Friday, August 26, 2016

The Humble Flu Shot Protects Seniors From a Host of Illnesses

By Erica Swegler, MD, Austin Family Physician
Member, TMA Be Wise — ImmunizeSM Advisory Panel

Imagine the headlines: "If you’re over age 65, you’re half as likely to die in the next year if you take (product XYZ)!"

"What?" you ask, "We have such a thing?" The answer is YES. If you are over age 65, you can decrease your risk of dying of any cause by about 50 percent in the coming year if you get an immunization of the high-dose flu vaccine (HD flu vaccine).

This HD flu vaccine is four times as potent as a traditional flu shot. For a year after getting the high-dose vaccine, you will:

  • Decrease your chance of dying of a stroke by 65 percent,
  • Decrease your risk of dying of kidney disease by 60 percent,
  • Decrease your risk of death from diabetes by 55 percent,
  • Decrease your risk of dying of pneumonia by 53 percent, and
  • Decrease your risk of dying of heart disease by 22 percent.

Two studies published during the past two years say you are less likely to have a heart attack (or die from one) if you had a flu shot in the year preceding it. Given this excellent data, as a physician interested in prevention, it puzzles me that only 70 percent of people over age 65 get a flu shot each year.

This vaccine rate has not changed in decades, despite a universal recommendation for people aged 65 and older to get the flu shot every year. Doctors and other health care experts have recommended this for longer than my entire 30 years as a physician. We fall far short of medicine’s Healthy People 2020 goal of 90 percent of the population immunized against flu. (Unfortunately, this was the same goal we had in 2010. Because we made no progress toward it, the goal was not increased.)

Why is this vaccination so important? The answer: These are potentially preventable deaths. When we’re over the age of 65, our bodies do not fight infection as well. Although seniors make up only 14.5 percent of the U.S. population, they represent more than one-third (35 percent) of hospital admissions. More importantly, seniors represent 60 percent of flu-related hospitalizations and 90 percent of flu-related deaths. On average, 36,000 people die each year in the United States from influenza, or flu, and pneumonia.

One published study shows the high-dose flu shot prevents 25 percent more people from getting the flu than the traditional flu shot, as well as decreasing their hospitalization and death rate by 25 percent. The high-dose flu shot is individually dosed, each in its own syringe, with no preservatives or thimerosol/mercury-like substance. Additionally, the flu shot has few true drawbacks; this is an extremely safe vaccine. (There was a concern about the flu shot by some people with egg allergies, but, as of last year, that is no longer an issue.) We understand the flu shot’s effectiveness varies year-by-year. However, I believe preventing even one out of five flu cases would be worthwhile, and last year it was better — we estimate the vaccine protected two out of three individuals.

The flu is not just a bad cold. It can leave you miserable and incapacitated for five to 10 days with symptoms like fever, body aches, sore throat, and cough. In some people, it can lead to pneumonia. Some die.

The flu vaccine should begin to be available by the end of this month and should become more widely available throughout September and October. You can get your shot as soon as it’s available to protect you throughout the 2016-17 flu season.

So, like any good barker at the county fair, I say "HEAR YE, HEAR YE!! Step right up to receive the shot proven to allow you to live longer!”

Let’s all roll up our sleeves!

Dr. Swegler is a family physician in Austin. Because adult vaccines in particular are so underutilized and because Dr. Swegler is a firm believer in vaccines and what they do for prevention, she speaks for both Merck and Sanofi Pasteur, the latter of which makes flu vaccines.

Be Wise — Immunize is a service mark of the Texas Medical Association.

Thursday, August 25, 2016

Doctors Raise Concerns For Small Practices In Medicare’s New Payment System

By Steven Findlay
Kaiser Health News

Dr. Lee Gross is worried. He has practiced family medicine in North Port, Florida, near Sarasota, for 14 years. But he and two partners are the last small, independent practice in the town of 62,000. Everyone else has moved away, joined larger groups, or become salaried employees of hospitals or health companies.

“We’re struggling to survive,” Gross, 47, said. “Our kind of practice is dying in this country, and medicine itself is changing so rapidly that doctors everywhere seem to be burning out.”

Indeed, in their professional journals, at conferences, on social media and health care blogs, and in comments to federal regulators, the nation’s doctors are expressing growing anger and frustration.

The focal point of their angst is a 2015 federal law that changes the way Medicare pays doctors.

The Medicare Access & CHIP Reauthorization Act — is Congress’ boldest step since the 2010 Affordable Care Act to push the health care system to reward quality over quantity. It replaces a reimbursement system that was widely criticized by doctors and regularly ran into budget problems on Capitol Hill.

“This is a big change, we know,” said Tim Gronniger, deputy chief of staff at the Centers for Medicare & Medicaid Services. But, he added, “the current way we pay doctors incentivizes them in bad ways — to waste resources, for example.”

The law has bipartisan support and does not come with the political tension of the ACA. Still, the Obamacare battles have shown that broadly reshaping health care is no easy task.

Poor and wasteful care accounts for a quarter to a third of all health care spending, according to the National Academy of Sciences’ Institute of Medicine.

That would total between $875 billion to $1.1 trillion of the $3.5 trillion expected to be spent on health care in the U.S. in 2016.

The law sets up two payment tracks. All doctors must choose one, except for those who see too few Medicare patients or whose income from Medicare is too low.

On one track, doctors whose performance and quality of care exceeds benchmarks get bonuses up to 4 percent of their total Medicare reimbursements. Those will start in 2019, based on evaluations of care delivered in 2017, and will rise a maximum of 9 percent by 2022. By the same token, physicians who score poorly on quality benchmarks — which include requirements for the use of electronic health records — face penalties at the same levels.

The amount the government spends on the bonuses — estimated at $833 million for 2019 — must be balanced by the penalties, keeping the program “budget neutral.” However, Congress also authorized an extra $500 million a year bonus pool through 2024 for doctors judged “exceptional.”

On the other path, doctors choose to join larger practices or organizations — called “alternative payment models” — that would be held accountable for the quality of care delivered by all the doctors in the organization.

Congress’ intent, experts say, was to push doctors to join such larger organizations, which generally are considered better equipped to manage and coordinate care, improve quality and lower costs than are solo or small groups of doctors.

Doctors get a 5 percent annual bonus between 2019 and 2024 if they join an alternative payment organization, along with any bonuses or penalties the organization chooses to mete out.  Starting in 2026, doctors in such organizations will continue to get a small annual payment adjustment from Medicare that’s larger than doctors who don’t choose the alternative path — 0.75 percent versus 0.25 percent.

Physicians’ concern is that the new payment system — laid out in a 962-page proposed regulation in April — will put doctors in solo or small practices at high risk of incurring payment penalties and will push thousands into larger practices and alternative payment organizations.

“The ways it’s structured now, the large practices will do well and the small practices will do badly,” said Paul Ginsburg, director of the Center for Health Policy at the Brookings Institution.

During a public comment period, the American Medical Association and dozens of other physician trade organizations and every state medical association said the system needs to be simplified and must “accommodate the needs of physicians in rural, solo, or small practices in order to enhance their opportunities for success and avoid unintended consequences.”

One of those unintended consequences, the AMA says, is that penalized doctors would limit the number of Medicare patients they see, or drop Medicare.

“I have no idea what I’m going to do yet,” says Dr. Jean Antonucci, a primary care physician who has a solo practice in Farmington, Maine. Half her patients are covered by Medicare. “If I’m going to lose money, I’ll have to see what my options are. I don’t want to limit how many Medicare patients I see.”

Antonucci and Gross say they want to preserve their small practices. “I don’t want to spend the bulk of my time doing paperwork or collecting data on my patients,” said Antonucci. “That’s what the doctors in my community who are employed [in larger groups] seem to spend most of their time doing.”

Some experts agree that the burden to report quality-of-care to the government is significant.

“We don’t yet have a good system to measure the performance of individual physicians,” says Robert Berenson, a physician and fellow at the Urban Institute and former director of Medicare payment policy for the federal government. “And yet we are going to peg billions of dollars in payment to such measurement. It’s a little crazy.”

A study published in March in the journal Health Affairs calculated the scope of that data collection now. It found physicians and their staffs spend $40,000 per doctor per year — $15.4 billion nationwide — collecting and reporting information about their care to Medicare, private insurers and others.

Gronniger says CMS has, in the proposed rule, scaled back the number of measures doctors must report. “We are eager to work through the issues doctors’ groups have raised,” Gronniger said.

Even so, the AMA and other physician groups are pushing CMS to delay the start for collecting quality-of-care information from  next January until at least July. Medicare administrators have pledged to issue final regulations by Nov. 1.

“This is all very complex,” said AMA President Andrew Gurman. “A lot of doctors are very frustrated … but we are committed to trying to make the new law work.”

This story was originally published at Kaiser Health News and also ran in The Washington Post.

Friday, August 19, 2016

Walking the Walk — Moving On

By Ana Leech, MD
Houston Palliative Care and Hospice Physician
Medical Director, Memorial Hermann Hospice IPU
Medical Director of Palliative Medicine, Memorial Hermann Southwest

Editor’s Note: Physician Ana Leech, MD, shares her family’s experience caring for her father, who had a terminal illness. As a hospice and palliative medicine physician, Dr. Leech is able to tell her story from both a personal and medical professional perspective. This is the fourth and final part in a series. Read parts one, two, and three.

He is gone. I gave him one more kiss and now he is gone. I will never be able to see my father again, put my arm around his back or watch him make silly faces with his dentures.

I feel honored and privileged to have been the medical point of contact. Somehow I had the opportunity to understand what was going on better than the other members of my family. As both his daughter and a palliative care and hospice physician, I had access to information and a level of understanding that no one else did. I knew what was going on more than the other doctors because they don't routinely care for patients at the end of life (and don’t like to acknowledge it when they do), and I knew more than my family because I had more medical information. I think this is one of the most special privileges doctors have, and this time it means a lot more because it gave me a special bond with my dad during his dying process. I feel that I started to process his death the day I saw the MRI images. After looking at those images and reviewing them with colleagues, I appreciated every time I saw him from that point forward as the true gift that it was.

I am grateful that I had the insight and training to do some legacy work (creating memories and mementos for friends and family to remember a loved one by) when we still had time. I have always had frank discussions with my children, so they seem to be coping well with his death, almost too mature for their age. The kids will always remember driving lessons (at 11 and 14) from him.

It seems like he is gone too soon. He still had plans and things to do, but then again my husband wondered if my dad would have run out of things to do. I feel like I should have spent more time with him — like I didn’t do enough to cherish his life. However, I did so many things with him even when I was young. Those memories will be with me forever.

The first few days after his death were rough. I felt numb. I could not believe I would never see him again. I spent a lot of time with my mom doing nothing; just letting the day go by. I am particularly lucky because all my coworkers are used to comforting people after the death of a loved one, so I have gotten an extra-large dose of love from every one of them.

The hospice team provides 13 months of bereavement support after someone’s death. I am glad they will be there to check in on my mom and one of my sisters and her children. For different reasons, they are all having a hard time with his death, and they can all use the extra support from hospice. If they are still having difficulty after the first year, it is considered complicated grief, and they will be referred for more counseling. I am glad someone else will be making that decision.

He was cremated with no viewing, so getting to closure took some time. He did not want a pompous funeral because he always wanted to be enjoyed while alive. My dad was always a creative guy, so in his honor we tried to reinvent the funeral experience. We had a progressive celebration of life composed of events ranging from the very formal to the very casual to allow everyone to say goodbye. I have always felt that final services are supposed to be about the deceased, not about cultural norms. Surely I learned that from him. His remains were placed in a crypt at the cemetery. We all went out for ice cream afterwards.

As a complete coincidence, about a month after he died, my husband and I went a road trip very similar to those I went on with Dad when I was a child. It was bittersweet, but the experience helped me say goodbye while ensuring he lives on as I pass on to my children what he taught me, and hopefully they will pass it on to their kids.

We live longer when people whose lives we touched remember us. He will always live in my heart.

Dr. Leech is a Houston palliative care and hospice physician. She is medical director at Memorial Hermann Hospice IPU and medical director of palliative medicine at Memorial Hermann Southwest.

Tuesday, August 16, 2016

Colorectal Cancer Screening: 80 Percent by 2018

By Sid Roberts, MD
Lufkin Radiation Oncologist

This article originally appeared on Dr. Roberts' blog. Dr. Roberts lives in Lufkin, in Angelina County, Texas. This post contains valuable information for people anywhere, though some of it is relevant to his hometown.

Katie Couric has raised awareness of colorectal cancer ever since her husband died of the disease in 1998. Yet colorectal cancer remains the second leading cause of cancer death in the United States, only surpassed by lung cancer. Both are preventable: lung cancer by not smoking, and colorectal cancer by screening for and removing precancerous polyps.

The American Cancer Society has teamed up with the CDC (the Centers for Disease Control and Prevention) and other organizations to set an ambitious goal of screening 80 percent of eligible people for colorectal cancer by the year 2018. Screening for colorectal cancer is incredibly important because removing precancerous polyps actually prevents colorectal cancer. Across the nation, if 80 percent of the eligible population gets screened, it would prevent 277,000 new cases of colorectal cancer and 203,000 deaths (270 of those in Angelina County!) within 20 years. Those are staggering numbers.

Why so high? Because one in three adults in the United States between ages 50 and 75 – about 23 million people – are not getting tested as recommended. In Texas in 2016, there will be 9,680 new cases of colorectal cancer and 3,520 deaths. This translates in Angelina County to about 36 new cases and 14 deaths this year alone. Remember, these are preventable deaths.

How are we going to achieve this screening goal locally?

The Angelina County & Cities Health District, CHI St. Luke’s Health Memorial, the Temple Cancer Center and our local gastroenterologists have teamed up with the American Cancer Society and CPRIT – the state-funded Cancer Prevention Research Institute of Texas – to educate our area population and screen eligible patients for colorectal cancer through a cooperative grant headed by UT Tyler. Most insurances cover routine screening, but this group stands ready to make sure that any eligible patient, whether insured or not, has access to life-saving screening and, if a cancer is found, treatment as well.

There are many ways to be screened, but I want to focus on the two most available. These two  - colonoscopy and FIT testing – are also funded under the CPRIT grant and by almost all insurances. Having a colonoscopy is the best test, in my opinion, because if any polyps are found they can be removed right then and there. If the colonoscopy is negative, nothing else needs to be done for 10 years! My wife and I had ours done the year we turned 50, and it really is not a big deal. Yes, you have to do a bowel prep to clean out your colon, but that is a small price to pay for peace of mind for 10 years.

The second test covered under the CPRIT grant – and the one that will be done most often at the Health District – is the FIT (fecal immunochemical) test. It is a test for hidden blood in the stool, which can be an early sign of colon cancer. This test is done at home by using a small brush to collect some stool and place it on a test card. The test kit is then mailed back to the clinic for processing. The FIT test must be done every year, as opposed to the colonoscopy every 10 years, but it is cheaper and doesn’t require a bowel prep. If the FIT test is positive, a colonoscopy is then necessary.

If you are between the ages of 50 and 75 and have not had a colonoscopy in the last 10 years or had an annual FIT test, ask your doctor to schedule you for one. If you do not have insurance, call Angelina County Connects at (936) 633-1442 and ask the eligibility specialists if you qualify to be screened under the CPRIT grant. Let’s work together to prevent cancer and get to 80 percent by 2018!

Dr. Sid Roberts is a radiation oncologist at the Arthur Temple, Sr. Regional Cancer Center in Lufkin. He is a contributing writer for the Lufkin Daily News and blogs at SRob61.blogspot.com

Monday, August 15, 2016

Cyber Threat Invading Texas Puts Patient Records at Risk

Physicians’ efforts to protect patients’ private medical information could be in jeopardy as Texas medical practices — large and small — face an increasing cyber-attack threat that can leave health records vulnerable. The computer-hack threat, known as ransomware, is software designed to invade and block access to office computer systems that store patient information. To regain access, cyber thieves typically demand ransom payments in exchange for an encryption key to unlock the system. Reports of ransomware extortion have made national headlines and are now occurring in Texas at an increasing rate. Medical practices often are vulnerable to cyber-attack because of outdated computer systems and obsolete data security. The Texas Medical Association (TMA) considers ransomware a direct threat to patient care, according to TMA’s August Texas Medicine magazine.

“It impedes the ability to take care of patients who are in the office, as well as those who call the office,” said Matt Murray, MD, chair of TMA’s Ad Hoc Committee on Health Information Technology (HIT). “At the end of the day, the physician is left struggling to take care of patients who are sick without access to information that is really needed.”

According to Texas Medicine, the FBI reported cyber criminals collected $209 million in the first three months of 2016 by extorting various entities with a locked computer server. The Texas Medical Liability Trust (TMLT), which provides medical liability and cyber liability coverage for physicians, reports 12 policyholders across the state reported receiving cyber extortion-related threats mostly within the last two years. And in one case earlier this year, a physician alerted TMA that his small South Texas practice was under ransomware attack. According to John Southrey, TMLT director of product development and consulting services, any medical practice connected to the internet is vulnerable to attack.

“They’re a target because cyber criminals know that they don’t have those resources like some organizations do. They’re kind of a training ground, or as some commentators have stated, ‘low-hanging fruit’ for cyber criminals to be able to get into their systems. And it’s a quick buck for these cyber criminals if their ransom demand is reasonable, such as $500 or $600,” Mr. Southrey said.

TMA plans to raise physicians’ awareness of the threat of ransomware and will help them manage their security and technology risks. Not only is security of health information important but also a physician’s data breach might violate Texas law, potentially leading to civil or administrative penalties. So TMA’s Ad Hoc Committee on HIT is monitoring the development of the SECURETexas certification program, one potential avenue to mitigate cyber-security risk. SECURETexas is the first state program of its kind to certify that medical practices’ data privacy and security comply with state and federal laws that govern the use of protected health information. In the meantime, TMLT's cyber liability coverage for cyber extortion covers physicians’ expenses in case of an attack and will sometimes pay cyber extortion funds to terminate a threat to physician policyholders.

Patrick Casey, a former meaningful use and quality assurance specialist for the North Texas Regional Extension Center, said, “Honestly, I don’t want doctors having to become experts in HIT security. They’ve got enough on their plate to be doctors. We have to find a way to continue to and even increase the support that we make available to the health care community.”

Although no system is completely cyber-attack-proof, Dr. Murray said a preventive strategy, including a business continuity plan for technology, will give physicians a greater chance to safeguard their patients.

“If the practice can do that, they will not have to pay ransom, and the impact on patient care can be minimized if the backup and restore tools are effective,” he said.

Friday, August 12, 2016

Infographic: Get the Facts About Whooping Cough

Editor’s Note: Vaccinations are important, safe, and effective. During National Immunization Awareness Month this August, Texas physicians want to remind people of all ages to stay up-to-date on their recommended vaccinations. 

Protecting newborns from dangerous whooping cough (also known as pertussis) starts with mom before the baby is born. Texas physicians say pregnant moms and moms-to-be need to get their recommended pertussis vaccination to protect themselves and their babies.

Whooping cough is especially dangerous for infants younger than 1 year of age. It is highly contagious, and the Texas Department of State Health Services says more than half of babies less than a year old with pertussis must be hospitalized. Many will have serious complications, like pneumonia or apnea (slowed or stopped breathing), and some become so sick they will die.

Check out the infographic below created by the Texas Medical Association to learn why getting the whooping cough vaccination is so important and how the disease ― and the vaccine that prevents it ― works.

Monday, August 8, 2016

Texas Physicians Fighting Potential Zika Epidemic

With cases of local Zika virus transmission now being reported in Florida, Texas physicians and state officials are preparing to confront inevitable local transmission here, reports Texas Medicine magazine. Local transmission means mosquitoes in the area carry the Zika virus and have bitten someone and infected him or her with the virus. Zika, a primarily mosquito-borne illness, has become a major concern for physicians and other public health experts since outbreaks began spreading in other parts of the world in 2015.

Organized medicine took swift action in Texas to try to prevent the emergence of Zika. For example, Texas Children’s Hospital’s infectious disease pregnancy clinic in Houston opened a Zika-specific clinic where women can discuss their risk factors with physicians and receive Zika testing. The primary Zika concern is pregnant women could spread the disease to their fetus, which can then develop birth defects such as microcephaly, or a smaller, underdeveloped brain.

“We see a lot of pregnant women very concerned,” said Catherine Eppes, MD, an obstetrician-gynecologist at the Texas Children’s clinic. “In the last couple of months, pregnant women possibly exposed to Zika virus have become the largest volume of patients that we’re seeing in that clinic.” Dr. Eppes, a member of the Texas Medical Association’s (TMA’s) Committee on Infectious Diseases, says the clinic has seen a spike in women requesting a Zika screening.

“Not being able to prevent the virus, offer vaccination, or treat it once women have gotten Zika really makes all of the focus needing to be on preventing exposure, and … that means we have to do the majority of the hardest work now,” Dr. Eppes told lawmakers at a state Senate Health and Human Services Committee meeting in May.

As physicians try to prevent the disease from emerging or spreading, TMA offers physicians ways to help. The medical association in June formed a Zika workgroup of physician experts from numerous TMA committees offering the best response to the public health threat. The workgroup discussed challenges with Zika testing, reporting, and referral; emerging shortages at blood banks as a result of bans on donors who had traveled to Zika-infested areas; and potential TMA activities to help physicians and the public prevent and stop Zika. In addition, TMA and the Texas Association of Obstetricians and Gynecologists have prepared guidance for physicians on screening and talking to patients about Zika.

TMA President Don Read, MD, prodded a gridlocked Congress to fund a Zika epidemic response. (Congress recessed without yet funding money for Zika.) Dr. Read knows firsthand the havoc a mosquito-borne illness can wreak on the human body; he contracted West Nile virus in 2005. Its devastating effects sidelined him from work for seven months.

“My arms were paralyzed. My legs were paralyzed. I couldn’t talk. I couldn’t hear. I couldn’t write. I was sleeping 23-and-a-half hours a day, and my legs hurt like hell,” he said. In a letter to the Texas congressional delegation in May, Dr. Read described his personal experience, saying soon local Zika transmission would occur in Texas.

“Local and state public health officers in Texas are working hard to prepare for that day, but we need help,” he wrote. “We have the experience and expertise necessary, but our public health infrastructure is not up to a task of this magnitude.”

Texas Department of State Health Services (DSHS) Commissioner John Hellerstedt, MD, says federal funding would allow state and local officials to bolster every aspect of their Zika response. DSHS drafted its own plan of action to deal with the threat including coordinating with local public health agencies, since the response to an epidemic often begins with local authorities.

“In my opinion, it’s not all about hardware and hiring professionals to go out and spray,” Dr. Hellerstedt told Texas Medicine. “A lot of it is leadership and getting out into communities and faith-based organizations, service organizations in those communities, to get out there and help their neighbors … and make people aware of just how powerful and effective these very simple measures are that they can undertake.”

For example, he urges every Texan to remove standing water from yards where mosquitoes breed, wear mosquito repellent and long clothing, avoid outdoor activity during mosquito-heavy times of the day like dusk and dawn, and put up window and door screens to keep the insects out.

Dr. Hellerstedt is optimistic that with if people take these preemptive measures, Texas has a good chance of preventing a Zika outbreak.

“What I hope will happen is that any kind of evidence of local transmission will only be a further call to action for the rest of the state, for everyone else to keep doing those other things more intensely and more observantly. And that’s going to give us the best chance. Even if we have isolated pockets of Zika transmission, they’ll die out over a period of time,” he said.

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