In a big hotel conference room near New York’s Times Square, six doctors huddle around a greasy piece of raw pork. They watch as addiction medicine specialist Michael Frost delicately marks the meat, incises it and implants four match-sized rods.

“If you can do it well on the pork, you can easily do it on the person,” Frost tells his audience.

Frost consults for Braeburn Pharmaceuticals, the company behind the newly FDA-approved treatment Probuphine, and is teaching doctors how to use it. They are learning to implant it in pork so they can later implant it in patients’ arms.

Although addiction specialists welcome Probuphine, which delivers a constant dose of the drug buprenorphine over six months, at this early stage it’s complicated for physicians to add it to their repertoire. Because physicians who treat addiction don’t necessarily have experience with surgery or access to sterile spaces, some are having to learn a new skill and develop new systems.

Probuphine is unlike any other addiction treatment on the market. It promises to be life-changing for people already stable in recovery using medication-assisted treatment, who would otherwise need a daily dose of a similar drug to stay free of cravings and withdrawal pains.

Patients using Probuphine were 14 percent more likely to stay opioid-free compared to those using a daily sublingual version of buprenophine, according to a study published this month in JAMA, the Journal of the American Medical Association. Patients in this study had been stable on buprenorphine for an average of three and a half years beforehand. The authors do caution against generalizing these findings. Most participants, they note, were white, employed, had at least a high school education and were previously addicted to prescription opioids rather than heroin.

“They don’t have to be dependent on taking something every day. It takes the choice out of that,” says Ella Leers, a doctor who treats substance abuse at the Carnegie Hill Institute in Manhattan.

The FDA approved Probuphine under the condition that physicians are trained and tested before implanting or even prescribing the treatment. There are three kinds of certification: implanter, prescriber or both. If doctors can’t perform the implanting themselves, they need to coordinate with another doctor who can.

To date, over 1,800 healthcare practitioners have been certified — 27 have implanted dozens of patients, according to a representative for Braeburn Pharmaceuticals, Probuphine’s maker.

Gloria Baciewicz, chief of addiction psychiatry at the University of Rochester Medical Center, says using the new treatment will take some adjustments. But, she adds, there need to be as many effective treatments as possible for opioid use disorder.

“Now with Probuphine, we have to take it up to a whole different level because we have to have either agreements with implanters or a room where we can implant. We have to get the equipment. There will be a lot more to do,” she says. Her team was already planning on moving to another space, which will have the facilities they need to conduct minor surgery.

Prescribing Probuphine may also call for a new approach to the counseling and behavioral therapy that is typically recommended for those on medication-assisted treatment.

“If you’re implanting something that can be there for six months, you want to make sure that the patients are still coming in to get the other types of support that they can use because of their addiction issues,” says Leers.

There are also questions about insurance coverage. Billing codes are still being established. For now, doctors need to buy the Probuphine kits that run almost $5,000 themselves, and then bill patients or insurance companies.

Braeburn has offered to help physicians verify if an insurance plan would reimburse any of the cost. According to the company, Blue Cross Blue Shield and United Healthcare approved reimbursement for a few patients who have implants. Medicare, Medicaid and the VA have Probuphine in their formulary and are required to cover it if deemed medically necessary.

Despite having to get certified and the other hurdles, many doctors welcome the treatment option. Opioid drug overdoses have reached epidemic levels — roughly 78 Americans die every day from opioid overdose, according to the Center for Disease Control and Prevention.

So it’s good to have a another way to deliver medication-assisted treatment, says Richard Rosenthal, medical director of addiction psychiatry for the Mount Sinai Health System. Rosenthal was one of two principal investigators on a Probuphine clinical trial.

“Everybody is waking up to the fact that we’re in the midst of an opioid epidemic,” says Rosenthal. “There are actually very few medications for addiction of any kind. Given the addiction treatment system in the United States, most of the treatment that’s given is psychosocial. There’s very little use of FDA-approved medications.”

Probuphine made a difference, says Scott Jernigan of Jacksonville, Fla. He was in recovery for almost a year, taking another medication, when he signed up for a Probuphine clinical trial. He said Probuphine freed him from weekly doctor visits and pharmacy runs, and from fears of how sick he’d feel if he missed a dose or forgot to take his medication.

“[It] meant that I could become more of what my normal is going to be,” Jernigan says.

Some specialists recommend patients stay on medication-assisted treatment for years, or even indefinitely. For now, Probuphine can only be prescribed for two runs of six-month use and is meant for people already stable on 8 mg or less of a medication like buprenorphine.

Authors of the JAMA study suggest further investigation of Probuphine to gauge issues often associated with buprenorphine, such as diversion or pediatric exposure.

This story is part of a reporting partnership with NPR, Side Effects Public Media and Kaiser Health News.

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Healthy young women can be forgiven for being confused about how often they’re supposed to be getting into see their primary care doctor.

After all, annual checkups in general have come under scrutiny. Doctors who have reviewed the data say there is little scientific evidence to support routine pelvic exams or clinical breast exams in women who have no symptoms. Cervical cancer screening is now recommended only every three years. Even a routine blood test to measure cholesterol levels isn’t recommended for women under 45.

So, is it best to skip that annual wellness visit with a gynecologist or other family practitioner?

Not necessarily. For one, there may be tests you aren’t aware you should be getting. The U.S. Preventive Services Task Force recommends screening for chlamydia and gonorrhea in sexually active women 24 and younger, and in women older than that if they are “at increased risk for infection.” And it recommends screening everyone ages 15 to 65 for HIV. It’s not clear how often those tests should be done, but the task force says a “reasonable” approach would be a one-time screening, with further tests for people who engage in unprotected sex with a new partner, or develop other risk factors.

And even if you don’t need a physical exam, it’s good to schedule periodic face-to-face discussion with your doctor about preventive care or other health concerns, says Dr. Jennifer Gunter, a San Francisco Bay Area OB-GYN and pain specialist. Recommended routine care includes screening for problems like alcohol misuse, depression, obesity and intimate partner violence.

“It’s about the conversations,” says Dr. Wanda Filer, a family physician and president of the American Academy of Family Physicians. “What I like to say is, if there’s something you want to talk to me about, it’s fair game.”

Women often save up questions for an annual office visit that they think don’t warrant a sick visit to the doctor during the year, says Dr. Barbara Levy, an OB-GYN and vice president of health policy for the American Congress of Obstetricians and Gynecologists. That could mean asking whether the irregularities of your period are normal, or why you’re tired all the time, or what Zika means for your plans to conceive. Or maybe you’re wondering whether the method of birth control you’ve been using is the right one for you, or why you’re experiencing incontinence when you sneeze, or whether you should start mammograms in your 40s, at 50 — or earlier — if you have a family history of the disease.

Some of those concerns might prompt a physical exam or test, but others won’t.

Lots of women have questions for a doctor about their sex lives, says Gunter. Sex and some other topics are easier to discuss with a practitioner you know. “If you want to ask why you’re having trouble orgasming, are you going to ask someone you’ve never met before?” says Gunter.

In some cases, that sort of check-in could even be done over the phone, she says.

Filer says patients shouldn’t feel guilty about skipping an annual visit if they’re up to date on recommended preventive care, including adult immunizations. But those who do like to touch base every year shouldn’t feel guilty about scheduling an office visit, or worry they’re wasting the doctor’s time, she says. If your primary aim is to chat, just say that up front.

“You can say ‘I don’t think I need any tests, but please tell me if that’s not true — I just want to be sure I have a relationship with a doctor,’ ” Filer advises. “Most family medicine doctors would value that immensely.”

Katherine Hobson is a freelance health and science writer based in Brooklyn, N.Y. She’s on Twitter: @katherinehobson

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As he takes the stage tonight at the Democratic National Convention in Philadelphia, vice presidential nominee Tim Kaine, is firmly in Hillary Clinton’s camp — and his party’s — on the big health care issues. Now a U.S. senator from Virginia, Kaine supports the Affordable Care Act and pushed its Medicaid expansion. He also worked to reform the mental health system when he was governor of Virginia.

Here are highlights and a few flashpoints of controversy from Kaine’s health policy record:

Mental Health

A defining moment in Kaine’s tenure as governor was the 2007 mass shooting at Virginia Tech, where 33 people, including the gunman — a student at the school — died.

Almost exactly one year later, Kaine signed a $42 million legislative package to reform the state’s mental health system. The money was used mostly for emergency mental health services, children’s mental health services, increased case managers and doctors and jail diversion projects, according to the Virginia Office of the Attorney General.

“Somebody shouldn’t be imprisoned because we won’t provide funding for community mental health,” Kaine said at a mental health conference in 2008, shortly after the bills were signed, according to the Virginian-Pilot in Norfolk, Va.

The package of laws made it easier for authorities to commit someone having a mental health crisis into treatment involuntarily. They no longer had to prove the patient was in “imminent danger.” Instead, the new standard only required authorities to demonstrate a “substantial likelihood” that the person could cause serious harm to themselves or others.

Together, Kaine and the state’s General Assembly made a down payment on longer-term reforms for the delivery of mental health and behavioral health services in Virginia, says Peter Cunningham, a professor of health behavior and policy at Virginia Commonwealth University.

Abortion

As a Catholic who worked with Jesuit missionaries in Honduras in 1980, Kaine says he opposes abortion personally, but supports a woman’s right to choose for herself. His stance has drawn criticism over the years.

“Personally, I’m opposed to abortion and I’m opposed to the death penalty,” he said on NBC’s Meet the Press in June. “The right thing for government is to let women make their own decisions.”

That was a change from Kaine’s position in 2005, when he supported parental consent laws and bans on “partial birth” abortions, causing the Virginia chapter of NARAL Pro-Choice America to withhold an endorsement in his gubernatorial campaign. As governor, he signed a bill creating “Choose Life” license plates in Virginia, which he said was an issue of free speech.

Since then, Kaine has actively supported Planned Parenthood and opposed abortion restrictions.

In 2013, Kaine cosponsored legislation to improve access to contraception.

Affordable Care Act

Kaine did not mark himself as a health care reformer when he was Virginia’s governor, but his 2006-2010 term overlapped the recession when little reform was happening anywhere at state or national levels, Cunningham points out.

“He was probably pretty typical of the middle-of-the-road Democratic governors in sort-of-purple states,” Cunningham says. “When the recession hit, that precluded any other major health reform effort that he might have contemplated.”

Kaine supported Obamacare when he ran for Senate in 2012 and has since co-sponsored bills to improve the law. Kaine has pushed for Medicaid expansion in Virginia and co-sponsored legislation to incentivize expansion in other states as well. Like Clinton, Kaine has proposed adjusting the federal health care law to include some low-income families that aren’t currently covered — fixing the so-called “family glitch.” This year, he co-sponsored a bill to require more businesses to provide benefits under the Affordable Care Act.

Public Health

Kaine has occasionally incited controversy, as in 2007 when Virginia became the first state to require all girls get the human papillomavirus vaccine (protection against a virus that can cause cervical cancer) before enrolling in high school. In 2009, he backed a bill that banned smoking in bars and restaurants in the tobacco-producing commonwealth.

Opioids

Since his election to the Senate four years ago, Kaine has co-sponsored bills that would establish an advisory committee to help the FDA approve new opioids, reform guidelines for the VA regarding the prescription of opioids, protect first responders from lawsuits when they administer emergency drugs to counteract an overdose, and create a drug monitoring program for Medicare.

Many of those bills were rolled into CARA— the Comprehensive Addiction and Recovery Act of 2016, which was signed by President Obama in July. The bill bore Kaine’s name as a co-sponsor.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

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The federal government released its first overall hospital quality rating on Wednesday, slapping average or below average scores on many of the nation’s best-known hospitals while awarding top scores to many unheralded ones.

The Centers for Medicare & Medicaid Services rated 3,617 hospitals on a one- to five-star scale, angering the hospital industry, which has been pressing the Obama administration and Congress to block the ratings.

Hospitals argue that the government’s ratings will make teaching hospitals and other institutions that treat many tough cases look bad. They argue that their patients are often poorer and sicker when admitted, and so are more likely to suffer further complications or die, than at institutions where the patients aren’t as sick.

Medicare, which already publicizes on its website more than 100 hospital metrics, many of which deal with technical matters, acknowledges that the ratings don’t reflect cutting edge care, such as the latest techniques to battle cancer. Still, it has held firm in publishing the rankings, saying that consumers need a simple way to objectively gauge quality. Medicare does factor in the health of patients when comparing hospitals, though not as much as some hospitals would like.

Medicare based the star ratings on 64 individual measures that are published on its Hospital Compare website, including death and infection rates and patient reviews.

Just 102 hospitals received the top rating of five stars, and few are those considered as the nation’s best by private ratings sources such as U.S. News & World Report, or viewed as the most elite within the medical profession.

Medicare awarded five stars to relatively obscure hospitals and a notable number of hospitals that specialized in just a few types of surgery, such as knee replacements. There were more five-star hospitals in Lincoln, Neb., and La Jolla, Calif., than in New York City or Boston. Memorial Hermann Hospital System in Houston and Mayo Clinic in Rochester, Minn., were two of the only nationally known hospitals to get five stars.

Medicare awarded the lowest rating of one star to 129 hospitals. Five hospitals in Washington, D.C., received just one star, including George Washington University Hospital and MedStar Georgetown University Hospital, both of which teach medical residents. Nine hospitals in Brooklyn, four hospitals in Las Vegas and three hospitals in Miami received only one star.

Some premiere medical centers received the second-highest rating of four stars, including Stanford Health Care in California, Massachusetts General Hospital in Boston, Duke University Hospital in Durham, N.C., New York-Presbyterian Hospital and NYU Langone Medical Center in Manhattan, the Cleveland Clinic in Ohio, and Penn Presbyterian Medical Center in Philadelphia. In total, 927 hospitals received four stars.

Medicare gave its below-average score of a two-star rating to 707 hospitals. They included the University of Virginia Medical Center in Charlottesville, Beth Israel Medical Center in Manhattan, North Shore University Hospital (now known as Northwell Health) in Manhasset, N.Y., Barnes-Jewish Hospital in St. Louis, Tufts Medical Center in Boston and MedStar Washington Hospital Center in D.C. Geisinger Medical Center in Danville, Pa. — which is a favorite example for national health policy experts of a quality hospital — also received two stars.

Nearly half the hospitals — 1,752 — received an average rating of three stars. Another 1,042 hospitals were not rated, either because they did not have enough cases for the government to evaluate accurately, or because, as with all Maryland hospitals, Medicare does not collect the necessary data.

The government said in a statement that it has been using the same type of rating system for other medical facilities, such as nursing homes and dialysis centers, and found them useful to consumers and patients. Those ratings have shown, Medicare said, “that publicly available data drives improvement, better reporting, and more open access to quality information for our Medicare beneficiaries.”

In a statement, Rick Pollack, president of the American Hospital Association, called the new ratings confusing for patients and families. “Health care consumers making critical decisions about their care cannot be expected to rely on a rating system that raises far more questions than answers,” he said. “We are especially troubled that the current ratings scheme unfairly penalizes teaching hospitals and those serving higher numbers of the poor.”

A preliminary analysis Medicare released last week found hospitals that treated large numbers of low-income patients tended to do worse.

A sizable proportion of the nation’s major academic medical centers, which train doctors, scored poorly, according to a Kaiser Health News analysis. Out of 288 hospitals that teach significant numbers of residents, six in 10 received below-average scores, the analysis found. Teaching hospitals comprised one-third of the facilities receiving one-star. A number were in high-poverty areas, including two in Newark, N.J., and three in Detroit.

“Hospitals cannot be rated like movies,” Dr. Darrell Kirch, president of the Association of American Medical Colleges, said in a statement. “We are extremely concerned about the potential consequences for patients that could result from portraying an overly simplistic picture of hospital quality with a star-rating system that combines many complex factors and ignores the socio-demographic factors that have a real impact on health.”

Kaiser Health News is an editorially independent news service supported by the nonpartisan Kaiser Family Foundation.

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Jonathan Goodman can recall most of the lectures he’s attended at the Stanford University School of Medicine. He can recite detailed instructions given more than a year ago about how to conduct a physical.

But at the end of his second year, the 27-year-old M.D.-Ph.D. student could not remember any class dedicated to addiction medicine. Then he recalled skipping class months earlier. Reviewing his syllabus, he realized he had missed the sole lecture dedicated to that topic.

“I wasn’t tested on it,” Goodman says, with a note of surprise.

Americans are overdosing on opioids such as heroin and prescribed painkillers at epidemic rates, and the nation’s doctors appear to be inadequately prepared to help.

The problem begins in medical school.

A report in 2012 by The National Center on Addiction and Substance Abuse revealed that medical schools devoted little time to teaching addiction medicine — only a few hours over the course of four years. Since then, the number of Americans overdosing from prescribed opioids has surpassed 14,000 per year, quadrupling from 1999 to 2014.

But Stanford’s medical school may offer an example of what faculty-driven change in teaching about addiction can look like.

The school began retooling its curriculum after the director of its addiction medicine fellowship, Dr. Anna Lembke, expressed concern about its meager offerings in that field.

Lectures on addiction will no longer be folded into the psychiatry series as a side note, but instead will be presented as a separate unit relevant to future doctors in any subspecialty, Lembke says. And that training will continue when the students leave the classrooms for clinical rotations.

“We’re at the very bottom of a very long uphill road,” says Lembke, who gave the lecture Goodman missed.

Medical faculties have traditionally eschewed teaching the subject, in part because many physicians viewed addiction as a personal vice rather than a disease. And, even now, some doctors who specialize in addiction treatment are skeptical that the best care for the problem comes out of a medical model.

For example, Dr. Joe Gerstein, a retired internist and clinical assistant professor at Harvard Medical School, is founding president of SMART Recovery, an international program that emphasizes cognitive behavioral therapy and positive thinking to help people beat their drug habit.

“Clearly, if you’ve got an addiction, you’ve been making a lot of bad choices,” says Gerstein. Framing substance abuse strictly as a disease ignores the fact that some people are able to quit their use of a drug with willpower, he says.

Still, those who believe in the value of medical treatment for addiction say it can no longer be an afterthought in medical education. Because the current opioid epidemic is largely linked to prescribed opioid painkillers, many doctors are being forced to grapple with addicted patients in their practices. In March, the American Board of Medical Specialties officially recognized addiction medicine as a subspecialty.

In a March report, the California Health Care Foundation cited inadequate medical school training as one of the challenges in treating patients addicted to opioids.

The White House has also been pressuring medical schools to improve instruction on opioid addiction by issuing pledges for schools to sign, promising to change their curricula. But as recently as April, Lembke hadn’t yet heard of any concrete plans to change Stanford’s curriculum.

In late spring, however, she was asked to meet with the dean of the medical school about bolstering education in addiction medicine. Working with fellow faculty members, Lembke is now expanding addiction medicine beyond the lone talk she gives on opioids each year to a series of lectures that recommend and teach alternative treatments for pain, like acupuncture or massage.

Lembke will also seek an endorsement of her fellowship program by the Accreditation Council of Graduate Medical Education. Accreditation can help programs get additional funding.

One of Lembke’s Stanford colleagues, Dr. Jordan Newmark, who directs education in medical school’s pain division, is seeking to increase medical students’ training on opioids in their third and fourth years. His plans for clinical training sessions include having actors portray patients with opioid addictions.

The next hurdle is to recruit doctors to specialize in addiction medicine, says Emily Feinstein, director of health law and policy at the National Center on Addiction and Substance Abuse.

Among the challenges in getting young doctors interested in the field, Feinstein says, are low insurance reimbursement rates and having to deal with patients who can be difficult behaviorally because of their drug use.

It’s best to reach doctors at the start of their careers, Lembke says — before they’ve established a practice and get set in their ways.

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With recent reports that drugmakers have sharply raised the prices of some prescription drugs, a reader has written in to ask why a common generic drug is also suddenly costing him more. Another reader has questions about health plans with high deductibles. Here are those readers’ questions, and what I’ve learned about the answers.

I take levothyroxine, the generic form of Synthroid, to treat a thyroid disorder. This generic has been on the list of drugs that cost $10 for a 90-day supply at my pharmacy for as long as I can remember. Starting in April, the drug was dropped from the list and the price rose 300 percent. The pharmacist tells me all the generic drug manufacturers are raising prices. How is it possible that this drug increased in price so quickly?

Generic drug price hikes have come under close scrutiny lately, as reports continue to surface of significant and seemingly inexplicable increases. Some drugs affected — including your thyroid medicine, as well as the common heart medicine digoxin — are widely used and have had relatively modest prices for years.

What gives? Health care professionals like your pharmacist often blame drug manufacturers, claiming they raise prices simply because they can. There’s no question that happens, says Dan Mendelson, president of the consulting firm Avalere Health. But there are other reasons that generic drug prices may increase as well.

For example, insurers may have simply changed the design of their health plan’s drug benefit, Mendelson says. They may have moved the drug into a higher tier — one that requires consumers to pay a bigger chunk of the cost. Drug prices also sometimes increase because the cost of manufacturing or distributing the drug has increased.

But consumers don’t have to simply pay up. Drug costs often vary widely from pharmacy to pharmacy, so shopping around makes financial sense. In addition, some retailers offer rock-bottom prices on dozens of generic drugs to consumers who pay cash. If you’re ponying up $4 in cash instead of a $30 copay for each refill, the savings can quickly add up.

Do you know of any insurance carriers that are selling high-deductible marketplace plans where once the deductible is met, the plan pays 100 percent of the costs after that? In other words, the deductible and the out-of-pocket maximum would both be the same?

It’s not unusual to find plans that are structured the way you describe, particularly among bronze-level plans, says Linda Blumberg, a senior fellow in the Health Policy Center at the Urban Institute. Blumberg and colleagues analyzed the availability of these plans on the federal marketplace, which runs the insurance exchanges for about two-thirds of U.S. states.

Such a plan might have a deductible of $6,850 for individual coverage, for example, which is also the maximum that someone with an individual plan can be required to spend out of pocket for covered care in 2016.

Some insurers have touted this type of plan for its simplicity, noting that there’s only one number to keep track of. Still, at the bronze level, a health plan that picks up all costs after the deductible is met is likely to have a deductible of several thousand dollars. Bronze plans are the least generous of the four levels of coverage on the exchange.

Still, even in a high-deductible plan, some care is covered before the deductible is met, including preventive services. Under the Affordable Care Act, consumers don’t have to pay out of pocket for preventive care if it has been recommended by the U.S. Preventive Services Task Force. In addition, some insurers offer plans that cover a certain number of primary care visits or generic drugs, for example, that are exempted from the deductible.

If you’re considering a plan whose deductible and out-of-pocket maximum are the same, Blumberg says, carefully check the particulars of what’s covered.

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Health care reporter Michelle Andrews’ column appears as part of NPR’s partnership with Kaiser Health News. Andrews is on Twitter: @mandrews110

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Imagine your heart can no longer pump enough blood to your vital organs. Even minimal exercise tires you out, and you’re often short of breath when lying flat. Your lungs are accumulating fluid. Your kidneys and liver are impaired.

You’ve been hospitalized and started on an intravenous drug that improves your heart’s ability to contract. It has helped, but it is not a long-term solution. You need a new heart.

You’re a good candidate, but there is a problem: a chronic shortage of donor hearts. In 2014, for example, about 6,950 Americans were approved for heart transplants, but only about 2,250 donor hearts became available. You need to move higher up on the list.

I’m your doctor. I want to help you get you a heart. But I face an ethical dilemma: Do I ramp up your medical treatment, even beyond what I consider necessary, to bump you higher on the list?

Aiming for Status 1A

The United Network for Organ Sharing, or UNOS, has established criteria to make sure that donor hearts go to patients with the most severe disease. These criteria are based on which treatments a doctor has prescribed, on the assumption that they’re a good indication of how critical the illness is.

Generally, that’s a fair assumption. Except that the system itself creates a perverse incentive.

It works like this: Your place on the waiting list for hearts depends on your “status.” If you weren’t getting that IV drug, you’d be considered “Status 2,” and your median wait time for a heart would be 630 days. Not good.

You’re on the IV drug, though, so you’re considered “Status 1.” But “Status 1” is divided into two more categories: If you’re on a low dose of the IV drug, you’re classified as “1B,” cutting your median wait to 301 days. That’s where you are now. Better, but still not great.

But if you were in an intensive care unit, receiving a high dose of your IV drug, and you had a catheter placed in your pulmonary artery to monitor cardiac performance, you would be “Status 1A.” Your median wait would drop to 110 days.

So you’re unlikely to get a heart anytime soon unless you can be listed as 1A. And in your case, if you weren’t up for a transplant, there would be no call to implant a pulmonary-artery catheter; it’s uncomfortable (it is inserted through your neck or under your collarbone) and carries a risk of infection. There would also be no call to raise your dose of the IV drug that’s helping your heart contract; when used long term, higher doses can increase the risk of sudden cardiac death.

But I have to balance these risks against the danger of your having to wait three times as long for a transplant if you remain 1B. That means spending an additional 291 days on the waiting list, during which your condition may deteriorate. You may end up needing a mechanical pump or an artificial heart, both of which would entail major cardiac surgery and potentially serious complications. And you may die.

When I take all that into account, the risks of keeping you waiting at 1B seem higher than the risks of placing a pulmonary-artery catheter and raising the dose of your IV medication to make you 1A.

This is the system I have to navigate.

So, as your doctor, even though these measures aren’t medically indicated, do I admit you to intensive care, insert a pulmonary-artery catheter and increase your medication to qualify you for 1A status? And if I do, is it ethical?

The transplant list is a zero-sum game

The American Medical Association, in a statement on the allocation of limited medical resources, asserts that “a physician has a duty to do all that he or she can for the benefit of the individual patient.”

And dishonesty on behalf of others can be virtuous. Ludvik Wolski, a Roman Catholic priest in Otwock, Poland, forged certificates of baptism to save the lives of Jewish children during the Nazi occupation.

If I adjust your treatment to help you get a donor heart, I might be tempted to believe I’m acting similarly.

But there is an important difference between Wolski’s situation and mine: His actions had no adverse consequences for other Jewish children in the community.

In contrast, if I increase your odds, I decrease another patient’s — because the transplant list, with its vast excess of prospective recipients over donors, is functionally a zero-sum game. If I’ve bettered your chances at someone else’s expense, I’ve provided no overall benefit.

So I might be inclined to resist overtreating you here — if I can be confident that other doctors are resisting as well.

And there’s the rub: If I have reason to believe that other doctors are escalating care to move their patients up on the list, then I may be putting you at a disadvantage by refusing to do the same.

And I do have reason to believe that. I’ve read a 2013 editorial in the Journal of Heart and Lung Transplantation commenting on how invasive treatments are being overused in patients on the transplant list. And a commentary this year in the same journal noted that when the criteria for transplant status changed, medical practice evolved in step with them.

So my personal integrity ends up being in direct conflict with my responsibility as your advocate.

In the big picture, this system increases the number of medically unnecessary treatments, thereby driving up both cost and complication risk.

And perhaps worst of all: When “gaming the system” goes from being an aberration to a standard strategy — when, as the authors of the new commentary write, “treating to the priority is almost as fundamental as studying to the test” — then dishonesty becomes normal.

This cannot be good.

New rules

The United Network for Organ Sharing is now considering a new system for allocating donor hearts that has many more priority stratifications.

Among the new criteria proposed for determining a patient’s waitlist status are measures that are far more aggressive than pulmonary-artery catheters and IV drugs. They include procedures such as the insertion of an intra-aortic balloon pump, which helps the heart generate more blood flow, or the use of extracorporeal membrane oxygenation, which provides a heart-lung bypass outside the body.

Under the new criteria, we should be better able to select patients with the most severe disease.

But that’s what we thought about the original criteria. And the new proposed criteria, too, are “gameable,” so that doctors might feel pressured to take more extreme steps to improve their patient’s chances. Some transplant doctors are already expressing concerns about the potential use of intra-aortic balloon pumps that will allow patients to walk about while waiting for transplants.

The same perverse incentive to escalate care will remain — and so will the ethical dilemma it creates.

Matthew Movsesian, a cardiologist, is a professor at the University of Utah School of Medicine in the Division of Cardiovascular Disease. This essay was first published by NPR member station WBUR.

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The Justice Department calls it the largest criminal health care fraud case ever brought against individual suspects: Three people are accused of orchestrating a massive fraud involving a number of Miami-based health care providers.

The three facing charges are all from Florida’s Miami-Dade County; they include Philip Esformes, 47, owner of more than 30 Miami-area nursing and assisted living facilities; hospital administrator Odette Barcha, 49; and physician assistant Arnaldo Carmouze, 56, the Justice Department says.

“Medicare fraud has infected every facet of our health care system,” U.S. Attorney Wifredo Ferrer said as indictments against the three were announced Friday.

The indictments accuse Esformes of leading “a complex and profitable health care fraud scheme that resulted in staggering losses — in excess of $1 billion,” said Special Agent in Charge George L. Piro of the FBI’s Miami field office.

Investigators say Esformes used his access to thousands of Medicare and Medicaid beneficiaries to perpetrate a fraud:

“Many of these beneficiaries did not qualify for skilled nursing home care or for placement in an assisted living facility; however, Esformes and his co-conspirators nevertheless admitted them to Esformes Network facilities where the beneficiaries received medically unnecessary services that were billed to Medicare and Medicaid.”

More money was in play, investigators say, in the form of kickbacks Esformes and his co-conspirators received in return for “steering beneficiaries to other health care providers — including community mental health centers and home health care providers — who also performed medically unnecessary treatments that were billed to Medicare and Medicaid.”

In addition to charges of conspiracy, money laundering and health care fraud, Esformes and Barcha were also charged with obstructing justice.

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The Justice Department and a number of states filed suit today to block two big mergers in the health insurance industry. Anthem was planning to acquire Cigna, and Aetna sought to buy Humana. Justice Department officials said they had no doubt the mergers would reduce competition and hurt consumers.

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The Justice Department is suing to block two proposed mergers between major health insurance companies, saying the deals violate antitrust laws and would lead to higher health care costs for Americans.

U.S. Attorney General Loretta Lynch explained the decision at a press conference:

“If allowed to proceed, these mergers would fundamentally reshape the health insurance industry. They would leave much of the multitrillion-dollar health insurance industry in the hands of three mammoth insurance companies, drastically constricting competition in a number of key markets that tens of millions of Americans rely on to receive health care.

“Among other consequences, the number of health insurance options available to nationwide employers would shrink from four to three. Two of the largest and fastest-growing providers of Medicare Advantage plans, which millions of seniors rely on for crucial medical coverage, would combine into just one. And competition would be substantially reduced for hundreds of thousands of families and individuals who buy insurance on the public exchanges established under the Affordable Care Act.”

The lawsuits filed Thursday morning challenged a $37 billion merger between Humana and Aetna, which the Justice Department alleges “would lead to higher health-insurance prices, reduced benefits, less innovation, and worse service for over a million Americans,” and a $54 billion acquisition of Cigna by Anthem, which the court filing states would be the largest merger in the history of the health insurance industry.

The two suits both list eight states and the District of Columbia as co-plaintiffs in the antitrust action. Those states are Delaware, Florida, Georgia, Illinois, Iowa, Ohio, Pennsylvania and Virginia in the Aetna-Humana suit, and California, Colorado, Connecticut, Georgia, Iowa, Maine, Maryland and New Hampshire in the Anthem-Cigna suit.

The planned merger between Aetna and Humana was announced a year ago, and the companies were quick to react after news of the Justice Department suit. In a joint statement, Aetna and Humana said the companies intend to “vigorously defend the companies’ pending merger in response to a U.S. Department of Justice lawsuit seeking to block the transaction. A combined company is in the best interest of consumers, particularly seniors seeking affordable, high-quality Medicare Advantage plans.”

A statement by Cigna indicated the company had not yet decided how to proceed in light of the lawsuit:

“Given the nature of the concerns raised by the DOJ and the overall status of the regulatory process, which under the terms of the merger agreement was led by Anthem, Cigna is currently evaluating its options consistent with its obligations under the agreement.”

The proposed Anthem-Cigna deal was also announced last summer. Both mergers being challenged are part of a wave of consolidation sweeping the health care industry, as NPR’s Scott Hensley reported last year.

He wrote:

“One reason these health insurers are seeking to get bigger is that the hospitals and doctor groups across the negotiating table have also gotten bigger.

“There were 95 hospital mergers and acquisitions in 2014, according to management consulting firm Kaufman Hall. That’s pretty much been the pace for the past few years. Deals that create larger health systems give the providers of health care more leverage in negotiating rates with private insurers.”

If the health insurers decide to fight the lawsuits, Bloomberg reports that it would likely take months to resolve.

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