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NEWS & VIEWS

REPORTS PAINT GRIM PICTURE OF MALPRACTICE INSURANCE CRISIS

Data continue to mount on the effects that drastic increases in the cost of medical malpractice insurance are having on access to and quality of care – and the picture they paint is not good. Two reports – one by the Department of Health and Human Services (HHS) and one by the Medical Group Management Association (MGMA) – quantify the repercussions of unaffordable liability insurance.

The HHS report, which draws data from published insurance studies and news reports, portrays a litigation system that impedes access to care and is increasingly expensive for all Americans. It suggests that a cap on non-economic damages could cut health care costs by 5 to 9 percent annually – a $70 to $126 billion savings – without substantially affecting mortality or medical complications. Furthermore, states with non-economic damage caps of $350,000 or less have experienced two-year premium increases of only 18 percent on average, whereas states without this cap have had average increases of 45 percent.

Among the examples of the repercussions of high insurance costs is one that hits close to home for neurologists: a patient in Gulfport, MS, suffered permanent brain damage because high liability insurance costs had left only one head trauma specialist to cover all hospitals in the city, and no neurosurgeon was available to treat the injuries.

The MGMA report – based on survey responses from 700 group practices employing a total of 16,800 physicians – found that the average increase in medical liability insurance premiums between 2001 and 2002 was 36.38 percent; between 2002 and 2003 it was 53.15 percent. Because of these increases, 14.1 percent of responders reported that they no longer see high-risk patients, and 22.6 percent said that they would take this step within the next three years. Sixteen percent plan to eliminate some specialty services or physicians; 26.1 percent expect some physicians to retire, relocate, or restrict their practice within a three-year span.

Last month, Neurology Today reported that physicians in several states have organized job actions to draw attention to the problem. This trend appears likely to continue; at press time, Connecticut physicians were considering an action, according to the New York Times.

NEW DMD TEST – ACCURATE AND AFFORDABLE

A new test – Single Condition Amplification/Internal Primer sequencing (SCAIP) – developed by University of Utah researchers can detect Duchenne muscular dystrophy (DMD) in at least 95 percent of cases, researchers say – including 35 percent that current testing methods miss. The test will also have applications for several other types of muscular dystrophies, researchers say. Furthermore, the cost of the test – under $1,000 – should make SCAIP affordable to those who need it.

Current testing methods diagnose the disorder by looking for deletions or duplications on the dystrophin gene; they identify DMD in about 60 percent of cases. In the past, another 35 percent, caused by mutations that are not deletions or duplications, required a muscle biopsy for diagnosis, an expensive and invasive procedure. However, SCAIP identifies all three causes of DMD. To get results, researchers perform a direct sequence analysis of the gene, which allows scientists to look at all of the genetic information in a gene and identify specific mutations. Researchers credit their experience working on the Human Genome Project for giving them the expertise to make a cost-effective test.

Commenting on the study, Jerry R. Mendell, MD, Professor and Chair of Neurology at Ohio State University College of Medicine, said that gene sequencing tests are valuable because, in addition to diagnosing a large percentage of those patients missed by other testing methods, a gene sequencing test can identify carriers of the disease and can be used prenatally. Furthermore, he said, “if the SCAIP test can be used to detect all cases of DMD for under $1,000, it will probably be more cost effective to get this test immediately, rather than getting the traditional tests first – which detect about 60 percent of cases and cost $400 to $500 at our institution – and moving on to SCAIP if those tests are negative.”

Another dystrophin gene analysis method – which uses a technique called “denaturing high performance liquid chromatography” – is being tested for accuracy by researchers at Baylor College of Medicine in Houston, TX. The City of Hope National Medical Center in Duarte, CA, also offers a complete dystrophin gene analysis test, which can detect mutations. The test has been available for two years.

The University of Utah researchers published their findings in this month's American Journal of Human Genetics. The new test became available at the University of Utah Muscular Dystrophy Clinic in April.

STUDY: BYSTANDERS CAN IDENTIFY STROKE WITH THREE-QUESTION TEST

A simple three-step test allows untrained bystanders to identify a person having a stroke – with a high degree of accuracy – according to a study done by researchers at the University of North Carolina-Chapel Hill. This could streamline the triaging of stroke patients and allow more of them to receive tissue plasminogen activator within its three-hour window, researchers say. The study was presented at the American Stroke Association conference in Phoenix, AZ.

For the study, researchers had 100 untrained volunteers administer a version of the Cincinnati Prehospital Stroke Scale to stroke survivors with unresolved symptoms. The Cincinnati scale tests for arm weakness, speech deficits, and facial weakness. Over the phone, researchers acting as 911 dispatchers prompted the volunteers on how to administer the test. The test generally took less than a minute, and the volunteers administered it correctly 96 percent of the time.

Commenting on the study, Jeffrey L. Saver, MD, Assistant Professor of Neurology at the University of California-Los Angeles, called the test “a promising approach to improving early recognition of stroke,” noting that other tests used by emergency dispatchers fail to identify half of all strokes. Gregory Albers, MD, Professor of Neurology at Stanford University, said he would like to see if the test can be accurate in a real emergency situation, when concern for a loved one could impede the test. The UNC team plans to conduct such a test. Both neurologists agree that patients failing to seek emergency help when a stroke occurs – because they downplay or do not recognize symptoms or because they are incapacitated, among other reasons – is still a barrier to timely stroke care.

Dr. Saver suggested that public education efforts should focus on recognizing sudden weakness – “the single most important stroke symptom” – rather than a multitude of symptoms, but, Dr. Albers stressed, “any small part of the system that we can expedite will be beneficial.”

CHRONIC CARE NEEDS UNMET, PUBLIC SAYS

Both experts and the general public agree that the needs of the chronically ill are not met by the current health care system, according to a survey done by Gerard Anderson, PhD, of the Johns Hopkins School of Public Health in Baltimore, MD. The survey was published in the Archives of Internal Medicine (2003;163:437–442).

Researchers polled 1,741 physicians, 1,663 adults from the general public, and 155 health policy makers about their knowledge and attitudes toward chronic conditions and their opinions on how the health care system handles chronic health needs.

A majority of respondents agreed that government programs are inadequate to meet chronic health care needs and that health insurance does not cover many needed services for the chronically ill. The policy makers tended to be the least positive about the state of health care for the chronically ill, whereas the general public was most positive. For example, 38 percent of the general public surveyed believe that current government programs meet the needs of the chronically ill, only 11 percent of health policy makers do.

Commenting on the study, James Bernat, MD, Professor of Medicine (Neurology) at Dartmouth-Hitchcock Medical Center in Lebanon, NH, said that he was not surprised that health policy makers had the most pessimistic view of chronic illness care. “[They] know the inadequacies of our current ‘system,’ which is not a coherent system but rather a pastiche of public insurance, private insurance, self-pay, and public and private institutions that inadequately covers or leaves out entirely tens of millions of citizens.” He agreed that many needs of chronically ill patients are not adequately addressed. “Our health care insurance enterprise is based on the model of acute care, not on the model of chronic care. For example, home health care and nursing home care are only partially covered or not covered at all by most private and public health insurance policies.” He said he hopes that acknowledgment of inadequacies in the system will lead to better care for the chronically ill.

WILL CASE OPEN DOOR FOR PATIENTS TO SUE HMOS?

A decision by the Second US Circuit Court of Appeals, Cicio v. Vytra Healthcare and Brent Spears, MD, granted a woman the right to sue a health maintenance organization (HMO) for medical malpractice over the death of her husband. Will this translate into a general right for patients to sue HMOs for denying certain procedures? While it is too soon to answer this question, this case could be the catalyst for a national decision on how the Employee Retirement Income Security Act (ERISA) relates to the patient-HMO relationship.

Originally crafted to protect pension plans, ERISA has gained influence over employer-sponsored health plans, and ensures that all disputes over these health plans are heard in federal court, where there is little legislation addressing coverage disputes. Essentially, this means that HMOs cannot be sued for denying coverage of certain procedures.

In this case, however, the Circuit Court decided that Vytra Healthcare engaged in the practice of medicine, not just an interpretation of an insurance contract. Vytra Healthcare denied Carmine Cicio a cancer treatment recommended by his primary care physician and instead offered to cover a different treatment – a treatment that had not been recommended by Mr. Cicio's physician. Because the Vytra Healthcare practiced medicine, it can be sued under state law, the court decided.

Not only will this precedent hold in all similar cases in New York, Vermont, and Connecticut, but it could also influence other circuit courts. Furthermore, if the case is appealed to the Supreme Court, the issue of how much responsibility HMOs have for the medical ramifications of their coverage decisions will be addressed on a national level.

Commenting on the case, Robert Weinmann, MD, a neurologist in private practice who is President of the Union of American Physicians and Dentists, said: “The HMOs have taken advantage of ERISA, which means that every time an HMO misdirects a doctor, the doctor ends up getting sued.”

Dr. Weinmann believes the case will likely be heard by the Supreme Court because it touches on an issue at the heart of several other court decisions, and it had been appealed and reversed by the higher court.