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January Issue 2017

Inside This Issue

Memorial Hermann address Nations Shortage of Organs See pg. 10

INDEX Legal Health..................pg.3 Mental Health...............pg.5 Oncology Research......pg.6 Healthy Heart................pg.8 Pharmacy Corner........pg.14

UTMB develops oral vaccine Against salmonella See pg. 12

The Doctor’s Dilemma By Howard Marcus, MD, FACP

The Doctors Company Internal Medicine Closed Claims Study analyzed 1,180 claims that closed from 2007–2014. The study found that the top allegation, representing 39 percent of claims against internists, was diagnosis related and resulted from a delay or failure to diagnose. This finding is consistent with data published in Improving Diagnosis in Health Care (National Academies of Sciences, Engineering, and Medicine), which found that 34 percent of nonsurgical specialty claims are diagnosis related.

diagnose may be viewed as an error include the following: or lapse in reasoning rather than just ∙∙ Anchoring bias: The tendency a failure of clinical skill. Therefore, to rely too heavily on, or diagnostic accuracy can be improved “anchor” to, one trait or with a better understanding of how piece of information when to avoid pitfalls in medical decision Physicians fail to diagnose making decisions—usually accurately for many reasons. The making. the first piece of information dilemma can be understood best The monograph Improving or diagnosis that is acquired. in the context of the complexity of Diagnosis in Health Care characterizes ∙∙ Premature closure: The clinical medicine. Illnesses present failure to diagnose in terms of two tendency to apply premature with an infinite number of variations, types of thinking processes—rapid and closure to the decision-making illustrated by the 68,000 ICD-10 slow—and the effects of psychological process by accepting a diagnostic codes and 8,000 recognized biases on medical decision making. diagnosis or treatment before diseases and syndromes—many of Type I, or rapid decision making, it has been fully verified. which are uncommon. The average involves pattern recognition (heuristics) ∙∙ Overconfidence bias: A primary care physician diagnoses that allows the clinician to successfully universal tendency to believe about 400 different diseases a year and, diagnose and treat most patients we know more than we do. every now and then, encounters a rare efficiently. For example, a female medical condition that he or she may patient with dysuria and frequency ∙∙ Optimism bias: The tendency have never seen before. to be overly optimistic by will most often have an uncomplicated overestimating favorable and It is in this context that failure to urinary tract infection. pleasing outcomes. This can Type II, or slow decision making, also be considered a form of requires recognition by the clinician denial. of the possibility of a complex medical The following illustrations are problem and the need for careful taken from The Doctors Company thought, a differential diagnosis, lab and imaging studies, reference Internal Medicine Closed Claims resources (such as UpToDate), and/ Study. or consultation with a specialist. Case One Recognition of risk factors is essential. A 53-year-old male presented to Psychological biases may the hospital with acute chest, epigastric, undermine accurate diagnosis and and back pain. Risk factors included see The Doctor’s Dilemma page 15 treatment. Some common examples

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Legal Health

HIGHLIGHTS OF THE 2017 OIG WORK PLAN By Mark S. Armstrong Epstein, Becker & Green, P.C.

Recently, the Department of Health and Human Services Office of the Inspector General (“OIG”) published its Work Plan for Fiscal Year (“FY”) 2017 (“Work Plan”). The Work Plan is published annually and describes OIG’s new and continuing audit and enforcement priorities for the upcoming year. There is significant overlap between the FY 2017 Work Plan and OIG’s previous work plan activities. However, this article highlights select new and revised OIG reviews that impact hospitals, nursing homes, hospices and home health agencies. Health care providers and organizations of all types should use the FY 2017 Work Plan to identify corporate compliance risks, prioritize audit focus areas and facilitate program activities. Hospitals ∙ Hyperbaric Oxygen (“HBO”)

Therapy Services (New) HBO therapy involves giving a beneficiary high concentrations of oxygen within a pressurized chamber, primarily as an adjunctive treatment for the management of select nonhealing wounds. OIG will determine whether Medicare payments related to HBO outpatient claims were reimbursed in accordance with Federal requirements. Incorrect Medical Assistance Days Claimed by Hospitals (New) - The Medicare program, like the Medicaid program, includes provisions under which Medicare-participating hospitals that serve a disproportionate share of low-income patients may receive disproportionate share hospital payments. OIG will determine whether, with respect to Medicaid patient days, Medicare administrative contractors properly settled Medicare cost reports for Medicare disproportionate share hospital payments in accordance with Federal requirements Inpatient Psychiatric Facility Outlier Payments (New) Inpatient Psychiatric Facilities, either freestanding hospitals or specialized hospital-based units,

provide active psychiatric treatment to meet the urgent needs of those experiencing an acute mental health crisis. OIG will determine whether Inpatient Psychiatric Facilities complied with Medicare documentation, coverage, and coding requirements for stays that resulted in outlier payments. ∙ Intensity-Modulated Radiation Therapy (Revised) Intensity-modulated radiation therapy (IMRT) is an advanced mode of high-precision radiotherapy. OIG will review Medicare outpatient payments for IMRT to determine whether the payments were made in accordance with Federal requirements. Nursing Homes ∙ Nursing Home Complaint Investigation Data Brief (New) - All nursing home complaints categorized as immediate jeopardy and actual harm must be investigated within a 2- and 10-day timeframe, respectively. OIG will determine to what extent

State agencies investigate the most serious nursing home complaints within the required timeframes. Skilled Nursing Facilities (“SNF”) Unreported Incidents of Potential Abuse and Neglect (New) - OIG will assess the incidence of abuse and neglect of Medicare beneficiaries receiving treatment in SNFs and determine whether these incidents were properly reported and investigated in accordance with applicable Federal and State requirements. SNF Reimbursement (New) Some SNF patients require total assistance with their activities of daily living and have complex nursing and physical, speech, and occupational therapy needs. The more care and therapy the patient requires, the higher the Medicare payment. OIG will review the documentation at selected SNFs to determine if it meets the requirements for each particular resource utilization group. National Background Checks for Long-Term Care Employees (Revised) - The Patient Protection and Affordable Care Act provides grants to States, through CMS, to implement background see Legal Health page 16

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MD Anderson affirms Surgeon General’s conclusions on e-cigarette use among youth and young adults The University of Texas MD Anderson Cancer Center fully supports the United States Surgeon General’s call to action to prevent the use of e-cigarettes by our nation’s youth. The Surgeon General’s Report, released today, emphasizes that this diverse class of nicotine delivery devices presents a significant public health threat that must be addressed. “With the staggering amount of lives claimed by tobacco use each year, we must make every effort to limit youth exposure to products that may lead to lifelong tobacco dependencies,” said Ronald A. DePinho, M.D., president of MD Anderson. “The Surgeon General’s Report provides much-needed clarification of short and long-term health risks of e-cigarette use by young people and offers sound recommendations to prevent a new generation from developing nicotine addictions.” According to the Centers for Disease Control and Prevention (CDC), e-cigarettes are the most commonly used form of tobacco among youth, with

rates that have increased significantly in recent years.

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Population Sciences. “These devices are designed to deliver nicotine, an incredibly addictive drug which is unsafe for youth in any form. I hope increased awareness from today’s report will help reverse the growing popularity of these devices.”

The Surgeon General’s Report also reiterates that aerosol produced e-cigarette use and associated harms in Approximately 16 percent of high by e-cigarettes is not harmless vapor. our nation’s youth. These include: school students and 5 percent of Rather, it contains a number of volatile ∙ Raising and enforcing middle school students reported current chemicals and known carcinogens. minimum legal-age of purchase e-cigarette use in 2015, compared to Advocates of e-cigarettes often 1.5 percent and 0.6 percent in 2011, for all tobacco products suggest they may be useful for smokers respectively. ∙ Including e-cigarettes into attempting to quit. MD Anderson is The Surgeon General’s Report strongly supportive of smokers using smoke-free policies affirms a strong association between current evidence-based cessation ∙ Regulating e-cigarette marketing the use of e-cigarettes and conventional methods; however, according to the ∙ Educating the public on the tobacco products, and research has CDC, there is no sufficient evidence suggested that e-cigarette use may lead to support that e-cigarettes are safe and dangers of youth e-cigarette use to using traditional cigarettes. effective cessation tools for smokers. ∙ Expanding and improving Recently, the CDC reported that Acknowledging the potential research related to e-cigarettes American rates of conventional cigarette public health impacts of alternative “MD Anderson is committed to use has dropped to an all-time low since tobacco products, the Food and Drug 1964 of 15.1 percent. Still, tobacco use Administration issued new rules ending cancer, and one of the single remains the leading preventable cause of earlier this year to extend its regulatory most important steps toward that goal is death in the U.S. and kills an estimated authority over all tobacco products, to eliminate tobacco use,” said DePinho. 480,000 Americans annually. including e-cigarettes, cigars, hookah “Through our EndTobacco program, “Though we have made tremendous and other previously unregulated an initiative of MD Anderson’s Cancer Moon Shots Program, we are supportive progress in reducing cigarette use in tobacco products. both adults and children, trends in The Surgeon General’s Report of any evidence-based policy actions e-cigarette use are troubling,” said confirms the need for federal regulation to protect our country’s public health Ernest Hawk, M.D., division head and of these products while proposing especially that of future generations, vice president, Cancer Prevention and additional necessary actions to prevent from the devastating effects of tobacco.”

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Mental Health

Fighting professional burnout: seven ways to take control By Michael Groat Ph.D. Menninger Clinic

The challenge of providing ethical, compassionate, and patient-centered care can be strenuous. High patient volume, continuous patient contact, complex medical needs, decreased income, the demands of paperwork, limited coverage for vacations, government regulations, and the perfectionistic, workaholic characteristics of many physicians all fuel a potentially toxic brew of stress. Stress, or the heightened emotional and physical arousal that accompanies perceived demands, requires adequate problem-solving to relieve tension. Most of the time, physicians and health care administrators find solutions and manage stress well. When stress piles up and lingers, however, the ability to manage stress can deteriorate, especially as fatigue and the perception

of insurmountable problems increases. Unresolved stress leads to burnout—a state of mental or physical exhaustion caused by excessive and prolonged stress. Burnout approaches gradually and sequentially. Thus, learning to recognize the stages of burnout can lead to prevention. In the early stages of burnout, symptoms like persistent anxiety, irritability, headaches, GI upset, forgetfulness, and insomnia may be present, signaling states of increased arousal. As burnout progresses, efforts to compensate for sustained stress through energy conservation take over. Physicians may show late for work, drink alone and often, use frequent sleep aids, have less interest in sex, procrastinate, and spend less time with colleagues and loved ones. In the later stages of burnout, exhaustion peaks. Physicians can experience chronic mental and emotional fatigue, persistent complaints of headaches, stomach or bowel problems, unhappiness, tearfulness, loss of interest in work,

Call 713-600-9500 for a free assessment, 24/7.

and social isolation. At worst, the physician may also entertain suicidal thoughts as a way of coping with unbearable misery. According to various surveys, 31% to 67% of physicians report having experienced symptoms of burnout, especially in high demand fields such as family medicine, emergency medicine, obstetrics, and gynecology. And most physicians report fatigue, demoralization, and muscle tension as a result of workplace stress. Not only does the physician suffer, but so may the patients. Research indicates that physician burnout negatively impacts patient outcomes,

and increases the risk of disruptive behavior in the workplace (e.g., angry outbursts). Seven ways to manage stress and prevent burnout From my experience treating physicians and other professionals, I recommend the following tips to ease stress: 1. Re-evaluate priorities: Now’s the time to make some lifestyle changes and review your values. You may decide to go home earlier one evening a week and spend rejuvenating time with friends or family. Remember what is most see Mental Health page 16

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Oncology Research

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Why do some patients respond only to immunotherapy? By Jorge Augusto Borin Scutti, PhD Houston Medical Times

Based on current immunological developments there is no doubt that the immune system can recognize and eliminate transformed cancer cells. Several studies have investigated the immune system of cancer patients, and they suffer from large immunosuppression mainly due to decrease lymphocyte proliferation and cytotoxic activity. This means that

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the immune system, responsible for immunosurveillance now becomes weak, inactive and inefficient. Cancer immunotherapy is one of the best therapies compared to traditional therapies that may cause potential toxicities such as chemotherapy and radiation. The potential use of immunotherapy is to restore the immune system of patients in attempt to stimulate it to reject and destroy cancer cells. Tumor cells are defined as a heterogeneous and structurally complex tissue. These cells can recruit diversity of cell types, including endothelial cells, fibroblasts and immune cells, and, through production and secretion of stimulatory growth factors. This collection of cells and molecules together compose the tumor microenvironment. We know the microenvironment plays a major role during the

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initiation and development of tumor progression. There are some strategies to modulate the microenvironment - targeting regulatory cells, blocking differentiation or recruitment, blocking immunosuppressive enzymes, regulatory cell depletion, re-programming immunosuppressive cells, modifying the chemokine and cytokine profile are some examples. The attractively of new strategies for immunotherapy is driven by immune response and microenvironment discovery. Usually, scientists have relied on conventional laboratory research tools to identify, for example, altered genes and changes in mRNA and protein expression. To put these cancer biomarkers in the context

the researchers can use several strategies to find a good parameter to take care of patient and drug development. Since Ipilimumab arrived on the scene, a number of other molecules, such 4-1BB, TIM-3, LAG-3, OX40, VISTA, GITR and PD-1 have gathered researchers attention. Most famous is an antibody that targets a molecule on immune cells called PD-1. Data collected from analysis of tumor tissue can then guide rational searches for important markers in the blood. According to Robert et al 2015 in a scientific article entitled “ Nivolumab in previously untreated melanoma without BRAF mutation�, the initial phase I trial with anti-PD-1 (Nivolumab) therapy reported that PD-L1 expression on tumor cells may serve as a prognostic marker to suggest which patients would benefit from treatment suggesting a correlation between pre treatment tumor PD-L1 see Oncology Research page 18


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Healthy Heart

Smaller Artificial Heart Implanted at Baylor St. Luke’s, Bringing New Hope to More Patients Doctors at CHI St. Luke’s Health–Baylor St. Luke’s Medical Center (Baylor St. Luke’s) announced today that they have successfully implanted the new 50cc SynCardia Total Artificial Heart (TAH) into a patient suffering from biventricular end-stage heart failure. The new device is a smaller version of its predecessor, the 70cc SynCardia temporary Total Artificial Heart, which received FDA approval in 2004. The patient is the third person in the country and the first in Texas to be discharged home with this smaller artificial heart. The procedure was performed by Jeffrey Morgan, MD, Surgical Director, Mechanical Circulatory Support and Cardiac Transplant, Texas Heart® Institute (THI) at Baylor St. Luke’s, and Chief, Division of Cardiothoracic Transplant and Circulatory Support, Baylor College of Medicine. For the last half-century, the Texas Heart® Institute at Baylor St. Luke’s has led

January 2017

the world in the push to develop a viable, durable total artificial heart. “This device has the potential to revolutionize the field of artificial heart technology,” said Dr. Morgan. “Due to its smaller size, we can now treat patients who previously could not be treated with artificial heart technology and get them back to living a close to normal lifestyle.” The 50cc device is designed to fit patients, smaller in stature, with life-threatening non-reversible biventricular (both sides) heart failure. These patients are typically women and adolescents who do not have the body surface area (1.85m² or less) to receive the 70cc device. With as many as 100,000 people in the U.S. in need of new hearts and a little more than 2,500 receiving a transplant last year, the device is designed to be used either as a bridge to a donor heart transplant or for destination therapy,

which provides long-term support to patients who are not candidates for transplant. Similar to a heart transplant, SynCardia's Total Artificial Heart replaces both failing heart ventricles and the four heart valves. In most cases, SynCardia's heart restores blood flow, pumping up to 9.5 liters per minute, and eliminates complications associated with the patient's failing heart. This helps vital organs to recover faster and allows patients to be better transplant candidates when a donor heart does become available. As a result, patients usually see an improvement in their activity levels and overall quality of life.

Caption The new 50cc SynCardia Total Artificial Heart (TAH) is designed to fit patients, smaller in stature, with life-threatening non-reversible biventricular heart failure.

The recently implanted patient is "This device was instrumental a 55-year-old woman who previously in saving the patient’s life both by had a pacemaker. Other artificial heart eliminating the symptoms and source devices were too large for her. of end stage heart failure and acting as “This is an important step in the bridge to transplant in someone dying evolution of artificial heart devices,” from heart failure,” said the patient’s said James T. Willerson, MD, primary cardiologist Leo Simpson, President, THI. “We’re proud that MD, FACC, FHRS, FSCAI, Assistant THI continues to lead the way in such Professor, Baylor College of Medicine technology to help patients.” and Director of Interventional Heart Failure, Baylor St. Luke’s.

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Houston Medical Times

Memorial Hermann-Texas Medical Center Joins Forces with LifeGift to Address Nation’s Critical Shortage of Organs

NOW LEASING PHASE II

As part of an initiative by Memorial Hermann-Texas Medical Center (TMC) and LifeGift to address the growing national organ shortage by raising awareness for the mission while celebrating those who make the selfless decision to share the gift of life. Demand for organs has risen sharply in recent years, but the number of organ donors and organs transplanted has remained relatively stagnant in the past decade, creating a widening gap that has lengthened the waiting list for those who need lifesaving transplants. There are nearly 120,000 people across the nation on the waiting list for an organ transplant, and every 10 minutes, a new name gets added to the list.

the importance of organ donation,” said Dr. J. Steve Bynon, chief of abdominal transplantation at Memorial Hermann-TMC and McGovern Medical School at UTHealth, who gave remarks at Friday’s event. “As healthcare providers, we are committed to saving lives, and we are beyond grateful for the thousands of registered organ donors who help make that possible. We hope others who have not registered find it in their hearts this season to make the decision to join this important cause.” Dr. Bynon’s remarks were followed by a moving personal account from Karen Abercrombie, a Houston woman whose sister, Julie De Rossi, tragically perished in a car crash in 2004 and went on to save many lives through organ

Dozens of attendees gathered together at Memorial Hermann-Texas Medical Center to show off their Donate Life bracelets in honor of organ donation.

Some recipients wait months, even years, before a match is found. Sadly, 22 people lose their lives every day before receiving the call that could save them. In response to the growing national crisis, the U.S. Health Resources & Services Administration has called on hospitals to play a greater role in promoting donor registration. Memorial Hermann-TMC has responded to this request with a special tribute to organ donors, donor families and recipients that was unveiled to the public Friday morning in the hospital’s Rick Smith Gallery. The installment, called The Ultimate Gift, highlights the importance of organ donation through specially commissioned portraits of donors, donor families and recipients which will be on display for the next several weeks. In addition, Memorial Hermann-TMC hosted an event Friday with more than 150 employees, affiliated physicians, patients and visitors in attendance, demonstrating an impressive show of solidarity for the lifesaving power of organ donation. “I am so glad we can use the holiday season – the season of giving – as an opportunity to raise awareness about January 2017

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donation. A year and a half afterward, Abercrombie’s family discovered that De Rossi’s tissue donation – specifically her Achilles tendon – had benefitted NFL star quarterback Carson Palmer, who is now with the Arizona Cardinals. Since her sister’s death, Abercrombie has become a vocal advocate for organ and tissue donation. According to a Gallup Poll, nearly 95 percent of people surveyed say they strongly support organ donation, but only about 40 percent of eligible donors have actually registered in part because of the myths surrounding organ donation. In fact, most major religions support organ and tissue donation; organs can be donated at nearly any age; and organ and tissue recovery takes place only after all efforts to save a person’s life have been exhausted and death has been legally declared, according to LifeGift. “I’ve come to realize that there are so many misconceptions about donation that just aren’t true. Through my sister’s donation, upwards of 80 lives were either saved or enriched,” Abercrombie said. “Julie was bigger than life while she was living, and she has definitely outlived herself.”


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UTMB develops an oral vaccine against Salmonella Researchers from The University of Texas Medical Branch at Galveston have developed a vaccine against salmonella poisoning designed to be taken by mouth. The findings are detailed in an article published in Frontiers in Cellular and Infection Microbiology.

to wreak havoc on the digestive system.

“In the current study, we analyzed the immune responses of mice that received the vaccination by mouth as well as how they responded to a lethal dose of salmonella, said Ashok Chopra, UTMB professor of microbiology and immunology. “We In earlier studies, the UTMB found that the orally administered researchers developed potential vaccines produced strong immunity vaccines from three genetically mutated against salmonella, showing their cult intentionally contaminated versions of the salmonella bacteria, that potential for future use in people.” restaurant salad bars and sickened is Salmonella Typhimurium, that were There is no vaccine currently 1,000 people. shown to protect mice against a lethal available for salmonella poisoning. Salmonella is responsible for dose of salmonella. In these studies, Antibiotics are the first choice in one of the most common food-borne the vaccines were given as an injection. treating salmonella infections, but the illnesses in the world. In the US alone, However, oral vaccination is simplest and least invasive way to protect people against salmonella infection. Taking this vaccine by mouth also has the added advantage of using the same pathway that salmonella uses

January 2017

fact that some strains of salmonella are quickly developing antibiotic resistance is a serious concern. Another dangerous aspect of salmonella is that it can be used as a bioweapon – this happened in Oregon when a religious

the Centers for Disease Control and Prevention estimates that there are about 1.4 million cases with 15,000 hospitalizations and 400 deaths each year. It is thought that for every reported case, there are approximately

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39 undiagnosed infections. Overall, the number of salmonella cases in the US has not changed since 1996. Salmonella infection in people with compromised immune systems and children under the age of three are at increased risk of invasive non-typhoidal salmonellosis, which causes systemic infection. There are about one million cases globally per year, with a 25 percent fatality rate.


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Pharmacy Corner WHY ARE PRESCRIPTION DRUGS SO EXPENSIVE? A look at the factors behind why brand name drugs are expensive—and their price keeps rising By Christina Sumners

“Brand name drugs, due to the It’s no secret that the cost of high cost of their development, start prescription drugs—especially out expensive and then tend to go brand-name drugs—has been rising up in price every year,” said Lixian far faster than inflation over the last Zhong, PhD, assistant professor of few years. This high cost is one reason that some people aren’t taking the medication their providers prescribe for them. It’s not just people paying out of pocket who are affected. Although those with good insurance from their employer or elsewhere may feel the sting far less dramatically each time they pick up a prescription, those costs do eventually trickle out to everyone. Ultimately insurance companies or other payers shift some of the burden to patients in the form of higher co-payments or deductibles. pharmaceutical sciences at the Texas With prescription drug spending A&M Irma Lerma Rangel College of totaling an estimated $457 billion Pharmacy. “Combine this with other in 2015, it seems like a good time to factors affecting the industry, and you examine why these life-saving and life-improving medications cost so have ballooning prices.” much.

January 2017

up the cost of development—which can The cost of prescription drugs run more than $2.5 billion per drug, isn’t going up evenly across the board. according to a 2014 estimate. Therefore, the starting price of these drugs is quite In fact, the average price of a generic high. drug actually went down between 2010 Other drugs—especially the and 2015. However, the high initial and increasingly rising prices of brand so-called specialty drugs that treat name drugs, especially some specialty complex, chronic conditions—also treatment drugs, bring the overall tend to be very expensive. “For example, there is a drug to treat hepatitis C that average up. is much better than earlier treatments, “The most expensive drugs tend with a higher cure rate and fewer side to treat orphan diseases, those with effects,” Zhong said. “However, it also costs a great deal more than other hepatitis C drugs on the market.” Other expensive specialty medications include new drugs for treating cancer, rheumatoid arthritis, multiple sclerosis and other diseases. These easily cost more than $10,000 a year. overall average

The price of certain drugs drive up

Even expensive drugs can be cost-effective

a patient population of less than 200,000,” Zhong said. This makes a certain amount of sense: the fewer potential customers who will buy the drug before the patent expires, the fewer opportunities the company has to make

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That expensive hepatitis C drug— despite its staggering price tag of $90,000 for 12 weeks’ supply—could actually be cost-effective if it can keep people out of the hospital. “Because 90 percent of people who take the drug are cured, which is far higher than less expensive treatments, there might potentially be cost savings in terms of improved patient health,” Zhong said. see Pharmacy Corner page 18


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The Doctor’s Dilemma Continued from page 1

hypertension, diabetes, tobacco use, and a family history of coronary artery disease. An EKG was negative for acute changes. Lab studies included a normal CPK and minimally borderline troponin. The lipase was 1,455, and a diagnosis of acute pancreatitis was made. The epigastric pain improved, but the patient continued to report lower chest pain associated with chest palpation. Two weeks after discharge, he presented with an acute myocardial infarction.

Discussion

Primary care physicians see many patients with nonspecific symptoms of nausea and fever. Most of these patients have an acute and self-limited viral illness. However, complaints of acute visual loss are relatively uncommon in a general practice, and most primary care physicians do not have the training or equipment to properly evaluate those patients. This case illustrates overconfidence bias in which the physician appears to Discussion have failed to recognize the potential The physician correctly diagnosed significance of an unusual visual pancreatitis but, in retrospect, missed complaint, concentrating instead on subtle suggestions of myocardial the more common viral illness. ischemia, including a slightly elevated Case Four troponin and persistent, although A 45-year-old male, febrile, atypical, chest pain in the setting of with poorly controlled diabetes, multiple risk factors. The physician was admitted to the hospital with anchored on the single diagnosis of vomiting and weight loss. Blood pancreatitis, which led to premature cultures revealed gram-positive cocci closure of the diagnostic process. in chains. The patient was discharged Case Two A 60-year-old female presented to the internist with abdominal pain and rectal bleeding. She was referred to a gynecologist, who diagnosed a likely uterine fibroid on ultrasound. An endometrial biopsy was benign. Symptoms persisted, and several months later the internist ordered an abdominal CT scan that revealed a malignant rectal mass displacing the uterus. Discussion The internist appears to have been reassured by the gynecologist’s finding of benign pelvic disease. This is an example of premature closure, demonstrating that when the referral was made, the thinking stopped. Both patient and physician want pleasing outcomes, but a differential diagnosis— in this case, focusing on the common causes of rectal bleeding—would have probably led to a more timely diagnosis of rectal cancer.

on antibiotics before the final culture and sensitivity report was available, but he was readmitted a week later with hemodynamic decompensation and fever and diagnosed with mitral and aortic valve endocarditis. The results of the prior culture demonstrated Streptococcus viridans. He underwent valve replacement, developed severe left ventricular decompensation, and died from end-stage congestive heart failure before a heart transplant could be performed.

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Discussion This patient’s initial improvement appears to have led to another example of premature closure and optimism bias. It is, of course, essential to review final blood culture results and not make the assumption that the patient’s initial improvement is a predictor of a successful outcome. Case Five

A 59-year-old male admitted with abdominal pain was diagnosed with Case Three acute diverticulitis and treated with A 65-year-old female presented Garamycin, Avelox, and Flagyl. The with nausea, fever, and a dark area in patient was discharged on the same the visual field of the right eye. She three antibiotics without an order to was diagnosed with a viral infection. monitor serum gentamicin levels. Four days later, she presented to an Subsequent symptoms of vertigo were ophthalmologist with the loss of ultimately diagnosed as gentamicin central vision in the right eye and was vestibular toxicity. diagnosed with a retinal detachment, Discussion resulting in permanent loss of vision.

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see The Doctor’s Dilemma page 16

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The Doctor’s Dilemma Continued from page 15

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Traditional physician education has emphasized memorization and “thinking on your feet.” Stopping to consult with a reliable reference in the middle of rounds has not been part of that tradition. No clinician can possibly know all of the information required to practice medicine. There should be a low threshold for reviewing references to help with diagnosis and treatment—even for relatively common conditions such as diverticulitis. This case provides another example of overconfidence bias.

2017

Accurate diagnosis and treatment are often challenging—particularly in the context of time limitations and multitasking required in today’s practice environment. Having a better understanding of current theories on how to improve the diagnostic process may help clinicians reduce errors and improve outcomes.

Learn More Read the Internal Medicine Closed Claims Study at www.thedoctors.com/ internalmedicinestudy. Find Improving Diagnosis in Health Care at www.nap. edu/catalog/21794. Dr. Marcus is a board certified internal medicine physician who practices in Austin, Texas. He is chair of the Texas Alliance for Patient Access (a tort reform organization) and a member of and consultant to The Doctors Company Texas Advisory Board. Reprinted with permission. ©2017 The Doctors Company (www. thedoctors.com). This article originally appeared in The Doctor’s Advocate, fourth quarter 2016.

Legal Health

Continued from page 3

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check programs of prospective long-term-care employees and providers. OIG will determine the outcomes and consequences of state procedures implemented for long term care facilities and providers to conduct background checks on prospective employees who would have direct contact with patients. Hospices ∙ Review of Hospices’ Compliance with Medicare Requirements (New) - Hospice provides palliative care for terminally ill beneficiaries. When a beneficiary elects hospice care the hospice agency assumes the responsibility for medical care related to the beneficiary’s terminal illness and related conditions. OIG will review hospice medical records and billing documentation to determine whether Medicare payments for hospice services were made in accordance with Medicare requirements. Home Health Services ∙ Comparing Home Health Agency

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(“HHA”) Survey Documents to Medicare Claims Data (New) OIG will assess whether HHAs are accurately providing patient information to state agencies for recertification surveys to avoid scrutiny of potentially unqualified or fraudulent providers. SUMMARY The FY 2017 Work Plan outlines many of the OIG’s enforcement priorities and provides significant detail on the OIG’s audit and evaluation plans. Health care providers and organizations should use the FY 2017 Work Plan to identify potential risk areas to maintain an effective compliance program. Although the OIG will remain extremely active, an organization that understands the risk areas and prioritizes compliance goals may experience a decrease in government scrutiny and enforcement activity.

Mental Health

Continued from page 5 important to you, and live accordingly. 2. Be alert to red flags: Many physicians use their professional capacity to maintain emotional distance medicaltimesnews.com

to ignore their own feelings. Ignoring pain and distress, however, is like ignoring messages the brain is trying to convey to you, especially when see Mental Health page 18


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Mental Health

HOUSTON

Continued from page 16

3.

4.

5.

6.

the emotions warrant notice. Paying attention to signs of extended stress symptoms can prevent worsening difficulties and health problems. Take care of yourself: Often times when we are very stressed our good coping strategies fall by the wayside. Self-care is vital even in times of low stress. Eat right, get enough sleep, take a walk or do something else that rejuvenates you. Share your concerns with others: Knowing you’re not the only one stressed and talking through ways to reduce even minor stressors can help. Take time out from the situation: Give yourself permission to let problems go for a while. Allow time to rest, play, and relax. Tackle problems in small steps: Huge problems are made easier when broken

down. Taking things one day at a time helps ground us in the present, and keeps us from ruminating on future uncertainties or past regrets. 7. Know your limits: Knowing our limits allows us to protect our time, our interests, and our health. When demands mount, no one is going to send us home. We have to be our own advocate, and be willing to assert when enough is enough. If stress or anxiety is overwhelming, causing significant distress or impacting your daily functions at work or home, professional help may be needed. Granted, physicians are used to being in charge and solving others’ problems, but at Menninger we recognize that they are often very reluctant to seek help. Personal pride, feeling overly responsible, fears of stigma and embarrassment, and excessive independence all contribute to

difficulties with slowing down and fighting the ravages of stress. Preventing burnout is not a chance event. Physicians can fight back by recognizing signs of trouble early and regaining control again.

Published by Texas Healthcare Media Group Inc.

About the author: Psychologist Michael Groat is program director of The Menninger Clinic’s Professionals in Crisis inpatient program, which works with medical caregivers, executives, business owners, attorneys, administrators, and others in professions with high levels of responsibility. The professionals in the program suffer from the effects of psychiatric and/or addictive disorders, as well as stress or other personal health issues. The Menninger Clinic is a national psychiatric center for treatment, research and education, located on a new campus at 12301 Main St. southwest of the Texas Medical Center. Menninger is also a primary teaching hospital of Baylor College of Medicine.

Director of Media Sales Richard W DeLaRosa

Continued from page 6

cell populations and response in clinical trials. They will be dedicated to support immune monitoring during novel cancer immunotherapy, being essential for characterizing the immune status in patients receiving immune-modulating therapies such as levels of serum cytokine, cancer biomarkers on tumor samples, microenvironment, status of T cell activation, Natural Killer cells (NK), presence of immunosuppressive

profile – T regs and MDSC (Myeloidderived suppressor cell) and some molecules like IDO (indoleamine 2,3 dioxygenase), Galectin among others. A harmonized struggle to assess the value nongenetic biomarkers that address different aspects of the cancer-immunity cycle in T cell checkpoint blockade will allow us to integrate information on individual aspects of tumor-immune interaction.

Pharmacy Corner Continued from page 14

“When you consider the cost of the average hospital stay—which varies by state but easily runs several thousand dollars per night—then $90,000 to cure a patient doesn’t seem as extreme.” The listed price isn’t what people actually pay Very few patients actually pay the “sticker” price of a drug. Many people have insurance, and insurance companies manage their own costs by negotiating with the drug companies. The pharmaceutical manufactures themselves often have patient assistance programs that cover much or all of the cost for those people without insurance. January 2017

Many also offer vouchers or coupons to reduce the out-of-pocket cost of the drug for people who have coverage. Americans subsidize the cost of drug development “We cannot look at this problem without looking at the whole health care system, which is fragmented in the United States with many different payers,” Zhong said. “Countries with a single-payer system tend to have more negotiating power, so we pay more than other countries, often by quite a bit. On the other hand, those countries may limit the access to new medications due to economic concerns.” The end

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Oncology Research expression and clinical response. In another study tumor samples with PD-L1 positive had an objective response rate of 36% (9 of 25 patients) whereas tumors with PD-L1 negative didn’t show any objective clinical response (0 of 17 patients). From now on, it is going to be more often the presence of specialized laboratories doing translational research – studies of cellular immunity including assays of

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result is that Americans have access to the newest treatment but also pay a higher price to subside the cost of drug research and development, a lengthy and inherently risky process that involves preclinical research and three phases of increasingly large and expensive human clinical trials. “Pharmaceutical companies spend lots of money on research,” Zhong said. “Only the very lucky drugs make it through the entire process and get on the market, where they can both treat patients and recoup some of their development costs.”

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