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November Issue 2014
Inside This Issue
RESPITE CARE: CARING FOR THE CAREGIVERS By Jeff Carmack Managing Editor Texas Department of Aging and Disability
Cheaper Medications may be Counterfeit See pg. 10
INDEX Legal Health..................pg.3 Money Matters..............pg.4 Mental Health...............pg.5 Healthy Heart................pg.7 Marketing Essentials.......pg.9
What you don’t know about Hospice Care could hurt you See pg. 15
Janet Barker could write a book about being a caregiver. Barker spent 13 years taking care of her mother, evolving from tracking her mother’s medications to living with her in a senior housing setting. Along with a sister, she now helps care for her 95-year-old aunt. People like Barker who provide unpaid voluntary care and assistance for family members are sometimes called “family caregivers.” By helping with daily activities such as meal preparation, bathing and dressing, medication, transportation, shopping, and more, they provide much of the support that lets people stay in their homes and out of institutions.
significant symptoms of depression, and that women – who make up the bulk of the caregiver cohort – tend to have higher rates of depression and anxiety and lower levels of well-being and life satisfaction than do male caregivers. More than one-fifth of all caregivers report being exhausted when they go to bed at night.
There are an 2.7 million caregivers in Texas. “The value of care given by unpaid – or family – caregivers in Texas is estimated at $34 billion a year,” said Joyce Pohlman, grants coordinator at the Texas Department of Aging and Disability Services (DADS). “Their work is estimated to save the state $3.2 billion to $12.6 billion in Medicare and institutional spending a year.”
One in 10 caregivers reports that caregiving has caused their physical health to suffer. Additionally, caregivers are known for neglecting themselves by not addressing their needs, leading to chronic health conditions such as heart disease, heart attacks and cancer at twice the rate of non-caregivers. Seventy percent of caregivers who also work outside the home say that their caregiving duties negatively affect their Pohlman said that about 50 percent work, forcing them to juggle work hours of caregivers are reported to have clinically or take leave to deal with their caregiving responsibilities. Fortunately, there is help for caregivers in the form of respite care -short-term help that provides temporary relief to caregivers “Research shows that respite and other supports have a positive effect on mental and physical health,” Pohlman said.
Caregivers have respite options, Pohlman said. Most DADS waiver programs offer respite as part of their services, and the National Family Caregiver Support Program -- operated by the area agencies on aging -- provides respite information for caregivers. The AAAs and aging and disability resource centers also use the “train the trainer” model to equip caregivers to take care of themselves, and manage their lives better. Another resource assembled by DADS and the Texas Respite Coordination Center is the Take Time Texas (TTT) website. The centerpiece of TTT is a searchable database with a list of more than 1,000 respite care providers. Users can filter searches by county, type of provider, age of recipient and the type of respite they provide. The Texas Lifespan Respite Care Program is a state-funded program that pays for respite care. People who are not qualified to get respite services through other programs can sometimes receive them through this program, Pohlman said.
If you provide care for a family member and need a break, respite can help. www.dads.state.tx.us/taketimetexas.
PRSRT STD US POSTAGE PAID PERMIT NO 1 HOUSTON TX
Houston Medical Times
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November 2014
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Legal Health
2. Public Comments
OIG Proposes New Safe Harbors to the Anti-Kickback Statute By Daniel E. Gospin, J.D. EPSTEIN BECKER GREEN
1. Background
Page 3
health care services and the alignment of financial incentives among health providers. The Proposed Rule also attempts to further assist patients in being able to access health care in situations in which these laws have impeded health care providers and suppliers from offering services free of charge or at reduced amounts.
The OIG has asked the public to provide comments on a number of significant issues addressed in the Proposed Rule. While the Proposed Rule addresses a number of important topics, it falls short of providing full flexibility to health care organizations to accomplish the access and cost-efficiency goals the Affordable Care Act amendments were designed to address, and is otherwise unnecessarily narrow. In some instances, additional clarity is necessary in order to aid providers in determining how best to comply with the proposed new safe harbor provisions. Below are two examples where comments to the OIG are critical:
On October 3, 2014, the Department The various proposed new safe of Health and Human Services’ Office of harbors that are included in the Proposed Inspector General (the “OIG”) published Rule relate to the following issues: a Proposed Rule to add new safe harbors 1. Part D Cost Sharing Waivers to the federal health care program a. Local Transportation by Pharmacies anti-kickback statute (the “Anti-Kickback The proposed safe harbor protecting Statute” or “AKS”). 2. Cost Sharing Waivers for free or discounted local transportation Emergency Ambulance Services services to federal health care program It is the first time in seven years that the OIG has either issued any significant 3. Federal Qualified Health beneficiaries is unduly narrow. The OIG changes to or proposed any new safe Centers and Medicare proposes limiting the safe harbor to only local transportation (anything within harbors under the Anti-Kickback Advantage Organizations 25 miles). The OIG also proposes Statute. The Proposed Rule sets forth a 4. Medicare Coverage Gap to exclude transportation by certain number of provisions that codify certain Discount Program entities (e.g., suppliers or pharmaceutical exceptions and modifications to laws manufacturers) to certain providers (e.g. 5. Local Transportation that Congress has adopted over the last referral sources of the transportation decade. In addition, the Proposed Rule provider) and to new, as opposed to addresses changes regarding payment for
existing, patients. If the concept of a transportation safe harbor is, as the OIG states, to promote “legitimate financial and patient care interests in the provision of local transportation to patients” then the safe harbor should not universally exclude from protection a whole segment of the industry who may be legitimately offering transportation services. There are many legitimate reasons why these entities may provide transportation services. Potentially excluding transportation services to referral sources unnecessarily limits the applicability of the safe harbor, and its beneficial effect on patient access because health care organizations and professionals are typically part of a community of intertwined referral networks. In addition, limiting the transportation safe harbor to existing patients means that new patients with see Legal Health page 18
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Page 4
Money Matters
How to Solve Your Retirement Funding Dilemma By Margaret SucréVail Sucré-Vail Wealth Advisors
$80,000 a year in retirement income to avoid outliving one’s assets. Is a Cash Balance Retirement Plan for You?
Physicians and Physician Groups who are looking for larger tax deductions Most physicians have a limited and accelerated retirement savings may understanding of how much they find that a Cash Balance Plan may be need to save in order to fund 25 to the perfect solution for them. Adding a 30 years of retirement. With annual cash balance plan to the existing 401(k) 401(k) and profit-sharing contributions plan can squeeze 20 years of savings capped at $57,000, options seem into just 5 or 10 years. limited, especially for older physicians A Cash Balance Plan is a type of who need to save aggressively. Early IRS-qualified retirement plan known as in their careers, many physicians have a “hybrid,” since it combines the high priorities centered on school tuition contribution limits of a defined benefit and mortgage payments. Even later in plan with the flexibility and portability their careers when physicians focused of a 401(k) plan. This type of plan can on their retirement, they found that be an ideal retirement vehicle because there was no easy way to “catch-up” physicians can accelerate their savings, to accumulate an adequate nest egg yet there is a fair amount of flexibility; without having to continue to work. not everyone in a group has to receive The bottom line is it will require having the same contribution. Each participant $2 million in conservatively managed has accounts that grows annually in two assets to generate approximately
ways; first an employer contribution owner and employee contributions. and second an interest credit, which Like any other qualified plan, is guaranteed rather than dependent a Cash Balance Plan is subject to on the plan’s investment performance. non-discrimination testing. Employers This type of plan is an employer-only can anticipate contributions in the contribution plan and the employer range of 5% to 7.5% of pay for rank in contribution is determined by a formula file if the owners or partners receive the specified in the plan document. It can maximum Cash Balance contribution. The exact percentage required for be a percentage of pay or a flat dollar employees depends on the number of amount and can be offered in addition employees included in the plan and the to 401(k) Profit Sharing plans or other results of non-discrimination testing. plans the employer offers. In fact, in Cash Balance plans can be most cases, a 401(k) Profit Sharing plan amended periodically to permit different in conjunction with a Cash Balance contribution levels; additionally, a plan Plan is necessary to produce the desired see Money Matters page 18 ©2014 Tiff’s Treats
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Mental Health
ALCOHOL – SPECIAL AND DEADLY By Jason Powers MD, MAPP Chief Medical Officer Right Step & Spirit Lodge
costs, and criminal justice costs. Alcohol is special, albeit arbitrarily. Alcohol is certainly not the most benign Alcohol is special, but it’s not unique. drug human beings abuse, but since it’s To be sure, alcohol is a mind-altering been around the longest, it has simply had more time to ingratiate itself into abusable drug like cocaine and heroin. Ethanol, the active intoxicating our psyche. ingredient is a central nervous system After thousands of years, alcohol depressant drug. Like all drugs of abuse, has managed to become enmeshed in alcohol mainly exerts its effects and our cultural DNA. It is a necessary causes dysfunction in the mesolimbic component of many religious rituals. dopamine system (aka “the addiction Indeed, even under Prohibition, Jewish center”). Additionally, the signs and people were given special permission symptoms of alcohol addiction…scratch to purchase and possess wine. Every that, alcoholism, are just as predictable Sunday, wine is consumed in many and generally identical to every other Churches across the country, and who drug of abuse. could fault the Irish for drinking at wakes – funerals are painful! Birthdays, Amongst all the drugs of abuse, Anniversaries, New Year’s Eve, and alcohol addiction generally takes the St. Patrick’s Day are but a few other longest to develop. That is, people examples of alcohol’s prominence. Even can and do drink for decades before on other lesser-known holidays, such as alcohol addiction sets in whereas crack Arbor Day or Friday, alcohol is simply or methamphetamine addiction has a ubiquitous. very short gestation period. Alcohol is over-imbibed for so long in fact that it's Whether or not we drink the the only addiction which has a “high stuff, most of us at least recognize functioning” qualifier. I would bet that alcohol is a sacred ingredient of dollars to donuts you've never heard holidays, celebrations, and even religious anyone refer to himself or herself as a ceremonies. Of course, it feels pretty functional heroin addict. good as well. Alcohol is fully legal (only at 21 years of age) and alcohol drug dealers are still allowed to advertise on television, unlike nicotine drug dealers. Who could deny the ‘special-ness’ of booze? Alcohol is special - it’s the most commonly used mind-altering drug in the United States. But this popularity comes at a high price. Nearly 20 million Americans suffer with an alcohol abuse disorder. Millions more engage in high-risk drinking that very well could lead to alcoholism. Alcohol stands alone as the largest contributor to preventable causes of death in the U.S. - alcohol abuse disorders eliminate nearly 3 million years of potential life each year, or approximately 30 years of potential life lost for each death. Furthermore, alcohol costs us north of $185 billion annually in lost productivity, healthcare
The only reason why people are allowed to abuse alcohol instead of other drugs, even while maintaining respectable lives (often in marriages with a home and kids) is that alcohol is legal, sacred, and in a word: special. But its not unique – alcohol addiction is just as wretched as heroin addiction. So-called “high-f unctioning alcoholics” seem to maintain enough of a normal life semblance that their alcohol-related boo-boos are excused or overlooked. From my perspective, using “high functioning” to describe a chronic progressive and fatal illness is not only misleading, it’s negligent. The risks we take in accepting and permitting alcoholism to progress are too grave to ignore. As someone who sees more than a fair share of the bad stuff, early signs of alcoholism are more than cute red see Mental Health page 18 medicaltimesnews.com
November 2014
Houston Medical Times
Page 6
Wielding Nature’s Sword: Researchers at Texas A&M discover new treatments against drug-resistant infections By Lindsey Hendrix Texas A&M Health Science Center
Since World War II, antibiotics have saved countless lives by killing disease-causing bacteria. To this day, traditional antibiotics remain the
only treatment against such illnesses, but overuse and misuse have caused some bacteria to develop resistance to commonly used antibiotics. These bacteria, known as multi-drug resistant organisms (MDROs), are able to survive
Texas Southwestern Medical Center in Dallas, have the potential to kill MDROs. Specifically, the researchers have their sights set on methicillin-resistant Staphylococcus aureus(MRSA) – a bacterial infection caused by a strain of staph bacteria that’s become resistant to and even multiply in the presence of commonly used antibiotics, making it so antibiotics, making treatment against hard to treat, it’s been deemed a “super them nearly impossible. bug.” This discovery is predicted to yield Carolyn Cannon, M.D., Ph.D., pediatric an entirely new class of treatments for pulmonologist and associate professor at the But now, after decades of using the a multitude of drug resistant infections. Texas A&M College of Medicine same basic ingredients for antibiotics, a antimicrobials was originally isolated new way to treat bacterial infection is “Microorganisms have been battling by researchers more than a decade ago each other for millennia, so they have from a bacterium that originates from a whole armamentarium of ways to the ocean. Then, only tiny amounts kill each other,” said Cannon, who is could be extracted from cultures of the a pediatric pulmonologist and associate bacteria with great effort. Fast forward professor at the Texas A&M College to present day, and the current team of Medicine. “It’s just a matter of us now has developed a simple method noticing and isolating those weapons to synthesize the molecule and tweak it. and then synthesizing them for use as treatments against pathogens, the bad “The beauty of the discovery is guys.” that these compounds can now be synthesized in one pot in 30 minutes. Penicillin and cephalosporin – the finally on the horizon. Carolyn Cannon, bases for the most commonly used It’s a very scalable procedure that can M.D., Ph.D., and her team at Texas modern antibiotics – were first isolated easily yield large quantities,” Cannon A&M Health Science Center have from fungi. Most new FDA-approved said. “We have been able to take the discovered that a new set of compounds antibiotics are simply tweaks of those new compounds into the lab to study synthesized by medicinal chemist Lászlo original molecules. The first molecule their activity, and have found that they Kürti, Ph.D., with the University of of Cannon and Kürti’s new class of see Wielding Nature’s Sword page 20
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Healthy Heart
Healthy Choices, Smart Eating: How to End the ‘Eat Your Vegetables’ Fight By Apiyo Obala Director of Communications, American Heart Association
With the change in seasons fast approaching, now is a great time to focus on taking active steps to incorporate heart-healthy eating as part of your daily life. A healthier lifestyle starts with making smarter choices regarding food. Adopting a better dietary habits and choosing a varied combination of healthy foods is your first step towards better nutrition. A long life of heart health is about taking small steps each day to change how you eat and live. As those small steps add up, you’ll change
choices can add up to a big difference in your long-term health. Here are a few easy ways to incorporate some of these changes into your daily routine: ∙
Track what you eat. Keep a food diary or use technology to figure out what you’re eating and why. Identify opportunities to swap out sugary or salty snacks with fruits and veggies. Do you grab a bag of chips from the vending machine around 4 p.m. each day? Try bringing an apple or some veggie sticks with hummus to satisfy your craving.
∙
Start with foods you like. Not a huge fan of salads? Try working vegetables into foods you do
Page 7
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November 2014
Houston Medical Times
Page 8
UTMB prepared to help Texas fight Ebola As the situation regarding Ebola cases in Texas continues to develop, state officials are asking the University of Texas Medical Branch at Galveston to take a leadership role on several fronts to help combat the infectious disease. If necessary, UTMB is ready to provide clinical care for Ebola patients and to dispose of medical waste, said Dr. David L. Callender, president of UTMB. State officials have been discussing how UTMB, which has some of the world’s top Ebola researchers and is helping to develop a possible vaccine, can also lend its clinical expertise to combat the disease. “UTMB is uniquely positioned to help Texas deal with the Ebola situation,” said Callender
∙∙ UTMB safely has conducted Biosafety Level 4 research for 10 years, with no infections among those who work in its high-containment labs. ∙∙ UTMB is home to the National Biocontainment Training Center where scientists train to safely work in high-containment research laboratories all over the globe. The training center also care worker well before the first lends its expertise to UTMB’s Ebola case was diagnosed in clinical staff, making sure that Texas. all safety protocols are in place. ∙∙ UTMB is experienced in safely ∙∙ UTMB runs a Level I Trauma destroying medical waste. Center, capable of handling the UTMB does not have any patients most complex health emergencies. who have Ebola and has not been asked ∙∙ UTMB has been providing to accept such patients from elsewhere. specialized training to its health “But should we have a patient
suspected of having the virus, we are well prepared to provide quality care in a way that protects our employees and the community,” Callender said. He added that only UTMB health care workers who have received specialized training would be involved in caring for Ebola patients, if that became necessary.
ExxonMobil commits $10 million to MD Anderson’s cancer prevention and control initiative Gift to help Houston-area community reduce risk of cancer and other chronic diseases
ExxonMobil announced a $10 million grant to The University of Texas MD Anderson Cancer Center’s Moon Shots Program, an unprecedented, comprehensive initiative to significantly reduce deaths from cancer.
Children’s Hospital and $5 million to the Texas Heart Institute. “These world-renowned institutions are helping improve the health and lives of families in the Greater Houston area and that of other patients around the world, and we’re proud to support their important mission,” said Tillerson. “The grants will bolster their lifesaving medical research, prevention programs and patient care.”
Exxon Mobil Corporation Chairman and CEO Rex W. Tillerson shared the news at a press conference preceding the Greater Houston Partnership’s State of Energy luncheon at the Hyatt Regency downtown. He The MD Anderson grant supports also announced $8 million in additional the Healthy Community Initiative, health grants to two other Texas Medical developed by leaders of the Moon Center institutions: $3 million to Texas Shots Program’s cancer prevention and
control platform to encourage policies, serve as a model for other cities across education, behaviors and services that the state and nation. promote health and prevent cancer. “Just as ExxonMobil has made a MD Anderson will designate a significant economic impact on the targeted population in the Houston economy of the greater Houston area, area and collaborate with schools, so will it now have a powerful impact workplaces, clinics, social service on its residents’ health and well-being,” agencies, faith-based organizations and said Ron DePinho, M.D., president of neighborhood centers. Its purpose is MD Anderson. “With this leadership to implement strategies that promote gift we have the opportunity to make the healthy behaviors, improve health and vision of a healthy Texas a reality. We’re prevent disease by reaching children grateful for ExxonMobil’s generosity to and families with information, activities MD Anderson, its commitment to our and services that reduce their risk of community and its partnership in our developing cancer and other chronic mission to end cancer.” diseases. It’s hoped that the project will
CHI St. Luke’s Health and Aetna Reach Agreement, Sign Multi-Year Contract New contract secures access to high-quality care for Aetna patients in Houston
“Healthy partnerships with insurance companies have become even more essential in not only protecting patient access, but also in building and maintaining high-quality patient care. This partnership with Aetna “On behalf of CHI St. Luke’s will better support our mission to we’re very pleased to announce continually improve our healthcare our new contract with Aetna that offerings to the Houston community.” Details of the new agreement will ultimately benefit thousands have not been disclosed; however, of patients’ access to care,” said With a new agreement in place, both CHI St. Luke’s and Aetna have Deborah Lee-Eddie, Interim Chief patients with Aetna insurance can stressed the importance of having Operating Officer, CHI St. Luke’s. continue to see their physicians at a strong partnership to best meet CHI St. Luke’s Health (CHI St. Luke’s) announced a new, multi-year agreement that will ensure continued in-network access to all CHI St. Luke’s hospitals and facilities for patients with Aetna health insurance, effective immediately.
November 2014
patient needs. The agreement also is expected to help ongoing efforts at CHI St. Luke’s to improve care qualit y, while reducing overall healthcare costs.
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CHI St. Luke’s hospitals and facilities as they have, without any disruptions. The agreement comes well before the original deadline for negotiations. To confirm in-network benefits, CHI St. Luke’s recommends that patients call the phone number for customer service on the back of their Aetna insurance card. For more information and a full list of locations, visit stlukestexas.com.
Houston Medical Times
Page 9
Marketing Essentials
Flu Shots Are a Marketing Opportunity (But Competition is Tough for Doctors) By Lonnie Hirsch Co-founder, HealthCare Success Strategies
Perhaps the idea of promoting “flu shots” isn’t particularly “glamorous” in healthcare marketing. Some doctor’s offices, healthcare providers (and marketing professionals) consider vaccinations and immunizations as ordinary and routine as remembering to turning off the lights at night. Nobody gives it much thought. Preventative care and patient wellbeing
are at the top of the list, but in addition, here are some new reasons to rethink the importance of “flu shots” as a healthcare marketing opportunity. It seems like everyone wants a slice of the pie. Most people—particularly those who should—don’t get flu shots. Professionals understand the health risks, and despite ongoing efforts to inform the public, the Centers for Disease Control and Prevention (CDC) reports that only 46 percent of Americans got flu shots last year. Vaccination rates are even worse in certain age categories, according to this detailed article in USA Today. In their published report, USA Today observes: “At a time when many people are preoccupied with the dangers of Ebola and a rare respiratory virus striking children, [the CDC] announced that fewer than half of Americans are being vaccinated against the flu, which kills an average of more than 30,000 people a year.” Competition from non-doctors’ offices has skyrocketed (and is still climbing). Virtually every pharmacy in the neighborhood now provides vaccinations, and these and other “non-doctor-office” options are devouring market share. Convenience alone is a big sell-point for consumers who can easily find flu shots available inside supermarkets, big-box retailers, drug stores, shopping malls and,
for many, at their workplace. A widely circulated article from the Associate Press reports: “The nation’s biggest drugstores and other retailers are grabbing larger chunks of the immunization market, giving customers options outside the doctor’s office to protect themselves against the flu, pneumonia and other illnesses. Nearly half of all flu vaccines provided to adults are now administered in non-medical settings like drugstores or worksite clinics.” [TwinCities.com HEALTH] By the way, it’s not just flu shots. Competition from non-medical settings— particularly the nation’s largest pharmacy chains—includes ongoing promotional
messages about vaccinations including: ∙
Chicken Pox
∙
Hepatitis A and Hepatitis B
∙
HPV (Human papillomavirus)
∙
Meningitis /Meningococcal
∙
Pneumonia (Pneumococcal)
∙
Shingles (Herpes zoster)
∙
Whooping Cough (Pertussis)
What you’re up against…. Unlike doctor’s offices, pharmacies and others don’t require an appointment, and in fact, sometimes the flu shot decision is an “impulse buy” that is born out of convience in non-medical settings. It’s usually quick and it’s often paid for by insurance. What’s more, “needle-free” options—such as patches and nasal spray appeal—are appealing to many individuals. From a marketing perspective, nearly everyone needs a flu shot and potential market is still underserved. And if that’s the marketing opportunity “good news,” the other news is that doctors and other providers are up against tough and growing competition. www.healthcaresuccess.com medicaltimesnews.com
November 2014
Houston Medical Times
Page 10
If the Cost of a Medication Is Too Good to Be True, the Drug May Be Counterfeit been FDA-approved are still illegal to use. Physicians and their office staff may inadvertently order counterfeit drugs or devices. Follow these tips to protect yourself and your patients from the risks of illegal medications and devices: By Thomas T. Kubic, Treasurer, Partnership for Safe Medicines, and Susan Shepard, MSN, RN, Director, Patient Safety Education, The Doctors Company
In the past few years, a number of developments have occurred, including drug shortages and patients having trouble affording their prescriptions, that might seem to justify importing medications from overseas. The world outside of U.S. borders appears to offer a ready supply of cheaper medications easily obtained through unlicensed distributors, trips across the border, or online pharmacies. The laws that prohibit importing non-FDA-approved medicines are designed to ensure that patients receive medications that meet the FDA’s requirements for safety, purity, and potency. Under the Federal Food, Drug, and Cosmetic Act, it is illegal to import unapproved, misbranded, adulterated, or foreign versions of U.S.-approved medications into the country. The law also applies to medical devices such as intrauterine devices, which, along with oncology drugs and cosmetic injectables, are commonly involved in legal actions against physicians concerning counterfeit items. Every healthcare professional who purchases medications is familiar with daily price-list faxes from persistent direct sales companies. Regardless of the supplier, purchasing or using non-FDA-approved drug products exposes the physician to criminal and civil liability. Medical malpractice insurance may not cover any errors in this area—making physicians personally liable for claims that they provided counterfeit drugs.
∙∙ Require training for everyone involved in purchasing medications. ∙∙ Be wary of fax or e-mail blast offers from an unauthorized distributor selling “discounted” foreign medications or devices. ∙∙ Have clear policies that dictate how to verify the license of a wholesaler providing medications. For example, require that your staff verify all vendors by checking wholesaler accreditation and licensing at http://safedr.ug/ VAWDaccredited and http:// safedr.ug/fdalicense. ∙∙
Obtain medications only from secure sources.
∙∙
Know the warning signs that a product may be counterfeit:
∙∙
Are prices or deals too good to be true?
∙∙
Was the fax/e-mail offer unsolicited and from an unknown seller?
∙∙
Is the labeling in a foreign language when it’s normally in English?
∙∙
Is the package damaged or soiled?
∙∙
Are all tamper seals present and intact?
∙∙
If in doubt, call the manufacturer to check if the lot number is still valid and matches the expiration date.
∙∙
Educate patients about avoiding counterfeit drugs with free resources like the S.A.F.E.D.R.U.G. checklist at www.safemedicines.org/ safedrugs.html.
The medication doesn’t even have to be counterfeit for the physician to suffer legal consequences: Medications that have the correct ingredients but haven’t ∙∙
November 2014
Identify at-risk patients who may be purchasing
medicines online and discuss with them the risks and challenges of buying medications over the Internet. ∙∙
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Dispense free samples of brand name drugs so
that patients can establish a baseline of the medicine’s characteristics, including appearance, taste, texture, reactions, and packaging.
Houston Medical Times
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New Affordable Care Act tools and payment models deliver $372 million in savings, improve care
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Centers for Medicare & Medicaid Services (CMS) issued quality and financial performance results showing that Medicare Accountable Care Organizations (ACOs) have improved patient care and produced hundreds of millions of dollars in savings for the program.
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patient experience this year. (Please see the accompanying fact sheet for additional details.)
“We all have a stake in improving the quality of care we receive, while spending our dollars more wisely,” Health and Human Services Secretary Sylvia M. Burwell said. “It’s good for In addition to providing more businesses, for our middle class, and for Americans with access to quality, our country's global competitiveness. affordable health care, the Affordable That’s why at HHS we are committed Care Act encourages doctors, hospitals to partnering across sectors to make and other health care providers to progress.” work together to better coordinate Memorial Hermann Accountable care and keep people healthy rather Care Organization is eligible to share than treat them when they are sick, in savings. “A collaborative program which also helps to reduce health care like this is second nature to Memorial costs. ACOs are one example of the Hermann,” said Chris Lloyd, CEO
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innovative ways to improve care and reduce costs. In an ACO, providers who join these groups become eligible to share savings with Medicare when they deliver that care more efficiently. ACOs in the Medicare Shared Savings Program (Shared Savings Program) and Pioneer ACO Model generated over $372 million in total program savings for Medicare ACOs. The encouraging news comes from preliminary quality and financial results from the second year of performance for 23 Pioneer ACOs, and final results from the first year of performance for 220 Shared Savings Program ACOs.
of Memorial Hermann ACO. “Our Clinically Integrated network, which we launched in 2007, was focused on bringing together high quality physicians who collaborate to provide the best clinical outcomes to our patients. When the ACO model was announced, we were already ahead of the game. We had an established group of physicians with access to innovative technology working together to ensure high quality outcomes at the lowest cost possible.”
Since passage of the Affordable Care Act, more than 360 Medicare ACOs have been established in 47 states, serving over 5.6 million Americans with Medicare. Medicare Me a nw h i le , t he AC O s ACOs are groups of providers and outperformed published benchmarks suppliers of services that work together for quality and patient experience last to coordinate care for the Medicare year and improved significantly on fee-for-service (FFS) beneficiaries they almost all measures of quality and serve and achieve program goals. November 2014
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November 2014
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Houston Medical Times
Treatment of vein disease in 2014 By Michael Bardwil, M.D. Texas Vein & Cosmetic Specialists
In recent years, there has been a transition from traditional surgical procedures, which involved making standard incisions to perform the operations, to minimally invasive surgical procedures, which involve smaller incisions, and quicker return to normal activity. No place is this transition more than apparent in treatment varicose veins and venous insufficiency. This is fortunate, because the number of Bulging Varicose Veins Americans affected by varicose veins has been estimated at about 25 million.
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Proper treatment begins with proper diagnosis. Thus, the biggest advance in treating vein problems has been the increased use of venous ultrasound the office setting. Even radiologists have acknowledged that 94 % of the ultrasounds that are performed in the hospital have not been performed properly. This is not surprising, because even though vascular surgeons developed vascular ultrasound, when venous ultrasound is performed in the hospital setting, the studies are performed in the radiology department, and most radiologists lack the Registered Physician in Vascular Interpretation (RVPI) credential. Also, the technician performing the exam may not have their vascular certification. (RVT). For vascular surgeons the venous ultrasound has become an extension of the physical exam, and most of vascular surgeons who treat patients with vein problems, perform the ultrasound study themselves. Vascular surgeons like Dr. Bardwil are credentialed to perform the ultrasound, because not only have the RVPI credential, to interpret the vascular ultrasound, but they are also credential as registered vascular techs, (RVT).
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The diagnosis of venous insufficiency is made by patient history, and the physical exam, and confirmed by ultrasound. Rarely are other studies or tests required. Venous insufficiency is usually not difficult for an experienced vascular surgeon to diagnosis. Regarding the treatment of venous disease, it has long been established,
November 2014
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Varicose Veins with Leg Swelling
that the treatment involves elimination of abnormal veins. Interestingly, eliminating the abnormal veins actually improves the circulation. The principals for treatment haven’t changed, but what have changed are the techniques involved in eliminating the abnormal veins. Procedures which once required an operate room with a general anesthetic, are now performed in an office setting utilizing local anesthesia. The procedures are staged and subsequent procedures are only performed if necessary. This results in fewer incisions. The Saphenous vein, which was previously stripped, is now closed with a laser. The technique of the procedure involves using ultrasound guidance to insert the laser fiber into the vein, advancing it up the leg, and verifying the proper position of the laser fiber. Ultrasound is then used to direct injection of local anesthesia along the vein intended for closure. The laser is then activated and slowly withdrawn. see Vein Disease page 22
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What You Don’t Know About Hospice Care Could Hurt You By Karla Goolsby Houston Hospice Communications
The truth is, most people don’t think about hospice at all until it becomes a necessity. The concept of hospice is relatively new in the United States. However, as the number of hospice providers grows, with varying degrees of quality, it’s important to be informed. Hospice places its emphasis on quality of life with care that’s tailored to the unique needs
Health, Education, and Welfare task force noted both the altruistic and practical advantages of government support for hospice care: “The hospice movement as a concept for the care of the terminally ill and their families is a viable concept and one which holds out a means of providing more humane care for Americans dying of terminal illness while possibly reducing costs. As such, it is the proper subject of federal support.” In 1982, Congress included a provision to create a Medicare hospice benefit in the Tax Equity and Fiscal Responsibility Act. With hospice services covered
Dear Doctors and Staff,
of each individual and their support network. When curative treatments cease to help, the relief of palliative care can bring a new form of hope for terminally ill patients and their families, as hospice services help them make the most of their time together. In 2007, research published in the Journal of Pain and Symptom Management reported that hospice patients lived an average 29 days longer than similar patients who did not have hospice care. When it came to the United States from England in the 1970s, the hospice movement began as a grass-roots campaign to address the unmet needs of patients with terminal illnesses. The benefits of this care were quickly recognized by the medical establishment. In a 1978 report, a U.S. Department of
by Medicare, what started as a purely charitable movement became a probable source of revenue. As a result, the number of for-profit agencies entering into the business of hospice has grown exponentially, with alarming results. An article published by the Washington Post on May 3, 2014 entitled “Terminal neglect: How some hospices treat dying patients” reported that the quality of care provided by hospices varies widely. A Washington Post investigation analyzed Medicare billing records for over 2,500 hospices, obtained an internal Medicare tally of nursing care in patients near death and reviewed complaint records at hundreds of hospices. At many hospices, they discovered that little care was provided for patients most in need. The investigation ascribed this absence of care to skimping on see Hospice Care page 22
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November 2014
by a staff of professionals who are experienced in assessment of clinical situations. To help patients who call, nurses use their training, experience, evidence-based decision-support tools, and peer-reviewed materials to conduct Get help with both kid and their assessments. adult medical complaints. While manned by staff from Decide when and where to go Memorial Hermann Health System, the for treatment. Nurse Health Line is funded through Get help after your doctor’s the Center for Medicare and Medicaid Services and Texas Health and Human office has closed. Services Commission and open to Find a better way to get medical everyone. care than sitting for hours in It is not designed to assist an emergency room. with life-threatening conditions or Figure out options to treat a emergencies. People with life-threatening sick child. conditions and emergencies should Talk over your health concerns immediately call 911.
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Legal Health
Continued from page 3 no means of transportation to a health care provider will never be able to obtain the necessary transportation to develop a relationship. b. Cost Sharing for Emergency Ambulance Services Over the years, the OIG has issued numerous advisory opinions on the issue of the reduction or waiver of coinsurance or deductible amounts owed for emergency ambulance services. The OIG now proposes to establish a
new safe harbor for cost sharing waivers as long as certain conditions are met, including but not limited to, that the ambulance provider or supplier must be owned and operated by a state, a political subdivision of a state or a federally recognized Indian Tribe. The proposed safe harbor does not address either for-profit or not-for-profit (but not government operated) ambulance providers offering such waivers, even if the other conditions of the safe harbor are satisfied, and even if the ambulance
provider is operated pursuant to a federal, state or municipal contract. This is an issue for which non-government ambulance providers should consider submitting comments. The OIG has recognized that emergency ambulance services have inherent safeguards that warrant special treatment in a number of Advisory Opinions, and these safeguards exist irrespective of whether the ambulance supplier is operated by
a governmental authority. 3. Conclusion The OIG will be accepting comments on the Proposed Rule until 5:00 pm on December 2, 2014. Stakeholders are encouraged to provide public comment to the OIG regarding these proposals. Comments should address significant challenges related to implementation of the Proposed Rule and provide detailed suggestions based on experience with similar requirements.
Money Matters Continued from page 4
can also be frozen or terminated. As with other retirement plan distributions, any vested account in a Cash Balance Plan can be paid as a lump-sum distribution or annuity. A lump sum distribution can also be rolled over to an IRA or another qualified retirement plan. Although it may appear that Cash Balance Plans are more expensive to set up and maintain than 401(k) Profit Sharing plans, Cash Balance Plans are typically more cost-effective. Because of the legal contribution limits imposed on
401(k) Profit Sharing Plans combined with hidden fees to cover the high cost of plan administration, 401(k) plans are a more costly way to deliver retirement savings. Cash Balance Plans ultimately help employers and participants save more with significantly higher tax-deferred contribution limits and major tax deductions.
grow tax-free until distribution. Contributions are age-weighted, with higher contributions for those closer to retirement. Additionally Qualified Retirement Plans remain a premier asset protection vehicle.
Any entit y can sponsor a Cash Balance Plan which includes individuals and partnerships. Get Tax deferral is one of the many additional information from your tax advantages of a cash balance plan. All professional on the tax deductions contributions are tax deferred, reducing and allocations of plan contributions both ordinary income and adjusted for partnerships made on behalf of gross income (AGI). Account balances
non-partner employees and partners. A report from 2014 National Cash Balance Research done by Kravitz shows growth in these plans have soared by 22%; the most recent rise in taxes is certainly driven part of this growth. The research has also shown California and New York have the most plans, while the fastest growth is in Texas and Florida. Medical and dental groups account for 39% of all Cash Balance Plans nationally. It would be prudent to have an expert complete a study for your medical practice or group.
Mental Health
Continued from page 5 flags or signs of occasional excess - they are downright frightening. Alcoholism is a deadly disease. Period. On a larger scale, Einstein commented that humankind wouldn’t perish at the hands who do evil deeds, but by those who stay silent. High functioning alcoholics, like despots, can trudge along for a long time. Alcoholism is progressive, which means sooner or later something horrible happens. Eventually, alcohol abuse will cause one or major crises, such as a driving under the influence arrest, loss of employment, or divorce. Sooner or later, one or more persons cannot remain silent. The pain of watching a loved one suffer is horrible. At that point, the lucky one’s become people of interest…to the police, their partners, or their friends. The others, those who aren’t so fortunate, end up November 2014
in jail or dead.
but addiction has no mercy. Addiction Surgeons have been known to operate robs its host of volition and suffocates even though they smell like booze and I joined one of the lucky ones when, authentic inter- and intra-personal shake. on June 8, 2003, my friends and family connections. Admittedly, it’s difficult to notice staged an intervention just like you see and intervene on people who have on TV. I fell so far down the rabbit Alcoholism is not a disease that powerful positions such as pilots or hole that had they remained silent, I cares about your socioeconomic surgeons because they aren’t closely would be dead. position, either – it can and does monitored and there is always a fear of On many levels, I was a very affect anyone. Several high-profile repercussions. “What can I do?” you “high-functioning” alcoholic. I was “high-functioning” alcoholics who have may ask. The answer is this: a lot. not only employed, I had a boutique publicly acknowledged having alcohol Most importantly, if you witness private practice with quite a few A-list abuse disorders include Robert Downey, alcoholism and remain silent, you are patients. But in terms of well-being, I Jr., Betty Ford, and former President essentially aiding and abetting the deadly was extremely low functioning. Like so George W. Bush. As healthcare workers, disease of alcoholism. Just as alcoholics many others with addiction, I suffered we may not interact regularly with the likes of Downey, but we do see more avoid seeking help because they fear unspeakably agony. alcoholism than most people, even if we the repercussions, people who witness Approximately half of all alcoholics don’t know what we are seeing. alcohol abuse and do not speak up, may are “high-functioning”…but only on be killing with their silence. Healthcare professionals have a the outside. The hidden agony happens While “high-functioning” alcoholics inside, where no one can see. Being higher risk of developing alcoholism than may not be physically addicted to alcohol, out of integrity with oneself is bad the general population. The trouble is, abstaining for long periods of time without enough without the pain of isolation, like pilots, alcoholic healthcare workers put other people’s lives in grave danger. see Mental Health page 20 medicaltimesnews.com
Houston Medical Times
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Page 20
Houston Medical Times
Mental Health
Continued from page 20 experiencing withdrawal symptoms, they are nonetheless psychologically dependent. This psychological piece often provides clues they’re headed for a crisis, such as blackouts, elaborate excuses for their drinking and behaviors, or frequent severe hangovers. Some signs are obvious, but many are subtle. For example, if you’re worried about someone’s drinking, ask yourself if he or she is willing to attend functions where alcohol is served but reluctant to go anywhere if there isn’t any, Alcoholism is characterized by a combination of hard to define subjective and objective criteria; and science cannot measure the point at which overuse or even abuse turns into alcohol addiction. How much, how often, and even how long you drink are not as important as what happens 1) when you drink, 2) after you drink, and 3) in your head. Thoughts and actions matter most. Alcoholism includes craving - a tenacious and powerful urge to drink; tolerance the need to drink more in order to achieve the same desired effects (get buzzed or wasted); loss of control - inability to stop
or limit drinking once its started and the inability to predict what happens once you start drinking; substantial impairment in life arenas (relationship, occupational, educational, physical, and leisure); and physical dependence reflected by withdrawal symptoms when one-to-three days pass in between drinks (i.e., shakiness, irritability, nausea, sweating, and anxiety). Alcohol is not de facto bad. Like my wife who can take it or leave it, most people who drink aren’t alcoholics and never will be. However, many of us aren’t as fortunate - millions of Americans are at risk of losing themselves to booze. Early identification and intervention (instead of waiting until its too late) prevents the unnecessary pain and suffering of irreversible complications, such as brain damage, liver disease, legal problems, divorce, unemployment, and death. The beauty of expressing your concerns is that it shows them you care. Don’t stay silent if you even suspect someone is headed down the rabbit hole. You’re words are more powerful than you imagine.
Wielding Nature’s Sword Continued from page 6
are more active against MRSA than the gold-standard treatment, vancomycin. Plus, we have found compounds with better activity than the compound made by the bacterium from the ocean.” These constitute a completely new class of antimicrobial molecules that don’t look like anything else currently used in medicine.
bacteria are on the micrometer scale, averaging about a micron or two long. Even the largest nanoparticle – one that is 100 nanometers – is merely a tenth of a micron. Because they are so small, these nanoparticles contain some very useful properties. For instance, they can be designed to slip through sticky mucus and penetrate into biofilms. They can be synthesized from polymers, large While modern-day antibiotics molecules composed of many repeated readily go into solutions that can be subunits, designed to be broken down injected, inhaled or ingested, these new in the body. molecules are not water soluble. That factor may seem like a major barrier, but “Think of a microscopic baseball thanks to new nanoparticle technologies, with a rubber center covered by yarn, what was once an obstacle has become a then cowhide. Our otherwise insoluble momentous opportunity that Cannon’s antibiotic contained in the ‘rubber group, as part of a National Institute center’ is shielded by a water-loving of Health’s Program of Excellence in hydrophilic surface, the ‘yarn,’ which Nanotechnology, has the expertise to renders the nanoparticle compatible seize. with suspension in a solution. You can Nanoparticles are simply particles that decorate the outside, the ‘cowhide,’ with exist on the nanometer scale (anything molecules that specifically bind to the up to 100 nanometers is considered a surface of bacteria to allow accumulation nanoparticle). As a comparison, most November 2014
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see Wielding Nature’s Sword page 21
Houston Medical Times
Wielding Nature’s Sword
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1315 St Joseph Pky
Continued from page 20
which is huge.”
Healthy Heart
Continued from page 7 diet. Not only do they help you get on the healthy eating bandwagon feel full and sustain energy with these tips: between meals, they can also Make it easy to grab. After you buy help prevent stroke. groceries, prepare a week’s worth of ∙ Make it veggie. Go meatless veggie sticks or cut up a melon in bite-size once a week. Try using hearty chunks. Put them in clear containers so portobello mushrooms instead they’re easy to spot in the fridge when of meat for a burger or other you’re making lunches or your kids are favorites such as spaghetti and looking for snacks. lasagna. Give yourself shortcuts. Weeknight ∙ Think toppings. Slip a handful dinners can be hectic with work, school of vitamin-rich spinach into a and kids’ activities. Give yourself a break sandwich. Add dried or fresh by buying frozen or canned vegetables fruit to your cereal or yogurt. you can toss in the microwave. Fresh, frozen and canned can all be healthy Healthy eating is a family affair! choices. Compare food labels and choose items without sauces and too When you get home from a long much sodium. day at work, the last thing you want to do is wage war over broccoli at the Make fruit and vegetable shopping dinner table. That’s why it’s so easy to fall fun. Visit your local farmers’ market into the trap of making mac-n-cheese or or grocery store with your kids. Show ordering pizza. It keeps you out of an “eat them how to select ripe fruits and fresh your vegetables” fight. The good news vegetables. Let them pick out new ones is, eat a nutritious meal doesn’t have to to try. be a battle. Don’t be afraid to include your kids in the prep work. By being Be a role model. Try to eat together involved in grocery shopping and food as a family. If you’re eating (and enjoying!) preparation, your kids will have more a wide range of fruits and vegetables, ‘buy-in.’ if they feel some ownership they’ll be more likely to try them. over the meal, they may be more likely to eat it. It may take some effort and Offer healthy options. Instead of creativity to get kids to choose fruits and asking “What would you like to eat?” vegetables instead of the sweet and salty offer healthy choices. Let them choose processed snacks they see advertised. between a banana, strawberries with Just remember that developing good cereal, or ask them if they want carrots eating habits young helps set the stage for lifelong heart health. Help your family
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of the drug at the site of the infection. not the entire body. This nanoparticle delivery is much more targeted than traditional antibiotics,” The next step for Cannon’s team Cannon said. is to test nanoparticles containing the antimicrobial molecules in animal Targeting in this precise manner models, which, she says, is very close allows for a dramatic drop in the amount to happening. of medication that a patient needs in order to kill infection. Further, targeting “This really is a game changer in may spare beneficial bacteria that are the battle against these enemies we can’t often killed secondarily by traditional see with the naked eye,” Cannon said. delivery of antibiotics that are dispensed “Now, we have a weapon that is even throughout the body. What’s more, more precise than those of their natural targeting may allow for the use of more enemies that have been killing them for potent drugs, since the drugs would eons. We can zero in on and eliminate merely affect the site of infection and them with almost no collateral damage,
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see Healthy Heart page 22
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Houston Medical Times
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Healthy Heart
HOUSTON
Continued from page 21 or broccoli with dinner.
casseroles.
Have fun. Spear some fruit chunks Be patient. Kids’ tastes change over on a kabob or create fun shapes with time. Keep offering fruits and vegetables cookie cutters. and don’t give up! Many kids need to Sneak it in. Fortify your family’s see and taste a new food a dozen times favorite recipes with fruits or vegetables. before they know whether they truly Add grated or pureed carrots or zucchini like it. to muffins, pasta and pizza sauces, and
National Eating Healthy Day is
on Wednesday, November 5. The American Heart Association has great resources available online that can provide more information on setting diet goals, heart-smart shopping, healthy cooking, dining out, and recipes. Visit us online at: www.heart.org/NationalEatingHealthyDay. Join the conversation online and tag us in your discussion with #houstoniswhy #NEHD.
Vein Disease
After a short period, the patient’s legs are re-examined. Visible varicose veins will have shrunk. If there are any residual bulging varicose veins, they are eliminated either by making 2-3 mm-sized incisions and removing, or by injecting them with solutions to shrink them. All of this is performed in the office. This technique, for treating veins,
has been used for over ten years and has an established record of success. However, the quest for improvement is unending. The latest development in the treatment of vein disease has been the introduction of Varithena, which was approved by the FDA, for use in the United States in February 2014, and released in August. BTG, the manufacturer of Varithena, has chosen to initially restrict access of this product, only those physicians, with the most experience in treatment of vein disease. Because of his reputation for treating veins, Dr. Bardwil was asked to be one the first vascular surgeons in the United states to use Varithena. On September 22, Dr. Bardwil performed the first Varithena treatments in Houston. Both
of the treated patients were pleased with the ease of the procedure, and the results. Varithena is a prescription medication, which is injected directly into the abnormal veins, by using the ultrasound to direct placement. It works to chemically destroy the abnormal vein. The advantage to Varithena is that no anesthesia, not even local anesthesia is required. Not all patients are candidates to have their veins treated with Varithena, The long-term results aren’t known yet, but the early results are promising. At this time, Dr. Bardwil sees Varithena as an additional tool in the treatment of vein disease. http://txvein.com/
Hospice Care
Continued from page 15 nurses, and to the failure of these hospices to have access to a facility where continuous crisis care could be provided. The investigation found that about 18 percent of U.S. hospices did not provide a single day of crisis care. The investigation noted that the absence of crisis care at those hospices stands in stark contrast to most others, where such care is common. Medicare payment rates and their unintended financial incentives may be responsible. Providing routine care such as semiweekly nursing visits can be very lucrative. However, symptom management that requires continuous nursing care or inpatient care can be financially draining and logistically problematic, especially for smaller
November 2014
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Continued from page 14 The heat closes the abnormal vein. The patient is awake during the procedure, and walks immediately following the procedure. Number and size of incisions is greatly reduced. This procedure has the same effect as stripping the saphenous vein, but is less traumatic.
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show that profit-making has trumped patient care in Medicare's home health An area of great concern is the program, that's no surprise. A large burgeoning growth of home health body of research on hospitals, nursing care businesses that offer hospice. homes, dialysis facilities, and HMOs "For-profit home care agencies are has shown that for-profits deliver bleeding Medicare; they raise costs inferior care at inflated prices." by $3.3 billion each year and lower the Researchers believe that most quality of care for frail seniors," said hospices are providing quality care Dr. Steffie Woolhandler, professor of public health at CUNY's Hunter and many nurses in the field consider College, lecturer at Harvard Medical palliative medicine as much a calling School. "Letting for-profit companies as a job. When the hospice movement into Medicare was a huge mistake that took root in the United States, hospice practitioners were typically Congress needs to correct." part of religious groups, or were William Cabin, assistant professor community-supported like the Texas of social work at Temple University Medical Center’s Houston Hospice. and lead author of a nationwide However, since for-profit businesses study published in the August 2014 have come to dominate the industry, issue of the journal Health Affairs early planning and investigation of said, "While our study is the first to hospice care options is a necessity. medicaltimesnews.com
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