By; Laird Harrison.
November 17, 2010 — Looking back, historians may mark 2010 as the most significant year for US medicine in decades. The healthcare reform legislation signed into law by President Barack Obama March 23 profoundly changes the way care is provided, and even if opponents succeed in repealing the legislation, the debate itself will shape the way we think about the issue for years to come.
The law didn’t come out of nowhere. Stresses and discontents in healthcare have been building for decades. Costs are rising at the same time that budgets are getting leaner. Most sophisticated tests are forcing physicians and patients to decide whether and how to treat diseases that previously went ignored. And new research calls old guidelines into question. Such tensions are reflected in nearly all the stories that surfaced as the most viewed by Medscape readers during the past year.
1. Cuts Loom in Medicare Reimbursement
The conflict over healthcare stems largely from a gap between the care we expect and the care we can afford. That gap is now threatening to undermine Medicare, which is scheduled for a 25% cut in reimbursements if Congress doesn’t act soon. The reduction would be triggered by the sustainable growth rate formula used for setting physicians’ pay. It could force many physicians to drop Medicare, which would send shockwaves throughout the system, as Medicare patients make up about a third of the practices of 70% of physicians. Almost no one wants to see the cuts take place, but the Congressional Budget Office estimates that keeping reimbursements at current levels through 2020 will cost $276 billion. Under pressure to reduce the national deficit, Congress so far hasn’t been able to agree on a source for that much money. Throughout 2010, it kept delaying the cut with a series of short-term fixes. What’s likely to happen next? More delays. With the Republicans controlling one chamber of Congress and the Democrats the other, gridlock could doom long-term “doc fix” legislation for the coming year.
2. Healthcare Reform
Whatever else you might say about healthcare reform, it’s a big deal. The most comprehensive overhaul of the nation’s healthcare system at least since Medicare, the Affordable Care Act seeks to dramatically expand the number of people who can afford healthcare. It does that by subsidizing the cost for those who can’t afford it, penalizing those who refuse to buy it, and limiting the cases in which insurers can deny coverage. Among scores of other provisions, it boosts pay for primary care physicians, encourages compensation based on quality of care, and bars copayments for most preventive services. As the law is implemented, questions about these and other provisions are cropping up. For starters, do we have enough physicians, nurses and other healthcare workers to care for an estimated additional 32 million insured? Also, who will make up the difference if fewer copayments are collected? These questions and more are certain to arise as legislators critical of the law attack it with renewed vigor.
3. New Guidelines for Prostate Cancer Screening
The advent of better tests — such as prostate-specific antigen (PSA) screening — can in some cases save lives with early treatment. However, these tests can also pose new dilemmas, as the American Cancer Society (ACS) emphasized on March 3 when it updated its prostate cancer screening guidelines. The test picks up benign disease in addition to cancer, and it can’t distinguish between aggressive and mild forms of the disease, the ACS pointed out. In some cases, PSA screening has led to expensive and invasive treatments in patients who might never have experienced symptoms. So the ACS is calling on physicians to spend more time counseling patients about their options (despite the difficulty of billing for such counseling). The PSA controversy intensified when the scientist who discovered PSA in 1970, Richard Ablin, PhD, from the University of Arizona College of Medicine in Tucson, said categorically that the test should not be used to screen all men older than 50 years. That’s a direct contradiction of the ACS guidelines. Controversy about the value of PSA testing continued when results of studies on both the effectiveness of the test and on chemoprevention were reported.
4. Whistle-Blowing Nurses Prosecuted
Healthcare is not without its scandals, perhaps the biggest of which in 2010 was the criminal prosecution of 2 nurses who reported Rolando Arafiles Jr, MD, at Winkler County Memorial Hospital in Kermit, Texas, to the Texas Medical Board for low quality of care. As it turned out, Dr. Arafiles was friends with the local sheriff, who arrested Anne Mitchell, RN, and Vickilyn Galle, RN, for misuse of official information — a third-degree felony. Prosecutors dropped charges against Galle, and a jury quickly acquitted Mitchell, but the hospital fired both of them. Subsequently the medical board charged Dr. Arafiles with 9 instances of substandard care. In one charge, it accused him of suturing the rubber from suture-kit scissors to a patient’s torn and broken thumb in an unorthodox attempt to stabilize the digit. The nurses sued Dr. Arafiles and the hospital in federal court for, among other things, violating their freedom of speech, but dropped the suit after the defendants agreed to pay them $750,000 as part of a settlement.
5. Centers for Medicare and Medicaid Services Appointment Stirs Controversy
When Obama nominated Donald Berwick, MD, administrator of the Centers for Medicare and Medicaid Services, critics pointed to comments Dr. Berwick had made in admiration of Britain’s National Health Service and in calling for the redistribution of wealth “from the richer among us to the poorer and less fortunate.” However, Dr. Berwick has a track record of success in helping many organizations to solve practical healthcare problems, which earned him support among groups of physicians, consumers, businesses, and insurers, including the American Medical Association. Facing opposition in the Senate, Obama took advantage of a loophole allowing him to appoint Dr. Berwick without the need for confirmation while the Senate was in recess.
6. Revised Diabetes Guidelines Highlight A1c
Screening technology popped up in the news again in December 2009 when the American Diabetes Association published new clinical practice recommendations. (Despite the timing, the news story quickly moved to into the top 10 most-read topics on Medscape.) The guidelines promote the use of the hemoglobin A1c (A1c) as a faster, easier diagnostic test that could help reduce the number of undiagnosed patients and better identify patients with prediabetes. A1c measures average blood glucose levels for a period of up to 3 months. Previously it was used only to evaluate diabetic control with time, but because it doesn’t require fasting, A1c testing will encourage more people to get tested, leading to treatments and lifestyle changes that could prevent the worst effects of the disease, the American Diabetes Association said.
7. Calcium Boosts Heart Attack Risk
Prevention guidelines also made headlines when a large study found that calcium supplements taken without vitamin D may increase the risk for heart attack as much as 30%. Researchers reported the finding online July 29 in BMJ, based on their meta-analysis of 15 randomized trials with up to 11,921 participants. Most guidelines for osteoporosis currently recommend the supplements, despite relatively small benefits in bone health, but senior author Dr. Ian R. Reid, from the University of Auckland in New Zealand, said that in most cases, “discontinuation of calcium would seem appropriate.” The study raised many questions, such as why calcium could have this effect during a relatively short period of time. Pending further research, some experts advised eating foods high in calcium, rather than taking supplements.
8. Volunteers Moved by Haiti Earthquake
When an earthquake devastated Haiti on January 12, thousands of physicians and other healthcare professionals started packing their black bags and booking airplane tickets. Experts at a webinar held by the American Medical Association warned against a rush, pointing out that volunteers without the proper preparation could hinder relief efforts. During the next 10 days, however, the need for specialists in emergency medicine, orthopaedic surgery, and neurology became increasingly clear. By the end of the month, more than 600 relief organizations were working in Haiti, and the American Medical Association established a physician registry for volunteers.
9. FDA Warns Against Quinine for Cramps
What do you do when no one pays attention to your guidelines? Issue them again. That was the approach taken by the US Food and Drug Administration (FDA) July 8 after it noticed that most of the quinine being prescribed in the United States isn’t for the approved indication — uncomplicated malaria — but, rather, for leg cramps. Taking quinine (marketed by AR Scientific as Qualaquin) may result in serious and life-threatening hematologic adverse effects, the FDA said. The statement reiterated a 2006 warning about the off-label use of this drug that apparently fell on deaf ears.
10. Task Force Revises Mammography Guidelines
For those who follow such things, 2010 also may also be remembered as the year of the mammoth mammography muddle. On November 17, 2009, the US Preventive Services Task Force called for an end to routine mammography for women younger than 50 years, citing a lack of evidence for benefits in women that young, sparking outrage from screening advocates. On January 6, 2010, however, the American College of Radiology and the Society of Breast Imaging directly contradicted the task force, recommending routine mammography at age 40 years and older. The debate got further fuel from a Swedish epidemiological study of breast cancer, touted as the largest ever, which found that mammography produced a 26% reduction in mortality from breast cancer in women aged 40 to 49 years. Another study from Norway found that the benefits from mammography screening were modest, however, and an accompanying editorial highlighted the delicate balance between potential benefit and potential harm, concluding that the decision to undergo mammography is “a close call.”