Posts Tagged health

X-Ray Images — lost in space

chest CT

Laura Landro of the Wall Street Journal published the article:  “Image Sharing Seeks to Reduce Repeat Scans” on April 1, 2013.  Ms. Landro reported on an academic project to store x-ray pictures on the Internet called the “Imaging Sharing Project” (image share news release).  The idea is to have patients own a secure copy of their personal x-rays.  By having this storehouse of x-rays in the “cloud” they can be given to any health care provider or hospital as needed.

Any patient who has had to take x-ray images from one provider to another understands the problem.   The provider handed the disk of images may or may not be able to look at them because of incompatible ways of recording the material.  Of course, this means another visit to the provider (or worse, a repeat x-ray and unnecessary x-ray exposure).

Storage of images is nothing new.  But, the concept of the patient owning the images is indeed  something new.  It allows a patient to seek a second opinion without all the hassle of getting the disk.  This is a real asset to a patient who keeps copies of their own medical information.  The typed radiologist report is usually very brief and does not allow for alternate interpretations.

The difficulty transmitting images is partly intentional.   Radiologists fear someone else far away could be a business competitor.   It would be very bad for local radiologists if patients always wanted their brain CT evaluated by some expert in Boston or London.

Cancer patients will find this service very helpful.  If a woman has an abnormal mammogram she can pick the oncologist or surgeon and then share the images with them.  If she has a mammogram at a different facility she can share the older image for the purpose of comparison.

People who move from city to city would still retain easy access to x-ray images.  The US population is much more mobile than in the past so this is very important.

The Image Share project is not available everywhere.  There is a commercial product called LifeIMAGE.  It is a great idea so hopefully the idea will spread.  It would be a step forward if all insurance programs and x-ray offices were required to provide this as a benefit.  If you know of other similar products please leave a reply.

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Financial Considerations — great graphs

Graph Graphic

Dan Munro of Forbes Magazine assembled several interesting health care economics graphs for 2012.  See his article for details and for the source of the data.  Here are some of the graphs:

The first shows the rise in costs for working Americans.  Currently the premium is 50% paid by employer and 50% by the employee.


The second shows how the US compares to other countries — basicaly the US spends more but does not get a benefit in life expectancy.


The third shows the US spends a lot more than other countries in the Medicare age group.


So what is the problem?  One would be tempted to conclude Medicare is the cause of the high costs in the older age group.  But Medicare is more efficient than private insurance based on loss ratios.  And, Medicare has spearheaded reduced payments to hospitals with DRGs.  If Medicare replaced private insurance many estimate a small reduction in total health care cost.   However, the inability of Medicare to set or negotiate prices for drugs, imaging  and devices is sadly lacking compared to the other 40 countries in the world with health systems.   Efforts to cap Medicare cost without giving Medicare the economic tools other health systems have will just result in low quality, high cost and poor access to care.

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Good Advice from Clinical Research


The ABIM foundation asked all the major medical and surgical specialty societies  in the US to each submit “Five Things Physicians and Patients Should Question“.   The specialty societies picked five tests or procedures they thought were being overused or wasteful.  Each one of the “things” is an important well researched piece of advice the societies believe health care  providers and patients should know.  Who is doing the questioning is not clear — but it seems if providers are not following the advice then other doctors, quality assurance departments and patients themselves should ask questions.

The assortment of ABIM documents is mainly intended for physicians so they do contain technical terms.  Fortunately, the ABIM partnered with Consumer Reports to write FREE consumer friendly versions of the ABIM recommendations.  The site has a nice navigation bar so you can quickly find helpful information.  Here is a link to the site:  Consumer Health Choices.

The author of this blog created an abridged version  for a quick scan of everything to date.  Take your choice, either the original, the Consumer Reports version or the abridged (no beating around the bush) version.   A few societies have not yet submitted information so check back with the ABIM Foundation site later if interested.

There seem to be some common threads in the advice:

  1. Don’t do tests if there is no plan to act on the tests (or to find a disease that has no treatment)
  2. Don’t do screening tests if testing errors cause unnecessary or harmful surgery or other tests.
  3. The time interval for screening tests is very important (especially for cost reasons)
  4.  Imaging (nuclear scans, CT, MRI, PET, ultrasound etc.) has been massively overused — always question whether imaging is needed.
  5. In general, don’t fix things that don’t eventually cause symptoms

The advice is both favorable for patients and favorable to reduce the cost of health care.  The US needs more of these evidence-based guidelines.


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Errors at the Pharmacy — what is that pill?


Assume you just picked up your prescription for pills at the pharmacy.  The bottle has a label with a drug name, dose and how often to take it.  But, is the pill the right one, the one the doctor had in mind?  Or did somebody make a mistake and put the wrong little green pills in your bottle?  Or perhaps the bottle has the wrong label?  Did you actually get the pills Dr. Jekel prescribed for Mr. Hyde?  Just to keep this in perspective the picture above is of the same medication: losartan;  made in different strengths and by different manufacturers.  Pharmacists do their best to keep the pills straight but they are only human.

To err is human.  But, in most medical situations the goal is an error rate better than 1 in a million.

million (1)

The rate of uncorrected pharmacy errors is much worse:


The estimate of errors varies widely, see the article by James et al.  The 1 error in 33 prescriptions (3%) is an overall estimate of  errors (like the wrong directions on the bottle).  An article by Flynn et all notes “An estimated 51.5 million errors occur during the filling of 3 billion prescriptions each year.”  Death resulting from these errors is unlikely but still is reported.  In everyday terms a local pharmacy will make dispensing errors several times a day.  Large automated pharmacies actually do much better, sometimes in the range of 1 error in 100,000 prescriptions — not too bad but still not good enough.

What can the prescriber do?

  • Always discuss prescribed medications with the patient
  • Tell the patient why each medication is needed
  • Give the patient a complete list of medications and
    indicate which are new, changed, or just continued
  • Send prescriptions electronically

What can the patient do?

  • At the prescriber office or when leaving the hospital
    • Get a complete medication list (or make a list yourself)
    • Record why you take each medication
    • Understand if the medication is scheduled
    • or just taken as-needed for some symptom
    • Record the drug name, dose and how often to take
    • Are you getting enough refills to last until next visit?
    • Ask what the top 3 side effects might be (printed list of a zillion possible side effects is nearly worthless)
  • At the pharmacy, before paying for the medication:
    • Look at the medication bottles and verify
      • Your name
      • The prescribers name
      • Drug name, dose, how often to take
      • Confirm this medication is for your known diagnosis –“this one is for my high blood pressure, right?”
      • Is the quantity and number of refills correct?
    • Ask to look at the pills themselves
      • If this is a refill the pill should look the same as before
        • if not, why not?
    • Did all the prescriptions the doctor prescribe get filled?
    • If you are getting a new medication always allow the pharmacist to talk to you about the medication
    • If the medication is an inhaler ask for instructions and a demonstration
    • If the medication is an injection ask for instructions
    • If the medication is a liquid ask how to measure it
    • If the medication costs $100 a dose or more you have a right to know where it was made and what precautions were taken to avoid counterfeit medications.
  • At home
    • Read the information you were given about the medications
    • ID your pills with an online pill identifier like
    • If you find errors, obviously, contact the pharmacy immediately
    • Report medication errors to the ISMP (Institute for Safe Medication Practices) or if severe to the state pharmacy board.
    • Report pharmacy errors to your prescriber

If you have experienced errors or have other suggestions to avoid errors please leave a comment.

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Drug Reps — it’s in the details

devil rep

What Are Drug Reps?

They are the sales force for drug companies called drug representatives.  They visit prescribers and hospitals and health plans or anyone perceived as having the ability to influence the use or purchase of the company medical or surgical products.  When they sell surgical products the word “drug” is changed to “device” or “equipment” or “training”.


What is the ecology of drug reps?  What do they look like?  What is their habitat?  They seem to live in doctor’s waiting rooms.  The large briefcase, the laptop computer and the perpetual smile are the hallmarks.  They can be tracked by the trail of ballpoint pens with drug logos.  The men are rugged-looking and wear fashionable suits.  The women are good-looking with tailored short dresses.   They seem to whisk back to see the doctor no matter how busy the schedule and no matter how difficult patients have in getting an appointment.  If only patients could be so pleasant.

Friend or Foe

Are reps the patient’s friend?  Absolutely not.  Their only allegiance is to the product they sell.  The reps job is to minimize the side effects, the hazards, the opposing research, the deaths, and the cost of what they sell.  They visit prescribers as a friend, someone who admires the prescriber, and someone who thinks the prescriber is smart and sexy.  They give gifts and provide meals if the prescriber will listen to an “educational” presentation.  The reps suggest only fuddy-duddies stick with generic drugs.  Primary care providers are told the specialist the provider likes always prescribes the drug the rep sells.

No Visits, No Samples

If providers do not see reps the providers actually could get excellent  unbiased recommendations from several sources.   But, those sources (like subscription news letters) cost money and don’t come with a good-looking sales person.  Furthermore, free samples are not given to those who fail to see the company rep (no matter what the drug companies say).   Then patients gripe “why don’t you give me samples like the other doctors?’ — even the patient becomes a sales person!

Marketing Surgeons

A new device is a marketing problem.  The surgeon who might use the device does not want to travel to see the device.  So, the device comes to the operating room.  The sales person demonstrates the device and talks the surgeon through a procedure (while the patient is under anesthesia).   Or, with certain inducements the surgeon goes to a course on the device and, amazingly, they get a certificate saying they are proficient with the device — do surgeons every fail these courses?  Of course not.  And, hospitals rarely question the certificates, after all, the hospital did not pay for them.  Should patients feel comfortable with the level of training? No.

Doctors Like Reps

When doctors are asked about industry reps they say they need the information provided and like to ask questions about drugs or devices.  And, they are not influenced by the sales effort.  But, drug companies know better and continue the very successful sales technique.  So, the drug reps march on.

Free Training

Hospitals like surgeons to start using new procedures, especially if they do not have to pay for the training.  New procedures often have higher reimbursement than old procedures which are more time-consuming.  Thus, more money for less work — who approved that higher payment anyway?  The reps help surgeons inform the insurance company  about new technology “revolutionizing” treatment — denial of such an advance would not look good to regulators.  And regulators are sent fact sheets about the new procedure  insurance companies want to cover.  So the reps march on.

Hospitals Are No Match

The sales techniques for hospitals or drug suppliers are diabolical.  A one-of-a-kind drug is pared with a drug made by the same company which has lots of competition.  If the buyer purchases the two drugs together they get a discount on the high-priced item.  Another favorite tactic is to bundle a whole group of medications — the deal is if the buyer will use that group (like antibiotics) to the exclusion of competitors they get a good discount.  When a competitor invents a better medication the buyer is faced with huge losses to make a change just for one drug.   This market-basket approach undercuts the competition – often driving smaller drug companies out of business.

So Why Are They Bad?

Why are drug reps bad for patients and the U.S. health system?  Because the marketing target is the prescriber not the payor.  The prescriber does not pay for the medications or device, they don’t suffer the side effects, and they don’t die from complications.  As a group they are easy marks for sales.  The failure of adequate drug evaluation (cost-effectiveness) is extremely wasteful both in terms of the cost of care in this country and the health and financial well-being of patients.

Nobody Does It Better

In England purchasing is done by a national agency that evaluates medications for cost effectiveness.  The very reasonable English seem to have a grip on the problem.  The disorganized U.S. health system is no match for the marketing efforts.

What Can Be Done?

  • Clinics and hospitals  should not allow drug reps to visit
  • Clinics and hospitals should provide unbiased drug and device newsletters for the physicians and surgeons
  • Hospitals should pay for surgeon training for new procedures
  • Patients should be happy a doctor does not allow drug reps and accept the fact samples are actually costing money indirectly.
  • Clinics should be able to obtain (or purchase) samples of drugs needed (like for demonstration of inhalers or medication injection techniques)
  • Hospitals should participate in large purchasing organizations and follow the recommendations of third parties who advise on drugs and devices.
  • Government health plans  should have a nation-wide formulary.  The cost of drug and device evaluation is too high to allow duplication by every insurance plan or government department.
  • Market-basket sales techniques need to be stopped due to the anti-competitive effects.  One drug, one price, should be the rule.

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Real Life ER Visit — Some Pitfalls

One winter afternoon Mr. C was at his health club  enjoying a workout on the StairMaster. Suddenly, he began to have a nosebleed.    In the past, any nosebleed would go away with some pressure but this was different, the bleeding  just would not stop.  Driving his car was out of the question.  Fortunately, another health club member offered him a ride to the ER.  On the way they passed an urgent care clinic but did not stop.  They were concerned the urgent care clinic might not be able to stop a nosebleed.   The towel he used to catch blood was getting very red and he was a little frightened by the thought of bleeding to death.

Holding his nose with the towel he checked in to the ER and was quickly taken to an ER room.  After 20 minutes a nurse evaluated him and took his blood pressure.  His nose continued to bleed and 30 minutes later a doctor arrived.  He put drops of epinephrine in the nose followed by a nasal pack.  The bleeding stopped, he was given an antibiotic  pill (ciprofloxacin), he  rested a few minutes then his wife took him home.  A few days later his wife removed the packing as directed.  Problem solved — at least the bleeding problem.

He eventually got a statement from his Medicare (MC) supplemental insurance company.  

Item Charges MC Allowed Out-of-Pocket
Facility charges $3,569.05 $310.92 $0
Procedure (30903) $681.00 $139.85 $0
epinephrine 4 drops $204.60 $0 * $204.60
ciprofloxacin 500mg $50.82 $0 * $50.82
TOTAL $4,505.47 $450.77 $255.42

* Medicare would not cover (“allow”) the medication because the medication was categorized as an outpatient charge.  What Medicare does not allow supplemental insurance will not allow either.  So, the patient has to pay.

Wholesale prices of medications are as follows:
epinephrine 1 mg/ml (0.1%) 1 ml ampule $2.55   (charged 80 x cost)
ciprofloxacin 250 mg 2 tablets $0.45                       (charged 110 x cost)

See the reference on nosebleeds (epistaxis).

Could there have been another way?  Less waiting and less cost?  Perhaps.  Consider the following alternative scenario:

A patient had a nose bleed for 5 minutes at which point he called his on-call primary care provider (PCP).  The patient was instructed to go to an urgent care center.  Waiting was minimal since bleeding is a big deal at the urgent care center (at the ER there are bigger things going on).   The treatment at the urgent care center was the same as the ER except a prescription for ciprofloxacin was given to him which he picked up at the 24 hour pharmacy ($0.50).    The charges and out of pocket expenses for the urgent care visit were as follows:

Item Charges MC Allowed Out-of-Pocket
Procedure (30901) $275 $94.32 $0
epinephrine nasal $20 (est) $0 $20.00
ciprofloxacin 500mg $0.50 $0 $0.50
TOTAL $270.50 $94.32 $20.50

It is important to note there is no “facility” charge at the urgent care.  Only hospitals can charge for use of the facility.  Ostensibly, this is to offset the costs of maintaining higher staff levels to be ready for really big emergencies.  In effect, by going to the hospital ER the patients with minor problems subsidize the patients with major problems.

The bottom line:  At your next visit with your PCP discuss how they want you to handle minor and major emergencies.  In general, if you feel you have time, call your PCP’s office (even at night because someone is on call) before going to the emergency room.  Use urgent care centers rather than the ER if possible.  Don’t accept a facility dispensed medication to take at home if there is a nearby 24 hour pharmacy.  If your PCP is aware of an urgent problem they will likely follow up when needed.

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Observation Unit — Between ER and Hospital

Laura Landro of the Wall Street Journal reported on a growing trend in US hospitals.  The trend is the “Observation Unit”.  In hockey terms it is the penalty box where hospitals put patients they can’t send home but can’t admit, at least for a few hours.

The origin of this idea may have come from English hospitals.  Those hospitals run at almost 100% occupancy.  So, when a patient from the ER needs to be admitted there is a delay to wait for a room.  Those patients  get put in a big room next to the ER with several gurneys, a few nurses,  and lots of curtains (the observation unit).  The patients do get tests and treatments but they wait for a room.  As it turns out, some of the patients get better and don’t actually get admitted — they go home — the rest eventually go to a hospital room.  In England hospital care is free and the hospitals don’t have to worry about insurance or Medicare rules that separate  outpatient and inpatient charges.

US hospitals have plenty of beds available but US hospitals do have to worry about insurance and Medicare rules.  Care is not free and if a hospital makes a mistake (like admitting for indigestion) they don’t get paid.  And, if a doctor makes a mistake and sends a patient home who should have been admitted (for a heart attack) they could be in legal trouble.  Consequently, unlike the English hospital that needs to hold patients to wait for a bed the US hospitals need to hold patients because of red tape and legal worries!  It’s hard to tell which is worse.

The Wall Street Journal article puts a positive spin on the “new” idea:  “when operated efficiently observation units have been shown to reduce health-care costs and improve treatment”.  Obviously there is a balance of forces between the Hospital that makes money and the insurance company that looses money with each admission.  Regulators try to develop rules to speed evaluation and treatment so some patients can go home safely without a hospital admission and the huge associated costs.  Any patient who can bypass the hospital will also avoid the risk of hospital errors and exposure to hospital acquired infections.

Patients have two main concerns:

1) Getting the right care the first time and not coming back sick.   The unit may provide a little longer time to get test results and see if treatment is working which is good unless unnecessary tests are being done.
2) Minimizing out of pocket cost.  A person without insurance would get a lower bill by avoiding the hospital but having both the cost of observation and hospitalization is a real possibility.   The current trend for insurance  is to shift a higher percent of outpatient charges to the patient compared to inpatient charges.  So, depending on what a person’s insurance covers, there might be higher out of pocket expense for using observation.

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Satisfaction VS Quality

The following is extracted from data presented by the Dartmouth Atlas.


Data about high ranking academic medical centers is plotted above.  On the vertical axis is the patients rating of their experience at the hospital — the higher the percent the better.  On the horizontal is the rate of a severe infection complication of tubes put in the veins (which should be taken out periodically) — the lower the rate the better.  The hospitals in the lower right have the highest rate of undesirable “line” infections AND the lowest rating by patients.  The hospitals in the upper left have the lowest rate of such infections AND the highest satisfaction.

The point is:  the hospitals are all over the map (poor reliability).  Worse yet, patients seemed to give some hospitals high marks for poor performance.   To be fair, very few patients actually get line infections so the negative effect on overall satisfaction is small.  It would be interesting to evaluate  satisfaction of patients who had line infections (if they survive).

So, you say, hospitals need to work harder.  That would be true but where are the guidelines for removing these problematic vascular catheters?  The CDC and others describe how to care for the catheters but leave it to “judgement” when to take them out.  The problem is “judgement” is not conducive to reliability.

Make a rule and follow the rule!  Sure there are exceptions, like it’s the last vein the patient has — judgement is when you state why you are not following the rule.  The specter of malpractice litigation is here.   Although the rule of law is doctors are not held responsible for a well considered judgement (which later may prove to be wrong) it often does not work that way in court.   So,  a good defense would be that a national guideline was followed — if it existed.

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Getting Satisfaction

OK, patients are not satisfied with many provider visits.    Some people just avoid health care or just complain about it.  Consider that mummies have been found who had serious health problems during life.  Is that what we want, a postmortem in a thousand years? — “yep, he didn’t get good care”.

It is  not the patient’s job to make health care give satisfaction, but that may be what is necessary while we wait for system changes.   And yet, many patients currently walk away from a provider visit, the hospital or outpatient surgery feeling satisfied with the care and satisfied their questions were answered.  How did they do it?  What did they say?  Were they just lucky to have the “right” provider?   Getting satisfaction currently involves being proactive, doing your homework and speaking up.  Those who do are getting some degree of satisfaction.

First, understand the cycle each health care provider works in.

The “agenda” for the visit is made in step #1.   Make a list of 3 things you want to get accomplished during the visit and keep the list in hand.   Be assertive with the list right after the greeting “Just so I don’t forget I made a list of things I need today: 1)____ 2) ____ 3) ____”.  For example, this might be “review my stomach pains,  would a specialist help, get prescription refills”.  ABSOLUTELY do not wait until step #5 with these questions.  Make sure all items were answered by step #3 — if not, look at the list and repeat the items not addressed.

Make step #2 easy.  Have an up to date history in hand including past illness, past surgery, current medications and allergies.

Make step #3 understandable.  Before the visit research the symptom or known diagnosis on the Internet (like  So when the situation is discussed you have some basis for questions, and ASK THEM.

Make step #4 interactive.  As each action is listed if you don’t know what it is (like CBC or CT scan) then  speak up “what is that and what will it tell us”.   If a procedure or surgery is suggested make sure to understand the top 2 risks and what the provider and you can do to reduce the risk.  And, what are the alternatives — understand the alternative of not doing the surgery or procedure.  Understand how you will get test results (make it clear you want the result as soon as  available whether  “normal” or not).

An informed and engaged patient will ask the above questions.  Many patients ask such questions.  Don’t be demanding, just persistent.  Give the provider a chance to do the right thing since most really want to please patients.  And, give the provider a second chance.  If there is a problem with the plan or medications discovered later, call the provider’s office for clarification.  But, repeated failure to respond to these simple questions means it is time to find another provider.

Sometimes people just can’t think clearly knowing a shot, pelvic exam, or prostate check are going to be done.  Thinking during a health care visit is essential.  So, if there are bothersome aspects to a certain visit ask to have those things done at a separate visit (yes it is more trouble for you but at least you can discuss problems intelligently).

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