Back pain treatment often not in line with guidelines | Reuters

Back pain treatment often not in line with guidelines | Reuters.

Back pain treatment often not in line with guidelines

1:57am IST

By Genevra Pittman

NEW YORK (Reuters Health) – Despite guidelines to treat back pain conservatively, the proportion of people prescribed powerful painkillers or referred for surgery and other specialty care has increased in recent years, according to a new study.

“This is kind of concerning,” said Dr. Steven Cohen, an anesthesiologist and critical care doctor at the Johns Hopkins School of Medicine in Baltimore who didn’t participate in the research.

Surgery, injections and scans for back pain “have all gone up pretty dramatically,” he told Reuters Health.

“We have increased utilization, yet we don’t have better treatment outcomes.”

The American College of Physicians and the American Pain Society recommend that people with low back pain consider treatment with Tylenol or non-steroidal anti-inflammatory drugs (NSAIDs), as well as heating pads and exercise.

The groups say doctors should only order CT and other scans when they suspect nerve damage. Opioids are only recommended for patients with “severe, disabling pain” that doesn’t get better with over-the-counter medicines – and their risks, such as for abuse and addiction, should be weighed against potential benefits.

For the new study, Dr. Bruce Landon from the Harvard Medical School in Boston and his colleagues tracked nationally-representative data on outpatient visits for back and neck pain collected between 1999 and 2010.

The researchers had information on about 24,000 visits, which represented a total of 440 million appointments across the U.S.

During that span, they found the proportion of patients prescribed Tylenol and NSAIDs dropped from 37 percent to 25 percent. At the same time, the proportion given narcotics rose from 19 percent to 29 percent.

About 11 percent of people with back pain had a CT or MRI scan in 2009 and 2010, compared to seven percent in 1999 and 2000.

Finally, although the rate of referrals to physical therapy held steady during the study period, the proportion of patients referred to another doctor – likely for surgery or other treatments – doubled from seven to 14 percent, the researchers reported Monday in JAMA Internal Medicine.

“Physicians want to offer patients treatments that are going to work sooner and patients are demanding them and sometimes it’s just easier to order the MRI or order the referral,” Landon said.

But, he added, “They often lead to things that are unnecessary and expensive and maybe not better in the long run and maybe even worse,” such as surgery or injections that haven’t proven to be effective.

According to the National Institutes of Health, eight out of ten people have back pain at some point in their lives.

One of the difficulties of treating back pain, Cohen said, is that there are so many possible causes – including disc, joint and nerve problems.

He said the strongest evidence supports treating the pain with exercise, including stretching and some aerobic activity.

Landon said 95 percent of patients will recover from back pain with a little bit of time and conservative treatment.

“They key thing for patients is, give it time,” he told Reuters Health.

“Patients expect and want it to get better in seconds and that’s not always going to happen. But if you give it time, work on it, do stretching and physical therapy exercises, that’s what’s going to make it better in the long run.”

SOURCE: bit.ly/LvmYaB JAMA Internal Medicine, online July 29, 2013.

Shaming docs to reduce inappropriate imaging? Its worth a try – FierceMedicalImaging

Shaming docs to reduce inappropriate imaging? Its worth a try – FierceMedicalImaging.

‘Shaming’ docs to reduce inappropriate imaging? It’s worth a try

In the current debate about healthcare in this country, medical imaging has been a large target of ongoing efforts to reduce costs while maintaining quality of care.

Campaigns like Choosing Wisely or the development of evidence based guidelines to establish appropriateness criteria are just a couple of the ways the medical imaging community is tackling the problem by focusing on inappropriate imaging.

Now, a recent study out of Sweden, performed jointly by New York University and Swedish researchers, has come up with what appears to be a fairly easy strategy to curb inappropriate imaging–a “gentle shaming” of the doctors who don’t follow guidelines that discourage inappropriate imaging of men with early-stage, low-risk prostate cancer. It may be an initiative worth considering in the U.S., considering the high rates of inappropriate prostate imaging we’re experiencing here.

According to study co-author Danil Makarov, M.D., of NYU’s Langone Medical Center, the researchers determined that use of “gentle shaming” reduced imaging rates among Swedish men with very low-risk prostate cancers from 43 percent to an astonishingly low 3 percent.

The initiative in Sweden publicized imaging rates–along with information about imaging guidelines–from institution to institution. For example, one aspect of the Swedish campaign involved presenting local statistics on inappropriate imaging at urology meetings. It was a way of incentivizing the reduction of unwarranted testing, and it worked.

Of course “gentle shaming” may just be a clever term representing the strategic use of data as a way of educating physicians about imaging guidelines and modifying behaviors. And there are a variety of ways in which this can work.

An article in last week’s FierceMedicalImaging detailed a program at Massachusetts General Hospitalin which the hospital introduced an email feedback report system to successfully reduce the number of cardiac CT angiography examinations performed with significantly higher radiation doses than the departmental mean. The physicians involved may not have experienced “gentle shaming,” but they were presented with information that encouraged them to modify their behaviors.

According to Makarov, a Swedish-style campaign at urological conferences in this country could result in more uniform and appropriate prostate cancer imaging rates, which are badly needed.

Whether that kind of campaign could work here is unclear, but we do know that the imaging community has done a commendable job establishing guidelines for the appropriate use of imaging for all clinical conditions. The question has been how best to implement these guidelines.

Whether it’s the introduction of a campaign like Image Wisely, or the “gentle shaming” program out of Sweden, the more initiatives we have to consider, the better. – Mike  @FierceHealthIT

Related Articles:
Radiologists who email CCTA dose reports use less radiation
Removing denial provisions won’t increase imaging utilization

Many affected by chronic pain – inMyCommunity – Perth, Western Australia

Many affected by chronic pain – inMyCommunity – Perth, Western Australia.

Many affected by chronic pain

26/Jul/2013

Comments:

call for radiology to be indexedcall for radiology to be indexed

A LOCAL radiology worker has welcomed a call for the Federal Government to close the gap in fees for medical imaging.

The Australian Diagnostic Imaging Association (ADIA) has used National Pain Week (July 22-28) to raise concerns for those living with chronic pain conditions.

Rockingham SKG Radiology office manager Kylie Parrott told the Courier many people living with chronic pain in Rockingham and Kwinana avoided going to SKG because they could not afford the procedures.

Medicare rebates for medical imaging, including X-rays and CT scans, have not been indexed since 1998, forcing people seeking radiology services to cover the gap. Over the past 15 years, the gap has steadily increased by 10 per cent per annum, according to ADIA president Sue Ulreich.

Mrs Parrott said a large number of people in the area were affected by chronic pain.

“A lot of patients are working people who need to get better so they can return to work,” she said. “These people are forced to pay the gap or run into an out-of-pocket experience.

“A good example of costs is an ultrasound guided injection, which costs around three times more than what the Medicare rebate pays, so it’s vitally important for radiology to be indexed.

“Public hospitals do not tend to provide imaging guided injections so the majority of injections by radiology for chronic pain have to be done in community practices like ours, so there is nowhere else to go.”

Dr Ulreich said pain was the third most common cause for people seeking medical imaging, behind arthritis and cancer.

“The reality is that many imaging services can not be bulk-billed under Medicare and the cost of providing quality imaging services is much higher than (the) Medicare fee,” she said.

“We want to work with the Government to develop a sustainable solution that will improve Medicare rebates for patients experiencing pain.”

In the past six months, the ADIA has received more than 1000 letters from people voicing their concerns about the increasing costs of medical imaging.

Diagnostic Imaging: Should Radiologists Get Paid for Reading Prior Studies? | Diagnostic Imaging

Should Radiologists Get Paid for Reading Prior Studies? | Diagnostic Imaging.

Aunt Minnie: Why we are not in the business of exclusion


Why we are not in the business of exclusion

By Dr. Paul McCoubrie, AuntMinnieEurope.com columnist

July 24, 2013This adage could equally be a rallying cry for today’s radiologists — particularly if you have high clinical standards and loathe sloppiness of medical thought, word, and deed. Specifically, if you believe that sloppiness of deed stems from sloppiness of word, which in turn derives from sloppiness of thought.

Dr. Paul McCoubrie

Dr. Paul McCoubrie is a consultant radiologist at Southmead Hospital in Bristol, U.K.

When I was a newly appointed consultant (or senior radiologist), the terms “rule out x” or “exclude y” on a radiology request used to be minor irritations. I was more forgiving. Nowadays, I just can’t abide them. It seems that every other request now bears these poisonous words. So I asked clinicians why they write this. They always state, “Well, obviously I didn’t mean that.” So why did you put it then? I just don’t understand why it is so commonplace in modern medicine. I don’t know what has changed.

Some of my colleagues frown at me, puzzled at clumps of hair that I’ve just torn out (again). Indeed, many of those reading this may be wondering why I am getting immensely frustated. Just why is “exclusion” or “ruling out” so bad? It isn’t pedantry, honestly; let me explain.

First up, it is an anathema to high standards of medical practice. It heralds a move away from medical diagnostic acumen, based on knowledge and expertise. The backbone of Western medicine, probabilistic hypothetico-deductive reasoning, is rejected. Diagnostic indecision is embraced “just in case.” It is clinically and morally lazy.

Second, it reveals ignorance on behalf of the requester. Now I am no guru of clinical epidemiology. Quite the reverse. I’ve always found medical stats textbooks a reliable cure for insomnia. But ask a junior doctor about Bayesian probabilities and 9 out of 10 of them fish-mouth quite predictably. I remind them that virtually no radiological test is sufficiently sensitive and specific to “rule out” anything. Ever. Occasionally, there is a glimmer of recognition when I mention pre- and post-test probabilities. Not often, though.

Third, such language influences thoughts. I hear otherwise sensible doctors say things such as, “Well, the CT excluded a hepatorhubarboma.” To which I cannot help but say, “No, the CT is normal, but it doesn’t exclude a hepatorhubarboma.” Clinicians develop inappropriate dependence on and faith in test results, forgetting the patient whose signs and symptoms are screaming the diagnosis.

Fourth, it is wasteful of taxpayer’s money. Inadequate triage leads to high negative rates and cost-inefficiency. For example, an audit of our last 1,000 CT urograms and the pickup rate for upper tract transitional cell carcinoma was just 3%. Similarly, about 25% of CT pulmonary angiography scans were positive a decade ago; it felt like a worthy and interesting thing to do. Now the pickup rate is in single figures. Normal pulmonary arteries were once a rare and fascinating structure, but the sheer volume of the scan we all look at has rendered them distinctly mundane. Finding a significant thrombus these days brings the registrars running to gawp.

Last, and most important, “ruling out” is bad for patients. It is not that patients like having tests (they don’t). Nor is it that tests are risky (they most certainly can be). It isn’t even the diagnostic delay or personal inconvenience that multiple investigations bring. It is that the doctor-patient relationship is betrayed: Inappropriately extensive investigation apes thorough and hence, caring, medicine. The truth is the doctor is transferring risk to the patient under the guise of being thorough. “Ruling out” is defensive medicine, plain and simple.

The only way forward is a zero-tolerance approach. All paper requests are stamped with Prof. Middlemiss’ wise words and politely returned. It wouldn’t be too much to program any order comms system to screen for the offending phrases (including the ugly “r/o”) and automatically reject them with the message: “Error 404: It looks like you are trying to phrase a clinical question using a negative diagnostic paradigm.” If they do it three times, the system crashes irreversibly. Clinicians will soon get the message.

Dr. Paul McCoubrie is a consultant radiologist at Southmead Hospital in Bristol, U.K.

The comments and observations expressed herein do not necessarily reflect the opinions of AuntMinnieEurope.com, nor should they be construed as an endorsement or admonishment of any particular vendor, analyst, industry consultant, or consulting group.


Copyright © 2013 AuntMinnieEurope.com

Last Updated rm 7/24/2013 8:43:42 AM

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The blame game: MDs say lawyers, insurers responsible for healthcare cost control | Health Imaging

The blame game: MDs say lawyers, insurers responsible for healthcare cost control

 - finger point

A majority of doctors abdicated “major responsibility” for reducing healthcare costs in a physician survey about cost control. They also expressed a lack of enthusiasm for eliminating fee-for-service payment models.

Results of the survey, which was designed to characterize physicians’ views about controlling healthcare costs, were published in the July 24/31 edition of JAMA.

Jon C. Tilburt, MD, MPH, of Mayo Clinic in Rochester, Minn., and colleagues, conducted a cross-sectional survey of 3,897 randomly selected U.S. physicians in 2012 and reviewed the 2,556 responses.

When asked which stakeholders bore major responsibility for controlling costs, respondents indicated that trial lawyers (60 percent), health insurance companies (59 percent), hospitals and health systems (56 percent) and pharmaceutical and device manufacturers (56 percent) topped the list. A mere 36 percent assigned major responsibility to practicing physicians.

Generic cost-containment strategies fared well, with 75 percent of respondents very enthusiastic for interventions such as “promoting continuity of care.” Many also liked the following strategies: expanding access to quality and safety data, promoting head-to-head trials of competing treatments and limiting corporate influence on physician behavior.

While there was lukewarm acceptance for limits on access to expensive treatments with little net benefit and using cost-effectiveness data to determine available treatments, readmission penalties and bundled payments garnered less support.

Eliminating fee-for-service payments, implementing Medicare payment cuts and reducing compensation to the highest paid specialties were downright unpopular, with 70 percent, 94 percent and 44 percent of respondents not enthusiastic, respectively.

The authors characterized physicians’ views about their perceived responsibility for healthcare costs as “inconsistent” and “nuanced.” Approximately three-fourths of physicians agreed with the following statements:

  • Physicians “should be solely devoted to [their] individual patients’ best interests, even if that is expensive;”
  • “Trying to contain costs is the responsibility of every physician;” and
  • “Doctors need to take a more prominent role in limiting use of unnecessary tests.”

“Our data suggest that physicians struggle with navigating the tensions between their responsibilities to address overall health care resource use and their primary obligation to do what is best for individual patients,” wrote Tilburt and colleagues.

The authors suggested policy makers focus on cost-containment strategies that enjoy strong physician support, such as improving quality and efficiency of care and sharing transparent cost information and evidence from comparative effectiveness research in EHRs. They cautioned that more aggressive measures should be phased in and monitored as they may have a negative impact on individual clinical relationships.

Aunt Minnie Healthcare IT Community – NDSC hires Cooke as marketing VP

Healthcare IT Community – Healthcare Informatics Systems, News, Vendors, and Links.

 

NDSC hires Cooke as marketing VP

By AuntMinnie.com staff writers

July 24, 2013 — Clinical decision-support software firm National Decision Support Company (NDSC) has appointed two new vice presidents.

Bob Cooke will join the firm as vice president of marketing. He previously served at Agfa HealthCare and Fujifilm Medical Systems USA; most recently, Cooke founded ImagingElements, an organization focused on radiology meaningful use.

In addition, Mick Brown will join NDSC as vice president of business development. He formerly worked at Agfa, Siemens Healthcare, and Nuance Communications.

 

The appointments are part of NDSC’s effort to bring ACR Select, a national standard set of evidence-based guidelines that help healthcare providers choose appropriate medical imaging exams, to market, according to the firm.

Dizziness Visits Account for About 4 Percent of ER Costs –Doctors Lounge

Dizziness Visits Account for About 4 Percent of ER Costs

Last Updated: July 24, 2013.

 

 

Mean cost of emergency department dizziness visit estimated at $1,004 in 2011 dollars

 

 

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Emergency department costs for patients presenting with dizziness or vertigo are considerable, accounting for about 4 percent of total costs, according to a study published in the July issue ofAcademic Emergency Medicine. 

 

WEDNESDAY, July 24 (HealthDay News) — Emergency department costs for patients presenting with dizziness or vertigo are considerable, accounting for about 4 percent of total costs, according to a study published in the July issue of Academic Emergency Medicine.

Ali S. Saber Tehrani, M.D., from Johns Hopkins University in Baltimore, and colleagues used emergency department visit data (1995 to 2009) from the National Hospital Ambulatory Medical Care Survey and cost data (2003 to 2008) from the Medical Expenditure Panel Survey (MEPS) to estimate the national costs associated with emergency department visits for dizziness. Healthcare Cost and Utilization Project’s Clinical Classifications Software (HCUP-CCS) was used to define diagnosis groups, and the average emergency department visit cost-per-diagnosis-group was calculated from MEPS.

The researchers found there were 3.9 million U.S. emergency department visits for dizziness or vertigo in 2011. Of these, 39.9 percent of patients underwent diagnostic imaging by computed tomography, magnetic resonance imaging, or both. In 2011 U.S. dollars, the mean per-emergency-department-dizziness-visit cost was $1,004, with extrapolated national costs of $3.9 billion in 2011. For key HCUP-CCS diagnostic groups presenting with dizziness and vertigo, the fraction of dizziness visits, cost-per-emergency-department-visit, and attributable national costs, respectively, were 25.7 percent, $768, and $757 million for orologic/vestibular; 16.5 percent, $1,489, and $941 million for cardiovascular; and 3.1 percent, $1,059, and $127 million for cerebrovascular. About 12 percent of the total cots for dizziness visits in 2011 were attributed to neuroimaging.

“Total U.S. national costs for patients presenting with dizziness to the emergency department are substantial and are estimated to now exceed $4 billion per year (about 4 percent of total emergency department costs),”the authors write.

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Health News Copyright © 2013 HealthDay. All rights reserved.via Dizziness Visits Account for About 4 Percent of ER Costs –Doctors Lounge.

National Decision Support Company Announces Additions to Team

National Decision Support Company Announces Additions to Team.

 

 

National Decision Support Company Announces Additions to Team

Healthcare veterans join executive staff to support business development and marketing.

Andover, MA (PRWEB) July 24, 2013

As part of its strategy to bring ACR Select—a national standard set of evidence-based guidelines that help health care providers choose the most appropriate medical imaging exam for a patient’s clinical condition—to market, National Decision Support Company (NDSC) is expanding its team as healthcare veterans Mick Brown and Bob Cooke join the executive lineup.

Mick Brown, Vice President, Business Development

Mick holds an extensive background in healthcare information technology, international business development and sales. He has held pivotal positions at Agfa HealthCare, Siemens and Nuance, and was a key member of the Commissure team, leading business development initiatives that contributed to the companies early stage success. Most recently, Mick has broadened his experience through involvement with Southern Innovation, focusing on radiation detection in the x-ray instrumentation and national laboratory market.

“We are excited about Mick joining the NDSC team, as he is widely respected in our industry. Mick’s strength and passion are in early stage companies with disruptive technologies where he has a proven track record in breaking into and developing new markets,” said Michael Mardini, CEO, NDSC.

Bob Cooke, Vice President, Marketing

Bob Cooke will also be joining NDSC as Vice President of Marketing. He joins NDSC after senior leadership roles at Agfa HealthCare and Fuji Medical Systems. Most recently, Bob founded ImagingElements, an organization focused on Radiology Meaningful Use where he will also retain his role as CEO.

“I’m excited to be a part of NDSC. “There is tremendous synergy between Clinical Decision Support and Meaningful Use as both are foundations of the American College of Radiology’s Imaging 3.0 initiative. It’s a tremendous opportunity to be working with organizations that are enabling radiologists to better participate in the future healthcare environment,” said Bob Cooke.

According to Mardini, “these new additions to the team bring the experience, passion and track record for driving success and are a perfect complement to help the company enter its next phase of growth and continue its world-changing mission to deliver standards-based decision support.”

About National Decision Support Company

National Decision Support Company (NDSC) is the exclusive distributor of national standards clinical decision support (CDS) imaging guidelines. NDSC provides the technical platform, support, and licensing of digitally consumable CDS that continuously educates providers regarding the latest evidence-based approach to medicine without disrupting the doctor-patient relationship or delaying needed care. For more information, visit http://www.NationalDecisionSupport.com.

About ACR Select

ACR Select, provided by National Decision Support Company, is the complete web service version of American College of Radiology (ACR) Appropriateness Criteria® (AC). ACR AC is a comprehensive national standards clinical decision support database with more than 130 topics and 614 variant conditions that provide evidence-based guidance for the appropriate utilization of all medical imaging procedures. More than 300 volunteer physicians, representing more than 20 radiology and non-radiology specialty organizations, participate on the ACR AC expert panels, continuously updating these nationally transparent guidelines, and providing real-time access to the latest medical imaging procedure guidance. The ACR Select platform can be easily integrated with computerized ordering and electronic health record (EHR) systems so healthcare organizations can effortlessly consume ACR AC guidelines and ensure that the right patient gets the right scan for the right indication. For more information, visit http://www.ACRselect.org.

 

The Supreme Court and the value of knowing – The Hill’s Congress Blog

The Supreme Court and the value of knowing – The Hill’s Congress Blog.

The Supreme Court and the value of knowing

By Gregory Sorensen, M.D. – 07/23/13 03:30 PM ET

A decade ago, health economists asked a group of physicians this question: “Which medical innovation would have the biggest impact on you if it was gone from your practice?  The top answer, for the lives it improved, was “cross-sectional imaging: MRI and CT scanning.”  Since then, medical imaging and testing are in headlines for another reason: With the Institute of Medicine estimating that up to half of health spending is unnecessary, studies show that reimbursing doctors for every scan and test just encourages more testing, and isn’t necessarily good for patients. That’s why the focus of health reform is to shift our system away from rewarding things (paying for every service performed) to rewarding the right things (paying for better results). Deciding what to cover and what not to cover is health care’s costliest question.  With its ruling last week, the Supreme Court showed that America doesn’t have as much time as it thought to get the answer right. By deciding that human genes cannot be patented, the Court did more than open the door to a rush of newer, more affordable forms of genetic testing for cancer and other diseases.  It provided a glimpse at the kinds of breakthroughs that will define medicine’s next decade, enabling people to receive diagnoses long before they show symptoms. But a near-constant string of genetic breakthroughs will soon bring a never-ending challenge to the question: Who pays? 

To guide our decisions, the debate should focus on a simple question: What is the value of knowing?  

Not all things are worth knowing.  Some procedures have been found to be unnecessary or harmful.  For instance, CT scans should not automatically be done on a child with a minor head injury; simple observation can be as good and spares radiation.  A routine chest X-ray is unnecessary prior to outpatient surgery for patients with an unremarkable history and physical exam; they rarely improve patient outcomes. To identify the proper course of treatment, clinicians have developed criteria to assist them in prescribing appropriate tests and therapies. One example is the American Board of Internal Medicine Foundation’s Choosing Wisely campaign, which lists 130 such recommendations. Guidelines like these could be a starting point to right-size the system.

On the other hand, some things are worth knowing. In Angelina Jolie’s case, the value of knowing her genotype (she had a damaged BRCA1 gene) and her phenotype (her mom died of ovarian cancer at 56) after a predictive genetic test led to a diagnosis that she had an 87 percent chance of breast cancer, empowering her to undergo a preventive double mastectomy, reducing her cancer risk to five percent. The Affordable Care Act requires that private insurers cover the costs of genetic counseling and testing for similar high-risk women, without co-payment.

But how should we apply the value of knowing to other breakthroughs? Consider lung cancer.  In 2010, the National Cancer Institute found that long-time smokers who underwent advanced CT screening had a 20 percent lower death rate from cancer than those who had standard chest X-rays, since it allowed patients to make changes early.  Yet, CT scans are not covered.  For a disease that takes 160,000 American lives each year, should they be? 

Or consider thyroid cancer.  According to a recent study, a new genetic test accurately diagnoses benign growths on the thyroid gland, much more consistently than the current test, one in four of which are inconclusive, leading to many unnecessary surgeries.  For a disease that affects 60,000 Americans each year, should the more expensive genetic test be covered, too? 

Sometimes, the value of knowing doesn’t lead to cures, but can improve patient well-being, as with Alzheimer’s disease. Studies show that older Americans who receive early Alzheimer’s diagnoses can actively participate in decisions about their future, while better avoiding accidents and falls. A new imaging test can pinpoint the presence of a plaque linked with Alzheimer’s. Not every person with this plaque has Alzheimer’s, but its absence can allow it to be ruled out, potentially leading to other treatable causes.  With Alzheimer’s cases expected to triple by 2050, should this test be covered?

Our system will never be able to pay for every new treatment and procedure that comes available.  But we need to get smarter about how we choose.  For interventions, health experts use a metric called quality adjusted life years, which determines the cost of year per life saved. A drug that costs more than $100,000 per year of life saved is a harder sell than interventions like colon cancer screenings, which are in the $20,000 range.  There is not yet an equivalent paradigm for diagnosis, something a robust debate over the value of knowing could address. 

For years, predictive genetic testing has tantalized us with the possibility of knowing more about ourselves, through our DNA. The Supreme Court just opened a new door to that genetic future. It’s up to us to decide how often—and to what extent—the value of knowing is worth the value of paying for it.   

Sorensen is a former professor of radiology at Harvard Medical School. He is the U.S. chief executive officer of Siemens Healthcare.



Read more: http://thehill.com/blogs/congress-blog/healthcare/312893-the-supreme-court-and-the-value-of-knowing#ixzz2ZuQ59tM0 
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