Hospitals consolidation: Brill says yes, new Massachusetts AG says no

From Shirley Leung’s Monday column in the Globe:

partnersNo judge or jury delivered a verdict on the Partners HealthCare settlement Monday, but we didn’t need either after Attorney General Maura Healey’s three-page court filing.

She thinks the deal stinks, and if given the chance, she would bring an antitrust suit to block Partners’ efforts to expand. And just like that, the 43-year-old rising political star dared to rock the biggest boat in Massachusetts health care. In the wake of her threat, Healey left a list of winners and losers.

From Steven Syre’s column in today’s Globe:

Maura Healey has been on the job less than a week, but we don’t have to wonder where she stands on the biggest health care conflict in Massachusetts.

And, a Q. & A. from Steven Brill, author of “America’s Bitter Pill: Money, Politics, Backroom Deals and the Fight to Fix Our Broken Health System. That book looks at focuses on the debate over the Patient Protection and Affordable Care Act. But it also returns to Brill’s indictment of high hospitals costs that filled an entire issue Time magazine in 2013. His solution looks very much like a combination of the Kaiser Permanente insurer-plus-provider approach and the Partners’ plan.

HLM: Why will this consolidation approach work to curb costs where other reforms have failed?

Brill: The reason this idea may work is it is going to happen without my writing about it. It’s going to happen. The question is, do we seize that momentum, turn it around jujitsu- style and attach a whole bunch of regulations to it?

I really started thinking about this after my [heart] surgery. I decided: New York Presbyterian, it’s a damn good place and the guy who runs it is a good guy. [Later] I was watching a panel including Toby Cosgove [CEO of Cleveland Clinic] and someone said: You’re gobbling up Cleveland and your market share is way too high.

Cosgrove said, the FTC would never let us have too much of a market share. I’m thinking, this guy Cosgrove, he’s a celebrated surgeon, a war hero. He seems like a pretty good guy to me. The idea the he wants to control and provide healthcare all over Ohio, why is that such a bad thing?partners-logopartners-logo

Daily Dose archived, health blogger Kotz leaves “The Boston Globe”

Deborah Kotz,  the Globe’s Daily Dose health blogger for the past four years, has taken a buy-out and that Daily Dose will be archived.

We’ll miss Kotz. While often stuck fielding the barrage of journal studies coming out of Boston medical centers,  she always managed to avoid disease-of-the week reporting.  Some stories just confuse readers. But writers who skip them often have to face editors asking “Why didn’t we have this?”

Still, it’s the kind of reporting that wins health writers like Kotz kudos.

The Globe no longer shares content with, so that website produces its own health reports. Mostly aggregation, but a few stories. We’ll miss the science touch Kotz brought to that site before the Globe/ divorce.  We wish them well as they find their way.They seem to have taken over the @bewellboston twitter feed.


Check in here for your sort-of-weekly, but always insightful dose of local health blogging. Or check out WBUR’s CommonHealth for daily posts.

Don’t have a hot attack: Framingham Heart Study carries on

fhsWhat is up with the Framingham Heart Study? That long-running research project has been tracking the cardiac health of hundreds of local folk for decades.  (The algorithm used to estimate the 10-year risk of heart disease is called the “The Framingham Risk Score.”)

A story and a blog post recently reported woefully about a 40 percent sequester cut to the study’s National Institutes of Health funding.  Neither quoted anyone from NIH.

So, both pieces failed to note that the cut is to the study’s administrative grant from the National Heart Lung and Blood Institute, not its research grants.  According to BU, the study receives an estimated $5.4 million in NIH grants for research. This funding is not impacted by the 40 percent cut.

In other words, the cuts come from the money used to run the program – office staff, data collection and the management of study subjects, not the scientific research projects that fall under the program’s umbrella. The data collected from the locals helps researcher understand the mechanics and, more recently, the genetics of heart disease as it impacts the rest of us.

In total, NIH says it will spend $21 million this year contracts for the FHS study infrastructure – including a study looking for biomarkers for heart disease. In addition to funding the BU research, NIH says its grants cover 17 FHS related studies at eight different organizations and universities. In addition to the Heart Lung and Blood institute, that money comes from five other NIH institutes and centers, including the National Institute on Aging, The National Institute of Diabetes and Digestive and Kidney Diseases and the National Institute of Neurological Disorders and Stroke.

None of this was clear in this first, July 20 story from the Metro West Daily:

The Framingham Heart Study expects to lose $4 million in funding as part of the federal budget cuts known as sequestration, study officials confirmed Friday in a statement. The $4 million cut takes effect Aug. 1 and represents 40 percent of funding it receives from the National Heart, Lung and Blood Institute (NHLBI), a division of the National Institutes of Health, the statement said.

 The story quotes a spokeswoman from Boston University, which is home to the study.

The cut with “result in a reduction in workforce affecting 19 staff from a variety of clinical and administrative areas, as well as reductions in clinic exams and lab operations.”

Then it quotes from a statement about NIH cuts in general from new Sen. Ed Markey:

“Slashing critical federal investment in medical research jeopardizes the health of many Massachusetts residents, while putting at risk tens of thousands of jobs in the commonwealth’s innovation economy and the industries they support,” Markey said. 

Then it quotes from Karen LaChance, a Framingham resident and president of the Friends of the Framingham Heart Study.

“We just hate to see any cut. It delays hopefully finding whatever the magic bullet might be to prevent heart disease.

Then it doesn’t quote anyone from NIH.

In a post on the Metro West Daily story,  WBUR’s CommonHealth blog offers the headline “Famed Framingham Heart Study Faces Deep Cuts From Federal Sequester.”

It was a “Say it isn’t so” moment this morning when I saw this MetroWest Daily News headline: Framingham Heart Study Faces $4 Million Cut. “Heart disease is the country’s number 1 killer, and chances are whatever you do to prevent it or treat it was influenced by the Framingham Heart Study, a venerable epidemiological gem right here in our own Boston suburbia….”

But, you could argue that it ain’t so.

As far as the impact of the cuts, Metro West Daily quote  BU as noting that “This loss of funding will result in a reduction in workforce affecting 19 staff from a variety of clinical and administrative areas, as well as reductions in clinic exams and lab operations.”

BU tells us that approximately 80 people work at the FHS. “The affected staff will see a reduction in hours beginning Aug. 19; if alternative funding sources are not identified, a layoff would occur Nov. 1. “

The FHS site was a little clearer on all this, with note on its home page:

New Information for FHS Participants edited July 20 2013

Q. Is the FHS closing?
A. No. The current Offspring and Omni Group 1 exams are continuing to Oct. 31, 2013. Ancillary studies are continuing as planned. Medical history updates are being collected on the regular schedule. Please respond to calls for FHS participation as usual.

By Wednesday August 1, BU had posted its own story on the BU Today website with the headline: “Framingham Heart Study Carries on, Despite Budget Cuts: 65-year-old core contract loses 40 percent of funding.”

NU prof in NYTimes: Can meditation teach manners?

Update 7/18 :The folks at WGBH’s Boston Public Radio took calls after an interview with David DeSteno, the author of this meditation study. Note:  Jim Braude does not mediate: his co-host Margery Eagan does.

7/7: This piece in the NYTimes magazine, “The Morality of Meditation” is of interest for two reasons. It was written David DeSteno is a professor of psychology at Boston’s Northeastern University. And, this reporter has spent the past five weeks in a brace and on crutches with a fractured tibia plateau — top of the shin bone. Anecdotally, that 16 percent of people would give up a seat for a person on crutches seems about right.

bll-leg-pix-web Buddha: “I teach one thing and one only: that is, suffering and the end of suffering.” For Buddha, as for many modern spiritual leaders, the goal of meditation was as simple as that….

Here’s how they tested that concept:

When a participant entered the waiting area for our lab, he (or she) found three chairs, two of which were already occupied. Naturally, he sat in the remaining chair. As he waited, a fourth person, using crutches and wearing a boot for a broken foot, entered the room and audibly sighed in pain as she leaned uncomfortably against a wall. The other two people in the room — who, like the woman on crutches, secretly worked for us — ignored the woman, thus confronting the participant with a moral quandary. Would he act compassionately, giving up his chair for her, or selfishly ignore her plight?

The results were striking. Although only 16 percent of the nonmeditators gave up their seats — an admittedly disheartening fact — the proportion rose to 50 percent among those who had meditated.

BHN Report: On MV, Berwick takes a break from his break to comment on Ryan Medicare plan, new film

Former Medicare chief Donald Berwick was present both on and off the screen for a Thursday Martha’s Vineyard showing of a new film on the health care system. Berwick, who spends part of his summer in Chilmark, was fresh off an interview with WBUR’s On Point call-in show. So, he was ready to comment on the Medicare voucher plan proposed by Republican Vice Presidential candidate Paul Ryan.

Berwick thinks the addition of Ryan to the ticket will be good for the debate over the Medicare budget.

“You see Romney trying to explain the Ryan plan. I think it will help clarify the difference in viewpoints,” between the two parties, he said.

At the same time, Berwick noted that issues surrounding Medicare are complicated – he admited that he had study up on some technicalities when he took over the national health plan for the elderly for a year.  So, voters are already hearing a lot of “irresponsible rhetoric” and one-liners, he said.

As it turns out Romney and Ryan were also in New England this week– talking about Medicare during yesterday’s campaign stop in New Hampshire. The Boston Globe reported that Ryan said he invites a debate on the plan. He characterized Obama’s approach this way:

            Mitt Romney and Paul Ryan, campaigning in a state with a median age higher than Florida’s, criticized President Obama on Monday morning for his health care law and said the Republican ticket would be more likely to put Medicare on sounder financial footing.

     “Medicare should not be a piggybank for Obamacare!” Ryan said.

Romney and Ryan charge that the health reform law takes $750 billion from Medicare to pay for the new health law.  Berwick said that’s “not really true.” The changes in payment are designed to promote changes in the way care is delivered, he said. “It doesn’t take a nickel away from beneficiaries. The Ryan plan is the one that takes money away from beneficiaries by putting them at risk. “

      The Ryan plan cuts Medicare by setting up a voucher system, he said. Instead of a guaranteed benefit, the approach would become a guaranteed payment in the form of a voucher. It cuts the budget, Berwick noted, by telling beneficiaries – “It’s your problem now.”

Interest in the topic drew a full house to see Escape Fire: The Fight to Rescue American Health Care in a small viewing room in Edgartown’s Harbor View Hotel. (The title refers to a method firefighters use to avoid being burned by a wildfire.) The movie offers a beginner’s overview of the problems facing the health system, as well as three engaging stories of people coping with them.   The subjects – interspersed between talking heads — include a doctor, a soldier and a victim of grossly excessive treatment for heart disease. Judging from the gasps from members of the audience, familiar facts about problems like medical errors were new to them.  “Disturbing,” one woman leaned over and whispered to her companion.

Besides Berwick and Steve Nissen of the Cleveland Clinic, those commenting in the  film did not represent the usual suspects. Most people associate Andrew Weil and Dean Ornish with healthy lifestyles, not systemic change. Still, they spoke to the need from more preventative care. The audience seemed to agree. A heart attack patient opening a can of Vienna sausages and smoking a cigarette generated the loudest groans.

Berwick also offered something different. Instead of demonizing doctors and drug companies, he notes that they just are working within the system as it stands.

“They’re just doing what makes sense,” he said. “We have to change what makes sense.”

FDA says – Ask yourself, your doc: Should I take drugs for #osteopenia, #osteoporosis or bone loss?

Twelve years ago, a Boston Globe story raised doubts some Canadian researcher had about bone scans for the diagnosis of osteoporosis. It was a scary story to write.  Doctors, some patient advocacy groups, researchers and drug makers were enthusiastic about the new-found ability to measure bone density and the development of bisphosphonates like Fosamax to treat it.  Osteoporosis was under-treated, they said. Still, it seemed the concerns needed to be explored.

Now comes this from the FDA, which rarely uses The New England Journal of Medicine as a forum .

The long-term safety and efficacy of bisphosphonate therapy for osteoporosis are important concerns for the Food and Drug Administration (FDA). In response to postmarketing reports of rare but serious adverse events associated with bisphosphonates, such as atypical femur fractures, osteonecrosis of the jaw, and esophageal cancer, the FDA performed a systematic review of long-term bisphosphonate efficacy. The findings, summarized here, were presented at a joint meeting of the FDA Advisory Committee for Reproductive Health Drugs and the Drug Safety and Risk Management Committee.1 The committees jointly recommended that bisphosphonate labeling be updated, although there was consensus that the data did not support a regulatory restriction on the duration of drug use.

In an unusual move that may prompt millions of women to rethink their use of popular bone-building drugs, the Food and Drug Administration published an analysis that suggested caution about long-term use of the drugs, but fell short of issuing specific recommendations.

Specialists differ on the value of tests for bone density

By Tinker Ready Globe Correspondent 4//25/00

When Winchester gynecologist Robert Shirley does an ultrasound bone scan of a patient’s heel, the news he delivers  is often less than comforting.      Based on the heel scan, which measures bone density in the foot, Dr. Shirley diagnoses 1 in 3 of his older patients with either osteoporosis or osteopenia, the bone-thinning disease that is common in aging women and
also affects some older men.

“It’s a very helpful tool to make them realize that osteoporosis is real, and they need to think about it,” said Shirley.

Certainly, few women will fail to take notice when they hear they have a disease that may lead to brittle bones, a hunched back or “Dowager’s hump,” and painful, disabling fractures. As frightening as the diagnosis sounds, however, it does not always lead to serious fractures _ the most severe of which is  hip fracture _ and the bone scan itself cannot  accurately predict who will get hip fractures, or even fully measure bone strength.       Still, osteoporosis is now defined by bone density, even though density only accounts for about 70 percent of bone strength. Other factors _ such as the actual shape, structure and size of a bone, and the presence of tiny cracks know as “microdamage” _ seem to factor in as well.       But these things are not measured by bone scans. And, when it comes to hip fractures and the elderly, a person’s risk of falling seems to play as much of a role in fracture risk as does bone density.

So, when a group of scientists convened by the National Institutes of Health met for three days in late March to review the most current data on the diagnosis and treatment of osteoporosis, they declined to endorse the bone scan as a screening test for osteoporosis. In its March 29 consensus statement, the panel noted that the risks for osteoporosis _ as reflected by low bone density _ and the risks for fracture, overlap but are not identical.

In addition, the panel expressed concern that different bone scanning devices and techniques produce conflicting results. A committee of scientists is working on a plan to standardize the tests, but right now, an ultrasound bone scan of the heel might indicate osteoporosis, while an x-ray scan of the spine may not. And even though bone loss can accelerate at menopause, tests in women under the age of 60 are particularly weak at predicting hip fractures.

“There are other things outside of bone density that we may want to measure to better improve our prediction of fracture risk,” Mary Bouxsein, an instructor in the Orthopedic Biomechanics Laboratory at Beth Israel Deaconess Medical Center told the panel.

This is in stark contrast to what many doctors and advocacy groups say about bone scans and osteoporosis. Many see the disease as a silent epidemic that goes undiagnosed in millions of women.  The National Osteoporosis Foundation cites an alarming list of statistics to drive that point home: 28 million people either have the disease or are at risk, and half of all women will suffer a fracture of the spine, hip or    wrist during their lifetime.

The group recommends bone scan screening for all women over 65, has lobbied Medicare to cover the test, and is now pushing for mandatory private insurance coverage.

Bone scans are not perfect, but they are the best tool available to identify women with the disease, said Conrad Johnston, director of the Bone Studies Laboratory at Indiana University, who is the current president of the National Osteoporosis Foundation.

“Everybody who has high cholesterol doesn’t have a heart attack, and everyone who has low bone mass doesn’t have a fracture.   But for many women, he said, “low bone density is the single best predictor of who will    fracture.”

So should women just ignore this? The pharmaceutical industry certainly isn’t. The makers of bone building drugs are active in promoting bone scans. Merck, which makes Fosamax, recently ran ads in magazines like Good Housekeeping and Parade encouraging healthy women to seek testing. Warning that undiagnosed osteoporosis can lead to broken bones or the disfiguring Dowager’s hump, the ad equates the simple, painless bone density test with mammography to detect breast cancer.

Osteoporosis is serious business for many who have it. According to the National Osteoporosis Foundation, the disease causes 1.5 million fractures annually, about half of them in the spine. Spinal fractures can cause a range of symptoms; some people may feel nothing at all, others may have back pain, and yet others may develop the Dowager’s hump.      The scientific data on the incidence and severity of spinal fractures is incomplete. But, all agree that the hip fracture, which strikes about 300,000 people per year in their 70s and 80s, can be a devastating and sometimes deadly event.  About 30 percent of older people who fall and break a hip end up in a nursing home.      Bone density contributes to hip fractures, but so does a long list of other factors including age, low body weight, smoking, mobility, exercise habits, and poor eyesight, which can make someone more vulnerable to falls, says Dr. Arminee Kazanjian, the director of the British Columbia Office of Health Technology Assessment.

After reviewing years of research into bone mass and fracture, her agency released on of the most scathing critiques on the use of bone scans. It concluded that as many as 70 percent of the women who eventually break a hip will not be diagnosed at menopause with osteoporosis, if that diagnosis is based on a bone scan alone. And, only half of the 30 percent of women identified as having osteoporosis or osteopenia will go on to have a fracture.

“The important health outcome is bone fracture,” said Kazanjian. “Bone mineral density is a minor factor. Any other combination of factors is much more important.”  Rather than rely on the bone scans alone to diagnose osteoporosis,    Kazanjiam and others suggest that doctors focus on the other factors that contribute to fracture risk.     For example, a woman with low bone density, but who doesn’t smoke (which contributes to thinning bones) and has good eyesight, may be less likely to break a hip than a woman with high bone density who uses a walker and has a family history of fractures, she said.
Amy Allina of the National Women’s Health Network, a Washington,  D.C.-based advocacy group, says that women who are told they don’t have  osteoporosis based on a bone scan alone may not take steps to prevent the  falls that cause hip fractures, even though they may be at risk. And those  whose bone scans indicate that they have osteoporosis may spend years on medication, even though they may never have broken a bone.

That’s a problem, Allina said, because the treatments for osteoporosis themselves come with risks. Hormone replacement therapy, which millions of women take to both treat and prevent osteoporosis, can increase a woman’s odds of developing breast cancer. And Fosamax, a non-hormone drug that builds bone,  irritates the throat and its long-term effects are unknown.

A 1993 decision by a World Health Organization panel set the stage for the bone scan to inadvertently become a routine diagnostic test for osteoporosis. The panel established a scale _ based on the average bone density of a premenopausal woman _ that allows doctors to measure bone loss, diagnose osteoporosis, and establish fracture risk.     The average 55-year-old woman has a 15 percent chance of breaking her hip someday. If her bone density is 1 point below the WHO average, she is defined as having osteopenia, a level of bone thinning that increases the lifetime risk of hip fracture by 20 to 45 percent. Osteoporosis is diagnosed when bone density falls 2.5 points below the WHO average. This, by some measures, raises the risk of hip fracture to greater than 45 percent.         Brigham and Women’s Hospital in Boston recently produced a detailed set of osteoporosis diagnosis and treatment guidelines for its patients and doctors. The guidelines don’t endorse bone scans to be used as screening tools alone, but they advise doctors to recommend bone scans to all women over the age of 65.
Dr. Robert Barbieri, chairman of the Department of Obstetrics and Gynecology at Brigham and Women’s, sees the bone scan as a useful tool but  he emphasized that a diagnosis of osteoporosis should not be based on the test alone. He says he is confident that doctors are considering other factors when assessing a patient’s bone strength and risk of a fracture.
“They use history and physical exams and laboratory tests in an integrative way and pull them all together,” he said.

But Mark Hefland, a researcher at the Oregon Health Sciences University, told the NIH pane that doctors are relying too heavily on bone scans, even though many of them admit that they don’t understand how bone scan scores relate to fracture risk.

“However we may like it, this is how diagnosis is occurring in everyday practice,” said Hefland, the director of the school’s Evidence-Based Practice Center.

Dr. Shirley of Winchester says he relies on bone scans to diagnose osteoporosis, but said that he also spends a lot of time with patients talking about fracture risk and alternatives to drug therapy like increasing weight-bearing exercise and boosting calcium intake.     But according to Diane Saparoff, who runs a monthly support group for women with osteoporosis at the Jenks Senior Center in Winchester, Dr. Shirley’s approach differs greatly from that of other doctors.

“Many of  the doctors order these tests but there is no follow up,” she said. The
doctors often don’t explain the test scores or help women come up with a fracture prevention plan, she said. “They just throw Fosamax at them.”

Dr. Johnston of the National Osteoporosis Foundation acknowledges that some doctors may be relying too much on bone scans to diagnose
osteoporosis. “I think that’s probably happening but it shouldn’t be,” he said. “This is a reasonably new area. Bone mineral measurements have only been around for about 10 years. Its takes a while for people to get up speed.”

Report lists ways to avoid injuries

A recent report from the National Institutes of Health offers advice on how to build and maintain strong bones:

*Get adequate calcium and vitamin D both early in life and throughout adulthood.

* Engage in regular exercise; it contributes to the development of peak bone mass and may reduce the risk of falls in older individuals.

*As needed, use drugs that enhance bone mass; medications have been been shown to reduce the risk of osteoporotic fractures.

In addition to regular exercise, there are several steps seniors can take to avoid falls, according to the National Center for Injury Prevention and Control:

* Use non-slip rugs and bath mats. Put grab bars in the  bathroom and handrails on the stairs.

* Ask your doctor to review medicines that may cause drowsiness or
confusion when combined with others you may be taking.

*Stay current with eye exams.

–Tinker Ready

This story ran on page D01 of the Boston Globe on 4/25/2000.

What are #Harvard docs and #medical school students reading? Countway tweets tell all #library

The Countway Library at Harvard Medical School has a twitter account listing the books Harvard students, docs and profs return. Here are a few samples.  “Cooper:Therapy dog” seems popular, as do books by Paul Farmer of Partners in Health. For more see @HMSreturns.

History, memoir and colons

Medieval technology and social change by  Lynn Townsend White

Alfalfa to ivy : Memoir of a Harvard Medical School dean by  Joseph B. Martin

Alice Hamilton: Pioneer doctor in industrial medicine by  Madeleine P. (Madeleine Parker) Grant

The puzzle people : Memoirs of a transplant surgeon by  Thomas E. (Thomas Earl) Starzl

The mentally ill in America : A history of their care and treatment from colonial times by  Albert Deutsch

Power, sex, suicide : Mitochondria and the meaning of life by  Nick Lane

On the pill : A social history of oral contraceptives, 1950-1970 by  Elizabeth Siegel Watkins

Subjected to science : Human experimentation in America before the Second World War by  Susan E Lederer


Ophthalmology secrets in color

Trauma secrets

Dental secrets

Med School

Assessment measures in medical school, residency, and practice : the connections

So you want to be a brain surgeon?

The Washington manual internship survival guide by  Grace A Lin

Iserson’s getting into a residency : a guide for medical students by  Kenneth V Iserson


Shattering culture : American medicine responds to cultural diversity

Health issues in Latino males : a social and structural approach

Race, ethnicity, and health : a public health reader

Not too medical

Gold: recovery, properties, and applications by  Edmund M. (Edmund Merriman) Wise

Hair transplantation


[Cooper : therapy dog]

Better than well : American medicine meets the American dream by  Carl Elliott

How to

Electroconvulsive therapy : a guide for professionals and their patients by  Max Fink

Schmidek & Sweet operative neurosurgical techniques : indications, methods, and results

Fundamentals of clinical trials by  Lawrence M. Friedman

Pocket medicine

Introduction to anesthesia; the principles of safe practice by  Robert Dunning Dripps

Janeway’s immunobiology by  Kenneth (Kenneth M.) Murphy

Good general practice

Next generation microarray bioinformatics : methods and protocols

Bethesda handbook of clinical oncology

The breath, and the diseases which give it a fetid odor : with directions for treatment by  Joseph W. (Joseph William)

Sapira’s art & science of bedside diagnosis by  Jane M Orient


Callous disregard : autism and vaccines — the truth behind a tragedy by  Andrew J Wakefield


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