Your kidneys are workin' it!

New Medicare payment rules for kidney dialysis are making it easier for patients to have their treatment at home.

The changes, which just went into effect, are motivating more clinics to teach the do-it-yourself form of dialysis using specially designed portable equipment.

Some patients may be nervous or intimated at the thought of home dialysis. Currently, only 8 percent of kidney patients do dialysis at home and many patients do not know that have that option.

Home dialysis includes an intensive training program. People who prefer the home program, according to physorg.com, cite the convenience as a major factor in choosing home dialysis. The possibility of traveling with the machine gives them more freedom, as well as setting a more flexible schedule.

Despite concerns about infection and control in the home environment, a study published last year in The Archives of Internal Medicine found that patients “with end-stage kidney disease who have dialysis at home fare just as well as their counterparts who do hemodialysis,” traditionally performed at a dialysis center.

One additional key factor that is boosting home treatment is that new Medicare rules also pay physician reimbursement for patient education. This means that the home care training is no longer a burden to the system, but a covered cost.

As for the patients, Dr. Leslie Spry of the National Kidney Foundation says, once they “experience the difference between home and in-center dialysis most will not return to in-center treatment.”

Spry is a consulting physician for the National Kidney Foundation. In 2003, he also established at the first home hemodialysis program in the Midwest at his home clinic, the Dialysis Center of Lincoln in Nebraska.

To learn more about home kidney dialysis, check out this handy, downloadable comparison chart.

New to dialysis and Medicare? For a checklist of questions for your treatment plan and physician, click here.

Avastin still covered regionally on Medicare during appeal

One regional Medicare provider has decided to continue to cover Avastin, a breast cancer drug, reversing their decision from last week’s announcement to refuse coverage.

Questions about coverage of the pricey drug were sparked by the Food and Drug Administration (FDA)’s12-1 ruling in July to revoke approval of the drug for use to treat breast cancer. Genentech, the manufacturer of the drug, is appealing the decision.

A spokesperson for Medicare contractor Palmetto GB, a subsidiary of Blue Cross Blue Shield of South Carolina, reported in the New York Times that Palmetto “has suspended consideration of changes in its reimbursement policy for Avastin as a treatment for breast cancer” while the appeal process continues.

Last week, in a notice posted on its website, Palmetto GB, a regional company that determines Medicare coverage for South Carolina, Ohio, West Virginia, California, Nevada and Hawaii had said that it would stop paying for the use of Avastin for breast cancer treatment as of Jan. 29. That notice was updated this week to state it will “continue coverage of Avastin under current policy.”

In July, the F.D.A. decided to revoke approval of Avastin, also called bevacizumab, because the F.D.A. said follow up studies had found the drug was not effective and had dangerous side effects.

In 2008, the expensive drug was a part of the F.D.A.’s accelerated approval program, according to the FDA’s website. The approval was based on a trial of patients who had not received chemotherapy for mestatic breast cancer.

“Under the accelerated approval program, a drug may be approved based on clinical data that suggest the drug has a meaningful clinical benefit, with more information being needed to confirm this.  The program provides earlier patient access to promising new drugs to treat serious or life-threatening conditions while confirmatory clinical trials are conducted.”

According to the F.D.A., follow-up trial results submitted by Genentech only showed a small effect on “progression-free survival.”

The F.D.A.’s decision to revoke approval for use of the drug for breast cancer treatment will not affect its approval for use for treating other cancers.

From bone marrow cancer breakthroughs to drug development to treat blood cancer, medical research finds new ways, daily, to keep sick patients alive longer.

But the American obsession with having “the best health care” is not only costing billions annually—it is often taking the dignity out of a patient’s end days.

The system is broken, according to Richard Meyer, executive director for Online Strategic Solutions. Most patients want to spend their last days at home, but 75 percent either die at a hospital or nursing home. Meyer’s research study, conducted with cancer patients, found that many terminally ill patients “do not want to go through extensive treatments that have horrible side effects if there is no hope of a better quality of life.”

The problem, according to a Dartmouth Medical School’s Dr. Eliot Fisher is supply and demand. Fisher noted in Meyer’s research that hospitals need beds full of paying patients to bill their bills. And Medicare is restricted by law from denying patients the treatments required, based on cost.

“The real problem,” Dr. Fisher notes, “is that many of the patients that are being treated aggressively, if you ask them, they would prefer less aggressive care. They would prefer to be cared for at home. They’d prefer to go to hospice. If they were given a choice. But we don’t adequately give them a choice.”

Meyer notes that patients are too quickly sent from their overloaded GPs to hospitals, where they see a flurry of disconnected specialists who order tests, needed or not.  The result is patients receiving all kinds of costly and often unnecessary treatments for the underlying complications to their disease.

Last year, $55 billion was spent for doctor and hospital bills in the last two months of patients’ lives. Of that amount, research shows that 20 to 30 of the treatments had “no meaningful impact.” 

Dr. John Schumann, an internist with University of Chicago, calls hospitals “factories” and no place for the dying.

 “Hospitals are like giant factories where all the focus is on process: diagnosing, treating, rehabbing, and discharging. Death, while a natural endpoint, is still too frequently viewed as medical failure. Nothing could be further from the truth.”

Schumann argues that the patients and their families need to advocate loudly for the patient’s wishes:  to listen to their desire for how they want to end their life.

“I’d like to empower the folks … especially their family members and loved ones, who will be called on to help with decision making, to take the initiative and die at home. Or in hospice. Or on a mountain top in bright sunshine.”

During the annual Medicare Open Enrollment, going on now through December 31, people with Medicare can add, drop, or change their prescription drug coverage. They can also select a health plan for their 2011 coverage.

The Center for Medicare and Medicaid Services offer online comparison tools to help you decide what changes you need to make. The U.S. Government’s Medicare page also offers a “Plan Finder” that allows users to compare policies, research choices, and links to resources on enrollment.

Evaluate the “three Cs,” experts say, when you decide on a plan: cost, coverage and convenience. There are multiple factors such as mail-order services for prescriptions, coverage gaps, copayments, and others to consider as you weigh your options.

The online tools will assist you in estimating of your out-of-pocket costs and reviewing quality and customer service ratings from current plan members.

Since health care and prescription changes to Medicare can be confusing, an organization called State Health Insurance Assistance Program (SHIP) offers one-on-one counseling and assistance to families on Medicare.

E-Prescriptions May Be in Your Future

Many doctors have already chosen to use electronic prescriptions because they see the many benefits of this practice.  Electronic prescriptions (e-prescriptions) will help to eliminate many dilemmas that arise with paper prescriptions.  For example, e-prescriptions reduce the chance of a paper prescription being misplaced or misread (since doctors are notorious for their bad handwriting).  They will also be faster because the doctors can send the prescription directly to the pharmacy and it should be ready when you arrive.  E-prescriptions will be able to forewarn if the patient is allergic to the prescribed medication. Importantly, the Drug Enforcement Administration (DEA) has approved the use of e-prescriptions for the time being as they prove themselves beneficial to the world of medicine.

E-prescriptions can prevent medical incidents before they happen, such as asthma attacks.  One of the many advantages of using this new system is it gives doctors the ability to regularly track patients’ use of medications.  A doctor can automatically refill the prescription and alert the patient about the refill.  This could prevent an asthma attack because the patients’ meds won’t run out and their inhaler will always be ready at hand.  A full prescription will get patients in the habit of routinely using their inhaler; therefore, reducing the risk of asthma attacks.  By monitoring a patient’s routine use of an inhaler, doctors can also decide if the prescribed medication is the best one for the patient.

Additionally, electronic patient records seem to be the next step for hospitals.  In fact, hospitals will be required to have most of their records filed electronically by 2015.  This will endure prompt and correct information.  Patients will receive better care because electronic records will be able to alert a doctor before they make a mistake.  This will help to eliminate medical malpractice and medication mistakes that may be otherwise overlooked.  Also, hospitals and doctors will benefit from the use of electronic records because they will receive money from Medicare and Medicaid for complying with the electronic system.

One concern that has arisen from the practice of electronic prescriptions and health records is confidentiality.  Patients have expressed fear that personal information will be exposed to public access.  However, the electronic information is secure.  Doctors and hospitals can ensure confidentiality and privacy to its patients.  Hence, the future of electronic healthcare looks bright.  Now that the journey is underway for many, we will wait and see if the hectic schedules of remaining doctors and hospitals can allow time for conversion to electronic healthcare.

But how can you live such a long life?

Part of the credit can go to the improved medical care available after World War II, especially in the United States. Resources like Medicare and nursing facilities specialized in elder care have undoubtedly helped boost those numbers. Still, health care is likely only one small piece of the puzzle.

Such longevity has often proved puzzling to the general public and researchers alike.  Some experts believe that diet and exercise are key to a long, healthy life.  Over 40,000 people over the age of 100 currently live in Japan, quadruple the number from a decade ago. The large population of centenarians and super centenarians in Okinawa, Japan highlights the importance of diet to lifespan. In Okinawa, the standard diet is high in fish, soy, seaweed, and other vegetables, reducing obesity, diabetes, and other diseases.

In Vilcabamba, Ecuador, there is yet another group of centenarians. Allegedly, one man lived for 127 years, and his relatives attribute his longevity to the village’s traditional diet.  Vilcabamba natives drink traditional horchata tea, and low-cholesterol, low fat diets.  The elderly also remain physically active: according to a Boston Globe article, one 92 year old man stopped working the bean fields a year before the reporter’s visit.  The elderly in Vilcabamba continued working, walking, and even romancing well into later life, keeping both minds and bodies active.

Celebrating Longevity: More Active People Living to 100

So all you have to do to live to 100 is eat right and exercise?

Not so fast.  Recently, researchers have been looking at a link between certain genes and old age. In Vilcabamba, where the elderly flourish, genes may play a huge part in the story: marriage was often limited to the small village, where many people are related.    Jeanne Calment, the woman who lived to a record 122 years, had parents who lived into their 90s.

Recently, researchers conducted a study which revealed genes related to longevity.  By looking at a group of 150 gene variants, researchers were able to distinguish centenarians from non centenarians over 75% of the time. According to the study, some of the participants’ genes were linked to the delay in cancer, heart disease, and other diseases related to old age. Still, there was no specific “long life” gene; rather, a combination of the 150 genes tended to appear in the centenarians. Still, researchers highlighted the importance of healthy lifestyles, especially exercise and diet, in connection to living long.

Undoubtedly, genetics plays a large role in determining how long you’ll live. However, genetics isn’t everything.  Some studies report that genes determine up to 30 percent of your longevity likelihood.  The environment in which you live has a strong impact on your life span.  Finally, how you fuel your body ultimately has the greatest say.  Eating a healthful diet and remaining active—both mentally and physically—is still crucial in living a long, fulfilling life.

WellPoint study concludes Boniva is not effective at preventing osteoporosis

Boniva is a bisphosphonate, among one of the most common treatments for the bone-thinning disease. Bisphosphonates treat osteoporosis by slowing down bone thinning, preventing bones from weakening and deteriorating. Osteoporosis patients who take bisphosphonates will preserve their bone density and avoid bone fractures—so long as the drug is effective.

The WellPoint study considered more than 25,000 of members who are treated by osteoporosis drugs, comparing Boniva, Actonel, and Fosamax.  Although the drugs should provide the same treatment to patients, WellPoint noted key differences between Boniva and the other two drugs. Ultimately, Fosamax and Actonel were more effective than Boniva: Fosamax and Actonel users spent less money on health care and were less likely to fracture their bones than patients on Boniva.   Plus, patients were more likely to continue and comply with treatment on Actonel.

As a result, the health insurance giant decided to restrict Boniva, and kept on the third tier of non preferred drugs on the WellPoint drug formulary. Another health insurance leader, Aetna, has also placed Boniva on its formulary’s third tier, preferring Actonel and the generic drug Fosamax.  Luckily for Boniva, it is still the first tier preferred drug for Cigna ahead of its two competitors.  WellPoint’s Medicare prescription drug plan still lists Boniva as a second tier prescription in the plan formulary.

Like many other health insurance companies, WellPoint hopes to reduce treatment costs by using the most effective medications at the best prices.  The 2010 health care reform provided $1 billion worth of funding to conduct comparative-effectiveness studies, hoping to both improve quality of care and cut health care costs.  If such studies are effective, they could truly slash costs and cut down on unnecessary expenses.

Earlier research linked Boniva use to bone fractures (specifically in the femur) and a higher risk of heart disease, although the Food and Drug Administration later found no correlation between Boniva, heart disease, and bone fractures. WellPoint’s research also did not find a correlation between Boniva and other bisphosphonates and certain femur fractures. Boniva is also linked to heartburn.

Genentech, the company that produces Boniva, claims that Boniva is cost effective.  Contrary to the WellPoint study, the company also states that patients find it very easy to comply with Boniva doses.

Ultimately, the most important point of the WellPoint study is the growing need to use cost-effective prescription drugs. As health care costs rise in the United States, comparative-effectiveness research will grow ever more important.  With widespread health care reform around the corner, comparative-effectiveness studies could be key to making health care affordable for all.

In an interesting article for Bloomberg Business week, Pat Weschler takes a look at a study of med schools, the amount of primary care doctors produced, and the “social mission” of the institutions. According to the study, Atlanta’s Morehouse School of Medicine is the top ranked med school in terms of “social mission” and primary care physicians.  Meanwhile, Harvard Medical School didn’t even break the study’s top 50, coming in at number 62.  Weschler writes that the study compiled data based on the amount of the med school graduates enter primary care, the number that serve in short-handed regions, and the amount that serve minorities.

The study focused on the “research culture” fostered at many top institutions, where specialists often model behavior to students.  One of the authors of the study, Fitzhugh Mullan, claims that schools could boost the number of primary care physicians by focusing on adding higher numbers of women, minorities, and older med students to the mix. At the same time, shifting the focus of med school curricula from research to primary care may also influence more med students to consider becoming primary care physicians.

I found the study’s claims very compelling. The culture of a college, medical school, or any other institution can very well alter your career path.  Medical schools can help reduce the primary care deficit by steering more students towards primary care. Dr Candice Chen, another one of the study’s authors, emphasizes the role of medical schools in increasing the nation’s number of primary care physicians. Breaking away from typical med school rankings may be able to help build a strong primary care base by the time the new health care reforms kick in for real.

Although I tend to agree with many of the points in the study, I do not think that one should count out the money factor.  The cost to complete medical school is astronomically high and rising higher, on top of loans from undergraduate courses of study. Primary care physicians also make far less than specialists after completing similar courses of study, which serves as another deterrent from the primary care profession. Like it or not, money plays a large role in job selection—although as the study showed, it is not the sole factor involved in the decision.

Our Primary Care Physician shortage is a national healthcare issue

By targeting medical schools in addition to (possibly) improving primary care salaries, perhaps this nation can create a strong foundation of primary care providers.  Ultimately, health care reform hinges on such a base of physicians, especially as over 30 million people will gain health insurance coverage in 2014, many of whom will most definitely seek preventative care.

Men Need to Schedule Routine Check-Ups

Preventative efforts for your health can treat a medical condition before it becomes a problem.  Going to your routine doctor’s visits will boost your chance of detecting a medical condition when it first arises.  If you are able to detect the condition early on, you will increase the likelihood that the condition will be treatable.  Otherwise, letting the condition go unnoticed and untreated could cause it to turn into a bigger medical concern that could have been prevented.  The earlier you find a medical condition, the easier and cheaper it will be to treat it.  If you wait until the symptoms are too real and painful to ignore, the conditions have already had time to progressively develop.  The treatment of the developed condition is going to be more extensive, and hence, will have higher healthcare costs.  If you wait too long to see a doctor, you risk the chance of your condition becoming permanent.  Simple preventative doctor’s visits will help to keep medical conditions from going unnoticed.

Depending on your age and your family history of particular diseases, certain tests are more necessary to get routinely at an office visit in order to maintain preventative efforts in your healthcare.  The older you are, the more often you should make routine visits and the more tests you should get at each visit.  There are simple tests, such as blood pressure and cholesterol screenings, which are important to take routinely at each office visit.  Making sure your cholesterol and blood pressure are at the right levels is a basic foundation to good health.  Eliminating a simple cholesterol or blood pressure health condition will allow you to focus on other medical conditions that could arise.  Routine visits are also very important because it gives you time to talk to your doctor.  Routine visits help your to get to know you better.  By talking to your doctor and asking questions, you can learn about symptoms you may be experiencing or diseases you may be at risk for based on family history.

There are several ways to take preventative efforts with your health from the beginning.  To start, keep yourself healthy and exercise often; do not put yourself at risk for avoidable health problems.  There are nine tests you should take routinely to have preventative healthcare: BMI, cholesterol, blood pressure, cardiovascular disease, colorectal cancer, other cancers, STDs, HIV, depression, abnormal aortic aneurysm, diabetes, and tobacco use.  Another easy way to start your preventative healthcare is getting the flu shot once annually.  This will take you one step close to reducing your risk of getting sick and it will help you get into a more routine healthcare practice.

Medicare Fraud Identity Theft

One issue plaguing the Medicare reforms is Medicare fraud. Every year, both seniors and the government lose quality health care and billions of dollars to corrupt providers.  Medicare fraud isn’t new (see my previous blogs on fraud and scams), but as the new health care reforms have passed, fraud has been in the spotlight. Medicare fraud affects everyone, from the government to seniors to taxpayers.

Cutting costs for health care is integral to health care reform. According to the United States government, taxpayers lose over 60 billion dollars every year due to Medicare fraud.  The government uses taxpayer money to finance Medicare, so when people abuse the system, it is the taxpayers who pay the price.

South Florida is the hotbed of these schemes, full of phantom pharmacies and providers, where criminals can earn tremendous amounts of money by cheating the government. Scammers sometimes purchase businesses like pharmacies, along with Medicare licenses and patient records, and use that information to charge Medicare for drugs and other services. According to a report by ABC news, one man’s Medicare card was used to purchase two prosthetic legs—even though the man had both of his legs, Medicare was slow to respond. Because Medicare moves very slowly, even when dealing with something like fraud, it is easy for con men to get away with their crimes.

Con men and fraudsters aren’t the only ones to participate in Medicare fraud schemes. Some corrupt health care providers overcharge Medicare for certain services that may or may have been performed improperly. Not only does this swindle the government out of millions of dollars, but also can harm the health of Medicare beneficiaries.  Most doctors and other providers are not involved in any of these scams, but the minority who do fraudulently charge Medicare waste government cash and harm senior health.

Preventing Medicare fraud could save the government—and taxpayers—billions of dollars annually, making it imperative to crack down on scammers and corrupt providers.  In the current system, responses to fraud are often slow and cumbersome, with little action taken. When Medicare cracked down on fraudulent equipment sales in South Florida, Medicare durable medical equipment claims dropped by $1.76 billion. By making more of an effort to combat fraud, it will be possible to save billions of dollars.

Recently the Department of Health and Human Services proposed that individual workers found responsible for Medicare fraud should be removed from the Medicare program.  Currently, only people who are still working for a company convicted of Medicare fraud can be excluded from the program, so employees can leave the company in order to evade exclusion.  Two Representatives from Florida proposed legislation that cracks down on individual executives, preventing them from working with Medicare after they have been convicted.

President Obama plans to sign a memo that would create a “do not fraud” list to combat Medicare fraud.  Consequently, the government would not send payments to deceased people, suspended contractors, or other delinquents to cut down on fraudulent payments. According to the Washington Post, within a three year time span, CMS sent approximately $182 million to dead people. CMS will use an online tool that will detect fraud, and provide more comprehensive background tests on providers, hoping to cut down on fake payments.

In general, I feel that the crackdown on such scams will be beneficial to the Medicare system. By preventing employees responsible for fraud from again working with Medicare, and keeping more detailed records of payments and providers, the government can save billions of dollars that will be better used elsewhere.  Hopefully these measures will improve the current health care environment in the United States.