"The new health care reform law is chock-full of new taxes and tax increases that will affect many individuals and businesses, but it will be years before most of these hikes take a bite out of your -- or your company’s -- wallet."
http://www.kiplinger.com/businessresour … e-way.html
I especially like the the part where the Government is raising the AGI rate for out of pocket expenses so you can deduct less, limiting flexible spending accounts so you have less control over your health care choices, taxing benefits as income, and of course the slew of anti-business penalties.
This going to make businesses want to hire more people for sure!
Risky Back Surgery Surge Costs Medicare a Bundle
Study: Riskier surgeries for back pain raise costs
By CARLA K. JOHNSON, AP Medical Writer
Wednesday, April 7, 2010
(04-07) 00:35 PDT CHICAGO, (AP) --
A study of Medicare patients shows that costlier, more complex spinal fusion surgeries are on the rise — and sometimes done unnecessarily — for a common lower back condition caused by aging and arthritis.
What's more alarming is that the findings suggest these more challenging operations are riskier, leading to more complications and even deaths.
"This is exactly what the health care debate has been dancing around," said Dr. Eugene Carragee of Stanford University Medical Center.
"You have one kind of operation that could cost $20,000 and another that could cost $80,000 and there's not good evidence the expensive one is being used appropriately in the majority of cases," Carragee said.
Add to that the expense for patients whose problems after surgery send them back to the hospital or to a nursing home and "that's not a trivial amount of money" for Medicare, said Carragee. He wrote an accompanying editorial in the Journal of the American Medical Association where the federally funded study appears Wednesday.
The cost to Medicare, just for the hospital charges for the three types of back surgery reviewed is about $1.65 billion a year, according to the researchers.
All the patients in the study had stenosis in their lower backs, a painful squeezing in the spine that's most common in people over 50. The researchers compared the risks for three different types of surgery for the condition: decompression, simple fusion and complex fusion.
"All operations aren't the same and some seem to be associated with higher complication rates than others," said lead author Dr. Richard Deyo of Oregon Health and Science University in Portland. "It's not necessarily true that the more aggressive surgery is better, at least in terms of safety."
There's little agreement about the best way to treat chronic lower back pain, and much depends on what's causing the pain.
Patients should ask their doctors about alternatives to complicated operations, Deyo said. Could steroid injections and physical therapy be tried? Would a simple decompression procedure be as helpful as a spinal fusion and with less risk?
In a decompression procedure, the simplest method in the Medicare study, a surgeon cuts away part of the bone that's painfully pressing on nerves. It can cost about $30,000 in hospital and surgeon fees.
For a fusion, a surgeon binds two or more vertebrae together using a bone graft, with or without plates and screws. The researchers defined a complex fusion as one involving three or more vertebrae or more than one side of the spine. Fusions cost $60,000 to $90,000.
The researchers analyzed data on more than 32,000 Medicare patients who had one of the three types of surgeries in 2007.
About 5 in 100 patients who had simple or complex fusions suffered major complications such as stroke compared to 2 in 100 with decompressions. The risk of death within 30 days after surgery was different too: 6 in 1,000 for complex fusions compared with 5 in 1,000 for simple fusions and 3 in 1,000 for decompressions.
The study didn't address how successful the various types of surgeries were at relieving pain.
More than half the patients who had complex fusions had a simple stenosis, which usually calls for decompression alone. They did not have the curvature of the spine or a slipped vertebra — additional conditions that might suggest a fusion is needed. There's not much evidence for doing a complex fusion for a person with simple stenosis, Carragee and other experts said.
"It certainly looks like there's more complex surgery being done than we have very good evidence to support," Carragee said.
Rates of complex fusions in Medicare patients rose 15-fold from 2002 to 2007, while decompressions and simple fusions declined, the study found. Although the overall procedure rate fell, hospital charges grew 40 percent.
Aggressive marketing of devices used in complex fusions is likely playing a role in the increase, Deyo said. The marketing includes ads in medical journals and lectures by surgeons on the payroll of device manufacturers.
Allegations of kickbacks to spine surgeons for using products and questionable financial arrangements to doctors as consultants have plagued the multibillion-dollar industry. One company, Medtronic Inc., reached a $40 million settlement with the U.S. Justice Department in a whistleblower case that included allegations the company paid doctors to use its spine surgery products. The company denied any wrongdoing.
Dr. Charles Rosen, a spine surgeon at the University of California, Irvine, founded the Association for Medical Ethics to nudge doctors toward scientific evidence over vested interests. Forty-nine spine surgeons have joined, pledging to refuse any type of compensation or earnings from companies for using a product.
Rosen applauded a provision in the new health care law that requires device makers and others to file annual reports to the government on their financial ties to doctors. Patients will be able to look up possible conflicts in a government database.
"Too much fusion surgery is done in this country and often for inappropriate reasons," Rosen said. While complex fusions are needed for some conditions, he said, patients "should not hesitate to get a second opinion."
Read more: http://www.sfgate.com/cgi-bin/article.c … z0kSIeMXLB
http://www.sfgate.com/cgi-bin/article.c … 025D22.DTL
Learning to Just Say NO by David Leonhardt
In Medicine, the Power of No
By DAVID LEONHARDT
Published: April 6, 2010
The federal government is now starting to build the institutions that will try to reduce the soaring growth of health care costs. There will be a group to compare the effectiveness of different treatments, a so-called Medicare innovation center and a Medicare oversight board that can set payment rates.
But all these groups will face the same basic problem. Deep down, Americans tend to believe that more care is better care. We recoil from efforts to restrict care.
Managed care became loathed in the 1990s. The recent recommendation to reduce breast cancer screening set off a firestorm. On a personal level, anyone who has made a decision about his or her own care knows the nagging worry that comes from not choosing the most aggressive treatment.
This try-anything-and-everything instinct is ingrained in our culture, and it has some big benefits. But it also has big downsides, including the side effects and risks that come with unnecessary treatment. Consider that a recent study found that 15,000 people were projected to die eventually from the radiation they received from CT scans given in just a single year — and that there was “significant overuse” of such scans.
From an economic perspective, health reform will fail if we can’t sometimes push back against the try-anything instinct. The new agencies will be hounded by accusations of rationing, and Medicare’s long-term budget deficit will grow.
So figuring out how we can say no may be the single toughest and most important task facing the people who will be in charge of carrying out reform. “Being able to say no,” Dr. Alan Garber of Stanford says, “is the heart of the issue.”
It’s easy to come up with arguments for why we need to do so. Above all, we don’t have a choice. Giving hospitals and drug makers a blank check will bankrupt Medicare. Slowing the cost growth, on the other hand, will free up resources for other uses, like education. Lower costs will also lift workers’ take-home pay.
But I suspect that these arguments won’t be persuasive. They have the faint ring of an insurer’s rationale for denying a claim. Compared with an anecdote about a cancer patient looking for hope, the economic arguments are soulless.
The better bet for the new reformers — starting with Donald Berwick, the physician who will run Medicare — is to channel American culture, not fight it. We want the best possible care, no matter what. Yet we often do not get it because the current system tends to deliver more care even when it means worse care.
It’s not just CT scans. Caesarean births have become more common, with little benefit to babies and significant burden to mothers. Men who would never have died from prostate cancer have been treated for it and left incontinent or impotent. Cardiac stenting and bypasses, with all their side effects, have become popular partly because people believe they reduce heart attacks. For many patients, the evidence suggests, that’s not true.
Advocates for less intensive medicine have been too timid about all this. They often come across as bean counters, while the try-anything crowd occupies the moral high ground. The reality, though, is that unnecessary care causes a lot of pain and even death. Dr. Berwick, who made his reputation campaigning against medical errors, is a promising (if much belated) selection for precisely this reason.
Can we solve the entire problem of rising health costs by getting rid of needless care? Probably not. But the money involved is not trivial, and it’s the obvious place to start.
Learning to say no more often will be a three-step process, and if the new agencies created by the health act are run well, they can help with all three.
The first is learning more about when treatments work and when they don’t. “All too often,” the Institute of Medicine reports, the data is “incomplete or unavailable.” As a result, more than half of treatments lack clear evidence of effectiveness, the institute found. It says the most promising areas for research include prostate cancer, inflammatory diseases, back pain, hyperactivity, and CT scans vs. M.R.I.’s for cancer diagnosis.
As part of the health act, a Patient Centered Health Research group will have an annual budget of $600 million. Relative to total health spending, that’s a paltry sum. But it’s real money relative to what’s now being spent on such research.
The second step — and maybe the most underappreciated one — is to give patients the available facts about treatments. Amazingly, this often does not happen. “People are pretty woefully undereducated about fateful medical decisions,” says Dr. Michael Barry of the Massachusetts General Hospital, an advocate for sharing more with patients.
Dale Collins Vidal, a reconstructive breast surgeon at the Dartmouth-Hitchcock Medical Center, told me a story about a patient’s husband who asked to sit in on the medical team’s discussion of his wife’s case. The doctors said no, because they were uncomfortable with him knowing about the uncertainty surrounding the case. “The paternalism is a little more kind-hearted than it was in the past,” Dr. Vidal says, “but it’s still paternalism.”
When patients are given information about potential benefits and risks, they seem to choose less invasive care, on average, than doctors do, according to early studies. Some people, of course, decide that aggressive care is right for them — like the cancer patient (and palliative care doctor) profiled in this newspaper a few days ago. They are willing to accept the risks and side effects that come with treatment. Many people, however, go the other way once they understand the trade-offs.
They decide the risk of incontinence and impotence isn’t worth the marginal chance of preventing prostate cancer. Or they choose cardiac drugs and lifestyle changes over stenting. Or they opt to skip the prenatal test to determine if their baby has Down syndrome. Or, in the toughest situation of all, they decide to leave an intensive care unit and enter a hospice.
The health act requires Medicare and other agencies to help hospitals and doctors give patients more information — which is practically a no-lose proposition. In the course of receiving more control and more choice, two distinctly American values, patients will probably help hold down costs.
The final step is the bluntest. It involves changing the economics of medicine, to reward better care rather than simply more care. Health reform doesn’t go nearly far enough on this score, but it is a start.
The tax subsidies for health insurance will shrink, which should help people realize medical care is not free. And doctors who provide good, less expensive care won’t be financially punished as often as they now are.
None of these steps will allow us to avoid the wrenching debates that are an inevitable part of health policy. Eventually, we may well have to decide against paying for expensive treatments with only modest benefits. But given how difficult that would be for this country, it makes sense to start with the easier situations — the ones in which “no” really is the best answer for patients.
“In the United States, I don’t know that we’re ever going to get to a point where we limit health care spending,” as Dr. Vidal says. “But maybe we could get patients to the same place on their own.”
http://www.nytimes.com/2010/04/07/busin … amp;st=cse
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