User login
Official Newspaper of the American College of Surgeons
MedPAC recommends scrapping MIPS, gets pushback from doctors
WASHINGTON – As unpopular as the new Quality Payment Program may be, repealing all or part of it at this stage will be a tough sell.
That was the message heard by members of the Medicare Payment Advisory Commission (MedPAC) during public comments at their Jan. 11 meeting. Comments followed a 14-2 vote by commissioners in favor of recommending that Congress scrap the Merit-Based Incentive Payment System (MIPS) track of the QPP.
“We do agree that there are problems with MIPS,” said Sharon McIlrath, assistant director of federal affairs and coalitions at the American Medical Association. “We would like to fix it rather than kill it, and partly that’s because we don’t want to send shifting messages to physicians. Are they going to invest in building an infrastructure on shifting ground?”
She also questioned whether this proposal could gain any traction at all in Congress.
“We don’t think that it is politically viable to think that you are going to go up there and get the Hill to kill MIPS,” she said.
The Alliance of Specialty Medicine in a Jan. 9 letter to MedPAC also voiced its objections to the commission’s plan to recommend the end of MIPS.
“Our efforts to work with CMS and congressional leaders to improve MIPS and allow for more meaningful and robust engagement are ongoing. We urge you to withdraw your forthcoming recommendation, which diminishes the important role of specialty medicine in Medicare,” alliance members wrote to MedPAC Chairman Francis J. Crosson, MD. “Instead, the commission and staff, under your leadership, should work toward a new recommendation that would improve aspects of the MIPS program that remain a challenge for all clinicians.”
MedPAC had been working on its recommendations regarding MIPS since the program was launched, but ultimately came to the conclusion that it was not fixable. During a presentation on the draft recommendation, MedPAC staff listed a variety of reasons why MIPS “cannot succeed,” including how it replicates flaws of previous value-based purchasing plans and is burdensome and complex, the information reported is not meaningful, scores are not comparable across clinicians, and the payment adjustments, while minimal early on, could vary widely from year to year with even the smallest of MIPS score changes.
Instead, current draft MedPAC recommendations put forward a voluntary value program (VVP) to replace MIPS. VVP would withhold a specific percentage of Medicare pay for physicians who are not involved in a QPP advanced Alternative Payment Model (APM).
Physicians would be able to earn back the withheld pay, plus be eligible for potential bonuses by voluntarily participating in virtual groups. Those groups would be scored on population-based measures.
As was the case across previous meetings where this was discussed, commissioners David Nerenz, PhD, of the Henry Ford Health System of Detroit, and Alice Coombs, MD, of South Shore Hospital, Weymouth, Mass., continued to voice their objections about repealing MIPS and ultimately voted against the recommendation.
The MIPS recommendation will be included in MedPAC’s June report to Congress; it then will be up to Congress to decide whether to act on it.
WASHINGTON – As unpopular as the new Quality Payment Program may be, repealing all or part of it at this stage will be a tough sell.
That was the message heard by members of the Medicare Payment Advisory Commission (MedPAC) during public comments at their Jan. 11 meeting. Comments followed a 14-2 vote by commissioners in favor of recommending that Congress scrap the Merit-Based Incentive Payment System (MIPS) track of the QPP.
“We do agree that there are problems with MIPS,” said Sharon McIlrath, assistant director of federal affairs and coalitions at the American Medical Association. “We would like to fix it rather than kill it, and partly that’s because we don’t want to send shifting messages to physicians. Are they going to invest in building an infrastructure on shifting ground?”
She also questioned whether this proposal could gain any traction at all in Congress.
“We don’t think that it is politically viable to think that you are going to go up there and get the Hill to kill MIPS,” she said.
The Alliance of Specialty Medicine in a Jan. 9 letter to MedPAC also voiced its objections to the commission’s plan to recommend the end of MIPS.
“Our efforts to work with CMS and congressional leaders to improve MIPS and allow for more meaningful and robust engagement are ongoing. We urge you to withdraw your forthcoming recommendation, which diminishes the important role of specialty medicine in Medicare,” alliance members wrote to MedPAC Chairman Francis J. Crosson, MD. “Instead, the commission and staff, under your leadership, should work toward a new recommendation that would improve aspects of the MIPS program that remain a challenge for all clinicians.”
MedPAC had been working on its recommendations regarding MIPS since the program was launched, but ultimately came to the conclusion that it was not fixable. During a presentation on the draft recommendation, MedPAC staff listed a variety of reasons why MIPS “cannot succeed,” including how it replicates flaws of previous value-based purchasing plans and is burdensome and complex, the information reported is not meaningful, scores are not comparable across clinicians, and the payment adjustments, while minimal early on, could vary widely from year to year with even the smallest of MIPS score changes.
Instead, current draft MedPAC recommendations put forward a voluntary value program (VVP) to replace MIPS. VVP would withhold a specific percentage of Medicare pay for physicians who are not involved in a QPP advanced Alternative Payment Model (APM).
Physicians would be able to earn back the withheld pay, plus be eligible for potential bonuses by voluntarily participating in virtual groups. Those groups would be scored on population-based measures.
As was the case across previous meetings where this was discussed, commissioners David Nerenz, PhD, of the Henry Ford Health System of Detroit, and Alice Coombs, MD, of South Shore Hospital, Weymouth, Mass., continued to voice their objections about repealing MIPS and ultimately voted against the recommendation.
The MIPS recommendation will be included in MedPAC’s June report to Congress; it then will be up to Congress to decide whether to act on it.
WASHINGTON – As unpopular as the new Quality Payment Program may be, repealing all or part of it at this stage will be a tough sell.
That was the message heard by members of the Medicare Payment Advisory Commission (MedPAC) during public comments at their Jan. 11 meeting. Comments followed a 14-2 vote by commissioners in favor of recommending that Congress scrap the Merit-Based Incentive Payment System (MIPS) track of the QPP.
“We do agree that there are problems with MIPS,” said Sharon McIlrath, assistant director of federal affairs and coalitions at the American Medical Association. “We would like to fix it rather than kill it, and partly that’s because we don’t want to send shifting messages to physicians. Are they going to invest in building an infrastructure on shifting ground?”
She also questioned whether this proposal could gain any traction at all in Congress.
“We don’t think that it is politically viable to think that you are going to go up there and get the Hill to kill MIPS,” she said.
The Alliance of Specialty Medicine in a Jan. 9 letter to MedPAC also voiced its objections to the commission’s plan to recommend the end of MIPS.
“Our efforts to work with CMS and congressional leaders to improve MIPS and allow for more meaningful and robust engagement are ongoing. We urge you to withdraw your forthcoming recommendation, which diminishes the important role of specialty medicine in Medicare,” alliance members wrote to MedPAC Chairman Francis J. Crosson, MD. “Instead, the commission and staff, under your leadership, should work toward a new recommendation that would improve aspects of the MIPS program that remain a challenge for all clinicians.”
MedPAC had been working on its recommendations regarding MIPS since the program was launched, but ultimately came to the conclusion that it was not fixable. During a presentation on the draft recommendation, MedPAC staff listed a variety of reasons why MIPS “cannot succeed,” including how it replicates flaws of previous value-based purchasing plans and is burdensome and complex, the information reported is not meaningful, scores are not comparable across clinicians, and the payment adjustments, while minimal early on, could vary widely from year to year with even the smallest of MIPS score changes.
Instead, current draft MedPAC recommendations put forward a voluntary value program (VVP) to replace MIPS. VVP would withhold a specific percentage of Medicare pay for physicians who are not involved in a QPP advanced Alternative Payment Model (APM).
Physicians would be able to earn back the withheld pay, plus be eligible for potential bonuses by voluntarily participating in virtual groups. Those groups would be scored on population-based measures.
As was the case across previous meetings where this was discussed, commissioners David Nerenz, PhD, of the Henry Ford Health System of Detroit, and Alice Coombs, MD, of South Shore Hospital, Weymouth, Mass., continued to voice their objections about repealing MIPS and ultimately voted against the recommendation.
The MIPS recommendation will be included in MedPAC’s June report to Congress; it then will be up to Congress to decide whether to act on it.
REPORTING FROM A MEDPAC MEETING
Innovative cholecystectomy grading scale could pay off for surgeons
ORLANDO – according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
As payment models shift toward bundled care, providers will be more closely evaluated on their postoperative outcomes, which can vary based on the difficulty of surgery, even for relatively common procedures.
“Gallbladder disease affects roughly 20 million people annually in the United States, with laparoscopic cholecystectomy being one of the most common operations performed by the typical surgeon,” said presenter Tarik Madni, MD, of the department of surgery, University of Texas Southwestern Medical Center, Dallas. “However not all cholecystectomies are created equal; increased inflammation can lead to increased operative times, increased conversion rates, as well as increased risk of complications.”
Given the increased scrutiny of surgical procedures, the current application of modifier 22, which allows surgeons to receive greater reimbursement for a more difficult surgery, is not enough, according to Dr. Madni.
To address this shortfall, investigators developed the Parkland grading scale, a five-tiered grading system that is designed to be easy to remember, limited in the number of grades, and correlated with clinical outcomes.
To determine the grades of the scale, Dr. Madni and his fellow investigators used 200 gallbladder images collected immediately before dissection and analyzed anatomy and inflammatory characteristics.
Gallbladders with a grade 1 would be relatively normal looking, while a grade 5 gallbladder would show perforation, necrosis, or not be clearly visible because of adhesions, according to Dr. Madni.
Between September 2016 and March 2017, investigators asked 11 acute care surgeons to prospectively grade gallbladders they saw before surgery using the Parkland scale and to fill out a questionnaire describing the difficulty of the procedure afterwards.
Of 667 gallbladders graded, 60 were assessed to be grade 1 (19%), 90 were grade 2 (28%), 102 were grade 3 (32%), 28 were grade 4 (9%), and 37 were grade 5 (12%) on the Parkland scale.
Grade 1 gallbladders had a mean procedure difficulty score of 1.43, while grade 5 gallbladders had a mean difficulty of 4.46. Grade 1 gallbladders also corresponded with the shortest mean surgery time of 63.31 minutes, compared with an average of 108.13 minutes for grade 5.
Acute cholecystitis diagnosis also increased by Parkland grade, from 36.7% in grade 1 gallbladders to 83.8% in grade 5 (P less than .0001), as did open conversion rates, from 0% to 21.6% (P less than .0001).
Mean length of stay rose fivefold between grade 1 and grade 5 procedures, from around 8 hours to 36 hours, respectively (P less than .0001).
Discussant Martin Zielinski, MD, FACS, director of medical trauma clinical research at the Mayo Clinic, Rochester, Minn., recognized the importance of having a grading scale but was curious why investigators did not analyze the American Association for the Surgery of Trauma’s (AAST) Emergency General Surgery anatomic grading scale, which is already in place.
“The AAST is a uniform, anatomic grading scale to measure the severity of diseases from the 16 most common [Emergency General Surgery] diseases,” Dr. Madni responded. “Unlike our operative-only finding scale, the AAST scale gives grades 1 through 5 definitions for four categories in each disease, not just operative, but clinical, imaging, operative, and pathologic categories.”
Comparatively, the Parkland scale is less cumbersome and covers a wider range of difficulty variation, according to Dr. Madni.
In the future, Dr. Madni and his colleagues will work to compare the Parkland scale to the AAST scale and look for ways to bridge the two.
Dr. Madni reported no relevant financial disclosures.
SOURCE: Madni T et al. EAST Scientific Assembly 2018 abstract #11.
ORLANDO – according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
As payment models shift toward bundled care, providers will be more closely evaluated on their postoperative outcomes, which can vary based on the difficulty of surgery, even for relatively common procedures.
“Gallbladder disease affects roughly 20 million people annually in the United States, with laparoscopic cholecystectomy being one of the most common operations performed by the typical surgeon,” said presenter Tarik Madni, MD, of the department of surgery, University of Texas Southwestern Medical Center, Dallas. “However not all cholecystectomies are created equal; increased inflammation can lead to increased operative times, increased conversion rates, as well as increased risk of complications.”
Given the increased scrutiny of surgical procedures, the current application of modifier 22, which allows surgeons to receive greater reimbursement for a more difficult surgery, is not enough, according to Dr. Madni.
To address this shortfall, investigators developed the Parkland grading scale, a five-tiered grading system that is designed to be easy to remember, limited in the number of grades, and correlated with clinical outcomes.
To determine the grades of the scale, Dr. Madni and his fellow investigators used 200 gallbladder images collected immediately before dissection and analyzed anatomy and inflammatory characteristics.
Gallbladders with a grade 1 would be relatively normal looking, while a grade 5 gallbladder would show perforation, necrosis, or not be clearly visible because of adhesions, according to Dr. Madni.
Between September 2016 and March 2017, investigators asked 11 acute care surgeons to prospectively grade gallbladders they saw before surgery using the Parkland scale and to fill out a questionnaire describing the difficulty of the procedure afterwards.
Of 667 gallbladders graded, 60 were assessed to be grade 1 (19%), 90 were grade 2 (28%), 102 were grade 3 (32%), 28 were grade 4 (9%), and 37 were grade 5 (12%) on the Parkland scale.
Grade 1 gallbladders had a mean procedure difficulty score of 1.43, while grade 5 gallbladders had a mean difficulty of 4.46. Grade 1 gallbladders also corresponded with the shortest mean surgery time of 63.31 minutes, compared with an average of 108.13 minutes for grade 5.
Acute cholecystitis diagnosis also increased by Parkland grade, from 36.7% in grade 1 gallbladders to 83.8% in grade 5 (P less than .0001), as did open conversion rates, from 0% to 21.6% (P less than .0001).
Mean length of stay rose fivefold between grade 1 and grade 5 procedures, from around 8 hours to 36 hours, respectively (P less than .0001).
Discussant Martin Zielinski, MD, FACS, director of medical trauma clinical research at the Mayo Clinic, Rochester, Minn., recognized the importance of having a grading scale but was curious why investigators did not analyze the American Association for the Surgery of Trauma’s (AAST) Emergency General Surgery anatomic grading scale, which is already in place.
“The AAST is a uniform, anatomic grading scale to measure the severity of diseases from the 16 most common [Emergency General Surgery] diseases,” Dr. Madni responded. “Unlike our operative-only finding scale, the AAST scale gives grades 1 through 5 definitions for four categories in each disease, not just operative, but clinical, imaging, operative, and pathologic categories.”
Comparatively, the Parkland scale is less cumbersome and covers a wider range of difficulty variation, according to Dr. Madni.
In the future, Dr. Madni and his colleagues will work to compare the Parkland scale to the AAST scale and look for ways to bridge the two.
Dr. Madni reported no relevant financial disclosures.
SOURCE: Madni T et al. EAST Scientific Assembly 2018 abstract #11.
ORLANDO – according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
As payment models shift toward bundled care, providers will be more closely evaluated on their postoperative outcomes, which can vary based on the difficulty of surgery, even for relatively common procedures.
“Gallbladder disease affects roughly 20 million people annually in the United States, with laparoscopic cholecystectomy being one of the most common operations performed by the typical surgeon,” said presenter Tarik Madni, MD, of the department of surgery, University of Texas Southwestern Medical Center, Dallas. “However not all cholecystectomies are created equal; increased inflammation can lead to increased operative times, increased conversion rates, as well as increased risk of complications.”
Given the increased scrutiny of surgical procedures, the current application of modifier 22, which allows surgeons to receive greater reimbursement for a more difficult surgery, is not enough, according to Dr. Madni.
To address this shortfall, investigators developed the Parkland grading scale, a five-tiered grading system that is designed to be easy to remember, limited in the number of grades, and correlated with clinical outcomes.
To determine the grades of the scale, Dr. Madni and his fellow investigators used 200 gallbladder images collected immediately before dissection and analyzed anatomy and inflammatory characteristics.
Gallbladders with a grade 1 would be relatively normal looking, while a grade 5 gallbladder would show perforation, necrosis, or not be clearly visible because of adhesions, according to Dr. Madni.
Between September 2016 and March 2017, investigators asked 11 acute care surgeons to prospectively grade gallbladders they saw before surgery using the Parkland scale and to fill out a questionnaire describing the difficulty of the procedure afterwards.
Of 667 gallbladders graded, 60 were assessed to be grade 1 (19%), 90 were grade 2 (28%), 102 were grade 3 (32%), 28 were grade 4 (9%), and 37 were grade 5 (12%) on the Parkland scale.
Grade 1 gallbladders had a mean procedure difficulty score of 1.43, while grade 5 gallbladders had a mean difficulty of 4.46. Grade 1 gallbladders also corresponded with the shortest mean surgery time of 63.31 minutes, compared with an average of 108.13 minutes for grade 5.
Acute cholecystitis diagnosis also increased by Parkland grade, from 36.7% in grade 1 gallbladders to 83.8% in grade 5 (P less than .0001), as did open conversion rates, from 0% to 21.6% (P less than .0001).
Mean length of stay rose fivefold between grade 1 and grade 5 procedures, from around 8 hours to 36 hours, respectively (P less than .0001).
Discussant Martin Zielinski, MD, FACS, director of medical trauma clinical research at the Mayo Clinic, Rochester, Minn., recognized the importance of having a grading scale but was curious why investigators did not analyze the American Association for the Surgery of Trauma’s (AAST) Emergency General Surgery anatomic grading scale, which is already in place.
“The AAST is a uniform, anatomic grading scale to measure the severity of diseases from the 16 most common [Emergency General Surgery] diseases,” Dr. Madni responded. “Unlike our operative-only finding scale, the AAST scale gives grades 1 through 5 definitions for four categories in each disease, not just operative, but clinical, imaging, operative, and pathologic categories.”
Comparatively, the Parkland scale is less cumbersome and covers a wider range of difficulty variation, according to Dr. Madni.
In the future, Dr. Madni and his colleagues will work to compare the Parkland scale to the AAST scale and look for ways to bridge the two.
Dr. Madni reported no relevant financial disclosures.
SOURCE: Madni T et al. EAST Scientific Assembly 2018 abstract #11.
REPORTING FROM EAST SCIENTIFIC ASSEMBLY
Key clinical point: A five-tiered grading system was developed to determine grades of cholecystectomy operative difficulty.
Major finding: Acute cholecystitis diagnosis also increased by Parkland grade, from 36.7% in grade 1 gallbladders to 83.8% in grade 5.
Study details: Eleven acute care surgeons graded gallbladders on initial view and then filled out a postoperative questionnaire.
Disclosures: The investigator reported no relevant financial disclosures.
Source: Madni T et al. EAST Scientifc Assembly 2018 abstract #11.
FVC deterioration signals increasing risk in rib fracture patients
ORLANDO – according to a study presented at the annual scientific assembly Eastern Association for the Surgery of Trauma.
Daily, easily conducted, bedside FVC monitoring can help identify the first signs of a worsening condition and lead to earlier intervention, according to presenter Rachel Warner, DO, a surgical resident at West Virginia University, Morgantown.
“Unplanned upgrades to the ICU have been associated with prolonged hospital stay, mechanical ventilation, and even higher risk of mortality when compared to planned upgrades,” Dr. Warner explained. “We aim to decrease these events by creating a system where early decline can be recognized by any member of the health care team.”
In a retrospective study, investigators analyzed 1,106 rib fracture patients enrolled in a rib fracture care pathway at a Level I trauma center during 2009-2014, all of whom were admitted with an FVC greater than 1 L. Patients’ FVCs were assessed with spirometry in the ED, and the results were then used to determine their care placement. Then FVC was continually monitored throughout each patient’s stay at the hospital. The investigators hypothesized that those patients whose FVC level deteriorated to lower than 1 L were at higher risk for complications.
Two groups of patients were analyzed: Group A was composed of patients whose initial FVC scores were greater than or equal to 1 but deteriorated over time to below 1, while Group B was composed of patients whose scores remained above 1. Group A patients were an average age 58 years and were majority male (61%); their had FVC scores initially averaged 1.3 but dropped to a low of 0.7. Patients in group B were on average younger, at 48 years, but also majority male (79%); they had a slightly higher initial average FVC of 1.6, with a low of 1.4.
Rate of complications among patients whose FVC scores dropped below 1 was 15%, compared with 3.2% in the other group (P less than .001).
Group A patients were significantly more likely than were Group B patients to develop pneumonia (9% vs. 4%, respectively), be upgraded to the intensive care unit (3.7% vs. 0.2%), require intubation (1.6% vs. 0.1%), or be readmitted (4% vs. 1%).
Average length of stay for patients whose FVC score dropped below 1 was 10 days, compared with 4 days among the patients who maintained a higher FVC. Mortality rates were also significantly higher at 3%, compared with 0.2%. Dr. Warner said that FVC levels can be the first indication of worsening clinical status and should be treated as an early warning sign for which patients may need to be preemptively moved to a higher level of care.
Dr. Warner and her colleagues were limited by the retrospective nature of their analysis, as well as not including other injuries into their analysis.
In a discussion of the study, Bryce R.H. Robinson, MD, FACS, of Harborview Medical Center, Seattle, Wash., supported using data such as FVC to help identify at-risk patients early. “I am encouraged to see others utilize easily obtainable, objective measures for those at risk for pulmonary decompensation with rib fractures,” said Dr. Robinson.
While keeping the cutoff at 1 L for FVC testing regardless of other factors, like sex or weight, would make it easy to train all members of the medical team, this may be oversimplifying FVC measurements, cautioned Dr. Robinson.
“While it is a little bit less specific to the patient, broad adaptation across the health care team is much more feasible with standard values,” responded Dr. Warner. “Given this, we do intentionally accept a level of overtriaged patients. We have found these patients generally make up the geriatric population and have confounding factors that would otherwise make them high risk for complications.”
Investigators reported no relevant financial disclosures.
SOURCE: Warner R et al. EAST Scientific Assembly 2018 abstract #9
ORLANDO – according to a study presented at the annual scientific assembly Eastern Association for the Surgery of Trauma.
Daily, easily conducted, bedside FVC monitoring can help identify the first signs of a worsening condition and lead to earlier intervention, according to presenter Rachel Warner, DO, a surgical resident at West Virginia University, Morgantown.
“Unplanned upgrades to the ICU have been associated with prolonged hospital stay, mechanical ventilation, and even higher risk of mortality when compared to planned upgrades,” Dr. Warner explained. “We aim to decrease these events by creating a system where early decline can be recognized by any member of the health care team.”
In a retrospective study, investigators analyzed 1,106 rib fracture patients enrolled in a rib fracture care pathway at a Level I trauma center during 2009-2014, all of whom were admitted with an FVC greater than 1 L. Patients’ FVCs were assessed with spirometry in the ED, and the results were then used to determine their care placement. Then FVC was continually monitored throughout each patient’s stay at the hospital. The investigators hypothesized that those patients whose FVC level deteriorated to lower than 1 L were at higher risk for complications.
Two groups of patients were analyzed: Group A was composed of patients whose initial FVC scores were greater than or equal to 1 but deteriorated over time to below 1, while Group B was composed of patients whose scores remained above 1. Group A patients were an average age 58 years and were majority male (61%); their had FVC scores initially averaged 1.3 but dropped to a low of 0.7. Patients in group B were on average younger, at 48 years, but also majority male (79%); they had a slightly higher initial average FVC of 1.6, with a low of 1.4.
Rate of complications among patients whose FVC scores dropped below 1 was 15%, compared with 3.2% in the other group (P less than .001).
Group A patients were significantly more likely than were Group B patients to develop pneumonia (9% vs. 4%, respectively), be upgraded to the intensive care unit (3.7% vs. 0.2%), require intubation (1.6% vs. 0.1%), or be readmitted (4% vs. 1%).
Average length of stay for patients whose FVC score dropped below 1 was 10 days, compared with 4 days among the patients who maintained a higher FVC. Mortality rates were also significantly higher at 3%, compared with 0.2%. Dr. Warner said that FVC levels can be the first indication of worsening clinical status and should be treated as an early warning sign for which patients may need to be preemptively moved to a higher level of care.
Dr. Warner and her colleagues were limited by the retrospective nature of their analysis, as well as not including other injuries into their analysis.
In a discussion of the study, Bryce R.H. Robinson, MD, FACS, of Harborview Medical Center, Seattle, Wash., supported using data such as FVC to help identify at-risk patients early. “I am encouraged to see others utilize easily obtainable, objective measures for those at risk for pulmonary decompensation with rib fractures,” said Dr. Robinson.
While keeping the cutoff at 1 L for FVC testing regardless of other factors, like sex or weight, would make it easy to train all members of the medical team, this may be oversimplifying FVC measurements, cautioned Dr. Robinson.
“While it is a little bit less specific to the patient, broad adaptation across the health care team is much more feasible with standard values,” responded Dr. Warner. “Given this, we do intentionally accept a level of overtriaged patients. We have found these patients generally make up the geriatric population and have confounding factors that would otherwise make them high risk for complications.”
Investigators reported no relevant financial disclosures.
SOURCE: Warner R et al. EAST Scientific Assembly 2018 abstract #9
ORLANDO – according to a study presented at the annual scientific assembly Eastern Association for the Surgery of Trauma.
Daily, easily conducted, bedside FVC monitoring can help identify the first signs of a worsening condition and lead to earlier intervention, according to presenter Rachel Warner, DO, a surgical resident at West Virginia University, Morgantown.
“Unplanned upgrades to the ICU have been associated with prolonged hospital stay, mechanical ventilation, and even higher risk of mortality when compared to planned upgrades,” Dr. Warner explained. “We aim to decrease these events by creating a system where early decline can be recognized by any member of the health care team.”
In a retrospective study, investigators analyzed 1,106 rib fracture patients enrolled in a rib fracture care pathway at a Level I trauma center during 2009-2014, all of whom were admitted with an FVC greater than 1 L. Patients’ FVCs were assessed with spirometry in the ED, and the results were then used to determine their care placement. Then FVC was continually monitored throughout each patient’s stay at the hospital. The investigators hypothesized that those patients whose FVC level deteriorated to lower than 1 L were at higher risk for complications.
Two groups of patients were analyzed: Group A was composed of patients whose initial FVC scores were greater than or equal to 1 but deteriorated over time to below 1, while Group B was composed of patients whose scores remained above 1. Group A patients were an average age 58 years and were majority male (61%); their had FVC scores initially averaged 1.3 but dropped to a low of 0.7. Patients in group B were on average younger, at 48 years, but also majority male (79%); they had a slightly higher initial average FVC of 1.6, with a low of 1.4.
Rate of complications among patients whose FVC scores dropped below 1 was 15%, compared with 3.2% in the other group (P less than .001).
Group A patients were significantly more likely than were Group B patients to develop pneumonia (9% vs. 4%, respectively), be upgraded to the intensive care unit (3.7% vs. 0.2%), require intubation (1.6% vs. 0.1%), or be readmitted (4% vs. 1%).
Average length of stay for patients whose FVC score dropped below 1 was 10 days, compared with 4 days among the patients who maintained a higher FVC. Mortality rates were also significantly higher at 3%, compared with 0.2%. Dr. Warner said that FVC levels can be the first indication of worsening clinical status and should be treated as an early warning sign for which patients may need to be preemptively moved to a higher level of care.
Dr. Warner and her colleagues were limited by the retrospective nature of their analysis, as well as not including other injuries into their analysis.
In a discussion of the study, Bryce R.H. Robinson, MD, FACS, of Harborview Medical Center, Seattle, Wash., supported using data such as FVC to help identify at-risk patients early. “I am encouraged to see others utilize easily obtainable, objective measures for those at risk for pulmonary decompensation with rib fractures,” said Dr. Robinson.
While keeping the cutoff at 1 L for FVC testing regardless of other factors, like sex or weight, would make it easy to train all members of the medical team, this may be oversimplifying FVC measurements, cautioned Dr. Robinson.
“While it is a little bit less specific to the patient, broad adaptation across the health care team is much more feasible with standard values,” responded Dr. Warner. “Given this, we do intentionally accept a level of overtriaged patients. We have found these patients generally make up the geriatric population and have confounding factors that would otherwise make them high risk for complications.”
Investigators reported no relevant financial disclosures.
SOURCE: Warner R et al. EAST Scientific Assembly 2018 abstract #9
REPORTING FROM EAST SCIENTIFIC ASSEMBLY
Key clinical point: Rib fracture patients with FVC below 1 are at higher risk for pulmonary complications.
Major finding: Rate of pulmonary complications was 15% among patients with FVC under 1, compared to 3% in patients with FVC above 1 (P less than .001).
Study details: Retrospective study of 1,106 patients enrolled at a Level I trauma center from 2009 through 2014.
Disclosures: Presenters reported no relevant financial disclosures.
Source: Warner R et al. EAST Scientific Assembly 2018 abstract #9.
Age at RRSO affects peritoneal cancer risk in BRCA mutation carriers
Carriers of the BRCA1/2 mutation who undergo risk-reducing salpingo-oophorectomy (RRSO) still face a risk of developing metachronous peritoneal carcinomatosis, according to new findings published in Cancer.
The risk was predominantly observed in BRCA1 mutation carriers, and disease development generally occurred within 5 years following RRSO. Women who underwent RRSO at an age older than that currently recommended also had a higher risk of developing peritoneal carcinoma.
Their median age was 52 years at the time they underwent surgery, and 60 years when they were diagnosed with peritoneal carcinomatosis. As compared with the control group, the patients were older at the time they underwent RRSO (P = .025).
In eight RRSO specimens that were obtained from women who subsequently developed peritoneal carcinomatosis, five (62.5%), had serous tubal intraepithelial carcinoma (STIC) and one had epithelial atypia.
“The findings of the current study can be used to refine gynecologic counseling for BRCA1/2 mutation carriers who consider risk-reducing surgery and to stress the importance of complete RRSO at the recommended ages,” wrote lead author Marline G. Harmsen, MD, PhD, of the Radboud University Medical Center, Nijmegen, the Netherlands.
BRCA1/2 mutation carriers face a higher risk of developing ovarian carcinoma, and RRSO can reduce that risk by 80%-96%. Surgery is recommended for carriers of BRCA1 mutations aged 35-40 years and for BRCA2 mutation carriers aged 40-45 years.
In this study, Dr. Harmsen and her colleagues conducted a literature search in order to collect and analyze clinical and pathological data from women with BRCA1/2 mutation who developed peritoneal carcinomatosis following RRSO. The cases that were identified were then compared with a cohort from a single institution.
Of the 36 cases that were identified, 86.1% were BRCA1 mutation carriers and the remaining 5 patients had a BRCA2 mutation. The median age at the time of surgery differed significantly between BRCA1 (51 years; range, 30-71 years) and BRCA2 mutation carriers (57 years; range, 56-65 years) (P = .006).
The majority of women had undergone salpingo-oophorectomy (31; 86.1%), and 16 (44.4%) had also had a hysterectomy.
The authors found that several statistically significant differences between the case studies and the control group: the median age surgery (52 vs. 46 years), percentage of BRCA1 mutation carriers (86.1% vs. 53.1%, P less than .001), and percentage of serous tubal intraepithelial carcinomas in the RRSO specimens (62.5% vs. 0%; P less than .001).
SOURCE: Hamsen MG et al. Cancer. 2018 Jan 9. doi: 10.1002/cncr.31211.
In an accompanying editorial, Christine S. Walsh, MD, of Cedars-Sinai Medical Center in Los Angeles, notes that the study authors have “done a commendable job in trying to shed light on a rare condition,” which occurs in about 1%-4% of women who undergo risk-reducing salpingo-oophorectomy (RRSO).
These findings can provide more information to clinicians, as they seek to guide and counsel women after they undergo RRSO, she wrote.
Dr. Walsh pointed out that National Comprehensive Cancer Network guidelines for genetic/familial high-risk assessment of breast and ovarian cancer specify the optimal ages when RRSO should be performed, but despite efforts to encourage this, occult gynecologic carcinomas still are found in approximately 4.5%-9% of women, with serous tubal intraepithelial carcinoma lesions developing in approximately 5%-8% of them.
“Ideally, the goal should be to intervene with a prophylactic surgery before the development of cancerous or precancerous pathology,” she wrote. Dr. Walsh had no disclosures.
In an accompanying editorial, Christine S. Walsh, MD, of Cedars-Sinai Medical Center in Los Angeles, notes that the study authors have “done a commendable job in trying to shed light on a rare condition,” which occurs in about 1%-4% of women who undergo risk-reducing salpingo-oophorectomy (RRSO).
These findings can provide more information to clinicians, as they seek to guide and counsel women after they undergo RRSO, she wrote.
Dr. Walsh pointed out that National Comprehensive Cancer Network guidelines for genetic/familial high-risk assessment of breast and ovarian cancer specify the optimal ages when RRSO should be performed, but despite efforts to encourage this, occult gynecologic carcinomas still are found in approximately 4.5%-9% of women, with serous tubal intraepithelial carcinoma lesions developing in approximately 5%-8% of them.
“Ideally, the goal should be to intervene with a prophylactic surgery before the development of cancerous or precancerous pathology,” she wrote. Dr. Walsh had no disclosures.
In an accompanying editorial, Christine S. Walsh, MD, of Cedars-Sinai Medical Center in Los Angeles, notes that the study authors have “done a commendable job in trying to shed light on a rare condition,” which occurs in about 1%-4% of women who undergo risk-reducing salpingo-oophorectomy (RRSO).
These findings can provide more information to clinicians, as they seek to guide and counsel women after they undergo RRSO, she wrote.
Dr. Walsh pointed out that National Comprehensive Cancer Network guidelines for genetic/familial high-risk assessment of breast and ovarian cancer specify the optimal ages when RRSO should be performed, but despite efforts to encourage this, occult gynecologic carcinomas still are found in approximately 4.5%-9% of women, with serous tubal intraepithelial carcinoma lesions developing in approximately 5%-8% of them.
“Ideally, the goal should be to intervene with a prophylactic surgery before the development of cancerous or precancerous pathology,” she wrote. Dr. Walsh had no disclosures.
Carriers of the BRCA1/2 mutation who undergo risk-reducing salpingo-oophorectomy (RRSO) still face a risk of developing metachronous peritoneal carcinomatosis, according to new findings published in Cancer.
The risk was predominantly observed in BRCA1 mutation carriers, and disease development generally occurred within 5 years following RRSO. Women who underwent RRSO at an age older than that currently recommended also had a higher risk of developing peritoneal carcinoma.
Their median age was 52 years at the time they underwent surgery, and 60 years when they were diagnosed with peritoneal carcinomatosis. As compared with the control group, the patients were older at the time they underwent RRSO (P = .025).
In eight RRSO specimens that were obtained from women who subsequently developed peritoneal carcinomatosis, five (62.5%), had serous tubal intraepithelial carcinoma (STIC) and one had epithelial atypia.
“The findings of the current study can be used to refine gynecologic counseling for BRCA1/2 mutation carriers who consider risk-reducing surgery and to stress the importance of complete RRSO at the recommended ages,” wrote lead author Marline G. Harmsen, MD, PhD, of the Radboud University Medical Center, Nijmegen, the Netherlands.
BRCA1/2 mutation carriers face a higher risk of developing ovarian carcinoma, and RRSO can reduce that risk by 80%-96%. Surgery is recommended for carriers of BRCA1 mutations aged 35-40 years and for BRCA2 mutation carriers aged 40-45 years.
In this study, Dr. Harmsen and her colleagues conducted a literature search in order to collect and analyze clinical and pathological data from women with BRCA1/2 mutation who developed peritoneal carcinomatosis following RRSO. The cases that were identified were then compared with a cohort from a single institution.
Of the 36 cases that were identified, 86.1% were BRCA1 mutation carriers and the remaining 5 patients had a BRCA2 mutation. The median age at the time of surgery differed significantly between BRCA1 (51 years; range, 30-71 years) and BRCA2 mutation carriers (57 years; range, 56-65 years) (P = .006).
The majority of women had undergone salpingo-oophorectomy (31; 86.1%), and 16 (44.4%) had also had a hysterectomy.
The authors found that several statistically significant differences between the case studies and the control group: the median age surgery (52 vs. 46 years), percentage of BRCA1 mutation carriers (86.1% vs. 53.1%, P less than .001), and percentage of serous tubal intraepithelial carcinomas in the RRSO specimens (62.5% vs. 0%; P less than .001).
SOURCE: Hamsen MG et al. Cancer. 2018 Jan 9. doi: 10.1002/cncr.31211.
Carriers of the BRCA1/2 mutation who undergo risk-reducing salpingo-oophorectomy (RRSO) still face a risk of developing metachronous peritoneal carcinomatosis, according to new findings published in Cancer.
The risk was predominantly observed in BRCA1 mutation carriers, and disease development generally occurred within 5 years following RRSO. Women who underwent RRSO at an age older than that currently recommended also had a higher risk of developing peritoneal carcinoma.
Their median age was 52 years at the time they underwent surgery, and 60 years when they were diagnosed with peritoneal carcinomatosis. As compared with the control group, the patients were older at the time they underwent RRSO (P = .025).
In eight RRSO specimens that were obtained from women who subsequently developed peritoneal carcinomatosis, five (62.5%), had serous tubal intraepithelial carcinoma (STIC) and one had epithelial atypia.
“The findings of the current study can be used to refine gynecologic counseling for BRCA1/2 mutation carriers who consider risk-reducing surgery and to stress the importance of complete RRSO at the recommended ages,” wrote lead author Marline G. Harmsen, MD, PhD, of the Radboud University Medical Center, Nijmegen, the Netherlands.
BRCA1/2 mutation carriers face a higher risk of developing ovarian carcinoma, and RRSO can reduce that risk by 80%-96%. Surgery is recommended for carriers of BRCA1 mutations aged 35-40 years and for BRCA2 mutation carriers aged 40-45 years.
In this study, Dr. Harmsen and her colleagues conducted a literature search in order to collect and analyze clinical and pathological data from women with BRCA1/2 mutation who developed peritoneal carcinomatosis following RRSO. The cases that were identified were then compared with a cohort from a single institution.
Of the 36 cases that were identified, 86.1% were BRCA1 mutation carriers and the remaining 5 patients had a BRCA2 mutation. The median age at the time of surgery differed significantly between BRCA1 (51 years; range, 30-71 years) and BRCA2 mutation carriers (57 years; range, 56-65 years) (P = .006).
The majority of women had undergone salpingo-oophorectomy (31; 86.1%), and 16 (44.4%) had also had a hysterectomy.
The authors found that several statistically significant differences between the case studies and the control group: the median age surgery (52 vs. 46 years), percentage of BRCA1 mutation carriers (86.1% vs. 53.1%, P less than .001), and percentage of serous tubal intraepithelial carcinomas in the RRSO specimens (62.5% vs. 0%; P less than .001).
SOURCE: Hamsen MG et al. Cancer. 2018 Jan 9. doi: 10.1002/cncr.31211.
FROM CANCER
Key clinical point: BRCA mutation carriers who undergo risk-reducing surgery at an older age have a higher risk of developing metachronous peritoneal carcinomatosis.
Major finding: Women with BRCA 1 were at a higher risk for developing peritoneal carcinomatosis, as were those who underwent surgery at an older age.
Data source: A literature search to identify patients with BRCA 1/2 mutations who had undergone risk-reducing surgery and developed peritoneal carcinomatosis; 36 cases were identified and compared with a control group from a single institution.
Disclosures: No specific funding was disclosed. The authors had no disclosures.
Source: Hamsen MG et al. Cancer. 2018 Jan 9. doi: 10.1002/cncr.31211.
Trump administration clears way to require work for some Medicaid enrollees
The Trump administration early on Jan. 11 initiated a pivotal change in the Medicaid program, announcing that
The announcement came in a 10-page memo with detailed directions about how states can reshape the federal-state health program for low-income people.
The document says who should be excluded from the new work requirements – including children and people being treated for opioid abuse – and offers suggestions as to what counts as “work.” Besides employment, it can include job training, volunteering, or caring for a close relative.
“Medicaid needs to be more flexible so that states can best address the needs of this population,” Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said in a press release. “Our fundamental goal is to make a positive and lasting difference in the health and wellness of our beneficiaries.”
Adding a work requirement to Medicaid would mark one of the biggest changes to the program since its inception in 1966. It is likely to prompt a lawsuit from patient advocacy groups, which claim the requirement is inconsistent with Medicaid’s objectives and would require an act of Congress.
Republicans have been pushing for the change since the Affordable Care Act added millions of so called “able-bodied” adults to Medicaid. It allowed states to provide coverage to anyone earning up to 138% of the federal poverty level (about $16,600 for an individual).
The Obama administration turned down several state requests to add a work requirement.
Ten states have applied for a federal waiver to add a work requirement – Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, New Hampshire, North Carolina, Utah and Wisconsin. Officials in several other states have said they are interested in the idea.
An HHS official, who spoke on the condition of anonymity because the official had not been authorized to discuss the developments, said the agency may approve Kentucky’s request as early asJan. 12. Gov. Matt Bevin, a Republican, first sought to add such a provision in 2016. The current request would require able-bodied adults without dependents to work at least 20 hours a week.
Kentucky, which has some of the poorest counties in the country, has seen its Medicaid enrollment double in the past 3 years after the state expanded eligibility under the ACA.
While more than 74 million people are enrolled in Medicaid, only a small fraction would be affected by the work requirement. That’s because children – who make up nearly half of Medicaid enrollees – are excluded. So are the more than 10 million people on Medicaid because they have a disability.
More than 4 in 10 adults with Medicaid coverage already work full time, and most others either go to school, take care of a relative, or are too sick to work.
Still, critics fear a work requirement could have a chilling effect on people signing up for Medicaid or make it harder for people to get coverage.
But work requirements have strong public backing. About 70% of Americans say they support states imposing a work requirement on non-disabled adults, according to a Kaiser Family Foundation poll last year.
The Trump administration, along with many Republican leaders in Congress, has long supported such a move. The failed efforts in the House to replace Obamacare included a work requirement for Medicaid.
In its guidance to states, CMS said they should consider how some communities have high unemployment rates and whether enrollees need to care for young children and elderly families.
CMS also advised states to make work requirements for Medicaid similar than those used with food stamps to “reduce the burden on both states and beneficiaries.”
“This new guidance paves the way for states to demonstrate how their ideas will improve the health of Medicaid beneficiaries, as well as potentially improve their economic well-being,” Brian Neale, CMS deputy administrator and director for the Center for Medicaid and CHIP Services, said in the press release.
Ms. Verma, who has said she doesn’t think Medicaid should become a way of life for people who are not disabled, said the new guidance shows how the administration is trying to give states more flexibility in running Medicaid.
“Our policy guidance was in response to states that asked us for the flexibility they need to improve their programs and to help people in achieving greater well-being and self-sufficiency,” she said.
Ms. Verma, who worked with Kentucky and Indiana on their work requirement waivers as a health consultant before joining the Trump administration, recused herself from the decision on those states’ waiver requests.
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
The Trump administration early on Jan. 11 initiated a pivotal change in the Medicaid program, announcing that
The announcement came in a 10-page memo with detailed directions about how states can reshape the federal-state health program for low-income people.
The document says who should be excluded from the new work requirements – including children and people being treated for opioid abuse – and offers suggestions as to what counts as “work.” Besides employment, it can include job training, volunteering, or caring for a close relative.
“Medicaid needs to be more flexible so that states can best address the needs of this population,” Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said in a press release. “Our fundamental goal is to make a positive and lasting difference in the health and wellness of our beneficiaries.”
Adding a work requirement to Medicaid would mark one of the biggest changes to the program since its inception in 1966. It is likely to prompt a lawsuit from patient advocacy groups, which claim the requirement is inconsistent with Medicaid’s objectives and would require an act of Congress.
Republicans have been pushing for the change since the Affordable Care Act added millions of so called “able-bodied” adults to Medicaid. It allowed states to provide coverage to anyone earning up to 138% of the federal poverty level (about $16,600 for an individual).
The Obama administration turned down several state requests to add a work requirement.
Ten states have applied for a federal waiver to add a work requirement – Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, New Hampshire, North Carolina, Utah and Wisconsin. Officials in several other states have said they are interested in the idea.
An HHS official, who spoke on the condition of anonymity because the official had not been authorized to discuss the developments, said the agency may approve Kentucky’s request as early asJan. 12. Gov. Matt Bevin, a Republican, first sought to add such a provision in 2016. The current request would require able-bodied adults without dependents to work at least 20 hours a week.
Kentucky, which has some of the poorest counties in the country, has seen its Medicaid enrollment double in the past 3 years after the state expanded eligibility under the ACA.
While more than 74 million people are enrolled in Medicaid, only a small fraction would be affected by the work requirement. That’s because children – who make up nearly half of Medicaid enrollees – are excluded. So are the more than 10 million people on Medicaid because they have a disability.
More than 4 in 10 adults with Medicaid coverage already work full time, and most others either go to school, take care of a relative, or are too sick to work.
Still, critics fear a work requirement could have a chilling effect on people signing up for Medicaid or make it harder for people to get coverage.
But work requirements have strong public backing. About 70% of Americans say they support states imposing a work requirement on non-disabled adults, according to a Kaiser Family Foundation poll last year.
The Trump administration, along with many Republican leaders in Congress, has long supported such a move. The failed efforts in the House to replace Obamacare included a work requirement for Medicaid.
In its guidance to states, CMS said they should consider how some communities have high unemployment rates and whether enrollees need to care for young children and elderly families.
CMS also advised states to make work requirements for Medicaid similar than those used with food stamps to “reduce the burden on both states and beneficiaries.”
“This new guidance paves the way for states to demonstrate how their ideas will improve the health of Medicaid beneficiaries, as well as potentially improve their economic well-being,” Brian Neale, CMS deputy administrator and director for the Center for Medicaid and CHIP Services, said in the press release.
Ms. Verma, who has said she doesn’t think Medicaid should become a way of life for people who are not disabled, said the new guidance shows how the administration is trying to give states more flexibility in running Medicaid.
“Our policy guidance was in response to states that asked us for the flexibility they need to improve their programs and to help people in achieving greater well-being and self-sufficiency,” she said.
Ms. Verma, who worked with Kentucky and Indiana on their work requirement waivers as a health consultant before joining the Trump administration, recused herself from the decision on those states’ waiver requests.
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
The Trump administration early on Jan. 11 initiated a pivotal change in the Medicaid program, announcing that
The announcement came in a 10-page memo with detailed directions about how states can reshape the federal-state health program for low-income people.
The document says who should be excluded from the new work requirements – including children and people being treated for opioid abuse – and offers suggestions as to what counts as “work.” Besides employment, it can include job training, volunteering, or caring for a close relative.
“Medicaid needs to be more flexible so that states can best address the needs of this population,” Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said in a press release. “Our fundamental goal is to make a positive and lasting difference in the health and wellness of our beneficiaries.”
Adding a work requirement to Medicaid would mark one of the biggest changes to the program since its inception in 1966. It is likely to prompt a lawsuit from patient advocacy groups, which claim the requirement is inconsistent with Medicaid’s objectives and would require an act of Congress.
Republicans have been pushing for the change since the Affordable Care Act added millions of so called “able-bodied” adults to Medicaid. It allowed states to provide coverage to anyone earning up to 138% of the federal poverty level (about $16,600 for an individual).
The Obama administration turned down several state requests to add a work requirement.
Ten states have applied for a federal waiver to add a work requirement – Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, New Hampshire, North Carolina, Utah and Wisconsin. Officials in several other states have said they are interested in the idea.
An HHS official, who spoke on the condition of anonymity because the official had not been authorized to discuss the developments, said the agency may approve Kentucky’s request as early asJan. 12. Gov. Matt Bevin, a Republican, first sought to add such a provision in 2016. The current request would require able-bodied adults without dependents to work at least 20 hours a week.
Kentucky, which has some of the poorest counties in the country, has seen its Medicaid enrollment double in the past 3 years after the state expanded eligibility under the ACA.
While more than 74 million people are enrolled in Medicaid, only a small fraction would be affected by the work requirement. That’s because children – who make up nearly half of Medicaid enrollees – are excluded. So are the more than 10 million people on Medicaid because they have a disability.
More than 4 in 10 adults with Medicaid coverage already work full time, and most others either go to school, take care of a relative, or are too sick to work.
Still, critics fear a work requirement could have a chilling effect on people signing up for Medicaid or make it harder for people to get coverage.
But work requirements have strong public backing. About 70% of Americans say they support states imposing a work requirement on non-disabled adults, according to a Kaiser Family Foundation poll last year.
The Trump administration, along with many Republican leaders in Congress, has long supported such a move. The failed efforts in the House to replace Obamacare included a work requirement for Medicaid.
In its guidance to states, CMS said they should consider how some communities have high unemployment rates and whether enrollees need to care for young children and elderly families.
CMS also advised states to make work requirements for Medicaid similar than those used with food stamps to “reduce the burden on both states and beneficiaries.”
“This new guidance paves the way for states to demonstrate how their ideas will improve the health of Medicaid beneficiaries, as well as potentially improve their economic well-being,” Brian Neale, CMS deputy administrator and director for the Center for Medicaid and CHIP Services, said in the press release.
Ms. Verma, who has said she doesn’t think Medicaid should become a way of life for people who are not disabled, said the new guidance shows how the administration is trying to give states more flexibility in running Medicaid.
“Our policy guidance was in response to states that asked us for the flexibility they need to improve their programs and to help people in achieving greater well-being and self-sufficiency,” she said.
Ms. Verma, who worked with Kentucky and Indiana on their work requirement waivers as a health consultant before joining the Trump administration, recused herself from the decision on those states’ waiver requests.
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
CMS launches advanced APM focused on bundled payments
The Centers for Medicare & Medicaid Services is launching a new voluntary bundled payment demonstration project that for the first time will qualify as an advanced alternative payment model under the Quality Payment Program.
The Bundled Payments for Care Improvement Advanced (BPCI Advanced) “builds on the earlier success of bundled payment models and is an important step in the move away from fee-for-service and towards paying for value,” CMS Administrator Seema Verma said in a statement. “Under this model, providers will have an incentive to deliver high-quality care.”
Both categories of participants may enter into agreements with individual physicians and nonphysician providers to furnish care under the bundled payment model.
It will cover 29 in-patient episodes and three outpatient clinical episodes. Payment will be tied to performance on quality measures.
The 29 in-patient clinical episodes cover a range of conditions, including liver disorders (excluding malignancy, cirrhosis, and alcoholic hepatitis); various cardiac conditions; chronic obstructive pulmonary disease, bronchitis, and asthma; spinal fusion; joint replacements; femur, hip, or pelvis fractures; gastrointestinal hemorrhage or obstruction; renal failure; sepsis; simple pneumonia and respiratory infections; stroke; and urinary tract infections.
The three outpatient clinical episodes include percutaneous coronary intervention, cardiac defibrillator implantation, and back and neck surgery except spinal fusion.
Seven quality measures will be tracked as part of the payment. For all clinical episodes, measurement of all-cause hospital readmissions and advance care plan will be required.
The other five will be applied to the payment when appropriate, as follows:
- Perioperative care: selection of prophylactic antibiotic: first- or second-generation cephalosporin.
- Hospital-level risk-standardized complication rate following elective primary total hip arthroplasty and/or total knee arthroplasty.
- Hospital 30-day, all-cause, risk-standardized mortality rate following coronary artery bypass graft surgery.
- Excess days in acute care after hospitalization for acute myocardial infarction; and AHRQ patient safety indicators.
CMS has scheduled an open-door forum for those interested in participating in BPCI Advanced on Jan. 30.
Applications for participation will be accepted through March 12.
The Centers for Medicare & Medicaid Services is launching a new voluntary bundled payment demonstration project that for the first time will qualify as an advanced alternative payment model under the Quality Payment Program.
The Bundled Payments for Care Improvement Advanced (BPCI Advanced) “builds on the earlier success of bundled payment models and is an important step in the move away from fee-for-service and towards paying for value,” CMS Administrator Seema Verma said in a statement. “Under this model, providers will have an incentive to deliver high-quality care.”
Both categories of participants may enter into agreements with individual physicians and nonphysician providers to furnish care under the bundled payment model.
It will cover 29 in-patient episodes and three outpatient clinical episodes. Payment will be tied to performance on quality measures.
The 29 in-patient clinical episodes cover a range of conditions, including liver disorders (excluding malignancy, cirrhosis, and alcoholic hepatitis); various cardiac conditions; chronic obstructive pulmonary disease, bronchitis, and asthma; spinal fusion; joint replacements; femur, hip, or pelvis fractures; gastrointestinal hemorrhage or obstruction; renal failure; sepsis; simple pneumonia and respiratory infections; stroke; and urinary tract infections.
The three outpatient clinical episodes include percutaneous coronary intervention, cardiac defibrillator implantation, and back and neck surgery except spinal fusion.
Seven quality measures will be tracked as part of the payment. For all clinical episodes, measurement of all-cause hospital readmissions and advance care plan will be required.
The other five will be applied to the payment when appropriate, as follows:
- Perioperative care: selection of prophylactic antibiotic: first- or second-generation cephalosporin.
- Hospital-level risk-standardized complication rate following elective primary total hip arthroplasty and/or total knee arthroplasty.
- Hospital 30-day, all-cause, risk-standardized mortality rate following coronary artery bypass graft surgery.
- Excess days in acute care after hospitalization for acute myocardial infarction; and AHRQ patient safety indicators.
CMS has scheduled an open-door forum for those interested in participating in BPCI Advanced on Jan. 30.
Applications for participation will be accepted through March 12.
The Centers for Medicare & Medicaid Services is launching a new voluntary bundled payment demonstration project that for the first time will qualify as an advanced alternative payment model under the Quality Payment Program.
The Bundled Payments for Care Improvement Advanced (BPCI Advanced) “builds on the earlier success of bundled payment models and is an important step in the move away from fee-for-service and towards paying for value,” CMS Administrator Seema Verma said in a statement. “Under this model, providers will have an incentive to deliver high-quality care.”
Both categories of participants may enter into agreements with individual physicians and nonphysician providers to furnish care under the bundled payment model.
It will cover 29 in-patient episodes and three outpatient clinical episodes. Payment will be tied to performance on quality measures.
The 29 in-patient clinical episodes cover a range of conditions, including liver disorders (excluding malignancy, cirrhosis, and alcoholic hepatitis); various cardiac conditions; chronic obstructive pulmonary disease, bronchitis, and asthma; spinal fusion; joint replacements; femur, hip, or pelvis fractures; gastrointestinal hemorrhage or obstruction; renal failure; sepsis; simple pneumonia and respiratory infections; stroke; and urinary tract infections.
The three outpatient clinical episodes include percutaneous coronary intervention, cardiac defibrillator implantation, and back and neck surgery except spinal fusion.
Seven quality measures will be tracked as part of the payment. For all clinical episodes, measurement of all-cause hospital readmissions and advance care plan will be required.
The other five will be applied to the payment when appropriate, as follows:
- Perioperative care: selection of prophylactic antibiotic: first- or second-generation cephalosporin.
- Hospital-level risk-standardized complication rate following elective primary total hip arthroplasty and/or total knee arthroplasty.
- Hospital 30-day, all-cause, risk-standardized mortality rate following coronary artery bypass graft surgery.
- Excess days in acute care after hospitalization for acute myocardial infarction; and AHRQ patient safety indicators.
CMS has scheduled an open-door forum for those interested in participating in BPCI Advanced on Jan. 30.
Applications for participation will be accepted through March 12.
Pain after breast surgery may not be caused by the operation
, according to a study of almost 2,000 women recruited from the Mastectomy Reconstructive Outcomes Consortium (MROC).
In the February issue of The Breast, investigators from the University of Michigan, Ann Arbor and Memorial Sloan Kettering Cancer Center, New York, wrote that almost half of the study subjects had some level of pain before their operations and that, at 2 years afterward, their pain had increased but not in a clinically meaningful way. This finding is consistent with earlier research, which investigators noted found that “one-fourth to one-half of women who undergo postmastectomy report persistent pain months and years after surgery.”
“Average clinical pain severity was strikingly similar for preoperative and postoperative assessments,” said lead author Randy S. Roth, PhD, of the University of Michigan, and his coauthors. “Postoperative levels of pain, acute postoperative pain and (marginally) level of depression held consistent relationship at 2-year follow-up with all outcome measures.”
The prospective, multicenter cohort study of 1,996 women was undertaken over 5 years. Most patients had immediate (92.7%) and bilateral (53.8%) reconstruction; 47.6% had sentinel lymph node biopsy and 25.9% had axillary lymph node dissection. Most had no adjuvant therapy: 70.3% received no radiation and 52.7% no chemotherapy.
At 2 years, the Numerical Pain Rating Scale (NPRS) measured what Dr. Roth and his coauthors called a “significant increase in pain intensity” – from an average rating of 1.1 to 1.2, an increase of 9%. However, the absolute change and standard deviation (1.7 for both intervals) “suggest that this was not a clinically meaningful change.” The researchers also recorded more complaints of bodily discomfort after 2 years, “but the statistical parameters again indicate little clinically meaningful differences from preoperative status.”
Pain ratings measured with the McGill Pain Questionnaire showed a significant decrease in the MPQ affective pain rating, from 1.6 preoperatively to 0.8 at 2 years (P less than .001), and virtually no change in the MPQ sensory rating, from 3.2 to 3.1.
The researchers drew some conclusions about demographic profiles and pain after breast reconstruction. Older age was associated with more severe pain on NPRS, and higher body mass index was linked with chronic postsurgical pain for the MPQ sensory rating, NPRS score, and body discomfort scores.
Treatment characteristics associated with chronic postsurgical pain (CPSP) include radiation therapy during or after reconstruction and chemotherapy before reconstruction. Chemotherapy during or after reconstruction was associated with higher MPQ affective rating scores at 2 years (P = .011), as was chemotherapy both before and during or after reconstruction (P = .001). The latter also was linked to higher NPRS scores (P = .0015).
The type of surgery also was a factor in CPSP, the researchers wrote. Both MPQ sensory and affective ratings were higher in women who had free transverse flap surgery, or deep or superficial inferior epigastric perforator surgery than in women who had tissue expander/implant reconstruction. Lymph node status and timing of surgery had no impact on chronic pain.
One noteworthy finding, Dr. Roth and his coauthors wrote, is that “careful examination of our data suggests that CPSP following breast reconstruction may be of less clinical concern as a direct consequence of breast reconstruction than suggested by previous investigations of major surgery, including mastectomy and breast reconstruction.” Future studies of chronic postsurgical pain in breast reconstruction “will require greater methodological rigor” to reach more sound conclusions to use in patient counseling.
Dr. Roth and his coauthors had no financial relationships to disclose.
SOURCE: Roth RS et al. Breast 2018;37:119-25.
, according to a study of almost 2,000 women recruited from the Mastectomy Reconstructive Outcomes Consortium (MROC).
In the February issue of The Breast, investigators from the University of Michigan, Ann Arbor and Memorial Sloan Kettering Cancer Center, New York, wrote that almost half of the study subjects had some level of pain before their operations and that, at 2 years afterward, their pain had increased but not in a clinically meaningful way. This finding is consistent with earlier research, which investigators noted found that “one-fourth to one-half of women who undergo postmastectomy report persistent pain months and years after surgery.”
“Average clinical pain severity was strikingly similar for preoperative and postoperative assessments,” said lead author Randy S. Roth, PhD, of the University of Michigan, and his coauthors. “Postoperative levels of pain, acute postoperative pain and (marginally) level of depression held consistent relationship at 2-year follow-up with all outcome measures.”
The prospective, multicenter cohort study of 1,996 women was undertaken over 5 years. Most patients had immediate (92.7%) and bilateral (53.8%) reconstruction; 47.6% had sentinel lymph node biopsy and 25.9% had axillary lymph node dissection. Most had no adjuvant therapy: 70.3% received no radiation and 52.7% no chemotherapy.
At 2 years, the Numerical Pain Rating Scale (NPRS) measured what Dr. Roth and his coauthors called a “significant increase in pain intensity” – from an average rating of 1.1 to 1.2, an increase of 9%. However, the absolute change and standard deviation (1.7 for both intervals) “suggest that this was not a clinically meaningful change.” The researchers also recorded more complaints of bodily discomfort after 2 years, “but the statistical parameters again indicate little clinically meaningful differences from preoperative status.”
Pain ratings measured with the McGill Pain Questionnaire showed a significant decrease in the MPQ affective pain rating, from 1.6 preoperatively to 0.8 at 2 years (P less than .001), and virtually no change in the MPQ sensory rating, from 3.2 to 3.1.
The researchers drew some conclusions about demographic profiles and pain after breast reconstruction. Older age was associated with more severe pain on NPRS, and higher body mass index was linked with chronic postsurgical pain for the MPQ sensory rating, NPRS score, and body discomfort scores.
Treatment characteristics associated with chronic postsurgical pain (CPSP) include radiation therapy during or after reconstruction and chemotherapy before reconstruction. Chemotherapy during or after reconstruction was associated with higher MPQ affective rating scores at 2 years (P = .011), as was chemotherapy both before and during or after reconstruction (P = .001). The latter also was linked to higher NPRS scores (P = .0015).
The type of surgery also was a factor in CPSP, the researchers wrote. Both MPQ sensory and affective ratings were higher in women who had free transverse flap surgery, or deep or superficial inferior epigastric perforator surgery than in women who had tissue expander/implant reconstruction. Lymph node status and timing of surgery had no impact on chronic pain.
One noteworthy finding, Dr. Roth and his coauthors wrote, is that “careful examination of our data suggests that CPSP following breast reconstruction may be of less clinical concern as a direct consequence of breast reconstruction than suggested by previous investigations of major surgery, including mastectomy and breast reconstruction.” Future studies of chronic postsurgical pain in breast reconstruction “will require greater methodological rigor” to reach more sound conclusions to use in patient counseling.
Dr. Roth and his coauthors had no financial relationships to disclose.
SOURCE: Roth RS et al. Breast 2018;37:119-25.
, according to a study of almost 2,000 women recruited from the Mastectomy Reconstructive Outcomes Consortium (MROC).
In the February issue of The Breast, investigators from the University of Michigan, Ann Arbor and Memorial Sloan Kettering Cancer Center, New York, wrote that almost half of the study subjects had some level of pain before their operations and that, at 2 years afterward, their pain had increased but not in a clinically meaningful way. This finding is consistent with earlier research, which investigators noted found that “one-fourth to one-half of women who undergo postmastectomy report persistent pain months and years after surgery.”
“Average clinical pain severity was strikingly similar for preoperative and postoperative assessments,” said lead author Randy S. Roth, PhD, of the University of Michigan, and his coauthors. “Postoperative levels of pain, acute postoperative pain and (marginally) level of depression held consistent relationship at 2-year follow-up with all outcome measures.”
The prospective, multicenter cohort study of 1,996 women was undertaken over 5 years. Most patients had immediate (92.7%) and bilateral (53.8%) reconstruction; 47.6% had sentinel lymph node biopsy and 25.9% had axillary lymph node dissection. Most had no adjuvant therapy: 70.3% received no radiation and 52.7% no chemotherapy.
At 2 years, the Numerical Pain Rating Scale (NPRS) measured what Dr. Roth and his coauthors called a “significant increase in pain intensity” – from an average rating of 1.1 to 1.2, an increase of 9%. However, the absolute change and standard deviation (1.7 for both intervals) “suggest that this was not a clinically meaningful change.” The researchers also recorded more complaints of bodily discomfort after 2 years, “but the statistical parameters again indicate little clinically meaningful differences from preoperative status.”
Pain ratings measured with the McGill Pain Questionnaire showed a significant decrease in the MPQ affective pain rating, from 1.6 preoperatively to 0.8 at 2 years (P less than .001), and virtually no change in the MPQ sensory rating, from 3.2 to 3.1.
The researchers drew some conclusions about demographic profiles and pain after breast reconstruction. Older age was associated with more severe pain on NPRS, and higher body mass index was linked with chronic postsurgical pain for the MPQ sensory rating, NPRS score, and body discomfort scores.
Treatment characteristics associated with chronic postsurgical pain (CPSP) include radiation therapy during or after reconstruction and chemotherapy before reconstruction. Chemotherapy during or after reconstruction was associated with higher MPQ affective rating scores at 2 years (P = .011), as was chemotherapy both before and during or after reconstruction (P = .001). The latter also was linked to higher NPRS scores (P = .0015).
The type of surgery also was a factor in CPSP, the researchers wrote. Both MPQ sensory and affective ratings were higher in women who had free transverse flap surgery, or deep or superficial inferior epigastric perforator surgery than in women who had tissue expander/implant reconstruction. Lymph node status and timing of surgery had no impact on chronic pain.
One noteworthy finding, Dr. Roth and his coauthors wrote, is that “careful examination of our data suggests that CPSP following breast reconstruction may be of less clinical concern as a direct consequence of breast reconstruction than suggested by previous investigations of major surgery, including mastectomy and breast reconstruction.” Future studies of chronic postsurgical pain in breast reconstruction “will require greater methodological rigor” to reach more sound conclusions to use in patient counseling.
Dr. Roth and his coauthors had no financial relationships to disclose.
SOURCE: Roth RS et al. Breast 2018;37:119-25.
FROM THE BREAST
Key clinical point: Breast reconstruction surgery may not be the cause of persistent pain afterward.
Major finding: McGill Pain Questionnaire affective pain rating decreased from 1.6 preoperatively to 0.8 at 2 years.
Data source: Five-year prospective multicenter cohort study of 1,966 women recruited for the Mastectomy Reconstruction Outcomes Consortium.
Disclosures: Dr. Roth and his coauthors reported having no financial disclosures.
Source: Roth RS et al. Breast 2018;37:119-25.
HHS nominee Azar open to price negotiations for Part B drugs
Negotiating Medicare Part B drug prices could be on the agenda if Alex Azar, President Trump’s nominee to run the Health and Human Services department, gets confirmed.
before the Senate Finance Committee on Jan. 9. “In Part D, we do significant negotiation through pharmacy benefit managers that get the best rates of any commercial payers. We don’t do that in Part B. ... We basically pay sales price plus 6% or some other number. ... In Part B, we should be looking at those approaches” to price negotiations.
Mr. Azar added that in specific cases, such as when the government buys naloxone for use by first responders, “there is absolutely nothing wrong with the government negotiating that.”
The tone at Mr. Azar’s confirmation hearing generally was more conversational and less adversarial than that of his predecessor, Tom Price, MD, although contentious exchanges did occur, particularly around drug pricing.
“Across the board, drug prices are too high,” said Mr. Azar, who previously was president of Eli Lilly’s U.S. operations. “This is what is so bizarre about the way this system is organized that those price increases happen and ... during that same period, the net realized price by the company stayed flat. So just to cover for increased rebates, the patient who walks into the pharmacy whose insurance may not be paying for that is absorbing that cost and that is what I want to work with you to try and solve.”
Echoing comments made at a courtesy hearing before the Senate Health, Education, Labor and Pensions Committee on Nov. 29, Mr. Azar suggested the need for patent reform to push generic competition as a price-lowering tool.
The cordial tone to the hearing does not guarantee bipartisan support for Mr. Azar’s confirmation.
Sen. Maria Cantwell (D-Wash.) made it explicitly clear that her vote would be based on Mr. Azar’s thoughts about Medicaid expansion and on Mr. Azar’s suggested use of block grants “in the interest of sustainability.”
Regarding Medicaid, Mr. Azar sidestepped questions related to requiring “able-bodied” recipients to work.
“I don’t have a definition [of able-bodied] in hand,” Mr. Azar responded to Sen. Sherrod Brown (D-Ohio). “It would be something we’d work on with Congress.”
“You have no definition of ‘able-bodied adult’ that would be appropriate for differentiating between and among Medicaid recipients that you can share with us?” Sen. Brown replied, to which Mr. Azar had no specific answer.
Mr. Azar testified that said he was “a big supporter of telehealth and alternative means of providing care, especially in rural communities. I think sometimes we can be penny-wise [and] pound-foolish in these areas.”
Mr. Azar also voiced support to wellness incentive programs.
In the area of insurance access and premiums, Mr. Azar said that, as secretary, “I [would] have a very important obligation to make whatever program that I am entrusted with work as well as possible. What we have now is not working for people. It is not working for the 10 million who are in that individual market right now. For many of those people, it can be a false insurance card. It can be insurance, but a very high deductible or not having access to providers, so it’s unaffordable use of care. I want to solve the program for them,” as well as for the 28 million who are not in the individual market, to make it more affordable for all.
Regarding the contentious Center for Medicare and Medicaid Innovation, Mr. Azar voiced support of its use of mandatory participation demonstration projects and said that, depending on the circumstance, sometimes the use of mandatory participation is necessary to test out ideas, and if it is, he said, “so be it.”
Mr. Azar said he was interested in learning more about ensuring access to long-acting reversible contraception. He declined to answer questions on this because of his lack of knowledge but said he wanted more information.
A committee vote on Mr. Azar’s nomination had not been scheduled at press time. Should the committee support him, the full Senate would then consider his nomination.
Negotiating Medicare Part B drug prices could be on the agenda if Alex Azar, President Trump’s nominee to run the Health and Human Services department, gets confirmed.
before the Senate Finance Committee on Jan. 9. “In Part D, we do significant negotiation through pharmacy benefit managers that get the best rates of any commercial payers. We don’t do that in Part B. ... We basically pay sales price plus 6% or some other number. ... In Part B, we should be looking at those approaches” to price negotiations.
Mr. Azar added that in specific cases, such as when the government buys naloxone for use by first responders, “there is absolutely nothing wrong with the government negotiating that.”
The tone at Mr. Azar’s confirmation hearing generally was more conversational and less adversarial than that of his predecessor, Tom Price, MD, although contentious exchanges did occur, particularly around drug pricing.
“Across the board, drug prices are too high,” said Mr. Azar, who previously was president of Eli Lilly’s U.S. operations. “This is what is so bizarre about the way this system is organized that those price increases happen and ... during that same period, the net realized price by the company stayed flat. So just to cover for increased rebates, the patient who walks into the pharmacy whose insurance may not be paying for that is absorbing that cost and that is what I want to work with you to try and solve.”
Echoing comments made at a courtesy hearing before the Senate Health, Education, Labor and Pensions Committee on Nov. 29, Mr. Azar suggested the need for patent reform to push generic competition as a price-lowering tool.
The cordial tone to the hearing does not guarantee bipartisan support for Mr. Azar’s confirmation.
Sen. Maria Cantwell (D-Wash.) made it explicitly clear that her vote would be based on Mr. Azar’s thoughts about Medicaid expansion and on Mr. Azar’s suggested use of block grants “in the interest of sustainability.”
Regarding Medicaid, Mr. Azar sidestepped questions related to requiring “able-bodied” recipients to work.
“I don’t have a definition [of able-bodied] in hand,” Mr. Azar responded to Sen. Sherrod Brown (D-Ohio). “It would be something we’d work on with Congress.”
“You have no definition of ‘able-bodied adult’ that would be appropriate for differentiating between and among Medicaid recipients that you can share with us?” Sen. Brown replied, to which Mr. Azar had no specific answer.
Mr. Azar testified that said he was “a big supporter of telehealth and alternative means of providing care, especially in rural communities. I think sometimes we can be penny-wise [and] pound-foolish in these areas.”
Mr. Azar also voiced support to wellness incentive programs.
In the area of insurance access and premiums, Mr. Azar said that, as secretary, “I [would] have a very important obligation to make whatever program that I am entrusted with work as well as possible. What we have now is not working for people. It is not working for the 10 million who are in that individual market right now. For many of those people, it can be a false insurance card. It can be insurance, but a very high deductible or not having access to providers, so it’s unaffordable use of care. I want to solve the program for them,” as well as for the 28 million who are not in the individual market, to make it more affordable for all.
Regarding the contentious Center for Medicare and Medicaid Innovation, Mr. Azar voiced support of its use of mandatory participation demonstration projects and said that, depending on the circumstance, sometimes the use of mandatory participation is necessary to test out ideas, and if it is, he said, “so be it.”
Mr. Azar said he was interested in learning more about ensuring access to long-acting reversible contraception. He declined to answer questions on this because of his lack of knowledge but said he wanted more information.
A committee vote on Mr. Azar’s nomination had not been scheduled at press time. Should the committee support him, the full Senate would then consider his nomination.
Negotiating Medicare Part B drug prices could be on the agenda if Alex Azar, President Trump’s nominee to run the Health and Human Services department, gets confirmed.
before the Senate Finance Committee on Jan. 9. “In Part D, we do significant negotiation through pharmacy benefit managers that get the best rates of any commercial payers. We don’t do that in Part B. ... We basically pay sales price plus 6% or some other number. ... In Part B, we should be looking at those approaches” to price negotiations.
Mr. Azar added that in specific cases, such as when the government buys naloxone for use by first responders, “there is absolutely nothing wrong with the government negotiating that.”
The tone at Mr. Azar’s confirmation hearing generally was more conversational and less adversarial than that of his predecessor, Tom Price, MD, although contentious exchanges did occur, particularly around drug pricing.
“Across the board, drug prices are too high,” said Mr. Azar, who previously was president of Eli Lilly’s U.S. operations. “This is what is so bizarre about the way this system is organized that those price increases happen and ... during that same period, the net realized price by the company stayed flat. So just to cover for increased rebates, the patient who walks into the pharmacy whose insurance may not be paying for that is absorbing that cost and that is what I want to work with you to try and solve.”
Echoing comments made at a courtesy hearing before the Senate Health, Education, Labor and Pensions Committee on Nov. 29, Mr. Azar suggested the need for patent reform to push generic competition as a price-lowering tool.
The cordial tone to the hearing does not guarantee bipartisan support for Mr. Azar’s confirmation.
Sen. Maria Cantwell (D-Wash.) made it explicitly clear that her vote would be based on Mr. Azar’s thoughts about Medicaid expansion and on Mr. Azar’s suggested use of block grants “in the interest of sustainability.”
Regarding Medicaid, Mr. Azar sidestepped questions related to requiring “able-bodied” recipients to work.
“I don’t have a definition [of able-bodied] in hand,” Mr. Azar responded to Sen. Sherrod Brown (D-Ohio). “It would be something we’d work on with Congress.”
“You have no definition of ‘able-bodied adult’ that would be appropriate for differentiating between and among Medicaid recipients that you can share with us?” Sen. Brown replied, to which Mr. Azar had no specific answer.
Mr. Azar testified that said he was “a big supporter of telehealth and alternative means of providing care, especially in rural communities. I think sometimes we can be penny-wise [and] pound-foolish in these areas.”
Mr. Azar also voiced support to wellness incentive programs.
In the area of insurance access and premiums, Mr. Azar said that, as secretary, “I [would] have a very important obligation to make whatever program that I am entrusted with work as well as possible. What we have now is not working for people. It is not working for the 10 million who are in that individual market right now. For many of those people, it can be a false insurance card. It can be insurance, but a very high deductible or not having access to providers, so it’s unaffordable use of care. I want to solve the program for them,” as well as for the 28 million who are not in the individual market, to make it more affordable for all.
Regarding the contentious Center for Medicare and Medicaid Innovation, Mr. Azar voiced support of its use of mandatory participation demonstration projects and said that, depending on the circumstance, sometimes the use of mandatory participation is necessary to test out ideas, and if it is, he said, “so be it.”
Mr. Azar said he was interested in learning more about ensuring access to long-acting reversible contraception. He declined to answer questions on this because of his lack of knowledge but said he wanted more information.
A committee vote on Mr. Azar’s nomination had not been scheduled at press time. Should the committee support him, the full Senate would then consider his nomination.
REPORTING FROM A SENATE FINANCE COMMITTEE HEARING
Biologic mesh safe, effective for prevention of parastomal hernia recurrence
at 18.9%.
Theadore Hufford, MD, of the University of Illinois at Chicago and his colleagues conducted a study to look at the effects of placement and type of mesh on postop morbidity and recurrence of parastomal hernia (PSH). The study was a retrospective analysis of 58 patients who had undergone local PSH repair with biological mesh between July 2006 and July 2015 at a single medical center.
All procedures were conducted by three board-certified surgeons at a tertiary medical center, and decisions such as the mesh type, placement and incision type were determined by the attending surgeon’s operative preferences.
In the study group, mesh placement (overlay, underlay, or sandwich technique) was found to have a statistically significant effect on recurrence. Of the patients who received an underlay of biologic mesh, 33% had a recurrence, compared with 25% of those who had overlays. The sandwich technique (a combination of overlay and underlay) was found to have the lowest rate of recurrence at 6.7%. The type of mesh (human origin, bovine, or porcine) and type of stoma (colostomy vs. ileostomy) had no statistically significant effect on the rate of recurrence.
Total recurrences in the study patients was 18.9%, a figure consistent with the current literature on parastomal hernia repair, the investigators wrote.
A key factor in recurrence was type of incision. Keyhole incisions had a much lower rate of recurrence than did circular incisions (32% vs. 9.1%; P = .042).
In the study group, “one patient was readmitted for mesh infection within 30 days of the repair and required mesh removal. Even with the biologic mesh in place there was an overlying skin infection that warranted reoperation that resulted in the stoma being moved to a new site altogether,” the investigators wrote.
The limitations of this study include the retrospective nature of the research and the difficulty in diagnosing PSH, which is often asymptomatic, the investigators mentioned. In addition, the techniques for local PSH repair with biologic mesh are not fully standardized. Mesh type and location decisions are often made on a case-by-case basis which limits the applicability of the study data for general PSH repairs.
Dr. Hufford and his associates wrote, “Our results suggest local parastomal hernia repair with biological mesh is both a safe and effective method, especially when used with the sandwich technique for mesh placement, for definitive treatment of parastomal hernias with very low morbidity, and acceptable recurrence rate.”
The investigators reported no disclosures.
at 18.9%.
Theadore Hufford, MD, of the University of Illinois at Chicago and his colleagues conducted a study to look at the effects of placement and type of mesh on postop morbidity and recurrence of parastomal hernia (PSH). The study was a retrospective analysis of 58 patients who had undergone local PSH repair with biological mesh between July 2006 and July 2015 at a single medical center.
All procedures were conducted by three board-certified surgeons at a tertiary medical center, and decisions such as the mesh type, placement and incision type were determined by the attending surgeon’s operative preferences.
In the study group, mesh placement (overlay, underlay, or sandwich technique) was found to have a statistically significant effect on recurrence. Of the patients who received an underlay of biologic mesh, 33% had a recurrence, compared with 25% of those who had overlays. The sandwich technique (a combination of overlay and underlay) was found to have the lowest rate of recurrence at 6.7%. The type of mesh (human origin, bovine, or porcine) and type of stoma (colostomy vs. ileostomy) had no statistically significant effect on the rate of recurrence.
Total recurrences in the study patients was 18.9%, a figure consistent with the current literature on parastomal hernia repair, the investigators wrote.
A key factor in recurrence was type of incision. Keyhole incisions had a much lower rate of recurrence than did circular incisions (32% vs. 9.1%; P = .042).
In the study group, “one patient was readmitted for mesh infection within 30 days of the repair and required mesh removal. Even with the biologic mesh in place there was an overlying skin infection that warranted reoperation that resulted in the stoma being moved to a new site altogether,” the investigators wrote.
The limitations of this study include the retrospective nature of the research and the difficulty in diagnosing PSH, which is often asymptomatic, the investigators mentioned. In addition, the techniques for local PSH repair with biologic mesh are not fully standardized. Mesh type and location decisions are often made on a case-by-case basis which limits the applicability of the study data for general PSH repairs.
Dr. Hufford and his associates wrote, “Our results suggest local parastomal hernia repair with biological mesh is both a safe and effective method, especially when used with the sandwich technique for mesh placement, for definitive treatment of parastomal hernias with very low morbidity, and acceptable recurrence rate.”
The investigators reported no disclosures.
at 18.9%.
Theadore Hufford, MD, of the University of Illinois at Chicago and his colleagues conducted a study to look at the effects of placement and type of mesh on postop morbidity and recurrence of parastomal hernia (PSH). The study was a retrospective analysis of 58 patients who had undergone local PSH repair with biological mesh between July 2006 and July 2015 at a single medical center.
All procedures were conducted by three board-certified surgeons at a tertiary medical center, and decisions such as the mesh type, placement and incision type were determined by the attending surgeon’s operative preferences.
In the study group, mesh placement (overlay, underlay, or sandwich technique) was found to have a statistically significant effect on recurrence. Of the patients who received an underlay of biologic mesh, 33% had a recurrence, compared with 25% of those who had overlays. The sandwich technique (a combination of overlay and underlay) was found to have the lowest rate of recurrence at 6.7%. The type of mesh (human origin, bovine, or porcine) and type of stoma (colostomy vs. ileostomy) had no statistically significant effect on the rate of recurrence.
Total recurrences in the study patients was 18.9%, a figure consistent with the current literature on parastomal hernia repair, the investigators wrote.
A key factor in recurrence was type of incision. Keyhole incisions had a much lower rate of recurrence than did circular incisions (32% vs. 9.1%; P = .042).
In the study group, “one patient was readmitted for mesh infection within 30 days of the repair and required mesh removal. Even with the biologic mesh in place there was an overlying skin infection that warranted reoperation that resulted in the stoma being moved to a new site altogether,” the investigators wrote.
The limitations of this study include the retrospective nature of the research and the difficulty in diagnosing PSH, which is often asymptomatic, the investigators mentioned. In addition, the techniques for local PSH repair with biologic mesh are not fully standardized. Mesh type and location decisions are often made on a case-by-case basis which limits the applicability of the study data for general PSH repairs.
Dr. Hufford and his associates wrote, “Our results suggest local parastomal hernia repair with biological mesh is both a safe and effective method, especially when used with the sandwich technique for mesh placement, for definitive treatment of parastomal hernias with very low morbidity, and acceptable recurrence rate.”
The investigators reported no disclosures.
FROM THE AMERICAN JOURNAL OF SURGERY
Key clinical point: In a comparison of the biologic meshes and placement techniques, the sandwich technique was most successful in preventing recurrence.
Major finding: Rate of recurrence of parastomal hernia was 33% with underlay surgical mesh placement, 25% with overlay placement, and 6.7% with sandwich placement.
Study details: A retrospective analysis of 58 patients who had undergone local parastomal hernia repair with biological mesh at a single medical center.
Disclosures: The investigators reported no disclosures.
Source: Hufford T et al. Am J Surg. 2018 Jan. 215(1):88-90.
Sexual harassment
Question: A medical assistant alleged that Dr. Y sexually harassed her by sending anonymous gifts and messages such as, “you’re gorgeous,” and “I love your figure.” It was a repeat of Dr. Y’s previous behavior pattern directed at a different worker, who had lodged a complaint with the human resources department. The medical assistant now files a sexual harassment action under Title VII of the federal Civil Rights Act of 1964 against the health care institution, alleging a hostile work environment.
Which of the following is false?
A. Sexual harassment is a form of sexual misconduct regulated by state medical boards.
B. Mere words, without physical action, may suffice to be deemed sexual harassment.
C. A hostile environment arises when offensive conduct is so severe and pervasive as to amount to job discrimination.
D. Sexual harassment is a civil rights violation unique to the workplace.
E. Liability may attach to the supervisor, institution, or the harasser.
Answer: D. This hypothetical is modified from an actual Connecticut case that was recently decided in favor of the plaintiff.1 In that case, which involved a dentist, the federal Second Circuit unanimously rejected the University of Connecticut Health Center’s appeal against a jury’s verdict holding it responsible for its employee’s sexual harassment of a coworker, who was awarded $125,000. It ruled that the health center should have known of its employee’s harassing behavior.
Sexual harassment, a current hot topic, is pervasive, affecting a diversity of individuals in the fields of media, sports, politics, judiciary, education, entertainment, and others. The medical profession is no exception, and studies indicate that sexual harassment affects patients and physicians alike, occurring in hospitals, private offices, and academic centers.
In a large questionnaire study involving 4,501 female physicians, the authors found a prevalence rate of 47.7%. Harassment was more common while in medical school or during internship, residency, or fellowship than in practice.2 Patients may be the harassers. In 599 of the 1,064 licensed female family physicians in Ontario, more than 75% reported sexual harassment by patients at some time during their careers, either in their own offices by their own patients, or in settings such as emergency departments and clinics, where unknown patients presented an even higher risk.3
When physicians sexually harass fellow workers such as nurses, they distract their victims from providing attentive and competent care. In a review of the subject, researchers cited a study of 188 critical care nurses in hospitals, where nearly half (46%) reported experiencing sexual harassment that included “offensive sexual remarks, unwanted physical contact, unwanted nonverbal attention, requests for unwanted dates, sexual propositions, and physical assault.”4 To this list must now be added misconduct via the use of social media. In the study, physicians (82%), coworkers (20%), and immediate supervisors (7%) accounted for most of the incidents.
Neglecting to look seriously into complaints or to monitor and remedy the situation may create a hostile environment and trigger liability.
An example is the recent well-publicized case of Olympics team physician Dr. Larry Nassar, who was also a faculty member at Michigan State University. Olympic gold medalist McKayla Maroney named both the university and the U.S. Olympic Committee as codefendants in a lawsuit alleging that the institutions failed to properly investigate the team doctor’s criminal sexual conduct.
In Anania v. Daubenspeck Chiropractic, two employees of a chiropractor alleged that his patients sexually harassed them, but he did not remedy the situation.5 The trial court initially dismissed their lawsuit, holding that Ohio law did not recognize a cause of action for sexual harassment by a nonemployee patient, and that liability for sexual harassment can only exist in the context of respondeat superior (employer-employee) liability.
However, the court of appeals held that so long as the chiropractor knew or should have known of the harassment, and failed to take corrective action, he could be liable for allowing a hostile environment to exist.
Negligent supervision is another favorite plaintiff’s cause of action. In Doe v. Borromeo, a patient sought to hold the hospital liable for sexual assault by a physician during a medical exam.6 The lower state court had summarily dismissed the case, which was based on vicarious liability, but the state court of appeals reversed, finding the patient’s complaint against the hospital included a negligent supervision claim.
The appeals court reasoned that this was distinguishable from one based upon vicarious liability, so long as the supervising entity had a duty to protect the victim – and such a duty can only be established if the supervising entity knew or should have known of the existence of the harasser’s propensities, if any, to commit criminal and tortious acts.
Sexual harassment is a form of sex discrimination under Title VII of the Civil Rights Act of 1964, which is enforced by the Equal Employment Opportunity Commission. The commission’s website explains the law in clear and simple language:
“It is unlawful to harass a person (an applicant or employee) because of that person’s sex. Harassment can include ‘sexual harassment’ or unwelcome sexual advances, requests for sexual favors, and other verbal or physical harassment of a sexual nature. Harassment does not have to be of a sexual nature, however, and can include offensive remarks about a person’s sex.
“For example, it is illegal to harass a woman by making offensive comments about women in general. Both victim and the harasser can be either a woman or a man, and the victim and harasser can be the same sex.
“Although the law doesn’t prohibit simple teasing, offhand comments, or isolated incidents that are not very serious, harassment is illegal when it is so frequent or severe that it creates a hostile or offensive work environment or when it results in an adverse employment decision (such as the victim being fired or demoted). The harasser can be the victim’s supervisor, a supervisor in another area, a coworker, or someone who is not an employee of the employer, such as a client or customer.”7
For sexual harassment to occur, the aggrieved party must either show a “hostile environment” or “quid pro quo” situation.
In a hostile environment case, the harassment is serious and persistent, creating unacceptable and offensive work conditions. The plaintiff has to show that the employer knew or should have known of the situation but failed to remedy it.
The “quid pro quo” type of case requires a showing that a person in authority conditioned some aspect of the employee’s employment, such as promotion or retention, upon a sexual favor or relationship.
The U.S. Supreme Court has both clarified and muddied the law’s position on these two previously distinct types of sexual harassment.
In the landmark case of Burlington Industries v. Ellerth, the plaintiff, who was a salesperson, alleged that a supervisor made advances to her and threatened to deny her certain job benefits if she did not cooperate.8 The threats were never carried out, and she was in fact promoted; but her lawsuit alleged that the harassment caused her resignation and amounted to a “constructive” discharge.
Likewise, in Faragher v. City of Boca Raton, the plaintiff, employed as a lifeguard, alleged that her work environment was riddled with crude remarks and obscenities.9 One of the two supervisors reportedly once said to Faragher, “Date me or clean toilets for a year.” Another lifeguard had previously lodged similar complaints. The plaintiff ultimately resigned and brought suit.
The U.S. Supreme Court characterized both of these as “hostile environment” rather than “quid pro quo” cases, because the plaintiffs did not suffer any direct adverse job action. In its decisions, the court defined the scope of liability and affirmative defenses, holding that employers can be subject to vicarious liability when supervisors create actionable hostile work environments.
In other cases, the Supreme Court has ruled for the use of “the reasonable person in the plaintiff’s position” standard in judging the severity of sexual harassment. The court has also held that the genders of the harasser and the harassed employee are not material in determining whether sexual harassment has occurred.
A physician can be accused of harassing an employee, a nurse, an assistant, a fellow worker, a third party, or a patient. Focusing on misconduct within the doctor-patient relationship, the Federation of State Medical Boards adopted in May 2006 a policy entitled “Addressing Sexual Boundaries: Guidelines for State Medical Boards.”10
Although it did not use the term sexual harassment, the policy emphasized that physician sexual misconduct may include behavior that is verbal or physical, and may include expressions of thoughts and feelings or gestures that are sexual. It used the term “sexual impropriety” to denote behavior, gestures, or expressions that are seductive, sexually suggestive, disrespectful of patient privacy, or sexually demeaning to a patient. Together with “sexual violation,” a term the FSMB used when referring to physical sexual contact, they form the basis for disciplinary action by a state medical board.
Caveat: When performing a physical exam, physicians should always use good judgment and sensitivity, relying on the presence of a medical assistant to ensure patient comfort and to alleviate possible embarrassment or anxiety.
Under the federal EEOC rules, the employer rather than the harasser is the defendant. But there are other legal recourses, including tort and criminal actions, that directly target the harasser. Successful plaintiffs may be awarded lost wages, as well as damages for emotional distress, medical expenses, and punitive damages. They may also recover attorney fees.
In one case, a psychiatric nurse was awarded $1.2 million (later reduced to $850,000); in another, a nurse successfully sued a physician’s medical practice and received $150,000 in damages.4 And in an unusual case, a plaintiff was awarded only $1 in damages, but her counsel was paid $41,598 in fees.11 For the practicing doctor, medical board sanction, notoriety, and loss of professional standing and privileges constitute additional costs.
The medical profession is as susceptible as any other – perhaps more so – to allegations of sexual harassment. The magic words for actionable sexual harassment are severe, pervasive, and unwelcome. Although laws in the workplace generally do not prohibit simple teasing, offhand comments, or minor isolated incidents, the line separating these behaviors from bona fide sexual harassment is thin.
Erring on the side of strict and sober professional propriety seems prudent, given the current climate of zero tolerance.
References
1. MacCluskey v. University of Connecticut Health Center, United States Court of Appeals, Second Circuit, No. 17-0807-cv, Dec. 19, 2017.
2. Arch Intern Med. 1998 Feb 23;158(4):352-8.
3. N Engl J Med. 1993 Dec 23;329(26):1936-9.
4. J Nurs Care Qual. 2004 Jul-Sep;19(3):234-41.
5. Anania v. Daubenspeck Chiropractic, 718 N.E. 2d 480 (Ohio 1998).
6. Doe v. Borromeo, Nos. 305162, 305163 (Mich. Ct. App. Sept. 20, 2012).
7. Available at https://www.eeoc.gov/laws/types/sexual_harassment.cfm.
8. Burlington Industries, Inc. v. Ellerth, 524 US 742 (1998).
9. Faragher v. City of Boca Raton, 524 U.S. 775 (1998).
10. Federation of State Medical Boards, “Addressing Sexual Boundaries: Guidelines for State Medical Boards.”
11. J Healthc Risk Manag. 1999 Summer;19(3):14-25.
Question: A medical assistant alleged that Dr. Y sexually harassed her by sending anonymous gifts and messages such as, “you’re gorgeous,” and “I love your figure.” It was a repeat of Dr. Y’s previous behavior pattern directed at a different worker, who had lodged a complaint with the human resources department. The medical assistant now files a sexual harassment action under Title VII of the federal Civil Rights Act of 1964 against the health care institution, alleging a hostile work environment.
Which of the following is false?
A. Sexual harassment is a form of sexual misconduct regulated by state medical boards.
B. Mere words, without physical action, may suffice to be deemed sexual harassment.
C. A hostile environment arises when offensive conduct is so severe and pervasive as to amount to job discrimination.
D. Sexual harassment is a civil rights violation unique to the workplace.
E. Liability may attach to the supervisor, institution, or the harasser.
Answer: D. This hypothetical is modified from an actual Connecticut case that was recently decided in favor of the plaintiff.1 In that case, which involved a dentist, the federal Second Circuit unanimously rejected the University of Connecticut Health Center’s appeal against a jury’s verdict holding it responsible for its employee’s sexual harassment of a coworker, who was awarded $125,000. It ruled that the health center should have known of its employee’s harassing behavior.
Sexual harassment, a current hot topic, is pervasive, affecting a diversity of individuals in the fields of media, sports, politics, judiciary, education, entertainment, and others. The medical profession is no exception, and studies indicate that sexual harassment affects patients and physicians alike, occurring in hospitals, private offices, and academic centers.
In a large questionnaire study involving 4,501 female physicians, the authors found a prevalence rate of 47.7%. Harassment was more common while in medical school or during internship, residency, or fellowship than in practice.2 Patients may be the harassers. In 599 of the 1,064 licensed female family physicians in Ontario, more than 75% reported sexual harassment by patients at some time during their careers, either in their own offices by their own patients, or in settings such as emergency departments and clinics, where unknown patients presented an even higher risk.3
When physicians sexually harass fellow workers such as nurses, they distract their victims from providing attentive and competent care. In a review of the subject, researchers cited a study of 188 critical care nurses in hospitals, where nearly half (46%) reported experiencing sexual harassment that included “offensive sexual remarks, unwanted physical contact, unwanted nonverbal attention, requests for unwanted dates, sexual propositions, and physical assault.”4 To this list must now be added misconduct via the use of social media. In the study, physicians (82%), coworkers (20%), and immediate supervisors (7%) accounted for most of the incidents.
Neglecting to look seriously into complaints or to monitor and remedy the situation may create a hostile environment and trigger liability.
An example is the recent well-publicized case of Olympics team physician Dr. Larry Nassar, who was also a faculty member at Michigan State University. Olympic gold medalist McKayla Maroney named both the university and the U.S. Olympic Committee as codefendants in a lawsuit alleging that the institutions failed to properly investigate the team doctor’s criminal sexual conduct.
In Anania v. Daubenspeck Chiropractic, two employees of a chiropractor alleged that his patients sexually harassed them, but he did not remedy the situation.5 The trial court initially dismissed their lawsuit, holding that Ohio law did not recognize a cause of action for sexual harassment by a nonemployee patient, and that liability for sexual harassment can only exist in the context of respondeat superior (employer-employee) liability.
However, the court of appeals held that so long as the chiropractor knew or should have known of the harassment, and failed to take corrective action, he could be liable for allowing a hostile environment to exist.
Negligent supervision is another favorite plaintiff’s cause of action. In Doe v. Borromeo, a patient sought to hold the hospital liable for sexual assault by a physician during a medical exam.6 The lower state court had summarily dismissed the case, which was based on vicarious liability, but the state court of appeals reversed, finding the patient’s complaint against the hospital included a negligent supervision claim.
The appeals court reasoned that this was distinguishable from one based upon vicarious liability, so long as the supervising entity had a duty to protect the victim – and such a duty can only be established if the supervising entity knew or should have known of the existence of the harasser’s propensities, if any, to commit criminal and tortious acts.
Sexual harassment is a form of sex discrimination under Title VII of the Civil Rights Act of 1964, which is enforced by the Equal Employment Opportunity Commission. The commission’s website explains the law in clear and simple language:
“It is unlawful to harass a person (an applicant or employee) because of that person’s sex. Harassment can include ‘sexual harassment’ or unwelcome sexual advances, requests for sexual favors, and other verbal or physical harassment of a sexual nature. Harassment does not have to be of a sexual nature, however, and can include offensive remarks about a person’s sex.
“For example, it is illegal to harass a woman by making offensive comments about women in general. Both victim and the harasser can be either a woman or a man, and the victim and harasser can be the same sex.
“Although the law doesn’t prohibit simple teasing, offhand comments, or isolated incidents that are not very serious, harassment is illegal when it is so frequent or severe that it creates a hostile or offensive work environment or when it results in an adverse employment decision (such as the victim being fired or demoted). The harasser can be the victim’s supervisor, a supervisor in another area, a coworker, or someone who is not an employee of the employer, such as a client or customer.”7
For sexual harassment to occur, the aggrieved party must either show a “hostile environment” or “quid pro quo” situation.
In a hostile environment case, the harassment is serious and persistent, creating unacceptable and offensive work conditions. The plaintiff has to show that the employer knew or should have known of the situation but failed to remedy it.
The “quid pro quo” type of case requires a showing that a person in authority conditioned some aspect of the employee’s employment, such as promotion or retention, upon a sexual favor or relationship.
The U.S. Supreme Court has both clarified and muddied the law’s position on these two previously distinct types of sexual harassment.
In the landmark case of Burlington Industries v. Ellerth, the plaintiff, who was a salesperson, alleged that a supervisor made advances to her and threatened to deny her certain job benefits if she did not cooperate.8 The threats were never carried out, and she was in fact promoted; but her lawsuit alleged that the harassment caused her resignation and amounted to a “constructive” discharge.
Likewise, in Faragher v. City of Boca Raton, the plaintiff, employed as a lifeguard, alleged that her work environment was riddled with crude remarks and obscenities.9 One of the two supervisors reportedly once said to Faragher, “Date me or clean toilets for a year.” Another lifeguard had previously lodged similar complaints. The plaintiff ultimately resigned and brought suit.
The U.S. Supreme Court characterized both of these as “hostile environment” rather than “quid pro quo” cases, because the plaintiffs did not suffer any direct adverse job action. In its decisions, the court defined the scope of liability and affirmative defenses, holding that employers can be subject to vicarious liability when supervisors create actionable hostile work environments.
In other cases, the Supreme Court has ruled for the use of “the reasonable person in the plaintiff’s position” standard in judging the severity of sexual harassment. The court has also held that the genders of the harasser and the harassed employee are not material in determining whether sexual harassment has occurred.
A physician can be accused of harassing an employee, a nurse, an assistant, a fellow worker, a third party, or a patient. Focusing on misconduct within the doctor-patient relationship, the Federation of State Medical Boards adopted in May 2006 a policy entitled “Addressing Sexual Boundaries: Guidelines for State Medical Boards.”10
Although it did not use the term sexual harassment, the policy emphasized that physician sexual misconduct may include behavior that is verbal or physical, and may include expressions of thoughts and feelings or gestures that are sexual. It used the term “sexual impropriety” to denote behavior, gestures, or expressions that are seductive, sexually suggestive, disrespectful of patient privacy, or sexually demeaning to a patient. Together with “sexual violation,” a term the FSMB used when referring to physical sexual contact, they form the basis for disciplinary action by a state medical board.
Caveat: When performing a physical exam, physicians should always use good judgment and sensitivity, relying on the presence of a medical assistant to ensure patient comfort and to alleviate possible embarrassment or anxiety.
Under the federal EEOC rules, the employer rather than the harasser is the defendant. But there are other legal recourses, including tort and criminal actions, that directly target the harasser. Successful plaintiffs may be awarded lost wages, as well as damages for emotional distress, medical expenses, and punitive damages. They may also recover attorney fees.
In one case, a psychiatric nurse was awarded $1.2 million (later reduced to $850,000); in another, a nurse successfully sued a physician’s medical practice and received $150,000 in damages.4 And in an unusual case, a plaintiff was awarded only $1 in damages, but her counsel was paid $41,598 in fees.11 For the practicing doctor, medical board sanction, notoriety, and loss of professional standing and privileges constitute additional costs.
The medical profession is as susceptible as any other – perhaps more so – to allegations of sexual harassment. The magic words for actionable sexual harassment are severe, pervasive, and unwelcome. Although laws in the workplace generally do not prohibit simple teasing, offhand comments, or minor isolated incidents, the line separating these behaviors from bona fide sexual harassment is thin.
Erring on the side of strict and sober professional propriety seems prudent, given the current climate of zero tolerance.
References
1. MacCluskey v. University of Connecticut Health Center, United States Court of Appeals, Second Circuit, No. 17-0807-cv, Dec. 19, 2017.
2. Arch Intern Med. 1998 Feb 23;158(4):352-8.
3. N Engl J Med. 1993 Dec 23;329(26):1936-9.
4. J Nurs Care Qual. 2004 Jul-Sep;19(3):234-41.
5. Anania v. Daubenspeck Chiropractic, 718 N.E. 2d 480 (Ohio 1998).
6. Doe v. Borromeo, Nos. 305162, 305163 (Mich. Ct. App. Sept. 20, 2012).
7. Available at https://www.eeoc.gov/laws/types/sexual_harassment.cfm.
8. Burlington Industries, Inc. v. Ellerth, 524 US 742 (1998).
9. Faragher v. City of Boca Raton, 524 U.S. 775 (1998).
10. Federation of State Medical Boards, “Addressing Sexual Boundaries: Guidelines for State Medical Boards.”
11. J Healthc Risk Manag. 1999 Summer;19(3):14-25.
Question: A medical assistant alleged that Dr. Y sexually harassed her by sending anonymous gifts and messages such as, “you’re gorgeous,” and “I love your figure.” It was a repeat of Dr. Y’s previous behavior pattern directed at a different worker, who had lodged a complaint with the human resources department. The medical assistant now files a sexual harassment action under Title VII of the federal Civil Rights Act of 1964 against the health care institution, alleging a hostile work environment.
Which of the following is false?
A. Sexual harassment is a form of sexual misconduct regulated by state medical boards.
B. Mere words, without physical action, may suffice to be deemed sexual harassment.
C. A hostile environment arises when offensive conduct is so severe and pervasive as to amount to job discrimination.
D. Sexual harassment is a civil rights violation unique to the workplace.
E. Liability may attach to the supervisor, institution, or the harasser.
Answer: D. This hypothetical is modified from an actual Connecticut case that was recently decided in favor of the plaintiff.1 In that case, which involved a dentist, the federal Second Circuit unanimously rejected the University of Connecticut Health Center’s appeal against a jury’s verdict holding it responsible for its employee’s sexual harassment of a coworker, who was awarded $125,000. It ruled that the health center should have known of its employee’s harassing behavior.
Sexual harassment, a current hot topic, is pervasive, affecting a diversity of individuals in the fields of media, sports, politics, judiciary, education, entertainment, and others. The medical profession is no exception, and studies indicate that sexual harassment affects patients and physicians alike, occurring in hospitals, private offices, and academic centers.
In a large questionnaire study involving 4,501 female physicians, the authors found a prevalence rate of 47.7%. Harassment was more common while in medical school or during internship, residency, or fellowship than in practice.2 Patients may be the harassers. In 599 of the 1,064 licensed female family physicians in Ontario, more than 75% reported sexual harassment by patients at some time during their careers, either in their own offices by their own patients, or in settings such as emergency departments and clinics, where unknown patients presented an even higher risk.3
When physicians sexually harass fellow workers such as nurses, they distract their victims from providing attentive and competent care. In a review of the subject, researchers cited a study of 188 critical care nurses in hospitals, where nearly half (46%) reported experiencing sexual harassment that included “offensive sexual remarks, unwanted physical contact, unwanted nonverbal attention, requests for unwanted dates, sexual propositions, and physical assault.”4 To this list must now be added misconduct via the use of social media. In the study, physicians (82%), coworkers (20%), and immediate supervisors (7%) accounted for most of the incidents.
Neglecting to look seriously into complaints or to monitor and remedy the situation may create a hostile environment and trigger liability.
An example is the recent well-publicized case of Olympics team physician Dr. Larry Nassar, who was also a faculty member at Michigan State University. Olympic gold medalist McKayla Maroney named both the university and the U.S. Olympic Committee as codefendants in a lawsuit alleging that the institutions failed to properly investigate the team doctor’s criminal sexual conduct.
In Anania v. Daubenspeck Chiropractic, two employees of a chiropractor alleged that his patients sexually harassed them, but he did not remedy the situation.5 The trial court initially dismissed their lawsuit, holding that Ohio law did not recognize a cause of action for sexual harassment by a nonemployee patient, and that liability for sexual harassment can only exist in the context of respondeat superior (employer-employee) liability.
However, the court of appeals held that so long as the chiropractor knew or should have known of the harassment, and failed to take corrective action, he could be liable for allowing a hostile environment to exist.
Negligent supervision is another favorite plaintiff’s cause of action. In Doe v. Borromeo, a patient sought to hold the hospital liable for sexual assault by a physician during a medical exam.6 The lower state court had summarily dismissed the case, which was based on vicarious liability, but the state court of appeals reversed, finding the patient’s complaint against the hospital included a negligent supervision claim.
The appeals court reasoned that this was distinguishable from one based upon vicarious liability, so long as the supervising entity had a duty to protect the victim – and such a duty can only be established if the supervising entity knew or should have known of the existence of the harasser’s propensities, if any, to commit criminal and tortious acts.
Sexual harassment is a form of sex discrimination under Title VII of the Civil Rights Act of 1964, which is enforced by the Equal Employment Opportunity Commission. The commission’s website explains the law in clear and simple language:
“It is unlawful to harass a person (an applicant or employee) because of that person’s sex. Harassment can include ‘sexual harassment’ or unwelcome sexual advances, requests for sexual favors, and other verbal or physical harassment of a sexual nature. Harassment does not have to be of a sexual nature, however, and can include offensive remarks about a person’s sex.
“For example, it is illegal to harass a woman by making offensive comments about women in general. Both victim and the harasser can be either a woman or a man, and the victim and harasser can be the same sex.
“Although the law doesn’t prohibit simple teasing, offhand comments, or isolated incidents that are not very serious, harassment is illegal when it is so frequent or severe that it creates a hostile or offensive work environment or when it results in an adverse employment decision (such as the victim being fired or demoted). The harasser can be the victim’s supervisor, a supervisor in another area, a coworker, or someone who is not an employee of the employer, such as a client or customer.”7
For sexual harassment to occur, the aggrieved party must either show a “hostile environment” or “quid pro quo” situation.
In a hostile environment case, the harassment is serious and persistent, creating unacceptable and offensive work conditions. The plaintiff has to show that the employer knew or should have known of the situation but failed to remedy it.
The “quid pro quo” type of case requires a showing that a person in authority conditioned some aspect of the employee’s employment, such as promotion or retention, upon a sexual favor or relationship.
The U.S. Supreme Court has both clarified and muddied the law’s position on these two previously distinct types of sexual harassment.
In the landmark case of Burlington Industries v. Ellerth, the plaintiff, who was a salesperson, alleged that a supervisor made advances to her and threatened to deny her certain job benefits if she did not cooperate.8 The threats were never carried out, and she was in fact promoted; but her lawsuit alleged that the harassment caused her resignation and amounted to a “constructive” discharge.
Likewise, in Faragher v. City of Boca Raton, the plaintiff, employed as a lifeguard, alleged that her work environment was riddled with crude remarks and obscenities.9 One of the two supervisors reportedly once said to Faragher, “Date me or clean toilets for a year.” Another lifeguard had previously lodged similar complaints. The plaintiff ultimately resigned and brought suit.
The U.S. Supreme Court characterized both of these as “hostile environment” rather than “quid pro quo” cases, because the plaintiffs did not suffer any direct adverse job action. In its decisions, the court defined the scope of liability and affirmative defenses, holding that employers can be subject to vicarious liability when supervisors create actionable hostile work environments.
In other cases, the Supreme Court has ruled for the use of “the reasonable person in the plaintiff’s position” standard in judging the severity of sexual harassment. The court has also held that the genders of the harasser and the harassed employee are not material in determining whether sexual harassment has occurred.
A physician can be accused of harassing an employee, a nurse, an assistant, a fellow worker, a third party, or a patient. Focusing on misconduct within the doctor-patient relationship, the Federation of State Medical Boards adopted in May 2006 a policy entitled “Addressing Sexual Boundaries: Guidelines for State Medical Boards.”10
Although it did not use the term sexual harassment, the policy emphasized that physician sexual misconduct may include behavior that is verbal or physical, and may include expressions of thoughts and feelings or gestures that are sexual. It used the term “sexual impropriety” to denote behavior, gestures, or expressions that are seductive, sexually suggestive, disrespectful of patient privacy, or sexually demeaning to a patient. Together with “sexual violation,” a term the FSMB used when referring to physical sexual contact, they form the basis for disciplinary action by a state medical board.
Caveat: When performing a physical exam, physicians should always use good judgment and sensitivity, relying on the presence of a medical assistant to ensure patient comfort and to alleviate possible embarrassment or anxiety.
Under the federal EEOC rules, the employer rather than the harasser is the defendant. But there are other legal recourses, including tort and criminal actions, that directly target the harasser. Successful plaintiffs may be awarded lost wages, as well as damages for emotional distress, medical expenses, and punitive damages. They may also recover attorney fees.
In one case, a psychiatric nurse was awarded $1.2 million (later reduced to $850,000); in another, a nurse successfully sued a physician’s medical practice and received $150,000 in damages.4 And in an unusual case, a plaintiff was awarded only $1 in damages, but her counsel was paid $41,598 in fees.11 For the practicing doctor, medical board sanction, notoriety, and loss of professional standing and privileges constitute additional costs.
The medical profession is as susceptible as any other – perhaps more so – to allegations of sexual harassment. The magic words for actionable sexual harassment are severe, pervasive, and unwelcome. Although laws in the workplace generally do not prohibit simple teasing, offhand comments, or minor isolated incidents, the line separating these behaviors from bona fide sexual harassment is thin.
Erring on the side of strict and sober professional propriety seems prudent, given the current climate of zero tolerance.
References
1. MacCluskey v. University of Connecticut Health Center, United States Court of Appeals, Second Circuit, No. 17-0807-cv, Dec. 19, 2017.
2. Arch Intern Med. 1998 Feb 23;158(4):352-8.
3. N Engl J Med. 1993 Dec 23;329(26):1936-9.
4. J Nurs Care Qual. 2004 Jul-Sep;19(3):234-41.
5. Anania v. Daubenspeck Chiropractic, 718 N.E. 2d 480 (Ohio 1998).
6. Doe v. Borromeo, Nos. 305162, 305163 (Mich. Ct. App. Sept. 20, 2012).
7. Available at https://www.eeoc.gov/laws/types/sexual_harassment.cfm.
8. Burlington Industries, Inc. v. Ellerth, 524 US 742 (1998).
9. Faragher v. City of Boca Raton, 524 U.S. 775 (1998).
10. Federation of State Medical Boards, “Addressing Sexual Boundaries: Guidelines for State Medical Boards.”
11. J Healthc Risk Manag. 1999 Summer;19(3):14-25.