Cervical Cancer Awareness

This January, Care to Care is proud to participate in National Cervical Health Awareness Month. Cervical cancer was once one of the most common causes of cancer death for women. However, the cervical cancer death rate has gone down by more than 50% over the last 40 years, mainly due to the increased use of the Pap test for screening and early detection. This amazing screening tool can find changes in the cervix before cancer ever develops, enabling doctors to treat pre-cancerous states. Unfortunately, not all women are getting screened. In 2012, 10% of US women ages 21-65 reported they had not been screened for cervical cancer in the last 5 years. According to the American Cancer Society (ACS), there will be an estimated 12,820 new cases of invasive cervical cancer diagnosed in 2017, with an estimated 4,210 deaths from the disease.

Another important fact that many may not know is that most cervical cancers are preventable! Nearly all cases of cervical cancers are caused by human papillomavirus (HPV) infection, with approximately 70% due to HPV types 16 and 18. In addition to causing cervical cancer, HPV is also a common cause of anal cancer, mouth/throat cancer, and cancers of the vulva, vagina, and penis. The HPV vaccine, which became available in 2006, offers the best protection against the virus. However, the vaccine is only effective if administered before exposure to the virus, which is why vaccination must be given before one becomes sexually active, in the preteen years.

To prevent more cervical cancer deaths, screening and vaccination efforts must increase! The ACS and the Centers for Disease Control and Prevention recommend routine HPV vaccination for females and males starting at age 11 or 12. The ACS recommends all women begin cervical cancer screening at age 21. Women between 21 and 29 should have a Pap test every 3 years. Women between ages 30-65 should have both a Pap test and an HPV test every 5 years. Women over age 65 who have had regular screenings with normal results do not require screening, but those who have been diagnosed with cervical pre-cancer should continue to be screened. Women who have had the HPV vaccine should still follow the screening guidelines for their age group.

With a vaccine to prevent the cancer causing HPV infection and with the sensitive Pap screening test to detect the disease in a pre-cancerous state, no woman should die of cervical cancer! It is our job as clinicians to help women understand what screening tests are best for them and help parents know the best time to immunize their children against HPV.

Rachel Title, MD

Chief Medical Officer

Care to Care LLC

Why is Compliance and Ethics important in Medicine?

National Compliance and Ethics Week offers a great opportunity to shine a spotlight on the importance of compliance and ethics at Care to Care and in the entire healthcare system at large. The culture of compliance is at the core of medicine.

This begins for doctors with the mandatory Hippocratic oath which is frequently recited at the beginning of medical school and again at its culmination, when the medical degree is received. The Hippocratic oath states the obligations and proper conduct of doctors, laying the groundwork for a career devoted to the care of others through strict adherence to medical ethics and compliance to government laws, hospital regulations, and specialty society guidelines. It is this strict obedience to an unyielding moral code that makes the physician worthy of the trust that the patient bestows on him, a trust that is essential in the physician-patient relationship.

Physicians are entrusted with the most personal information by their patients and are obligated to maintain complete privacy and security of this health care information. Our compliance with federal HIPAA laws is only one way that compliance plays an integral role in the physicians’ daily responsibilities.

Here at Care to Care, the medical directors and physician reviewers are dedicated to maintaining the highest degree of compliance and are committed to upholding the oath we took many years ago.

Rachel Title, MD
Chief Medical Officer

Breast Cancer Awareness Month

This October, Care to Care is proud to participate in National Breast Cancer Awareness Month. Breast Cancer is the second most common cancer in women, affecting 1 in 8 U.S. women over the course of her lifetime. In 2016, there are more than 2.8 million U.S. women with a history of breast cancer. Breast cancer is a disease that affects women of all ages, races, and ethnicities. The most significant risk factors for breast cancer are gender (being a woman) and age (risk of breast cancer increases with age). Although a woman’s risk of breast cancer almost doubles if she has a first-degree relative with breast cancer, it is important to know that an overwhelming majority (85%) of breast cancers occur in women who have no family history.

The goal of Breast Cancer Awareness Month is to increase understanding and awareness of the disease, encourage women to take the lifesaving steps to detect the disease in its early stages, and inspire others to do the same. Most women can survive breast cancer if it is found and treated early. Early detection with annual screening mammogram has been the main reason why the breast cancer death rate has decreased by 36% since 1989. The American College of Radiology (ACR) and Society of Breast Imaging (SBI) recommend that women at average risk of breast cancer get yearly mammograms starting at age 40. Women at high risk (greater than 20% lifetime risk) of breast cancer may need to begin annual screening mammogram at an earlier age and should also include annual screening Breast MRI as an adjunct to screening mammography. All women should become familiar with both the appearance and feel of their breasts and report any changes promptly to their physician. Most importantly, talk to your doctor about your risk for breast cancer and your appropriate screening plan. Early detection is your best protection!

Rachel Title, MD
Chief Medical Officer

Limiting Radiation Exposure to Children

As a Radiologist and Senior Medical Director at Care to Care, I find it my moral responsibility and professional obligation to explain the importance of a prior-authorization requirement for advanced imaging, and specifically CT examinations, for the pediatric population. Children are considerably more sensitive to radiation exposure than adults, as demonstrated by epidemiologic studies of exposed populations.

Since children have a longer life expectancy than adults, they have a larger window of opportunity for expressing radiation damage, most notably the development of cancer. As a result, the risk for developing a radiation-related cancer can be several times higher for a young child compared with an adult exposed to an identical CT scan.

A study published in the Lancet on June 7, 2012 described a clear dose-response relationship for both brain tumors and leukemia. The study found that the amount of radiation exposure from an estimated 2 to 3 head CT scans given to a child can triple the risk of brain cancer, and an estimated 5 to 10 head scans can triple the risk of leukemia.

Major national and international organizations responsible for evaluating radiation risks agree that no amount of radiation should be considered absolutely safe and that only necessary CT examinations should be performed. For these reasons, it is of utmost importance to make sure that only appropriate CT scans are being performed on children. A prior-authorization requirement will help ensure the appropriate use of CT imaging and limit its inherent harmful radiation.

Rachel Title, MD
Chief Medical Officer

Care to Care’s RBM Programs Treat Referring Physicians as Partners in Promoting Better Patient Care

When most people concerned with the delivery of healthcare — whether as providers, administrators or payers — think about Radiology Benefit Management, their first and often only thought is that RBM is useful, if at all, only to reduce utilization. While this is an accurate assessment of most RBM programs it fails to recognize the great potential that a well-designed RBM program has to promote better medicine. The primary focus of any RBM process is the identification of inappropriate use of high-cost imaging procedures. What comes next separates the minimally utilitarian RBMs from those dedicated to fulfilling its true potential.

Care to Care, LLC. was founded long after other established RBM companies and has turned this to its advantage. We had observed, from many viewpoints, the strengths and weaknesses of other RBMs and their approach to reducing wasteful imaging. Perhaps the most glaring weakness we saw concerned the treatment of referring doctors. All prior authorization programs require additional administrative work from the referrer, this is inevitable. We determined that we would keep that burden to a minimum, would show respect for the knowledge and effort of the referring physician, and try to provide something of value in exchange for the extra effort we require.(I will discuss minimizing the administrative burden in future postings.)

Treating referring doctors with the respect they are entitled to receive becomes a vehicle that drives improved patient care. No one questions that there is over-utilization of imaging procedures. This should not however be read as an indictment of those who occasionally order a test that is not clinically appropriate.

New modalities in imaging have been developed so rapidly that it is impossible for physicians in other specialties to keep abreast of which studies are likeliest to be of value, and which have been rendered obsolete, or shown to be marginal in answering a particular clinical question. A good RBM program has to begin with an understanding of the pressures faced by referring doctors, their professionalism and skills if it is to be more than another annoyance disguised as a utilization management device.

All RBMs doing prior authorization require clinical information for each request, and compare what is received to a set of clinical criteria. Our approach was designed to identify questionable requests as rapidly as possible, and to have them reviewed by one of our board certified radiologists right away. All of our physician reviewers are radiologists. No criteria set — even ours — can cover all foreseeable clinical situations, so having experienced radiologists involved in the prior authorization process is an advantage that allows us to clear roughly half of the cases that do not get approved at the intake level without demanding anything more from the referring doctor. Just as important is how we deal with those cases that do not meet criteria and are not approved by our radiologist physician reviewers.

Our approach sets our approach apart. No request is ever denied without offering the referring doctor a chance to discuss the case directly with one of our radiologists. We believe that this is an indication of our respect for their judgment.By employing radiologists exclusively for this role we increase the credibility of our positions, as these are truly peer-to-peer discussions. Not only are these conversations an opportunity for us to explain why a particular request was not clinically appropriate, given the information we received, but we may also learn of other facts sufficient to allow approval. The collegial tone we foster makes it likelier that the referring doctor will accept a suggestion for an alternative test or agree that a test is untimely and should be withdrawn. Even when a request is denied we have a chance to provide to the referrer information about imaging that can be helpful in future similar cases. From time to time we learn about new indications for imaging, which we then research and if appropriate add to our criteria.Finally, Care to Care is always open to suggestions.

By avoiding an adversarial atmosphere, and trying to project an informative voice, we have attempted to create an RBM that serves the interests not just of payers, but also of providers of health care and their patients.