Good Health And Wellness For Life

The Nation: Sending Back the Doctor’s Bill

HOW to fix the health care system?

Easy, liberals say. If Washington would just force cuts in prescription drug prices and insurance company profits, plenty of money would be left over to cover the uninsured.

Conservatives prefer to argue that the answer lies in forcing people to pay more of their own medical costs.

But many health care economists say both sides are wrong. These economists, some of whom are also doctors, say the partisan fight over insurers and drug makers is a distraction from a bigger problem: the relatively high salaries paid to American doctors, and even more importantly, the way they are compensated.

“I always find it ironic that when I go to doctor groups and such, they always talk about the cost of prescription drugs,” said Dana Goldman, director of health economics at the RAND Corporation, a nonprofit research institute in Santa Monica, Calif.

Prescription drugs cost, on average, 30 percent to 50 percent more in the United States than in Europe. But the difference in doctors’ salaries is far larger, Dr. Goldman said.

Doctors in the United States earn two to three times as much as they do in other industrialized countries. Surveys by medical-practice management groups show that American doctors make an average of $200,000 to $300,000 a year. Primary care doctors and pediatricians make less, between $125,000 and $200,000, but in specialties like radiology, physicians can take home $400,000 or more.

In Europe, however, doctors made $60,000 to $120,000 in 2002, according to a survey sponsored by the British government in 2004.

Given the years of training that doctors require and the stress and importance of their jobs, few would disagree that they should be well paid. In addition, with a year of medical school now about $30,000, many doctors leave school deeply in debt. And many doctors would argue that cutting salaries would only persuade talented, college graduates to pursue better-paying professions.

Still, the lower salaries are a significant part of the reason that European countries spend less on health care than the United States does — a fact liberals avoid mentioning when they preach the advantages of a European-style single-payer system.

Americans generally do not seem to mind the fact that doctors are well paid. In public opinion surveys, doctors usually rank as the most trusted professionals. Congress has repeatedly blocked Medicare’s efforts to reduce the amount it pays for each procedure doctors perform, even though overall Medicare payments to doctors are soaring and the cuts are legally required to keep the program’s budget balanced.

The way that doctors are paid may be an even more significant factor driving up costs and may lead to unnecessary care, said Dr. Peter B. Bach, a pulmonary physician at Memorial Sloan-Kettering Cancer Center and a former senior adviser to Medicare and Medicaid.

In the United States, nearly all doctors are paid piecemeal, for each test or procedure they perform, rather than a flat salary. As a result, physicians have financial incentives to perform procedures that further drive up overall health care spending.

Doctors are paid little for routine examinations and very little for “cognitive services,” such as researching different treatment options or offering advice to help patients get better without treatment.

“I don’t have a view on whether doctors take home too much money or not enough money,” Dr. Bach said. “The problem is the way they earn their money. They have to do stuff. They have to do procedures.”

Primary care doctors and pediatricians, who rarely perform complex procedures, make less than specialists. They are attracting a declining percentage of medical students, and some states are facing a shortage of primary care doctors.

Doctors are also paid whether the procedures they perform go well or badly, Dr. Bach said, and whether they are crucial to a patient’s health or not..

“Almost all expenditures pass through the pen of a doctor,” he said. So a doctor may decide to perform a test that costs a total of $4,000 in order to make $800 for himself — when a cheaper test might work equally well. “This is a highly inefficient way to pay doctors,” Dr. Bach said.

Medicare, especially, does not like to second-guess doctors’ clinical decisions, said Dr. Stephen Zuckerman, a health economist at the Urban Institute. “There’s not a lot of utilization review or prior authorization in Medicare,” he said. “If you’re doing the work, you can expect to get paid.”

As a result, doctors have steadily increased the number of procedures they perform on Medicare beneficiaries — and thus have increased their income from Medicare, Dr. Zuckerman said. But the extra procedures have not helped patients’ health much, he said. “I don’t think there’s any real strong evidence of improvements in health status.”

Private insurers like H.M.O.’s are more aggressive than Medicare in second-guessing physicians’ clinical decisions, and they will refuse to pay for imaging scans or other expensive new procedures. Now Medicare and private insurers are moving cautiously to change the current system. Recently, they have proposed pay-for-performance measures that would give doctors small bonuses if their care meets the standards set by national medical organizations such as the American Heart Association.

BUT all those measures are a minor fix, said Dr. Alan Garber, a practicing internist and the director of the Center for Health Policy at Stanford University. Instead, he argues, the United States should move toward paying doctors fixed salaries, plus bonuses based on the health of the patients they care for.

Even in the existing system, some health insurers, notably Kaiser Permanente, already have large networks of salaried doctors. But it would require doctors to give up some of their autonomy and move into larger group practices or work directly for insurers, a step they have been reluctant to take. About 40 percent of doctors are in single or two-physician practices, Dr. Garber said.

Nor is the American Medical Association, which represents doctors, eager for wholesale changes in the system, said Dr. Edward L. Langston, chairman of the A.M.A. board.

Insurance company profits and the rising cost of preventable diseases like diabetes are big culprits in soaring health care spending, Dr. Langston said.

But Dr. Goldman of RAND said that doctors are misleading themselves if they think the current system serves patients’ needs.

For example, if a diabetic patient visits a doctor, he said, “the doctor is paid to check his feet, they’re paid to check his eyes; they’re not paid to make sure he goes out and exercises and really, that may be the most important thing.”

“The whole health-care system is set up to pay for services that are rendered,” he said, “when the patient, and society, is interested in health.”

Senator Attacks Health Agency Director on Personal Spending

A National Institutes of Health director spent millions of agency dollars for his laboratory at the institute and continued as an expert consultant in asbestos cases despite conflict-of-interest rules discouraging that, Congressional investigators have said.

The director, Dr. David A. Schwartz, was recruited in 2005 to lead the agency, the National Institute of Environmental Health Sciences. He spent $6 million last year on his laboratory despite agreeing when he was hired to limit such spending to $1.8 million, according to a letter sent to the agency on Wednesday by Senator Charles E. Grassley, Republican of Iowa.

Mr. Grassley, ranking Republican on the Senate Finance Committee, is investigating the case. The $4.2 million would have usually financed other laboratories at the institute.

Dr. Schwartz continued as an expert witness long after joining agency, Mr. Grassley wrote.

The accusations are part of a Congressional inquiry that The Washington Post reported in detail last month. An ethics inquiry by the agency found that Dr. Schwartz had improperly asked staff members to run personal errands for him and had improperly billed the government for personal items.

A spokesman for the institutes, John Burklow, said that it had withdrawn its permission for Dr. Schwartz to consult with law firms and that Dr. Schwartz had stepped down from running his laboratory, resigned his faculty position at Duke University and repaid unauthorized office and travel expenses.

In a statement, Dr. Schwartz said, “I firmly believe that I have acted ethically and in the best interests” of the health institute. He said he was working to resolve “the issues raised.”

Months before he started at the agency, it adopted strict conflict-of-interest rules that severely limit consulting by scientists and administrators. The rules discourage scientists from undertaking outside activities that appear to promote or take advantage of their government posts.

Transcripts of court testimony obtained by Mr. Grassley’s office appear to show that lawyers often referred to Dr. Schwartz’s government post when asking him questions. In his letter, Mr. Grassley said Dr. Schwartz might have failed to recuse himself from financing decisions involving scientists with whom he was collaborating.

Dr. Schwartz delayed joining the health institutes in 2005 in part, he said at the time, because of concerns that the new ethics rules would make recruiting top scientists more difficult. Opponents of the new rules cited the delay as proof that the rules would hurt the agency.

Recalled Canned Foods Continue to Be Found on Grocery Shelves

WASHINGTON, July 27 (AP) — Stores continue to sell recalled canned chili, stew, hash and other foods potentially contaminated with poisonous bacteria even after repeated warnings.

Thousands of cans are being removed from shelves as quickly as investigators find them, more than a week after Castleberry’s Food began recalling more than 90 potentially contaminated products over fears of botulism.

The recall now covers two years’ and tens of millions of cans from a factory in Augusta, Ga. Spot checks by the Food and Drug Administration and state officials continue to find recalled products for sale in convenience stores, gasoline stations and family-run groceries, from Florida to Alaska. The agency has found the items in 250 of the more than 3,700 stores visited, according to figures the agency gave to The Associated Press.

In states like North Carolina, more than one in three stores checked by state officials in recent days continued selling recalled products. Officials there pulled 5,500 cans.

“We’re not going to quit,” said Joe Reardon, who oversees food protection for the state’s Department of Agriculture and Consumer Services. “These numbers are too high.”

Four people have become ill and were hospitalized because of the contaminated food, according to the Centers for Disease Control and Prevention. California health officials are investigating whether botulism confirmed in a San Diego County woman was linked to the recall. The woman reported eating a Castleberry’s product before falling sick this month.

“Frankly, the fact we have had only four illnesses in this situation has people saying, ‘Well, what is the big deal?’ ”said Dr. David Acheson, the food agency’s lead food safety expert, said before the news of the possible California case. “The deal is this is something that can land you in the I.C.U., not being able to breathe, for weeks.”

Federal investigators theorize that Castleberry’s, a unit of Bumble Bee Seafoods, failed to cook properly some or all the products, letting the Clostridium botulinum bacteria survive canning. In the oxygen-free and moist environment of the sealed cans, the bacteria thrive and produce a toxin that causes botulism, a paralyzing disease.

The bacteria produce gases that can cause contaminated cans to swell and burst. Cans in a company warehouse have begun to break open. Health officials say the extremely potent toxin can infect people if it is inhaled, swallowed or absorbed through the eye or skin breaks.

Health experts consider botulism a severe health threat and worry that word of the recall has not reached all consumers or retailers, especially mom-and-pop operations.

“It has been a problem getting the message out,” Lynae Granzow, an epidemiologist with the Indiana Health Department, said. “We’re having a problem reaching the smaller stores.”

In Massachusetts, health inspectors found recalled products in fewer than 50 small stores, mostly in the Boston metropolitan region, a spokeswoman for the state’s Public Health Department, Donna Rheaume, said. Spot checks in Alaska, Florida, Indiana, Kentucky, Montana, New York and elsewhere have also found the recalled products on shelves.

Castleberry’s has hired a company to collect the recalled products and has posted a complete list of recalled products, including some dog foods, at www.castleberrys.com/news_productrecall.asp.

People who have any recalled product at home should double bag it and throw it away, the food agency recommends.

Medtronic to Buy Spinal Device Maker

Medtronic, a major medical device maker, said yesterday that it had agreed to purchase Kyphon, which sells a minimally invasive therapy for spinal compression and fractures, for $3.9 billion.

The companies said that Medtronic would also become responsible for an additional $320 million allocated to fulfilling the terms of Kyphon’s acquisition of two smaller device companies.

Kyphon makes a catheter that is inserted where a segment of backbone has collapsed from injury or illness. A balloon is then inflated to restore the bone to a more normal position. Once the space is created, the balloon is withdrawn and cement is inserted to keep the bone in place while the patient heals.

Kyphon reported yesterday that sales in its second quarter this year reached $144.3 million, more than 40 percent higher than a year ago. About half the growth came from its vertebral compression procedure, which is called kyphoplasty, and half from the acquisition in January of St. Francis Medical Technologies, which developed a spacer that reduces pressure on diseased spinal disks and the surrounding bone.

Medtronic’s offer for Kyphon, in cash and assumed debt, values the company at $71 a share, a 32 percent premium over the closing price on Thursday of $53.68. Kyphon’s shares rose $12.92, to $66.60. Shares of Medtronic fell 11 cents, to $50.81.

The deal is expected to close early next year. In addition to reinvigorating Medtronic’s spine subsidiary, which has slowed to single-digit sales growth this year, the deal is seen by some analysts as a harbinger of a new wave of acquisitions in the medical device industry.

Medtronic is one of several major device makers that led consolidation in the cardiovascular device industry. It continues to generate big profits from products like implantable defibrillators, but growth rates in the cardiovascular business have plunged from the mid-20s to about 7 percent in recent years, said Thomas J. Gunderson, who follows the industry for Piper Jaffray & Company in Minneapolis. Hence, Mr. Gunderson said, Medtronic and cardiovascular rivals like Johnson & Johnson have both the incentives and the cash to go on a shopping spree for smaller, faster-growing device companies.

Even before the Kyphon deal was announced, Lawrence Biegelsen, who follows devices in New York for Wachovia Capital Markets, had singled out spine products as an area ripe for consolidation. He noted that leaders like Medtronic and the DePuy subsidiary of Johnson & Johnson were losing market share to smaller companies,

Medtronic entered the spine business when it acquired Sofamor Danek for $3.3 billion in 1999. Its current spinal products are sold primarily to middle-age patients with problems like scoliosis and degenerating disks. Kyphon, by contrast, has focused mostly on elderly patients since it was founded in 1994. It has also cultivated ties to thousands of spine specialists trained in radiology who operate with catheters rather than traditional surgical tools — a group that Medtronic has so far rarely approached with its products.

The deal would mean an end to patent litigation between the two companies that some analysts had predicted Medtronic would lose. “I think that’s the main reason for this acquisition,” said Alexander K. Arrow of Lazard Capital Markets. “Medtronic has been trying for five or six years to get around Kyphon’s intellectual property. This was the one patient niche in spine they couldn’t get into.”

Arthur D. Collins Jr., chairman and chief of Medtronic, denied in an interview that Kyphon’s patent position had been a major driver of the deal. Medtronic said the deal would not add to its profits before the fiscal year ending in April 2009.

Richard W. Mott, Kyphon’s president and chief executive, said that joining Medtronic would be particularly helpful in expanding kyphoplasty in overseas markets like Japan, where Kyphon has just completed clinical trials, but has few employees. He said Medtronic would help draw attention to the problem of vertebral compression, which can cause pain, numbness or tingling, weakness and urinary problems.

“More than half of the people suffering compression from osteoporosis are undiagnosed,” Mr. Mott said. “We don’t have the resources to reach a lot of them.”

Swabs in Hand, Hospital Cuts Deadly Infections

PITTSBURGH — At a veterans’ hospital here, nurses swab the nasal passages of every arriving patient to test them for drug-resistant bacteria. Those found positive are housed in isolation rooms behind red painted lines that warn workers not to approach without wearing gowns and gloves.

Every room and corridor is equipped with dispensers of foamy hand sanitizer. Blood pressure cuffs are discarded after use, and each room is assigned its own stethoscope to prevent the transfer of microorganisms. Using these and other relatively inexpensive measures, the hospital has significantly reduced the number of patients who develop deadly drug-resistant infections, long an unaddressed problem in American hospitals.

The federal Centers for Disease Control and Prevention projected this year that one of every 22 patients would get an infection while hospitalized — 1.7 million cases a year — and that 99,000 would die, often from what began as a routine procedure. The cost of treating the infections amounts to tens of billions of dollars, experts say.

But in the past two years, a few hospitals have demonstrated that simple screening and isolation of patients, along with a relentless focus on hygiene, can reduce the number of dangerous infections. By doing so, they have fueled a national debate about whether hospitals are doing all they can to protect patients from infections, which are now linked to more deaths than diabetes or Alzheimer’s disease.

At the Veterans Affairs hospital in Pittsburgh, officials say the number of infections with a virulent bacterium known as methicillin-resistant Staphylococcus aureus, or MRSA, dropped to 17 cases last year from an average of 60 before the program started. The 40-bed surgical unit that began the experiment in 2001 has cut its infection rate by 78 percent.

Such results are not unprecedented. Several European countries, including the Netherlands and Finland, have all but eliminated MRSA through similarly aggressive campaigns. But at many American hospitals, experts say, high infection rates have been accepted as a cost of doing business. Barely a quarter of American hospitals screen patients for bacterial colonies in any methodical way, a recent survey found.

“People don’t believe it’s in their institution, and, if it is, that it’s too big to do anything about, that you just have to accept it,” said Terri Gerigk Wolf, director of VA Pittsburgh Healthcare Systems. “But we have shown you can do something about it.”

Three state legislatures, including Pennsylvania’s, broke ground this year by passing bills to require that hospitals routinely test high-risk patients, like those in intensive care units. But some infection-control experts warn that such regulations may have unintended consequences, including lesser care for patients who linger in isolation. Studies have found that patients in isolation are seen by hospital staff members half as frequently and tend to suffer more from falls, bed sores and stress.

Dr. John A. Jernigan, a MRSA expert at the disease control agency, said there was “a legitimate scientific debate” about whether hospitals should devote precious resources to screening every patient.

“It is a daunting problem, and it has been a recalcitrant problem,” Dr. Jernigan said. “We’re starting to see encouraging results. But I think we’ve been so stuck in this argument about what works and what doesn’t that people have not put programs in place.”

The problem of infections in hospitals is growing. MRSA has been a particularly troublesome pathogen since its emergence in the United States in 1968. Resistant to a number of antibiotics, it can cause infections of surgical sites, the urinary tract, the bloodstream and the lungs, leading to extended hospital stays.

MRSA can be brought into hospitals by patients who show no symptoms, and it then thrives in settings where immune systems are weakened and where incisions provide inviting ports of entry. It now accounts for 63 percent of hospital staphylococcus infections, up from 22 percent in 1995.

Johanna Sullivan Daly, a 63-year-old Brooklyn woman, developed MRSA and other infections after surgery to repair a broken shoulder in 2004, said one of her daughters, Maureen J. Daly. Ms. Daly said that just before her mother’s discharge from a Manhattan hospital, she watched a doctor remove her dressings with bare, unwashed hands.

Five days later, her mother developed intense pain and they went to have her wound examined. “When the dressing came off,” Ms. Daly said, “I saw this — I can’t describe the smell, it was the foulest thing — just this greenish fluid coming out of her arm, oozing and oozing.”

Soon after, her mother developed a high fever and then lost the ability to move her limbs, Ms. Daly said. She spent several months on a ventilator before dying in a nursing home. The hospital bill came to $600,000 for what was to have been a $40,000 procedure.

“I have lost friends to breast cancer, to AIDS, to car accidents, to things we don’t have answers to,” she said. “That I lost my mother to someone not washing their hands or cleaning a hospital room properly is disgusting to me.”

The disease control agency projected seven years ago that the added annual cost of treating infected hospital patients was nearly $5 billion. Now officials there believe it may approach $20 billion, or 1 percent of the nation’s $2 trillion health care bill. Other experts put the number above $30 billion.

As at other hospitals experimenting with rigorous controls, the Pittsburgh veterans hospital has found that preventing infection is cost-effective.

Dr. Rajiv Jain, the hospital’s chief of staff, said its infection control program cost about $500,000 a year, including test kits, salaries for three workers and the $175-per-patient expense of gloves, gowns and hand sanitizer. But the hospital, which has a $431 million budget, realized a net savings of nearly $900,000 when the number of infected patients fell, Dr. Jain said.

The V.A. began phasing in the program at each of its 140 acute-care centers in March.

Dr. Richard P. Shannon, who championed a program to reduce catheter infections at Allegheny General Hospital in Pittsburgh, was able to show administrators that the average infection cost the hospital $27,000. He demonstrated that reimbursement payments for weeks of extended treatment were not keeping pace with actual costs. “I think it was assumed that hospitals didn’t mind treating these infections because they were getting paid for it,” Dr. Shannon said.

A major emphasis at the Pittsburgh hospitals has been hand hygiene. Studies have consistently shown that busy hospital workers disregard basic standards more than half the time. At the veterans hospital, where nurses have taken to pushing elevator buttons with their knuckles, annual spending on hand cleaner has doubled.

State governments, which reimburse hospitals for infection-related costs through Medicaid and other insurance programs, have taken notice and are beginning to impose new mandates.

Eighteen states now require hospitals to publish their infection rates. Last month, legislatures in New Jersey and Illinois approved bills that would make those states the first to require hospitals to screen all intensive-care patients for MRSA.

Here in Pennsylvania, Gov. Edward G. Rendell recently signed a bill requiring MRSA screening of certain high-risk patients. Mr. Rendell did not, however, win legislative approval to end state reimbursements to hospitals for the treatment of infections and to test all hospital patients for drug-resistant bacteria.

It is the screening and isolation of patients that draws the most debate. Screening presents an upfront cost for hospitals, and administrators worry that keeping patients in isolation will further clog emergency rooms and reduce the quality of care. Some researchers believe that improving hygiene and surgical practices alone may be equally effective.

In guidelines released last year, the centers recommended that other precautions be taken first and that hospitals resort to screening high-risk patients if they cannot otherwise reduce their infection rates. The guidelines are endorsed by the American Hospital Association, which believes that hospitals must be able to tailor plans to varying needs.

Others do not see the issue that way. Betsy McCaughey, who became a hospital infection crusader after serving as the New York lieutenant governor, said it was paradoxical that the centers encourage hospital screening for H.I.V. but not for bacterial infections, which are associated with seven times as many deaths. Ms. McCaughey said the agency “is largely to blame” for the failure to contain drug-resistant organisms.

“Their lax guidelines,” she said, “have given hospitals an excuse to do too little.”