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Just 15 medical conditions account for half of the increase in health care spending between 1987 and 2000 – and two of them are neurological. In fact, cerebrovascular disease and back pain caused 6.5 percent of the increase in total health care dollars spent in those years. An increase in the number of cases treated accounted for a majority of the cost hike – for 60.3 percent in cerebrovascular disease and 52.6 percent in back pain.

The study was published in the August 25th issue of Health Affairs by lead author Kenneth E. Thorpe and coauthors.

Commenting on the study by e-mail, S. Claiborne Johnston, MD, PhD, Director of the Stroke Service of the University of California-San Francisco (UCSF) Medical Center, said: “For cerebrovascular disease, there is no question we are reducing mortality and, probably to a lesser extent, reducing long-term disability” with increased costs.

Opinions were more mixed on back pain treatment, however. “I think we are more likely to consider back pain a medical condition so it is getting diagnosed and treated more frequently,” Dr. Johnston said.

Commenting by phone, Gary Franklin, MD, MPH, noted several reasons the cost of back pain treatment is on the rise: “We are seeing more invasive procedures, the lumbar fusion rate is up, and minimally invasive procedures are way up… we are also spending more money on opiates.” Dr. Franklin is Research Professor of Neurology and Environmental and Occupational Health Sciences at the University of Washington in Seattle and Medical Director for the Washington State Department of Labor and Industries, and he has conducted a variety of research on the epidemiology of pain.



Dr. Franklin said workers compensation data in Washington state show that two-thirds of workers who undergo lumbar fusion are still completely disabled two years after surgery. And, while opiates reduce pain, there is almost no evidence that they improve function, although they cause increasing morbidity and mortality at high doses, he continued.

Both neurologists agreed data are lacking on the effectiveness of invasive and expensive back pain treatments, and that more research is needed. “Procedures are not regulated in any way, and no evidence of efficacy is needed, unlike for drugs and, to a lesser extent, devices. We are paying for things that there is not necessarily enough evidence to support,” Dr. Franklin said.

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The editors of prominent international medical journals are pledging to make drug trial data more transparent by refusing to publish human clinical trials that do not register in a public database, such as, before or at the start of enrolling patients. The policy statement was published in early September by the International Committee of Medical Journal Editors in the New England Journal of Medicine (NEJM) and the Journal of the American Medical Association, among others, and is available free on both journals' Web sites.

Editors of several major neurology journals told Neurology Today in September that they support the concept of a public registry for drug trials, and that their journals plan to institute similar requirements. Richard T. Johnson, MD, Editor of Annals of Neurology, said in an e-mail that, although there are details to be worked out, he has told the editors of NEJM that Annals will probably adopt the policy. The Annals editorial board will be discussing the issue this month. Dr. Johnson is Distinguished Service Professor of Neurology, Microbiology, and Neuroscience at Johns Hopkins University School of Medicine in Baltimore, MD.

Roger N. Rosenberg, MD, Editor of Archives of Neurology, reports that his journal will also adopt the policy, which he feels is extremely important. Dr. Rosenberg is Zale Distinguished Chair and Professor of Neurology at the University of Texas Southwestern Medical Center in Dallas.

Robert C. Griggs, MD, Editor of Neurology and Professor and Chair of the Department of Neurology at University of Rochester School of Medicine, said in an e-mail message that his journal will adopt the policy as well.

Meanwhile, the pharmaceutical industry lobbying group Pharmaceutical Research and Manufacturers of America (PhRMA) announced plans in September to create its own database, which would contain summaries of both positive and negative studies completed since October 2002. Participation in the database would be voluntary. Several individual pharmaceutical companies, including Eli Lilly and GlaxoSmithKline, plan to make their research findings more public as well, according to company press releases.

Congress is also throwing its hat in the ring, with House Democrats announcing their plans to introduce bills that would require human drug trials to be registered in a public database in order to be approved.

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Think Medicare can answer your complicated billing questions? Think again. A Government Accountability Office (GAO) survey found that call centers set up to answer physicians' Medicare billing questions got complicated questions right only 4 percent of the time – that amounts to 12 complete and correct responses out of 300.

This is a worse record than the GAO's 2002 survey, when 15 percent of the calls were answered correctly – and neurologists have cause to worry. One of the four test questions used by the GAO dealt with billing for an office visit and a procedure for the same patient on the same day.

As Orly Avitzur, MD, explained: “It is not uncommon for patients to be referred to neurologists for procedures such as electrodiagnostic testing, as well as a consultation. These are often done on the same day to save the patient the hassle of coming back at another time. Another common scenario is when a neurologist is called to evaluate a patient and determines that an urgent procedure, such as a lumbar puncture, is needed.” Dr. Avitzur is a neurologist in private practice in Tarrytown, NY, and writes Neurology Today's In Practice column.

Dr. Avitzur noted that the AAN was instrumental in convincing the Centers for Medicare and Medicaid (CMS) services to stop requiring neurologists to use modifier −25 – used with a separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service – for sleep studies and EEG, EEG monitoring and analysis, functional cortical mapping, as well as neurostimulator analysis and programming. The modifier is still required for lumbar punctures.

The full GAO report is available online here:

Why are so many calls answered incorrectly or incompletely? The GAO suggests that the lack of comprehensive, searchable information available to the customer service representatives, high turnover, and confusing policies are largely to blame. To improve call center performance, the GAO suggests creating a system to screen out complicated calls and route them to experienced staff and redrafting policy information so it is easier to understand, among other things.

Neurologists shouldn't hold their breath waiting for an improvement in call center responses, however. While the CMS is implementing several initiatives to improve aspects of their call centers, none would make it easier for customer service representatives to answer the physician's tough billing queries. Dr. Avitzur noted that her local insurer, Empire BC/BS, is a good resource for information on tough billing questions, and “it helps a great deal to have knowledgeable office staff who can trouble-shoot in advance.”

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While the debate over the safety of drugs imported from Canada rages and several states are suing for importation rights, the Food and Drug Administration (FDA) has convinced one importer to stop bringing Canadian drugs to US consumers. In late August, Rx Depo, Inc. and Rx of Canada, LLC signed a consent decree in which they agreed to stop illegally importing US-manufactured and unapproved drugs – and to pay stiff penalties if they violate the agreement.

When it was still in business, Rx Depot operated a chain of stores that facilitated the purchase of cheap Canadian prescription drugs for Americans. Rx Depot would collect prescriptions from customers in the US and send them to its sister store, Rx of Canada, where they were filled and sent directly to the customers. Rx Depot collected a commission on each filled prescription.

To enforce the consent decree, the FDA can inspect the company's business practices and charge a $4,000 daily fine if the company starts up an import business again. The FDA is leaving it to the court to decide if Rx Depot will have to make restitution to its former customers or pay back its profits.

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Oregon's Death with Dignity Act may be changing the way people look at pain at the end of life, although it may not be positively influencing palliative pain management in the state. So concluded an Oregon Health and Science University survey by Erik K. Fromme, MD – Director of Palliative Care Research there – and colleagues, which found a significant increase in the number of people who reported having a family member die in severe to moderate pain or distress (J Palliat Med 2004;7(3):431–442).

For the study, the authors randomly surveyed the surviving relatives of a random sample of deceased Oregonians at two different times. The researchers asked respondents to rate their relative's level of pain in the week before death, using a four-point scale. They surveyed 340 people between November 1996 and December 1997 and 1384 people between June 2000 and March 2002. Respondents in the early group rated their relatives' pain as moderate to severe 30.8 percent of the time – the later group, 48 percent of the time.

Commenting by e-mail, Oregon neurologist Mark Yerby, MD, Associate Professor of Neurology, Public Health, and Obstetrics/Gynecology at Oregon Health Sciences University in Portland, agreed that “there has been a marked improvement in communication between patients and physicians about end of life care and pain management. There is a greater willingness to treat pain aggressively, and more use of pumps which give patients more control over the amount and rate of medication.”

On the other hand, some evidence suggests that pain management at the end of life may have declined over the study's duration. The authors point out that end-of-life care reimbursement has declined, hospice stays are shorter and punctuated by fewer nursing visits, and increased opioid purchases are not going to dying patients. Dr. Yerby did not agree with this conclusion, however.

“I see the quality of end of life care improved as well as the quality of pain management,” he said. “The hospital-based pharmacists seem much better versed and cooperative in assisting physicians in planning effective management. Utilization of hospice has increased as well,” he said.

©2004 American Academy of Neurology