhood obesity children's health diet exercise nutrition physical activity physical inactivity research schools

Gusty 17:31 Add Comment

By Melissa Patrick
Kentucky Health News

Obesity worsens the damage that arthritis does to joints, but simply telling patients to go home and diet and exercise is not working, and health care providers must proactively monitor their patients and help them find affordable solutions to succeed. And daily walking is still the best exercise.

Those were examples of research findings discussed at the 10th annual Center for Clinical and Translational Science conference sponsored by the University of Kentucky on March 25. More than 700 researchers, students, policymakers and guests discussed research with a focus on physical activity across the lifespan.

Stephen Messier, professor and director of a biomechanics laboratory at Wake Forest University, said obesity has a significant effect on joint health, particularly osteoarthritis, which he said is quite painful. He called for closer attention to obese patients with arthritis.

He said a study found that a combination of diet and exercise over an extended period of time offers the best results for less pain and less disability. He said that a separate study found those who lost 10 percent of their body weight had the most "significant outcomes" related to function, which included walking speed.

The conference featured 31 oral presentations and 270 poster presentations, addressing a vast array of topics including physical inactivity in children, physical inactivity in chronic disease and biomedical informatics.

"The conference was designed to raise awareness of the science behind the benefits of exercise and the dangers of physical inactivity," Charlotte Petterson, professor and associate dean of research in the College of Health Sciences, who chaired this year's conference, said in a UK press release.

The keynote speaker, Duke University medicine professor William E. Kraus, encouraged walking as a proven and simple activity that can improve health and actually extend life. "Fitness always trumps fatness," he said, noting that a "culture of convenience" and conditions of built environments, such as absence of sidewalks, deter people from physical activity.

Research on fourth and fifth graders in two Clay County schools, while in the early stages of analysis, found that obesity and inactivity begins early.

Karyn Esser, professor of physiology at the UK College of Medicine, said her research was examining the circadian rhythms and physical activities of students because changes in natural circadian rhythms "can create pre-cursors to disease" in just seven days, even in healthy young people. She said her study is intended to help schools improve students' health by adjusting meal times and offering physical activities to best coincide with circadian rhythms.

The data for Esser's study was gathered through electronic devices that the 136 students wore for seven days to measure activity, heart rate and skin temperature. The students also kept a daily journal to record their activities. So far, Esser said, the data show 33 percent of the students are considered obese, their initial blood pressure measurements are on the high end of normal, and the students are less active on weekends and nights than during the school week.

Another UK study found that students who are more active during the school day do better in mathematics.

Alicia Fedewa and Heather Erwin of the College of Education said they found that increased physical activity levels "significantly improved" math scores and slightly improved reading scores of the students who got an extra 20 minutes of movement on each school day. They recommended two short 15-minute recesses per day, rather than one long one. They also said that classroom "energizers" and stability balls also help students with these behaviors.

The researchers said many studies show that students who participate in recess and physical education during the school day are more focused and less fidgety, show less listlessness, and have better overall classroom behavior. They said more controlled studies need to be conducted, but said most studies to date have found that fit kids have less anxiety and better overall well-being. Also, a regimen of consistent physical activity is best for kids with attention deficit hyperactivity disorder (ADHD).

Princess Health andWashington Post columnist looks at data, talks to experts and concludes Obamacare is working, at less cost than expected.Princessiccia

Princess Health andWashington Post columnist looks at data, talks to experts and concludes Obamacare is working, at less cost than expected.Princessiccia

health care costs health insurance health reform obamacare politics president

Gusty 15:47 Add Comment

The federal health-reform law "has accomplished its goal of expanding coverage � at a significantly lower cost than expected," columnist Ruth Marcus writes for The Washington Post "after talking to numerous health-care experts and examining the data."

Marcus writes up front, "There is a legitimate ideological debate about whether it is a wise use of federal power to require individuals to obtain health insurance or a wise use of federal resources to spend so much on subsidizing coverage. What�s more puzzling, and more disturbing, is the still-raging division over the real-world effect of the ACA."

She says President Obama "over-promised when he told people that, if they liked their health insurance, they could keep it; by its own terms, the law set new standards for required coverage. Certainly, some individuals, particularly younger and healthier customers, find themselves paying more; again, such winners and losers were an inevitable consequence of the individual mandate and minimum-coverage rules. Meantime, the scariest warnings � of employers rushing to drop coverage and insurance markets ensnared in death spirals of ever-rising premiums � have not come to pass.
Where the law has yet to fully deliver on its promises � and some wonder whether it will � is in the area of cost containment and quality improvement."

Marcus backs up her assessment with facts. For example, "Health-care costs and premiums for employer-sponsored insurance (the way most of us obtain coverage) have been rising at their lowest levels in years. On the exchanges, premium increases during the law�s second year mirrored that modest growth � averaging 2 percent on some mid-range plans and 4 percent on the lowest-cost ones, according to the Kaiser Family Foundation."

Princess Health andWoman needing lung transplant falls through cracks of health-care system, says she's treated as nothing more than a 'price tag'.Princessiccia

Princess Health andWoman needing lung transplant falls through cracks of health-care system, says she's treated as nothing more than a 'price tag'.Princessiccia

health insurance lung disease lung transplant Medicaid Medicare

Gusty 09:57 Add Comment

Katie Prager, a 24-year-old cystic fibrosis patient from Ewing in Fleming County, needs a lung transplant, but has been denied one because she has met her lifetime maximum on Medicare, Christy Hoots reports for The Ledger Independent in Maysville.

Photo from The Ledger Independent

"They've put a price tag on my name. That's all I am to these people right now," Prager told Hoots from her hospital bed at the University of Kentucky's Chandler Medical Center.

Prager has had cystic fibrosis her entire life, but it was a diagnosis of an infection called burkholderia cepacia in 2009 that caused her lung function to rapidly decline and caused the need for a lung transplant. She was told in 2013 that the UK Center for Cystic Fibrosis does not do transplants on cystic fibrosis patients with this infection, so she was sent to the University of Cincinnati hospital, Hoots reports.

She and her husband Dalton Prager, who also has cystic fibrosis, were then sent to the University of Pittsburgh Medical Center because it is only one of two hospitals that will transplant a lung into a patient with this infection. They began evaluations in January 2013.

Dalton Prager was quickly approved and successfully received a double lung transplant in November 2013. Katie Prager wasn't approved until June 2013. While waiting for a donor lung, she was discharged to spend Christmas with her family, only to hear from the hospital that she could not return there because the Medicare maximum had been reached.

"At first, I thought I might be able to use Medicaid, but was told that it wouldn't cover my transplant due to UPMC being out of network," Katie Prager told Hoots. "After explaining to Medicaid that there are only two places in the country who would operate, due to cepacia, they still refused to work together to help me. In January 2015 I filed an appeal with Medicaid to have them reconsider. The appeal was denied."

She was recently told she would never be eligible to return to UPMC for a transplant and there was nothing else they could do for her, Hoots reports.

"They told me to basically stop wasting my time," she told Hoots. "These are people who we're trusting with our lives and they say that. Most people have no problems when they have to have medical treatments or transplants, and I'm being given the runaround. I'm not trying to be a burden on the system -- that isn't what I want. If I could work and get my own insurance, I would. All I want is a normal chance at life. I want to get my bachelor's degree, get up every day and go to work, run a 5K and have a normal life with my husband. I want to do all the things that young people in love get to do. Is that so much to ask?"

Princess Health andKentucky is one of three states to get Walmart Foundation money to expand farm-to-school programs.Princessiccia

Princess Health andKentucky is one of three states to get Walmart Foundation money to expand farm-to-school programs.Princessiccia

education farm to school philanthropy schools state government

Gusty 09:50 Add Comment

Kentucky will use money from The Walmart Foundation to partner with the National Farm to School Network to expand efforts to get more local foods into schools.

A project called Seed Change will �jump start� programs that get local foods into schools and enhance food education for more than 1.8 million school children at 100 sites in Kentucky, Louisiana and Pennsylvania, the network said in a news release. Each site will get $5,000 grants, with applications to be accepted later this spring.

The state Department of Agriculture�s farm-to-school program connects schools with local farmers and food producers and helps students "learn to appreciate the importance of local foods and grow into well-informed consumers who demand local foods as adults," the release said. The program served an estimated 364,000 children in about 700 schools in 84 districts in the 2011-12 school year. For more information on the program, go to www.kyagr.com or contact Tina Garland at 502-382-7505 or tina.garland@ky.gov.

Princess Health andNew health-related laws deal with heroin, dating violence, end-of-life care, prescriptions, colon-cancer and newborn screening.Princessiccia

Princess Health andNew health-related laws deal with heroin, dating violence, end-of-life care, prescriptions, colon-cancer and newborn screening.Princessiccia

colorectal cancer domestic violence drug treatment end-of-life care General Assembly health heroin legislation physician assistants prescription drugs research stroke

Gusty 10:39 Add Comment

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. � The Kentucky General Assembly passed several health-related bills this session, including high-profile measures on heroin and dating violence. It did not pass many others, including one that would have a great influence on the state's health: a statewide smoking ban, which passed the House for the first time ever, but never got out of an unfavorable committee in the Senate. Here's a roundup:

Heroin: Kentucky's heroin-overdose epidemic was caused partly by a 2012 legislative crackdown on prescription painkillers, which steered users to the illegal drug. Last year's bill died because of deadlock over sentences for traffickers and needle-exchange programs for addicts, and Gov. Steve Beshear and legislators gave this year's bill top priority. It was not finally negotiated until a few hours before passage, but Beshear signed Senate Bill 192 into law less than 12 hours after it passed so that its emergency clause could put it into effect immediately.

SB 192 includes both a needle-exchange program and harsher penalties against traffickers, the main points of contention between the House and Senate, but requires local governments to approve needle exchanges and allows judges to be lenient in sentencing addicts, to help them get treatment. It allocates money for drug-treatment programs, allows increased access to Naloxone, a drug that reverses the effects of an overdose, and allows jailers to provide medically assisted treatment for inmates with opiate addiction.

Dating violence: After 10 years of lobbying and debate, the dating violence bill will allow dating partners to get interpersonal protective orders from a judge if they have been the victim of dating violence, sexual abuse or stalking. This year's bill largely dissolved social conservatives' opposition by creating a new chapter in the law for dating violence, with the same protections as the domestic-violence law. Kentucky is the last state to offer protection to dating-violence victims. House Bill 8 was sponsored by Rep. John Tilley, D-Hopkinsville, who also sponsored the House heroin bill.

Beshear has signed these bills into law:

Prescription synchronization: SB 44, sponsored by Sen. Julie Raque Adams,R -Louisville, will allow patients with multiple prescriptions, in consultation with their health-care provider and their pharmacist, to synchronize prescriptions so that they may be picked up at the same time.

Medical order scope of treatment: SB 77, sponsored by Sen. Tom Buford, R-Nicholasville. will create a medical order scope of treatment (MOST) form that specifically directs the type of treatment a patient would like to have, and how much intervention he or she would like to have, during end-of-life care.

Colorectal cancer screening: SB 61, sponsored by Sen. Ralph Alvarado, R-Winchester, will require that a fecal test to screen for colon cancer, and any follow-up colonoscopy, be considered preventive measures that health insurance is required to cover without imposing additional deductible or co-insurance cost. The governor also signed a similar measure, HB 69, sponsored by Rep. Tom Burch, D-Louisville, which contains an amendment by Sen. Julian Carroll, D-Frankfort, for a Medicaid savings study.

Newborn screenings for fatal disease: SB 75, sponsored by Sen. Alice Forgy Kerr, R-Lexington, will require all newborns to be tested for Krabbe disease, a neurological disorder that destroys the protective coating of nerve and brain cells and is fatal once symptoms occur.

Spina bifida: SB 159, sponsored by Adams, will require medical providers to supply written, up-to-date, accurate information to parents when their unborn child is diagnosed with spina bifida so they can make informed decisions on treatment.

Emergency care for strokes: SB 10, sponsored by Sens. Stan Humphries, R-Cadiz, and David Givens, R-Greensburg, requires that local emergency services have access to a list of stroke-ready hospitals, comprehensive stroke centers and primary stroke centers in Kentucky. Emergency medical providers will set their own protocols for assessment, treatment and transport of stroke patients.

Alcohol and drug counselors: HB 92, sponsored by Rep. Leslie Combs, D-Pikeville, creates an enhanced licensing program to recognize three levels of certified alcohol and drug counselors, with different levels of education. The goal is to increase the number of counselors in the state.

UK cancer research center: HB 298, sponsored by Rep. Rick Rand, D-Bedford, revises the state budget to authorize $132.5 million, half of the cost, for a new medical research center at the University of Kentucky. The university says it will raise money to cover the other half.

These health bills awaited the governor's signature Monday morning:

Physician assistants: HB 258, sponsored by Rep. Denver Butler, D-Louisville, to allow physicians to supervise up to four physicians at the same time, rather than two.

In-home care: HB 144, sponsored by Burch, to establish a 60-day, hospital-to-home transition program through an approval waiver from the Department for Medicaid Services.

Pharmacist-practitioner collaboration: HB 377, sponsored by Rep. Dean Schamore, D-Hardinsburg, to allow collaboration between pharmacist and practitioners to manage patients' drug-related health needs.

Tax refund donations: SB 82, sponsored by Sen. Max Wise, R-Campbellsville, to put an income tax check-off box on tax forms to allow people the option of donating a portion of their tax refund to support pediatric cancer research, rape crisis centers or the Special Olympics.

Health related bills that were left hanging:

The smoking ban, HB 145, sponsored by Rep. Susan Westrom, D-Lexington, never got a hearing in the Senate Veterans, Military Affairs and Public Protection Committee, and neither did the Senate companion bill, SB 189, sponsored by Adams.

Three bills challenged Medicaid managed-care companies. SB 120, sponsored by Alvarado, would have created a process for health-care providers to appeal the companies' decisions to the state passed the Senate, but not the House.  And the following two bills that never got out of the Senate: SB 88, also sponsored by Alvarado, which challenged the $50 "triage fees" MCOs pay for emergency-room visits that they conclude were not emergencies, and would have required them to pay contracted fees instead and SB 31, sponsored by Buford, which would limited the amount of co-payments. Also not getting House action was Alvarado's SB 6 would have created review panels for lawsuits seeking damages from health-care providers.

Princess Health andYou can volunteer for medical research by signing up through a national registry that connects volunteers and researchers .Princessiccia

Princess Health andYou can volunteer for medical research by signing up through a national registry that connects volunteers and researchers .Princessiccia

research University of Kentucky

Gusty 20:18 Add Comment

Have you ever wondered how you could volunteer for medical research?

ResearchMatch provides this opportunity through a national registry that brings together volunteers who are interested in research, and researchers who are looking for participants for their studies, University of Kentucky President Eli Capilouto said in a letter of invitation to participate.

"Too often, studies end early because there are not enough volunteers, leaving important questions unanswered and new treatments undiscovered. But you can help make a difference," Capilouto said in the letter.

ResearchMatch is an easy-to-use, secure registry where anyone can sign up to volunteer to participate in studies. It needs both healthy participants as well as those with medical conditions to sign up. Specific medical conditions and studies can be searched for on its "About" or "Volunteer" pages. The list of current research studies at UK can be found by visiting UKclinicalresearch.com or e-mailing ukclinicalresearch@uky.edu.

Participation might involve filling out a questionnaire, maintaining a diary, taking new medications or using a new device. The choice to participate in the study is always up to the volunteer and your name can be removed at any time. The registry has more than 74,000 participants and is operated by Vanderbilt University, a partner of the UK Center for Clinical and Translational Science.  

Princess Health andHow has the federal health-reform law changed your care?.Princessiccia

Princess Health andHow has the federal health-reform law changed your care?.Princessiccia

cancer screening doctors electronic health records immunizations obamacare physicians prevention vaccinations women's health

Gusty 15:04 Add Comment

Despite the controversy that continues to surround the Patient Protection and Affordable Act five years after its passage, it has probably changed the way your health care is delivered as it drives new models of payment, forces providers to approach care differently, and changes how health care is evaluated, Kavita Patel and Domitilla Masi report for the Brookings Institution.

Here are five ways the authors say that your health care might be different than it was five years ago because of the reform law:

Your physician might be part of a patient care team. New payment models in the ACA encourage an interdisciplinary team-based approach, which evidence shows "can lead to higher quality care and better health outcomes for patient." This approach allows the physician to spend more time diagnosing and devising a treatment plan, while the patient may spend more time interacting with non-physician staff for support care.

Prevention and wellness are more important than ever. The ACA requires health plans to cover all preventive screenings, immunizations and well visits for women at no cost, as part of the minimum benefits required in order for health-insurance plans to participate in exchanges like Kynect. The new payment models also pay physicians who work toward keeping their patients healthy, instead of just treating them when they are sick. " Since the policy took effect in September 2010 it is estimated that an additional 76 million people now receive preventive care," the authors write.

You may have better access to care on evenings and weekends. New payment models are driving this change as practices are often required to offer extended hours to decrease the overuse of emergency departments. Many offices now offer clinical advice around the clock with a clinician who has immediate access to their medical records.

Chances are your health information is being stored in an electronic health record, not a paper file. A separate law encouraged the use of EHRs, but "participation in the new ACA-promoted delivery models is practically impossible" without them. And while EHRs can be used to greatly improve patient care, not all EHRs are created equal and it will take time before patients see seamless integration and exchange between different doctors and settings in "real-time".

You can access care remotely, wherever you are. Doctors are using mobile technology and tele-health in rural and remote areas to provide more efficient care to patients. Insurance companies and employers are beginning to recognize this mode of treatment not only as a way to save money, but to also provide timely access to care, that does not involve the emergency room.

Princess Health and Opinion, CIO Magazine: "The medical profession needs to get over its fear of information technology"- their complaints bogus. Princessiccia

Princess Health and Opinion, CIO Magazine: "The medical profession needs to get over its fear of information technology"- their complaints bogus. Princessiccia

CIO magazine healthcare IT dangers healthcare IT dissatisfaction healthcare IT usability healthcare IT utopianism

Gusty 13:47 Add Comment

There comes a time when the pundits defending the status quo in the healthcare information technology sector and health IT utopianism simply need to be thoroughly and definitively refuted.

This is such a time.  CIO magazine reaches the country's information technology leadership, including those in heathcare.   Hence, canards and meritless defamation of physicians can (and in my experience does) impact the attitudes and decisions of the leaders of the very technology physicians are increasingly dependent upon to deliver safe care.

Ultimately, such misinformation can and does result in patient harm through bad health IT.

Let's start with the title and subtitle alone of an opinion piece in CIO magazine:

March 26, 2015 
Paddy Padmanabhan - Opinion
http://www.cio.com/article/2886751/healthcare/the-medical-profession-needs-to-get-over-its-fear-of-information-technology.html 

The medical profession needs to get over its fear of information technology
Continued objections to Electronic Health Records ( EHR) by sections of the physician community are bogus. They arise from past entitlements and a lack of accountability.

The term "bogus" has clear meaning:

Merriam-Webster dictionary
http://www.merriam-webster.com/dictionary/bogus
Bogus

:  not genuine :  counterfeit, sham

This is a laughable yet alarming, cavalier defamation and attempted character assassination of the medical profession.

Mr. Padmanabhan is described as a business leader & entrepreneur with over 25 years of experience in Technology and Analytics in the Healthcare sector as well as being a consultant in that domain.  I can openly aver that, with an apparent significant bias as seen below towards the medical profession, I would not want him involved in any way in my own care...

There is nothing "bogus" about, for instance,

• The complaints of nearly 40 medical societies ("Meaningful Use Not so Meaningful", http://hcrenewal.blogspot.com/2015/01/meaningful-use-not-so-meaningul.html), 

• Countless nurses ("Nurses Warn That Serious Patient Complications 'Only a Matter of Time' in Open Letter", http://hcrenewal.blogspot.com/2013/11/another-survey-on-ehrs-affinity-medical.html and "RNs Say Sutter�s New Electronic System Causing Serious Disruptions to Safe Patient Care at East Bay Hospitals" at http://hcrenewal.blogspot.com/2013/07/rns-say-sutters-new-electronic-system.html; there are links there to still more examples),

• Organizations studying health IT including the U.S. National Academies ("Current Approaches to U.S. Health Care Information Technology are Insufficient to achieve medical leaders' vision of health care in the 21st century and may even set back the cause"), http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12572), 

• Institute of Medicine ("Health IT and Patient Safety: Building Safer Systems for Better Care", http://hcrenewal.blogspot.com/2011/11/iom-report-on-health-it-safety-nix-fda.html), 

• ECRI Institute (Deep Dive Study on Health IT Safety, http://www.healthit.gov/facas/sites/faca/files/STF_Deep_Dive_Health_Information_Technology_2014-06-13.pdf) 

• and others as memorialized on this blog (e.g., http://hcrenewal.blogspot.com/search/label/EHR%20death, also http://hcrenewal.blogspot.com/search/label/glitch) and elsewhere.

The author risibly dismisses them all with the word "bogus."  It might be opined that he was too indolent to conduct research, but I'll just opine he doesn't know what he doesn't know and that the opinion piece was based on simple ignorant arrogance.

I am uncertain what "entitlements" he refers to, but using paper records was not a physician "entitlement" - in fact, they are still used when the lousy hospital IT decides to go on vacation as it recently did, for example, at Children's Hospital Boston ("Boston Children�s emerges from electronic records shutdown", Boston Globe, March 25, 2015,  http://www.bostonglobe.com/metro/2015/03/25/boston-children-emerges-from-day-shutdown-electronic-medical-records/Q6sE7hRM4CxFeMEDYWP8IK/story.html#). 

(Of course, patient safety was not compromised - it never is when the IT goes out - right.  See the many posts at the query link http://hcrenewal.blogspot.com/search/label/Patient%20care%20has%20not%20been%20compromised.)

Further, the true "lack of accountability" lies with the healthcare IT industry itself and the hospital leadership who agree to their terms of contractual indemnification (Health care information technology vendors' "hold harmless" clause: implications for patients and clinicians. Koppel & Kreda, JAMA. 2009 Mar 25;301(12):1276-8. doi: 10.1001/jama.2009.398, http://medecon.pbworks.com/f/IT%20Accountability%20JAMA09.pdf. 

Also see my commentary in a JAMA letter to the editor of July 2009 at http://jama.jamanetwork.com/article.aspx?articleid=184302 emphasizing how these arrangements violate Joint Commission safety standards, and my posting my health IT academic site at http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=koppel_kreda).

And that was just responding to the title and subtitle.  Now to the body of the piece:

... In a recent article in a national publication, a member of our physician community raked up a debate by declaring the Electronic Health Records (EHR ) mandate to be a debacle and argued that EHR�s actually harm patients.  These are bogus objections.

Congratulations for disrespecting my mother's grave, Mr. Padmanabhan (http://hcrenewal.blogspot.com/2013/09/on-ehr-warnings-sure-experts-think-you.html)  and that of many other people harmed by Information Technology Malpractice as for example in the above links

Also see "The Malpractice Risk of Electronic Health Records", Legal Intelligencer - a Pennsylvania Legal newspaper, March 17, 2015, http://www.thelegalintelligencer.com/most-read-articles/id=1202720405290/The-Malpractice-Risk-of-Electronic-Health-Records.

Thanks for being an expert on the issues you so glibly dismiss, Mr. Padmanabhan.  I guess you forgot to check out the AHRQ hazards taxonomy (http://healthit.ahrq.gov/sites/default/files/docs/citation/HealthITHazardManagerFinalReport.pdf) and similar resources on health IT risk:

A "bogus" checklist of known EHR risks from the U.S. government.  Click to enlarge.

Back to the opinion piece:

... According to a Rand Corporation study, the three key objections against the implementation of EHR�s:

--It costs too much to implement an EHR system: Yes, it costs money to implement any new software. Given a choice, physicians would prefer not to use email or even the telephone because all of these things cost money and have no direct relation to the treatment of patients. What these same physicians also fail to mention is that large hospital systems have been extending significant subsidies to small physician practices in order to help them address the costs.

"Given a choice, physicians would prefer not to use email or even the telephone because all of these things cost money and have no direct relation to the treatment of patients." (?)


Really?

This is an example of a profound anti-physician bias, although one could argue that the term mentioned by Yves Smith on Naked Capitalism, "lunatic triumphalism", comes into play with that statement.

What these same physicians also fail to mention is that large hospital systems have been extending significant subsidies to small physician practices in order to help them address the costs.

And just what % of the total costs of ownership are covered, Mr. Padmanabhan?   The financial analyses I see show significant clinician unreimbursed expense for the office.

Inpatient settings - that's another matter entirely - we're talking hundreds of millions of dollars or more per organization.

Perhaps my math is wrong, but hundreds of millions of dollars hospitals dish out on corporate health IT can pay for entire new hospitals, or pay for the medical care of countless disadvantaged people.  (e.g., http://hcrenewal.blogspot.com/2014/06/100-million-epic-install-dampens.html, as well as http://hcrenewal.blogspot.com/2014/06/in-fixing-those-9553-ehr-issues.html and http://hcrenewal.blogspot.com/2013/06/want-to-help-hospital-go-bankrupt-get.html)

--It takes time away from patient care: Physicians love to talk about how much they care about being with their patients. However, they also routinely overbook their schedules with the sole intention of increasing patient visits and claiming additional reimbursement.

That's a very serious and, to my knowledge, completely unfounded accusation.  Many physicians are burned out from being compelled to see too many patients by administrators, especially if they are employed which is becoming very common. You in my opinion need to be taught how not to hate physicians and other clinicians, Mr. Padmanabhan:

Physician Burnout: It Just Keeps Getting Worse
Medscape, Jan, 26, 2015
http://www.medscape.com/viewarticle/838437

A national survey published in the Archives of Internal Medicine in 2012 reported that US physicians suffer more burnout than other American workers.[1] This year, in the Medscape Physician Lifestyle Report, 46% of all physicians responded that they had burnout, which is a substantial increase since the Medscape 2013 Lifestyle Report, in which burnout was reported in slightly under 40% of respondents. Burnout is commonly defined as loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment

Back to the opinion piece:

EHR�s can actually aid their productivity by reducing the time it takes to pull up medical history, so that they have more time to spend on actually talking to their patients.

An expert with far more experience than you, Mr. Padmanabhan, says you are flat wrong (not counting me).  His name is Dr. Clement McDonald, and he is an EHR pioneer ("The Tragedy Of Electronic Medical Records", http://hcrenewal.blogspot.com/2014/10/the-tragedy-of-electronic-medical.html):

... McDonald now has a nationally influential post to promote electronic medical records, as the director of the Lister Hill Center for Biomedical Communications, a part of the National Library of Medicine, which is one of the National Institutes of Health.

During his talk, McDonald released his latest research survey, which found that electronic medical records �steal� 48 minutes per day in free time from primary care physicians.

Back to the opinion of Mr P.:

--EHR systems are hard to use and are not secure: There may be some merit to this. No one is making claims that EHR systems are perfect.

"May be some merit?"

"May?"


There is perhaps merit to saying Mr. Padmanabhan is either ill-informed, or delivering deliberate misinformation  (e.g., "NIST on the EHR Mission Hostile User Experience", http://hcrenewal.blogspot.com/2011/10/nist-on-ehr-mission-hostile-user.html, and multiple posts on breach issues retrievable via query link http://hcrenewal.blogspot.com/search/label/medical%20record%20privacy).

However, there are a few key aspects that these physicians prefer to not acknowledge when making these arguments:

--Shared electronic medical records can reduce expenses: Physicians routinely bill for duplicate medical expenses, such as tests, that would be avoided if the test results can simply be pulled up electronically. This should logically reduce healthcare costs at a system level.

Great in theory, but the real world is just not that simple.  Mr. Padmanabhan like many other IT hyper-enthusiasts apparently see IT as a silver bullet.  Just put it in and .... presto!  All complex multi-factorial social problems are solved, with no ill effects. Perhaps he and other hyper-enthusiastic health IT pundits need to read this article:

Pessimism, Computer Failure, and Information Systems Development in the Public Sector.  (Public Administration Review 67;5:917-929, Sept/Oct. 2007, Shaun Goldfinch, University of Otago, New Zealand).  Cautionary article on IT that should be read by every healthcare executive documenting the widespread nature of IT difficulties and failure, the lack of attention to the issues responsible, and recommending much more critical attitudes towards IT.  linkto pdf

And this:

"Doctors and EHRs: Reframing the "Modernists v. Luddites" Canard to The Accurate "Ardent Technophiles vs. Pragmatists" Reality", http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html

More opinion:

--Quality of treatment can improve significantly: When a complete medical record is available about a patient, including details of visits to multiple healthcare professionals, the quality of diagnosis and hence treatment decisions should improve greatly. This improves patient safety and reduces medical errors, since everyone has access to the same set of data.

 That may be the only accurate statement in the opinion piece.  Yet, even this is not proven in the real world, and with today's highly experimental health IT.

--EHR�s can enable preventive diagnosis and early intervention that reduces costs and improves patient health: Enter healthcare analytics. Having patient medical records in an electronic system enables this data to be analyzed for preventive and early action, improved disease management, and reduced hospitalizations. The whole notion of population health management rests on this premise and is hard to argue with.

It's actually easy to argue with, as are most grandiose pronouncements about computational alchemy (i.e., in the world of data, turning lead into gold).

Again in theory, yes, but Mr. Padmanabhan is seemingly unaware of issues I raised in my article "The Syndrome of Inappropriate Overconfidence in Computing: An Invasion of Medicine by the Information Technology Industry?" at http://www.jpands.org/vol14no2/silverstein.pdf.  The uncontrolled nature of aggregated EHR data, and social factors that skew and bias it, never seem to enter into the minds of the computational alchemists.

The truth is:

• Physicians, nurses and other clinicians are rightfully afraid of having bad health IT forced upon them due to the constraints of their time, their concentration, and their obligations and legal liabilities; 

• Physicians are rightfully unwilling to be the experimental subjects of IT hyper-enthusiasts who are so hooked on theory, they ignore the actual downsides of an immature, experimental technology in the real world, including patient injury and death; and

• Patients should be scared to death of this technology as it now exists in the real world - and should also object to being experimental subjects for life-critical software debugging (e.g., see "We�ve resolved 6,036 issues and have 3,517 open issues" (http://hcrenewal.blogspot.com/2013/11/weve-resolved-6036-issues-and-have-3517.html), especially without informed consent of the risks.

I note that I feel dirtied even having to write this post.

-- SS

Addendum 3/27/15:  

A colleague observed:

.. And I suppose all those current med students and residents who grew up with information technology and have known nothing but  EHR�s are �afraid� of information technology?  I�m hearing complaints from the younger generation about the problems with using them. 

-- SS

Princess Health andFederal dietary guidelines recommend cutting back on red and processed meat, sugar and refined grains.Princessiccia

Princess Health andFederal dietary guidelines recommend cutting back on red and processed meat, sugar and refined grains.Princessiccia

food nutrition obesity sugar

Gusty 20:09 Add Comment

The Department of Agriculture and the Department of Health and Human Services have released proposed 2015 Dietary Guidelines for Americans. The guidelines, released every five years, "provide authoritative advice about consuming fewer calories, making informed food choices, and being physically active to attain and maintain a healthy weight, reduce risk of chronic disease, and promote overall health," says USDA.

It shouldn't come as a surprise that the 2015 guidelines recommend eating healthier foods, while cutting back on less healthy alternatives. "The committee basically recommended Americans take up a diet that is higher in vegetables, fruits, whole grains, low- or non-fat dairy products, seafood, legumes and nuts," Chris Clayton reports for DTN The Progressive Farmer. "We should cut back on red and processed meats and sugar-sweetened foods, drinks and refined grains. And we should be moderate in our alcohol."

Recommended cutbacks of certain foods have not gone over well with those food producers, who met this week to give feedback on the Dietary Guidelines Advisory Committee's recommendations, Clayton writes. The North American Meat Institute argued that "lean meat, poultry, red and processed meats should all be part of a healthy dietary pattern because they are nutrient-dense protein."

Shalene McNeill, a nutritionist for the National Cattlemen's Beef Association, "told the committee that its recommendation to exclude lean meat ignores decades of nutrition science," Clayton writes. McNeill said Americans should be encouraged to eat more lean meat, along with fruits, vegetables and whole grains. Grain, sugar and milk producers also expressed displeasure with the proposed rules.

Most nutritionists have embraced the proposed rules, but say the key is getting people to adopt them, Andrea McDaniels reports for The Baltimore Sun. Among those rules is limiting sugar intake to 200 or less calories, or 10 percent of total calories, per day. Currently, Americans get about 13 percent of their calories, or 268 calories, from added sugar.

"On the flip side, some foods once shunned are now accepted," McDaniels writes. "Research has found that cholesterol-high foods are no longer believed to contribute to high blood cholesterol, so people can now indulge in shrimp, eggs and other foods that were once off limits, the panel said. Rather than focus on cholesterol, people should curb saturated fat to about 8 percent of the diet."

The panel also said "up to five cups of coffee a day are fine, so long they are not flavored with lots of milk and sugar," McDaniels writes. "The panel also singled out the Mediterranean diet�rich in fish and chicken, fruits and vegetables, nuts, whole grains, olive oil and legumes�for its nutritional value."

Princess Health and Is Meat Unhealthy? Consolidated links. Princessiccia

Princess Health and Is Meat Unhealthy? Consolidated links. Princessiccia

Gusty 14:25 Add Comment

Several people have asked for a consolidated list of links to my series on meat and health.  Here it is!  This should make it easier to share.  

Is Meat Unhealthy?  Part I.  Introduction and ethical/environmental considerations.

Is Meat Unhealthy?  Part II.  Our evolutionary history with meat.

Is Meat Unhealthy?  Part III.  Meat and cardiovascular disease.

Is Meat Unhealthy?  Part IV.  Meat and obesity risk.

Is Meat Unhealthy?  Part V.  Meat and type 2 diabetes risk.

Is Meat Unhealthy?  Part VI.  Meat and cancer risk.

Is Meat Unhealthy?  Part VII.  Meat and total mortality.

Is Meat Unhealthy?  Part VIII.  Health vs. the absence of disease.

Is Meat Unhealthy?  Part IX.  Summary.

Princess Health andHeroin bill finally passes and is signed into law; Naloxone program put into motion; dating-violence bill sent to Beshear.Princessiccia

Princess Health andHeroin bill finally passes and is signed into law; Naloxone program put into motion; dating-violence bill sent to Beshear.Princessiccia

drug abuse drug treatment drugs General Assembly heroin legislation violence women's health

Gusty 20:54 Add Comment

By Melissa Patrick
Kentucky Health News

The long-negotiated bill to tackle Kentucky's heroin-overdose epidemic passed in the final hours of the 2015 legislative session.

Almost immediately after the heroin bill passed the Senate, a bill to offer immediate civil protections to dating partners who are victims of dating violence was passed after being held in the chamber since February 13 -- likely because Democratic Rep. John Tilley of Hopkinsville, chair of the House Judiciary Committee, was the original sponsor of both bills.

Tilley told reporters that the passage of the two bills meant it had been a successful session.

Gov. Steve Beshear signed the heroin legislation, Senate Bill 192, into law Wednesday, March 25, less than 12 hours after it passed, so that its emergency clause could put it into effect immediately. The dating violence bill, House Bill 8, has been delivered for his signature.

"Senate Bill 192 is tough on traffickers who bring these deadly drugs into our communities, but compassionate toward those who report overdoses or who admit they need help for their addiction," Beshear said in a release. "I applaud our legislators for putting aside partisan interests for the greater good of all Kentuckians who have been affected by this devastating drug."

The bill passed the Democrat-controlled House 100-0 and the Republican-controlled Senate 34-4. Republican senators John Schickel of Union, Joe Bowen of Owensboro, Chris Girdler of Somerset and Paul Hornback of Shelbyville voted against it.

The stickiest issues were a needle-exchange program, which many senators opposed, and tough new penalties for drug traffickers, which Tilley and many House members said would not be effective. The new law allows needle-exchange programs of approved by local governments, and the tough penalties, but allows the judge to be lenient in sentencing if the defendant is an addict.

The bill also allocates money for drug treatment programs; includes a "good Samaritan" provision that allows a person to seek medical help for an overdose victim and stay with them without fear of being charged; access for addicts and their families to the drug Naloxone, a drug that reverses the effects of an overdose; and allows the Department of Corrections to provide an approved medication to inmates to prevent a relapse in their addiction.

"The bill includes provisions that are important to law enforcement and me: increasing penalties for large volume traffickers, expanding access to treatment, and getting heroin overdose reversal kits into the hands of our first responders. I know this legislation will save lives," Attorney General Jack Conway said in a news release.

Hornback argued that "forced rehab doesn't usually work," providing addicts with Naloxone and free needles simply enables them and the bill does not allow addicts any "consequences for their actions."

He said that while he knows there are people dying from heroin overdoses,"I didn't make that decision for them and I for one, and a lot of my constituents are tired of paying for people's bad decisions and that is what this (bill) does."

Tilley said in an interview after the vote that needle exchange programs are proven to work, will save taxpayers money and are absolutely necessary to "stem the tide of two tidal-waves that are headed Kentucky's way: HIV and Hepatitis C and Hepatitis B."

"The cost of treating someone with HIV is $350,000. The cost of treating someone with Hepatitis C is $85,000. The budget now had a $55 million hit just with the explosion of Hepatitis C last year. We can't afford that in Kentucky," he said. Advocates say the programs can be a gateway to treatment and rehabilitation.

Meanwhile, Conway and first lady Jane Beshear announced that funding for Naloxone kits would be made available to the hospitals in Kentucky with the highest rates of heroin overdose deaths. The kits will be provided free to every treated and discharged overdose victim at the pilot-project hospitals.

They made the announcement at the University of Louisville, which treated 588 people in 2013 for heroin overdoses, a news release said. In 2013, the latest data available, 230 of the 722 autopsied overdose deaths, or 32 percent, were caused by heroin, according to the Kentucky Office of Drug Control Policy.

Tilley and Republican Sen. Whitney Westerfield, also of Hopkinsville, "forged a friendship that allowed the two men to work out differences on a pair of high profile bills fraught with political pitfalls," Adam Beam reports for The Associated Press. "Westerfield, a former prosecutor, is running for attorney general against the son of Democratic Gov. Steve Beshear, giving Democrats all the reason in the world not to work with him."

The AP notes that Republican Sen. Chris McDaniel wrote the first draft of the heroin bill that passed the Senate in January, but it omits McDaniel's other role: candidate for lieutenant governor on a slate headed by Agriculture Commissioner James Comer. As the Senate prepared to give the final bill final passage, Republican Floor Leader Damon Thayer accused the House of not passing McDaniel's bill because of his candidacy.

Read more here: http://www.kentucky.com/2015/03/25/3767938_political-compromises-brokered.html?rh=1#storylink=cpy

Princess Health andCounty Health Rankings look familiar, but show that some counties overcame bad factors to have encouraging outcomes.Princessiccia

Princess Health andCounty Health Rankings look familiar, but show that some counties overcame bad factors to have encouraging outcomes.Princessiccia

Gusty 14:25 Add Comment

The 2015 County Health Rankings for Kentucky, compiled by the University of Wisconsin Population Health Institute in collaboration with the Robert Wood Johnson Foundation, have been released. For the fourth year in a row, Oldham County ranked highest in Kentucky for health outcomes. Statistical differences among closely ranked counties are very small, so rankings are arranged in quartiles (quarters) in the maps below.

The rankings fall into two categories: factors and outcomes. Health factors, left, include the health behaviors (with factors such as adult smoking), clinical care (with factors such as the ratio of population to primary-care physicians), social and economic factors (such as the percentage of children under 18 in poverty) and physical environment (with factors such as the percentage of workforce that drives alone to work). Oldham County was followed by Boone, Woodford, Scott and Anderson counties. Clay County ranked last, preceded by Martin, Leslie, Wolfe and Knott. Generally, health factors and outcomes reflect income and education levels.

Health outcomes, right, include premature death, poor or fair health, poor physical health days, poor mental health days and low birthweight. Boone County ranked first, followed by Oldham, Shelby, Fayette and Jessamine. Owsley County ranked last, preceded by Floyd, Leslie, Clay and Perry.

Some counties, such as Morgan and Wayne, overcame their poor health factors to have better-than-average outcomes. To see the full, specific list of county rankings, click here.

Princess Health and Two New Independent Reports on the Death of Dan Markingson, But Now What Will Happen? . Princessiccia

Princess Health and Two New Independent Reports on the Death of Dan Markingson, But Now What Will Happen? . Princessiccia

anechoic effect AstraZeneca atypical anti-psychotics clinical trials conflicts of interest manipulating clinical research research subjects suppression of medical research University of Minnesota

Gusty 13:53 Add Comment

Years after his death, there is now a little more clarity about the clinical trial in which Dan Markingson was enrolled when he died.  Whether this clarity will have any impact remains to be seen.

We most recently posted about the aftermath of Mr Markingson's death here, (and see posts in 2013 here, and in 2011 here.)  Very briefly, Mr Markingson was an acutely psychotic patient enrolled in a drug trial sponsored by Astra Zeneca at the University of Minnesota.  His enrollment was said to be voluntary although at the time he enrolled he had been under a stayed order that could have involuntarily committed him to care.  Despite his mother's ongoing and vocal concerns that he was not doing well on the study drug and under the care of trial investigators, he continued in the trial until he died violently by his own hand.  After his death, his mother Mary Weiss, friend Mike Howard, and University of Minnesota bioethics professor Carl Elliott campaigned for a fair review of what actually happened.  University managers not only rebuffed their concerns, but harshly criticized Professor Elliott, and ended up reprimanding him for "unprofessional conduct."

Two New Reports

In the last few weeks, two new independent reports on the case appeared.  Both vindicated the concerns and questions raised by Mary Weiss, Mike Howard, and Prof Elliott.

Association for Accreditation of Human Research Protection

One, called for by the University of Minnesota faculty senate, was by the Association for Accreditation of Human Research Protection,  and said that the university left research subjects "susceptible to risks that otherwise would be avoidable" (see this Minneapolis Star-Tribune article.)  Furthermore, according to a post in the Science Insider blog from the American Association for the Advancement of Science, it said,

[T]he external review team believes the University has not taken an appropriately aggressive and informed approach to protecting subjects and regaining lost trust,

Also, it said the university has been

assuming a defensive posture. In other words, in the context of nearly continuous negative attention, the University has not persuaded its critics (from within and outside the University) that it is interested in more than protecting its reputation and that it is instead open to feedback, able to acknowledge its errors, and will take responsibility for deficiencies and their consequences.

Finally, it noted a "climate of fear" in the Department of Psychiatry.

Office of the Legislative Auditor for the State of Minnesota

The second report, available in full here,was from the Office of the Legislative Auditor for Minnesota.  If anything, it was more damning. Its summary included,

the Markingson case raises serious ethical issues and numerous conflicts of interest, which University leaders have been consistently unwilling to acknowledge. They have repeatedly claimed that clinical research at the University meets the highest ethical standards and dismissed the need for further consideration of the Markingson case by making misleading statements about past reviews. This insular and inaccurate response has seriously harmed the University of Minnesota�s credibility and reputation.

It seemed to affirm in detail nearly all of Weiss', Howard's and Elliott's concerns.  It recommended that the University should suspend new psychiatric drug trials until the problems it identified were remedied (see Star-Tribune article here.)

Vindication, but Will It Lead to Progress?  

Taken together, these reports vindicate the work of Mr Markingson's mother, friend, and academic watchdog Professor Elliott and their supporters.  As the Star-Tribune reported,

'Over the past eleven years the University of Minnesota has made us feel as if we have no voice, no rights and absolutely nothing remotely called justice,' wrote Mike Howard, a close friend to Markingson�s mother, in a letter in the audit. 'This report is the first step toward accountability.'

The Minnesota Post added the response of Professor Elliott and a colleague,

'It�s nice to have an independent confirmation of what we�ve been telling the university for five years, but which they have refused to listen to,' he told MinnPost on Thursday.

Elliott said he is not convinced, however, that Kaler and other university leaders are going to take responsibility for what happened in the Markingson case � or take the necessary steps to fix the problem going forward.

'One of the most worrying findings in the report was the widespread belief on campus that the university leadership doesn�t care about human study subjects,' he said.

Leigh Turner, another U bioethicist who has also been outspoken about the issues raised by the Markingson case, expressed similar concerns. 'Can we expect reform from the very people who have done nothing for the past several years?' he said in a phone interview.

'I hope there�s some change,' he added. 'But the fact that [Markingson died in 2004] and it�s now 2015, I think hope has to be tempered with a dose of realism. There are some very powerful forces interested in minimizing the findings and suggesting that there are only minor things that need to be done.'

It appears there a several major remaining questions.

What Were the Underlying Causes?

Although both reports went into some detail about what happened to Mr Markingson, they seemed not to dwell on why it happened.  They did not seem to address relevant contextual factors, policies, and decisions.  For example, the report by the Office of the Legislative Auditor included,

We understand that the University of Minnesota has been and should continue to be an institution that delivers not only high quality medical care but also engages in cutting edge medical research� research that does pose risks to human subjects. In addition, we do not question the appropriateness of the University obtaining money from pharmaceutical and other medical companies to support that research. However, in every medical research study�whether supported with public or private money�the University must always make the protection of human subjects its paramount responsibility.

However, as we and many others more erudite have discussed frequently, clinical research that evaluates products or services made by the commercial sponsors of the research has proven to be highly susceptible to manipulation by these sponsors to increase the likelihood that the results will serve marketing purposes, and suppression if the manipulation fails to produce the wanted results.  Commercial sponsors often strongly influence the design, implementation, analysis and dissemination of clinical research.  Often their influence is mediated by financial relationships with individual researchers and with academic institutions who seem more and more beholden to outside sponsors, that is, by conflicts of interest.  The report by the Auditor noted pressures, including financial pressures on the physician who ran the study in which Mr Markingson was a subject to enroll more patients and keep them enrolled.  To protect patients better in the future, in my humble opinion the relationships among commercial sponsors, academic medical institutions, and individual researchers need further consideration.  Is the easy money supporting research coming from commercial firms with vested interests in the outcome of that research really worth the risks of biased results, hidden results, and to research subjects?   

Will Anything Change and Will Anyone be Held Accountable?

Once these two reports were delivered, it now seems to be up to university managers to make needed changes.  In general, these are the same managers who are described above as so "defensive," who not only ignored complaints, but appeared to try to silence those who complained.  If they are left in charge, why should we expect them to make any meaningful changes?  Instead, should they  not be held accountable for their actions?  

Will the University Cease Hostilities Against Dr Elliott?

Again, as noted above, university managers did not merely disagree with Professor Elliott.  They disparaged him, appeared to try to intimidate him, and reprimanded him.  It seems at the very least he is owed an apology.  So far, nothing in the news coverage suggests he has or will receive one.

Will Anyone Notice? 

So far, this case has gotten good coverage in Minnesota media.  However, it has largely been ignored in the national media.  Beyond Minnesota, I could only find mention in some blogs, e.g., in PharmaLot by Ed Silverman, and in Forbes by Judy Stone.  I have seen nothing in any US medical or health care journal, although the British Medical Journal did cover it in a news feature.  This case clearly has global implications, and ought to be considered one of the most important cases illustrating the perils of commercially sponsored human research, but it remains proportionately anechoic.

Summary

The latest reports seem only to confirm that clinical research at major academic institutions has gone way off track.  It now seems that in their haste to bring in external funding, university administrators and the academic researchers who are beholden to them have sadly neglected the protection of their own patients.  As we have said ad infinitum, true health care reform would turn leadership of health care organizations over the people who understand and are willing to uphold the mission of health care, and particularly willing to put patients' and the public's health, and the integrity of medical education and research when applicable, ahead of the leaders' personal interests and financial gain.

ADDENDUM (25 March, 2015) - See also numerous posts by Professor Elliott on the Fear and Loathing in Bioethics blog,  by Bill Gleason in the Periodic Table blog,  and by Mickey Nardo on the 1BoringOldMan blog. 

ADDENDUM (30 March, 2015) - Note that after receiving offline comments, I changed the first paragraph to emphasize the clarity is about the trial, rather than the patient's death, and second paragraph to clarify that the order to commit was stayed.

Princess Health andHealth reform law has been good for hospital finances, health-care costs, Obama administration says.Princessiccia

Princess Health andHealth reform law has been good for hospital finances, health-care costs, Obama administration says.Princessiccia

health care costs health insurance health reform hospitals managed care Medicaid obamacare Patient Protection and Affordable Care Act

Gusty 20:15 Add Comment

U.S. hospitals have saved billions of dollars because the federal health-reform law has provided coverage for patients who were once charity cases, the Obama administration announced Monday, the fifth anniversary of the Patient Protection and Affordable Care Act.

"Hospitals also saw fewer emergency room visits, which rack up far higher costs and often leave hospitals with the tab," Sarah Ferris writes for The Hill, which covers Congress. "The government�s report, which focuses on the benefits of Medicaid expansion, is an effort to entice states that have been politically resistant to expanding the program."

Kentucky hospitals have acknowledged that the law has reduced their losses from "uncompensated care," but say other aspects of the law have created a mixed effect, depending partly on hospitals' ability to adapt. The increase in coverage has brought hospitals much more money, but they say continued problems with managed-care Medicaid have cause them financial difficulty.

From paying patients' point of view, the law appears to have reduced inflation in health-care costs, but has not achieved advocates' goal of reducing costs. A White House report said, "Since the Affordable Care Act was enacted, health care prices have risen at the slowest rate in nearly 50 years. Thanks to exceptionally slow growth in per-person costs throughout our health care system, national health expenditures grew at the slowest rate on record from 2010 through 2013."

For the White House's Kentucky-specific list of benefits of the law, click here.

Princess Health andReform law 'quietly accomplishing the goals it was created to achieve,' McClatchy Newspapers reporter writes.Princessiccia

Princess Health andReform law 'quietly accomplishing the goals it was created to achieve,' McClatchy Newspapers reporter writes.Princessiccia

health care costs health insurance health reform obamacare Patient Protection and Affordable Care Act

Gusty 08:25 Add Comment

The federal health-reform law is still controversial and still facing a legal challenge, but "is quietly accomplishing the goals it was created to achieve," Washington correspondent Tony Pugh reported for McClatchy Newspapers on the occasion of the law's fifth anniversary. (The Lexington Herald-Leader is a McClatchy paper.)

"The nation�s uninsured rate has plummeted as more Americans enroll in Medicaid or in federal and state marketplace coverage," Pugh notes. "The law�s consumer protections and insurance-benefit requirements have improved the quality of coverage for millions of people who get health insurance outside the workplace. Premiums for marketplace health insurance have largely been reasonable and have increased only moderately thus far. Long-term cost estimates for providing coverage under the law have been falling."

Howver, Pugh writes, "The law may never overcome the bitter politics that surrounded its enactment and that partly define its legacy. Long viewed as a government overreach, the health-care law has been problematic for those who want the private insurance market to dictate who gets health insurance and what it should cost. . . . Moreover, the law�s requirement that most Americans have health insurance is seen as an infringement on individual freedom. The Supreme Court ruled in June 2012 that the so-called individual mandate didn�t violate the Constitution."

The White House issued a state-specific list of the law's benefits. For Kentucky's, click here.

Princess Health andObama says health-reform law working better than expected.Princessiccia

Princess Health andObama says health-reform law working better than expected.Princessiccia

health insurance health reform obamacare president

Gusty 21:01 Add Comment

President Obama made this statement on the fifth anniversary of the Patient Protection and Affordable Care Act:

On the five-year anniversary of the Affordable Care Act, one thing couldn�t be clearer:  This law is working, and in many ways, it�s working even better than anticipated.

After five years of the Affordable Care Act, more than 16 million uninsured Americans have gained the security of health insurance � an achievement that has cut the ranks of the uninsured by nearly one third.  These aren�t just numbers.  Because of this law, there are parents who can finally afford to take their kids to the doctor.  There are families who no longer risk losing their home or savings just because someone gets sick.  There are young people free to pursue their dreams and start their own business without worrying about losing access to healthcare.  There are Americans who, without this law, would not be alive today.

For Americans who already had insurance before this law was passed, the Affordable Care Act has meant new savings and new protections.  Today, tens of millions of Americans with pre-existing conditions are no longer at risk of being denied coverage.  Women no longer have to worry about being charged more just for being women.  Millions of young people have been able to stay on their parents� plan until they turn 26.  More than 9 million seniors and people with disabilities have saved an average of $1,600 per person on their prescription medicine, over $15 billion in all since the Affordable Care Act became law.  More than 70 million Americans have gained access to preventive care, including contraceptive services, with no additional out-of-pocket costs.  And the law has helped improve the quality of health care: it�s a major reason we saw 50,000 fewer preventable patient deaths in hospitals over the last three years of data. 

The cynics said this law would kill jobs and cripple our economy.  Despite the fact that our businesses have created nearly 12 million new jobs since this law was passed, some still insist it�s a threat.  But a growing body of evidence � actual facts � shows that the Affordable Care Act is good for our economy.  In stark contrast to predictions that this law would cause premiums to skyrocket, last year the growth in health care premium costs for businesses matched its lowest level on record.  If premiums had kept growing over the last four years at the rate they had in the last decade, the average family premium would be $1,800 higher than it is today.  That�s $1,800 that stays in your pocket or doesn�t come out of your paycheck.  And in part because health care prices have grown at their slowest rate in nearly 50 years since this law was passed, we�ve been able to cut our deficits by two-thirds.  Health care costs that have long been the biggest factor driving our projected long-term up deficits up are now the single biggest factor driving those deficits down. 

The Affordable Care Act has been the subject of more scrutiny, more rumor, more attempts to dismantle and undermine it than just about any law in recent history.  But five years later, it is succeeding � in fact, it�s working better than even many of its supporters expected.  It�s time to embrace reality.  Instead of trying yet again to repeal the Affordable Care Act and allowing special interests to write their own rules, we should work together to keep improving our healthcare system for everybody.  Instead of kicking millions off their insurance and doubling the number of uninsured Americans, as the House Republican budget would do, we should work together to make sure every American has a chance to get covered.

Five years ago, we declared that in America, quality, affordable health care is not a privilege, it is a right.  And I�ll never stop working to protect that right for those who already have it, and extend it to those who don�t, so that all of us can experience the blessings of life, liberty, and the pursuit of happiness in this country we love.  

Princess Health andAs tax deadline nears, most uninsured appear likely to choose penalty; some with coverage are having to refund part of subsidy.Princessiccia

Princess Health andAs tax deadline nears, most uninsured appear likely to choose penalty; some with coverage are having to refund part of subsidy.Princessiccia

health insurance health reform income insurance insurance coverage obamacare taxes

Gusty 09:16 Add Comment

Kentucky Health News

Most people facing a tax penalty for not having health insurance appear likely to pay it instead of taking advantage of a special opportunity to but coverage and minimize the penalty.

"Major tax-preparation firms say many customers are paying the penalty and not getting health insurance," reports Stephanie Armour of The Wall Street Journal. "Research also suggests that many people who lack health insurance will pay the penalty and not get covered this year."

Many polls have found that many if not most people without health insurance are unaware that they are subject to a tax penalty under the federal health-reform law. That percentage appears to be declining as they prepare their income-tax returns, but a poll taken in late February found that when told of the penalty, only 12 percent of the uninsured said they would get coverage.

For many people, the choice is simply financial, since coverage for them would be more expensive than the penalty -- 1 percent of their income, or $95 per adult or $47.50 per child, whichever is larger. Others say they don't need coverage, and some object to the penalty or the law altogether.

The penalty will increase to 2 percent of income and $325 per adult or $167.50 per child for the 2015 tax year, so if you are uninsured and don't qualify for Medicaid or one of the law's exemptions, the end of the special enrollment period, April 30, is the last chance to avoid that penalty.

"In late February, H & R Block reported that its uninsured clients had paid an average penalty of $172," reports Abby Goodnough of The New York Times. "The money comes out of refunds, while people who do not get refunds are required to pay the Internal Revenue Service by April 15."

Some people who have coverage "might find another unpleasant surprise: As many as half the nearly 7 million Americans who got subsidies to offset their premiums may have to refund money to the government, according to an estimate by H & R Block," the Journal reports. "The subsidies are based on consumers� own projections of their 2014 income, but some estimated incorrectly and received overly generous credits. Those people will see smaller-than-expected refunds or could owe the government money."

"H & R Block also found that as of Feb. 24, just over half of its clients with subsidized marketplace coverage had to repay a portion of their subsidy because their 2014 income turned out to be higher than what they estimated when they applied for coverage," the Times reports. "The process includes "new forms that even seasoned preparers are finding confusing."

The Obama administration announced last month that 800,000 people with insurance bought under the reform law had received incorrect information needed for their tax returns. About 10 percent of them have still not received corrected forms, it announced Friday. "The administration said people who have not received the corrected forms do not have to wait to file their taxes and will not have to pay any additional tax due to the effort," The Hill reports.

The Wall Street Journal reports, "Consumers who already filed their tax returns using the incorrect forms provided though state or federal exchanges won�t be required to file amended forms, and the Internal Revenue Service won�t assess additional taxes, said Mark Mazur, the Treasury Department�s assistant secretary for tax policy."