Vietnam veterans sue to upgrade discharges, citing PTSD.{I have written about this major problem- am willing to share this sorry and sordid story. VM}

AMA Morning Rounds
Dr. Velandy Manohar
Dec 03 2012
Leading the News
"60 Minutes" carries allegations of admissions quotas at HMA hospitals.
The Tampa Bay (FL) Times (12/3, Tillman) reports, "The Naples-based hospital chain poised to buy Bayfront Medical Center is accused of pressuring doctors at some of its hospitals to admit patients regardless of medical need just to increase revenues, the CBS program 60 Minutes reported Sunday." The chain, Health Management Associates hospitals, is alleged to have "set quotas for admissions through their emergency rooms."
The Naples (FL) Daily News (12/2, Layden) reports, "On camera, several of the company's former employees shared the same story, saying there were admission targets and software that coerced HMA doctors into admitting more patients." However, "Alan Levine, an HMA senior vice president and Florida Group president, defended the company, saying allegations that the company put people in the hospital that shouldn't have been there were 'absolutely wrong.'" He also denied that quotas for admissions were established. He further "told the Daily News nobody in the program questioned the quality of care that HMA hospitals provide."
Modern Healthcare (12/3, Zigmond, Subscription Publication) reports, "Physicians interviewed for a '60 Minutes' investigation into Health Management Associates' admissions practices 'grossly mischaracterized' what goes on at the for-profit hospital chain's facilities, a top executive for the company said after the segment aired Sunday." He also said that "some of the doctors who spoke to reporter Steve Croft had reasons for doing so, including ongoing litigation with the company." He further "emphasized that a company called Opera Solutions conducted an independent analysis of HMA's admission percentages and found no difference from the rest of the industry."
The Knoxville (TN) News Sentinel (12/1, Harrington) reported, "Executives with Health Management Associates, the for-profit parent company of Knoxville-based Tennova Healthcare, on Friday refuted claims of inappropriate emergency department admissions that it believes will be the subject of a '60 Minutes' episode."
The Harrisburg (PA) Patriot-News (12/2, Wenner) reported, "The segment is called 'The Cost of Admission' and will focus on 'allegations from doctors that the hospital chain they worked for pressured them to admit patients regardless of their medical needs.'"
From the AMA
AMA study: Health insurer monopoly power widespread across U.S. AMA members can order for free the 2012 edition of the AMA’s Competition in Health Insurance: A Comprehensive Study of U.S. Markets, which shows a significant absence of health insurer competition for each of the three most popular managed care plans in the United States. The study finds that 70 percent of the 385 metropolitan areas examined lacked health insurer competition. These markets are rated “highly concentrated” based on guidelines issued by the U.S. Department of Justice and the Federal Trade Commission.

Government and Medicine
HHS issues two rules for insurance exchanges.
The AP (11/30) reported that "the Health and Human Services department is proposing a 'user fee' amounting to 3.5 percent of premiums for health insurers who want to offer policies in new federal exchanges coming in 2014." According to HHS, "the fee is to cover administrative costs of the new markets, which were designed to be self-supporting." According to the article, "The proposed administrative fee in the new exchanges would be higher than the 2 percent to 3 percent overhead commonly cited for running Medicare, a disparity that critics of the law were quick to point out."
The New York Times (12/1, A17, Pear, Subscription Publication) reported that in addition to the announcement of the 3.5 percent user fee, "federal officials said that consumers would soon have access to nationwide health plans similar to those available to members of Congress and other federal employees." According to the Times, the two announcements "show the White House rushing to carry out the health care law" and "also illustrate the rapidly growing role of the federal government in the nation's health care system." The Times added that HHS Secretary Sebelius "said that fees...would be 'sufficient to cover the majority of costs'" for the Federal role in the exchanges, although "she did not say how the remainder of the money would be raised."
Bloomberg News (11/30, Wayne) noted that "the total amount of the fee announced [Friday] won't be known until all states have made their decisions," regarding whether to set up a federally or state-run exchange.
The Hill (12/1, Baker) "Healthwatch" blog added, "HHS said it might change the amount of its user fee in later years, as more people enroll coverage through the exchanges. It will also monitor states' fees."
CQ (12/1, Adams, Subscription Publication) reported that in response, America's Health Insurance Plans spokesman Robert Zirkelbach said Friday that "any new fees to pay for the administration of exchanges will add to the cost of coverage, which is why it is important to focus on reducing these costs by streamlining operations, avoiding regulatory duplication, and utilizing the experience and expertise of health plans."
In a separate report, CQ (12/1, Adams, Subscription Publication) reported further on the new "multistate rule," issued by the Office of Personnel Management, under which "insurers that want to offer a national multistate plan would be allowed to phase in their participation in all 50 states over four years. In the first year, the plans would only have to operate in 31 states." The new program would be run by OPM, "which currently covers about 8 million workers and their families through the Federal Employee Health Benefit Program."
State lawmakers prepare for battle over Medicaid expansion.
With state legislatures preparing to convene in January, state lawmakers are preparing for battle over whether to sign on to the Affordable Care Act's expansion of Medicaid. The Washington Post (12/2, Aizenman) reports that with a year before the expansion, which is central to the law's goal of providing coverage to the uninsured, "only 14 states seem certain to join in. About 13 states seem likely to opt out because the GOP has a lock on both the governors's office and the legislature and many of these Republicans are dubious of expansion. ... Meanwhile, in more than a third of states, governors and state lawmakers have been so vague about their intentions, or so at odds, that it is impossible to predict how the debate will play out."
The AP (12/3, Alonzo-Zaldivar) reports on the "calculating and the lobbying" surrounding the question of whether to expand Medicaid in the states that have yet to make a decision. Opt-out, "and governors risk coming off as callous toward their neediest residents. Not to mention the likely second-guessing for walking away from a pot of federal dollars estimated at nearly $1 trillion nationally over a decade." Still, "cost-wary" states worry about the eventual price tag. And on top of that are the special interests, as "Conservative opponents of the health care law are leaning on lawmakers to turn down the Medicaid money. Hospitals, doctors' groups, advocates for the poor, and some business associations are pressing them to accept it."
CQ (12/3, McGlade, Subscription Publication) reported that on Friday, "at a panel discussion hosted by the Alliance for Health Reform, much discussion centered around a report by the Kaiser Commission on Medicaid and the Uninsured that calculated state savings at just $8 billion collectively if all of them decided to forgo expansion." Krista Drobac, director of the health division at the National Governor's Association Center for Best Practices, "said the governors have not had any reaction, at least publicly, to the Kaiser study." The article also noted many concerns and questions brought up at the conference by representatives of various states, including whether a state could partially expand its program, or if they could wait to expand.
State physician groups have remained neutral on Medicaid expansion. MedPage Today (12/3, Pittman) reports, "Most state physician groups have kept a low profile on their positions to expand Medicaid under the Affordable Care Act (ACA), even 6 months after the Supreme Court gave states an option to increase eligibility." According to the article, "unlike their hospital counterparts, professional doctor groups have been a bit slow to endorse the idea, even in states who have already said 'no' to the federal dollars." James Keeton, MD, dean of the School of Medicine at the University of Mississippi Medical Center, explained at the Alliance for Health Reform panel, "It's not that they're being resistant. They just didn't know what to say until the election was over."
Wyoming governor recommends state not expand Medicaid. The AP (12/1, Neary) reported that Wyoming Gov. Matt Mead recommends that his state "not accept federal money for an expansion of the Medicaid program, a key component of the Affordable Care Act." Mead said, however, that the legislature would ultimately decide the issue of whether to accept Federal funding of some $50 million. Mead "had steered Wyoming into litigation that challenged the constitutionality of the Affordable Care Act soon after he took office in 2011" and had criticized HHS Secretary Sebelius "over what he said has been her failure to respond to his questions." The state has some 77,000 people in the program, which costs about $500 million annually. The AP says another 30,000 could be aided if eligibility limits are raised.
Health Coverage and Access
Study highlights lack of competition in health insurance.
The Omaha World-Herald (12/3, Ruggles) reports that the American Medical Association "last week decried the lack of competition in health insurance here and nationwide." AMA President Dr. Jeremy Lazarus on Friday said the "risk is that there will not be significant competition both for quality of care as well as efficiency for patients," which could "drive up rates." The AMA study found that Nebraska is "among the least-competitive states in commercial health insurance and coverage provided by health maintenance organizations"; and Iowa is "among the least-competitive when it comes to preferred provider organizations." But America's Health Insurance Plans said the new AMA report is the "same fatally flawed study that has consistently been debunked by leading health care economists" in the past.
Arkansas Business (12/3) adds that the AMA study named Arkansas as the "state with the third least competitive health maintenance organization market, trailing only Rhode Island and Alabama." The AMA study said Arkansas Blue Cross & Blue Shield has "86 percent of the state's HMO market," followed by United HealthCare of Arkansas Inc., which has a "scant 12 percent." The study found that the only "product in which ABCBS did not rule was point-of-service plans, where United HealthCare had 41 percent, followed by Cigna with 29 percent."
Public Health
HPV may play role in laryngeal cancers.
Reuters (11/30, Pittman) reports that an analysis of 55 studies over 20 years published in the Journal of Infectious Diseases found that human papillomavirus is associated with a higher risk of laryngeal cancers. One expert commented that the risk is low and that laryngeal cancers are generally related to cigarette smoking or heavy drinking. HPV may also play a role in cancer of the tonsils and back of the tongue.
Relaxation may help some postmenopausal women reduce hot flashes.
Reuters (12/1, Raven) reported that according to a study published online Nov. 12 in the journal Menopause, relaxation techniques built on cognitive behavioral therapy seemed to help reduce the frequency of hot flashes in postmenopausal women. The study was based on 60 healthy Swedish women who were randomly assigned to no treatment or relaxation. Those assigned to relaxation were instructed in the technique. While at the beginning of the study, the group had an average of 10 hot flashes per day, among those taught exercise technique that number had fallen to four by the end of the study, while it declined to eight for the no treatment group.
Steroid injections for back pain may lead to increased bone loss in hips.
HealthDay (12/2, Norton) reported that a small study published in the journal Spine found that "older women who get steroid injections in the spine to treat lower back pain may be at risk for bone loss in their hips." Author Shlomo Mandel, MD, Henry Ford West Bloomfield Hospital, Michigan, said, "It's been thought that [the steroids] might stay in the epidural space of the spine." In the study, "women in the steroid group lost six times more bone mass in the hip than the comparison group did, although the absolute decrease was 'slight.'" While the bone loss may not be significant and may be due to other causes such as lack of exercise among patients with back pain, the authors "suggested that doctors be cautious about giving the injections to older women who are especially vulnerable to the bone-thinning disease osteoporosis - including thin women who are white or Asian."
MedPage Today (12/3, Walsh) reports, "Mean BMD at the hip declined from baseline by 0.018 g/cm2 (P=0.002) at six months after an injection of 80 mg triamcinolone acetonide," while "in an age-matched control population, women had a decrease of only 0.003 g/cm2, which was a significantly smaller loss in BMD (P=0.007)." In the sample, "all were post-menopausal, white, and were not taking other medications, such as anticonvulsants, that can affect BMD."
Young CF patients' exercise may be inhibited by impaired blood vessel function.
HealthDay (12/1, Preidt) reported that a study published in the journal Chest found that "children and teens with cystic fibrosis have impaired blood vessel function, which may affect their ability to exercise." In a test of "15 cystic fibrosis patients, aged 8 to 18, pedal[ing] a stationary bike as long and hard as they could. It was leg fatigue, rather than lung problems, that forced them to stop pedaling." Researchers found that "the cystic fibrosis patients could take in oxygen as well as a control group of 15 children and teens without cystic fibrosis, but their muscles were not as efficient at using oxygen." It appears that the reason is "the reduced ability of blood vessels to respond to important clues, such as expanding when exercise or stress increase the body's demand for blood and oxygen."
Greater availability of specialists may reduce stroke mortality.
MedPage Today (12/1, Neale) reported on a study published online in the Journal of Neurosurgery finding that "stroke deaths are lower in parts of the US that have a higher density of neurologists and neurosurgeons," as according to "county-level data, each increase of one neuroscience provider was associated with 0.38 fewer stroke deaths per year per million people." An accompanying editorial observed that "increased use of telestroke services and the operation of market forces promoting the creation of more comprehensive stroke centers may be more fruitful ways to bring high-quality stroke care to all US residents."
Study: Global health officials banning tanning salons.
Bloomberg News (12/3, Gale) reports that adolescent "girls trading the risk of deadly melanoma for a year-round tan have helped spur a global backlash against the sunbed industry," as "health officials from Brasilia to Sydney are banning tanning salons amid evidence that they cause malignant lesions. Use of tanning beds causes all three types of skin cancer, especially for people younger than 25 years," according to a study published in October in the British Medical Journal. The piece also points out, "Every day in the US, tanning beds are used by more than one million people, mostly Caucasian women ages 16 to 29, according to the American Academy of Dermatology."
Vietnam veterans sue to upgrade discharges, citing PTSD.
According to the New York Times (12/3, A12, Dao, Subscription Publication), a class-action lawsuit filed in Federal District Court argues that Vietnam veterans who were issued other-than-honorable discharges had post-traumatic stress disorder (PTSD) when the discharges were issued. The suit, which seeks to have the discharges upgraded, "raises two thorny issues that could affect thousands of Vietnam veterans: Can they be given a diagnosis of PTSD retroactively, to their time in service, though the disorder was not identified until 1980? And if they can, should recently instituted policies intended to protect troops with PTSD be applied retroactively to their cases?" An Army spokesperson "said the military has a policy of not discussing pending litigation."
Health and Diet
Study suggests extra fruit, vegetables won't curb appetite.
Reuters (12/1, Pittman) reported on a study published online Nov. 20 in the International Journal of Obesity, which suggests that filling up on vegetables and fruits won't curb one's appetite in the long run. Moreover, the study found that drinking fruit juice just added to the total amount of daily calories consumed. Researchers found that the 34 participants in the study gained 3.5 to five pounds eight weeks after incorporating fruit juice into their diets. The study also found that participants, particularly the more heavy-set ones, put on more weight when they ate extra fresh vegetables and fruit.
Global market for supplements, vitamins growing.
The Wall Street Journal (12/3, B2, Hodgson, Subscription Publication) reports the both pharmaceutical makers and consumer-product companies are battling it out to win a share in the supplement and vitamin market, not just in the US, but around the world. As prescription medications become more expensive and Baby Boomers get older, more people are spending money on vitamins and supplements to help them feel better longer. In less affluent countries, a growing middle class is purchasing vitamins and supplements to help prevent deficiencies in nutrition as well as to ward off diseases still prevalent in those places. The article also points out that the regulatory climate in Europe may be keeping a lid on vitamin and supplement market growth, due to strict requirements that makers of over-the-counter products, including vitamins and supplements, provide scientific backup documentation supporting their health claims.
Pharma & Device Update
SCOTUS to hear generic drug manufacturers' liability case.
The AP (12/1) reported that "the Supreme Court will decide whether generic drug manufacturers can be held responsible in state courts for possible design defects that are in the brand-name medicine they are copying." Last Friday, the court said it would hear an appeal from Mutual Pharmaceutical, manufacturer of the generic, anti-inflammatory medication sulindac. The article noted that "Karen Bartlett was awarded $21.6 million after claiming a design defect in sulindac caused blindness and severe burning of her skin and mucus membranes." However, Mutual argued "they shouldn't have to pay because they made sulindac exactly the same way as its brand-name equivalent, Clinoril, as required by federal law."
The Wall Street Journal (12/3, Kendall, Subscription Publication) reports that Mutual, a unit of Takeda Pharmaceutical Co., argues that Bartlett's claim, based on state law, should be pre-empted by Federal regulations. Last year, the court ruled that generic medicine manufacturers are shielded from lawsuits claiming that pharmaceutical companies inadequately label their medications.
Bloomberg News (12/1, Stohr) reported that Mutual argued that a ruling in a Federal appeals court, which upheld Karen Bartlett's award against the Takeda unit, "'blasts a gaping hole' in the 2011 Supreme Court ruling." According to the article, "Bartlett suffered what the appeals court called 'truly horrific' injuries after taking sulindac for shoulder pain." Bloomberg News noted that "the anti-inflammatory medicine triggered an allergic reaction that caused Bartlett to lose more than 60 percent of her outer skin layer."
Reuters (12/1, Baynes, Stempel) also covered the story.
Supreme Court to decide whether companies can patent human genes.
The AP (12/1) reported the Supreme Court "will decide whether companies can patent human genes, a decision that could reshape medical research." The court said last Friday it would hear the case of the Association for Molecular Pathology v. Myriad Genetics, Inc. The Times said a "decision will likely resolve an ongoing battle between scientists who believe that genes carrying the secrets of life should not be exploited for commercial gain and companies that argue that a patent is a reward for years of expensive research that moves science forward." Myriad Genetics has a test that probes for a gene that indicates a predisposition to breast cancer and is correlated with ovarian cancer. The American Civil Liberties Union (ACLU) has challenged Myriad Genetics' patents, with plaintiffs that include "geneticists who said they were not able to continue their work because of Myriad's patents, as well as breast cancer and women's health groups, patients and groups of researchers, pathologists and laboratory professionals."
The New York Times (12/1, A17, Liptak, Subscription Publication) reported that Myriad argues "that the 'isolated molecules' at issue 'were created by humans, do not occur in nature and have new and significant utilities not found in nature.'" Myriad also argues its work "is worthy of encouragement and that its fruits are worthy of protection."
The Wall Street Journal (12/1, Kendall, Subscription Publication) reported that a lower court had ruled that isolating the gene makes it no longer a product of nature and is therefore subject to patent. The company urged the court not to take the case.
Bloomberg News (12/1, Stohr, Decker) reported, "Biotechnology companies say they have been getting patents on genes for 30 years - and can't attract investment dollars unless they can protect their research from competitors." But "the challengers say isolated DNA is identical to the coding that exists naturally in the body."
Despite sanctions, US depends on Iran for snake bite antidote.
The Wall Street Journal (12/3, Phillips, Fassihi, Subscription Publication) reports that despite US-led international sanctions against Iran, the US Defense Department is dependent on Iran in obtaining antidotes for snake bites. Since January 2011, the Defense Department has purchased 115 vials through a middleman. According to the article, recommendations issued by US Central Command says treatment made by Iran's Razi Vaccine & Serum Research Institute should be used as the first line of antivenin therapy, said a US officer who read the medical guidance. Razi antivenin is considered an experimental treatment by the US Food and Drug Administration.
Allergan contemplates selling obesity business.
The Financial Times (12/3, Rappeport, Subscription Publication) reports that Allergan's chief executive David Pyott has indicated that the company is looking into moving on from the obesity business. Pyott said that its obesity business division has received several inquiries from potential buyers. Allergan produces Lap Band gastric devices, which constrict the stomach to cut patients' appetites. This year, sales have dropped to about $160 million.
Republican lawmakers introduce bill to address medicine shortage.
Modern Healthcare (11/30, Lee, Subscription Publication) reported that "Republican lawmakers introduced legislation that would aim to resolve" medicine shortages "by changing the way that generic sterile injectable" treatments "are reimbursed and offering brand-name" pharmaceutical companies "incentives to enter the market when" medicines "are in short supply." Last Thursday, Reps. Bill Cassidy (R-La.), Tom Rooney (R-Fla.), Andy Harris (R-Md.), Mike Rogers (R-Mich.), and Dan Benishek (R-Mich.) introduced the Patient Access to Drugs in Shortage Act in the House of Representatives. According to the article, "the bill would mandate that generic injectable" treatments "made by three or fewer manufacturers be reimbursed based on wholesale acquisition cost." Currently, Modern Healthcare noted that "these products have been reimbursed based on average sales price, plus a 6% markup, since the enactment of the Medicare Modernization Act of 2003."
Adderall contributing to rise in NFL drug suspensions.
The New York Times (12/2, Battista, Subscription Publication) reported on the trend of NFL players taking Adderall recreationally and failing drug tests because of it. That "almost certainly contributes to a most-troubling result: A record-setting year for NFL drug suspensions." According to NFL data, 21 suspensions "were announced this calendar year because of failed tests for performance-enhancing drugs, including amphetamines like Adderall. That is a 75% increase over the 12 suspensions."
Firms developing medications to treat hearing loss.
Reuters (12/2, Copley, Hirschler) reported that at present, there are no medications approved for hearing loss. However, Auris Medical of Switzerland has been testing its compound AM-111 and so far has shown that it is safe. The company has completed a mid-stage trial testing it as a treatment for sudden deafness. There are a number of other companies working on medications including: Pfizer with Audion Therapeutics; Roche with Inception Sciences; and Novartis with GenVec. Most of these medications are targeting hair growth in the ear. It is also pointed out that hearing loss has many different causes and so may require a range of treatments.
Generic epilepsy medications found equivalent to branded.
MedPage Today (12/3, Gever) reports that a study presented at the American Epilepsy Society's annual meeting found that "generic slow-release drugs for seizure disorders appear equivalent to branded versions," based on a review of "bioequivalence data from 53 studies submitted to the FDA for 25 generic modified-release drugs for epilepsy - including phenytoin, carbamazepine, levetiracetam, and divalproex." Researchers concluded that "the products could be interchanged without danger to patients."

Practice Management
Physicians who sell practices to hospitals, health systems face new pressures.
The New York Times (12/1, Creswell, Abelson, Subscription Publication) reported on "a growing national trend toward consolidation" in the healthcare sector. Doctors "who sold their practices and signed on as employees...describe growing pressure to meet the financial goals of their new employers - often by performing unnecessary tests and procedures or by admitting patients who do not need a hospital stay." The Times says "an array of new economic realities, from reduced Medicare reimbursements to higher technology costs, is driving consolidation. ... Many policy experts praise the shift away from independent practices as a way of making health care less fragmented and expensive."
Cincinnati area hospitals adopt readmission-reduction strategies.
The Cincinnati Enquirer (12/2, Driehaus, Peale) reported that as of October 1, the "Centers for Medicare and Medicaid Services, as part of the Health Care Reform Act, upended its old system of paying hospitals for every hospitalized Medicare patient with a new system that fines hospitals that have too many patients who are re-admitted within 30 days of their release. In the first year, the fines only apply to patients suffering from congestive heart failure, pneumonia or heart attacks. " Although "the fines are relatively modest - up to one percent of Medicare reimbursements in the first year --...they have helped spark a massive effort among Greater Cincinnati hospitals and their physician offices to ensure their patients continue to heal after they've been sent home." Of area hospitals, "each strives to ensure the patient schedules and attends a follow-up doctor's appointment quickly; fills and takes prescriptions; understands what foods to eat or avoid, and has well-informed caregivers."
Less assimilated Hispanic patients rate physicians higher in survey.
The American Medical News (12/3, O'Reilly) reports that "Hispanic immigrant patients who have limited English proficiency and in other ways demonstrate a lack of assimilation into American culture give doctors higher satisfaction grades than patients who are white or black, or than Hispanics who have lived in the US longer." The study, which was conducted by researchers from the University of Illinois College of Medicine, included 881 patients at outpatient family medicine clinics. The article says that "in addition to reporting demographic information, Hispanic patients completed a 12-item language proficiency scale that also measures psychometric properties." It details that "while 291 white patients gave their physicians an average grade of 8.8 on a scale of 10, the 303 black patients surveyed gave them a 9." Almost 200 assimilated Hispanic patients gave an average grade of 9.1, while 90 of the less assimilated Hispanic participants gave an average score of 9.7.
Friday's Lead Stories
• Clinton unveils global "AIDS-free generation" plan.
• White House's initial fiscal cliff offer met with Republican pessimism.
• California insurers proposing rate increases.
• Watchdog group calls on FDA to reinspect compounding pharmacies.
• US birth rate dropped to a record low in 2011.
• Study: US diets are falling short of USDA standards.
• FDA approves cabozantib medullary thyroid cancer treatment.