Lab Soft News

FDA Launches New Patient Network Website; Useful Resource for Clinical Trials

Here is some very big news. The FDA has just launched a patient network website (see: The FDA Patient Network Website - Pretty Darn Patient-Centered). Here are the details: 

The twin goals for this website are promoting the educational mission of the FDA, and promoting opportunities for patient advocacy within the FDA — and earlier in the policymaking process than has been the case historically....[A spokesperson described it in the following way:]“The idea is to engage the patient community, to have the patient voice heard at the FDA....The FDA Safety & Innovation Act (enacted in mid-2012) mandates the involvement of patient representatives in roles beyond those of the advisory committees. Draft procedures for patient involvement are due to be made public in September of this year....Unlike opportunities for patient involvement in other government agencies, the FDA recognizes patient representatives on advisory committees (and in the new roles) as consultants....and this means that patients involved in the FDA processes in an official capacity are paid for their time and expenses. Aside from this new program, the website really just puts a patient-friendly face on an existing set of resources — clinical trials, investigational products, and more — but the improvement is quite welcome.

Long overdue is the feature of the FDA site that provides a much clearer advice for patients regarding participation in clinical trials. Previously, most of this was in the hands of treating physicians. As I was browsing the various links in the clinical trials section of the FDA patient network website, I came across the following information regarding what a patient should think about before joining a clinical trial:

Before joining a clinical trial, it is important to learn as much as possible. Discuss your questions and concerns with members of the health care team conducting the trial. Also, discuss the trial with your health care provider to determine whether or not the trial is a good option based on your current treatment. Be sure you understand:

• what happens during the trial
• the type of health care you will receive
• any related costs once you are enrolled in the trial
• the benefits and risks associated with participating. 

Very succinct advice and also very important and relevant. As a former member of an IRB, I can attest to the fact that each of these bulleted points is critical and worthy of extensive conversation before joining a clinical trail. I encourage all patients with serious disease to utilize the FDA patient web site and not remain totally depend on their physicians' advice for consideration and admission to clinical trials. I am also impressed by the fact that the FDA has developed this web site in what seems to be a patient-friendly way and tried to avoid too much bureaucratic and regulatory jargon.

Medicare Officials Post Hospital Prices; A Step in the Right Direction

I am a supporter of greater transparency in hospital pricing. Unfortunately, the way hospitals price their services is so out of kilter that this will be a difficult goal to achieve (see: Why Medical Bills Are Killing Us). Nevertheless, we need to be encouraged by some small steps in the right direction. A recent article reported that Medicare officials have now posted prices for 3,000 hospitals on the web to raise consumer awareness (see: Medicare Officials Post Prices of 3,000 Hospitals in Effort to Raise Consumer Awareness of Arbitrary Hospital Pricing). Below is an excerpt from the article:

For the first time ever, a federal agency has posted on the Internet the prices hospitals charge for healthcare services specifically to help consumers price shop when they select a hospital see: Medicare Provider Charge Data). This is a major development and has direct implications for clinical laboratories and pathology groups that are based in hospitals and health systems.....This is the latest step forward on the march toward full transparency in the prices and outcomes of individual hospitals, physicians, and other providers, including medical laboratories. It is also another early warning to pathologists and clinical laboratory managers that they would be well-served to prepare for the day when the majority of consumers will expect labs and pathology groups to make lab test prices easy to find and understand....Some healthcare experts were quick to point out that this hospital price data has little value for consumers already covered by a health insurance policy. That’s because the prices posted on the Internet by HSS are largely the maximum price point from which hospitals negotiate discounts with government health programs and private health insurers....However, for patients who may need to pay cash and for patients with high-deductible health plans, access to hospital prices in advance of treatment is expected to help them negotiate more favorable rates. In turn, this would help to hold down the cost of healthcare.

....[O]ver time, pricing transparency may also have a “shaming” effect on providers, who are finding it increasingly tougher to answer questions from consumers about pricing disparities. Studies show that when consumers are exposed to data on higher prices, they reduce their use of medical care by about 40%....Even when patients do require emergency care, there is often room for negotiating price with hospitals and other providers,....[Emergency department] patients always ask for an itemized bill and try to negotiate charges, because they just might succeed. Healthcare experts predict a coming era of consumer-driven healthcare that will result in more competitive pricing for medical services. This trend is emerging due to growth in lower-cost health plans with higher copays and deductibles, along with an array of inexpensive wireless medical technologies entering the marketplace that are capable of performing accurate clinical laboratory and imaging tests. ....Clinical laboratory managers and pathologists can expect that there will be Medicare program officials who will want to post the prices of individual physicians and ancillary providers, including radiology groups, pathology groups, and clinical laboratories....Since Medicare officials have established the principle of putting provider price data on the Internet, it is likely they will continue to release the prices charged by other types of healthcare providers.

I think that the takeaway lesson from all of this is that the principle of hospital pricing transparency is slowly being established. The need to negotiate prices with hospital officials is most relevant currently for self-pay patients and for those with high-deductible health policies (see: High Deductible Health Insurance Plans Becoming the Norm in Large Companies; High Deductible Health Insurance Plans; Discount on Initial Services?; Hospitals in California Offer Steep Discounts to Uninsured Patients).

I think that it's possible that increased transparency in the cost of lab testing may also give a boost to direct access testing (DAT) -- the ordering of lab tests on-line by consumers themselves. This can be accomplished in about half the states without a physician test order. The cost of such tests is only a fraction of what is charged in most hospitals, clinics, and physician offices.

For me, the most important reform in hospital pricing transparency would be for hospitals to forced to provide an itemized, understandable bill for their services, which is the norm in every other service industry in the country. Imagine, for example, if a waiter in a restaurant provided a customer only with the total amount owed at the end of a meal with no itemization of the individual dishes that were consumed. Such a restaurant would be out of business in short order. The same thing needs to happen for hospitals.

Informed Consent as it Relates to Reporting Genomic Results to Patients

The question of how and when to report genomic results to patients and informed consent relating to such results is becoming much more complicated and controversial (see: Patients Should Always Receive Their Genomic Information According to Recent Report). This previous note made reference to a statement by the American College of Medical Genetics and Genomics (ACMG) suggesting that patients should always have access to their genomic information. However, the consenting of genetic testing and the return of these results is much more complicated than normal lab testing. This point was emphasized in a recent article (see: Returning Genetic Incidental Findings Without Patient Consent Violates Basic Rights, Experts Say). An excerpt of it is presented below:

Genetic testing has long required patient consent and patients have had a "right not to know" the results. However, as 21st century medicine now begins to use the tools of genome sequencing, an enormous debate has erupted over whether patients' rights will continue in an era of medical genomics....In a [recent] paper..., [the authors] push back against...[the ACMG] recommendations [that patients always have a right to review genomic results], and offer compelling reasons why patient autonomy must remain firmly in place as science advances...."There are many circumstances in which a patient may decline such testing and information, even if the results could open avenues for intervention. The patient may already be battling another disease, such as advanced cancer, or be late in life and see more burden than benefit in added genetic information. The patient may also fear that 'extra' results in their medical record will invite risk of discrimination."....The authors cite long-standing policy discouraging childhood testing for adult-onset conditions. "Delaying testing and return of genetic information not medically useful in childhood allows the child to reach adulthood and then make a choice based on his or her own values...."As the list [of possible genetic tests] expands, so will the scope of testing without consent…."The authors urge the importance of patients' rights, especially in an era of genome sequencing when extensive genetic information can be generated on any patient.

There is certainly no question that a patient has the right to refuse the performance of genomic testing for whatever reason in the first case because of patient autonomy. A second, and perhaps more interesting question. is whether a patient has the right to selectively receive only a portion of the results of such testing. In its consent form, the consumer genetic testing site 23andMe states that the client, once consenting to genomic testing preformed on his oral mucosa cells, does not have the right to refuse to be informed of any of the test results. I can envision a situation, for example, where the client would stipulate the following to the company: inform me about X and Y but do not report any negative health results. This would be a data management nightmare for the company and it appropriately refuses to do so.

Here's what I envision as one of the major problems of patient consent for genomic testing from the perspective of patient autonomy. Many patients, having given consent for genomic testing and the reporting of such results, will not have a firm grasp of exactly what he or she is consenting to. As in the case of 23andMe, such reporting can't be limited solely to good news. So the concept of informed consent, as we understand it, may not be relevant for genomic testing. It is often impossible to "inform" the patient of the potential significance of all of the information that can be measured and interpreted with a DNA sample. We need to replace the idea of informed consent for genomic testing with some new concept that takes into consideration that much of the significance of DNA testing, both now and in the future, is "unknowable" and therefore can't be consented to in the normal way to by a patient.

The Institutionalization of Healthcare; Consequences of Big Medicine?

I posted a note five days ago about how the cost of healthcare seems to be gradually declining (see: Decrease in Healthcare Costs May Persist as Economy Revives). A reader, Ajit Alles, responded with a comment that decreasing expenditures of health my result in a lower quality of care, which I responded to in another note (see: The Correlation between the Cost of Care and the Health of a Population). He has responded to this second note with the following comment:

As follow-up, I agree that we spend way too much on end of life care, but that won't be reduced without a cultural shift. People expect miracles from medicine based on what they hear on the news and see in TV dramas. We could spend less and get better results, but people have to first start accepting that modern healthcare has limitations, not the least of which is funding. The new push for genomic healthcare is a good example of unrealistic ideas being pushed for profit. If everyone thinks that they are going to get personalized gene targeted healthcare they are dreaming! I know I'm a curmudgeon in this regard, but we first need to have good basic healthcare before we get cadillac genomics....We in for-profit medicine must share the blame for pushing "new and improved" medicine that is unaffordable and only (marginally) benefits the few people who can afford it. I recently heard of a family that wants some genomic test done on their child with cancer. The test looks at sequence variation in multiple genes and provides a "report" of very limited utility since most of the variations have no specific treatment. The test costs about $25000 and is not covered by insurance ....The family can afford to pay for this so it's being done with the encouragement of the oncologist. There are others who peddle proteomics reports to desperate patients. Enough said. This is the road to ruin.

I would like to respond specifically to his suggestion that "[those of us] in for-profit medicine must share the blame for pushing new and improved medicine that is unaffordable and only (marginally) benefits the few people who can afford it." I agree that many providers participate in "for-profit" medicine. However, the nature of the healthcare enterprise is now changing to what has been called "Big Medicine" or "Big Med" (see: Physician Private Practice Declines; the Last Barrier to Emergence of "Big Medicine"; The Transition to "Big Med": Need for Emphasis on Standardization and Cost; Health Systems Use Their Regional Dominance to Muscle Insurance Companies). With the rapid decline of private physician practices, many of the key decisions about the future of healthcare will be made by the federal government, large hospital systems, health insurance companies, and Big Pharma. So while we indeed have a for-profit health system in this country, most of the resources will flow from institutions like the federal government and health insurance companies to large institutions like large hospital systems. The great majority of physicians will be hospital employees. I refer to this as the institutionalization of healthcare delivery. We need to better understand the consequences of this shift.

I think that this change will have a major effect on the incentives experienced by physicians. In previous notes, I have made the point that cancer patients receive better care if the treating oncologist is salaried and does not benefit directly from selecting the most expensive treatment. This idea becomes apparent, as one example, in the treatment of ovarian cancer patients where a private oncologist is incentivised to maximize revenue from patient "chair time" whereas salaried academic oncologists seem to be more inclined in select the preferable intraperitoneal infusion of chemotherapeutic agents (see: Patients with a Cancer Should Seek Treatment in Cancer Hospitals). This is the best therapy but complicated and with lengthy patient visits. Here's are a couple of additional articles about how oncologists are compensated for additional reading (see: Will the Sequester Cause Oncologists to Lose Money Prescribing Chemotherapy?; Who Pays Your Oncologist?).

For private oncologists, the so called "oncology concession" goes to their group practice and they themselves directly benefit financially from their clinical decisions (see: The Oncology Concession Under Attack by Health Insurance Companies). For a salaried oncologist, the "oncology concession" goes to the hospital whose executives may choose to pay their oncologists the internist market salary, retaining the difference. The hospital may then choose to reward its executives at a higher level for developing a bigger cancer center (see: Cancer Business Highly Remunerative for Sloan-Kettering Executives).

I believe that health system executives will be more highly compensated and physicians will be less so as a result of institutionalization. After all, it is the executives who are making macro compensation decision and it would be natural for them to reward themselves. Moreover, these same executives will also have critical decision-making power in terms of how "new and improved" medicine is delivered. I believe that most of decisions will be based on how such care is compensated by the various institutional payers.

Welcome to the World of Pseudo-Academia: Pathology-2013

A recent article detailed a conference and journal scam that is being foisted on gullible academics in search of publications and lecture appearances, probably to pad their CVs (see: Scientific Articles Accepted (Personal Checks, Too). Here is an excerpt from the article from the NYT. I am only quoting part of it so link to it for more details.

[Some] scientists [have recently] stumbled into a parallel world of pseudo-academia, complete with prestigiously titled conferences and journals that sponsor them. Many of the journals and meetings have names that are nearly identical to those of established, well-known publications and events....The number of these journals and conferences has exploded in recent years as scientific publishing has shifted from a traditional business model for professional societies and organizations built almost entirely on subscription revenues to open access, which relies on authors or their backers to pay for the publication of papers online, where anyone can read them....The phenomenon has caught the attention of Nature, one of the most competitive and well-regarded scientific journals. In a news report published recently, the journal noted “the rise of questionable operators” and explored whether it was better to blacklist them or to create a “white list” of those open-access journals that meet certain standards..... [A research librarian] estimates that there are as many as 4,000 predatory journals today, at least 25 percent of the total number of open-access journals....One of the most prolific publishers on Beall’s list, Srinubabu Gedela, the director of the Omics Group, has about 250 journals and charges authors as much as $2,700 per paper. Dr. Gedela, who lists a Ph.D. from Andhra University in India, says on his Web site that he “learnt to devise wonders in biotechnology.

As luck would have it, the same day that this NYT article was published, I myself received an email invitation to speak at Pathology-2013, a "conference" hosted by Dr. Gedala's Omics Group. Here is an excerpt from it copied verbatim:

We are inviting you to avail the speaker opportunity at the 2nd International Conference and Exhibition on Pathology (Pathology-2013). This conference will be held on August 05-07, 2013 at Embassy Suites Las Vegas, USA. The main theme of the conference is “To Stimulate the Technology in Pathology for Scientific Excellence.” Pathology-2013 is Supported by Journal of Clinical and Experimental Pathology and Journal of Plant Pathology and Microbiology. Pathology-2013 is designed to offer comprehensive sessions like Anatomic Pathology, Pathology Immunohistochemistry, Surgical Pathology and Laboratory Medicine, Pathology and Parasitology, Pathology of Gastrointestinal Tract, Osteopathy and Dermatopathology, Pathology of Chronic Disease, Forensic Pathology, Clinical Pathology and Diagnostic Tools, Advanced Diagnostics Modalities, Areas of Current Research in Pathology, Plant Pathology and Disease Management; which would lay a platform for the interaction between experts around the world and aims in accelerating scientific discoveries.

Here's a quote from the Pathology-2013 conference web site: Pathology-2013 is comprised of 12 tracks and 77 sessions designed to offer comprehensive sessions that address current issues in the field of Pathology. So that no human pathologist would leave the conference disappointed for lack of coverage of plant pathology, the topic is covered in Track 10. Here's a link to the twenty different conferences that the Omics Group has planned for this year. The only way that I can describe this conference enterprise, putting aside the journals, is comprehensively audacious. Do registrants actually show up at these conferences or is the audience just faculty members?  Aside from some grammatical slips and the misstep into plant pathology for Pathology-2013, the web content does have a semi-authentic feel. The biggest clue, of course, is the grandiosity of it all. It seems to be an example of pseudo-academia writ large.

NFL Physician Says Diagnosis of "Chronic Traumatic Encephalopathy" Lacks Validity

I have been closely following the topic of chronic traumatic encephalopathy (CTE) because of the evolving diagnostic aspects of the disease and also because of the large stakes involved with regard to the NFL and college football. I think that I already know how this story is going to turn out. Neurologists, pathologists, and radiologists are going to develop tests and imaging procedures that will provide earlier evidence of concussive injury for both amateur and professional football players. This will result in many players having to sit on the bench for longer periods of time after such injuries. This will cause some fans and league owners a lot of anxiety. Meanwhile, the NFL will do whatever it can to delay the development of faster and more accurate CTE diagnostic tools. One facet of this story was revealed in a recent newspaper article an excerpt of which is shown below (see: N.F.L. Doctor Says Disease Is Overstated):

When a government agency [NIOSH] prepared a workplace safety fact sheet based on a study of degenerative brain disease in retired N.F.L. players, the organization invited several people to comment on a draft. This seems too much like when tobacco companies denied the link between cancer and cigarettes. According to a memorandum obtained by The New York Times, most of the reviewers suggested simplifying the fact sheet so that players without a scientific background could better understand the findings. But one response stood out: a doctor on the N.F.L.’s head, neck and spine committee asked that a mention of chronic traumatic encephalopathy, or C.T.E., be removed....[T]he [NFL] has expressed skepticism about the possibility of a link between on-field head injuries and C.T.E., a sentiment captured in the league doctor’s request to the federal safety agency. The doctor, who was not named in the internal memo, said references to C.T.E. should be removed because it was “not fully understood” and because it was not listed on the death certificates of the retired players in the study and thus lacked “epidemiological validity.” He suggested that traumatic brain injury, or T.B.I., be used instead because it “may accomplish what you want to say in more established medical terms.” Researchers from the National Institute for Occupational Safety and Health, which wrote the fact sheet, rejected the league doctor’s proposed change. Independent medical experts said such a request was inappropriate and not in line with prevailing research.....But [a neurologist] said the [NFL] doctor was correct in wanting to include a reference to traumatic brain injury. T.B.I. is a clinical diagnosis that can be identified in living patients, [he] said, while C.T.E. is a pathological diagnosis that so far can be found only through autopsies....."I’m agreeing with the [NIOSH] study, but we just have to be more careful to make clear that C.T.E. is a pathological diagnosis and T.B.I. is a clinical diagnosis.”....The medical experts also expressed dismay that an N.F.L. doctor would point to the death certificates of former players in the study. C.T.E. is often diagnosed months after death, when brain samples are examined. 

To summarize, an NFL-salaried physician requested that the term chronic traumatic encephalopathy (CTE) in a National Institute for Occupational Safety and Health (NIOSH) report be replaced with the more non-specific diagnosis of traumatic brain injury (TBI). He said that the former term was not well understood and lacked "epidemiologic validity" because it was not listed on the death certificates of retired NFL players who had undergone autopsies. He is thus drawing a distinction between a clinical diagnosis such as TBI that is diagnosed in living patients and the pathological entity of CTE that is being confirmed with tissue examination at the time of autopsy.

It's true that, given the current state of the art, that traumatic brain injury (TBI) is a more general term than chronic traumatic encephalopathy (CTE). However, the latter is gaining favor as more cases are studied post-mortem. That's the way that things work in medicine. So this reaction to the use of terms in the NIOSH report is hair-splitting designed mainly to buy time. I suspect that as CTE becomes better defined and rapidly diagnosable, more attention will be paid to protecting the heads of players and the nature of professional football will need to be greatly modified.

Patients Should Always Receive Their Genomic Information According to Recent Report

I have always been enthusiastic about the need to provide patients and healthcare consumers with most, if not all, of their lab test results shortly after they become available. The only exceptions would be results relating to newly diagnosed serious diseases such as cancer where the information should be first communicated in person by a physician. In such cases, there should be a time delay baked into the release of the information to patients.

Genomic testing has prompted a new debate about the availability of test results. The wide availability of patient portals/personal health records (PHRs) has also fueled these discussions  (see: Publishing Test Results in Patient Portals: Holding a Tiger by the Tail; Next Step in Patient Portals: Secure Messaging and Administrative Functions; UPMC Deploys Its Patient Portal on iPhones and iPads). Fourteen genetics experts and American College of Medical Genetics and Genomics (ACMG) have come out in favor of broad patient access to their DNA results (see: Patients Should Get DNA Information, Report Recommends). Here's an excerpt from the article:

Fourteen genetics experts, with the backing of the American College of Medical Genetics and Genomics (ACMG), are proposing a radical shift in how and what patients learn about what's in their DNA. They argue that anyone whose genome is sequenced for any medical reason should automatically learn whether 57 of their genes put them at risk of certain cancers, potentially fatal heart conditions, and other serious health problems. The information would be provided whether patients want it—and often when they're seeking care from a doctor for something else entirely—because, the experts say, knowing the makeup of this DNA could save an individual's life. The recommendations apply to sequencing children's DNA as well, even if there's no preventive care available until adulthood. The college's guidelines on a range of issues are usually written by influential geneticists and physicians and carry significant weight, although they are not binding. Today's report includes the first recommendations ever given to labs and doctors about how to handle unexpected findings when the genome or its protein-coding "exome" is sequenced.The ACMG recommendations...come as DNA sequencing is about to take off in doctor's offices and hospitals....The effort is part of a much broader debate that spans research and clinical care over which genetic results should be returned—an ethical, legal, and practical minefield....Labs, they suggested, should "seek and report" mutations in dozens of genes, many of them linked to cancer syndromes. The doctor who ordered the test would be responsible for communicating the results to patients....Several experts who did not participate in the report voiced practical and ethical concerns. "The assumption that it's always benign to give that information, and potentially helpful—I don't think that's true," said...a law professor who studies bioethics and genetics...."Information is often very damaging to people, that's why they don't want it." 

What I find fascinating about this news is that a group of genetics and genomics experts have now come down strongly on the side of wide dissemination of medical test results. I use this latter phrase with some caution because the definition of medical test information is changing rapidly. With the emergence of web-based DNA testing sites such as 23andMe, medical consumers are gaining direct access to such test results (see: Clinical Labs Have Much to Learn from the Genetic Testing Web Sites; 23andMe Builds Online Sarcoma Research Community; 23andMe Requests FDA Clearance for DNA Saliva Testing). Physicians and hospital-baed medical labs no longer totally control this franchise. So, in a sense, this discussion is somewhat academic because the "horse is already out of the barn." Pathology informaticians may be involved in discussions about whether the appropriate waiting period for a surgical pathology result should be seven days or ten days but, in reality, the basic principle has already been established. Patient and healthcare consumers have a right to access most, if not all, of their medical records including all lab test results in a timely fashion and frequently within 24 to 48 hours after posting in the EHR.

The New Equation in Health Insurance: Cooperate in Screening or Pay More

There is no question in my mind that mandatory health screening will be the norm for many of us, at least those who receive health insurance as a job benefit. Such screening has the dual effect of alerting an individual's healthcare providers about real or potential problems and also engaging the individual in the process of monitoring his or her own health. The covered individual can opt out of such screening but it's going to cost more money to do so. Details about the plan offered to CVS Caremark were discussed in a recent article (see: A Choice for Employees: Get a Health Screening or Pay an Extra $600).  Below is an excerpt from it. Also see: If Workers Are Out of Shape, Should Companies Make Them Pay? (paywall).

CVS Caremark employees with company health insurance are being asked to take a free health screening—for basic metrics such as weight, body fat, blood pressure, and glucose levels—or have their premiums increase by $50 per month ($600 annually). In other words: Get examined or pay up. Fair?....CVS Caremark said in a statement that “79 percent of large employers have health assessments incorporated into their programs.” By making employees aware of their numbers, the company hopes to encourage healthier habits—and ultimately reduce overall health-care costs....Not everyone is convinced. Deborah Peel, founder of Patient Privacy Rights, a group that advocates for patient control of health records, says workers are being penalized for not handing over private health information. She [noted in an interview] that that while CVS says it never sees the personal health data, there is no way to verify that, and there’s a risk employers will discriminate against unhealthy workers. Still, as health costs rise, employers will look for ways to cut back. Encouraging workers to get in shape, especially those with costly conditions such as obesity, is a growing priority. In addition to screenings, many employers also subsidize gym memberships and organize on-site fitness activities. Financial incentives, even negative ones, do seem to get people’s attention. A recent Mayo Clinic study of obese Mayo employees and dependents found that when money is involved, people do better at losing weight. Those with money at stake—either penalized $20 each month if they failed to meet their goals or offered $20 per month for meeting weight-loss goals—lost more weight than those with no money on the line. Many Americans clearly are not good at maintaining their health for its own sake. But $20 a month? Apparently that’s worth some effort.

I am sure that this CVS Caremark model is similar to the the way in which most corporate health insurance plans will evolve. Financial incentives, both carrots and sticks, will rule the day. The more benign employers will use more of the former and more aggressive more of the latter. The goal is to improve the health of their employees and simultaneously lower the cost of health insurance. A variation on this theme is to provide a richer mix of benefits to the employees who take better care of themselves and and less coverage for the same price to employees who can't achieve the health targets (see: A Lottery to Improve Patient Adherence to Warfarin Therapy; Paying Patients to Stay Healthy; Discrimination Against the Poor?; Financial Incentives for the Pursuit of Wellness; Possible Impact on the Clinical Labs). As to whether this is fair or not, I will leave it up to you to decide. Cleveland Clinic decided not to hire smokers about two years ago and Geisinger has followed suit (see: Want a Job at the Cleveland Clinic?: Smokers Need Not Apply; Geisinger Follows Cleveland Clinic; Won't Hire Smokers). The University of Pennsylvania Health System has just announced a similar policy. 

Cancer Business Highly Remunerative for Sloan-Kettering Executives

I have posted a number of previous notes about the so-called oncology or chemotherapy concession that refers to the markups on the chemotherapeutic agents administered by oncologists to their patients (see: Academic Oncology and the "Chemotherapy Concession"; The Oncology Concession Under Attack by Health Insurance Companies). When the oncologists are salaried hospital employees, much of these profits are retained by the cancer hospitals that employ them. A recent article took a close look at Memorial Sloan-Kettering Cancer Hospital in New York and the salaries of their executive officers (see: The Profit Of Prestigious Cancer Care). Here is an excerpt from the article:

In 2011, the hospital and research institution of Sloan-Kettering had an operating profit of $406 million even after everything it spent on research and the education of a small army of young cancer doctors. The cash flow comes from more than just drug markups. It also comes from the high pricing enabled by a great brand and an enterprise that has learned how to expand the reach of its brand. One of Sloan-Kettering’s major revenue sources is the outpatient clinics it has been opening around New York City in recent years so that patients don’t have to travel to the busy Upper East Side of Manhattan ....There is a cancer-screening and treatment outpost...in Harlem and a chemotherapy clinic in Brooklyn, and clinical-care facilities can also be found in five of the New York City metropolitan area’s wealthier suburbs....Building on the deserved allure of the Sloan-Kettering brand, these outposts eat into the profits of area hospitals, which would otherwise be providing the same high-margin outpatient cancer care either on the basis of what their own doctors prescribed or according to instructions from Sloan-Kettering’s specialists.... Sloan-Kettering’s foray beyond the Upper East Side of Manhattan also represents a rare outbreak of competition in the current hospital marketplace.Sloan-Kettering may be fishing for business in these wealthy suburbs, but it does have a financial-aid process that is both proactive and well publicized to patients seeking care....That kind of brand strength produces not only lavish cash flow but also lavish incomes for the nondoctors who work to generate it. Six Sloan-Kettering administrators made salaries of over $1 million in 2010, the most recent year for which the hospital filed its nonprofit tax return.... Including those six, 14 made over $500,000. Compared with their peers at equally venerable nonprofits, these executives are comfortably ensconced in a medical ecosystem that’s in a world of its own. For example, Sloan-Kettering listed two development-office executives, or fundraisers, as making $1,483,000 and $844,000.

As this article points out, Sloan-Kettering is taking advantage of its brand by expanding its cancer care services in the New York area and grabbing these high-profit patients from other health systems. The New York hospital market is highly competitive so this may just be the nature of the business in the area (see: NYU Longone Tries to Claw Back Market Share after the Sandy Debacle). 

I am sure that there will be various opinions among the readers of this blog as to whether fourteen of the Sloan-Kettering executives should be compensated with salaries of more than a half-million dollars each. We have arrived at a point where many U.S. hospital executives are among some of the highest wage earners in the country. This may be justified on the basis of the responsibility that they bear. What galls me, though, is the non-profit status of many of these institutions. I posted a note five years ago about non-profit hospitals drifting from their mission (see: Non-Profit Hospitals Drift from Their Mission Despite Subsidies). Apparently institutions like Sloan-Kettering are still able to convince the IRS that they qualify as a non-profit despite the very high salaries of their executive officers and the aggressive way in which they market themselves.

Not Much Progress in the Development of Physician Practice Web Sites

I have always thought that the development of practice web sites by physicians would be a wonderful way to reach out to patients and provide medical information as well as services such as the ability to book office appointments. In retrospect, such sites have not been evolved in the same way as other business segments (see: Physicians’ websites are more “electronic brochures” than online health resources). Here is an excerpt from the article:

A new survey finds that doctors’ websites are woefully lacking when it comes to serving patients. No surprises there – after all, the most commonly used technology in a doctor’s office is still the fax machine. Here are the details of [a recent] survey [of] ...300 doctors with the highest patient satisfaction ratings in Boston, Denver and Portland. The specialists analyzed were OB/GYNs, urologists and orthopedic surgeons. 69 percent of these physicians have websites but only 33 percent of them have anything more than biographical and practice information on it. Only 99 in fact have information centered around patients such as medical conditions and treatment options. It gets worse with only 4 percent – 12 doctors – made at least one blog posting in the past 12 months on their websites to inform patients on trends and research.“Doctors in these cities are still using their websites primarily as electronic brochures about their practices rather than as online health resources,” said ,,,[a member of the survey group]. The results are all the more revealing given a recent Pew Internet survey that shows that patients continue to search for health information online. So doctors are missing a real opportunity to bridge the chasm they currently have with with patients by keeping website information limited to their bios.“In 14 years of helping doctors find new patients, our foremost conclusion is that patients look for health care information first and health care providers second,” [a spokesperson] said in the statement. “Any doctor offering online health education engenders public trust, attracts a better informed patient and grows his practice.” 

Unfortunately, this story confirms some of my perceptions about physician practices. Please note that my comments should not be construed to suggest that physicians in private practice are professionally inadequate. Rather, I think that they often lack an understanding and appreciation of information technology and marketing. Although they are running businesses for which a web site would be an important asset, physicians often do not perceive themselves in this way nor do they allocate resources for IT and marketing. I am sure that there must be local web designers to whom physicians could outsource the development and maintenance of web sites. However, if the physicians running such practices do not appreciate the value of this way to communicate with their patients, such resources would not develop.