A Chance to Cut is a Chance to Cure

Labels: Tales from the Trauma Service

Labels: Tales from the Trauma Service

The General Assembly finds that there presently exists a crisis affecting the provision and quality of health care services in this state. Hospitals and other health care providers in this state are having increasing difficulty in locating liability insurance and, when such hospitals and providers are able to locate such insurance, the insurance is extremely costly. The result of this crisis is the potential for a diminution of the availability of access to health care services and a resulting adverse impact on the health and well-being of the citizens of this state. The General Assembly further finds that certain civil justice and health care regulatory reforms as provided in this Act will promote predictability and improvement in the provision of quality health care services and the resolution of health care liability claims and will thereby assist in promoting the provision of health care liability insurance by insurance providers. The General Assembly further finds that certain needed reforms affect not only health care liability claims but also other civil actions and accordingly provides such general reforms in this Act.

The General Assembly makes the following findings: Georgia hospitals operating dedicated emergency departments are required by both state and federal law to provide examination and treatment to individuals who come to a dedicated emergency department, without regard to the financial or insurance status of such individuals. Hospitals and other health care providers have complied with these laws to their financial detriment and under the well-founded apprehension of increased liability. Due in large part to fear of such liability, hospitals are experiencing extreme difficulty attracting a sufficient number of physicians and other health care professionals to maintain an effective team of professionals, including on-call physicians, to provide needed care and assistance to citizens of this state. As a result, many hospitals are being forced to close their emergency departments or forgo other needed improvements in order to financially support such emergency services and their attendant liability. The shortage of these emergency providers poses a serious threat to the health, welfare, and safety of the citizens of Georgia.

Warning the patient of known complications of a procedure is protection against an informed consent lawsuit.

It is not an automatic protection or defense against lawsuit if the complication occurs. You still have to perform the procedure, and manage complications that might occur, provide adequate follow-up, etc, to the prevailing standard of care.

For example, you might warn me of bleeding. If I bleed to death, that doesn't protect you if it happened because you were negligent

I understand that during the course of the procedure described above it may be necessary or appropriate to perform additional procedures which are unforeseen or not known to be needed at the time this consent is given. I consent to and authorize the performance of such additional procedures as they deem necessary or appropriate.

Every year about 500 people on the waiting list for a heart transplant die before an organ is made available. Thousands more die because they are considered too old or sick to get on the list to begin with.

But some heart surgeons are demonstrating that many of these people could be saved if transplant hospitals were less particular about the quality of donor hearts. They're starting programs that provide lower-quality hearts to older and sicker patients -- and sparking debate about how a transplant system that fails to help many people could be improved.

Beyond the 2,058 hearts transplanted last year, an additional 3,058 were offered by families of the newly dead, according to the nonprofit Scientific Registry of Transplant Recipients. But these hearts were rejected, often because they were not top quality. They were either buried or cremated with their original owners.

Hillel Laks, a transplant surgeon at the University of California at Los Angeles, contends that half the rejected hearts are suitable for transplanting. In his "alternate heart" program here, Dr. Laks refurbishes defective donor hearts, sometimes performing bypass surgery on their clogged arteries while the organs are on ice. He and his colleagues give infected donors heavy-duty antibiotics after brain death but before their hearts are removed. Sometimes, as in the case of Fred Austin, Dr. Laks simply puts an old heart in an old person.

When Mr. Austin's failing heart brought him to the brink of death at age 75, he was too old to get one of the prime hearts used in mainstream transplant programs. UCLA offered him the heart of a 62-year-old donor -- one that other hospitals in the region didn't want.

Mr. Austin was delighted to get it. "I wouldn't have lasted another three months," he says. Eleven days after his surgery in December 2002, Mr. Austin called up some buddies for a game of golf. Now, at 77, he hits the links three times a week.

Mr. Austin, one of the oldest people ever to receive a transplant, was lucky. Some 50,000 people die each year of congestive heart failure, a progressive worsening of pumping function. Many of those patients would have liked to get placed on the heart-transplant waiting list but couldn't do so, doctors say.

The system for allocating hearts starts with a waiting list that gives priority to those who are sickest and have waited the longest. When a heart becomes available, the hospital treating the deceased person keeps him or her on life support and informs a regional "organ procurement organization." The organization, working through its waiting list, furiously makes calls to place the organ -- looking for a surgeon and patient, preferably nearby, who are ready to receive the heart right away.

With "marginal" hearts, the organization will often call around everywhere and find no takers. That's where UCLA and other hospitals with an "alternate" list come in. After everyone else says no, the organization will call one of these hospitals and look for an alternate patient to accept the marginal heart. Patients on the alternate list must agree that they won't ordinarily be eligible for a heart from the regular list.

The hearts that end up in alternate-list patients have various problems. A recent innovation at UCLA has been to accept hearts from patients who died from bacterial meningitis -- a practice viewed as almost unthinkable a few years ago. Over the past three years, nine such hearts have been transplanted at UCLA. Thanks to heavy antibiotic doses for both the donor and the recipient, none of the recipients have gotten meningitis so far.

Duke, which established its alternate program in 2000, and Columbia, which began its program in 2001, both have found that alternate recipients do somewhat worse than standard ones but still fairly well. Columbia found that 75% to 80% of its alternate patients live a year after the transplant, combined with 90% in its regular program.

Doctors say that those who don't make it usually die from underlying health problems, not problems with the donated heart. "A lot of the hearts that we classified as marginal are working extremely well," says Donna M. Mancini, a cardiologist at Columbia University Medical Center.

Rather than setting up alternate lists, some centers believe the best policy is to expand their definition of who is eligible for the regular list. Many surgeons are now willing to put patients as old as 70 on the regular list, giving them the same chance as younger people to get a good-quality heart.

Cedars-Sinai Medical Center in Los Angeles dropped its alternate list several years ago on the theory that it wasn't fair. "If a patient is a candidate for transplantation he should get a good heart, and age should not be a discriminatory factor," says Alfredo Trento, director of cardiothoracic surgery.

UCLA's Dr. Laks sees it differently. Since top-quality hearts are "a scarce resource," Dr. Laks says, "we have an obligation to give the heart to someone who has the best chance of surviving."

That conclusion still leaves another ethical dilemma: How far should transplant centers go in using marginal organs? A handful of centers have tried transplanting hearts from patients with hepatitis C, a virus that can lead to fatal liver disease. UCLA suspended such transplants when several recipients were infected, though it may restart. At the Cleveland Clinic, the hepatitis C transplant program has been scaled back after a study found that 14% of recipients contracted severe liver disease.

But some desperate patients would rather live with hepatitis C than face imminent death. One 59-year-old accountant from Long Island, who asked that his name not be used, was assigned to the alternate list at New York-Presbyterian Hospital, the teaching hospital for Columbia University, because of diabetes and kidney trouble. In March 2002, he received a heart from a 45-year-old man infected with hepatitis C.

The recipient is at risk for contracting hepatitis, but he says he is grateful for the chance at life. "Three years ago I was a dead man, and now here I am," he says. "I feel fantastic. I have a job, I have a family, life is good."

Outside of big urban hospitals few people have access to alternate-heart programs -- in large part because surgeons fear risk-taking could harm their statistics. "Cardiac transplant programs all over the U.S. are carefully scrutinized for outcome. If programs fall below a certain standard, it's a big hassle because you have to justify your program to Medicare and insurance carriers," says James Kirkland, director of cardiothoracic transplants at the University of Alabama at Birmingham.

Partly for this reason, UAB doesn't have an alternate-heart program, but Dr. Kirkland is in the early stages of organizing an international clinical trial in which UAB would likely participate. The trial would compare the success of programs such as UCLA's to the implantation of a left ventricular assist device.

Labels: Transplantation

Labels: Tales from the Trauma Service

Expecting her third child this winter, Sandra Hughes became an unexpected pioneer in the new world of health care -- a world in which consumers have a direct stake in limiting their spending on treatment and tests.

Mrs. Hughes and her self-employed husband had health insurance, but couldn't get maternity coverage because of two previous Caesareans. So in nine months, Mrs. Hughes went from novice health-care consumer to hard-knuckled haggler. She negotiated discounts with doctors, convinced her obstetrician to match another's offer and wrote to the chief executive of a local hospital demanding a reason for refusing to meet her price.

"In the beginning, you think, wait, this is my health care: I don't want to make these people mad or insult them by talking money," says the 31-year-old former special-education teacher. "But after a while, it felt like I was buying a car."

Pregnant women are by necessity and ingenuity paving the way in what is called "consumer driven" health care. As companies boost premiums for family coverage -- and in some cases drop dependents altogether -- a growing group of women lack health coverage for pregnancy, one of the biggest medical costs they face. Others are in some type of consumer-driven high-deductible plan, with a Health Savings Account, that gives patients incentives to shop around.

Ronna Alexander, a self-employed design consultant in Douglas, Mich., had a medical savings account and catastrophic-care policy, so she and her husband were used to paying upfront for much of their health care.

When she called hospitals for maternity-related prices, they were reluctant to break down specific charges, arguing that every delivery is different. By her 20th week, she says she already had paid out about $800 in prenatal care, but felt that most of the tests were done to protect her doctors against liability and that they had little time for counseling -- a sense all the more acute because she was paying the bills. So she made an appointment with a midwife who does only home births, even though "I am the last person who would do a home birth."

She liked the midwife's more-attentive approach, and the price: only $1,800. Yolanda Visser of Grand Rapids, the certified professional midwife, says that for about half of the mothers she works with, price is at least one factor in having a home birth. She now charges $2,200 for full prenatal care and delivery.

The new focus on limiting costs is putting added pressure on expectant parents. When Deborah Elissagaray and her husband shopped for a family policy a couple of years ago, they felt they couldn't afford an extra $200 to $300 for maternity coverage on top of the $700 a month for regular medical insurance. The couple was just starting up a winery in Placerville, Calif. Their broker assured that if they did have a child, they would spend less money by paying for it themselves.

When Mrs. Elissagaray became pregnant about six months later, she and her husband thought they would have to rely on money from their 401(k)s and part of a business loan. Worse, she says, was having to decide whether to forgo some prenatal tests, including a $3,000 amniocentesis test for genetic diseases. At age 38, she was at higher risk for having a baby with problems such as Down syndrome. She went ahead with the test.

In the end, Mrs. Elissagaray wound up qualifying for a maternity-assistance program in California called AIM, targeted at people who aren't poor enough to qualify for Medicaid. "When I found out, I cried right there in the office," she says. Her baby, Olivia, was born in February.

When Sandra Hughes in Florida reviewed a breakdown of what her previous insurer paid for her last pregnancy it showed her the rates were much lower than what the doctors and hospital charged so-called cash patients who pay out of pocket. When she asked for the same deal on her current pregnancy, one obstetrician complied. When she asked another doctor's practice to match it they did, cutting the usual $3,000 fee to $1,900.

When she tried the same with the hospital, she met resistance. Although her old insurer had paid $3,200 for her last Caesarean section there, Mease Dunedin Hospital in Dunedin, Fla., said its best price for a cash patient was $5,000. She says she wrote Jim Pfeiffer, president and chief executive of Mease Hospitals, demanding he justify the discrepancy. "By then, I was almost nine months pregnant, and I was angry!" she says.

Mr. Pfeiffer says he didn't receive the letter, but says the hospital's average cost for a Caesarean is actually $5,100, with a list price of about $10,200.

Since she already had negotiated deals with an anesthesiologist at Mease Dunedin and liked the care there before, she choose to remain at the hospital. But she says, "If more people asked about prices, it would all be far more transparent."

As policy-makers and medical community leaders determine the best response to physician shortage predictions, the question of whether the public will need more primary care physicians or more specialists is back on the table.

Work force experts and organized medicine leaders remain divided on how to answer that. And with no national health policy to guide medical school expansion, state legislators and medical educators likely will follow the discussions closely.

The latest salvo in the debate comes from Barbara Starfield, MD, MPH, with the Johns Hopkins School of Public Health. Her study's conclusion: The greater the supply of primary care physicians, the lower the mortality rate. She also found that a higher specialist-to-population ratio did not decrease mortality rates. In fact, she determined that too many specialists negatively impacts communities because patients are more likely to have unnecessary tests and procedures.

The nationwide study, "The Effects of Specialist Supply on Populations' Health: Assessing the Evidence," released in a Web-only March 15 edition of Health Affairs looked at mortality rates at the county level.

"Decisions about the physician supply should be made on the basis of evidence for their utility in improving health and reducing ill health and deaths," Dr. Starfield said. "Currently, the United States has many more specialists than do other comparable countries with better health levels."

Robert L. Phillips Jr., MD, MSPH, director of the Robert Graham Center, supported the study in his own commentary in Health Affairs.

"If we want our health care system to be an economic engine, we are headed in the right direction," Dr. Phillips said in an interview. "If what we want is a healthier population, we are headed in the wrong direction."

Specialists aren't bad, he said, but if the physician work force is going to expand, there is an opportunity to ask how it should be configured to make Americans healthier.

"Increasing the supply of subspecialists is not the way to go," he said. "This is not an indictment, but we have an option here, and physicians should weigh in on what's important to them."

In his critique, also published in Health Affairs, Salsberg questioned the validity of looking at the number of specialists by county and linking that to mortality rates.

Specialists, Salsberg said, tend to concentrate in urban areas that draw patients from large geographical areas, so they can see enough cases to be clinically sharp and financially viable. At the same time, the population that dominates urban areas tends to be higher risk and has higher mortality rates.

An analysis of mortality rates also does not capture quality-of-life improvements that specialists provide, he said. Ophthalmologists might not save lives, but cataract surgery can make the difference in a person's ability to see to drive or read.

In addition, he argued, many scientific advances have come from greater specialization. Achievements might mean drugs or treatments that primary care physicians can provide for patients, but they also result in highly complex treatments best handled by the subspecialists themselves, he said.