MCN | Medical Consultants Network

The Power of a Second Look

Home / MCNTalk / Tag: Clinical Issues

Viewing items tagged:

Clinical Issues

Adventures in Healthcare – a Short Chapter

I opened the mail to find a medical bill for some lab studies on a family member. Total billings from “Laboratory Corporation of America” for 8 line items of services was $568.50. The adjustments by our insurance carrier, United Healthcare, were a total of $495.56, leaving a remaining balance of $72.94 on which the carrier paid $58.35, leaving a balance payable by us of $14.49.

What does this mean to those who don’t spend much time thinking about this? It is quite simple. The lab, a large national company, billed $568.50, the retail price that they decided to charge, which had we lacked insurance, we would have been expected to pay. The discount was 87% of charges, which means that the carrier used some sort of fee schedule, which is acceptable to the lab as a member of their network, to determine what was likely “usual and customary.” I sampled one of the line items that was charged at $219.00, and while my carrier permitted $21.71, the maximum that Medicare would permit was $16.99. So my carrier is generous compared to Medicare, paying about 27% more.

Why does the lab charge so much relative to what they get from carriers? Because they can. They can make up any number they wish, but clearly are thriving and surviving on actual payments that are 15% or less of what they charge. The small number of uninsured or underinsured, those least able to pay, are getting billed six times or more what their insured neighbors or retired relatives on Medicare are expected to pay.

What if the person in the check-out line buying the same basket of groceries was asked to pay 6 times more than the person in the next aisle because of where they work, or because they are younger, older, or for any other reason? Would we stand for this? Why do we permit this?

That the real prices differ from billed is a given in health care. I am accustomed to seeing discounts of 40% or so. But 87% is a new one that reflects, to my view, flagrant behavior that must be called out and must be stopped.

Hidden Profits in Rare Diseases

As the parent of two small children, this is the kind of article that haunts me—a child with an incurable disease, a photo of that child, hopeful, bald due to medical treatment. Now deceased. I’m tempted to skip stories like this, but then again if nobody had the stomach to hear about the situations which are hard to face, solutions to problems would never be reached.

The gist of the situation is that thirty years ago, Congress passed the Orphan Drug Act as a way to lure pharmaceutical companies to develop drugs for rare diseases that had been “orphaned” — abandoned or ignored because they were unprofitable. The hope was that drugmakers would break even or post modest profits.

The act paid off, with hundreds of new drugs. But over the years, its good intentions have been subverted by the pharmaceutical industry, which has increasingly found ways to exploit this once-obscure health-care niche, transforming it into a multibillion-dollar enterprise. Read more…

Kennedy, Vaccinations, Autism, and Junk Science

It’s been quite a while since MCNtalk has posted on the subject of childhood vaccines—since our February 12, 2012 post, “More Doctors ‘Fire’ Vaccine Refusers.” But the issue has not gone away. As this article in Slate points out, there are still those who argue publicly that there is a link between autism and childhood vaccinations, specifically that a vaccine preservative called thimerosal causes autism when injected into children.

It is important to understand that the original study in 1998 linking childhood vaccinations and autism has been thoroughly debunked multiple times using rigorous standards of scientific evidence. (Read “Vaccinations and Autism—Junk Science Is Not a Victimless Crime” for a summary.)

Robert F. Kennedy Jr. gave this year’s (May 24) keynote address at the Autism One/Generation Rescue Conference in which he strongly argued for a link between childhood vaccination and autism. The Slate article touches upon the speech and subsequent conversation between Slate and Kennedy as well as neatly summarizing pertinent facts on the issue. Why is this important? Because when people are not vaccinated, they needlessly put not just themselves at serious health risk, but their entire community as well.

We refer to people who say vaccines cause autism with the shorthand “anti-vaxxers” or say that they are part of the “anti-vaccine movement.” Kennedy said that he is “very much pro-vaccine” and that “vaccines have saved millions and millions of lives.” They will save even more lives if he and his colleagues stop spreading fear and misinformation about them. Kennedy is a passionate guy with practically unique name recognition, powerful connections, and the ability to command attention. He could reverse the course of the anti-vaccine movement today if he announced that his concern about vaccines had been well-intentioned, but that research has shown that vaccines don’t cause autism after all. It would be a proud legacy, one worthy of his name.

Read more…

Release of the DSM-V

The American Psychiatric Association unveiled this past week the fifth edition of its handbook of diagnoses, the D.S.M-V (Diagnostic and Statistical Manual of Mental Disorders, Fifth edition), after 14 years in the making.

This article in The New York Times neatly summarizes a major, on-going discussion over the publication. Per the author,

The media will trumpet the release of the new D.S.M., but practicing psychiatrists will largely regard it as a nonevent. Unfortunately, the same cannot be said for other institutions — insurance companies, state and government agencies, and even the courts — which will continue to imbue the D.S.M. with a precision and an authority it does not have.

Psychiatrists tend to treat according to symptoms. However, the manual carries a fair amount of clout with the rest of society: They are the passports to insurance coverage, the keys to special educational and behavioral services in school and the tickets to disability benefits. Sometimes a diagnosis of a condition like autism, A.D.H.D. or conduct disorder is necessary for students to qualify for special therapies. And diagnoses also figure in disability determination.

As noted, the D.S.M. is an imperfect guide to predicting what treatments will benefit patients most — a reality tied to the fact that psychiatric diagnoses are based on clinical appearances that tend to cluster, not on the mechanism behind the illness, as is the case with, say, bacterial pneumonia.

There are definitely changes in the D.S.M.-V over the fourth edition, and as the article notes much of this this will most likely change as researchers learn more about genetics, brain circuitry and cognitive data to fashion better guides to what to prescribe for patients, and in terms of what new compounds to develop. Read more…

Inexcusable Sloppiness of Thinking: Blaming Mental Illness or Autism for the Recent Tragedy

By Brian L. Grant MD

The pain of recent events bring out the best and the worst in people’s responses. It also brings out ignorance, and in the case of some advocates for avoiding looking at the downside of our gun policies, malevolent efforts to shift blame and distract us from core causes and solutions.

These recent New York Times articles lend perspective the data to the debate on the relationship between violence and mental illness in one. The other addresses autism and Asperger Syndrome. It is clear in the latter that if anything, such individuals suffer from too much empathy and caring, not sociopathic disregard. It should also be noted that the diagnosis of autism is fraught with imprecision and some controversy as to whether one being a bit strange or awkward in the case of the milder variants, warrants a diagnosis at all. 

The closing paragraph in the first article referenced above, the debate on violence, states:

“All the focus on the small number of people with mental illness who are violent serves to make us feel safer by displacing and limiting the threat of violence to a small, well-defined group. But the sad and frightening truth is that the vast majority of homicides are carried out by outwardly normal people in the grip of all too ordinary human aggression to whom we provide nearly unfettered access to deadly force.”

 We can’t predict human nature, or predict and prevent the dark side of individuals emerging in unpredictable ways. We can and should do what we can to make those who act out due to callous disregard for the lives of others—as well as those who would turn on themselves—less lethal.

The Costly Marketing Budget for Antipsychotic Drugs

By Brian L. Grant, MD

At the American Psychological Association Conference, the pharmaceutical industry has a large marketing presence.

The New York Times article, “A Call for Caution in the Use of Antipsychotic Drugs,” was alarming but not surprising to me as a psychiatrist. The numbers are staggering though. The advertising budget alone, at 2.4 billion dollars for the new antipsychotic drugs equates to about $57,000 per US psychiatrist (about 42,000 total)!

This marketing budget total alone just approximates the entire market for non-Federal IME’s and medical reviews. If spread across the U.S. population evenly, each of us would have consumed about 58 dollars worth of antipsychotic drugs in the past year! The use of such medications is clearly concentrated to a small portion of the population and are prescribed in large amounts by a small portion of psychiatrists and other licensed practitioners.

Anyone who has been to a major psychiatric conference would not be surprised at the massive booths from the drug purveyors manned by sharp men and women hawking the wares, with various enticements to visit their booths. The incentives to over-prescribe is clear, given the money involved.

The fact that a number of medical lightweights fail to understand how they are being used as gatekeepers to these drugs is sad and costly, not only for payers, but for patients who are often given these costly drugs with very real side effects, when less costly alternatives with equal or better outcomes exist. To deny the positive impact of these medications in select patients is wrong. But common sense combined with available science should lead to the obvious conclusion that this is not right.

Label creep, where a good drug is advocated for the wrong reasons, is not unique to psychiatry. Articles like this by Dr. Friedman does little to bring pride to my profession. Similar scrutiny is warranted for so-called ADHD (attention deficit hyperactivity disorder) in adults, fibromyalgia and any other malady that is largely associated with profitable, or abused drugs and often direct to consumer advertising to create a wider market.

9/11 Health Program Will Now Cover 58 Types of Cancer

First reponders searching for victims at Ground Zero after WTC collapse.
Photo by Frank Schwere

In memory of the September 11th terrorist attacks,  first responders, construction workers, volunteers and survivors who helped with rescue and recovery at Ground Zero have reason to be even more hopeful today. The World Trade Center Health Program recently added 58 new types of cancer as a service that would be provided under the James Zadroga 9/11 Health and Compensation Act of 2010.  The act was initially signed by President Obama  in 2010 to provide health coverage to those who lived, worked or attended school in the immediate area of the 9/11 attacks. The Act was named after New York City police detective James Zadroga, who died after working at the site.

The Federal government set aside $4.3 billion dollars for 9/11 victims who had been exposed to airborne toxins and acquired adverse conditions such as asthma, acid reflux disease, back pain and chronic sinus irritation, etc. Though cancer had not originally been drafted in the act, studies have shown that over the course of 11 years the link between the 9/11 toxic dust cloud and cancer may be more evident.

Analysis found that substances in the dust included cement, gypsum, asbestos, glass fibers, calcium carbonate, lead and other metal particles.  Lead and other heavy metals can be toxic to the brain, and gypsum, a component of drywall, can cause respiratory problems if it’s inhaled over a prolonged period of time.

In an interview with ABC World News, Dr. Philip Landrigan, dean of global health at the Mount Sinai School of Medicine in New York explained that those who were in the immediate area during the attacks could have been exposed to an abnormally large amount of these toxins.

“That means it’s extremely caustic and would be like inhaling powdered lye or Drano… Asbestos is a human carcinogen. It causes lung cancer, laryngeal cancers and malignant mesothelioma, and these typically develop anywhere from 10 to 30 years after exposure.”

While it has not yet been proven whether the 9/11 dust cloud was the cause of cancer, the lobbying efforts of construction workers, firefighters, police officers, and others who fell ill a decade after the terror attack  was enough to convince the government to add health coverage for cancer to the list. Read More…

More on the PTSD-Military Conundrum

By Brian Grant, MD

The in-depth article, “Mind Field: PTSD & the Military,” from Seattle Weekly was impressive in its nuanced tone. The reader is left with more questions than answers, as befits such a complex topic. Themes include the impact of systems on behavior, the nature of psychiatric diagnosis, the impact of combat, how media exposure may impact others including family members of those traumatized, politics and partisanship and more.

The author of the article, Keegan Hamilton, wryly notes: “While noble in its intent, the monetization of PTSD diagnosis has created a classic catch-22.” One should ask whether veterans are better served with treatment upon diagnosis or compensation, and if the impact of a minimum of a 50% disability rating upon diagnosis serves the veteran and society? How often, once awarded a disability pension, does meaningful treatment occur and benefits reduced after such treatment? What is the impact upon treatment if it is tied into economic factors?

Every case should be addressed based upon individual facts, but it would be naive to suggest that the basic assumptions and economics of the veterans’ compensation and pension system do not significantly impact individual and group behaviors and outcomes. Passions and politics are inflamed. To frame the issue another way, we should ask ourselves under what circumstances in society do individuals actively desire a medical or psychiatric diagnosis, rather than strongly hope for a finding of good health or at least a short-term malady? PTSD is real. It is also treatable. The diagnosis is fairly easy to make based upon the criteria and a diagnosis does not equal impairment. We have written on this topic recently in previous posts, “Military Psychiatrists Under Fire for Doing Their Jobs,” and “Madigan Commander Reinstated After Army Investigates PTSD Diagnosis.”

The article also makes note of “secondary PTSD”. This is not a recognized diagnosis, but would appear to be an interesting social construct, perhaps reflecting the all too frequent drive to create medical diagnoses for the bad things that happen to people and societies in the course of life. Anyone who witnessed the constant televised replays of the Twin Towers collapse in the days following September 11, 2001 was traumatized, upset, and perhaps depressed. They may even have had many of the diagnostic criteria required for PTSD.  Many avoided flying, were fearful of individuals who reminded them of the bombers, felt numbness and estrangement from others, psychic numbing, and a variety of autonomic symptoms upon certain cues. Life in the U.S. changed tangibly, along with our group psyche. When the abnormal becomes normal, does it warrant a medical diagnosis or literary and journalistic treatment?

Follow Up: Madigan Commander Reinstated After Army Investigates PTSD diagnoses

Photo Credit: Sgt. Christopher M. Gaylord
Colonel Dallas Homas (far right), commander of Madigan Army Healthcare System at Joint Base Lewis-McChord, Wash., spoke during a press conference addressing the Army’s recent decision to discontinue the use of forensic psychiatry as part of its disability evaluation system.

After two weeks of following the Madigan Army Medical Center investigation, commander Col. Dallas Homas has been reinstated to his position. The investigation started mid-July after soldiers believed their Post Traumatic Stress Disorder (PTSD) diagnoses had been unfairly overturned by Madigan’s team of forensic psychiatrists and psychologists.

At an August 2nd press conference, the Army Vice Chief of Staff Gen. Lloyd Austin announced that forensic teams would no longer screen PTSD patients and reinstated Col. Dallas Homas to his position as commander, stating “he had not exerted any undue influence on the diagnostic process.”

In relation to our previous blog post “Military Psychiatrists Under Fire for Doing Their Jobs,” written by MCN’s Medical Director Brian Grant, MD, the Seattle Times featured him in an article last week. Here is an excerpt from the Seattle Times article “Reinstated Madigan Chief Happy to Be Back”:

Homas spoke to reporters along with Maj Gen. Richard Thomas, commander of the Western Regional Medical Command and Lt. Gen. Robert Brown, I Corps commander.

In his remarks, Homas confirmed before his removal he met with an ombudsman to discuss the forensic-screening team. At the time, Homas said he thought the forensic team was executing the accepted standard of care. “Now we have been given a new policy, and we’re going to execute that,” he said.

The Army’s decision to abandon the use of forensic screening has raised concerns among some doctors who practice forensic psychiatry. “I am baffled as to why making a psychiatric diagnosis in a military context should have different criteria from the civilian sector,” said Dr. Brian Grant, a Seattle-based forensic psychiatrist. “The matter deserves further study, hopefully including input from medical experts outside the military system.”

Read More…

The Causation Conundrum & Commentary On Who Should Perform Causation Analysis

by Brian L. Grant, MD

A core component on independent assessment and review is determination of causation. Such determinations should be evidence based. Evidence stands on its own merits. It is not a function of the degree of the expert or the opinion of a judge, legislator, advocate or journalist.

Examples abound of such errors in causation. These include Mild Traumatic Brain Injury (MTBI). Scientific evidence is lacking to prove a relationship between MTBI and permanent impairment. Similarly, legal and administrative pronouncements that presume a relationship between hypertension and law enforcement are unsupported by solid science. The media is awash with assumed links between military service and MTBI and PTSD at alarming rates, suggesting either a slippage of criteria, or a profound change in the nature of warriors or the nature of war. Just typing the prior sentence causes this writer anxiety, lest I be accused by advocates of demeaning military service.

Psychiatrists in Washington at Madigan Army Medical Center know all too well the dangers of exercising scrutiny in the politically fraught world or military PTSD. See the accompanying blog post that addresses this.

An expert expressing an opinion is just expressing an opinion – UNLESS the opinion is supported by solid evidence and scientific facts.

The book Guides to the Evaluation of Disease and Injury Causation addresses the challenge of causation determination in-depth as well as proper protocol to determine cause. Among other insights, it discusses the challenge of relatedness; that an event preceding a complaint does not establish causation but may, in the absence of specific evidence, constitute false reasoning.

The protocol to establish causation is a six step process:

1 – Definitely establishing a diagnosis

2 – Applying relevant findings from epidemiological science to the individual case

3 – Obtain and assess the evidence of exposure

4 – Consider other relevant factors

5 – Scrutinizing the Validity of the Evidence

6 – Evaluation of the results from all of the above steps, and generation of conclusions

The above points and much more are from a seminal article, “Determining Injury-Relatedness, Work-Relatedness, and Claim Relatedness” by Robert J Barth, Ph.D. (BarthRJ. Determining Injury-Relatedness, Work-Relatedness, and Claim Relatedness. AMA Guides Newsletter.May/June 2012: 1-10.) 

As of this writing, the issue of the newsletter is not yet listed on the AMA site, but presumably it will be soon and may be accessed by calling them at (800) 621-8335.

Barth is perhaps the foremost thinker and writer on this and many other related topics. The cited article is copyrighted and as such can’t be attached, but is well worth acquiring. In our opinion it is a must read and must own for anyone involved in medical or legal work involving medical causation.

We must quote another pearl from the above article that challenges the bias equation that is often applied to independent evaluators as opposed to treating clinicians:

“As is the case for any forensic work, a causation analysis should be conducted in an independent context. Treating clinicians face considerable financial and social conflicts of interest if they attempt to engage in any forensic activity (such as causation analysis) in regard to their patients. In contrast, independent evaluations minimize the evaluator’s conflicts of interest. Therefore, treating clinicians should refrain from engaging in any forensic work that involves their patients (including refraining from causation discussions).”

Clinicians not involved in the treatment of a particular claim may not be free of bias if they allow themselves to be swayed by requestors of their services. But in our experience the majority of those desiring evaluations are not overly invested in a particular outcome and more likely seek a realistic assessment of the truth, causation and related matters, in one of many cases they are managing at a given time. Contrast this to the considerable pressures that may be experienced in a treatment relationship where the emotional and economic stakes are very high for a patient, who may cause pressure to be felt by the treating clinician and impair objectivity as a result. Regardless of whether one is treating or evaluating, the same rigorous principles of causation analysis as well as other aspects of assessment, diagnosis and treatment must apply.