The Atlanta Journal-Constitution October 28, 2010
Grady's chief executive apologized Wednesday for saying Fulton County residents "should want to shine my shoes" for engineering the hospital's financial turnaround, according to Channel 2 Action News.
The TV station obtained a letter that CEO Michael Young sent to Grady Memorial Hospital's board of directors and the Fulton-DeKalb Hospital Authority. In it, he apologized for the comment he made to Buckhead business leaders.
"My statement was terribly [insensitive] to Fulton County taxpayers and does not reflect my true feelings," the letter states. "Please accept my heartfelt apology for this mistake and please keep in mind that it came from an innocent place. I often get excited about the changes we've made at Grady and the impact the health system is having on the community, and sometimes my words get ahead of my brain."
At a breakfast meeting with the Buckhead Business Association, Young said the people of Fulton County "should want to shine my shoes. In 2007, Fulton County gave Grady $76 million. This year Fulton County is going to give $50 million. So I have reduced your tax exposure by $26 million."
Young was hired in 2008 as part of a restructuring of Grady's leadership, which included replacing the old politically appointed board with one comprised of business and community leaders. A Grady spokesman credited Young with taking the hospital from a $51 million operating deficit in 2008 to a $34 million surplus last year, not including more than $300 million raised in a fund-raising drive for capital improvements.
Young improved bill collections and patient care, and workers received merit raises for the first time in about three years, according to the spokesman.
Young also laid off 141 employees and closed the outpatient dialysis unit.
In June, Young received a $290,800 bonus in addition to his base salary of $615,000. The bonus drew criticism from some elected officials, but it was unananimously approved by the hospital's board.
"We now have a hospital not in danger of closing," board chairman Pete Correll said then.
New Imaging Technique Reveals If Breast Cancer Treatments Are Working
Medical News Today 28 Oct 2010
Cancer Research UK scientists have developed a new imaging technique that can show when breast cancer treatment is working, weeks before current methods. The research is published in the British Journal of Cancer1 .
By using two specially labelled chemical markers the researchers were able to see the very early changes in cancer cells that show treatment is working, such as DNA damage and cell death.
Current approaches only show that treatment is effective if the tumour starts shrinking, but it can take several weeks before this becomes visible.
Looking at breast cancer cells in the lab and then in mice, the researchers were able to detect the early signs that tumours were responding to treatment with the chemotherapy drug doxorubicin2.
They were able to see this by developing two labelled markers that are involved in cellular processes that are targeted by doxorubicin, highlighting the early effects that the drug is having on cancer cells.
The first marker - [1-13C]pyruvate - shows that doxorubicin is damaging cancer cells DNA - in cancer cells this molecule is converted into other products but this conversion is reduced in cells whose DNA has been damaged by doxorubicin treatment.
The second marker - [1,4-13C2]fumarate - shows that doxorubicin is killing cancer cells as it is only converted into another molecule called malate in cells that are dying due to cancer treatment.
Lead researcher Professor Kevin Brindle, of Cancer Research UK's Cambridge Research Institute, said: "There has been a need to develop imaging methods that can detect treatment response more accurately and before tumours change size. Our new imaging method not only shows early evidence that treatment is working but could also help predict the long term outcome. We expect that these techniques will have an impact for patients in the near future."
Treatment for cancer is becoming increasingly personalised - where treatments are chosen according to a patient's individual cancer - and doctors need to know early on that the treatment is having an effect. While current approaches, including CT scanning and MRI, are relatively simple and readily available it can take several weeks before they detect changes and they can often overestimate tumour shrinkage.
This imaging technique was developed in conjunction with GE Healthcare. Jonathan A. Murray, general manager for Cross Business Programs, at GE Healthcare, said: "The potential for this technology is very exciting and we are delighted to collaborate with Cancer Research UK."
Dr Lesley Walker, director of cancer information at Cancer Research UK, said: "We need fast and accurate ways of knowing that the treatment is working. This research could help us tailor treatment to each patient by giving doctors a useful tool to check treatments are working after a short time, rather than waiting several weeks to see if the tumour is shrinking, reducing unnecessary treatment for women."
Reference
1. Witney TH, Kettunen MI, Hu DE, Gallagher FA, Bohndiek SE, Napolitano R, & Brindle KM (2010). Detecting treatment response in a model of human breast adenocarcinoma using hyperpolarised [1-(13)C]pyruvate and [1,4-(13)C(2)]fumarate. British journal of cancer PMID: 20924379
Notes
2. Doxorubicin is used to treat many types of cancer, including breast cancer. One of the ways it works is by binding to the cancer cells' DNA and blocking an important enzyme called topo-isomerase II. This makes the DNA get tangled up and cancer cells cannot divide and grow.
Source:
Cancer Research UK
Physician Panel Prescribes the Fees Paid by Medicare
Wall Street Journal By ANNA WILDE MATHEWS And TOM MCGINTY
Three times a year, 29 doctors gather around a table in a hotel meeting room. Their job is an unusual one: divvying up billions of Medicare dollars.
The group, convened by the American Medical Association, has no official government standing. Members are mostly selected by medical-specialty trade groups. Anyone who attends its meetings must sign a confidentiality agreement.
Pricing Medicare's Codes
View Interactive
Sortable Table: Top Procedures Billed to Medicare
Yet the influence of the secretive panel, known as the Relative Value Scale Update Committee, is enormous. The Centers for Medicare and Medicaid Services, which oversee Medicare, typically follow at least 90% of its recommendations in figuring out how much to pay doctors for their work. Medicare spends over $60 billion a year on doctors and other practitioners. Many private insurers and Medicaid programs also use the federal system in creating their own fee schedules.
The RUC, as it is known, has stoked a debate over whether doctors have too much control over the flow of taxpayer dollars in the $500 billion Medicare program. Its critics fault the committee for contributing to a system that spends too much money on sophisticated procedures, while shorting the type of nuts-and-bolts primary care that could keep patients healthier from the start—and save money.
"It's indefensible," says Tom Scully, a former administrator of the Medicare and Medicaid agency who is now a lawyer in private practice. "It's not healthy to have the interested party essentially driving the decision-making process."
Plenty of factors contribute to the spiraling costs of Medicare, which rose nearly 9% in 2009. Sheer demographics will add millions of new beneficiaries each year as the baby boomers begin turning 65. Other areas of Medicare—including the prescription-drug benefit and nursing-home expenses—are growing faster than payments to doctors.
Secrets of the System
Dividing the Medicare Pie Pits Doctor Against Doctor
In Medicare's Data Trove, Clues to Curing Cost Crisis (10/25/2010)
Moreover, the RUC's recommendations in theory affect only how doctors' piece of the Medicare pie is divided, not how big it is. RUC chairwoman Barbara Levy says the panel is moving aggressively to correct evaluations that lead to higher-than-appropriate payments for some services. By the start of November, the Medicare agency is due to come out with its doctor fees for next year, likely incorporating the RUC's most recent recommendations.
"We've made tremendous change in the last few years," says Dr. Levy, a Seattle-area gynecologist. "The RUC is not a perfect process, it's just the best that's out there."
Still, the impact of the decisions made by the doctors on the RUC goes well beyond physician fees for cardiac surgery or back procedures. When Medicare pays more for something, doctors have an incentive to do more of that something—with all the associated costs for hospitals, lab tests and drugs.
"Overvalued codes can lead to spending growth," says Jonathan Blum, deputy administrator for the Centers for Medicare and Medicaid Services.
A Wall Street Journal analysis of Medicare and RUC data suggests that services were paid too generously in some cases because the fees were based on out-of-date assumptions about how the work is done. The analysis found more than 550 doctor services that, despite being mostly performed outpatient or in doctors' offices in 2008, still automatically include significant payments for hospital visits after the day of the procedure, which would typically be part of an inpatient stay.
For instance, one operation to treat male urinary incontinence wraps in payment for 118 minutes of hospital visit time after the day of surgery, though 2008 Medicare data show it is done around 80% of the time outpatient or in a doctor's office. Stephanie Stinchcomb, manager of reimbursement for the American Urological Association, says the surgery used to be largely inpatient; its payment was last updated based on a RUC evaluation in 2003. It's not clear if a new analysis will find doctors should now be paid less for it, she says.
The RUC's Dr. Levy says the committee is already recommending changes for services that have moved to an outpatient setting.
The AMA, along with groups representing doctor specialties, formed the RUC in 1991. That's when Medicare was moving to its current system of setting doctor fees, which bases estimates of the cost of a service on the physician work and related expenses involved, as well as a small amount for liability. The panel's main focus is to estimate how much work it takes a physician to perform a given task.
In sessions that can stretch 12 hours or longer each day, the committee walks through dozens of services. The discussions can be mind-numbing—a subcommittee once debated whether to factor tissues into the payment for a psychoanalysis session.
Committee leaders like Dr. Levy have long emphasized that members need to look beyond the interests of their specialties, and she distributed red baseball caps with "RUC" printed on them at the beginning of her term last year. Past efforts at bonding activities include a bowling night where the physicians were randomly assigned to teams. The breakdown of votes is kept secret, and it takes two-thirds of the 26 voting panelists to endorse a value for a service.
The stakes are heightened by Medicare law that says if services get a boost in their values, the money is supposed to come out of existing services' reimbursement. The Medicare agency makes such tweaks to attain so-called "budget neutrality" and also aims to hit overall spending goals set by law. However, its projections are often exceeded due largely to increases in the number of services performed. Congress has stepped in to authorize higher-than-targeted spending.
Matt Lutton for The Wall Street Journal
Dr. Barbara Levy, a Seattle-area gynecologist who heads the RUC.
"This system pitted specialty against specialty, surgeons against primary care," says Frank Opelka, a surgeon and former RUC alternate member who is vice chancellor at Louisiana State University Health Sciences Center in New Orleans.
Primary-care groups have pushed for more representation on the committee, and their leaders have argued its results are weighted against their interests. (Please see accompanying article on WSJ.com/US.)
Dr. Levy says the committee is an expert panel, not meant to be representative, adding: "The outcomes are independent of who's sitting at the table from one specialty or another."
A recent analysis for the Medicare Payment Advisory Commission, or MedPAC, a Congressional watchdog, calculated how much American doctors would make if all their work was paid at Medicare rates. It found that the primary-care category did the worst, at around $101 an hour. Surgeons did better, at $161. Specialists who did nonsurgical procedures, such as dermatologists, did the best, averaging $214, and $193 for radiologists.
The imbalance has stoked fears of a shortage of primary-care doctors, as well as a relative shortfall in the amount of primary-care services patients receive, compared to specialist procedures. "The fee schedule we use to pay physicians in Medicare leads to the wrong mix of services and the wrong mix of doctors," says Robert Berenson, vice chair of MedPAC and a researcher at the Urban Institute. "It produces increased spending for Medicare and for the rest of the system."
Out-of-whack Medicare doctor payments are supposed to be corrected in a required review every five years. MedPAC says in the three previous reviews, the RUC endorsed boosts for 1,050 services, and decreases for just 167. Many recommendations on which services to examine came from doctor societies. The upshot may be that payments don't keep up with medical realities when procedures become easier or faster, MedPAC said.
The Medicare payment for placing cardiac stents in a single blood vessel stems from a 1994 RUC analysis. Medicare paid doctors for 326,000 of those procedures in 2008, at a cost of around $205 million. Compared to the mid-1990s, cardiologists say, stenting today is more routine and may often be less stressful.
The example used to set the code's value is "way out of date," says David L. Brown, a cardiologist at SUNY-Stony Brook School of Medicine. "In those days, stents were used when you were having a catastrophic event or thought you might have a catastrophic event." Stents and the catheters used to thread them into arteries are now smaller and easier to use, he says. The time varies by patient, but Dr. Brown says he required around 45 minutes on average to perform a single-vessel stenting. The RUC's valuation suggests a two-hour procedure.
The American College of Cardiology feels the service is "fairly valued," says James Blankenship, who represents the society on the RUC and is director of cardiology at Geisinger Medical Center. He concedes that two hours is "probably a little bit too long," but argues that the procedure may be harder because cardiologists now take on challenging patients who might once have gotten bypass surgeries.
The RUC's Dr. Levy says that the RUC has reduced values for nearly 400 services in the past and it is now reviewing hundreds more.
Where the Money Goes
Medicare Spending, in billions 2009
In 2006, Medicare phased in a payment for applying a skin substitute that used a new RUC evaluation. The estimate of doctor work was built around an example of treating a teenager with an extensive burn, who's seen in an operating room. The procedure was estimated to take 25 minutes, and payment wrapped in the cost of four doctor visits, including one for hospital discharge.
By 2008, according to Medicare data, the code was being billed by podiatrists 74% of the time, and they were applying the skin substitute to ulcers, not burns. Moreover, 53% of the procedures were outpatient and 44% done in doctors' offices. Some podiatrists suggest 25 minutes is longer than the procedure typically takes, though this can vary. Lee Rogers, associate medical director of the amputation-prevention center at Valley Presbyterian Hospital in Los Angeles, says he requires seven minutes on average.
"I can't believe that's the vignette they based this code off of," he says.
At a national podiatric meeting in July, podiatrist James Stavosky showed slides highlighting that doctors who treated a stubborn foot ulcer with Dermagraft, a skin substitute used when billing that code, could make $3,137.54—substantially more than with rival products paid for under different codes. Dr. Stavosky says the slides were his idea and he wasn't paid for the talk by Advanced BioHealing Inc., the maker of Dermagraft. The company confirms that.
The Medicare agency has proposed lopping its reimbursement for the Dermagraft procedure, and the RUC has suggested that the AMA committee that creates billing codes review the matter. Medicare's Mr. Blum says the agency is becoming "much more prescriptive" in working with the committee, prodding the panel to detect, and suggest fixes for, payments based on out-of-date assumptions. He adds that the agency has already made payment changes to "correct historical biases against primary-care professionals" and plans more such moves.
The RUC relies heavily on surveys performed by doctor specialty groups, requiring as few as 30 responses. The surveyed doctors estimate the time, stress, skill and other factors based on a hypothetical case that's supposed to represent a typical patient. They compare services to other, similar ones to help figure out relative difficulty. A blank example provided to The Wall Street Journal noted that the survey "is important to you and other physicians because these values determine the rate at which Medicare and other payers reimburse for procedures."
William Hsiao, the Harvard professor who led the original physician-work research used to set Medicare fees, argues the approach is almost guaranteed to inflate the values used to calculate fees.
"You do not turn this over to the people who have a strong interest in the outcome," he says. "Every society only wants its specialty's value to go up…. You cannot avoid the potential conflict."
A study published this June in the journal Medical Care Research and Review found the procedure times used by the RUC to calculate values may sometimes be exaggerated. The mean times for several types of surgeries were substantially shorter in a database drawn from hospital surgical records.
For instance, the time used by the RUC for carpal tunnel surgery—which was performed 106,000 times on Medicare patients in 2008, at a cost of around $44 million in doctor fees—is 25 minutes. According to Sullivan Healthcare Consulting Inc., which maintains the hospital database, the median time among teaching hospitals in recent years, based on 2,602 cases, was about one-third shorter, at 17 minutes. The figure for community hospitals, with 4,093 cases, was 18 minutes.
According to documents provided by the RUC, the 25-minute figure is based on 39 surveys of surgeons, out of 150 sent out by groups representing hand surgeons, orthopedic surgeons and plastic surgeons.
Robert H. Haralson III, former medical director for the American Academy of Orthopaedic Surgeons, says Medicare's payment isn't too high, because the surgery is a more intense procedure than the current value implies.
In a letter to the medical journal, RUC leaders said the article was "outdated" and questioned use of the surgical database, which classifies procedures in a different way than the RUC. Dr. Levy says the doctor surveys serve as "a beginning point" for the committee's experts.
Mr. Blum of the Medicare agency says that for now, "we are comfortable" with the RUC process. The federal health-care overhaul requires the government to insure that the doctor-fee values adopted by Medicare are accurate. "We're not going to rubber-stamp recommendations," he says.
Write to Anna Wilde Mathews at anna.mathews@wsj.com and Tom McGinty at tom.mcginty@wsj.com
Governor's race could be headed for post-Thanksgiving finish Aaron Gould Sheinin The Atlanta Journal-Constitution
The race for governor could end up being a holiday affair.
If no candidate gets the required majority of votes in Tuesday's general election, then the top two finishers will face off in a last-gasp runoff election Nov. 30. Leftover turkey and a return trip to the polls, anyone?
Depending on which candidate you're supporting, however, that's either an appetizing prospect or something akin to a grandma's hated boiled turkey surprise.
Those who back Democrat Roy Barnes see a runoff as their best, and perhaps only, chance of regaining the governor's office. Republican Nathan Deal's supporters see that their man has consistently led every poll in a Republican state in what's shaping up to be a Republican year and want to claim victory on Tuesday -- or at least end the madness that is campaign season.
"Please, no runoff," said Mark Glidewell, 39, of Savannah, who describes himself as a "soft" Deal supporter. "I cannot imagine [four] more weeks of these horrible ads being run by both Barnes and Deal."
But Emily Schunior, 39, of Ormewood Park is rooting hard for a chance to vote for Barnes twice in November.
"I definitely think [a runoff] is our best chance," she said.
But is it likely? Again, it depends on who is asked.
"My contention is I don't think there will be a runoff," said Brian Rell, a former state GOP executive director and campaign strategist.
Recent polls all have shown Deal with anywhere from a 5- to a 10-point lead over Barnes, with Libertarian John Monds in the low- to mid-single digits. While the polls have not yet shown Deal getting the magic 50-percent-plus-one vote needed to win, Rell believes the race is already trending that way.
Besides, he said, "I don't think the voters want [a runoff]."
Jack Staver sure doesn't.
The 57-year-old Atlanta resident said the race "needs to be over Tuesday."
"Nathan Deal will be the next governor," he said.
But Democratic political consultant Jim Coonan isn't so sure.
Georgia's electorate is less partisan than many believe, with a "very large pool of swing voters."
"The big question is whether the swing vote is being rung out of the Georgia electorate," Coonan, of Atlanta, said.
If those voters who split tickets still exist -- meaning if they haven't been swept up in the Republican wave -- "it boosts the chances of the gubernatorial race going to a runoff."
The campaigns, however, remain steadfast that there will be no runoff.
“We feel really good going into the final days and hours of this campaign," Deal spokesman Brian Robinson said.
Barnes' spokesman Emil Runge indicated similar optimism.
"Roy is gathering momentum from across Georgia, including from Republicans, independents and women," he said.
If there is a runoff, the outcome will be determined by several factors, Coonan said. Who has the volunteers and the campaign organization to keep voters interested and get them to return to the polls is a big factor. Another is which candidate does the best to make the runoff matter.
This year, Coonan said, Democrats could get swept in every other statewide election, lose one or two congressional seats in Georgia and see Republicans retake Congress. If that happens, the party faithful might see a Barnes runoff victory as one last strand of hope.
"We've got to save one," he said. "This is one we've got to save. We can make a difference."
But Rell believes a runoff "just delays the inevitable."
"There's no incentive for a Barnes vote coalition to turn out in greater numbers this time in a runoff than in the general election," he said.
Finally, there's the question of which candidate has the money to wage four more weeks of a campaign. Through Sept. 30, Barnes had raised more than $122,000 specifically for a general election runoff, while Deal had not taken a single contribution geared toward an extra election. Both candidates can spend whatever is left in their general election fund, but how much that will be won't be known for some time.
Eric Teusink, 29, of Grant Park is simply hoping Barnes gets the chance to spend that money.
"If there's not a runoff, that means Nathan Deal has won," he said. "As a Barnes supporter, that's a terrible thing."
There have been two statewide general election runoffs in modern Georgia history: in the 1992 U.S. Senate race when Republican Paul Coverdell ultimately beat Democrat Wyche Fowler and in 2008 when Republican Saxby Chambliss topped Democrat Jim Martin.
If there is a runoff, the pattern then obviously favors Deal. But, Coonan said, that's a myopic view.
"Patterns don't vote, people do," he said. "I think it's illusory to say there's some observable pattern you can talk about in a chat show that means anything."
Looking to save more lives in Georgia
Macon Telegragh October 28, 2010 By JAMES M. CUNNINGHAM M.D., F.A.C.S.
The Viewpoints letter titled “’No’ to Amendment 2” which was published in The Telegraph on Oct. 17, demands a reply. The writer stressed the “cons” of Amendment 2; but, in my opinion, your readers should also be exposed to the “pros” of the amendment.
Currently, the only four Level I Trauma Centers in Georgia are located in Atlanta, Augusta, Macon and Savannah. Ideally, all victims of major trauma would be in close proximity to one of these centers.
Unfortunately, the ideal situation is not always realized. The transfer of acutely injured patients may be delayed for hours due to difficulties with extrication from badly damaged vehicles or rough terrain which limits the use of rapid air evacuation via helicopter. These patients often require resuscitation and preliminary stabilization of their injuries if they are to survive.
The State Trauma Commission, which is composed of physicians, nurses, EMTs and trauma center administrators, has formulated a statewide plan to improve trauma care throughout Georgia. The Commission has received input from both regional and national organizations including the American College of Surgeons. As a result, a well thought out, strategic decision has been made to provide additional, much needed resources to a select group of existing facilities which are currently unable to participate in trauma care. With appropriate funding, the number of trauma centers in the state will increase to an acceptable level.
Those of us who actually treat victims suffering major traumatic injuries are not concerned with “diluting the effectiveness of major trauma centers” as the letter writer suggested. Additional resources strategically scattered throughout the state would, in fact, improve the effectiveness of the major centers because we would receive patients who have been locally resuscitated and are not in shock on arrival.
Once the detrimental physiologic changes associated with prolonged shock have continued unabated, resuscitative efforts, no matter how intense, are often futile. Additional Level I, Level II, and Level III centers in the state will allow more of these severely injured patients to be stabilized during the critical “golden hour” after major trauma. As a result, more victims will survive and fewer family members will be visiting the gravesites of their loved ones.
Importantly, for all Georgians who will vote in the upcoming election, the amount of money added to the annual tag purchase is limited to $10 by virtue of a constitutional amendment. Only another amendment can raise the fee. Additionally, all monies collected must go only to fund the trauma system. The State Trauma Commission will then determine the appropriate disbursement and distribution of the fees which are collected.
I encourage you to vote “yes” on Amendment 2 on November 2nd.
James M. Cunningham, MD, FACS, is the Chief Medical Officer for the Medical Center of Central Georgia.
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