While diagnostic and therapeutic medical radiation have many important benefits, a House subcommittee on Friday took a closer look at recent reports in which radiation reportedly caused injuries in a variety of settings—and how to avoid these risks and hazards.

Rep. Frank Pallone (D-NJ), chair of the Energy and Commerce Health Subcommittee, said the hearing was not because Congress thinks that medical radiation is bad. "I would like to assure you, this is not the case," he said. "We are not here today to make the statement that medical radiation should not be used."

However, with all the advancements the industry has made, "these technologies have become more complex and complicated to operate," Pallone said. "It is shocking to me that in many states individuals who operate these devices do not need to be licensed and are therefore not regulated at all in terms of education and expertise."

"Part of the problem could be the fact that no single agency has authority over the entire spectrum of issues related to medical radiation and because of this, things are more likely to fall through the cracks," he said.

One of the individuals testifying was the father of Scott Jerome Parks, who received treatments seven times more powerful than required for his tongue cancer. The accident allegedly occurred when a technician did not detect malfunctioning computer software. The story was featured in a series of articles from the New York Times.

James Parks told the subcommittee that because of the error, his son had become deaf and blind before dying in 2007.

"Medical accidents happen. We know that hospitals have a vested interest in making serious accident go away as quickly and quietly as possible," he said. "Hospitals in general cannot be relied upon to report or make public, serious medical accidents without strong external sanctions."

Parks called for the U.S. to develop "a strong, mandatory data base, and force all medical institutions to report all serious medical accidents." It would be a repository for "evaluating trends and identifying medical problems throughout the nation," he added.

While approximately a million patients per year are "safely and accurately treated" with radiation therapy, further steps are needed to ensure patient safety, Eric Klein, PhD, a professor of radiation oncology at Washington University, St. Louis, testified.

First, a national depository for anonymous error reporting should be created in order for communities to learn from such errors or "near misses," he said. Although the anecdotal reported rate of errors in radiation oncology is quoted as less than one in 10,000, this rate likely may be inaccurate because there is no depository or even statewide mandates for reporting such errors.

"In most states, hospitals are not obligated to report errors occurring with their linear accelerator," he said.

Hospitals also need to encourage scheduling patterns to allow for time outs before "each treatment begins to allow for cross checking of all parameters by the therapists," Klein said. In relation to this, the time leading up to the patient’s first treatment should allow for careful review "of all parameters to be used," he added.

The oversight for computed tomography (CT) radiation dosing is currently "very fragmented," said Rebecca Smith Bindman, MD, a professor of radiology, epidemiology, and biostatistics, obstetrics, gynecology ,and reproductive sciences at the University of California, San Francisco. "The Food and Drug Administration (FDA) oversees the approval of the CT scanners—as medical devices—"but does not regulate how the test is used in clinical practice."

While radiologists determine how the CT tests are performed, few national guidelines are available on how these studies should be conducted, Smith-Bindman said. "Therefore, there is great potential for practice variation that could introduce unnecessary harm from excessive radiation dosing."

Since information on radiation is reported differently across the various types of CT machines, radiologists may find it difficult to standardize their practice, she said. The American College of Radiology has established a voluntary accreditation process to standardize practice, Smith-Bindman said.

However, while the approach is promising, data collection is "extremely limited, making it difficult if not impossible for [ACR] to monitor if facilities comply with their recommendations."

In the current environment, medical technology and decision making "are increasingly complex, and rapid changes in diagnosis and care delivery compound the situation," said Tim Williams, MD, chairman of the board of Directors On behalf of the American Society for Radiation Oncology (ASTRAY).

ASTRAY recently launched a new quality- and safety-focused self assessment module based on best practices to improve clinical care in radiation oncology. "This online education tool provides best practice guidelines for dosimetrists, physicists, therapists, physicians, and nurses," Williams said.

The new module emphasizes the use of peer review, including an analysis of treatment steps that may be prone to human error, documentation of near misses, development of departmental checklists to catch errors, and engaging the entire radiation oncology treatment team to openly discuss patient safety, Williams added.

At Thursday's healthcare reform summit meeting in Washington, President Obama and selected members from the House and Senate came to either agree—or disagree—with the current state of healthcare reform.

Basically, they came, they sat, and they talked and talked. But will it move healthcare reform to the next level?

Here's how the summit could actually kickstart health reform:

1. A sense of urgency was created.

"We cannot have another year long debate about this," Obama said near the end of the summit. "So the question that I'm going to ask myself—and that I'll ask of all of you is—is there enough serious effort that in a month's time or a few weeks' time or six weeks' time we could actually resolve something?"

Obama made it clear that he would not be attempting a summit of this magnitude again.

"I thought it was worthwhile for us to make this effort. [But] we've got a lot of other things to do. I don't think that we're going to have another one of these because people don't have seven, eight hours a day to work some of these things through."

And if the Republicans decline to give bipartisan support?

"Then I think we've got to go ahead and some make decisions," Obama said. "That's what elections are for. [When] we have honest disagreements about the vision for the country, we'll go ahead and test those out over the next several months till November."

2. Underscored that the parties had more in common with each other than the public might perceive.

Sen. Tom Harkin (D-IA), who is chairman of the Senate Health, Education, Labor and Pensions Committee, said at the summit, "We may be closer together than people really think in actually getting agreement [so] that we can move forward."

"Of the 10 key elements in the House [Republican's proposed] bill, we have nine of them in our bill. That's not bad," Harkin said.

"This includes provisions on not being excluded from coverage for pre-existing conditions, no lifetime caps, no gender-bases ratings, and keeping children on a parent's health policy after they become young adults.

"The only one that's missing is the health savings accounts," Harkin added. "I think we're very close on this."

3. Could add fresh ideas into the current debate.

Sen. Ron Wyden (D-OR) suggested the two parties consider "real reform that would ... change the incentives that drive the system and empower the consumer." His plan would "build on the exchanges that we have today" that are used by the federal employee system.

"I think we can resolve a lot of our differences," he said.

But on the flip side, the dialogue may have indicated that stronger differences exist between the parties—and that agreements may be difficult to achieve.

Here are three barriers that impede the Democrats in moving forward with a large health reform program:

1. The continued push to start over.

A common theme voiced by many of the Republican attendees was that they wanted to push aside the bills already approved by the House and the Senate in favor of a new one.

As Rep. Joe Barton (R-TX), ranking member on the House Energy and Commerce Committee, said: "Let's start over in the sense that we change the vision and work together to do the things that we agree upon—but do it in a way that doesn't destroy the fundamental market system that's made the American healthcare system the best in the world," he said. "And if we do that, we can make a deal."

This is a move, however, that the president indicated at the end of the summit that he is unlikely to take.

2. Disagreements over individual mandates versus insurance reform.

Mandating that individuals obtain insurance "is a significant issue across the country," said Rep. Dave Camp (R-MI), the ranking minority member on the House Ways and Means Committee.

"The American people are telling us that the individual mandates—the requirements to buy insurance—are something that they want us to scrap and start over on," Camp said. "That's why you're seeing state legislatures around the country passing resolutions saying, our citizens are going to have a choice on whether they buy health care."

However, Obama and many of the Democrats said that it would remain difficult to reform the healthcare marketplace and keep costs down if individuals did not have to purchase healthcare insurance.

3. The size and complexity of the bill.

Throughout the summit meeting room, copies of the current 2,700-page reform bill sat next to several Republicans who cited the size of the current legislation—and said they would not vote for something this large.

Obama appeared unmoved by the request. "I did not propose—and I don't think any of the Democrats proposed—something complicated just for the sake of being complicated. We'd love to have a five page bill. It would save an awful lot of work."

He said the reason they didn't do it is because "it turns out that baby steps don't get you to the place where people need to go," Obama said.

"[People] need help right now. And so a step by step approach sounds good in theory, but ... we can't solve a preexisting problem if we don't do something about coverage," he added.

When you think about it, quality in healthcare is all about improvement. It means improving the daily lives of patients, improving the technology to deliver care, improving communications between providers and patients, and improving chances for survival.

But should this improvement cost more—or less? As two new studies out this week show, what you pay for up front may lead to results you may not expect—depending on what you are treating.

At the national level, policymakers are giving more emphasis over how to achieve better quality at far less cost. In recent years, they are giving more attention on whether earlier discharges from hospitals could be a way of saving money—or creating more expense if the patient returns to the hospital within 30 days or six months.

Research by Lena Chen, MD, a clinical lecturer in internal medicine at the University of Michigan Health System, found that sometimes you may get better results if you pay more upfront—but at other times it may not make that much difference, especially in the area of long-term results.

In a study that appears in the Archives of Internal Medicine, she and her colleagues found different results for Medicare patients with two common hospitalized conditions: congestive heart failure (CHF) and pneumonia.

For each condition, the researchers used data from national databases (Medicare, American Hospital Association, Hospital Quality Alliance) to review the association between hospital cost of care and several variables: 30 day death rates, readmission rates, six month inpatient cost of care, and a quality score based on performance indicators for each condition.

Costs of care for each condition showed wide variation. Care for a typical Medicare inpatient with CHF ranged between $1,522 to $18,927, depending on which of the 3,146 hospitals where the patient had been hospitalized. The average cost was $7,114. Meanwhile, cost of care for a typical patient with pneumonia averaged $7,040 and varied in cost from $1,897 to $15,829 per hospitalization among 3,152 facilities.

Hospitals among the top fourth of the highest cost hospitals had higher quality of care scores and lower mortality for CHF. However, for pneumonia, the opposite was true. When compared with low cost hospitals, high cost hospitals had lower quality of care scores and higher mortality for pneumonia.

Hospitals with lower costs had similar or slightly higher 30 day readmission rates (24.7% for CHF and 17.9% for pneumonia) when compared with higher cost hospitals (22% for CHF and 17.3% for pneumonia). However, patients initially seen in lower cost hospitals still incurred lower overall costs of care over six months following their initial visits in higher cost hospitals ($12,715 vs. $18,411 for CHF and $10,143 vs. $15,138 for pneumonia).

"The quality between the high-cost and the low-cost both weren't that great," Chen says. As for why costs were higher or lower—perhaps use of health information technology, the existence of vertical integration, or a variation in the number of tests ordered—is not evident from this study. "We didn't have the data to look at the potential reasons for the differences in costs," Chen says.

In a diabetes study released by the National Minority Quality Forum, Medicare beneficiaries with the condition who consumed the least of their Medicare benefits and services ended up not saving money. Instead, they cost Medicare more money because they went to the emergency room more often and required more hospitalizations.

The study divided Medicare beneficiaries into five groups—crisis consumers, heavy consumers, moderate consumers, light consumers and low consumers—based on how much Medicare reimbursed for services in any year. The two most costly clusters were crisis consumers and heavy consumers, representing about 11% of Medicare beneficiaries—but 65% of all costs.

But these cluster groups could vary each year—particularly beneficiaries who are low consumers one year. They could be catapulted into the heavy consumers group the next year—triggered by a critical and costly health event.

"If we can identify these patients, who are under managing their chronic condition putting them at high risk for disease complications, we can intervene to help these individuals manage their disease more effectively, and, ultimately, reduce overall healthcare costs," says Gary Puckrein, PhD, a founding partner of the Diabetes Care Project and President and CEO of the National Minority Quality Forum, who spoke at a telebriefing where the study was released.

"As a practicing physician, we really need a paradigm shift—from a population-based approach to treating diabetes to developing a more personalized management and strategy," says Kenyatta Lee, MD, an assistant professor of community health and family medicine at the University of Florida.

So do these studies provide a lesson in comparing treatment and costs? Well, maybe more research is needed, Chen says. Possibly more efforts, such as comparative effectiveness research—or as it's referred to as "patient-centered research" in the latest federal budget—could lay a foundation for some better answers on how much to spend—less or more—for quality care and get the best outcomes.

The healthcare reform proposal released by President Obama on Monday has some similarities—and some differences—to the Senate reform bill concerning how costs will be covered in the $950 billion bill.

Obama's plan includes these four ways to fund the nearly $1 trillion plan.

Cadillac Tax. Back is the so-called "Cadillac Tax" that would impose a 40% tax on the value of higher cost health plans above a certain amount. In the bill, passed by the Senate in December, that amount was $8,500 for individuals and $23,000 for families, which then would have raised $150 billion over 10 years.

However, a subsequent meeting with labor leaders at the White House in January—who thought the tax disproportionately weighed against many of their members with higher cost policies—negotiated trigger rates that were slightly higher.

In President Obama's reform plan, the amount was increased to $10,200 per individual and $27,500 per family, with the start-up date moved to 2018 to 2013. The Congressional Budget Office has estimated that this policy will reduce many high-cost premiums in the long run.

The proposed tax, though, still has opposition in the House. Rep. Joe Courtney (D-CT), who spearheaded a petition signed by 193 House members who opposed the tax, said that while the White House proposal "makes significant progress" on the excise tax, it should be set aside and studied rather than imposing a tax eight years in the future, he said.

"Delaying the tax by nearly a decade and hoping that it doesn't hurt working families is like throwing a dart in the dark."

Increase the Medicare Hospital Insurance (HI) tax base. The White House proposal adopts a Senate approach to increasing the HI tax on high-income taxpayers. The President's proposal calls for adding a 2.9% assessment—equal to combining employer and employee shares of the existing HI tax—on income from interest, dividends, annuities, royalties, and rents.

As proposed, this would apply to taxpayers with incomes above $200,000 for singles and $250,000 for married couples filing jointly. The additional revenues from the tax on earned income would be credited to the HI trust fund, and the revenues from the tax on unearned income would be credited to the Supplemental Medical Insurance (SMI) trust fund.

More pharmaceutical money. The White House proposal continues to call for a $23 billion assessment in the Senate bill over 10 years—plus another $10 million—starting in 2011. This would help begin to close the so-called doughnut hole by 2020. Currently with the "doughnut hole" provision, Medicare stops paying for prescriptions after the plan and the beneficiary have spent $2,830 on prescription drugs and begin paying after out of pocket spending reaches $4,550.

Device manufacturers tax. The White House proposal, noting that the medical device industry "stands to gain from expanding health insurance coverage," calls for a $20 billion excise tax beginning in 2013. This excise tax would "yield the same revenue" as the "fees" called for in the House and Senate bills.