After urologists got machine, cancer treatments soared

By Jay Hancock
The Baltimore Sun, January 17, 2012
Four years ago, doctors at Chesapeake Urology Associates started ordering the most expensive kind of prostate-cancer therapy for many more of their patients.
Before 2007, the large, multi-office practice was prescribing the treatment, known as intensity modulated radiation therapy, for 12 percent of its prostate-cancer patients covered by Medicare, according to data compiled by a Georgetown University researcher. But starting in mid-2007, Chesapeake Urology’s referral rate for IMRT more than tripled, rising to 43 percent of the Medicare cases.
What could have caused such a sharp change?
It couldn’t have been because IMRT, which costs about $40,000 per treatment, was new. Maryland hospitals had been offering it for years.
It couldn’t have been because IMRT was better.
“No randomized clinical trials show that prostate cancer patients receiving IMRT live longer or experience fewer long-term side effects than those getting the alternatives” of radiation-seed therapy or surgery, said Dr. James Mohler, a urologist at Roswell Park Cancer Institute in Buffalo, N.Y., and chairman of the national committee that sets standards for prostate-cancer care.
Chesapeake Urology tripled its percentage of prescriptions for IMRT after the practice acquired its own IMRT machine in 2007. The more patients the Baltimore-area urologists referred for that expensive therapy alternative, the more revenue and profits they would generate.
“They’re steering patients to IMRT because that’s where they make their money,” said Jean Mitchell, a professor and health care economist at Georgetown who’s working on a national study about IMRT referrals. “They’re making a ton of money out of this. There’s no question about it. At the expense of the taxpayers” who finance Medicare.
http://www.baltimoresun.com/health/bs-bz-hancock-chesapeake-urology-20120114,0,670418.column

Technology that improves patient outcomes and reduces costs is great. Technology that increases costs, produces undesirable side effects, and provides no evidence of extended life expectancy is… well… not so great, except for meeting the financial goals of the entrepreneurial owners of the technology. And when the owners of the technology are the same trusted physicians who are prescribing it, that’s reprehensible.
Theoretically a government-funded and government-administered health care financing program would have the power to prevent these abuses. Yet this diversion of radiation treatment fees to the referring physicians is occurring within the Medicare program. So simply expanding Medicare to everyone alone is not enough to fix our dysfunctional financing system.
A properly designed single payer national health program would do far more than simply remove private insurers from the system. In this instance the need for the radiation equipment would be determined by medical science confirming the value of the intervention. The decision to purchase the equipment would be made through regional planning based on need. The payment for the equipment would be through separate budgeting of capital improvements. The ownership would be public or non-profit and would have no investors to draw off profits.
Physicians would be paid appropriately for their professional services as urologists and radiation oncologists, but they would not receive extra dividends based on their insight as to the potential lucrative benefits of personally investing in the equipment.
So about that Medicare for all. We speak of an improved Medicare for all, but the improvements would have to be monumental.

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane”
–Martin Luther King Jr.

Among the Wealthiest One Percent, Many Variations

By Shaila Dewan and Robert Gebeloff
The New York Times, January 14, 2012

The colossal gap between the very rich and everyone else – the 1 percent versus the 99 percent – has become a rallying point in this election season. President Obama positions himself as a defender of the middle class, and Mitt Romney, the wealthiest of the Republican presidential candidates, decries such talk as “the bitter politics of envy.”

The range of wealth in the 1 percent is vast – from households that bring in $380,000 a year, according to census data, up to billionaires like Warren E. Buffett and Bill Gates.

Most 1 percenters were born with socioeconomic advantages, which helps explain why the 1 percent is more likely than other Americans to have jobs, according to census data. They work longer hours, being three times more likely than the 99 percent to work more than 50 hours a week, and are more likely to be self-employed.

In one survey of wealthy Chicago families, almost twice as many respondents said they would cut government spending as those who said they would cut spending and raise revenue.

“I don’t mind paying a little bit more in taxes. I don’t mind putting money to programs that help the poor,” said Anthony J. Bonomo of Manhasset, N.Y., who runs a medical malpractice insurance company and is a Republican. But, he said, he did mind taking a hit for the country’s woes. “If those people could camp out in that park all day, why aren’t they out looking for a job? Why are they blaming others?”

Still, David Mejias, a divorce and personal injury lawyer who once served as a Democratic legislator for Nassau County, said that the system everywhere was skewed in favor of the self-employed and business owners who could deduct part of the cost of their cars, trips, dinners and even collectibles like art.

“Not only do we make more money, but if you do a lifestyle analysis, we make a lot more money,” he said. “Before we even get paid, most of our life has been paid for already.”

“I definitely see it around me,” said Anu Chandok, 36, an oncologist in Lake Success, referring to the country’s economic pain. “It just personally hasn’t affected me yet.”

Dr. Chandok said that her husband, also a doctor, was still paying off his student loans. The couple has a nanny, but Dr. Chandok’s father-in-law does the shopping and cooking.

Dr. Chandok said she had never heard the Occupy Wall Street slogan “We are the 99 percent.” Two children and 11-hour workdays, she said, do not leave much time for politics.

But when the slogan was explained as a complaint against the wealthy’s growing share of income, she shook her head. “I spent four years in undergraduate school, four years in medical school, three years as a resident and three years as a fellow,” she said. “You have to look at the people who are complaining.”

http://www.nytimes.com/2012/01/15/business/the-1-percent-paint-a-more-nuanced-portrait-of-the-rich.html?_r=2&hp=&pagewanted=all

New York Times Interactive

Of 360,785 physicians who practice in offices and clinics, 27.2 percent have incomes in the top 1 percent (over $380,000).

http://www.nytimes.com/packages/html/newsgraphics/2012/0115-one-percent-occupations/index.html

Comment: 

By Don McCanne, MD

On Martin Luther King Jr Day it seems appropriate to contemplate what he might say about the dramatic increase in flow of wealth from middle- and lower-income families to the 1 percent who constitute the uber-wealthy. It seems safe to assume that he would be concerned about the negative impact on the issues of social justice to which he devoted his life.

One of those issues was health care justice. What do you think he might say about the fact that 27 percent of physicians practicing in offices and clinics fall into the highest 1 percent of income? It is likely that he would not frame the problem narrowly as excess compensation for physicians but rather as the larger issue of an excess accumulation of wealth at the very top when there is so much unmet need amongst the masses.

But for many of us who have had experience in the trenches, we have been annoyed, to say the least, that many of these same high-income physicians refused to see our uninsured and Medicaid patients. Was it because they didn’t want to make the smallest of dents in their high incomes by using a small amount of office time on just a few patients that did not cover their costs? Or was it that they didn’t want “that element” to frequent their waiting rooms? Both, in my experience, and as Dr. Chandok’s views suggest.

One concern that many physicians have about single payer, or an improved Medicare for all, is that the government, as a monopsony, could reduce physicians’ incomes perhaps to the level of teachers’ salaries. Although incomes of physicians in most other nations are lower than in the United States, they still rank well above average. Physicians do very well, though most are not able to accumulate large amounts of wealth that a $380,000 or more income might bring.

Most physicians who are truly dedicated to serving patients would be satisfied with incomes in the top 20 percent if they were provided a practice environment conducive to optimal care for all of their patients. That, of course, is precisely a major goal of single payer.

Many if not most of those physicians who want to be in the top 1 percent might not be satisfied. When deciding on career choices they might reject medicine if it had government controls on spending, and choose an educational path that might lead to the financial services industry, corporate leadership, or entrepreneurial endeavors.

Opponents of government-financed medicine have warned that controls on health care spending might deprive health care of some of the finest and brightest minds. What? Do we really want more physicians whose primary interest is to accumulate wealth while demonstrating absolutely no compassion for the least amongst us? There isn’t much doubt about what Dr. King’s position would be.

When we are asked if single payer might reduce physicians’ incomes we don’t need to fumble around trying to craft an answer that would placate physicians with very high incomes. We should state frankly that if an individual’s goal is to have a personal fleet of luxury automobiles and a condo in every climate, then medicine isn’t the field for them, or at least shouldn’t be.

On the other hand, if the goal is to obtain the best attainable health care for everyone, while adjusting incomes to reinforce the primary care infrastructure and to provide fair but not excessive compensation for procedure-oriented specialists, then practicing medicine in a single payer environment is just what the compassionate doctor ordered.

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane”
–Martin Luther King Jr.

Among the Wealthiest One Percent, Many Variations

By Shaila Dewan and Robert Gebeloff
The New York Times, January 14, 2012
The colossal gap between the very rich and everyone else – the 1 percent versus the 99 percent – has become a rallying point in this election season. President Obama positions himself as a defender of the middle class, and Mitt Romney, the wealthiest of the Republican presidential candidates, decries such talk as “the bitter politics of envy.”
The range of wealth in the 1 percent is vast – from households that bring in $380,000 a year, according to census data, up to billionaires like Warren E. Buffett and Bill Gates.
Most 1 percenters were born with socioeconomic advantages, which helps explain why the 1 percent is more likely than other Americans to have jobs, according to census data. They work longer hours, being three times more likely than the 99 percent to work more than 50 hours a week, and are more likely to be self-employed.
In one survey of wealthy Chicago families, almost twice as many respondents said they would cut government spending as those who said they would cut spending and raise revenue.
“I don’t mind paying a little bit more in taxes. I don’t mind putting money to programs that help the poor,” said Anthony J. Bonomo of Manhasset, N.Y., who runs a medical malpractice insurance company and is a Republican. But, he said, he did mind taking a hit for the country’s woes. “If those people could camp out in that park all day, why aren’t they out looking for a job? Why are they blaming others?”
Still, David Mejias, a divorce and personal injury lawyer who once served as a Democratic legislator for Nassau County, said that the system everywhere was skewed in favor of the self-employed and business owners who could deduct part of the cost of their cars, trips, dinners and even collectibles like art.
“Not only do we make more money, but if you do a lifestyle analysis, we make a lot more money,” he said. “Before we even get paid, most of our life has been paid for already.”
“I definitely see it around me,” said Anu Chandok, 36, an oncologist in Lake Success, referring to the country’s economic pain. “It just personally hasn’t affected me yet.”
Dr. Chandok said that her husband, also a doctor, was still paying off his student loans. The couple has a nanny, but Dr. Chandok’s father-in-law does the shopping and cooking.
Dr. Chandok said she had never heard the Occupy Wall Street slogan “We are the 99 percent.” Two children and 11-hour workdays, she said, do not leave much time for politics.
But when the slogan was explained as a complaint against the wealthy’s growing share of income, she shook her head. “I spent four years in undergraduate school, four years in medical school, three years as a resident and three years as a fellow,” she said. “You have to look at the people who are complaining.”
http://www.nytimes.com/2012/01/15/business/the-1-percent-paint-a-more-nuanced-portrait-of-the-rich.html?_r=2&hp=&pagewanted=all
New York Times Interactive
Of 360,785 physicians who practice in offices and clinics, 27.2 percent have incomes in the top 1 percent (over $380,000).
http://www.nytimes.com/packages/html/newsgraphics/2012/0115-one-percent-occupations/index.html

On Martin Luther King Jr Day it seems appropriate to contemplate what he might say about the dramatic increase in flow of wealth from middle- and lower-income families to the 1 percent who constitute the uber-wealthy. It seems safe to assume that he would be concerned about the negative impact on the issues of social justice to which he devoted his life.
One of those issues was health care justice. What do you think he might say about the fact that 27 percent of physicians practicing in offices and clinics fall into the highest 1 percent of income? It is likely that he would not frame the problem narrowly as excess compensation for physicians but rather as the larger issue of an excess accumulation of wealth at the very top when there is so much unmet need amongst the masses.
But for many of us who have had experience in the trenches, we have been annoyed, to say the least, that many of these same high-income physicians refused to see our uninsured and Medicaid patients. Was it because they didn’t want to make the smallest of dents in their high incomes by using a small amount of office time on just a few patients that did not cover their costs? Or was it that they didn’t want “that element” to frequent their waiting rooms? Both, in my experience, and as Dr. Chandok’s views suggest.
One concern that many physicians have about single payer, or an improved Medicare for all, is that the government, as a monopsony, could reduce physicians’ incomes perhaps to the level of teachers’ salaries. Although incomes of physicians in most other nations are lower than in the United States, they still rank well above average. Physicians do very well, though most are not able to accumulate large amounts of wealth that a $380,000 or more income might bring.
Most physicians who are truly dedicated to serving patients would be satisfied with incomes in the top 20 percent if they were provided a practice environment conducive to optimal care for all of their patients. That, of course, is precisely a major goal of single payer.
Many if not most of those physicians who want to be in the top 1 percent might not be satisfied. When deciding on career choices they might reject medicine if it had government controls on spending, and choose an educational path that might lead to the financial services industry, corporate leadership, or entrepreneurial endeavors.
Opponents of government-financed medicine have warned that controls on health care spending might deprive health care of some of the finest and brightest minds. What? Do we really want more physicians whose primary interest is to accumulate wealth while demonstrating absolutely no compassion for the least amongst us? There isn’t much doubt about what Dr. King’s position would be.
When we are asked if single payer might reduce physicians’ incomes we don’t need to fumble around trying to craft an answer that would placate physicians with very high incomes. We should state frankly that if an individual’s goal is to have a personal fleet of luxury automobiles and a condo in every climate, then medicine isn’t the field for them, or at least shouldn’t be.
On the other hand, if the goal is to obtain the best attainable health care for everyone, while adjusting incomes to reinforce the primary care infrastructure and to provide fair but not excessive compensation for procedure-oriented specialists, then practicing medicine in a single payer environment is just what the compassionate doctor ordered.

By James W. Moser, PhD, Kimberly E. Applegate, MD, MS
Journal of the American College of Radiology, January 2012

Compared with non-Medicaid insured ED patients, uninsured ED patients were less likely to get any imaging services and to get lower value imaging RVUs (relative value units), results that held for nearly all modalities. Similar results regarding the number and value of imaging services, as well as health status, were found for Medicaid patients.

Even after controlling for health status and other measurable factors, the average number of imaging tests received by uninsured ED patients was ≥8% lower than that for non-Medicaid insured ED patients. The deficit for Medicaid ED patients was even greater, at about 10%. Uninsured ED patients and Medicaid ED patients also received fewer imaging-related RVUs per visit than non-Medicaid insured ED patients: 13% and 19%, respectively. These differences amplify the potentially serious health implications for persons lacking conventional health insurance. As the number of uninsured Americans continues to rise, the use of ED services will also rise.

The differences in imaging RVUs by insurance group stemmed from a bias toward lower valued imaging modalities for persons lacking coverage compared with insurance persons. Medicaid patients, perhaps underinsured, also received lower valued imaging and less imaging compared with insured patients. Other studies have found that the uninsured are less likely to get timely medical care and consequently are sicker upon being admitted to the hospital.

http://www.jacr.org/article/S1546-1440(11)00445-5/fulltext

Comment:

By Don McCanne, MD

Fully predictable. Uninsured and Medicaid emergency department patients receive fewer imaging tests, and when they do receive them, they are more likely to be lower valued tests. Under the Affordable Care Act, many individuals will remain uninsured and many more will be enrolled in Medicaid. Thus this is a problem that is not going away.

We can do better than this.

Imaging and Insurance: Do the Uninsured Get Less Imaging in Emergency Departments?

By James W. Moser, PhD, Kimberly E. Applegate, MD, MS
Journal of the American College of Radiology, January 2012
Compared with non-Medicaid insured ED patients, uninsured ED patients were less likely to get any imaging services and to get lower value imaging RVUs (relative value units), results that held for nearly all modalities. Similar results regarding the number and value of imaging services, as well as health status, were found for Medicaid patients.
Even after controlling for health status and other measurable factors, the average number of imaging tests received by uninsured ED patients was ≥8% lower than that for non-Medicaid insured ED patients. The deficit for Medicaid ED patients was even greater, at about 10%. Uninsured ED patients and Medicaid ED patients also received fewer imaging-related RVUs per visit than non-Medicaid insured ED patients: 13% and 19%, respectively. These differences amplify the potentially serious health implications for persons lacking conventional health insurance. As the number of uninsured Americans continues to rise, the use of ED services will also rise.
The differences in imaging RVUs by insurance group stemmed from a bias toward lower valued imaging modalities for persons lacking coverage compared with insurance persons. Medicaid patients, perhaps underinsured, also received lower valued imaging and less imaging compared with insured patients. Other studies have found that the uninsured are less likely to get timely medical care and consequently are sicker upon being admitted to the hospital.
http://www.jacr.org/article/S1546-1440(11)00445-5/fulltext

Fully predictable. Uninsured and Medicaid emergency department patients receive fewer imaging tests, and when they do receive them, they are more likely to be lower valued tests. Under the Affordable Care Act, many individuals will remain uninsured and many more will be enrolled in Medicaid. Thus this is a problem that is not going away.
We can do better than this.

By Alicia L. Cooper, M.P.H., and Amal N. Trivedi, M.D., M.P.H.
The New England Journal of Medicine, January 12, 2012

This study examined the consequences of adding a fitness-membership benefit on the self-reported health status of enrollees in Medicare Advantage plans. Using a quasi-experimental design, we found that persons enrolling in plans after the addition of a fitness-membership benefit reported significantly better general health, fewer limitations in moderate activities, less difficulty walking, and higher PCS scores than did persons who enrolled in the same plan before the fitness benefit was added and in matched control plans that never offered a fitness benefit. These patterns persisted in the analyses of 2-year follow-up responses for all measures except self-reported general health. Our findings suggest that there is an association between the adoption of fitness-membership benefits in Medicare Advantage plans and the enrollment of healthier Medicare beneficiaries.

Risk-adjusted payments are designed to reduce incentives for plans to avoid high-cost patients. However, the enhanced Medicare risk-adjustment model has the power to explain only 11% of the total variation in health spending. Furthermore, the model overpredicts costs for persons in good health and underpredicts costs for persons in poor health, yielding overpayments for healthy enrollees and underpayments for less-healthy enrollees. Therefore, the continued limitations of the CMS payment model may not discourage Medicare Advantage plans from engaging in risk-selective activities. Our findings are consistent with the notion that Medicare managed-care plans have continued to selectively market their benefits to healthier beneficiaries, even after the improved risk-adjustment program was instituted.

http://www.nejm.org/doi/full/10.1056/NEJMsa1104273?query=TOC#t=articleTop

Comment: 

By Don McCanne, MD

This study further confirms what we have known all along – that private insurers selectively market to the healthy, further cushioning their profits by being paid at rates for those with only average health. Although risk adjustment has been introduced to correct overpayments due to their use of favorable selection, the insurers have found devious ways to use risk adjustment to further expand their profits, even though technically prohibited. It is the nature of private insurers to always work the system to their own advantage, and that will never change.

How many times do we have to say it? It is time to dismiss the private insurers and establish our own single payer national health program in which the benefits accrue to the patients/taxpayers and not to the expensive, intrusive, wasteful insurance intermediaries.

Fitness Memberships and Favorable Selection in Medicare Advantage Plans

By Alicia L. Cooper, M.P.H., and Amal N. Trivedi, M.D., M.P.H.
The New England Journal of Medicine, January 12, 2012
This study examined the consequences of adding a fitness-membership benefit on the self-reported health status of enrollees in Medicare Advantage plans. Using a quasi-experimental design, we found that persons enrolling in plans after the addition of a fitness-membership benefit reported significantly better general health, fewer limitations in moderate activities, less difficulty walking, and higher PCS scores than did persons who enrolled in the same plan before the fitness benefit was added and in matched control plans that never offered a fitness benefit. These patterns persisted in the analyses of 2-year follow-up responses for all measures except self-reported general health. Our findings suggest that there is an association between the adoption of fitness-membership benefits in Medicare Advantage plans and the enrollment of healthier Medicare beneficiaries.
Risk-adjusted payments are designed to reduce incentives for plans to avoid high-cost patients. However, the enhanced Medicare risk-adjustment model has the power to explain only 11% of the total variation in health spending. Furthermore, the model overpredicts costs for persons in good health and underpredicts costs for persons in poor health, yielding overpayments for healthy enrollees and underpayments for less-healthy enrollees. Therefore, the continued limitations of the CMS payment model may not discourage Medicare Advantage plans from engaging in risk-selective activities. Our findings are consistent with the notion that Medicare managed-care plans have continued to selectively market their benefits to healthier beneficiaries, even after the improved risk-adjustment program was instituted.
http://www.nejm.org/doi/full/10.1056/NEJMsa1104273?query=TOC#t=articleTop

This study further confirms what we have known all along – that private insurers selectively market to the healthy, further cushioning their profits by being paid at rates for those with only average health. Although risk adjustment has been introduced to correct overpayments due to their use of favorable selection, the insurers have found devious ways to use risk adjustment to further expand their profits, even though technically prohibited. It is the nature of private insurers to always work the system to their own advantage, and that will never change.
How many times do we have to say it? It is time to dismiss the private insurers and establish our own single payer national health program in which the benefits accrue to the patients/taxpayers and not to the expensive, intrusive, wasteful insurance intermediaries.