To Treat or Not to Treat? The Debate on Incidental Medical Findings

In an article dated August 29, 2016, doctors and researchers debate whether they should disclose to patients minor abnormalities that are incidentally found during an imaging procedure (such as an MRI or CT scan). On the one hand, researchers say that doctors are going “overboard” on disclosing low-risk findings that lead to overtreatment and unnecessary worry by the patient.   However, on the other hand, a decision not to follow up on an incidental finding can have serious consequences. For one patient, kidney cancer was incidentally found and led to early treatment that arguably saved his life. Although the professionals disagree on whether to treat or not to treat, most agree that guidelines are needed to help doctors make the difficult decision.

Excerpt from article:

Often there is “little benefit” to patients knowing about minor, low-risk findings, and it can have significant financial, psychological and clinical consequences, they say.  Failure to follow up incidental findings can come back to haunt some patients, other experts say. . .

To read full article: When a Medical Test Leads to Another, and Another

Americans are Increasingly Turning to Medicaid for Long Term Care Coverage

Currently, about 62% of nursing home beds in the U.S. are paid for by Medicaid. Many elderly individuals cannot afford to pay for such long term care—the average total cost of long term care received from age 65 to death is $91,100 for men and up to double that amount for women, based on the presumption that women live longer. Low income individuals rely on Medicaid to pay for these expenses and other middle-class individuals are forced to spend down their assets to qualify for Medicaid coverage for their long-term care.

Medicaid was created to provide health insurance to low-income individuals, and not to cover long term care for the majority of the elderly population. Yet, it has evolved into a “safety net” for millions of Americans who cannot afford to pay for their long-term care.  As the baby boomer generation continues to age, Medicaid spending on long term care is expected to rise by almost 50% by 2026, putting pressure on a system that was not designed to carry such a burden.

State and federal officials are working to control Medicaid costs. Some states, for example, are contracting with managed care companies to provide long term care services to Medicaid beneficiaries. However, many health advocates are concerned that these managed care companies, which traditionally provided only medical care, will restrict the coordination of care for the elderly.  California most recently announced that it will hold informational hearings to discuss possible resolutions to the increasing cost of long term care.


Tags: Long Term Care Coverage, Burdened Medicaid System, Lower and Middle Class Americans



Should Terminally Ill Patients have the Right to Decide When They Die?

In June 2016, California joined three other states – Washington, Vermont, and Oregon – in enacting legislation that legalizes physician-assisted suicide for terminally ill patients. Conversation surrounding such end-of-life decision-making sparked in 2014, when Brittany Maynard, a California schoolteacher diagnosed with brain cancer, decided to move to Oregon to die on her own terms.

The new California legislation allows a physician to prescribe lethal doses of medication only when requested by a terminally ill patient who is likely to have less than 6 months left to live. However, unlike other states that have similar laws, California is allowing physicians to demand that requests be made in writing.  Moreover, physicians are not required to prescribe the medication, nor are they required to refer the patients to another physician willing to do so. Catholic hospitals and other religious health groups have already expressed their unwillingness to participate, stating that “[w]e are crossing a line — from being a society that cares for those who are aging and sick to a society that kills those whose suffering we can no longer tolerate.” Some physicians say that they will require patients to go through rigorous psychological evaluations before prescribing the medication. Yet, the majority of patients with incurable diseases support the legislation, explaining that it will allow them not to be a burden to their families as their diseases progress.

While the enactment of the legislation has certainly not ended the debate over end-of-life decision-making in California, health care systems in the state are drafting new policies to help physicians and patients adjust to the new option for end-of-life care.


New Study Suggests that Medical Errors are the Third Leading Cause of Death in the U.S.

A new study published by BMJ (formerly the British Medical Journal) in May 2016 suggests that medical errors may cause more deaths than lower respiratory diseases.  This would make medical errors the third leading cause of death (following heart disease and cancer) in the United States.  The study indicates that at least 251,454 deaths each year are due to medical error.  This number is much higher than that reported by previous studies. One reason for such discrepancy may be the lack of accurate data regarding deaths caused by medical error.  Causes of death listed on death certificates are based on insurance billing codes, which “are designed to maximize billing rather than capture medical errors.” As a result, death certificates fail to address human errors or other system failures.

The doctors who completed the study hope that their analysis will “lead to real reform in a health care system [that] is letting patients down.” They suggest that better reporting mechanisms must be put in place to address medical errors that lead to death. Some proponents believe that a space should be added on death certificates to indicate whether death was related to a medical error. However, to avoid legal implications when a doctor indicates such a cause of death, legislation would need to attach some protection or privilege to this information (for example, by prohibiting the information to be used in a lawsuit). Such legal protections would encourage accurate reporting by doctors and, in turn, would help establish a course of action for minimizing the most common medical errors that lead to patient death.


Heroine Addicts: Assist Them or Save Costs?

American heart surgeons are facing a difficult decision with respect to heart valve transplants for heroin addicts: whether to continually replace addicts’ heart valves or refuse to operate. The cost of a heart valve transplant, including six to eight weeks in the hospital, can be over $500,000.  Although recipients of heart valve transplants are asked to abstain from drug use after the procedure, most heroin addicts fail to comply, meaning that the procedure will have to be repeated in the future. As a result, surgeons must decide whether performing a heart valve transplant for a heroin addict is a reasonable use of health care resources, especially considering that most heroin addicts do not carry health insurance.

Clinical ethicists opine that surgeons are not obligated to perform repeat operations on heroine addicts who fail to comply with treatment restrictions.  Such ethicists argue that heroine addicts have a responsibility to change their behavior and when they fail to do so, surgeons have no duty to perform repeat procedures that would otherwise be unnecessary. However, according to substance abuse counselors, abstaining from heroine once addicted can be extremely difficult and many addicts continue their drug use to avoid withdrawal symptoms and maintain a sense of equilibrium, not to simply “get high.” Unfortunately, heroine use is on the rise and, at least for the foreseeable future, cardiac surgeons will continue to face this ethical dilemma.


HIPAA: The “Toothless Tiger”

When Congress passed the Health Insurance Portability and Accountability Act (“HIPAA”) in 1996, the Office for Civil Rights (“OCR”) of the Department of Health and Human Services (“HHS”) was charged with enforcing regulations intended to protect the privacy of health information.  Although the premise of HIPAA was to allow a patient to safely assume that what was said in an examination room stayed in the examination room, a recent article in The Washington Post has revealed that the enforcement of HIPPA regulations is falling short.  For example, in 2014 alone, OCR received approximately 18,000 HIPPA complaints, but only brought 6 formal actions.  Moreover, the law does not allow patients a private right of action to sue an offending health care provider and OCR has admitted that repeat offenders are not tracked.

Solutions to protecting patient and consumer health care information, in large part, do not require legislative action.  For example, OCR could use the tools already at its disposal to levy punitive damages on repeat offenders, which would incentivize businesses to protect patient data.  Furthermore, in the long run, a “whistleblower” mechanism, such as a qui tam action under the False Claims Act, could incentivize HIPPA compliance, although such an action would involve Congressional approval.


Gitenstein Thought Leadership Conference




 A Spoonful of Sugar, Ethics and Practice:

Will It Help the Medicine Go Down?


Friday, October 24, 2014 | 8 a.m.-noon

David S. Mack Hofstra Student Center | Multipurpose Room East

More info | Register

Questions? Contact Melissa Kessler at

Government Questions Eligibility for Health Insurance Subsidies

Since June 1st, hundreds of thousands of people have been contacted by the government regarding their eligibility for subsidized health care.  Of the eight million people who signed up for healthcare through the government exchanges, two million provided information that differed from information in government records. The Obama administration has been asking those individuals for additional documentation such as birth certificates, social security cards, and driver’s licenses.  The government will use the documents to correct irregularities in areas including income, citizenship, and immigration status.  Consumer advocates worry that many people who fail to provide the information will be forced to repay the subsidies next April.

Representative Diane Black, Republican of Minnesota, attributes the problem to the government’s having enrolled people “before the systems were in place to accurately confirm eligibility.” Others such as Representative Joseph Crowley, Democrat of New York, say such criticism stems from Republicans’ “unending zeal to undermine the Affordable Care Act.”

In any event, the government has put thousands on notice that they “need to follow up as soon as possible” and if they don’t send the needed documents, they risk losing their marketplace coverage.

Read more here.

1,700 Patients Were Not Put On Official Waiting Lists at the Phoenix V.A.

Richard J. Griffin, the Inspector General for Veterans Affairs, reported that 1,700 veterans were not placed on the Phoenix V.A.’s official waiting lists for doctors’ appointments. In fact, many of these patients may not have received medical care at all, and there are allegations that some veterans may have died while waiting for care.

 Investigators found that out of a sample of 226 patients, the average wait time for an initial primary care appointment was 115 days.  But the Phoenix V.A.’s reported average to the National Veterans Affairs Office was 24 days. (The average wait time is a factor in determining bonuses and salary increases. Moreover, several waiting lists were uncovered during the investigation that were separate from the “official” waiting list suggesting that criminal activity may have been involved in reporting wait times in Phoenix.

Read more here.

Congress Looks to Revamp Mental Health System

Soon, Congress will hear testimony concerning the Helping Families in Mental Health Crisis Act. Republican representative, Tim Murphy, from Pennsylvania, sponsored the bill, and, though many agree that the mental health care system requires revamping, some provisions in the bill have sparked controversy. Among the more controversial provisions is one that supports the increased use of involuntary outpatient treatment—via court-ordered therapy for “certain mentally ill people with a history of legal or other problems.” Detractors of this provision claim that it will erode trust in doctor-patient relationships, and that it presents a civil rights issue. However, 45 states have compelled treatment programs already, one of which is New York.

New York’s compelled treatment program, Kendra’s Law, was passed in 1999. Since the implementation of Kendra’s Law, studies show that the percentage of patients returning to the hospital or getting arrested has greatly decreased. The statistic is significant, as “about 350,000 Americans with a diagnosis of severe mental illness…are in state jails and prisons” and the availability of psychiatric beds meets only 10 percent of that need. 

Read more here.