Thursday, July 23, 2015

Medicare and Medicaid Recipients Support Programs, Worry About Changes

Most Medicare and Medicaid recipients like the programs and don’t want to see any substantial changes made, according to the latest tracking poll by Kaiser Family Foundation (KFF).

A large majority (91 percent) of individuals covered by Medicare — government health insurance for senior citizens and people with disabilities — report positive experiences, while 86 percent of Medicaid recipients — government health insurance for lower-income people — also report positive experiences. These numbers are similar to the percent of individuals who report positive experiences with their employer-sponsored health insurance coverage (87 percent).

According to the poll, many Americans regard Medicare (77 percent) and Medicaid (63 percent) as “very important,” though fewer believe the programs are “working well” (60 percent for Medicare, 50 percent for Medicaid).


While most respondents (70 percent) say they do not support significant changes to Medicare, just more than half (54 percent) worry the program won’t be able to provide the same level of benefits to future enrollees, and even more (68 percent) acknowledge changes are needed to keep Medicare sustainable.

When asked what — if any — changes should be made to the program, 87 percent say the federal government should be allowed to negotiate Medicare drug prices. Other favorable options include increasing Medicare premiums for wealthier seniors (58 percent) and reducing payments to Medicare Advantage plans (51 percent). Lower on the list are raising the eligibility age from 65 to 67 (39 percent), raising premiums for everyone (31 percent), and increasing cost-sharing for future beneficiaries (24 percent).


Similar as for Medicare, 62 percent of respondents oppose changes to Medicaid. Still, 32 percent (including 50 percent of Republicans) say they would prefer if Medicaid were turned into a block grant program, whereby states would decide which groups of people and what health care services they want to cover through federal grants.
Read the full results at KFF.

Wednesday, July 22, 2015

Breast Cancer Is Not Biased. What Male Patients Need to Know.

By Nicole B. Saphier, MD
New Jersey Radiologist

This article originally appeared in the Doctor Blog.

We all know what the American Cancer Society, the American College of Radiology, and countless other professional societies recommend regarding screening and diagnosing breast cancer in women. But a subject that comes up far less frequently is what to do with men. While it is significantly lower than in women, a man’s risk is not nearly as low as we might think: one in a thousand will get breast cancer in his lifetime.

As with women, everything that increases estrogen in a man puts the breast tissue he was born with at an increased risk of developing malignancy. Chemicals and pollutants, obesity, radiation — all the same reasons breast cancer is an ever-growing concern among our female patients — affect our male populations as well.

However, because the lifetime risk of male breast cancer in the general population is considered low, screening is not universally recommended as it is for women. And, therefore, more men are diagnosed with breast cancer at a late stage. Men (and their doctors) can often ignore the signs that women have been constantly reminded to watch out for — such as a lump, nipple inversion, or skin changes — that may indicate invasive disease. Even if they do notice an abnormality, they tend to be embarrassed or discount it and do not seek medical attention.

The National Comprehensive Cancer Network (NCCN) recommends that men at highest risk for breast cancer (those who have a known BRCA2 mutation, or a strong family history) have a clinical breast exam every six to twelve months, starting at age 35. It is also suggested for them to obtain a mammogram at age 40 and depending on the findings from this baseline exam and the amount of breast tissue present, yearly mammograms may be recommended. Precise protocols, however, have yet to be established.

It is not practical to screen all men at average to moderate risk for breast cancer. Yet clinicians need to remind their male patients that breast cancer is not prejudiced and can occur in anyone. Educate them on the signs to be aware of, especially if they have any of the risk factors that may increase their likelihood of breast malignancy.

For the men who have any of the risk factors for breast cancer, consider performing clinical breast exams during their yearly physical, in addition to the dreaded rectal exam for prostate cancer screening. By being proactive about clinical breast exams, you would be introducing the concept of breast awareness as well as helping to detect the rare cancers at an earlier stage.

Dr. Saphier is an influential radiologist in breast and comprehensive women's oncological imaging. Following completion of her subspecialty training at Mayo Clinic, she soon after became a voice in the political arena of breast imaging. After championing the Arizona state legislature for breast density notification, Dr. Saphier took an active role in both the Radiological Society of New Jersey Executive Committee as well as the State Department of Health Breast Imaging Work Group. Dr. Saphier currently lives and practices in Northern New Jersey with her husband and three children. 

She can be reached at her self-titled site, Nicole Saphier, and on Twitter @NBSaphierMD

To help patients know what screening options are appropriate based on their risk assessment profile, Dr. Saphier created the app My Breast Friend: A Breast Cancer Risk Assessment and Associated Screening Options by Appsotutely, Inc.

Tuesday, July 21, 2015

We Can Prevent Unintended Pregnancy

By Shanna M. Combs, MD
Fort Worth Obstetrician-Gynecologist
Member, TMA Committee on Maternal and Perinatal Health

There was such excitement in the office this week. The resident I was working with had just found out she was pregnant.  She had done all the right things, getting her medical problems controlled and changing her medications to ones that are safe in pregnancy; she had even started taking her prenatal vitamins.  She was a little nervous about the prospect of being pregnant, but she and her husband were very happy with the new path their life was taking.

Now imagine being a single mom with two kids, barely keeping things together in your one-bedroom apartment, and discovering that you are pregnant, again. You had been on the pill; it was the only thing you could afford.  But with the day-to-day rush of life, it was hard to keep track of the pills and when you had taken them, and you may have missed one here and there.

Unfortunately, the second story is the one I see all too often. In the United States, we have an unintended pregnancy rate of 51 percent, and in Texas it is 54 percent.  Despite the wide variety of contraceptive options available as well as some very effective forms of contraception, there has not been much change in this number over the past 20 years. While some might think this is simply due to women not using contraception, that only accounts for half; the other half of unintended pregnancies are due to incorrect use of contraception or use of ineffective forms of contraception.

Fortunately, there is hope. The contraceptive Choice project out of Washington University School of Medicine in St. Louis showed us that when women are provided accurate, comprehensive contraceptive counseling as well as contraception at no cost, they often choose the most effective forms of contraception, the IUD and the implant (also known as long-acting reversible contraception or LARC) and continue to use them long term. From this study, it was shown that women had a decrease in the unintended pregnancy rate. We have also learned from Colorado that when women have access to low-or no-cost contraceptive devices (including IUDs and implants), LARC use increases, and the number of unintended pregnancies and abortions decrease. Lastly, for women whose insurance is following the mandate from the Affordable Care Act and covering contraception, there is significant cost savings on contraception, and the hope is that by no longer having the high up-front cost for LARC (sometimes a few hundred dollars), women will be more likely to choose this very effective form of contraception.

Unfortunately, not all insurance companies are following the mandate for contraceptive coverage, and many women still remain uninsured, especially in states that have not expanded Medicaid.  The evidence is there that low-cost or free access to LARC increases its usage and decreases unintended pregnancies.  We need to get insurance companies to realize this so that our patients can prepare for a pregnancy when they are ready and avoid one when it is not the right time.

Dr. Combs is a Fort Worth obstetrician-gynecologist and assistant professor at the University of North Texas Health Science Center.

Friday, July 17, 2015

WIC Program Deserves Support

Program Provides Essential Nutrition to 1 Million Texas Infants, Children, and Mothers

By Steven Abrams, MD
Austin Pediatrician

The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) has had unprecedented success in enhancing the nutritional status of pregnant women and young children in the United States since Congress authorized it in 1972. Sometimes perceived as a free infant formula program, it is much more. It is a comprehensive program that supports good nutrition during pregnancy, provides breastfeeding support for mothers, and provides nutritional planning for at-risk children in the first five years of life.

The government has until Sept. 30, 2015, to reauthorize the WIC program, providing funding through the Texas Department of State Health Services.

Texas is home to more than 1 million WIC recipients, about three-fourths of whom are infants and children. Among infant recipients, almost half receive some breast milk, critical to short- and long-term health.

It is critical that the WIC program be continued without being weakened. Deciding who receives WIC and what benefits are given is the job of scientific and governmental experts. It and other food assistance programs must be free of nonscientific input.

People who participate in Medicaid are automatically income eligible for WIC, but they must also meet other program requirements, such as being pregnant or having nutritional need.

This link between the two programs makes WIC available to families with relatively little administrative paperwork. Linking WIC to Medicaid is rational because the health care costs of inadequate early nutrition ultimately would be paid by Medicaid.

This approach has led to a fairly constant rate of WIC participation by families who are at risk. It also has allowed for contracting with suppliers, such as infant formula companies, to be done in a way that offers tremendous discounts for the government while meeting the needs of children. An April 27 Wall Street Journal article, “Makers of Baby Formula Press Their Case on WIC Program,” states that taking away this link would decrease the effectiveness of the program and would unnecessarily complicate the management of WIC.

It has been clearly demonstrated that the “1,000 days” from conception through about 2 years of age is absolutely critical to lifelong health and good outcomes. Good nutrition during that time sets a trajectory of good development and a decreased risk of later cardiovascular problems.

This early investment in nutrition is a moral imperative. For example, lactation counseling leads to increased rates of breastfeeding and decreases infections and other short- and long-term health problems in children.

WIC is a supplemental program; it does not meet 100 percent of its participants’ needs. It is flexible in providing for healthy and appropriate nutrition for all participants, especially mothers.

The food selections in WIC are limited, and it is inaccurate to believe recipients are using the benefits inappropriately. What is accurate: Infant formula is expensive, and families will dilute infant formula when they cannot pay for it. One study suggested formula dilution occurs in more than 10 percent of families who provide formula to their infants.

Take away WIC from at-risk families, and the rate of malnourished infants and their mothers will increase substantially.

Steven Abrams, MD, is professor of pediatrics and chair of the Department of Pediatrics at Dell Medical School at The University of Texas. He served as a member of the Committee on Nutrition of the American Academy of Pediatrics from 2009-15 and as a member of the Dietary Guidelines Advisory Committee in 2015.

Thursday, July 16, 2015

Physicians Choosing Fellowship as Medicine Becomes More Specialized, Competitive

More physicians are turning to fellowships — additional, specialized training after they become doctors — to serve patients in need of more specialized care, reports Texas Medicine, the Texas Medical Association’s (TMA’s) monthly physician publication. Doctors also find doing so can ensure the long-term viability of their practice.

After medical school, graduates continue their training in a medical specialty, such as internal medicine or emergency medicine, known as residency. A fellowship is additional training post-residency in a medical subspecialty, such as cardiology or hospice and palliative medicine.

2015 was a record year for fellowship appointments, according to the National Resident Matching Program. Fellowship programs filled nearly 90 percent of the 8,500 positions available, and 80 percent of programs filled all of their positions.

Fellowship positions have been on an upward trajectory since 2000, outpacing the growth rate of residency positions, according to the Accreditation Council for Graduate Medical Education. Most of the training is in more traditional specialties such as cardiology and gastroenterology, but in the past 15 years, new subspecialties have cropped up such as sleep medicine, and hospice and palliative care.

For the most part, physicians choose a particular area of expertise based on what they are passionate about. But now physician trainees are increasingly aware of the technical, financial, and lifestyle pressures facing them in today’s workforce, and say fellowships can help them fill a specific need and give their practice an edge.

“We have to be competitive. We have to provide good quality care. And everyone — Medicare, Medicaid — is looking at your performance,” said Hind N. Moussa, MD, a Houston obstetrician-gynecologist (OB-Gyn) and fellow in maternal-fetal medicine at The University of Texas Medical School at Houston. “With all of these changes, it makes sense to subspecialize to meet all of these new requirements to prove you are providing the best quality care.”

Before deciding to pursue her fellowship, Dr. Moussa worked five years as a general OB-Gyn, often referring many of her patients hours away for subspecialty care or filling in gaps when she could by providing some tests they needed immediately. She knew there was a nationwide shortage of maternal-fetal medicine specialists. “I had a great job,” she said. “My practice grew. But I really wanted to go back [into training] and felt like I could do more for high-risk patients.”

Angela Siler Fisher, MD, an emergency physician and director of the emergency medicine administration fellowship at Baylor College of Medicine, uses fellowships to arm physicians-in-training with leadership skills to cope with practice pressures. She says fellowships help create physician leaders and increase quality of care.

“Specialization is a good thing because you want experts taking care of you,” Dr. Fisher said. “We’re going to continue to see increases in fellowship and, as a result, stronger physician leaders in a position to advocate for their patients in a more meaningful way.”

Friday, July 10, 2015

Historic Spring Rains Bring Summer Drowning Risk

Lakes and rivers across the state are at the highest levels they have been in a long time, tempting Texans with the promise of a cool escape from the typical sweltering summer. But the Texas Department of Family and Protective Services (DFPS) says these downpours also brought an increased risk of drownings. Whether a raging river or a tiny pool, water can pose a threat to children; so the agency reminds families to watch little ones at all times around water.

“Water levels and rivers are high. Stream and creek beds are now flowing, posing more danger to children — particularly toddlers — who are not properly supervised,” DFPS wrote in a news release.

DFPS also cautions apartment pools can be especially dangerous because they tend to have no lifeguards on duty. This point was made tragically clear when three siblings — aged 9, 10, and 11 — were pulled from an Irving apartment complex in June.

Drowning has claimed the lives of 43 children in Texas this year, including seven over the long Fourth of July weekend. Seventy-three children drowned in Texas last year.

“Drowning is not what you think,” Dallas Judge John Specia, DFPS commissioner, said in the release. “It’s quick and silent and happens before you know it. I urge all Texans to keep a very close watch on children as they head outdoors. And watch a child closely any time around water.

“We can all make a difference just by being more aware of what is happening around us,” he said.

DFPS created a list of basic water safety tips for both outside and inside the house:

Outside the house

  • Never leave children alone around water whether it is in a pool, wading pool, drainage ditch, creek, pond, or lake.
  • Constantly watch children who are swimming or playing in water. They need an adult or certified lifeguard watching and within reach.
  • Secure access to swimming pools with fences, self-closing and -latching gates, and water surface alarms.
  • Completely remove the pool cover when the pool is in use.
  • Store and secure water toys away from the water when not in use, so they don’t attract a small child.
  • Don’t assume young children will use good judgment around water.
  • Be ready for emergencies. Keep emergency telephone numbers handy and learn CPR.
  • Find out if your child’s friends or neighbors have pools.

Inside the house

  • Never leave small children alone near any container of water.
  • Keep bathroom doors closed and secure toilet lids with lid locks.
  • Never leave a baby alone in a bath for any reason. Get what you need before running water, and take the child with you if you must leave the room.
  • Warn babysitters or caregivers about the dangers of water and emphasize the need to constantly supervise young children.
  • Make sure small children cannot leave the house through pet doors or unlocked doors to reach pools or hot tubs.

Thursday, July 9, 2015

Doctors Are From Another Planet

By Sid Roberts, MD
Lufkin Radiation Oncologist

Editor’s Note: This blog post was originally published July 7 at the Lufkin Daily News and on Dr. Roberts’ blog.

Jupiter and Venus aligned recently in what was called a Bethlehem Star event. The next time the two planets appear this close together will be in 2023. The rarity of planetary conversions reminded me of the 1993 bestseller from PhD counselor Dr. John Gray, titled Men Are from Mars, Women Are from Venus. If you haven’t read it, apparently there are more than 50 million copies floating around.

The basic premise of the book is that men and women are naturally different in the way they think and communicate. We all know that an underlying lack of communication in a relationship keeps that relationship from maturing or even kills it. The success of the book is rooted in the knowledge it imparts (in very humorous ways) about how our spouses think and, therefore, how we need to relate to one another.

Communication among doctors is equally important, but what may die in this physician-physician communication desert is you, the patient.

Everyone knows the phrase from the 1967 Paul Newman movie, Cool Hand Luke, “What we have here is a failure to communicate.” A scholarly article in the Journal of the American Medical Association in 2007 noted that direct communication between inpatient physicians and primary care physicians happened in fewer than one in five hospitalizations. It is just as bad inside our hospitals.

Physicians are notorious for expecting others to communicate for them. Part of that is time crunch, but mostly it is laziness. It is easier to write an order for a nurse to contact another physician to see a patient rather than to make the call yourself. Although, with cumbersome electronic medical records and CPOE — computerized physician order entry — it is getting easier again just to pick up the phone and call.

Consulting physicians are busy, too, and getting one on the phone can be a challenge. But if I am asking another physician see my patient, I’m the one who knows best why I am making that request and what I want from that consultant. I shouldn’t delegate critical communication to others. That gets back to one of my golden rules: Take the time and do what’s right.

What’s more, patients are demanding better communication among their health care team members and rating hospitals and physicians on whether or not they measure up. A 2011 National Academy of Medicine discussion paper noted, “Consistent and effective communication between patient and clinician has been associated in studies not only with improved patient satisfaction and safety, but also ultimately with better health outcomes, and often with lower costs.” In addition: “Breakdowns of communication, or disregard for patient understanding, context, and preferences, have been cited as contributors to health care disparities and other counterproductive variations in health care utilization rates.” In other words, when we don’t communicate, extra tests may get done and patients can get hurt.

However, communication is a two-way street. You, the patient, need to know at a minimum your own medical and surgical history, what medications you are taking (and what doses), and what you are allergic to. Medical records are not perfect, and as with any electronic media, if garbage goes in, garbage comes out. If you don’t give your physician or the hospital accurate and complete information, that’s just garbage in. Can’t remember everything? Write it all down and bring in a copy.

Communication is a skill, and skill development requires practice. Yes, some physicians (and patients) need more practice than others. Let’s work together to align our communication stars and usher in a new era of patient safety, better outcomes, lower costs, and greater satisfaction.

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