News

The Southwest Journal of Pulmonary, Critical Care & Sleep periodically publishes news articles relevant to pulmonary, critical care or sleep medicine which are not covered by major medical journals.

Rick Robbins, M.D. 12/3/16 Rick Robbins, M.D. 12/3/16

VAP Rates Unchanged

In a research letter to JAMA Metersky and colleagues (1) report that ventilator-associated pneumonia (VAP) rates have remained near 10% since 2005. The authors reviewed Medicare Patient Safety Monitoring System (MPSMS) data on a representative sample of more than 86,000 critically ill patients treated at 1330 US hospitals between 2005 and 2013. To meet a diagnosis of VAP patients were required to have at least 2 days' ventilation in intensive care units; a chest radiograph with a new finding suggesting pneumonia; a physician diagnosis of pneumonia; and an order for antibiotics. VAP incidence was 10.8% (95% confidence interval, 7.4% - 14.4%) during 2005 to 2006 and 9.7% (95% confidence interval, 5.1% - 14.9%) during 2012 to 2013.

In contrast, data from the CDC's National Healthcare Safety Network (NHSN) have shown declines in VAP rates of 71% and 62% in medical and surgical intensive care units, respectively, between 2006 and 2012 (2,3). "The most likely explanation for the discrepancy is thought to be bias in reporting to CDC by the hospitals," Dr. Metersky told Medscape Medical News (4). Dr. Charles S. Dela Cruz at Yale agrees. "Strict and varying VAP measure definitions and the hospital reporting mechanisms possibly contributed to the differences in rates," he said.

VAP has no standard definition and its diagnosis has considerable clinical variability. Other than removing the endotracheal tube as quickly as possible, VAP prevention guidelines are non- or weakly evidence-based (5). Furthermore, financial incentives from CMS for low VAP rates may have contributed to the bias in reporting (6).

Richard A. Robbins, MD

Editor, SWJPCC

References

Metersky ML, Wang Y, Klompas M, Eckenrode S, Bakullari A, Eldridge N. Trend in ventilator-associated pneumonia rates between 2005 and 2013. JAMA. 2016 Nov 11. [Epub ahead of print] [CrossRef] [PubMed]
Edwards JR, Peterson KD, Andrus ML, et al; NHSN Facilities. National Healthcare Safety Network (NHSN) Report, data summary for 2006, issued June 2007. Am J Infect Control. 2007;35(5):290-301. [CrossRef] [PubMed]
Dudeck MA, Weiner LM, Allen-Bridson K, et al. National Healthcare Safety Network (NHSN) report, data summary for 2012, device-associated module. Am J Infect Control. 2013;41(12):1148-66. [CrossRef] [PubMed]
Swift D. No drop in VAP rates, study contends. Medscape Medical News. November 21, 2016. Available at: http://www.medscape.com/viewarticle/872157?nlid=110853_3464&src=WNL_mdplsfeat_161129_mscpedit_ccmd&uac=9273DT&spon=32&impID=1243721&faf=1 (accessed 12/2/16).
Padrnos L, Bui T, Pattee JJ, Whitmore EJ, Iqbal M, Lee S, Singarajah CU, Robbins RA. Analysis of overall level of evidence behind the Institute of Healthcare Improvement ventilator-associated pneumonia guidelines. Southwest J Pulm Crit Care 2011;3:40-8.
Cassidy A. Medicare's hospital-acquired condition reduction program. Health Affairs. August 6, 2015. Available at: http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=142 (accessed 12/2/16).

Cite as: Robbins RA. VAP rates unchanged. Southwest J Pulm Crit Care. 2016;13(6):288-9. doi: https://doi.org/10.13175/swjpcc134-16 PDF

Rick Robbins, M.D. 12/1/16 Rick Robbins, M.D. 12/1/16

ABIM Overhauling MOC

Yesterday, the American Board of Internal Medicine (ABIM) announced proposed changes to their controversial Maintenance of Certification (MOC) (1). One of the biggest changes is an alternative path to recertification. For most physicians, that would mean they would not have to take the long-form test every 10 years, but instead would have a series of more frequent, but less onerous, assessments. To determine the MOC content ABIM will be using physician crowd-sourcing to determine what knowledge is essential for various physicians and what is most relevant to their practices. ABIM is also changing the format for scores so that physicians get more detailed feedback.

ABIM’s MOC program has been controversial (2). MOC has been viewed by most physicians as being irrelevant to their daily practice and a burden (3). This led to the formation of National Board of Physicians and Surgeons which is challenging ABIM’s monopoly on physician internal medicine certification (4).

ABIM claims that MOC is still the best way of assuring physician knowledge and skills in a particular field (1). Two studies were cited. One asserts that the cost of care for Medicare beneficiaries is 2.5% lower among physicians who were obliged to complete MOC than among those who were not (5). The second states death and emergency coronary artery bypass grafting is lower when patients undergoing percutaneous coronary interventions are treated by board-certified interventional cardiologists (6).

However, Paul Teirstein, MD, chief of cardiology and the director of interventional cardiology at Scripps Clinic in La Jolla, California takes issue with ABIM’s assertion. "There's no evidence that MOC, recertification or take-home computer modules improve patient outcomes," he told Medscape Medical News (7). "This is a money-making operation for [ABIM]. It's a tollbooth, and there's no evidence that it helps anybody, and it takes a ton of time." Teirstein also takes issue with the 2.5% reduction in costs which he points out was a reduction in the growth differences in cost, which is much smaller than the 2.5% lower cost the ABIM claims. That same study also shows an increase in emergency room use for patients treated by MOC-required physicians, he added. The second study concluded no “… consistent association between ICARD certification and the outcomes of PCI procedures.” (6).

References

Baron RJ, Braddock CH III. Perspective: knowing what we don’t know — improving maintenance of certification. New Engl J Med. November 30, 2016 Nov 30 [Epub ahead of print] [CrossRef]
Lowes R. ABIM suspends controversial MOC requirements through 2018. Medscape Medical News December 16, 2015. Available at: http://www.medscape.com/viewarticle/856076 (accessed 12/1/16).
Cook DA, Blachman MJ, West CP, Wittich CM. Physician Attitudes About Maintenance of Certification: A Cross-Specialty National Survey. Mayo Clin Proc. 2016 Oct;91(10):1336-45. [CrossRef] [PubMed]
https://nbpas.org/ (accessed 12/1/16).
Gray BM, Vandergrift JL, Johnston MM, et al. Association between imposition of a Maintenance of Certification requirement and ambulatory care-sensitive hospitalizations and health care costs. JAMA. 2014 Dec 10;312(22):2348-57. [CrossRef] [PubMed]
Fiorilli PN, Minges KE, Herrin J, et al. Association of physician certification in interventional cardiology with in-hospital outcomes of percutaneous coronary intervention. Circulation. 2015 Nov 10;132(19):1816-24. [CrossRef] [PubMed]
ABIM leaders say they are revamping MOC requirements. Medscape Medical News. December 1, 2016. Available at: http://www.medscape.com/viewarticle/872593?nlid=110968_2863&src=wnl_dne_161201_mscpedit&uac=9273DT&impID=1244926&faf=1 (accessed 12/1/16).

Cite as: Robbins RA. ABIM overhaulding MOC. Southwest J Pulm Crit Care. 2016:13(6):276-7. doi: https://doi.org/10.13175/swjpcc128-16 PDF

Rick Robbins, M.D. 11/21/16 Rick Robbins, M.D. 11/21/16

Substitution of Assistants for Nurses Increases Mortality, Decreases Quality

Substituting nursing assistants for professional nurses is associated with poorer quality of care and increased mortality according to a study published in BMJ Quality & Safety (1). Linda H. Aiken PhD and colleagues analyzed the effect of increasing the proportion of less extensively trained nurses at 243 acute care hospitals in Belgium, England, Finland, Ireland, Spain, and Switzerland. They surveyed 13,077 nurses and 18,828 patients who had been in 182 hospitals between 2009 and 2010. They also consulted mortality records for 275,519 patients who had had surgery in 188 of the hospitals between 2007 and 2009.

Overall, 47% of the professional nurses in the study had bachelor's degrees, although they were unevenly distributed, with some hospitals having none. In a hospital that has average nurse staffing levels and skill mix, the researchers estimated that replacing one professional nurse with a lower-skilled worker increased the odds of a patient dying by 21%. Conversely, each 10% increase in the proportion of nurses with high-level skills was associated with an 11% decrease in the odds of a patient dying postoperatively and a 10% decrease in the odds of a patient giving the hospital a low rating.

Overall, the findings paralleled those from the United States and are consistent with the concept that a higher level of education leads to improved care. "We find a nursing skill mix in hospitals with a higher proportion of professional nurses is associated with significantly lower mortality, higher patient ratings of their care and fewer adverse care outcomes," the researchers write. They conclude "that caution should be taken in implementing policies to reduce hospital nursing skill mix because the consequences can be life-threatening for patients."

Richard A. Robbins, MD

Editor, SWJPCC

Reference

Aiken LH, Sloane D, Griffiths P, et al. Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care. BMJ Qual Saf. 2016. Published on-line 11/15/16. [CrossRef]

Cite as: Robbins RA. Substitution of assistants for nurses increases mortality, decreases quality. Southwest J Pulm Crit Care. 2016;13(5):252. doi: https://doi.org/10.13175/swjpcc121-16 PDF

Rick Robbins, M.D. 11/15/16 Rick Robbins, M.D. 11/15/16

CMS Releases Data on Drug Spending

Yesterday (11/14/16) the Centers for Medicare and Medicaid Services (CMS) released data on spending for drugs under Medicare and Medicaid (1,2). Medicare paid $137.4 billion on drugs covered by its prescription drug benefit in 2015. About $8.7 billion of that spending occurred on drugs that had "large" price hikes, defined as a more than 25 percent increase between 2014 and 2015. In 2015, Medicaid paid $57.3 billion about $5.1 billion of which was spent on drugs that had large price increases.

The Medicare spending database highlights 11 drugs that doubled in price. The Medicaid database identified 20 drugs that more than doubled in price with 9 of these being old, generic drugs. Medicare drugs were led by Glumetza, a Type 2 diabetes drug which saw its price soar 380 percent and hydroxychloroquine sulfate, a generic malaria drug, which went up 370 percent. Medicaid drugs were led by Ativan, an anti-anxiety medication approved in 1977, which increased by 1,264 percent in price between 2014 and 2015. Daraprim, a decades-old antiparasitic drug that helped spark political attention to the issue of high drug prices after former pharmaceutical executive Martin Shkreli hiked the price, leapt up in average cost by 874 percent.

However, drugs commonly used in respiratory diseases also increased in price. These were led by mitomycin, an anticancer drug sometimes used in lung cancer, an antidepressant also used as a smoking cessation aid (Table 1).

Table 1. Medicare Spending on Respiratory Drugs. (Open table in separate window)

The data on price on small prices rises can be deceiving when calculating total costs. For example, Advair Diskus, a bronchodilator, ranked in the top-five of Medicare expenditures, with $2.3 billion in spending in 2015. However, he utilization of the drug has actually declined a little over the last five years. Meanwhile, the total spending has not gone down, but increased. Fueled by relatively modest price increases, from $3.81 per unit in 2011 to $5.28 in 2015, the spending on the drug increased by more than half a billion dollars over that period.

Of particular concern is a rise in price of some generics, a class of drugs that are intended to decrease drug prices and spending. Drugs that were responsible for large amounts of overall spending tended to see smaller increases that gradually increased the government outlay. In one outlier, the price of the hepatitis C treatment, Harvoni, decreased slightly in 2015, even as it led overall spending.

The prices do not include the impact of rebates, which are prohibited by law from being released (3). Those discounts can be significant, and not knowing what they are means the numbers almost certainly overstate how much the government actually paid for these drugs. CMS disclosed that, on average, rebates for brand name drugs were 17.5 percent for medicines covered by Medicare's "part D" prescription drug benefit in 2014.

Richard A. Robbins, MD

Editor, SWJPCC

References

CMS. 2015 Medicare drug spending dashboard. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Information-on-Prescription-Drugs/2015Medicare.html (accessed 11/15/16.
CMS. 2015 Medicaid drug spending dashboard. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Information-on-Prescription-Drugs/2015Medicaid.html (accessed 11/15/16).
Johnson CY. Drugs for hepatitis C and diabetes drove Medicare spending in 2015. Washington Post. November 14, 2016. Available at: https://www.washingtonpost.com/news/wonk/wp/2016/11/14/the-drugs-driving-up-medicare-spending/ (accessed 11/15/16).

Cite as: Robbins RA. CMS releases data on drug spending. Southwest J Pulm Crit Care. 2016;13(5):242-3. doi: https://doi.org/10.13175/swjpcc118-16 PDF

Rick Robbins, M.D. 11/15/16 Rick Robbins, M.D. 11/15/16

Trump Proposes Initial Healthcare Agenda

On Friday, November 11, President-elect Trump proposed a healthcare agenda on his website greatagain.gov (1). Yesterday, November 12, he gave an interview on 60 Minutes clarifying his positions (2). Trump said that he wanted to focus on healthcare and has proposed to:

Repeal all of the Affordable Care Act;
Allow the sale of health insurance across state lines;
Make the purchase of health insurance fully tax deductible;
Expand access to the health savings accounts;
Increase price transparency;
Block grant Medicaid;
Lower entrance barriers to new producers of drugs.

In his 60 Minutes interview Trump reiterated that two provisions of the ACA – prohibition of pre-existing conditions exclusion and ability for adult children to stay on parents insurance plans until age 26 – have his support (2). Other aspects of the ACA that might receive his support were not discussed.

On the Department of Veterans’ Affairs Trump proposed to make the VA great again by removing corrupt and incompetent individuals who let our veterans down (1). The website goes on to say that only honest and dedicated public servants in the VA have their jobs protected, and will be put in line for promotions.

Several aspects of healthcare were not addressed. Universal healthcare which Trump has supported in the past was not discussed (3). Trump did not make major policy proposals for Medicare during the campaign and Medicare was not addressed on his website or during his interview.

According to a survey conducted by the Kaiser Family Foundation the top three healthcare issues concerning voters were:

Ensuring that high-cost drugs for chronic conditions such as hepatitis and cancer become affordable;
Lowering prescription drug costs in general;
Making sure health plans have enough physicians and hospitals in their networks (4).

None were addressed on Trump's website or during his interview.

Richard A. Robbins, MD

Editor, SWJPCC

References

https://www.greatagain.gov/policy/healthcare.html (accessed 11/14/16).
CBS News. President-elect Trump speaks to a divided country on 60 Minutes. November 13, 2016. Available at: http://www.cbsnews.com/news/60-minutes-donald-trump-family-melania-ivanka-lesley-stahl/ (accessed 11/14/16).
CBS News. Trump gets down to business on 60 Minutes. September 27, 2015. Available at: http://www.cbsnews.com/news/donald-trump-60-minutes-scott-pelley/
Kirzinger A, Sugarman E, Brodie M. Kaiser Health Tracking Poll: October 2016. Available at: http://kff.org/health-costs/poll-finding/kaiser-health-tracking-poll-october-2016/ (accessed 11/14/16).

Cite as: Robbins RA. Trump proposes initial healthcare agenda. Southwest J Pulm Crit Care. 2016;13(5):240-1. doi: https://doi.org/10.13175/swjpcc117-16 PDF

Rick Robbins, M.D. 11/10/16 Rick Robbins, M.D. 11/10/16

Election Results of Southwest Ballot Measures Affecting Healthcare

Earlier this week an article was posted listing Southwest ballot measures that affect healthcare. Below are the results obtained from various internet sources.

States

Arizona

1. Recreational marijuana. Proposition 205: Legalizes recreational marijuana use for people 21 and older. Opponents of the measure include the Arizona Health and Hospital Association and Insys Therapeutics, a company that makes a cannabis-based pain medication.

Defeated: Yes 929,518 (48%)

No 1,011,836 (52%)

California

1. Medi-Cal hospital fee program. Proposition 52: Requires the legislature to get voter approval to use fee revenue for purposes other than generating federal matching funds and funding enhanced Medicaid payments and grants for hospitals. The initiative, which was written by the California Hospital Association and is supported by most state lawmakers, would also make the program permanent, requiring a supermajority in the legislature to end it.

Passed: Yes 5,950,642 (70%)

No 2,599,764 (30%)

2. Tobacco tax. Proposition 56: Increases the state's cigarette tax by $2 a pack and impose an "equivalent increase on other tobacco products and electronic cigarettes containing nicotine." The revenue primarily would support healthcare programs.

Passed: Yes 5,551,236 (63%)

No 3,271,626 (37%)

3. Prescription drug price regulations. Proposition 61: Ties the prices California state agencies pay for prescription drugs to the discounts negotiated by the U.S. Veterans Affairs Department. The initiative, backed by the AIDS Healthcare Foundation, has drawn more than $100 million in spending from opponents, most of it from the pharmaceutical industry.

Defeated: Yes 3,933,084 (46%)

No 4,570,245 (54%)

4. Legalization of recreational marijuana. Proposition 64: Legalizes recreational marijuana use for people 21 and older and creates taxes on the cultivation and retail sale of the drug.

Passed: Yes 4,957,215 (56%)

No 3,923,777 (44%)

Colorado

1. ColoradoCare, a single-payer health system. Amendment 69: Amends the state's constitution to establish a universal healthcare system financed by payroll taxes and governed by an elected 21-member board of trustees. The plan is opposed by Colorado Hospital Association.

Defeated: Yes 478,107 (20%)

No 1,876,618 (80%)

2. Cigarette tax. Amendment 72: Amends the state's constitution to increase the cigarette tax from 84 cents a pack to $2.59 a pack. Most of the revenue would fund health-related programs, research into tobacco-related health issues and education and prevention. E-cigarettes are exempt.

Defeated: Yes 1,115,022 (46%)

No 1,291,961 (54%)

3. Physician-assisted suicide. Proposition 106: The End of Life Options Act allows physicians to prescribe a lethal drug to their terminally ill patients and allows terminally ill patients to be prescribed lethal drugs to end their life.

Passed: Yes 1,542,219 (65%)

No 847,978 (35%)

Nevada

1. Recreational marijuana. Question 2: Legalizes recreational marijuana use for people 21 and older.

Passed: Yes 602,400 (54%)

No 503,615 (46%)

2. Medical equipment tax. Question 4: Exempts medical equipment like oxygen machines and hospital beds from the state sales tax.

Passed: Yes 768,803 (72%)

No 301,944 (28%)

Cities

1. Albany, CA. Soda tax: A 1 cent per ounce tax on sugary beverages.

Passed

2. San Francisco, CA. Soda tax: A 1 cent per ounce tax on sugary beverages.

Passed

3. Oakland, CA. Soda tax: A 1 cent per ounce tax on sugary beverages.

Passed

4. Boulder, CO. Soda tax: Imposes a 2 cent per ounce tax on sugary beverages.

Passed

Richard A. Robbins, MD

Editor, SWJPCC

Cite as: Robbins RA. Election results of Southwest ballot measures affecting healthcare. Southwest J Pulm Crit Care. 2016;13(5):223-4. doi: http://dx.doi.org/10.13175/swjpcc115-16 PDF

Rick Robbins, M.D. 11/7/16 Rick Robbins, M.D. 11/7/16

Southwest Ballot Measures Affecting Healthcare

Modern Healthcare (1) has published an article summarizing ballot measures affecting healthcare. Those from the Southwest are listed below:

States

Arizona

Recreational marijuana. Proposition 205: Legalizes recreational marijuana use for people 21 and older. Opponents of the measure include the Arizona Health and Hospital Association and Insys Therapeutics, a company that makes a cannabis-based pain medication.

California

Medi-Cal hospital fee program. Proposition 52: Requires the legislature to get voter approval to use fee revenue for purposes other than generating federal matching funds and funding enhanced Medicaid payments and grants for hospitals. The initiative, which was written by the California Hospital Association and is supported by most state lawmakers, would also make the program permanent, requiring a supermajority in the legislature to end it.
Tobacco tax. Proposition 56: Increases the state's cigarette tax by $2 a pack and impose an "equivalent increase on other tobacco products and electronic cigarettes containing nicotine." The revenue primarily would support healthcare programs.
Prescription drug price regulations. Proposition 61: Ties the prices California state agencies pay for prescription drugs to the discounts negotiated by the U.S. Veterans Affairs Department. The initiative, backed by the AIDS Healthcare Foundation, has drawn more than $100 million in spending from opponents, most of it from the pharmaceutical industry.
Legalization of recreational marijuana. Proposition 64: Legalizes recreational marijuana use for people 21 and older and creates taxes on the cultivation and retail sale of the drug.

Colorado

ColoradoCare, a single-payer health system. Amendment 69: Amends the state's constitution to establish a universal healthcare system financed by payroll taxes and governed by an elected 21-member board of trustees. The plan is opposed by Colorado Hospital Association.
Cigarette tax. Amendment 72: Amends the state's constitution to increase the cigarette tax from 84 cents a pack to $2.59 a pack. Most of the revenue would fund health-related programs, research into tobacco-related health issues and education and prevention. E-cigarettes are exempt.
Physician-assisted suicide. Proposition 106: The End of Life Options Act allows physicians to prescribe a lethal drug to their terminally ill patients and allows terminally ill patients to be prescribed lethal drugs to end their life.

Nevada

Recreational marijuana. Question 2: Legalizes recreational marijuana use for people 21 and older.
Medical equipment tax. Question 4: Exempts medical equipment like oxygen machines and hospital beds from the state sales tax.

Cities

Albany, CA. Soda tax: A 1 cent per ounce tax on sugary beverages.
San Francisco, CA. Soda tax: A 1 cent per ounce tax on sugary beverages.
Oakland, CA. Soda tax: A 1 cent per ounce tax on sugary beverages.
Boulder, CO. Soda tax: Imposes a 2 cent per ounce tax on sugary beverages.

Richard A. Robbins, MD

Editor, SWJPCC

Reference

Modern Healthcare. How the Nov. 8 state elections will affect healthcare. November 5, 2016. Available at: http://www.modernhealthcare.com/article/20161105/NEWS/161109991 (accessed 11/7/16).

Cite as: Robbins RA. Southwest ballot measures affecting healthcare. Southwest J Pulm Crit Care. 2016;13(5):218-9. doi: http://dx.doi.org/10.13175/swjpcc114-16 PDF

Rick Robbins, M.D. 11/5/16 Rick Robbins, M.D. 11/5/16

ACGME Proposes Dropping the 16 Hour Resident Shift Limit

The Accreditation Council for Graduate Medical Education (ACGME) is proposing that first-year residents would no longer be limited to 16-hour shifts during the 2017-2018 academic year under a controversial proposal released today (1). Instead, individual residency programs could assign first-year trainees to shifts as long as 28 hours, the current limit for all other residents. The 28-hour maximum includes 4 transitional hours that's designed in part to help residents improve continuity of care. The plan to revise training requirements does not change other rules designed to protect all residents from overwork. including the maximum80 hours per week.

The ACGME capped the shifts of first-year residents at 16 hours in 2011 as a part of an ongoing effort to make trainee schedules more humane and avoid clinical errors caused by sleep deprivation. ACGME CEO Thomas Nasca, MD, told Medscape Medical News that the problem arises largely from first-year residents not being on the same schedule as supervising residents and others on their "home" educational team (2). On a 16-hour clock, first-year residents can end up working under relative strangers, said Dr Nasca. "The lack of synchronization is very disruptive." The solution, he said, is putting everyone on the same clock.

The ACGME touts a study published in the New England Journal of Medicine in February showing that longer shifts and less rest in between for surgical residents did not affect the rate of serious complications or surgical fatalities (3). A review in 2014 suggested that patient outcomes might be worse with the restrictions (4).

Both the American Medical Student Association, the Committee of Interns and Residents, and Public Citizen oppose the move. The ACGME proposal will go to the group's board of directors for a final decision after a 45-day comment period. More information on the proposal is available for download at https://www.acgme.org/. Comments can be submitted to cprrevision@acgme.org.

References

ACGME. ACGME task force presents new residency training requirements for public comment. November 4, 2016. Available at: https://www.acgme.org/Portals/0/PDFs/CPRNewsRelease_Fall2016_FINAL.pdf (accessed 11/4/16).
Lowes R. Let first-year residents work longer shifts, ACGME proposes. Medscape. November 4, 2016. Available at: http://www.medscape.com/viewarticle/871432?nlid=110468_3901&src=wnl_newsalrt_161104_MSCPEDIT&uac=9273DT&impID=1228495&faf=1 (accessed 11/4/16).
Bilimoria KY, Chung JW, Hedges LV, et al. National cluster-randomized trial of duty-hour flexibility in surgical training. N Engl J Med. 2016 Feb 25;374(8):713-27. TU[CrossRef]UTH HTU[PubMed]UT
Ahmed N, Devitt KS, Keshet I, et al. A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes. Ann Surg. 2014 Jun;259(6):1041-53. HTU[CrossRef]UTH HTU[PubMed]UT

Cite as: Robbins RA. ACGME proposes dropping the 16 hour resident shift limit. Southwest J Pulm Crit Care. 2016;13(5):216-7. doi: http://dx.doi.org/10.13175/swjpcc113-16 PDF

Rick Robbins, M.D. 11/3/16 Rick Robbins, M.D. 11/3/16

Non-Small Cell Lung Cancer: RT Out, Pembrolizumab In, and Vaccine Hope or Hype

Three articles on non-small cell lung cancer (NSCLC) recently appeared which were of interest and might alter therapy. The first on whole brain radiation therapy (WBRT) was presented at the at the European Respiratory Society (ERS) International Congress 2016 and simultaneously published online in the Lancet (1). WBRT and dexamethasone have been the standard of care for patients with NSCLC brain metastases. However, the study of 538 randomized patients concludes that WBRT provides "little additional clinically significant benefit" with brain metastases. Notably, all the patients were unsuitable for surgical resection or stereotactic radiotherapy, owing to widespread metastases. However, patients younger than 60 years did seem to have a survival advantage and might represent an exception.

The second study presented at the European Society for Medical Oncology (ESMO) 2016 Congress reports that the addition of pembrolizumab to first-line treatment with pemetrexed and carboplatin significantly improved objective response rate and progression-free survival in NSCLC (2). The study included 123 treatment-naive NSCLC patients whose tumors did not harbor EGFR or ALK aberrations. Participants were randomly assigned to receive pemetrexed plus carboplatin with or without pembrolizumab. At a median follow-up of 10.6 months, results showed that objective response rate was 55% with pembrolizumab vs 29% with chemotherapy alone (treatment difference, 26%; 95% CI, 9-42; P = .0016). All responses were partial.

Pembrolizumab is a humanized IgG4 monoclonal antibody (mouse antibody grafted to human immunoglublin) which destroys a protective mechanism on cancer cells, allowing the immune system to destroy those cancer cells. It targets the programmed cell death 1 (PD-1) receptor. The drug was initially used in treating metastatic melanoma but is a promising new therapy for advanced cancers, now including lung cancer. Brighton et al. (3) recently reported in the SWJPCC that pembrolizumab can result in drug-induced pneumonitis.

Earlier this spring a Fox News report in Phoenix made some spectacular claims about a Cuban lung cancer vaccine concluding that it “could literally save millions of live” (4-includes a video of the original broadcast). Dr. Santosh Rao from Banner MD Anderson Cancer Center in Phoenix, who apparently has seen studies on the vaccine says that the vaccine does something, and that it extends life. However, he added that "the question will always come up, is it better than some of the new therapies that we have that also help the immune system function better". Banner MD Anderson Cancer Center has been promoting the coverage on social media adding that the vaccine is “potentially groundbreaking". Dr. Doug Campos-Outcalt, Chair of New Department of Family, Community and Preventive Medicine, commented that he was as baffled by the coverage. “Why MD Anderson would hype this alleged breakthrough before it has undergone controlled clinical trials is beyond my understanding,” said Campos-Outcalt. The drug has not been used in the United States but Roswell Park Institute in Buffalo, NY, has applied to do a clinical trial on the vaccine called CIMAVax. If approved, the trial will probably not begin until 2017 and will likely take several years.

Richard A. Robbins, MD

Editor, SWJPCC

References

Mulvenna P, Nankivell M, Barton R, et al. Dexamethasone and supportive care with or without whole brain radiotherapy in treating patients with non-small cell lung cancer with brain metastases unsuitable for resection or stereotactic radiotherapy (QUARTZ): results from a phase 3, non-inferiority, randomised trial. Lancet. 2016 Oct 22;388(10055):2004-14. [CrossRef] [PubMed]
Hoffman J. Adding pembrolizumab to chemo improves efficacy in metastatic NSCLC. Cancer Therapy Advisor. November 1, 2016. Available at: http://www.cancertherapyadvisor.com/lung-cancer/lung-cancer-nsclc-pembrolizumab-chemotherapy-improved-efficacy/article/569669/ (accessed 11/2/16).
Brighton AM, Jain T, Bryce AH, Sista RR, Viggiano RW, Wesselius LJ. November 2016 pulmonary case of the month. Southwest J Pulm Crit Care. 2016:13(5):191-5. [CrossRef]
Lomangino K. FOX, Banner MD Anderson hype Cuba cancer “breakthrough”. Health News Review. March 7, 2016. Available at: http://www.healthnewsreview.org/2016/03/fox-md-anderson-hype-cuba-cancer-breakthrough-rumors/ (accessed 11/2/16).

Cite as: Robbins RA. Non-small cell lung cancer: RT out, pembrolizumab in, and vaccine hope or hype. Southwest J Pulm Crit Care. 2016;13(5):205-6. doi: http://dx.doi.org/10.13175/swjpcc107-16 PDF

Rick Robbins, M.D. 10/28/16 Rick Robbins, M.D. 10/28/16

Dental Visits May Prevent Pneumonia

Several sources are reporting on a paper presented at IDWeek that showed people with a regular dental checkup had half the incidence of bacterial pneumonia (1). Michelle Doll and colleagues used the Medical Expenditure Panel Survey (MEPS) data from 2013. The researchers were able to assess participants' access to dental care and used ICD-9 codes to look for bacterial pneumonia in the previous year. The survey had data on 26,687 people, including 441 who had an episode of bacterial pneumonia. Thirty-four percent of those who developed pneumonia reported having at least two dental checkups a year, compared with 46% of those who did not. It is important to point out that this is an observational study and there were significant differences between those who developed and did not develop bacterial pneumonia. Those who got pneumonia were: more likely to be white and older, with an average age of 47 versus 40; more likely to have comorbidities and cognitive limitations; and less likely to have dental insurance.

Nevertheless, the data is consistent with the hypothesis that microaspiration is a frequent cause of bacterial pneumonia. Previous data has shown oral chlorhexidine reduces ventilator-associated pneumonia in the ICU (2). Although a large randomized study is needed, the data suggests that dental care may be another community-acquired pneumonia preventative in addition to conjugated pneumococcal vaccine (3).

Richard A. Robbins, MD

Editor, SWJPCC

References

Smith M. Regular checkups linked to protection against bacterial disease. Medscape. October 28, 2016. Available at: http://www.medpagetoday.com/MeetingCoverage/IDWeek/61071 (accessed 10/28/16).
Hua F, Xie H, Worthington HV, Furness S, Zhang Q, Li C. Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database Syst Rev. 2016 Oct 25;10:CD008367. [CrossRef] [PubMed]
Bonten MJ, Huijts SM, Bolkenbaas M, et al. Polysaccharide conjugate vaccine against pneumococcal pneumonia in adults. N Engl J Med. 2015 Mar 19;372(12):1114-25. [CrossRef] [PubMed]

Cite as: Robbins RA. Dental visits may prevent penumonia. Southwest J Pulm Crit Care. 2016;13(4):186. doi: http://dx.doi.org/10.13175/swjpcc105-16 PDF

Rick Robbins, M.D. 9/20/16 Rick Robbins, M.D. 9/20/16

Hospital Employment of Physicians Does Not Improve Quality

The Annals of Internal Medicine posted a manuscript on-line today reporting that the growing trend of physician employment by hospitals does not improve quality (1). In 2003, approximately 29% of hospitals employed members of their physician workforce, a number that rose to 42% by 2012. The authors conducted a retrospective cohort study of U.S. acute care hospitals between 2003 and 2012 and examined mortality rates, 30-day readmission rates, length of stay, and patient satisfaction scores for common medical conditions for 803 hospitals that switched to the employment model compared with 2085 control hospitals that did not switch. Switching hospitals were more likely to be large (11.6% vs. 7.1%) or major teaching hospitals (7.5% vs. 4.5%) and less likely to be for-profit institutions (8.8% vs. 19.9%) (all p values <0.001).

The authors used Medicare Provider Analysis and Review File (MedPAR) from 2002 to 2013 to calculate hospital-level risk-adjusted performance on mortality, readmissions, and length of stay for acute myocardial infarction, congestive heart failure, and pneumonia. Hospital Compare data from 2007 to 2013 was used to assess overall patient satisfaction. After conversion to a physician employed model, no difference was found in any of 4 primary composite quality metrics with the single exception of readmission rates for pneumonia. That decline was modest (19.3% vs. 19.1% readmissions) and judged not likely to be clinically significant by the authors.

Recently, Baker and colleagues found that hospital employment of physicians is associated with higher spending and prices (2). This data combined with the data from the present study suggest that the trend is for higher healthcare costs without an improvement in quality. Commenting in Medscape Richard Gunderman, a well-known healthcare delivery researcher from the University of Indiana, said that those who think quality comes from increasingly larger organizations with more advanced information technology and greater standardization across the system will see these results as surprising and disappointing (3). Pointing to high levels of burnout and widespread complaints of lack of time with patients, Gunderman said less physician control over individual patient care has taken a toll. "There's no doubt that a demoralized workforce will tend to drive quality down," he said. "Many hospitals and health systems around the country are grappling with poor and, in some cases, dismal engagement scores. I think that's an indication that a lot of physicians feel that the changes taking place across healthcare are problematic."

Funding for the study was provided by the Agency for Healthcare Research and Quality. Limitations of the study was that the patients were primarily Medicare beneficiaries aged 65 years and older. Therefore, the applicability of the findings to a younger population is unknown, however, the authors doubted that after switching to an employment model, hospitals would improve care for one group and not another.

Richard A. Robbins, MD

Editor, SWJPCC

References

Scott KW, Orav EJ, Cutler KM, Jha AK. Changes in hospital–physician affiliations in U.S. hospitals and their effect on quality of care. Ann Intern Med. 2016. Available at: http://annals.org/article.aspx?articleid=2552987 (accessed 9/20/16). [CrossRef]
Baker LC, Bundorf MK, Kessler DP. Vertical integration: hospital ownership of physician practices is associated with higher prices and spending. Health Aff (Millwood). 2014 May;33(5):756-63. [CrossRef] [PubMed]
Frellick M. Physician employment by hospitals does not improve quality Medscape. September 19, 2016. Available at: http://www.medscape.com/viewarticle/868978?nlid=109338_2863&src=wnl_dne_160920_mscpedit&uac=9273DT&impID=1200121&faf=1#vp_2 (accessed 9/20/16).

Cite as: Robbins RA. Hospital employment of physicians does not improve quality. Southwest J Pulm Crit Care. 2016;13(3):133-4. doi: http://dx.doi.org/10.13175/swjpcc099-16 PDF

Rick Robbins, M.D. 9/6/16 Rick Robbins, M.D. 9/6/16

Clinton's and Trump's Positions on Major Healthcare Issues

As the presidential election nears, the positions of the two major candidates on healthcare have received more attention. Both Clinton and Trump have their healthcare positions listed on their websites (1,2). Below is a table listing their positions from their websites and occasionally other sources followed by a brief discussion of each of the issues.

Table 1. Presidential candidate positions on healthcare issues. A questions mark denotes an unclear position.

Affordable Care Act (ACA, Obamacare)

This is a major difference between Clinton and Trump. Clinton favors its retention (1). Trump favors its repeal (2).

Access to reproductive health

Clinton supports reproductive preventive care, affordable contraception, and safe and legal abortion (1). Trump's position is unclear. He currently is pro-life but would not use Federal funds for abortion (2). Federal funding for abortions us is prohibited by law (3).

Allow importing drugs to reduce costs

Both candidates favor importation of prescription drugs to reduce prices (1,2).

Block-grant Medicaid to the states

Trump block-grants asserting that "the state governments know their people best and can manage the administration of Medicaid far better without federal overhead" (2). This idea is not new with Congressional Republicans pushing for block-granting Medicaid at least since the 1990s (4) Clinton's position is unclear (1).

Coverage of poor

Both candidates favor universal healthcare including the poor (1,2).

Healthcare for illegal immigrants

Clinton favors extending healthcare to families regardless of immigration status by allowing families to buy health insurance on the health exchanges (1). Trump's website notes that providing healthcare to illegal immigrants costs us some $11 billion annually and he favors strict enforcement of the current immigration laws (2).

Healthcare savings accounts

Trump favors savings accounts which are permitted under the ACA but with restrictions (2,5). Clinton's position is unclear.

Increase access to healthcare

Both candidates favor increased access to healthcare (1,2).

Increase income tax deductions for healthcare costs

Both candidates favor increasing income tax deductions for healthcare costs but their plans are different (1,2). Trump favors full deduction of health insurance premium payments from tax returns. Clinton favors a refundable tax credit of up to $5,000 per family for excessive out-of-pocket costs.

Price transparency

Both candidates favor increased healthcare price transparency (1,2).

Public option

Clinton favors a public option (1). Trump's position is unclear.

Reduce copays and deductibles

Clinton favors reducing copays and deductibles (1). Trump's position is unclear.

Sell insurance across state lines

Trump favors insurance companies selling healthcare insurance across state lines (2). This has been a part of the platform of every Republican presidential nominee and is permitted in 5 states but insurance companies have been reluctant to sell these policies (6). Clinton's position is unclear.

References

Hillary Clinton for America. Available at: https://www.hillaryclinton.com/issues/health-care/ (accessed 9/6/16).
Donald J. Trump for President. Available at: https://www.donaldjtrump.com/positions/healthcare-reform (accessed 9/6/16).
Salganicoff A, Beamesderfer A, Kurani N, Sobel L. Coverage for abortion services and the ACA. Kaiser Family Foundation. September 19, 2014. Available at: http://kff.org/womens-health-policy/issue-brief/coverage-for-abortion-services-and-the-aca/ (accessed 9/6/16).
Dickson V. GOP's Medicaid block-grant plan won't happen while Obama's in office. Medscape. March 19, 2015. Available at: http://www.modernhealthcare.com/article/20150319/NEWS/150319877 (accessed 9/6/16).
Norris L. Under the ACA, can I still have an individual HDHP and an HSA? Healthinsurance.org. May 16, 2016. Available at: https://www.healthinsurance.org/faqs/i-have-an-individual-hdhp-and-an-hsa-will-i-still-be-able-to-have-them-under-the-aca/ (accessed 9/6/16).
Cauchi R. Out-of-state health insurance - allowing purchases (state implementation report). National Conference of State Legislators. December, 2015. Available at: http://www.ncsl.org/research/health/out-of-state-health-insurance-purchases.aspx (accessed 9/6/16).

Cite as: Robbins RA. Clinton's and Trump's positions on major healthcare issues. Southwst J Pulm Crit Care. 2016;13(3):126-8. doi: http://dx.doi.org/10.13175/swjpcc091-16 PDF

Rick Robbins, M.D. 9/5/16 Rick Robbins, M.D. 9/5/16

IDSA Releases Updated Coccidioidomycosis Guidelines

The Infectious Diseases Society of America (IDSA) has released updated Guidelines for the Treatment of Coccidioidomycosis, also known as cocci or Valley Fever (1). Coccidioidomycosis is a fungal infection endemic to the southwestern United States and a common cause of pneumonia and pulmonary nodules in this area. However, the infection can disseminate systemically especially in immunocompromised hosts and certain ethnic populations resulting in a variety of pulmonary and extrapulmonary complications. In addition to recommendations for these complications, the new guidelines address management of special at-risk populations, preemptive management strategies in at-risk populations and after unintentional laboratory exposure. The guidelines also suggest shorter courses of antibiotics for hospitalized patients and more ambulatory treatment for most individuals who have contracted Valley Fever.

The panel was led by John N. Galgiani, MD, director of the Valley Fever Center for Excellence at the University of Arizona Health Sciences. Galgiani led a panel of 16 experts including faculty from the University of Arizona, Mayo Clinic Arizona, University of California San Diego, University of California Los Angeles, Utah, Barrows Neurological Institute and the University of Utah.

A reference booklet, “Valley Fever (Coccidioidomycosis)—Tutorial for Primary Care Physicians,” from the UA Valley Fever Center for Excellence complements the guidelines and is available through the Southwest Journal of Pulmonary and Critical Care (2) and also available at the Valley Fever Center for Excellence website.

The guidelines begin with a disclaimer that it is "important to realize that guidelines cannot always account for individual variation among patients and ... not intended to supplant physician judgment". This is especially important because many of the guidelines are based on expert opinion rather than strong scientific evidence.

References

Galgiani JN, Ampel NM, Blair JE, Catanzaro A, Geertsma F, Hoover SE, Johnson RH, Kusne S, Lisse J, MacDonald JD, Meyerson SL, Raksin PB, Siever J, Stevens DA, Sunenshine R, Theodore N. 2016 Infectious Diseases Society of America (IDSA) clinical practice guideline for the treatment of coccidioidomycosis. Clin Infect Dis. 2016 Sep 15;63(6):e112-46. [CrossRef] [PubMed]
Galgiani JN. Valley fever (coccidioidomycosis): tutorial for primary care physicians. Southwest J Pulm Crit Care. 2015;10(5):265-88. [CrossRef]

Cite as: Robbins RA. IDSA releases updated coccidioidomycosis guidelines. Southwest J Pulm Crit Care. 2016;13(3):125. doi: http://dx.doi.org/10.13175/swjpcc090-16 PDF

Rick Robbins, M.D. 8/29/16 Rick Robbins, M.D. 8/29/16

Withdraw of Insurers from ACA Markets Leaving Many Southwest Patients with Few or No Choices

Thirty-one percent of the nation’s counties are projected to have only one insurer offering health plans on the Affordable Care Act’s (ACA) exchanges next year, according to the nonpartisan Kaiser Family Foundation (1). Another 31% are projected to have only be only two. Most of the likely one-insurer counties are predominantly rural (Figure 1).

Figure 1. Estimated number of insurers participating in Affordable Care Act exchanges by county, 2017.

Particularly hard hit is Arizona where most of the rural portions of the state will have only one insurer and Pinal County will have none. Rural Nevada is similarly affected along with Utah, Wyoming, Oklahoma and much of the Southeast US.

That would give exchange customers in large areas of the U.S. far less choice than they had this year, when only 7% of counties had one insurer and 29% had two (Figure 2).

Figure 2. Net changes in number of insurers compared to 2016.

Many insurers are losing money on the health plans they sell through the exchanges. Insurance giants UnitedHealth, Humana, and Aetna have cited heavy losses as the reason for withdrawing from ACA marketplaces (2). The insurers that remain are in some cases seeking sharp premium increases for next year, trying to get back in the black amid higher-than-expected costs.

The marketplaces were supposed to hold down prices and expand choice by fostering competition among insurers. A concern when the exchanges were set up was that they might eventually reach the "tipping point". This is the point where too many sick patients with high health care costs are enrolled in the exchanges. Their high costs lead to higher insurance premiums driving the young and healthy enrollees out of the exchanges. According to the insurers the young and healthy enrollees low costs are necessary to balance out claims ledgers. President Obama has called for the creation of a public insurance option to compete alongside private plans in places where competition is limited.

References

Cox C, Semanskee A. Preliminary data on insurer exits and entrants in 2017 affordable care act marketplaces. Kaiser Health News. August 28, 2016. Avialble at: http://kff.org/health-reform/issue-brief/preliminary-data-on-insurer-exits-and-entrants-in-2017-affordable-care-act-marketplaces/ (accessed 8/29/16).
Mathews AW, Armour S. Health insurers’ pullback threatens to create monopolies. Wall Street Journal. August 28, 2016. Available at: http://www.wsj.com/articles/health-insurers-pullback-threatens-to-create-monopolies-1472408338 (accessed 8/29/16).

Cite as: Robbins RA. Withdraw of insurers from ACA markets leaving many southwest patients with few or no choices. Southwest J Pulm Crit Care. 2016;13(2):97-8. doi: http://dx.doi.org/10.13175/swjpcc085-16 PDF

Rick Robbins, M.D. 8/27/16 Rick Robbins, M.D. 8/27/16

Another Phoenix VA Director Leaves

The Arizona Republic reports that the director at the Phoenix VA Medical Center, Deborah Amdur, will retire after only 9 months for health reasons (1). Amdur will be replaced by Barbara Fallen, director of the VA Loma Linda Healthcare System. Fallen will be interim director until a permanent replacement for Amdur can be found. This is the fifth hospital director since former Director Sharon Helman was removed in mid-2014 amid the nationwide veterans health-care scandal that was first exposed at the Phoenix VA.

The Veterans Integrated Service Network (VISN) in Gilbert, which oversees the VA Medical Center in Arizona, New Mexico and West Texas has also been through a series of 4 directors since Susan Bowers retired under pressure in the wake of the VA scandal. Marie Weldon, current acting regional director, also oversees the Los Angeles-based VA Desert Pacific Healthcare System. Weldon described Fallen as “an experienced leader who will continue the tremendous effort being made to improve access to high quality health care for veterans in the Phoenix area.”

Amdur's retirement comes just one day after 12 News KPNX in Phoenix reported a taped conversation between a patient and employees at the Southeast VA Clinic in Gilbert (2). During the visit a nurse called the patient phone scheduling system “a nightmare", and a doctor employed by the VA for 3 months said he was “not a fan of the VA” and complained that assigning him 500 patients on May 23rd did not allow him sufficient time with patients. According to the tape the doctor expresses his desire to help but simply states, “It’s just I’m so lost in what to do.” Regarding the audio recording, Director Amdur said before her resignation that "the agency is looking into the matter" and threatened "actions with the providers involved”.

Congressman Matt Salmon, who represents Arizona's 5th District which includes the Southeast VA Clinic, told 12 News he was “disappointed” by what the audio recording revealed and does not consider it an anomaly. Salmon said while there are pressing matters facing the agency, he is optimistic new leadership can help turn it around. "I have nothing but praise for Director Amdur who is running the (Phoenix) VA. I think she is a breath of fresh air," Salmon said. "But the problem is so many people who still work there are the people that were there when the problem was created and getting rid of people that don’t do the job the way they are supposed to is almost impossible in the VA." Salmon said the VA's HR system needs to be revamped in order to recruit higher-quality employees. "It needs to be streamlined so that when they find good doctors they are able to hire them quickly," Salmon said.

Amdur's threats and Salmon's comments are in line with the last 2 and a half years of VA excuses for poor care by blaming bad employees rather than mismanagement and lack of oversight. Both the nurse and the doctor are new to the VA and will likely shortly be gone for telling the truth further worsening the shortage of providers. As predicted 2 and half years ago, no fundamental changes have been made at the VA and it is not surprising that problems with patient scheduling persist (3). The last 20 years demonstrate that if the VA wants to provide the best of care, it is time to stop putting VA bureaucrats in charge and replace them with professionals who know something about it, doctors and nurses. Those doctors and nurses need to be overseen by a local committee of professionals to ensure that Veterans get the best of care. Otherwise no real change occurs and VA bureaucrats and politicians will continue to blame bad employees rather than a bad system. If no fundamental change is made, it may be time to scrap the VA system and send patients to outside providers as suggested by both the patient who made the recording and implied by Salmon.

Richard A. Robbins, MD*

Editor, SWJPCC

References

Wagner D. Phoenix VA hospital getting yet another boss. Arizona Republic. August 26, 2016. Available at: http://www.azcentral.com/story/news/local/phoenix/2016/08/26/phoenix-va-hospital-getting-yet-another-boss/89412700/ (accessed 8/27/16).
Dana J. VA cancer patient secretly records doctor visit. 12 News KPNX. August 25, 2016. Available at: http://www.12news.com/news/local/valley/va-cancer-patient-secretly-records-doctor-visit/307185216 (accessed 8/27/16).
Robbins RA. VA administrators breathe a sigh of relief. Southwest J Pulm Crit Care. 2014;8(6):336-9. doi: http://dx.doi.org/10.13175/swjpcc077-14.

*The views expressed are those of the author and do not necessarily reflect the views of the Arizona, New Mexico, Colorado, or California Thoracic Societies or the Mayo Clinic. Dr. Robbins does see VA patients under the Veterans Choice Act.

Cite as: Robbins RA. Another Phoenix VA director leaves. Southwest J Pulm Crit Care. 2016;13(2):95-6. doi: http://dx.doi.org/10.13175/swjpcc084-16 PDF

Rick Robbins, M.D. 8/22/16 Rick Robbins, M.D. 8/22/16

Hospital Executive Compensation Act Dropped from Ballot

The Hospital Executive Compensation Act did not qualify for the November 8, 2016 ballot in Arizona as a state statute (1). The Service Employees International Union (SEIU) dropped the initiative just before arguments were to begin in a lawsuit that challenged the legality of signature gatherers who failed to register with the state. The measure would have limited total pay for executives, administrators and managers of healthcare facilities and entities to the annual salary of the President of the United States. A similar measure in California was also dropped by the SEIU in 2014.

Supporters of the proposal said it would decrease escalating healthcare costs. Opponents of the measure, including the Arizona Chamber of Commerce who filed the suit challenging the proposition, alleged that it would lead to poorer healthcare. However, a survey conducted by the Southwest Journal of Pulmonary and Critical Care showed that most supported the measure and felt that it would not lead to poorer healthcare (2).

References

Ballotpedia. Arizona hospital executive compensation act (2016). Available at: https://ballotpedia.org/Arizona_Hospital_Executive_Compensation_Act_(2016) (accessed 8/22/16).
Robbins RA. Survey shows support for the hospital executive compensation act. Southwest J Pulm Crit Care. 2016;13:90. [CrossRef]

Cite as: Robbins RA. Hospital executive compensation act dropped from ballot. Southwest J Pulm Crit Care. 2016;13:91. doi: http://dx.doi.org/10.13175/swjpcc081-16 PDF

Rick Robbins, M.D. 8/6/16 Rick Robbins, M.D. 8/6/16

Banner Hacked-3.7 Million at Risk

A large-scale computer cyberattack at Banner Health compromised the records of up to 3.7 million patients, health-insurance-plan members, food and drink customers, and doctors according to the an Arizona Republic article by Ken Alltucker (1). Banner Health discovered unusual activity on its computer servers in late June and uncovered evidence of two attacks, with hackers accessing both patient records and payment-card records of food and beverage customers. The Phoenix-based health-care provider said it will mail letters to those affected notifying them about details of the cyberattack and steps they can take to protect themselves. Banner employees, many of whom are patients and covered by Banner Health insurance plans, also are believed to be victims of the attack.

The Banner Health attack is the largest among 32 known data breaches involving Arizona-based health and medical providers since 2010 according to an U.S. Department of Health and Human Service list. The breach exceeds all other breaches in Arizona combined by over 1,000,000 affected individuals. Banner also has the dubious distinction of the previous high in Arizona when records of 55,207 were compromised in 2014 (2).

Banner Health officials said they thus far have not received reports of hackers misusing the information, but the health-care provider will offer a free one-year membership in credit-monitoring services to patients, health-plan members and others affected by the cyberattack. The hackers apparently accessed Banner computer systems that process payment-card data at food and beverage outlets at some Banner Health locations. Potential victims can view a list of affected Banner locations in Arizona, Alaska, Colorado and Wyoming at http://bannersupports.com/customers/affected-locations/. On July 13, Banner Health discovered that hackers also may have accessed patient and health-insurance records, which may have included information about doctors and health-care providers. Those records may have included names, birth dates, addresses, doctors' names, dates of service, claims information, health-insurance information and Social Security numbers.

Bob Gregg, chief executive of Portland, Ore.-based ID Experts. said health-care providers are increasingly facing attacks from criminal organizations that resell the information for profit. According to Gregg. a record containing a name, address and Social Security number sells for $1 to $3 on the black market but detailed medical records with unique patient identifying numbers can fetch up to $100 per record.

Banner Health has established a website that details information about the data breach at http://bannersupports.com. Patients or other customers who have questions or concerns about the cyberattack can call 1-855-223-4412.

References

Ken Alltucker. Banner Health cyberattack breaches up to 3.7 million records. Arizona Republic. August 3, 2016. Available at: http://www.azcentral.com/story/money/business/health/2016/08/03/banner-health-cyberattack-breaches-up-3-7-million-records/88035474/ (accessed 8/6/16).
Robbins RA. Banner prints social security numbers. Southwest J Pulm Crit Care. 2014;8(2):140-1. [CrossRef]

Cite as: Robbins RA. Banner hacked-3.7 million at risk. Southwest J Pulm Crit Care. 2016;13(2):80-1. doi: http://dx.doi.org/10.13175/swjpcc075-16 PDF

Rick Robbins, M.D. 12/31/15 Rick Robbins, M.D. 12/31/15

Banner Plans to Issue New Bonds to Cover University of Arizona Medical Center Purchase

Modern Healthcare is reporting that Banner Health is issuing new bonds this week to refinance older debt (1). Banner financed the $1 billion purchase of the University of Arizona Health Network (UAHN) including the University of Arizona Medical Center with a $700 million short-term loan from investment bank Mizuho in February. Banner is issuing $100 million in tax-exempt, fixed rate Series 2015A bonds. It is also planning to take on an additional $500 million in taxable and tax-exempt debt that will be used to replace the short-term loans associated with the purchase.

Banner is focusing on how to improve the return on its UAHN investment, which has dragged down its earnings. UAHN's financial performance has deteriorated with an operating margin declining to -4.3% in fiscal 2014, down from -1.2% the previous fiscal year. Before that, UAHN was profitable, according to Banner Chief Financial Officer Dennis Dahlen. Banner reported an operating surplus of $107.6 million on $3.4 billion in revenue for the first half of this year (2). In the prior-year period, its operating surplus was $186 million on $2.7 billion in revenue.

In an attempt to increase profitability, Banner has implemented a leadership incentive plan at UAHN and labor productivity tools. The executive compensation firm Sullivan Cotter has also been hired to design a new physician practice compensation structure. Dahlen noted that Banner believes that it will stabilize UAHN's finances by the end of next year, with profitability returning in 2017.

With the purchase of UAHN and the much smaller 44-bed Payson Regional Medical Center in July, Banner now reaches 82% of Arizona residents and is by far Arizona's largest health care system. Banner also plans to expand UAHN's health plans statewide to capture additional market share. The impact the debt from Banner's drive for market share will have on health care prices and Banner employees is unclear.

Richard A. Robbins, MD

Editor

Southwest Journal of Pulmonary and Critical Care

References

Kutscher B. Banner prepares to issue new debt amid UAHN turnaround efforts. Modern Healthcare. October 20, 2015. Available at: http://www.modernhealthcare.com/article/20151020/NEWS/151019914?utm_source=modernhealthcare&utm_medium=email&utm_content=20151020-NEWS-151019914&utm_campaign=am (accessed 10/21/15).
Kutscher B. Banner aims to cut costs from UAHN as earnings lag. Modern Healthcare. August 25, 2015. Available at: http://www.modernhealthcare.com/article/20150825/NEWS/150829923 (accessed 10/21/15).

Cite as: Robbins RA. Banner plans to issue new bonds to cover university of Arizona medical center purchase. Southwest J Pulm Crit Care. 2015;11(4):191. doi: http://dx.doi.org/10.13175/swjpcc136-15 PDF

Rick Robbins, M.D. 1/22/15 Rick Robbins, M.D. 1/22/15

HealthCare.gov Shares Personal Data with Third Parties

According to the Associated Press, the Centers for Medicare and Medicaid's (CMS) website, HealthCare.gov, has been sending consumers’ personal data to private companies that specialize in advertising and analyzing Internet data for performance and marketing (1). What information is being disclosed was not immediately clear, but it could include age, income, ZIP code, and smoking status. It could also include a computer’s Internet address, which can identify a person’s name or address when combined with other information collected by sophisticated online marketing or advertising firms. “We deploy tools on the window shopping application that collect basic information to optimize and assess system performance,” said CMS’s Aaron Albright in a statement. “We believe that the use of these tools are common and represent best practices for a typical e-commerce site.” There is no evidence that personal information has been misused. But connections to dozens of third-party tech firms were documented by technology experts who analyzed HealthCare.gov and then confirmed by AP. A handful of the companies were also collecting highly specific information.

Created under the Affordable Care Act (ACA, Obamacare), HealthCare.gov is the online gateway to government-subsidized private insurance for people who lack coverage on the job. It serves consumers in 37 states, while the remaining states operate their own insurance markets.

Marilyn Tavenner, administrator of CMS, resigned last Friday, effective February 1. Much maligned for the shaky roll-out of HealthCare.gov, it is unclear if Tavenner's resignation and the revelation of the breech in patient confidentiality are related.

References

Associated press. Government health care website quietly sharing personal data. Available at: http://www.cnbc.com/id/102355634 (accessed 1/22/15).
Alonso-Zaldivar R. Medicare chief steps down, ran health care rollout. Available at: http://abcnews.go.com/Health/wireStory/medicare-chief-steps-part-health-care-roll-28270777 (accessed 1/22/15).

Reference as: Robbins RA. Healthcare.gov shares personal data with third parties. Southwest J Pulm Crit Care. 2015;10(1):51. doi: http://dx.doi.org/10.13175/swjpcc009-15 PDF