Health Car Reform: Getting the Facts Right

As I write about the current national debate on health care, I get a sense of what Pope Benedict XVI might have felt at Regensburg. Compelled to speak about Islam and violence, the Holy Father was keenly aware he was walking on thin ice. The Vatican’s track record during the Crusades was not a shining example of Christ’s teaching on peace and justice . Yet, despite the historical baggage, Pope Benedict forged ahead to address the errors of Islamic fundamentalism.

In good company, therefore, I will speak about health care reform. A short essay like this simply cannot cover the health care debate in a fair and comprehensive manner. So, I will address the issue in a series of articles.

At a recent Knights of Columbus convention in Phoenix, a well-educated Filipino, upon learning that I was a surgeon, brought out the topic of health care reform. From his perspective, the solution to providing health care to 40 million people without medical insurance was simply to reduce payments to physicians, hospitals, and drug companies. He must have read the USA Today interview of House Speaker Nancy Pelosi, who assured the nation that securing $1.4 trillion to fund a new government program was easy – the government would simply tax doctors, hospitals, and pharmaceutical companies.

So I asked my brother knight what he thought I would get compensated for if I got out of bed at 2 in the morning, rushed to the ER to examine a patien t, reviewed the blood tests and CT scans, diagnosed appendicitis, then brought the patient to the Operating Suite for emergency surgery. And what if I kept the child or adult in the hospital for several days of intravenous antibiotic treatment, saw him or her every day on rounds, conferred with the nurses and updated the family regarding the patient’s clinical progress, then checked the patient again in the office for the next couple of weeks until he or she could go back to school or work?

My fellow knight promptly mentioned a dollar amount that was easily ten times what I would actually get paid for. Assuming, I did not get an IOU check from Sacramento, as is happening these days under the state budgetary crisis.

And what did he think I would get paid for services rendered after surgery? He guessed wrong again. How about zero dollars, I said. Everything that surgeons do after surgery falls into what is called a postoperative “global period” of 60-90 days when all services provided for the patient are free.

He thought I was joking. “Doc,” he said, “don’t you get paid $500 every time you opened a chart?” This led me to conclude that he (and millions of Americans) must have been listening to the President of the United States who claimed that surgeons got $50,000 for amputating a leg. I wonder on which planet these surgical fees are being disbursed. Overworked physicians can certainly use such generous reimbursements here on earth for the ever increasing malpractice premiums we pay to protect ourselves from lawsuits that have become casino lotteries for patients and malpractice lawyers.

Knowledgeable experts estimate that if tort or much-needed malpractice reforms were instituted, and defensive medicine eliminated, health care expenditure in the United States will immediately be reduced by $200 Billion a year.

Last year, an article entitled “Patient Perception of Medicare Fee Schedule of Laparoscopic Procedures was published in a surgical journal (Surgical Innovation, September 19, 2008). It was a study conducted by a team from the University of Miami School Of Medicine and presented to the Society of American Gastrointestinal Endoscopic Surgeons annual meeting.

Concerned that the public (and congressional representatives) are under the erroneous notion that physicians receive substantial remuneration for surgical procedures, the team surveyed 96 patients. 83% of the patients had been operated on.

The survey revealed the following: Almost all of the patients (98%) thought Medicare should pay more for technically difficult surgical procedures. 32% felt Medicare paid physicians well but 91% thought Medicare should increase fees for doctors.

Interestingly, patients thought that surgeons were paid $14,963 for a gastric bypass operation and that Medicare should increase payment for the laparos copic procedure to $16,877, when, in fact, Medicare pays only $1,504 for such an operation.

For gallbladder surgery, patients thought that surgeons were paid $8,746 and that they deserve to be paid $10,555 for the operation. In actual fact, Medicare pays $620.

Medical students surveyed in a 2007study thought that surgeons got paid $3,000 for gallbladder surgery while most surgeons thought they were getting paid $700. Again, the actual payment was $620 for removal of the gallbladder by laparoscopic surgery. Such compensation also included medical care before and after surgery.

For initial patient visit to the doctor’s office, the survey showed that patients think Medicare pays $144 and that doctors deserve to be paid $181. In fact, Medicare pays surgeons $90.58 for a patient’s visit. Additional visits are paid lower.

The study concluded that “lawmaker perception of Medicare physician reimbursement probably resembles public perception, which may explain the fact of the ever-threatening cuts in Medicare reimbursement to physicians.”

Next year, Medicare plans to cut reimbursements further by another 20%.

Jolted by facts, my friend in Phoenix said that Medicare had trouble containing costs and that Medicare constitutes only a fraction of most medical practices anyway. He was right. Depending on type and location of practice, Medicare makes up 20-40%. However, what he did not know is this: most, if not all insurance companies, now set fee schedules as close to Medicare rates as possible. And Medi-Cal rates are even lower than Medicare.

That is why most physicians, while recognizing the value of universal heal th care, are concerned that the proposed government option plan will be nothing more than a Medicare clone.

I will examine another aspect of health care reform in the next article.



more . . . E-mails from the Desert - Dr. Ed Gamboa
28.AUG.09 Health Care Reform: Getting the Facts Right
08.MAY.09 Yosemite's Half Dome
24.APR.09 Obama, Notre Dame and the Culture of Life
27.MAR.09 A friend goes on vacation
06.MAR.09 The Garden of Eden
06.FEB.09 Double Speak
30.JAN.09 A Cup of Tea, Before Sunrise
16.JAN.09 A different kind of Santa
19.DEC.08 A lonely Christmas...
28.NOV.08 The Perils of Capitalism
21.NOV.08 Sold-out Audience Cheers for Asian Silk Road Concert
31.OCT.08 The Sarah Palin Factor
10.OCT.08 Restore Traditional Marriage - Vote YES on Proposition 8
19.SEP.08 Olympics, Philippine Style
08.AUG.08 Wisdom - where to find it?
25.JUL.08 Moonlit Beach
11.JUL.08 Breast Cancer Treatments
27.JUN.08 Breast Cancer 101
13.JUN.08 PATHWAYS
06.JUN.08 Coming Out Soon! "Virtuous Healers"
30.MAY.08 Filipino Nuncio
23.MAY.08 Pan de Sal Cruise








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Breast Cancer Treatments

Breast Cancer Treatments
In the last article, we briefly alluded to the staging of breast cancer. Staging (I to IV) is important because early stage breast cancer can be successfully treated, even curable, while late stage cancer is difficult to treat. Thus, the importance of annual mammography cannot be overemphasized. Every woman over the age of 40 must get an annual mammogram (no excuses!) because the incidence of breast cancer rises dramatically at middle age.

If breast cancer is detected early by mammography -- that is, before the tumor has spread out to other areas of the breast or other regions of the body, such as lymph nodes, bones, liver, brain, etc., the tumor can be easily excised or removed completely by surgery.

Cancer is early when it is still "in situ" (in its place). It is late when it has become "invasive or infiltrating", i.e., the tumor has broken through the ducts and lobules of the breast to spread via the blood stream and lymphatics to other areas.

In situ cancer is easily treated with surgical excision (called "lumpectomy") without removing the entire breast. Even bigger cancers can now be removed in a limited way, or treated "conservatively" as opposed to "radically", as long as radiation is performed after surgery. Nevertheless, modified radical mastectomy is still considered the gold standard of treatment, until, perhaps, the advent of comprehensive genetic oncology (genetic treatment of cancer).

Dr. William S. Halsted, the father of American Surgery, developed the surgical treatment for breast cancer in New York and was the first to perform a radical mastectomy in 1882. For almost the next century, Halsted's operation became the standard treatment for breast cancer. In 1978, Dr. Bernard Fisher, from the University of Pittsburg, published a study which showed that lumpectomy (or limited breast resection) coupled with radiation therapy was as effective as total radical mastectomy. This led to a change in how breast cancer is currently treated. In the 1990s, sentinel node biopsy was developed to refine the removal of axillary nodes which determines whether cancer is localized or already spread out to the lymph glands.

Depending on the biological behavior of the cancer, its size, hormone dependence, etc., there is now an array of treatment modalities available.

When a tumor is detected by mammogram (remember, most breast cancers present as painless lesions), a choice can be made between a needle biopsy with ultrasound or stereotactic guidance (with the patient awake) or an open biopsy in the operating room under anesthesia (with the patient asleep).

The tissue that is sampled is then sent to pathology for a series of tests. Pathologists will examine the tissue under the microscope to determine if the lesion is cancer (malignant) or if it is not (benign fatty tissue, fibroadenoma, cyst, etc.). If the biopsy is positive for cancer, the patient can discuss with her surgeon the necessity of removing only a portion of the breast or removing the entire breast (with or without plastic surgery reconstruction).

If a limited resection is the choice, the patient will have to undergo radiation as well to guarantee that microscopic cancer cells, outside of the area of resection, are eradicated. If the entire breast is removed and the axillary nodes are found to be clean or free of cancer cells, no further treatment aside from hormonal treatment, such as the antiestrogen Tamoxifen, may be necessary. However, if the axillary lymph nodes are positive, adjuvant chemotherapy might be beneficial, regardless of the side effects.

Chemotherapy, which is started only after the surgical wound has healed, usually requires placement of a MediPort or access chamber into the subclavian vein so that powerful drugs such as clyclophosphamide, methotrexate, fluorouracil adriamycin, etc. can be safely administered for 3-6 months. External beam radiation for 5-7 weeks might also be necessary. Internal radiation or brachytherapy is an option. The latter involves low-dose or high dose implantation of radioactive substances.

Other treatments are put in place depending on whether the cancer is estrogen postive, progesterone positive or if there is overexpression or amplification of HER2/neu gene ( 15-20% of breast cancers) which is associated with a worse prognosis and higher recurrence rate. The monoclonal antibody trastuzumab (Herceptin) may be effective in these aggressive types of breast cancer.

The take home message is that breast cancer comes in many forms and can be treated in a variety of ways. The most important message to women in their 40s is: get your yearly mammogram.

###

Breast Cancer 101

Greetings from the Philippines!

Just before Lucie and I left El Centro for an emergency trip to Cebu City, I was invited to lecture on breast cancer to a cancer support grassroots organization.

Breast cancer incidence in the United States is an alarming 90 per 100,000 women. The take home message of my Saturday morning talk was: get a baseline mammogram. At age 40 and above, an annual mammogram can save your life. Regular mammography is the single most effective method of breast cancer surveillance.

While the incidence is highest in the United States and Western Europe where lifetime risk is 12% but lower in Asia and third world countries, carcinoma of the breast is the most common cancer among women worldwide.

Lowest incidence is in 20-24 year old women. However, breast cancer increases with age. 95% of new cases are diagnosed in 40 year old women and older. Median age is 61 years.

The statistics which I presented to the group of cancer survivors and supporters hit close to home this time. A day before our return flight to Southern California, my aunt called to say she had noticed a breast lump. I was very concerned, knowing that breast cancer most commonly manifests as a painless mass.

We brought her to the local hospital where a quick mammogram showed a suspicious 3 centimeter spiculated lesion. A core needle biopsy, done under local anesthesia with ultrasound guidance, confirmed invasive cancer on the frozen section microscopic slides.

We postponed our return flight. With another local surgeon, Dr. Spanky Tablante, who had relocated to the Philippines after practicing twenty years in Virginia, we performed a standard mastectomy with axillary node dissection. My 81-yr-old aunt is recuperating well as I write this and should be back home by the time you read this article.

The operating suite at Perpetual Succour Hospital in Cebu City may not have the latest gadgets we have at our disposal in the United States. For instance, we operated without a harmonic (bloodless) scalpel. But, during the entire two and a half hours of surgery, the Chief of Cardiology, Dr. Victor Gonzalez, was seated next to the Chief Anesthesiologist, Dr. Enricoso, constantly monitoring my aunt's vital signs. We certainly don't have that kind of personalized luxury in California!

Again, it is important to emphasize the need for yearly clinical examination and mammography. Early breast cancer cannot be felt. It is usually not painful. But a good mammogram should detect a suspicious lesion 85-90% of the time. In cases of dense or fibrocystic breasts, physicians may order an MRI (Magnetic Resonance Imaging) which increases detection rate by an additional 5-10%. Soon, digital mammography will be readily available, which will make detection of very tiny and early stage cancers even more accurate.

Several factors are known to put women at risk of developing breast cancer. Increasing age, as mentioned, is one. As one gets older, the risk increases. At age 20 - 24, only 1.4 per 100,000 women are diagnosed with breast cancer. At age 75-79, the incidence rises to 465 per 100,000.

A first degree relative with breast cancer, delayed childbearing, fewer children, late age at first full term pregnancy (>30 years), early menarche (<12>55 years), high dose radiation to the chest, obesity, use of contraceptive pills and hormone replacement therapy are all known risk factors.

Patients with a history of endometrial, ovarian, and colon cancer are also at risk. Mothers that do not breast feed are at higher risk than the average population. Women who are found to have atypical ductal or lobular hyperplasia (by mammography and biopsy) are at risk for developing breast cancer.

Bottom line is that all women should be vigilant. Monthly self breast examination is a worthwhile practice. A woman should be familiar with changes in her breast and should learn to detect thickening, swelling, redness, nipple inversion, discharge and skin erosion. Once noticed, she should not delay in bringing this to the attention of her physician.

In addition to self examination and regular mammography, avoiding rapid weight gain and obesity is important. Regular physical activity and exercise is known to cut down the rate of breast cancer, in addition to improving general health.

Minimize alcohol intake. Two alcoholic drinks a day increases cancer risk by 21%. Hormonal therapy should be taken with caution. Discuss thoroughly with your physician the risks involved before taking hormones as contraceptive pills or menopausal supplements.

In the next article, I will discuss the current standard treatment of breast cancer.