NeuroNews

Must Read....Beyond the Headline

A recent article in the Boston Globe was headlined "Pricey Imaging Pushes Up Heath Costs", but one has to look deeper into the story to unveil an interesting nugget truth of which the general public is unaware and that current health reform ideas are not addressing.
Blue Cross Blue Shield of Massachusetts, the state's largest insurer, said that in 2006, 40 percent of the MRIs it paid for were done at hospitals, compared with 50 percent by 2008. That has significant cost implications, said Andrew Dreyfus, executive vice president for health care services, because the insurer pays an average $700 for an MRI in a freestanding clinic, but twice that much at a hospital. Entire article.
The fact that hospitals charge much more for everything they do compared with outpatient centers is just the tip of the iceberg of waste in our current hospital-based healthcare system.  For more on this read Massachusetts Healthcare - Not Miracle, but Smoke and Mirrors.
 
It is ironic that in the state that is touted as the first experiment in universal health care, that hospitals are identified as driving up the cost of care while at the same time Boston Medical Center is suing the state of Massachusetts for non-payment of services.

by Vernon Rowe, MD

 

Does Hospitals Ownership Of Primary Care Practices Create A Dual Agency Problem?

The dual agency problem is just the way ethicists have defined the old saying "No man can serve two masters..."   When a hospital owns a patient population through the ownership of general medical practices, the doctors whose practices are owned are put in a tough position.  The hospital expects that doctor to refer to other doctors who are in that system, because the "bottom line" of the hospital or hospital system are increased when patients are kept within the system.  Whatever cosmetic face hospitals try to put on their administrations, they are nearly always run by businessmen, and to businessmen, the bottom line is everything.

When a doctor must treat a patient, and his or her practice is owned by a hospital or hospital system, then he or she is in an ethical pickle.  Most doctors know in their hearts that all medical care is not equal.  They themselves frequently go themselves or send their family members to doctors outside their own hospital systems.  One reason for this could be the protection of and respect for privacy.  But I don't think this is the primary reasons physicians go outside their own medical systems for care.  I believe it is because they on the inside know where the best care is available in the area, and that is where physicians in the know send themselves and their families. 

So if I were a patient, the next time a doctor suggests hospitalization or even evaluation or further testing, I would just ask him or her the simple question, "  Is this where you would go or send your family?"   If the answer is unhesitatingly "yes" coming from the doctor's mouth, then it's probably a good referral.  If there is any hesitation whatsoever in the answer to that simple question, then that patient needs to move on to a second opinion. 

Doctors are almost without exception truthful people.  The exceptions are so rare that they receive as much press as the Al Queda Christmas bomber when they occur.  Trying to create a TSA for doctors is certainly a jobs program, but is hardly necessary.  Doctors really do try to live by the maxim "first, do no harm," and they try to give their patients the best care they can.  Hospitals on the other hand are businesses run by businessmen.  Just like insurance companies.

So the next time your doctor wants you to undergo tests or be admitted for surgery, just ask him or her that simple little question: "Is that what you would do?  Is that where you would send your family?"  You'll find out a lot about your doctor, and you'll help him or here solve the dual agency problem very quickly.

by Vernon Rowe, MD 

New Research Into Potential Cause of Restless Leg Syndrome

A new theory about the potential cause of Restless Leg Syndrome (RLS) will be presented at SLEEP 2010 in San Antonio, the annual meeting of the American Academy of Sleep Medicine and the Sleep Research Society.

A summary of this research, the abstract, was developed at MidAmerica Neuroscience Institute. It was determined that an unusually large number of patients being treated at their AASM accredited sleep center, for RLS or Periodic Limb Movement Disorder (PLMD) also had a positive diagnosis of lumbar radiculopathy - or what is commonly called a "pinched nerve". 

The theory was confirmed through examination of electronic medical records of 1076 consecutive patients from a neurology practice suspected of having a sleep disorder requiring polysomnography (PSG).  The study revealed a surprisingly high overall prevalence of lumbar radiculopathy found in RLS/PLMD patients.

To receive further information when this study is published, including any new treatment implications, follow this link. RLS Study

Multiple Sclerosis Success Story

submitted by Cindy B. of Maryville, MO

I was diagnosed with multiple sclerosis (MS) in October 2002.  At that time, Dr. Rowe said it appeared that I have had MS for about 20 years.  Some people like me are relieved when we are given the diagnosis of MS.  I was shocked, but relieved at the same time.  I finally found a doctor who "listened" and saw how I was feeling.  For 20 plus years I was misdiagnosed.  I felt like a guinea pig.

Various doctors told me I was just depressed.  I felt like my symptoms were all in my head.  I became angry and irritable.  I had been diagnosed with Chronic Fatigue Syndrome; Lyme disease; fibromyalgia; inner ear infection because of balance problems; arthritis, depression and the list goes on.  Who wouldn't be depressed?! 

I was so relieved to find out what and why I wasn't feeling well.  I eventually had to stop working as an LPN because of my poor balance, severe weakness and fatigue.  I had to give up driving because of optic neuritis and poor peripheral vision.  I had severe headaches and my body hurt so much it would put me in tears.  I began falling more frequently, had tremors and began dropping things.  I also had to give up babysitting. 

My ophthalmologist questioned me..."Has anyone mentioned you might have MS?"  He referred me to my neurologist, Dr. Rowe.

After I was diagnosed, I was put on Avonex and physical therapy.  I'm happy to say, I've been able to volunteer at a school for 20 years now and I love it.  They are very supportive and understanding when I am sick with a relapse or just don't feel good.  I have a hard time knowing when I've done enough, and over done,until my body tells me so. 

I would like to suggest to those of us who have MS to try some type of volunteer work, if at all possible.  We don't have to let MS stop us from being a useful and worthwhile person.

Even though my MS has been progressing, I still work at school.  I am having to cut back.  Some days, or weeks, I can't go at all.  I feel that volunteering gives me a sense of purpose.  What works for one person doesn't always work for other.

I owe a big Thank You to my neurologist, Dr. Rowe and his team for all they continue to do for me.  Because of them and medications, I am able to keep going - just one day, one hour at a time.  Don't give up!!

Cindy also provided helpful information about transportation for those on Medicaid.  In Missouri, contact Logisticare at 1-866-269-5927  http://www.logisticare.com/home.asp Before you call, have the following information ready:
Your name 
Your address 
Your Medicaid number 
Date & time of your appointment 
Doctor's name & type of doctor
Doctor's address and phone number
  
There is a $2.00 copay.  Driver's cannot ask you for the co-pay if you can't pay it.  Call at least three business days in ahead.  Logisticare will set you up with the transportation company closest to you.  Driver will call you the day before your trip to let you know who is picking you up and what time they will pick you up.

If you have someone that can take you to your appointment, call Logisticare BEFORE the appointment to get gas reimbursement.  They will send you a form to fill out so that you can reimburse your driver for gas.

Massachusetts Healthcare - Not Miracle, but Smoke and Mirrors

Polls show the large majority of the American people are happy with their healthcare.  They just think it costs too much.  Most people think pre-existing conditions and concurrent illness shouldn't prevent insurance.  Fair enough.  Those are easy fixes.

Enter the Massachusetts Health Reform Bill, touted as the solution for the country's healthcare woes.  It's had a few years for a track record, and this has been examined in papers in the New England Journal of Medicine (1, 2).  It turns out that "only about half of the more than 400,000 residents who gained coverage by December 2008 were publically subsidized."  This means that half the newly insured could have insured themselves anyway, so "the individual mandate and employer incentives have provided good value for Massachusetts taxpayers..." 

But this came at a cost, with the average price of a family insurance premium increased by more than 12%, with another 10% increase in 2009.  Maybe the cost is worth it for the public good.  That's for us all to decide, but I invite you to read this article and come to your own conclusions. http://healthcarereform.nejm.org/?p=2135

This said, a follow-up poll of doctors in Massachusetts (2) published in the same journal reported that about 70% of doctors generally supported the plan, but only 34% liked it in its current form.  In addition, 87% of the doctors polled said the bill either didn't impact or negatively impacted the amount of time they could spend with patients.  71% didn't find any impact or a negative impact in getting patients to needed referrals to other doctors.  But, fairly enough, 42% found it easier for uninsured patients to pay for care, whereas 36% found either no change or a negative impact in uninsured patients' ability to pay for care.  Again, I invite you to read the article for yourself.  There are problems with the poll, as there are with any poll, but at least the data are presented in a coherent fashion.  http://healthcarereform.nejm.org/?p=2133

Though the New England Journal of Medicine, in my opinion, devotes a large amount of space in its editorial pages advocating a single payer system, only 3% of the doctors who responded to this poll suggested that single payer be implemented.  And as for streamlining care, 78% of the respondents saw no change or a negative impact on the administrative burden of their practices by Massachusetts health care reform.  To be fair, the summary presented here differs from that of the original article, but flows directly from the data presented.  I have connected the dots a little differently from the original authors.

Now back to the first article (1).  The estimated cost of the program was forecast to jump 20% from 2008 to 2009.  With a declining economy, where do you think the money will come from to pay for that increase?  Why from the federal government, of course, with an increase in total federal participation of 43%, so that the entire program will be 70% funded with federal dollars.  There was a corresponding decrease in Massachusetts state funding of the program, from $457 million to $205 million, or a decrease in the Massachusetts general fund contribution to 11% of the total program cost.  For the people of Massachusetts, looks like a pretty good deal, as long as the money comes from the federal government.  That is from all the rest of us.  Beginning to sound a little like Senator Ben Nelson's deal for Nebraska, isn't it? Reminds one of Margaret Thatcher's famous quote about socialism, or in this case, socialized healthcare, "The problem with socialism is that you eventually run out of other people's money."    

So... as we take a look at the Massachusetts Miracle, we have to ask whether it would be good for the rest of the country.  Most everyone agrees that we need to make sure everybody has insurance.  It is clear from Massachusetts that a mandate to buy insurance and a subsidy for those who cannot afford to buy it, will do just that. 

We need to decrease costs.  To do this, I believe a major step would be to take hospitals and hospital systems out of outpatient healthcare, and allow fair competition for our outpatient healthcare dollars among those with an interest in preserving quality while increasing efficiency of outpatient care.  Hospitals are the least appropriate candidate to do this, because as I have written previously, hospitals and hospital systems charge far more for outpatient testing than outpatient health systems, because they tack on facility fees for these outpatient tests.  They have no incentive to do otherwise, and they are exempt from self-referral legislation, so their captive doctors, patients, and their insurers have to pay the extra cost. 

We need to get rid of unfair insurance practices, such as rescission or the cancellation of patients who are sick, and denial of insurance based on pre-existing conditions.  With a mandate, and a few other tweaks, we will be able to afford this change.  It is also clear that health insurance companies have undergone a major change in the last two decades.  In the early 90's, their medical loss ratio (what they pay out for patient care relative to the premiums they take in) was about 95%.  However, recently, that medical loss ratio has decreased to 80%.  Presumably, this extra money goes to increase shareholder value, executive salaries, and corporate jets, and not to better patient care.  It's pretty clear to me that some of the costs of our healthcare system could be trimmed from insurance industry "overhead" costs.

Most important in healthcare, we should adhere to the ancient maxim that doctors try to live by every day: "First, do no harm." Unfortunately, the bills before congress, in my opinion, will do a lot of harm to patients as well as the health care delivery system that serves them. 

1.  Massachusetts Health Care Reform--Near-Universal Coverage at What Cost? by Weissman and Bigby, MEJM 361;21  November 19, 2009.

2.  Physicians' Views of the Massachusetts Health Care Reform Law--A Poll  by SteelFisher et al, 10.1056/NEJM  po909841.

 by Vernon Rowe, MD

The Next “Too Big To Fail” -The US Hospital-Based Health Care System

We as a country seem to have a penchant for the big.  Big, we think, is always good.  When the big becomes no longer good but bad and ugly, we ignore the old saying "the bigger they are, the harder they fall."  Witness the last year in the financial industry and the destruction the very big have wrought.  But taxpayers bailed that industry out.  And just around the corner I believe is the hospital-based portion of our health care system.

By way of background, when the federal government became involved in health care with Medicare and Medicaid, it became obvious to business interests that the business of medicine was far too financially rewarding to be left in the hands of mere doctors, nurses, and patients.  Medicine was referred to as a cottage industry.  So the denial-of-care models for HMO's were sold as our cost-saving salvation.  People bought that idea for awhile until they got sick.  Then they didn't like HMO's anymore.  Next, hospitals and hospital systems were sold as being able to bring down costs with economies of scale. 

But the economic engines of these hospitals and hospital systems had to be fed.  New diagnostic testing and treatment procedures became profit centers instead of advances in patient care.  Men and women who had never taken care of patients in their lives became the decision makers of medical practice within the hospital systems, and created giant lobbies, such as the one for the American Hospital Association.  And because they were able to speak the language of business to bureaucrats, their loud financial voices were heard in the halls of congress, and amplified to their political patrons.  And they were rewarded for their efforts by Congress.  A striking example of this is the exemption of hospitals from legislation that prohibits self-referral. Most people, patients as well as legislators, do not know that hospitals are paid far more  for such tests as MRI, X-rays, sleep studies, endoscopy and numerous others, than are outpatient facilities for the same test, because hospitals tack on a "facility fee".  This extra reimbursement is paid both by Federal and private insurers.  Hospitals also receive large government subsidies for their "losses".  These issues have not even been discussed so far, in the rush to "reform".

These large hospital systems continue to buy the general practices of primary care physicians, who are then encouraged to refer patients only within the hospital system itself.  Thus, fewer and fewer primary care givers are free to choose the best care for their patients by selecting test centers and physicians based on quality.  Similarly, large hospitals are buying up rural hospitals, where the elderly and poor used to go for care close to home, as feeder hospitals, with one of the results being that the last dollar possible is extracted from federally insured patients in their final months of life.  And these hospitals and hospital systems continue to build new buildings.  This consolidation of the power of hospitals and hospital systems is removing a large component of competition from the American health care system.

The irony is that most of the real patient care that goes on in this country has nothing to do with inpatient hospital care.  It could be delivered in appropriate outpatient settings that should not be owned by large hospital systems.  After all, the goal of medical care should be to keep patients out of hospitals if possible, using them only as a last resort.    You can get sick in hospitals, and you don't want to be there unless you have to be. 

And most preventive medicine in this country, with its good water supply, required immunizations, and shelter for most of its people, could be delivered by health departments, family practitioners, and internists. Yet general practice physicians are the lowest of the low in reimbursement.  They frequently go under and are forced to sell their practices to middlemen hospitals and hospital systems, which keep gobbling up our healthcare dollars.

We should not treat the disease of increasing medical care costs by building ever larger hospital based care delivery systems, the iron lungs of the past.  Instead, we should develop the vaccine, which in this case, is the removal of hospitals from outpatient care, whenever possible, by removing the profit motive they have for getting involved in outpatient care in the first place. 

We need to reimburse hospitals and hospital systems adequately for the important inpatient work they do, but they need to be taken out of outpatient healthcare.  Let's learn from the financial crisis of the past year.  Too big to fail is, simply, just too big.

 - by Vernon Rowe, MD

Multiple Sclerosis Patient Had Never Seen Her Own MRI’s

I saw a patient the other day who was looking for another neurologist. She was diagnosed with Multiple Sclerosis several years ago, but in all that time no one had ever shown her the MRI's used to make the diagnosis. MRI's are like fancy cameras that take pictures of the body with different lenses and filters. Every patient can understand these pictures when you take the time to explain them, because as we all know, a picture is worth a thousand words. MRI is the single most elegant development in neurology since its inception. It has revolutionized how we look at Multiple Sclerosis. Every patient deserves to see his or her MRI's. We always do that at our Multiple Sclerosis Center.  It's just a part of the way we see Multiple Sclerosis  patients, as people who happen to have Multiple Sclerosis  - by Vernon Rowe, MD

How Does A Neurologist Treat His Own Migraines?

As a neurologist that specializes in migraine headaches my patients are always interested to learn that I have migraines myself. I suppose this is one of the reasons I am very passionate about treating headaches and seeing headache patients. It is not an arena a lot of doctors want to get involved in because it can be so challenging. Through my own experiences however, I have come to realize that you really need to study headaches. You really need to develop a program to approach headaches and you really have to apply some expertise.  Primary care physicians just don't have the time to address the challenges that headaches present.

There are a lot of armchair experts out there who will give you advice when you get a headache. "Oh take this, it always works for me or my grandmother always told me to strap a poultice on my head that that's work great." If those things work, that's fine, but I know in my own case I've had headaches since I was 5 or 6 years old and they were misdiagnosed as sinus problems and dental problems and eyeglass problems. In fact, this persisted right through college and medical school. Nobody picked up on the idea that I had migraine headaches.

It wasn't until I was in a neurology residency program at the University of Oklahoma and the director of the program was the President of the American Headache Society and a member on the board of the International Headache Society. He pointed out to me, "Dana, the headaches that you're having meet all the criteria for migraine headaches." Then a light bulb went off and I said "Wait a minute, if that's true, I've been treating my headaches all wrong all this time" throwing over-the-counter medications at the headaches, when actually there are much better prescription medications. Regarding lifestyle, I had been doing things such as sleep deprivation and too much caffeine that would trigger migraines that I needed to modify.

 

Once I knew the diagnosis, then I knew a logical approach to address my headaches and now I'm in charge of my headaches instead of the other way around.

 

Migraines are not the only type of headache people experience, but they are by far the most common. In fact, of all people who go to see their doctor or go to an emergency room with the complaint "I have a headache", over 90% of those individuals have migraines. None have sinus headaches and very few have other types of headaches such as exertion headaches, trigeminal vascular headaches, cluster headaches, and so forth.  The road to gaining control over headaches begins with an accurate diagnosis and that journey is often starts with a headache program at a dedicated headache center. - by Dana Winegarner, DO

Efficient Healthcare Delivered in an Outpatient Neurology Setting

A young 40'ish female was referred to our clinic recently and we scheduled her to be seen on that same day.  She had developed a weakness in her left leg and was also having some problems with her vision and with facial numbness.

Within 24 hours of this referral, the providers at MidAmerica Neuroscience Institute were able to evaluate her rapidly, complete her MRI scans and an EMG to confirm a diagnosis.   A plan of care was developed within 24 hours.  We took what was essentially an emergency, treated it as an outpatient and evaluated it rapidly.  That type of care is unheard of outside an emergency room - where you can't get the same level of competency.

The alternative for this woman would have been to go into the hospital, get admitted so she could stay there a few days while the testing is completed.  She would have ended up with a bill that would be quadruple what she ended up with here.  Her care here at MidAmerica Neuroscience Institute was no fluke.  We have put a comprehensive team of healthcare providers together to make this happen efficiently and to get patients back to the normal lives as quickly as possible. - By Vernon Rowe, MD

Multiple Sclerosis Advancements On The Horizon

At MidAmerica Neuroscience Institute, multiple sclerosis is a passion and an area of focus we have dedicated ourselves to with a wealth of resources that are available to people with MS.  What is unique about our clinic is that our providers are focused on MS care and spend a majority of their time with people with MS as well as learning about the newest advances in MS. 

For example:

1. Our Physical Therapists aren't spending their time rehabbing patients who have had hip or knee replacement surgery.  They spend a large percentage of their time with patients with MS and specifically with the common problems they experience with walking and balance.  By being focused on this area, it makes them more of an expert on MS than the average physical therapist in any clinic in a hospital or on Main Street.
2. We also have a research department here that conducts research into a variety of neurological conditions but a majority of these are in the field of MS.  This allows our patients access to treatments and care that they would not otherwise have and options that they cannot get elsewhere.
3. Currently we're involved an investigational study evaluating a weekly oral dosing of MS medication.  Just about everyone I talk to who is currently on the shots is looking forward this becoming widely available - and we're thrilled to be a part of this advancement.

The field of treating MS has undergone a revolution in the past decade and a half and is going to continue to evolve - and probably at a very quick pace.  We've gone from having no available treatments that treat the underlying disease of MS in 1992, to having three proven medicines.  When I started working in the field of MS we called them the ABC drugs; Avonex, Betaserone and Copaxone.  Now it has expanded to six proven treatments that are FDA approved for MS and we have a whole wealth of other treatments that can be used in clinical trials that are experimental or investigational drugs.  So we have gone from having no treatments to the ABC drugs to where we are facing an "alphabet" of options for patients with MS.  Besides the six FDA approved drugs currently available, many of the drugs that are in clinical trials now are likely to come on the market and be approved by the FDA for broader use in the next several years. 

 

This is going to be an interesting time.  It is going to offer a lot more options and choices that will be more convenient or work better than choices we have now.  It also going to be more challenging because of all those choices and trying to fit the right treatment to the right patients.  Weighing the proven benefits of all these treatments against the cost and risks and possible side effects makes the future of dealing with MS both exciting and challenging at the same time. 

by Doug Schell, Clinical Nurse Specialist, Multiple Sclerosis Certified Nurse