Physician Exclusions From Medicare, Medicaid Increasing

Federal efforts to detect Medicare fraud may be driving an increase in the number of physicians excluded from Medicare and other forms of public insurance, according to the authors of a newly published study.

The number of physicians excluded from Medicare, Medicaid, and other state public insurance programs increased on average by 20% per year, or the equivalent of 48 additional cases a year, between 2007 and 2017, said Anupam B. Jena, MD, PhD, of Harvard Medical School and colleagues. They report their findings in an article published online today in JAMA Network Open.

“There were several explanations for the observed increase in exclusions, and rates of identified health care fraud, waste, and abuse,” Jena and colleagues write. “First, this finding could be evidence that regulators, who have been aided by recent public policies targeting the reduction of fraud and waste, may be getting better at identifying perpetrators of fraudulent activity.”

Since 2011, the Centers for Medicare & Medicaid Services has used predictive analytics to detect improper billing, the authors note. In addition, the Affordable Care Act of 2010 allocated $350 million to the Department of Health & Human Services’ Health Care Fraud and Abuse Control Account. The law also increased sanctions, including allowing state Medicaid programs to halt payments and requiring that Medicare overpayments be returned within 60 days instead of 3 years.

Jena and colleagues also cite the growth in the total number of US physicians participating in public insurance as a possible cause for the rising number of exclusions.

The implementation of the Affordable Care Act of 2010 allowed more people to gain access to public insurance programs. Enrollment in any government health insurance plan increased by 12.6% total from 2013 to 2017, which is significantly greater than the 7.9% increase in private insurance enrollment, the authors note.

“We cannot exclude the possibility that the increase in physician exclusions reflects a rise in fraudulent and untoward practices by US physicians,” the authors add. “However, we are unaware of any published data that support this potential explanation.”

Overall, the researchers found that 2222 physicians, or 0.3% of US physicians, were temporarily or permanently excluded from Medicare and state public insurance programs between 2007 and 2017 for fraud, unlawful prescribing of controlled substances, or health crimes.

Physicians can be excluded from Medicare and other public insurance programs for a variety of reasons. Common causes include the illegal distributing, prescribing, and dispensing of controlled substances such as opioids and surgical anesthetics. Other reasons include billing for services not rendered and filing duplicate claims and providing medically unnecessary procedures.

Jena and colleagues describe their study as “the most comprehensive and contemporary effort to assess trends in physician exclusion from participation in public health insurance owing to fraud, waste, and abuse concerns, and physician characteristics associated with exclusion.”

For the analysis, they matched each physician’s unique national provider identifier to their profile in Doximity, an online networking service that collects personal and professional information about physicians.

The authors found notable variation in the rates of exclusion, which were highest in the West and Southeast. With 32 exclusions among 5720 physicians, West Virginia had the highest rate of exclusions at 5.77 per 1000. Montana, in contrast, had 0 exclusions during the study period.

“Several physician characteristics, including being a male, older age, and osteopathic training, were significantly and positively associated with exclusion,” the authors said.

Radiologists Did Most Stroke Thrombectomy In Early Days

But most had neurointerventional training in Medicare data up to mid-2015

As clinical trial evidence turned the corner for mechanical thrombectomy in 2015, what few procedures were done remained solidly the province of radiologists, a study of Medicare data showed.

Looking at a nationally representative 5% sample of Medicare beneficiaries between January 1, 2009, and September 30, 2015, only 555 thrombectomy procedures for acute ischemic stroke were done among nearly 78,000 stroke hospitalizations.

While 61.4% of them were done by radiologists, an equally high proportion of operators had dedicated neurointerventional fellowship training (66.1%), albeit of unknown type or quality, Hooman Kamel, MD, Weill Cornell Medical College in New York City, and colleagues reported here at the International Stroke Conference and online in JAMA Neurology.

Neurologists and neurosurgeons roughly split the rest not done by radiologists — 19.8% and 16.4%, respectively — along with a sliver (2.4%) done by an assortment of other physicians.

“Clinician characteristics did not change significantly after December 17, 2014, when the first trial to show a clinical benefit for thrombectomy was published,” the researchers noted in the paper.

Early in 2015, a subsequent series of trials confirmed that, with advanced imaging-selection of patients, mechanical thrombectomy held a significant outcome benefit for large vessel strokes, kicking off a rapid uptake in the procedure.

How the workforce doing these procedures might have changed since the end of the study period isn’t clear.

Kamel’s group pointed to arguments “that a workforce shortage exists that could be filled by non-neuroscience clinicians with expertise in catheter-based procedures. Neurointerventionalists have countered that they are available to most U.S. patients, but vascular neurologists have nevertheless raised concerns about a shortage.”

“I know in my own institution right now, radiologists aren’t doing the procedures,” commented Ralph Sacco, MD, of the University of Miami, and president of the American Academy of Neurology.

“Radiologists are phenomenally good at working with catheters and often they are part of a team,” he told MedPage Today, “but it’s hard to say, and I’ve never seen differential data regarding outcomes by radiologists, a neurologist, or even interventional neurosurgeon.”

A lot of the future landscape may be up to trainees, Sacco noted. “It’s hard to say what the landscape will look like in the future. But our belief is that more neurologists will become interventional neurologists … Obviously, the demand for more people to do interventional procedures is rapidly rising.”

The researchers suggested that their study may help “inform plans for optimizing systems of acute stroke care across the United States.”

Medicare Is Getting A Serious Makeover

Medicare wants to shift away from paying doctors according to number of visits, procedures, hospitalizations, and tests — and toward paying for performance.

This week, Medicare officials unveiled an ambitious plan to do just that. The nearly thousand-page report proposes an opt-in track for doctors called the “merit-based incentive payment system” (MIPS), designed to reward or penalize them based on their performance. The proposal would also pay doctors to try out Medicare’s alternative payment models — non-traditional (and hopefully money-saving) new ways for the public health program to reimburse doctors.

The proposal is the first step toward what could be the biggest update to Medicare in its 50-year history. It’s part of a bigger plan to tie as much as half of doctor payments to patients’ health outcomes by 2019.

Proponents of the proposed “pay-for-performance” system say that Medicare’s traditional “fee-for-service” system is too costly and encourages waste. Under fee-for-service, doctors are paid a flat free for every test or procedure they perform, regardless of whether those services actually improve their patients’ health. As a result, doctors may administer expensive medical tests even when there’s little chance these tests will find a tumor or disease — and taxpayers end up footing the bill.

Medicare wants to save taxpayer dollars by penalizing wasteful doctors, but doctors have been known to fight tooth and nail against what Medicare considers wasteful. Facing criticism last year, Medicare had to abandon its proposal to penalize doctors for ordering routine prostate-cancer exams for their patients. On the one hand, prostate exams have led an estimated one million mento be treated for cancer that would never have bothered them — again, with taxpayers footing the bill. Yet, even the very authors of that study, doctors themselves, opposed Medicare’s proposal.

“[We] are not comfortable rewarding doctors for withholding a test that could help some men,” the two doctors wrote in the New York Times. They added that Medicare should not penalize doctors, but should raise patient deductibles for screenings it deems unnecessary.

The American Medical Association (AMA), the largest and most powerful group of doctors in the nation, has also criticized Medicare, calling its past attempts to implement pay-for-performance “burdensome, meaningless and punitive.” But Wednesday’s proposal got the AMA’s stamp of approval.

“Our initial review suggests that CMS has been listening to physicians’ concerns,” Steven Stack, the association’s president, said in a statement. “It is hard to overstate the significance of these proposed regulations for patients and physicians.”

The second way the proposal tries to save money and promote quality care is through “alternative payment models.” Under one common alternative model — the bundled payment model — Medicare pays doctors for all care in connection with a single “episode” of sickness or, for instance, a single knee replacement procedure. All the doctors in a given region get the same flat fee for a procedure based on the average cost of the procedure in that region. The model encourages pricey health care providers to bring down costs like their more cost-efficient neighbors.

Other models promote doctor innovation. For example, doctors can be part of a health home — “where doctors can help patients understand prevention and wellness,” the Center for Medicare and Medicaid Services explains in a video. “They can try innovative approaches like tele-health or nutrition classes.”

Patrick Conway, CMS’s chief medical officer, emphasized that the new payment system is opt-in, giving doctors “the opportunity to participate in a way that is best for them, their practice, and their patients.” Even so, CMS expects the vast majority of doctors to opt in.

The comment period for the proposal is open for the next two months.

Does Sodium Intake Affect Mortality and CV Event Risk?

Sodium intake may not be associated with mortality or incident cardiovascular events in older adults, according to a study published Jan. 19 in the JAMA: Internal Medicine.

In the Health, Aging and Body Composition (Health ABC) Study, initiated in 1997, researchers assessed self-reported sodium intake from 2,642 Medicare beneficiaries, ages 71-80 years old. Participants were excluded for difficulties with walking or activities of daily life, cognitive impairment, inability to communicate, and previous heart failure (HF). At the first annual follow-up visit, researchers recorded food intake as reported by participants, specifically examining sodium intake. After 10 years, 34 percent of patients had died, while 29 percent and 15 percent had developed cardiovascular disease and HF, respectively.

The results of the study showed that there was no association between participant-reported sodium intake and 10-year mortality, incident HF or incident cardiovascular disease. Further, there was no indication that consuming less than 1,500 mg/d of sodium benefitted participants any more than consuming the recommended amount (1,500-2,300 mg/d). However, the study showed a slight potential for harm when participants had a sodium intake of greater than 2,300 mg/d, especially in women and African Americans.

The authors note that while the food frequency questionnaire used by participants at the first annual follow-up has limitations in its accuracy, “self-reported adoption of a low-salt diet was not associated with significantly higher risk for [any] events.” They conclude that moving forward, there is a need for further research and stronger evidence in order to create better recommendations for older adults.

– See more at:

Hospital Readmission Not a Good Quality Measure for Children.

Preventable readmission rates for children are lower than all-cause readmission rates, according to a new study.

“The concern that many of us have is that there is much less to be gained from a major effort to reduce pediatric readmissions because so many are due to an unpredictable disease process,” James Gay, MD, from Monroe Carell Jr. Children’s Hospital at Vanderbilt University in Nashville, Tennessee, told Medscape Medical News.

“Pediatricians try very hard to keep their patients out of the hospital in the first place,” he explained, “so a large investment of time, energy, and funds to reduce pediatric admissions may not be very beneficial overall, and it might actually distract from efforts in other areas, such as concentrating on patient safety.”

Dr. Gay presented the results here at the American Academy of Pediatrics 2013 National Conference and Exhibition.

Pressure is on at hospitals to reduce 30-day readmissions, which are considered by some regulators to be a metric of patient safety and quality care. The Affordable Care Act requires a hospital readmission reduction program for facilities that treat Medicare patients and imposes penalties for institutions with high rates.


A large investment of time, energy, and funds to reduce pediatric admissions may not be very beneficial overall.


Hospital administrators are therefore keen to identify preventable readmissions. Some state Medicaid programs use the 3M Potentially Preventable Readmissions grouping software; however, data on its use in pediatric readmissions are lacking, said Dr. Gay.

His team assessed 1,749,747 hospitalizations in 58 Children’s Hospital Association member hospitals. They used the 3M software to calculate all-cause readmission rates with the company’s proprietary list of 314 All Patient Refined Diagnostic Related Groups.

The software flagged 80% or more of all-cause readmissions as potentially preventable for sickle cell crisis, bronchiolitis, ventricular shunt procedures, asthma, and appendectomy. In contrast, the software suggested that more than 40% of 30-day readmissions were not preventable, including those for seizures, gastroenteritis, central line infections, urinary tract infections, and failure to thrive.

For the 20 leading patient diagnostic groups for all-cause readmissions, the software algorithm removed chemotherapy, acute leukemia, and cystic fibrosis from the list of potentially preventable reasons.

Table. All-Cause vs Preventable Pediatric Readmissions


All-Cause Readmissions (%)

Preventable Readmissions (%)











“There are many fewer pediatric than adult hospitalizations in the first place, and the numbers and rates of readmissions are lower in children,” Dr. Gay pointed out. According to Medicare estimates, “older adults have readmission rates of about 20% at 30 days. The overall pediatric rates are closer to 6% to 10%,” he added.

Conditions that drive hospital readmission in children, or lead to admission in the first place, are very different from those in adults, Dr. Gay said. For example, adults are more likely to be readmitted within 30 days because of a high prevalence of chronic conditions, like congestive heart failure and chronic obstructive pulmonary disease, whereas children have more acute illnesses, such as pneumonia, bronchiolitis, and asthma.

“Because of these issues, many hospital pediatricians believe that readmission rates are not a good quality measure for pediatrics,” Dr. Gay said.

Asked by Medscape Medical News to comment on this study, Mark Shen, MD, from Dell Children’s Medical Center in Austin, Texas, noted that “in this study, the single most common reason for readmission was chemotherapy. We expect these kids to come back — we’ve wiped out their immune system.”

Other children are discharged with the expectation they will return as well, he added. “Sometimes we know they’re coming back. We’re just giving them a break at home, such as children with sickle cell disease or ventricular shunts.”

This study is useful because it indicates that the rate of 30-day hospital readmission is lower for children than for adults. Further research could focus on key chronic conditions associated with more readmissions in children, which so far only have been identified in adults. “But we’re getting closer in pediatrics,” Dr. Shen added.

The study authors caution that the 3M software might not completely reflect the reasons for pediatric readmissions, and future studies are warranted to validate its use in this population. The broader issue is whether efforts to track and reduce adult hospital readmissions apply equally to pediatric patients, Dr. Gay said.

Residential exposure to aircraft noise and hospital admissions for cardiovascular diseases: multi-airport retrospective study.


Objective To investigate whether exposure to aircraft noise increases the risk of hospitalization for cardiovascular diseases in older people (≥65 years) residing near airports.

Design Multi-airport retrospective study of approximately 6 million older people residing near airports in the United States. We superimposed contours of aircraft noise levels (in decibels, dB) for 89 airports for 2009 provided by the US Federal Aviation Administration on census block resolution population data to construct two exposure metrics applicable to zip code resolution health insurance data: population weighted noise within each zip code, and 90th centile of noise among populated census blocks within each zip code.

Setting 2218 zip codes surrounding 89 airports in the contiguous states.

Participants 6 027 363 people eligible to participate in the national medical insurance (Medicare) program (aged ≥65 years) residing near airports in 2009.

Main outcome measures Percentage increase in the hospitalization admission rate for cardiovascular disease associated with a 10 dB increase in aircraft noise, for each airport and on average across airports adjusted by individual level characteristics (age, sex, race), zip code level socioeconomic status and demographics, zip code level air pollution (fine particulate matter and ozone), and roadway density.

Results Averaged across all airports and using the 90th centile noise exposure metric, a zip code with 10 dB higher noise exposure had a 3.5% higher (95% confidence interval 0.2% to 7.0%) cardiovascular hospital admission rate, after controlling for covariates.

Conclusions Despite limitations related to potential misclassification of exposure, we found a statistically significant association between exposure to aircraft noise and risk of hospitalization for cardiovascular diseases among older people living near airports.

What is already known on this topic

·         Noise has been associated with hypertension, myocardial infarction, and ischemic heart disease

·         Aircraft noise in particular has been associated with several hypertension outcomes

·         Few studies, however, have investigated the relation of aircraft noise to cardiovascular disease, in part because studies surrounding a small number of airports are not typically adequately powered

What this study adds

·         Long term exposure to aircraft noise is positively associated with hospitalization for cardiovascular disease

·         The association between aircraft noise and hospitalization for cardiovascular disease is not confounded by air pollution, road density, or area level socioeconomic status

·         There may be a threshold for the association between aircraft noise and hospitalization for cardiovascular disease

·         Source:BMJ

Physician Gave Chemo to Patients Without Cancer..

Hematologist-oncologist Farid Fata, MD, in suburban Detroit, Michigan, was arrested August 6 and charged with Medicare fraud in a federal case that stands out from dozens of others recently brought against healthcare providers.

For one thing, the dollar amount of alleged fraud — $35 million — is higher than most for individual providers charged by the government. The potential physical harm to patients described by prosecutors also is far more substantial. In a criminal complaint filed in a federal district court in Detroit, prosecutors said that the 48-year-old Dr. Fata ordered toxic chemotherapy for patients who did not have cancer or whose cancer was in remission. Doing this “is simply poisoning the patient,” prosecutors said in a later court filing.

And something else happened in Dr. Fata’s case that is unusual: Rather than keeping their heads down, some employees at Dr. Fata’s high-profile practice challenged his actions before he was arrested, according to the government.

One employed oncologist, for example, told agents from the FBI and the Department of Health and Human Services that he discovered that Dr. Fata had ordered chemotherapy for a patient whose cancer was in remission. The oncologist said he advised the patient to get a second opinion and not return to Dr. Fata’s practice.

This oncologist and other employees also reported that Dr. Fata ordered intravenous immunoglobulin (IVIG) for patients whose antibody levels did not warrant the therapy. One nurse practitioner (NP) told federal agents that she pulled the charts for 40 patients scheduled for IVIG therapy and saw that 38 had neither low antibody levels nor a recurrent infection, which is another indication for the treatment. The NP consulted 2 other employees about the issue, and the 3 of them canceled the IVIG therapy for the 38 patients.

Dr. Fata’s employees had internally challenged other practices they considered unethical, such as fabricating cancer diagnoses in patient records to justify insurance claims for chemotherapy and positron emission tomography (PET) scans, according to interviews conducted by federal agents. Some employees quit over these issues. The employed oncologist, who had considered quitting, described working with Dr. Fata as “living with this hell.”

Dr. Fata has not yet had his day in court to refute these charges. “He vehemently denies all the allegations,” said Christopher Andreoff, the physician’s attorney, in an interview with Medscape Medical News.

Andreoff faulted federal prosecutors for failing to review patient files “to determine the propriety of diagnoses and subsequent treatment.” He also said that the federal charges do not identify the current and former employees of Dr. Fata cited in the criminal complaint. They may be “disgruntled,” he said.

“People shouldn’t race to make a judgment,” said Andreoff. “There’s still the presumption of innocence.”

On Thursday, US Magistrate Judge David Grand ruled that Dr. Fata could get out of jail once he posted a $170,000 bond. Prosecutors appealed the judge’s decision but lost, according to newspaper accounts of yesterday’s court proceedings. Grand said that Dr. Fata must not practice medicine or bill anyone for the time being as conditions of his release.

Federal prosecutors wanted Dr. Fata behind bars while he awaits trial. They argued in a court filing that he poses a flight risk and possesses the means to return to his native Lebanon because the taxable estate for him and his wife exceeds $40 million. Although the government has begun to seize some of his assets, others are at Dr. Fata’s disposal, prosecutors said. Andreoff countered that his client is a naturalized American citizen who has traveled only once to Lebanon since 2001.

Prosecutors also emphasized the severity of the charges against Dr. Fata in their arguments to keep him locked up. They said that if convicted, Dr. Fata faces substantial time in prison, especially if unwarranted chemotherapy has injured or killed any patients. They noted that some of his patients already have complained to a local newspaper that they suffered mistreatment. The Oakland Press quoted the father of one deceased patient as saying that his son had been “tortured” with needless chemotherapy.

An Otherwise Shiny Career

Regardless of whether Dr. Fata is found innocent or guilty, his arrest on August 6 stands in jolting juxtaposition to an otherwise shiny career.

Dr. Fata completed a hematology-oncology fellowship at Memorial Sloan-Kettering Cancer Center in New York City. In 2005, he founded Michigan Hematology Oncology (MHO), which now has 60 employees and 7 locations throughout suburban Detroit. According to the MHO Web site, Dr. Fata’s research has been published in peer-reviewed journals such as Cancer, the Journal of Clinical Oncology, and the Annals of Internal Medicine. A search of medical literature through PubMED unearthed 20 articles in which Dr. Fata is a coauthor and sometimes the lead author. The MHO Web site also states that Dr. Fata often lectures at hospitals in southeast Michigan and functions as principal investigator on cancer protocols funded by the National Institutes of Health.

Dr. Fata also has made a name for himself as the founder of Swan for Life, a nonprofit organization that provides “support, education and resources to cancer patients and their families,” according to the group’s Web site. Swan for Life programs range from support groups and educational workshops for patients to fee-based medical services such as acupuncture and clinical massage. The nonprofit has raised money through fashion shows, a gala ball, and an annual 5k run, the most recent one on August 4.

Dr. Fata was listed as president of the foundation, and his wife Samar Fata as treasurer, on the group’s tax return for 2011, the latest on file with GuideStar, an online database on nonprofits. The tax return put 2011 revenues at $595,904 and expenditures and disbursements at $267,836. Revenue included a $300,675 contribution from a tax-exempt trust called Fata 2011 Grantor Charitable Lead Annuity with the same address as Dr. Fata’s home in Oakland Charter Township, Michigan. Total assets for Swan for Life at the end of 2011 were valued at $950,954.

Head-Injured Patient Had to Receive Chemo Before ED Trip

The criminal complaint filed against Dr. Fata on Tuesday said that his practice, MHO, billed Medicare $35 million over the course of 2 years. Of that amount, roughly $25 million was billed specifically by Dr. Fata. Almost all of that $25 million was for drug infusions, the highest amount billed for those services by any hematologist-oncologist in Michigan.

It is not clear how long federal authorities have scrutinized Dr. Fata. One court document filed by prosecutors called the investigation “very brief.” The complaint suggests that the government has moved with extreme urgency. The allegations against Dr. Fata come from 8 current or former employees, all of whom were interviewed earlier this month. Only 7 such individuals, all unnamed, are mentioned in the complaint, however. Of these, 6 were interviewed the day before Dr. Fata was arrested as federal agents raided his home and office.

“Our first priority is patient care,” said US District Attorney Barbara McQuade in a news release. “The agents and attorneys acted with a great attention to detail to stop these allegedly dangerous practices as quickly as possible.”

Many of the allegations center on Dr. Fata’s use of chemotherapy, and in particular, administering it to patients who did not need it. One NP told federal agents that “Dr. Fata falsified cancer diagnoses to justify cancer treatment” and that blood cancers were easier to falsify than tumors because physicians have more discretion to interpret blood tests. This NP and other employees also said that patients whose cancer was in remission were put on “maintenance” doses of chemotherapy. A medical assistant quoted Dr. Fata as telling patients that once they had chemotherapy, “they had to have it for the rest of their lives.”

Dr. Fata also ordered chemotherapy for all patients with advanced cancer who would not benefit from it, according to the employed oncologist interviewed by federal agents. “No other physician would do this and would let the patients die in peace,” the complaint quotes the oncologist as saying. In April 2012, the American Society of Clinical Oncology said that administering chemotherapy to patients with advanced cancer who would not benefit from it is 1 of 5 practices that oncologists must abandon.

The current and former employees paint a picture of a physician who was obsessed with administering chemotherapy, no matter the circumstances. “A male patient fell down and hit his head when he came to MHO,” the complaint alleged. “Dr. Fata directed [an NP] that he must receive his chemotherapy before he could be taken to the emergency room.” Dr. Fata’s order was carried out. The man eventually died from the head injury.

In another alleged incident, a patient with extremely low and potentially fatal levels of sodium was given chemotherapy before he could go the emergency department, as ordered by Dr. Fata.

Doses of chemotherapy were excessive as well, according to the employed oncologist at MHO. For example, Dr. Fata would order 56 doses of rituximab (Rituxan, Genentech) over the course of 2 years for a patient with non-Hodgkin’s lymphoma compared with 12 doses that a “normal oncologist” might order.

Dr. Fata Owned Firm That Did PET Scans, Complaint Says

Current and former employees of Dr. Fata describe other practice patterns that are hallmarks of Medicare fraud cases:

  • Unusually high patient volume: One employee said Dr. Fata saw 30 to 60 patients per day. Three other employees put the count at 50 to 70. Several said that Dr. Fata could sustain this pace because he used unlicensed foreign physicians to conduct examinations that typically lasted several hours. Then Dr. Fata would pop in at the end.
  • Upcoding: One NP told federal agents that Dr. Fata “bills every patient at the highest possible code, even though he only spends 3 to 5 minutes with them.”
  • Interlocking services: The criminal complaint states that Dr. Fata incorporated a company called United Diagnostics in November 2012. According to a business office employee interviewed by federal agents, all the PET scans ordered by Dr. Fata were performed at United Diagnostics. Another employee said that the percentage of Dr. Fata’s patients who received PET scans increased from 30% to 70% once United Diagnostics opened for business. Likewise, Dr. Fata started a pharmacy in 2012, and he instructed MHO employees to make it their sole source for oral chemotherapy drugs.

In addition, the complaint alleges problems that could be classified as simply careless medicine.

  • Dr. Fata performed bone marrow biopsies assisted by medical assistants who were not wearing gloves.
  • Patients sometimes received the wrong medicine, or medicines out of sequence, because of poor record-keeping.
  • At one time, patients received chemotherapy without a physician present.


Washington State Cancer Patients Found To Be At Greater Risk For Bankruptcy Than People Without A Cancer Diagnosis.


Much has been written about the relationship between high medical expenses and the likelihood of filing for bankruptcy, but the relationship between receiving a cancer diagnosis and filing for bankruptcy is less well understood. We estimated the incidence and relative risk of bankruptcy for people age twenty-one or older diagnosed with cancer compared to people the same age without cancer by conducting a retrospective cohort analysis that used a variety of medical, personal, legal, and bankruptcy sources covering the Western District of Washington State in US Bankruptcy Court for the period 1995–2009. We found that cancer patients were 2.65 times more likely to go bankrupt than people without cancer. Younger cancer patients had 2–5 times higher rates of bankruptcy than cancer patients age sixty-five or older, which indicates that Medicare and Social Security may mitigate bankruptcy risk for the older group. The findings suggest that employers and governments may have a policy role to play in creating programs and incentives that could help people cover expenses in the first year following a cancer diagnosis.


Routine Propofol Sedation Increases Risk During Colonoscopy.

In a large database study, anesthesia assistance was associated with an elevated risk for perforation, splenic injury, or aspiration pneumonia.


The use of anesthesiologist-administered propofol sedation for colonoscopy is increasing in the U.S. (JW Gastroenterol April 13 2012 and JW Gastroenterol Feb 17 2012). Propofol use during colonoscopy is associated with shorter recovery time and higher patient satisfaction but also an estimated 20% increase in health care costs. Whereas most studies on the use of propofol sedation during colonoscopy have focused on its economic cost, researchers now explore another possible disadvantage — increased risk for complications.

Using a database of linked U.S. Medicare and cancer registry data, investigators identified patients without cancer who underwent diagnostic colonoscopy between 2000 and 2009, assessed whether they received anesthesiology services, and determined whether they were hospitalized during the 30 days following colonoscopy for perforation, splenic injury, or aspiration pneumonia. Data on the type of anesthetic agent used were unavailable, but investigators assumed that anesthesiologist-administered propofol was used most often.

Of 165,527 colonoscopy examinations in 100,359 patients, 35,128 procedures (21.2%) were performed with anesthesia assistance. Complications of aspiration, perforation, or splenic injury occurred more frequently in patients who received anesthesia assistance than in those who did not (0.22% vs. 0.16%, P<0.001; odds ratio, 1.46; 95% confidence interval, 1.09–1.94). This difference was mostly attributable to the difference in risk for aspiration (0.14% vs. 0.10%; P=0.02). The risks for perforation and splenic injury were similar between groups. Other independent risk factors for these complications were older age, male sex, increased comorbidity, and undergoing the procedure in a hospital.

Comment: Although the overall rate of complications was very low, the use of anesthesia services for diagnostic colonoscopy resulted in a higher risk for complications. These findings might result in part from confounding if patients who received anesthesia assistance were sicker or more prone to complications and were chosen to receive anesthesia for those reasons. Also, the data were from a period when propofol was sometimes administered by trained nurses rather than anesthesiologists, and the relative safety of this approach compared to anesthesia-administered services cannot be determined. Finally, these findings might be more pronounced in the types of patients included in this trial (65 years old), and whether the observed increased risk is present in younger or more healthy patients remains to be determined.

Source: Journal Watch Gastroenterology


More on Inappropriate Colonoscopy.

One in five screening colonoscopies performed in Medicare patients aged 70 was considered potentially inappropriate, but study design limitations might have introduced error.

Previous studies suggest that a significant number of physicians systematically perform screening colonoscopies at 5-year versus recommended 10-year intervals and that many colonoscopists recommend that surveillance colonoscopy after resection of polyps begin earlier than is accepted in guidelines.

Now, investigators have retrospectively assessed the receipt of inappropriate screening colonoscopy in Medicare beneficiaries who had received a recent colonoscopy (index colonoscopy), including a 100% sample in Texas and a 5% sample in the U.S. Screening colonoscopy was distinguished from diagnostic colonoscopy by the absence of a relevant diagnostic indication on the index colonoscopy claim or on any claim 3 months before the procedure. Early repeated colonoscopy was defined as an index colonoscopy with no diagnostic indications preceded by a colonoscopy within 10 years that had negative findings (based on the last colonoscopy if >1). An inappropriate colonoscopy was defined as an early repeated colonoscopy in patients aged 70 to 75, a routine screening colonoscopy in patients aged 76 to 85, or any screening colonoscopy in patients aged >85.

In Texas beneficiaries, 23.4% of colonoscopies were potentially inappropriate, with variation by age group (70–75, 10%; 76–85, 39%; >85, 25%). Procedure-level factors associated with increased risk for inappropriate colonoscopy were location of ambulatory surgery center or office setting (vs. a hospital) and performance by higher-volume colonoscopists (vs. lower-volume), generalists or surgeons (vs. gastroenterologists), or U.S.- trained physicians (vs. non–U.S.-trained physicians). Patient-level risk factors were male gender, white race, fewer comorbid conditions, lower educational level, and residence in an urban area. Six percent of the variance in whether a colonoscopy was potentially inappropriate was explained by the physician variable.

Comment: This study has several limitations. First, not all doctors accept USPSTF age recommendations for screening colonoscopy; many find them to be arbitrary and prefer use of the previous recommendation to stop screening when life expectancy is <10 years. Second, guidelines for postpolypectomy surveillance include consideration of findings not only from the last colonoscopy but from previous colonoscopies. For example, in patients with high-risk adenoma findings, surveillance colonoscopy is recommended at 5-year intervals even after a negative examination. These repeat examinations would have been considered inappropriate in this study. Finally, it is unclear whether the investigators were fully able to account for postpolypectomy surveillance colonoscopies, to which even the USPSTF did not apply their age recommendations.

This study will undoubtedly be cited as evidence of inappropriate colonoscopy. However, the use of claims data to identify indications for colonoscopy is fraught with problems. The absolute rates of inappropriate colonoscopy could be significantly lower than shown here, and not all of the observed trends may reflect real differences in inappropriate use.

Source: Journal Watch Gastroenterology