George W. Bush's heart surgery prompts debate about stents

Americans have become familiar with the idea of using stents to open blocked arteries, so when former President George W. Bush underwent stent surgery recently, most people probably viewed the decision as routine.

But there is -- and should be -- a national debate about when to use this expensive therapy.

Here's an excerpt from the blog Health Beat by Maggie Mahar, who quoted Bloomberg News: 

“The discussions have been ongoing since 2007, when the trial known as Courage first found that less costly drug therapy averted heart attacks, hospitalizations and deaths just as well as stents in patients with chest pain. The results were confirmed two years later in a second large trial.

“The debate has centered on both the cost of stenting, which can run as high as $50,000 at some hospitals, and its side effects, which can include excess bleeding, blood clots and, rarely, death. Opponents say the overuse of procedures like stenting for unproven benefit has helped keep U.S. medical care on pace to surpass $3.1 trillion next year, according to the U.S. Centers for Medicare and Medicaid Services.

“ 'This is really American medicine at its worst,' said Steven Nissen, head of cardiology at the Cleveland Clinic in Ohio  . . .  ‘It’s one of the reasons we spend so much on health care and we don’t get a lot for it. In this circumstance, the stent doesn’t prolong life, it doesn’t prevent heart attacks and it’s hard to make a patient who has no symptoms feel better’ . . .

“ 'Stents are lifesaving when patients are in the midst of a heart attack,’ added Chet Rihal, an interventional cardiologist at the Mayo Clinic in Rochester, Minnesota. ‘...They allow immediate and sustained blood flow that help a patient recover. For those who aren’t suffering a heart attack, the benefits are less clear   . . . While stents may be used in patients with clear chest pain, there’s no evidence that they prevent future heart attacks.’  A review of eight studies published last year in JAMA (Journal of the American Medical Association) Internal Medicine also found no differences."

How can patients be responsible consumers without knowing costs?

Earlier this week, I posted a reference to the Kaiser Health News article on the proliferation of high deductible health insurance plans and how hospitals have noticed an increase in the number of unpaid accounts as a result.

Reader William Ertel, a Charlotte financial planner, wrote to suggest the problem should be viewed differently.

People should be expected to pay their bills, he said. But how are patients supposed to be responsible consumers if they can’t find out the cost of the services they are buying? 

Ertel said he’s had a high-deductible policy for years, and a health savings account to build up a pot of money to use for medical expenses. But "the novelty of this has disappeared for me," he said.

That's because: “No one at a doctor’s office can tell you what anything costs... In my business (or just about any other) we would say that is crazy!”

When a doctor recommends a test, Ertel said he asks for the cost, and the answer is often, “It depends on your insurance.”

“This is, of course, factually incorrect. My insurance might dictate how much I will pay (which is important) but it certainly should have no bearing on what it costs. Should a (procedure) cost more if I have a (Blue Cross Blue Shield of North Carolina) high-deductible plan or if I am uninsured?

"So the original story about hospitals complaining about high deductible delinquency could easily have been -- Hospitals Are Unable to Tell Patients the Costs."

One of Ertel's relatives recently went to the emergency room, and was released after about an hour. The bill from the hospital said "ER services" for $1,200, which was discounted to $900 based on the insurance contract. It was due within 15 days. And there was no more explanation.

Ertel called the billing office for details. Five days later, he got a list of insurance codes and cryptic descriptions – “none of which could interpreted or understood by an average person,” he said. 

Instead of focusing on patients not paying their bills, Ertel said: “You ought to let people know how poorly medical service providers communicate their fees and provide billing information....Again, I think people should pay what they owe, but hospitals are failing at providing timely information on amounts and explanations. I think this may contribute to the hospital being paid slowly."

Charlotte hospital CEO arranges ballet for his wife

Carolinas HealthCare System CEO Michael Tarwater is well known in North Carolina for running one of the largest hospital and healthcare systems in the country.

But recently, we came across an article in The Chautauquan Daily that reveals a side of Tarwater you don't often see.

Tarwater

The July 24 article in the official newspaper of the Chautauqua Institution in New York was headlined "Evening of Pas De Deux: Couple makes trip to Chautauqua to fall in love all over again."

It's about Tarwater's idea to surprise his wife of 27 years, Ann, with a ballet, reliving the first time they met.

The ballet, "At First Sight," was first performed in February in Charlotte by the North Carolina Dance Theater as part of a fundraising gala at the Knight Theater. It was followed by a dance competition featuring local business leaders. The winner was Tarwater and his dance partner from Metropolitan Ballroom.

According to The Chautauquan Daily, Tarwater had approached Sasha Janes, NCDT associate artistic director, in 2012 about creating a surprise for his wife's birthday. The two met secretly for about six months as Janes choreographed the piece based on Tarwater's story. "He added music and dance and made it come to life again," Tarwater told the newspaper.

The newspaper said "At First Sight" was to be performed by NCDT dancers Sarah Hayes Watson and David Morse on the Amp stage at Chautauqua in late July, and the Tarwaters were expected to attend.

Twitter not a place for intimate moments of death

I love Scott Simon and National Public Radio, but I was shocked at his decision to send Twitter posts recently during his mother's final hours.

Having been with my parents and a dear friend as they died, I couldn't imagine stepping out from that sacred time to send an electronic message to hundreds -- or thousands -- of strangers. One of my closest friends died in June, and all I thought about that day was being with her, totally, to let her know, even on a subconscious level, that she was loved and cared for.

Response to Simon's tweets appeared to be overwhelmingly positive. I felt like I was the only person who was bothered by the idea until I read this essay by Kim Triedman, a poet and novelist, on the website for WBUR, Boston's public radio station.

Triedman writes about "what seems to me a disturbing phenomenon in our society whereby our communication technologies are increasingly commandeering what have historically been intimate human experiences."

She notes that the New York Times said Simon did not begin his deathbed vigil with a "project" in mind. And he did not know when he began tweeting that his mother's hospitalization would end in her passing. But he continued, for more than a week, during which time his mother continued to decline.

Triedman stresses that she's not critical of Simon or even of Twitter. "I know the impulse to reach out, to share the burden."

But she adds: "What I am most concerned with here is the fact that technology has once again afforded us a way to distance ourselves from the very substance of our lives -- to put some other 'thing' between us and our loved ones...

"Twitter, I would maintain, is a zone. A place that is decidedly not where you are. A state of mind in which you're always looking out for the next 140 character windfall, something you can scavenge out of this experience and that, like a photographer so intent on a picture that he neglects to take in the scene.

"Wherever it is, whatever it is, it's not a place I want to be when grief comes to call."

News about blood pressure drugs, monitoring

Joe and Terry Graedon of The People's Pharmacy shined a light recently on two pieces of news regarding blood pressure medicines and monitoring.

Anyone taking anti-hypertensive drugs or monitoring blood pressure at home might be interested in reading these items.

The first is about accumulating research which suggests that popular blood pressure drugs increase the risk for serious cancers.

The second discusses research that demonstrates the benefit of home monitoring of blood pressure.

Charlotte hospital executives on list of CEOs to watch

Becker's Hospital Review has included the two executives of Charlotte hospital systems on its newly published list of "130 nonprofit hospital and health system CEOs to know."

Like others on the list, Carolinas HealthCare System CEO Michael Tarwater and Novant Health CEO Carl Armato were chosen based on their "experience and achievements in the healthcare industry, as well as their professional involvement in the communities they serve," according to Becker's, a bimonthly publication about the healthcare industry.

Tarwater

Armato

Tarwater has been with Carolinas HealthCare since 1981, serving as CEO since 2002. In that time, the system has grown to be one of the largest public nonprofit healthcare systems in the country. It owns, leases or manages about 40 hospitals in the Carolinas, including the largest, Carolinas Medical Center in Charlotte.
It has more than 60,000 full- and part-time employees.

Armato has been with Novant Health since 1988, serving as CEO since 2012. Novant, based in Winston-Salem, is a private nonprofit system with 14 medical centers in the Carolinas, Virginia and Georgia. It has more than 24,000 employees in those states.

Other North Carolina hospital executives on the Becker's list include:

Dr. Victor Dzau, CEO of Duke University Health System, Durham.

John McDonnell, CEO of Wake Forest Baptist Medical Center, Winston-Salem.

Tim Rice, CEO of Greensboro-based Cone Health, which is part of Carolinas HealthCare System.

Dr. William Roper, CEO of UNC Health Care System in Chapel Hill.

David Strong, president of Rex Healthcare in Raleigh.

Does malpractice reform work?

A new study by researchers at the Center for Studying Health System Change has found that Medicare patients receive more diagnostic tests and emergency department referrals when treated by physicians who worry about malpractice liability, regardless of whether states have adopted common malpractice tort reforms.

The study findings, published in the August Health Affairs, indicate physicians’ perception of their risk — rather than their actual risk — of malpractice liability predicts their practice of defensive medicine and suggest that traditional malpractice reforms, such as caps on damages, don’t change how physicians practice.

Funded by the National Institute for Health Care Reform, the study breaks ground by analyzing office-based physicians’ concerns about malpractice liability and the actual tests and ER referrals — based on insurance claims data — they ordered for Medicare patients with chest pain, headache and lower back pain. Patients whose physicians reported higher levels of malpractice concern received more services, the study found.

When researchers compared physicians’ level of malpractice concern with objective state-level indicators of malpractice liability risk, such as whether a state limits economic damages, they found no consistent relationships. In a few cases, referrals and treatments were lower in states with a higher malpractice liability risk.

“Traditional malpractice liability reforms don’t appear to resolve the concerns that drive physicians to practice defensive medicine,” said Dr. Emily Carrier, coauthor of the study.

Past malpractice research has focused on physician self-reporting on hypothetical cases. That generated conflicting results, leading to disagreements about the role of defensive medicine in the overuse of care.

The Health Affairs article, titled “High Physician Concern About Malpractice Risk Predicts More Aggressive Diagnostic Testing in Office-Based Practice,” is is available at www.hschange.org.