September 18th, 2008 by Dr. Val Jones in True Stories
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I had the pleasure of interviewing the former president of the Society of Nuclear Medicine recently about the financial challenges threatening his specialty. (Reimbursement is not keeping up with the cost of technology).
As I prepared for the interview, I called in to the general society number to be transfered to his line.
The receptionist answered:
“SNM”
I paused for quite a few seconds as my cogs and wheels turned, wondering if I had misdialed. Nope, that’s just how they answer their phones over there. Ahem.
April 23rd, 2008 by Dr. Val Jones in Medblogger Shout Outs
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My radiologist friend in India pointed out an interesting blog post of his (via Twitter*) today. See if you can pick your jaw up off the floor on this one:
A basic MDCT scanner (6 or 8 detector rows) costs about 2 to 2.5 crore rupees here in India (INR 20 to 25 million = US $ 500,000 to 630,000). I learnt from a source in the industry that the cost of the scanner is about 40% subsidized for the Indian market (compared to its cost in the North American & European markets). So the same basic multislice CT scanner would cost about $ 900,000 in the US.
We have a basic four-slice MDCT scanner in our hospital. A patient would be charged Rs. 3500 ($ 90, yes ninety dollars) for a plain CT scan or Rs. 4500 ($ 115) for a contrast CT scan of the whole abdomen. Ours is a small city. The charges are likely to be as high as Rs. 8000 or Rs. 9000 ($ 200 to 230) in the bigger metros like Chennai, Mumbai or Delhi.
Compare that price to a patient in the US who was charged $6,500 for an abdominal CT scan.
(Usual cost is ~$2000, but still!)
*If you’d like to follow me on twitter.com, my user name is drval. Check it out for quick updates and daily eyebrow raises.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 23rd, 2008 by Dr. Val Jones in Expert Interviews, News
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Imagine that you were diagnosed with cancer, and were told that you had one of two treatment options: 1) you could receive a one time dose of a medicine that will go directly to the tumor cells and kill them only, having very few noticeable side effects or 2) you could undergo months of exposure to toxic chemicals that will kill the tumor cells and many other healthy cells as well, resulting in hair loss, bowel damage, nausea, and vomiting. Which would you choose?
Unfortunately, choice number one may no longer be an option for lymphoma patients due to government funding cutbacks, and the development of such treatments for other cancers is in jeopardy as well.
Radioimmunotherapy (RIT) is a relatively new approach to cancer treatment, new enough that the government is having difficulty categorizing it correctly. (RIT involves targeting cancer cells with special antibodies that carry tiny, lethal radiation doses to individual cells.) In fact, drugs like Bexxar and Zevalin have been misclassified by CMS as “supplies” rather than medications, and so the reimbursement allowed doesn’t come close to covering the cost of the therapy. Although there are many new targeted therapies under development, investors are worried that the drugs will never be used in patient care because the country’s number one payer (Medicare) is unwilling to cover their costs. Other health insurers often follow the government’s lead when it comes to treatment coverage policies. If no one will pay for the cost of the drug, then ultimately no one can afford to make it available.
Similar funding problems are beginning to limit access to diagnostic nuclear imaging modalities like PET scans, PET CT, cardiac SPECT scans, and bone scans. Reimbursement levels that do not cover the cost of the imaging drugs means that facilities cannot afford to offer these diagnostic technologies to patients, and centers are slowly reducing the number of tests they offer. Nuclear imaging studies are often critical in diagnosing heart problems, infections, and early detection of cancer. Senator Arlen Specter had his cancer recurrence diagnosed at the very earliest stages thanks to PET scanning technology. Early treatment offers him the best possible prognosis, but he is in a dwindling group of people who have access to this imaging modality.
I spoke with Dr. Peter Conti, professor of radiology at the University of Southern California, and former president of the Society of Nuclear Medicine, from Spain this week – as he is attending the 6th International Workshop for Nuclear Oncology, a lymphoma conference where the crisis in reimbursement for targeted cancer therapies is being discussed, along with exciting advances in treating patients with lymphoma. The two different RIT drugs (Bexxar and Zevalin) for non-Hodgkin’s lymphoma are in jeopardy of not being available to Medicare patients due to proposed cuts in reimbursement. Recent plans to cut payment for these drugs have been halted by a temporary moratorium from Senator Kennedy. Here’s what Dr. Conti had to say:
“Let’s face it, lymphoma is not as high profile as other cancers such as breast, colon, or prostate. However, we’ve found a fantastic treatment option for it, and there are implications for the more common cancers, but that treatment option is being denied to lymphoma patients because facilities cannot cover the costs of offering it. I’d like the entire cancer community to rise up in support of lymphoma patients so that Congress will tell Medicare to fix the funding problem. If this doesn’t happen, it’s only a matter of time until novel RIT treatments are no longer an option and we’ll be stuck in the dark ages of non-specific chemotherapy and radiation treatments that harm the good cells with the bad. Personalized, targeted therapy is the future – and we’re missing the opportunity to further develop these novel therapies due to budget cuts.”
I reached out to the current president of the Society of Nuclear Medicine, Dr. Alexander J. McEwan, for comment:
“Molecular imaging offers critical tools for the early detection, diagnosis and treatment of many life-threatening diseases, including cancer. SNM recommends that CMS establishes appropriate reimbursement for all forms of nuclear and molecular imaging and radioisotope therapies at levels that allow optimum access and improved outcomes for all patients.”
Denial of RIT to lymphoma patients may be the first sign of a new trend limiting the development of high tech therapeutic innovations. Will America’s research engine run out of gas before we figure out how to treat cancer without side effects? Should we buy one more tank to get us over the crest of the targeted therapy hill? This is a judgment call that affects all of us at a time of great need and limited resources. What’s your take?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 12th, 2008 by Dr. Val Jones in True Stories
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Every physician has a few traumatic patient stories forever etched in their minds. My friend Dr. Rob recently blogged about the sad case of a little boy with an ear infection – his bulging red eardrum suggested a common problem requiring antibiotics. Little did anyone know that the bacteria behind the drum would get into his spinal fluid, causing meningitis and rapid death. Another emergency medicine physician tells the story of an elderly woman whose aorta dissected right in front of the medical team, with barely enough time for the trauma surgeon to save her life.
One of my surprising moments occurred when I was an ER resident. A middle aged woman (we’ll call her Lizzy) was sent to the ER in the middle of the afternoon after a near-fainting episode in a pain management clinic. She was fairly well known to the more senior residents and staff (she was a chronic pain patient on multiple medications who came to the ER for frequent generalized pain work ups and rescue doses of her meds). So since this lady had cried wolf a few too many times, she was assigned to me – the newbie.
I had no pre-conceived notions about Lizzy, and hadn’t experienced her exaggerated and benign abdominal pain claims in the past. She was lucid, with a smoker’s cough and mildly disheveled, short hair with dark roots and blond tips. She explained that she had been at her usual pain management appointment when she got up from the waiting room chair to register and almost blacked out. She described feeling lightheaded, and needing to sit back down immediately. The clinic staff called our ER to transfer her for an evaluation.
Lizzy seemed fairly cheerful and unconcerned about her near fainting – as if swooning bought her a free ride to the ER to see her “other doctors.” But still, something didn’t seem right to me about her. She was light skinned, but not pink enough. Her blood pressure was low-normal. She had no particular pain anywhere, though on the levels of narcotics she was taking it would be a miracle if she could feel any pain at all. I decided to watch her, take serial vitals, and order a CBC and Chem 7 to see if there might be any signs of dehydration or anemia.
The second set of vitals showed a slightly lower blood pressure and a slightly higher pulse. She sat on the stretcher, watching the TV without any particular sense of urgency. Since it was an unusually slow afternoon, I got the chance to ask for more details of her medical history. Lizzy described her normal daily activities at the assisted living center, and how she had attended a party where she’d had a bit too much to drink and had fallen on a chair a couple of days ago. She said it hurt at first in her left upper quadrant, but it felt only slightly sore now.
Her CBC came back with a lowish hematocrit, and a third blood pressure reading was trending lower yet. I really wasn’t sure what was going on, but I was getting nervous. I presented the case to my attending (who knew the patient very well) and suggested that we get an abdominal CT to rule out internal bleeding.
He rolled his eyes and sneered at me. “Do you know how many CTs this woman has had already?”
“Um, no…” I winced.
“She gets one every freaking time she’s in here, and it’s always non-specific. Inexperienced residents like you are wasting hospital resources on drug seekers!”
“But she does have some anemia, low blood pressure, and a history of abdominal trauma…” I mumbled.
“She’s always slightly anemic, with low blood pressure – what would YOUR blood pressure be on high dose oxycontin?”
“But she looks pale and she almost fainted…” I tried to continue my argument.
“Alright, Jones… I’m going to let you order the CT as a learning experience for you. This is a teaching hospital, and I guess that means that we can irradiate patients at will. Go ahead… we’ll see what it shows.”
By this time I was really questioning myself. I’d gotten in an argument with one of our attendings who knew this patient intimately and had years of medical experience beyond my own. If I was wrong about her, he’d make me pay for the rest of the year – and tell all the other residents about my poor clinical judgment and wasted hospital resources. I was very nervous, but I just had to follow my instinct.
I sent the woman to the CT scanner with a reassuring pat on the shoulder. She winked at me and disappeared into the radiology suite.
Ten minutes later I was paged by the radiologist, his voice was tense – “Your patient has a splenic laceration, you’d better call in the trauma surgeons. She’s fading fast…”
Before I could put the phone down I heard the trauma team being paged overhead and some surgeons emerged from behind a curtain and started running to the CT scanner, almost knocking me off my feet in the hallway.
As it turns out, the trauma team was able to save Lizzy by removing her spleen. She spent several days in the hospital receiving blood transfusions and recovering from the operation. My attending never mentioned the incident again, though I never forgot Lizzy’s near-death experience. Maybe it was a blessing that I was a “newbie” when I met Lizzy – my lack of knowledge of her usual behavior allowed me to view her with a fresh eye, and take her complaints seriously. It’s really hard to hit that reset button with every “frequent flier” in the ER – but sometimes it can save a life.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
December 17th, 2007 by Dr. Val Jones in True Stories
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For more than a decade, I successfully avoided a visit to the orthopedist for a chronic elbow problem. Today I reluctantly decided, on the advice of a friend and orthopod, to go to the hospital and find out once and for all what could be causing my elbows to lock during certain exercises.
The process took 4 hours, all told. I registered at the clinic, then proceeded to the radiology suite to wait for some X-rays. There was a long line of legitimate-appearing X-ray candidates before me – some in casts, others in slings, still others limping pitifully. I was just fine and pain free, feeling a bit guilty – as if I might be wasting resources.
I glanced at the films as I put them in a folder to take back upstairs to the clinic – they looked perfectly normal. “Oh, boy.” I thought, “young Caucasian female complaining of elbow locking for 15 years, now with normal X-rays.” I bet the orthopedist is going to roll his eyes at me. I was escorted to an examining room where I sat on a table across from my normal X-rays, clipped on a light box.
A trim and athletic gentleman in his mid 60’s introduced himself to me. He had crystal blue eyes and short white hair… and disproportionately large hands (kind of the way Michelangelo’s David does). I was sure that I was the healthiest person he’d see that day. He glanced at my totally uninteresting elbow X-rays, took a deep breath and raised a skeptical eyebrow as he asked me to describe my difficulty.
“Well, when I’m at the gym, my elbows lock at about 15 degrees from full extension during certain exercises. It’s always during the eccentric phase of muscle contraction, and usually during a lat pulldown or seated row. If I rotate my forearm there’s a snap and the discomfort disappears and I can resume the exercise.”
He was impressed by the specificity of my description, and asked me to demonstrate the problem. I felt a little bit silly, but attempted to keep a straight face. Seeing that we were not going to be able to reproduce the problem without counter weight, the good doctor jumped in to simulate the exercise by pulling on my arm. I pulled back, and we soon realized that he was unable to apply a force strong enough to trigger the problem. In fact, I pulled the poor man off balance and nearly dropped him on the floor.
After a few more maneuvers he concluded that he had no idea whatsoever what the problem might be. He told me that since the X-rays were normal there was probably nothing to worry about, and that I might consider avoiding lifting weights in “clanky gyms filled with smelly, sweaty people.”
He dictated his note in front of me, highlighting my excellent health, unusual strength, and completely benign X-rays. He seemed to relish the whimsy of the fact that he was no physical match for me (a smallish blond woman) and added that I was unlikely to be damaging my elbows at the gym.
His advice, as I had anticipated, was to “stop doing the things that trigger the locking” and to consult him if I developed any neuropathic pain or effusions. He added that I reminded him of his daughter.
Well, it was an amusing interaction – but somewhat unsatisfying. It made me think of all the times that I wasn’t sure what was wrong with my patients, and how disappointed they were when I had to tell them this. Medicine is an inexact science at times – and the best that we can do is rule out the really bad stuff, and shrug when the rest remains unclear.
Have you had a problem but couldn’t find a diagnosis? Do tell…This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
