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dical Care Is Being Corrupted - NYTimes.

com

http://www.nytimes.com/2014/11/19/opinion/how-medical-care-is dical Care Is Being Corrupted - NYTimes.com

http://www.nytimes.com/2014/11/19/opinion/how-medical-care-is

required or feel forced to recommend treatment whose risks may outweigh

benefits.
It is not just treatment targets but also the particular medications to be used
that are now often dictated by insurers. Commonly this is done by assigning a
larger co-payment to certain drugs, a negative incentive for patients to choose
higher-cost medications. But now some insurers are offering a positive financial
incentive directly to physicians to use specific medications. For example,
WellPoint, one of the largest private payers for health care, recently outlined
designated treatment pathways for cancer and announced that it would pay
WHEN we are patients, we want our doctors to make recommendations that are in

physicians an incentive of $350 per month per patient treated on the designated

our best interests as individuals. As physicians, we strive to do the same for our

pathway.
This has raised concern in the oncology community because there is

patients.

considerable debate among experts about what is optimal. Dr. Margaret A.

But financial forces largely hidden from the public are beginning to corrupt
care and undermine the bond of trust between doctors and patients. Insurers,

Tempero of the National Comprehensive Cancer Network observed that every day

hospital networks and regulatory groups have put in place both rewards and

oncologists saw patients for whom deviation from treatment guidelines made

punishments that can powerfully influence your doctors decisions.

sense: Will oncologists be reluctant to make these decisions because of an adverse


effects on payments? Further, some health care networks limit the ability of a

Contracts for medical care that incorporate pay for performance direct
physicians to meet strict metrics for testing and treatment. These metrics are

patient to get a second opinion by going outside the network. The patient is

population-based and generic, and do not take into account the individual

financially penalized with large co-payments or no coverage at all. Additionally,

characteristics and preferences of the patient or differing expert opinions on

the physician who refers the patient out of network risks censure from the network

optimal practice.

administration.
When a patient asks Is this treatment right for me? the doctor faces a

For example, doctors are rewarded for keeping their patients cholesterol and
blood pressure below certain target levels. For some patients, this is good

potential moral dilemma. How should he answer if the response is to his personal

medicine, but for others the benefits may not outweigh the risks. Treatment with

detriment? Some health policy experts suggest that there is no moral dilemma.

drugs such as statins can cause significant side effects, including muscle pain and

They argue that it is obsolete for the doctor to approach each patient strictly as an

increased risk of diabetes. Blood-pressure therapy to meet an imposed target may

individual; medical decisions should be made on the basis of what is best for the

lead to increased falls and fractures in older patients.

population as a whole.
We fear this approach can dangerously lead to moral licensing the

Physicians who meet their designated targets are not only rewarded with a
bonus from the insurer but are also given high ratings on insurer websites.

physician is able to rationalize forcing or withholding treatment, regardless of

Physicians who deviate from such metrics are financially penalized through lower

clinical judgment or patient preference, as acceptable for the good of the

payments and are publicly shamed, listed on insurer websites in a lower tier.

population.
Medicine has been appropriately criticized for its past paternalism, where

Further, their patients may be required to pay higher co-payments.

doctors imposed their views on the patient. In recent years, however, the balance

These measures are clearly designed to coerce physicians to comply with the

of power has shifted away from the physician to the patient, in large part because

metrics. Thus doctors may feel pressured to withhold treatment that they feel is

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11/20/2014

dical Care Is Being Corrupted - NYTimes.com

http://www.nytimes.com/2014/11/19/opinion/how-medical-care-is nks Anxiety Drugs to Alzheimer's Disease - NYTimes.com

http://newoldage.blogs.nytimes.com/2014/09/24/study-links-anxiet

of access to clinical information on the web.

In truth, the power belongs to the insurers and regulators that control
payment. There is now a new paternalism, largely invisible to the public,
diminishing the autonomy of both doctor and patient.
In 2010, Congress passed the Physician Payments Sunshine Act to address
potential conflicts of interest by making physician financial ties to pharmaceutical
and device companies public on a federal website. We propose a similar public
website to reveal the hidden coercive forces that may specify treatments and limit
choices through pressures on the doctor.
Medical care is not just another marketplace commodity. Physicians should
I swear I dont go looking for alarming news about benzodiazepines, drugs

never have an incentive to override the best interests of their patients.

widely prescribed for insomnia and anxiety. But it shows up with some frequency,
so, mindful of your fervidly held views on the subject, I am donning a hazmat suit
to bring you the latest findings from the medical journal BMJ.
Theyre disturbing.
In previous posts, I reported that long-term use by older people of drugs
called sedative-hypnotics, which includes benzos (like Ativan, Xanax, Valium and
Klonopin) and the related z-drugs (Ambien, Lunesta), has for years caused
concern among some researchers.
Some readers took exception, arguing that critics minimize the miseries of
chronic sleeplessness, reflexively condemn all drug dependence or
condescendingly assume older people cant make smart decisions. The Ambien I
use is low dose and I am not an idiot, commented a miffed Margaret Moffitt of
Roanoke, Va.
The doctors and health organizations I have spoken to, however, point to
much higher rates of falls and fractures, auto accidents and cognitive problems in
older patients taking sedative-hypnotics, along with increased emergency room
visits and hospital admissions. Hence, the American Geriatrics Societys inclusion
of these drugs in its Choosing Wisely list of treatments that doctors and patients
should question.
Now French and Canadian researchers are reporting in a study designed

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nks Anxiety Drugs to Alzheimer's Disease - NYTimes.com

http://newoldage.blogs.nytimes.com/2014/09/24/study-links-anxiet nks Anxiety Drugs to Alzheimer's Disease - NYTimes.com

with particular care that benzodiazepine use is linked to higher rates of

http://newoldage.blogs.nytimes.com/2014/09/24/study-links-anxiet

Objection! This is just another example of correlation, not causation.

subsequent Alzheimers disease, and that the association strengthens with greater
Does the study show that extended benzodiazepine use causes Alzheimers?

exposure to the drugs.

No, an observational study like this can never directly answer that question. But
The more the cumulative days of use, the higher the risk of later being

the stronger association observed for long term exposures reinforces the

diagnosed with dementia, Dr. Antoine Pariente, a pharmacoepidemiologist at the

suspicion of a possible direct association, the researchers wrote.

University of Bordeaux and a co-author of the study, told me in an interview.


Dr. Malaz Boustani, a geriatrician at Indiana University Health and a
co-author of an accompanying BMJ editorial, praised the studys design, which

He and his colleagues reviewed medical records of almost 1,800 older people
diagnosed with Alzheimers in the public health insurance program in Quebec, and

attempts to correct for what is sometimes called reverse causation bias: the

compared them with nearly 7,200 control subjects. Most were over age 80.

danger, as Dr. Pariente put it, that its not the drug that caused the disease. Its
the early symptoms of the disease that caused the drug use.

About half those with Alzheimers and 40 percent of the control subjects had
Because Alzheimers symptoms develop slowly and can include some of the

used benzodiazepines, the researchers found. That translated to a 51 percent


increase in the odds of a subsequent Alzheimers diagnosis among the

very problems (like anxiety and insomnia) for which doctors prescribe benzos, the

benzodiazepine users.

study looked at Alzheimers patients who had not taken benzodiazepines for five
years before their diagnoses. Their use of the drugs occurred five to 10 years

It was not short-term use that drove that finding: Older people who took

earlier than that.

prescribed doses for 90 days or fewer over the course of the study patients were
They really did everything possible to overcome methodological issues, Dr.

followed for six years or longer had no increased risk.

Boustani said of the researchers.


But those who took the drugs longer were more likely to be diagnosed with
Alzheimers. In older patients who took daily doses for 91 to 180 days, the risk rose

Objection! Taking benzos only occasionally once or twice a week, perhaps


has no impact.

32 percent, compared to those who took none. In those who took daily doses for
more than 180 days, the risk was 84 percent higher.

Not in this study. Whether these elderly Quebecois took 180 daily doses in a
The association persisted whether users took 180 doses over six months or

row or spread them out over years, their risk of later developing Alzheimers

over five years, Dr. Pariente said. It also held when the researchers controlled for

disease was nearly double that of people who did not take the drugs or who

health and demographic factors, including conditions like anxiety, depression and

stopped at 90 doses.

insomnia.
And many people dont stop at 90, or stop at all. The problem is chronic use,
The link was stronger to longer-acting forms of the drug, like Valium, than to

especially in the very elderly, Dr. Pariente said. You develop a tolerance and a

formulations that leave the body more quickly, like Ativan and Xanax.

dependency.

Annoyed comments may already be on their way, so let me address a few

Objection! What about relative versus absolute risk?

likely objections:
For some ailments, an increase in risk of 51 percent or even 84 percent still

11/20/2014

11/20/2014

nks Anxiety Drugs to Alzheimer's Disease - NYTimes.com

http://newoldage.blogs.nytimes.com/2014/09/24/study-links-anxiet Quarantine for Ebola Exposure: 21 Days of Fear and Loathing -...

http://www.nytimes.com/2014/10/19/us/life-in-quarantine-for-ebo

means people face very low risk. But dementia affects roughly 25 to 30 percent of

the population over 80; Alzheimers accounts for about 70 percent of that. The
projected numbers are sobering. To date, the search for drugs, treatments, even
basic causes has been discouraging.
What if, instead of regarding these findings as scolding about drugs, we saw
them as a possible finding about Alzheimers prevention? Stopping these
medications is such an easy, cost-effective potential therapy, Dr. Boustani said.
Maybe that is a bit optimistic. But remember that in a different Quebec study,
a brochure alone helped 27 percent of long-term, elderly benzo users to taper
down (no one should simply stop these drugs cold) and discontinue their

DALLAS The refrigerator in Youngor Jallahs small apartment broke down last

prescriptions within six months. Another 11 percent reduced their dosage.

week, and it did not take long for the stench of rotting food to grow unbearable.
But when she reported the problem to the front office, the complexs manager said

People dont want to part with their sleeping pills, I told Dr. Boustani,

that a repairman would not be sent until Monday.

remembering our earlier discussions. They dont see why they should.

That is the expiration date for the 21-day, self-imposed quarantine that Ms.
Jallah, her partner and her four children have endured since the day her mothers

His reply: Tell them: Here is the information. Take this into account when

boyfriend, Thomas Eric Duncan, was hospitalized here with Ebola. Because her

you decide to take a sleeping pill or not.

mother was at work, it was Ms. Jallah, 35, who last cared for Mr. Duncan, making
If youre willing to take the risk, O.K., he added. Youre making an

him tea and handing him a thermometer but, she said, never touching him

informed decision.

before summoning an ambulance.


The complexs manager urged Ms. Jallah to move her food to the apartment
across the stairwell, which has been empty since a new renter decided against
moving in after hearing about the neighbors. When the landlord sent a
maintenance man to deliver the key, he arrived wearing two pairs of rubber gloves.
So it has been in Quarantine Nation. As the Ebola scare spreads from Texas to
Ohio and beyond, the number of people who have locked themselves away some
under government orders, others voluntarily has grown well beyond those who
lived with and cared for Mr. Duncan before his death on Oct. 8. The discovery last
week that two nurses at Texas Health Presbyterian Hospital here had caught the
virus while treating Mr. Duncan extended concentric circles of fear to new sets of
hospital workers and other contacts.
Officials in Texas said Thursday that nearly 100 health care workers would be
asked to sign pledges not to use public transportation, go to public places or

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