Will a New Medicare Disclosure Work?

http://goo.gl/BV3mQk

As reported by the Times last week, patients who are held at a hospital for "observation," even if that observation lasts days, but not formally admitted, and later released to a nursing home, won't have their stay in the nursing home covered by Medicare. That stay can cost tens of thousands of dollars. So Congress passed a law mandating disclosure of that fact. So far, so good. But there's a problem.  Remember that patients get this disclosure in a hospital, when they may be seriously ill and not at their best, and that they may also be deluged by other forms.  Will they pay attention to this disclosure, in light of the evidence that consumers largely disregard or misinterpret disclosures?  Some evidence even indicates that consumers can't absorb disclosures in the medical context.   Here's the new disclosure, which spans two pages (the formatting didn't survive pasting in, but you can view it here):


Elderly Hospital Patients Arrive Sick, Often Leave Disabled

Movement through space is a key part of maintaining the brain. This is true even if you can't use your limbs. Cognition deteriorates in anyone who is prevented from moving through space, including young adults.....

http://goo.gl/hgomEb

Many elderly patients like Prochazka deteriorate mentally or physically in the hospital, even if they recover from the original illness or injury that brought them there. About one-third of patients over 70 years old and more than half of patients over 85 leave the hospital more disabled than when they arrived,research shows.

As a result, many seniors are unable to care for themselves after discharge and need assistance with daily activities such as bathing, dressing or even walking.

“The older you are, the worse the hospital is for you,” said Ken Covinsky, a physician and researcher at the University of California, San Francisco division of geriatrics. “A lot of the stuff we do in medicine does more harm than good. And sometimes with the care of older people, less is more.”

Hospital staff often fail to feed older patients properly, get them out of bed enough or control their pain adequately. Providers frequently restrict their movements by tethering them to beds with oxygen tanks and IV poles. Doctors subject them to unnecessary procedures and prescribe redundant or potentially harmful medications. And caregivers deprive them of sleep by placing them in noisy wards or checking vital signs at all hours of the night.

Interrupted sleep, unappetizing food and days in bed may be merely annoying for younger patients, but they can cause lasting damage to older ones. Elderly patients are far different than their younger counterparts — so much so that some hospitals are treating some of them in separate medical units.

San Francisco General is one of them. Its Acute Care for Elders (ACE) ward, which opened in 2007, has special accommodations and a team of providers to address the unique needs of older patients. They focus less on the original diagnosis and more on how to get patients back home, living as independently as possible.

Early on, the staff tests patients’ memories and assesses how well they can walk and care for themselves at home. Then they give patients practice doing things for themselves as much as possible throughout their stay. They remove catheters and IVs, and encourage patients to get out of bed and eat in a communal dining area.

“Bed rest is really, really bad,” said the medical director of the ACE unit, Edgar Pierluissi. “It sets off an explosive chain of events that are very detrimental to people’s health.”

Finding Good Pain Treatment Is Hard. If You’re Not White, It’s Even Harder.

http://goo.gl/QVs3hk

Roslyn Lewis was at work at a dollar store here, pushing a heavy cart of dog food, when something popped in her back: an explosion of pain. At the emergency room the next day, doctors gave her Motrin and sent her home.

Her employer paid for a nerve block that helped temporarily, numbing her lower back, but she could not afford more injections or physical therapy. A decade later, the pain radiates to her right knee and remains largely unaddressed, so deep and searing that on a recent day she sat stiffly on her couch, her curtains drawn, for hours.

The experience of African-Americans, like Ms. Lewis, and other minorities illustrates a problem as persistent as it is complex: Minorities tend to receive less treatment for pain than whites, and suffer more disability as a result.

While an epidemic of prescription opioid abuse has swept across the United States, African-Americans and Hispanics have been affected at much lower rates than whites. Researchers say minority patients use fewer opioids, and they offer a thicket of possible explanations, including a lack of insurance coverage and a greater reluctance among minorities to take opioid painkillers even if they are prescribed. But the researchers have also found evidence of racial bias and stereotyping in recognizing and treating pain among minorities, particularly black patients.


Independence at Home Saved Medicare $10 Million In Second Year

http://goo.gl/l9Xtc2

The Independence at Home demonstration saved Medicare more than $10 million this year. On average, there was $1,010 per beneficiary saved this year among 15 practices and 10,000 Medicare beneficiaries, according to a new analysis by the Centers for Medicare & Medicaid Services (CMS).

Some of the participating practices include Cleveland Clinic Home Care Services, Doctors on Call, Housecall Providers, Inc. and VPA Milwaukee.

All 15 practices from the second performance year also improved quality in at least two of the six quality measures, when compared to last year. Four of the practices met the performance measures for all six quality measures, according to CMS.

CMS will also give incentive payments to seven practices for succeeding in reducing Medicare expenditures and meeting designated quality goals. The payments range from $1.4 million for Doctors Making Housecalls to $360,000 for VPA Lansing.

Last year, in the program’s first year, participants saved over $25 million, an average of $3,070 per participating beneficiary, according to CMS.

Inappropriate Prescribing of Transdermal Fentanyl in Opioid Naïve Nursing Home Residents

http://goo.gl/9w1QP1

If you had to guess what long acting opioid is most commonly started on in nursing home patients, which one would you guess?    A new study released last week in JAGS shocked me.   The answer to this question was a fentanyl patch.   Even more shocking, many of those started on this medication were never prescribed any opioids prior to being started on a patch.   

What they found was eye opening:

  • One out of ten nursing home residents (9%) were never on a short acting agent in the previous 60 days prior to starting a long acting opioid.   
  • The most-common initial long-acting opioids was a fentanyl patch, accounting for about half of all long acting opioids for both opioid-naïve and non-naïve patients. 
  • For those opioid-naïve patients put on fentanyl patches, 27% were placed on a 12 mcg/h patch.   38% were placed on a 25mcg/h patch, and the rest were placed on 50mcg/h or more of a patch.   

I have some worry about a blanket statement against the use of long acting opioids without starting a short acting agent first, I do feel that starting a fentanyl patch in an opioid naïve patient is dangerous.   My only hope is that the study didn't capture opioid prescriptions that were outside of the Medicare Part D benefit, which is possible but unlikely to account for all of their findings. 


Brain Stimulation Technique Shown Effective in Phantom Limb Pain

http://goo.gl/SqqPMe

As many as 25,000 people a year worldwide lose limbs from land mine blasts, and a new study, published in The Journal of Pain, shows that transcranial magnetic stimulation (rTMS) administered to the scalp can stimulate the brain and provide significant reductions in phantom limb pain.

“In our current study, results showed that treatment with rTMS for two weeks induced a clinically significant pain reduction in 70 percent of traumatic amputees with phantom limb pain up to 15 days after treatment with no serious side effects,” said Dr. Garcia.

The authors also noted the pain relief observed could be explained by the potential effect of rTMS over the central pathophysiological mechanisms related to PLP.


Hospitals are throwing out organs and denying transplants to meet federal standards

Better dead than have a less than perfect organ surgery. Hardly an ideal set of constraints.....

https://goo.gl/GdZwSc

ospitals across the United States are throwing away less-than-perfect organs and denying the sickest people lifesaving transplants out of fear that poor surgical outcomes will result in a federal crackdown.

As a result, thousands of patients are losing the chance at surgeries that could significantly prolong their lives, and the altruism of organ donation is being wasted.

“It’s gut-wrenching and mind-boggling,” said Dr. Adel Bozorgzadeh, a transplant surgeon at UMass Memorial Medical Center in Worcester, Mass.

He coauthored a recent study that showed a sharp uptick in the number of people dropped from organ transplant waiting lists since the federal government set transplant standards in 2007. These standards are tied to federal hospital ratingsand Medicare funding, which is the main payer for transplants and a key source of income for hospitals. And hospitals’ ability to meet those standards helps determine their reputation within the medical community. Surgeries involving imperfect organs and extremely ill patients are more risky, so hospitals that do many of them run the risk of poor outcomes that may hurt their performance on the standards.

Soon after the study was published in April, the Centers for Medicare and Medicaid Services changed its benchmarks to give hospitals — and surgeries — more leeway to fail. But patients and doctors are still uneasy about the erosion of one of transplantation’s fundamental principles: the sicker you are, the higher you move up the waiting list for donated organs. 

Competing Human Rights and MCS/ES

https://goo.gl/B8Irol

As more people become chemically “sensitive”, different types of human rights scenarios  emerge. In their latest elearning module, the Ontario Human Rights Commission has included a case study with someone who “has been diagnosed with a chemical sensitivity disability”.

This example involves two Code rights, both on the ground of disability.

Mira works in an office with 25 other employees. She has been diagnosed with a chemical sensitivity disability. Perfumes and scented hand creams give her migraines, nausea and make her feel dizzy. Her manager is aware of her disability and has tried to make sure that the other employees don’t wear perfumes or scented products to the office.

Recently Ramon, another employee at the office, was diagnosed with a severe skin condition. He has to use a medicated skin cream several times a day to treat his condition. The skin cream is scented, and causes Mira to react.

Mira told Ramon and their manager that Ramon’s cream is giving her migraines, nausea and dizziness when she comes to work.

Ramon told the manager that he understands Mira’s situation, but if he doesn’t use the cream, his condition will get worse and it will be hard for him to work.

This is a competing rights situation, because both Mira and Ramon have a Code right to have their disability accommodated.


The Long-Term Effects of Untreated Chronic Pain

https://goo.gl/cCpKXe

After a while, pain wears a person down, draining their energy and sapping their motivation. They sometimes attempt to limit social contact in an effort to reduce stress and to decrease the amount of energy they have to spend reacting to their environment. Eventually, many people with chronic pain develop depression-like symptoms: lack of interpersonal interaction, difficulty concentrating on simple tasks, and the desire to simplify their life as much as possible, which often manifests as seeking isolation and quiet. Sleeping often makes the pain less intrusive, and that combined with the exhaustion that pain induces means that it isn’t uncommon for a person to start sleeping upwards of ten hours a day.

Some recent studies have also shown that chronic pain can actually affect a person’s brain chemistry and even change the wiring of the nervous system. Cells in the spinal cord and brain of a person with chronic pain, especially in the section of the brain that processes emotion, deteriorate more quickly than normal, exacerbating many of the depression-like symptoms. It becomes physically more difficult for people with chronic pain to process multiple things at once and react to ongoing changes in their environment, limiting their ability to focus even more. Sleep also becomes difficult, because the section of the brain that regulates sense-data also regulates the sleep cycle. This regulator becomes smaller from reacting to the pain, making falling asleep more difficult for people with chronic pain.


Some Psychotic Disorders May Be Induced by Drugs Designed to Combat Epilepsy’s Effects

Rare, but important; if you are labeled psychotic, medicine stops looking........

http://goo.gl/MjHSEV

Epilepsy is one of the most common neurological disorders. People with epilepsy have increased vulnerability to psychiatric problems.

However, it is also possible that the drugs used by patients to control their seizures may increase the risk of psychotic symptoms in certain people.

To test this possibility, researchers screened the medical records of 2630 patients with epilepsy and identified 98 (3.7%) with psychotic disorders. Among these, 14 (14.3%) were diagnosed as having a psychotic disorder that had been triggered by their anti-epileptic drugs. Ten of the patients in the anti-epileptic drug-induced psychosis group were female, and ten had a type of epilepsy called temporal lobe epilepsy.

The researchers determined that, among epilepsy patients with psychotic disorders, one in seven could potentially be attributed to anti-epileptic drugs. Women and those with temporal lobe epilepsy seem to be more likely to develop psychological problems in response to anti-epileptic medication.