August 20, 2005
iPODs and Hearing Loss
Well, you knew that the fun could not last, it turns out that listening to iPODs or other MP3 players, particularly at the volumes at which many people listen, can cause hearing loss. This BBC article details some of the latest findings,
The surge in sales of iPods and other portable music players in recent years could mean many more people will develop hearing loss, experts fear.
If the volume through headphones is too high, there is a real risk of permanent damage to hearing, they say.
Sydney's National Acoustic Laboratories found a quarter of personal music system users in a random sample listened to music at dangerous volumes.
The Royal National Institute for Deaf people urged awareness of the risks.
Millions now own MP3 players - Apple has sold more than 20 million iPods.
A recent study by the Royal National Institute for Deaf People (RNID) found 39% of 18 to 24-year-olds listened to personal music players for at least an hour every day and 42% admitted they thought they had the volume too high.
The RNID regards 80 decibels as the level at which hearing is threatened - 20 less than a pneumatic drill.
Some MP3 players can reach 105 decibels. EU iPods have a sound limiter to comply with noise safety levels, however sometimes users hack through this in order to listen to it louder.
The RNID said it was possible that any rise in popularity of personal music players might lead to more cases of hearing loss in the future.
August 19, 2005
Merck's Biggest Hit (So Far): $253 Million
In most law school curricula, there's a fairly clear divide between med mal and health law, a divide that is largely reflected in the membership of the ABA Health Law Section and the AHLA, as well as here at HealthLawBlog. So today's jury verdict of $253 million for the plaintiff in the Vioxx trial in Angleton, TX (see Bloomberg's article on it) would be of only passing interest here except for one thing: what it tells us about Big Pharma in the early years of the 21st Century. An early attempt to put the verdict in a larger context of drug safety and the regulatory environment is Katrina Vanden Heuvel's "editor's blog" over on The Nation's website. [tm]
Eating Chips and Breast Cancer
Harvard has released a new study showing that children's consumption of certain trans fatty foods, such as chips, at an early age may increase the risk of breast cancer later in life. The TImes UK reports,
Eating chips as a young child may increase the risk of contracting breast cancer as an adult, research in America has claimed.
Thanks to the Huffington Post for this link. bm]
Researchers at the Harvard Medical School say that for every portion of chips eaten per week in the pre-school years, the risk of breast cancer is increased. The data comes from a long-running study into the health of 80,000 nurses who have been followed for decades by a team from the research institute. The Nurses’ Health Study has already produced many links between diet and disease, some disproved by further and better research.
The latest paper, in the International Journal of Cancer, used data from 582 women with breast cancer and 1,569 women without the disease in 1993.
The researchers looked at the diets of the women when they were aged between 3 and 5, using information from their mothers, who were asked how often their daughters ate or drank various products.
The risk of getting breast cancer by the age of 60 is about one in 25. Karin Michels and colleagues estimated that eating chips just once a week before the age of 5 would raise that to about one in 20 — an increase in risk of 27 per cent.
The team said that while eating potatoes was not associated with increased risk, the preparation of French fries — frying in fat high in saturated fats and trans-fatty acids — may be of relevance.
The Health Care Choice Act
I had not previously heard of this proposed legislation. It is called, The Health Care Choice Act, sponsored by Rep. John Shadegg of Arizona, and would increase the availability of private health care plans. The New Republic online has an article by Jonathan Cohn (free with registration) discussing this proposed legislation that exposes some of its drawbacks - apparently it would take away any state regulation of insurance. For an excellent and extra commentary on the Act and the New Republic article, see the Washington Monthly. [bm]
August 18, 2005
Race Still Matters: 3 Studies in NEJM
The NEJM published three "special reports" in today's issue, all pointing to persistent racial differences in access to care:
- Sex and Racial Differences in the Management of Acute Myocardial Infarction, 1994 through 2002
V. Vaccarino and Others
- Racial Trends in the Use of Major Procedures among the Elderly
A. K. Jha and Others
- Trends in the Quality of Care and Racial Disparities in Medicare Managed Care
A. N. Trivedi, A. M. Zaslavsky, E. C. Schneider, and J. Z. Ayanian
Black Americans still get far fewer operations, tests, medications and other life-saving treatments than whites, despite years of efforts to erase racial disparities in health care and help African Americans live equally long and healthy lives, according to three major studies being published today.
Blacks' health care has started to catch up to whites' in some ways, but blacks remain much less likely to undergo heart bypasses, appendectomies and other common procedures. They receive fewer mammograms and basic tests and drugs for heart disease and diabetes, and they have fallen even further behind whites in controlling those two major killers, according to the first attempts to measure the last decade's efforts to improve equality of care.
Together, the research paints a discouraging picture of the nation's progress in closing the gap for one of the fundamental factors that affect well-being -- health care -- during a period when blacks have made progress in areas such as income and education.
"We have known for 20 years that we have a problem in our health care system: that blacks and whites do not receive equal care. We had hoped all the attention paid to this topic would result in some improvement. What we found is we have not made much progress," said Ashish K. Jha of the Harvard School of Public Health, who led one of the studies published in the New England Journal of Medicine. "This should be a call to action to make the changes needed to make sure people get equal care."
Maryland Jails Mom Who Tested Positive for Cocaine
In a move that harkens back to South Carolina's prosecutorial initiative against cocaine-positive pregnant women, Maryland has sentenced to 2-1/2 years a woman who, along with her newborn, tested positive for cocaine, according to this morning's Baltimore Sun. The ACLU, which represents the woman on appeal, says:
"Nobody thinks it's a great idea to take cocaine while pregnant," said ACLU attorney David Rocah. "But the unanimous view of medical and public health professionals and drug treatment professionals is that if you want to stop people from doing that, the way to do that is to provide them with meaningful access to drug treatment and not criminally prosecute them."
This is a hard lesson for prosecutors to accept, but the courts have been pretty clear about the legal obstacles to such prosecutions:
Similar attempts to criminalize drug use by pregnant women became common in the United States during the crack scare of the late 1980s and early 1990s. But in dozens of cases, courts struck down criminal convictions as unconstitutional or beyond lawmakers' intent.
An exception is South Carolina, where about 70 women have been prosecuted for using drugs during pregnancy, according to a spokesman for the attorney general there. In 2001, the U.S. Supreme Court limited South Carolina's ability to mount such prosecutions by deeming drug tests administered without the mother's consent inadmissible in court.
It will be interesting to see what the Court of Appeals does with this one. According to the article, "One of the ACLU's main arguments against Cruz's conviction is that Maryland law defines reckless endangerment as conduct by one person that causes substantial risk of harm to another person, but that the term "person" does not legally include a fetus. In 1990, Maryland legislators rejected a bill that would have made prenatal drug use by women a felony."
FYI: In 2003, Texas amended its penal code so that "individual" means "a human being who is alive, including an unborn child at every stage of gestation from fertilization until birth" (Penal Code § 1.07(a)(26)). The legislature was careful, however, to make sure that the chapter on offenses against the person (including our reckless endangerment statute) "does not apply to conduct charged as having been committed against an individual who is an unborn child if the conduct is . . . committed by the mother of the unborn child" (id. § 22.12). [tm]
Misuse of Medical Research Funds Said to be Rampant
The August 17 Wall Street Journal (requires paid subscription) ran a front-page story on a suit against Cornell and 11 senior faculty for allegedly misusing NIH funds. The suit -- apparently a civil False Claims Act suit by a pediatrician at Cornell -- claimed that the money (which was intended to pay for nursing care for children enrolled in research studies) was diverted to pay for care for paying patients and for adults, and that some of the claimed studies were actually "phantom" studies. Cornell settled with the government for $4.4 million.
The article suggests this is only the tip of the iceberg:
The Cornell case exposes what some scientists call a dirty little secret of university medical research: the misuse of taxpayers' funds. The NIH last year funneled $20 billion to campus researchers, an amount that has doubled since the late 1990s. Now, a string of multimillion-dollar settlements by leading universities is showing how vulnerable the system has become to abuse.
Since the beginning of 2003, Northwestern University, Harvard University, Johns Hopkins University and the University of Alabama at Birmingham have agreed to civil settlements. In each case, the government alleged that the universities pledged to do one thing with their NIH money and then spent it on something else. This spring, the Mayo Clinic, Rochester, Minn., agreed to pay $6.5 million to settle charges it diverted money from one grant to other grants running short of funds. The institutions agreed to upgrade their accounting practices, but admitted no wrongdoing. All the cases except Harvard's began with whistleblowers; Harvard itself first alerted authorities to potential problems.
Physicians' RICO Suit Against MCOs Goes Forward
There's an interesting piece today in the on-line American Lawer about a federal lawsuit against 10 managed care companies claiming that they rigged their software so that legitimate claims for medically necessary and appropriate services were sytematically denied, adding as much as $10 billion to the companies' bottom line over the years. For their part, the defendants argue that their automated review procedures are are needed to spit out claims for which "the form was filled out incorrectly or because doctors are padding their bills. In a survey reported in the Journal of the American Medical Association in 2000, 39 percent of physicians admitted that they exaggerated the severity of patients' conditions, made up symptoms or altered diagnoses on claims." Here's a quick recap of the litigation history of the case:
The doctors brought their claims under the Racketeer Influenced and Corrupt Organizations Act and had some early success. In 2002 Moreno let the RICO claims go forward. The next year Whatley's team settled with Aetna Inc. and CIGNA Corp., two of the three largest health insurers. Aetna agreed to pay the doctors $500 million; CIGNA, $325 million. Both carriers agreed to modify their practices. They will, for example, no longer ignore exams like the one that Abidin performed.
In 2004 the case hit a setback when the U.S. Supreme Court ruled, 8-0, that insurers could force the doctors in their networks to arbitrate the RICO claims. To keep the case -- and the possibility of triple damages -- alive, Whatley's team switched tacks. The doctors dropped all their claims against the insurers with whom they had contracts, in order to avoid a binding arbitration clause in those contracts. Now the doctors are suing those insurers with whom they did not have a contract -- their insurers' competitors.
Klein, the insurers' lawyer, says the move was transparent. "They sue everybody else for conspiring with the company who they actually have the contract with," says Klein. "It's an absurd proposition." Yet the 11th U.S. Circuit Court of Appeals approved the doctors' reformulation of their case in November 2004; then, on May 31, the Supreme Court declined to intervene a second time, moving the case toward trial. Since that time, four smaller defendants have settled and have agreed to modify their practices. Health Net Inc., Prudential Insurance Company of America, Anthem Inc., and Wellpoint Health Networks Inc. will also pay a total of $200 million before legal fees.
More Public Hospitals Lost Than Private in Recent Years
Modern Healthcare's Daily Dose reported yesterday that "[t]he number of U.S. public hospitals declined at a faster rate than private hospitals from 1996 to 2002, especially in suburban areas, and public hospitals treated patients for longer lengths of stay." Here are the numbers:
The number of public hospitals in the suburbs of the nation's 100 largest cities fell 27% to 98 in 2002 from 134 in 1996. The number in the cities themselves dropped 16% during the same period, to 70 from 83. The number of private hospitals also shrank in both the top 100 cities and their suburbs, although not as rapidly . . . . The loss of private hospitals was 4% in suburban areas, as the total fell to 741 in 2002 from 772 in 1996, and 11% in the cities, as the total fell to 575 from 647.
The numbers are from a study by State University of New York Downstate Medical Center, New York. The report's "Summary and Conclusions" section is well worth reading in its entirety:
Our conclusions reflect analysis of hospital utilization and capacity in the 100 largest cities and surrounding suburban areas for the years 1996 to 2002.
The results by hospital ownership showed that the role of public hospitals, while highly significant as a safety net provider in both cities and suburbs, appears to be diminishing, as measured by their larger percentage losses and declining volume of total and Medicaid admissions in the largest cities. The analysis by community poverty levels revealed vast city-suburban differences in the distribution of hospital services and resources across low, medium and high poverty groups relative to their proportions of population. These patterns and trends raise questions about the future of the hospital safety net and its ability to adequately serve the most vulnerable residents, particularly in high poverty cities and suburbs, and about the appropriateness of the level of hospital resources concentrated in low and high poverty suburban areas.
Trends in Hospital Ownership
Our review of hospitals by ownership in the largest cities and suburbs revealed several trends about their total numbers and composition, their average size and growth in volume of care, and their share of Medicaid patients. The downward trend in the number of hospitals and total hospital beds in large metropolitan areas continued, with public hospitals showing the largest declines (16% in cities and 27% in suburbs) and the greatest decrease in the percentage of beds. These trends also represent an acceleration in the closing or merging of urban public hospitals, which declined by only 14 percent over a 16-year period between 1980 and 1996, and a continuation of a steep drop in suburban public hospitals, which declined by 43 percent over the same 16-year period.
The remaining urban public hospitals continued to be the largest providers as measured by their average bed size, but their presence across the urban landscape is diminishing. By 2002, non-profit hospitals had essentially pulled even with public facilities in admissions per hospital. Urban public hospitals also provided less inpatient and emergency care in 2002 than in 1996, while other hospital groups saw steady growth. By 1999, for-profit hospitals had surpassed public hospitals in staffed beds and total admissions for the 100 largest cities.
Of the remaining suburban public hospitals, average bed size increased by 26 percent, from 1996 to 2002, suggesting that relatively smaller public hospitals dominated the closings (or conversions/mergers). Correspondingly, the average increase in utilization measures per hospital were large, relative to suburban for-profit and non-profit hospitals. Given that the remaining suburban public hospitals are much larger, and perhaps more vital than ever to the communities they serve, one question is whether their numbers will stabilize or continue to decline.
Hospital Ownership and Medicaid Patients
As safety net providers, public institutions have provided the bulk of hospital care for Medicaid patients. In cities, public hospitals continued to have the largest proportion of Medicaid discharges, while in the suburbs, the proportions were similar across hospital ownership groups. Urban public hospitals were the only group to have a smaller percentage of Medicaid discharges in 2002 than in 1996, while all other groups saw their Medicaid share of total admissions increase by 4 percent to 15 percent.
We also note that public hospitals in urban and suburban areas had both the longest Medicaid ALOS, and the steepest rise in Medicaid ALOS between 1996 and 2002. The results suggest that, on average, public hospitals treat more seriously ill Medicaid patients than the other hospital types.
What do these findings say about metropolitan area hospitals and their Medicaid patients? They suggest that the landscape for Medicaid hospital care may be shifting. Remaining public hospitals may be diversifying their patient mix to improve their bottom line. These trends could also signal an increasing role for non-profit and for-profit community hospitals as safety net providers, a more even distribution of safety net care responsibilities, and/or an attempt to increase market share by attracting healthier, more profitable Medicaid enrollees.
Hospitals in Low, Medium and High Poverty Urban and Suburban Areas
Our review of hospital capacity and utilization by community poverty levels tells a dramatically
different story for urban than suburban areas. High poverty cities accounted for a somewhat larger proportion of hospital use relative to their proportion of the total urban population, while the opposite was true for low poverty suburbs. The availability of specialty services such as trauma care, and PET scanners across the urban poverty groups was generally in line with the population distribution across these groups. Only with NICU beds was capacity proportionally greater in low poverty cities relative to their percentage of urban population.
At the same time, the overall and Medicaid average lengths of stay for hospitals in high poverty cities were the highest among urban areas, suggesting that these hospitals are serving relatively sicker patients compared with hospitals in low and medium poverty cities. Other research supports the effect of an “urban health penalty,” that is, higher rates of disease and mortality in cities with higher rates of poverty.
Among suburban areas, high poverty communities represented the greatest proportion of suburban population in 2000 but had the smallest proportion of total inpatient use, outpatient use, level 1 or level 2 trauma centers, and PET scanners in 2002. The opposite was true of low poverty suburbs, which represented the smallest proportion of total suburban population, but had the largest proportions of suburban hospital use and specialty care capacity. Low poverty suburbs also saw exponential growth in the number of hospital PET scanners between 1996 and 2002 and the largest increase in NICU beds.
This lopsided distribution of hospital resources and use suggests that low poverty suburban areas may be attractive markets for hospitals. The population characteristics suggest that, on average, residents of low poverty suburbs are the most affluent residents of metropolitan America, and likely are the best insured. By the same token, hospital systems may be reluctant to expand into high poverty suburbs. Although we do not have data on uninsured rates for these areas, we noted earlier that the high poverty suburban areas averaged the largest percentages of Hispanic and foreign-born populations. Surveys have documented these groups as having among the highest uninsured rates in the country. A lack of health coverage may be a contributing factor in the relatively small proportion of hospital resources available in high poverty suburbs.
Between 1996 and 2002, these high poverty areas also saw the greatest decline in the number of suburban hospitals, which may exacerbate access problems, particularly for those with limited or no insurance and limited transportation options. Perhaps as an indicator of unmet need for primary care as well, hospitals in high poverty suburbs had the greatest increase in emergency department visits of all city or suburban poverty areas. The findings raise questions about whether residents in high poverty suburban areas, especially those who are poor or uninsured, will become increasingly dependent on nearby city public hospitals. This contention has already surfaced in Dallas, where the president of the city's public hospital stated that indigent or uninsured patients residing in five surrounding suburban counties accounted for 16 percent of the hospital's $1.2 billion in uncompensated care in 2002. This situation in Dallas and other cities creates the potential for a backlash among urban taxpayers about the care of suburban residents in their public hospitals.
Finally, the financial situation of hospitals in both urban and suburban high poverty areas raises concerns about their future–more so than with facilities in low and medium poverty cities and suburbs. Hospital operating margins were generally the lowest among hospitals in high poverty cities and suburbs. Hospitals in these areas also saw the smallest increases in net revenues and the smallest rise in Medicaid net revenues, and yet they have the greatest dependence on this payer.
Implications for Availability and Access to Care
What do these results by ownership and poverty say about the future of hospital care in urban and suburban areas? Although it is not possible to draw conclusions about the specific roles and changes of each community's hospital safety net, the continued losses of public hospitals in both cities and suburbs inject uncertainty as to where the sickest of the poor and the uninsured will access care in the future.
The fallout from these changes in cities may differ significantly from the suburbs. In large central cities, the size of public and other primary safety net institutions, their constituency, their presence as an employer and the political issues surrounding their status suggest that communities are more likely to demand a careful assessment of impact, as well as a viable, alternative safety net plan. Suburban areas losing their public or primary safety net hospitals may be less likely to have the strong constituencies found in central cities. As a result, there may be a less vocal and concerted effort to assure a viable alternative is available. Ultimately, regional cooperation may be required to ensure adequate financing and access to hospital care for the area's poor and uninsured, particularly in metropolitan areas with a high poverty central city or high poverty suburban area.
More on Medicaid
The New York Times has an article today discussing the debate occurring over whether to raise Medicaid co-pays. It states,
The Bush administration clashed with doctors on Wednesday over the merits of a proposal to charge higher co-payments to Medicaid recipients, with doctors warning that the fees could deter some poor people from seeking necessary medical care.
The debate came at a meeting of a federal advisory panel appointed by the administration to help rein in the growth of Medicaid, which provides health insurance to more than 50 million low-income people.
Congress may use the panel's advice as a basis for legislation this fall.
Under the current Medicaid law and rules, co-payments for most adults cannot exceed $3 for goods and services like prescription drugs, visits to doctors and outpatient hospital visits. For children younger than 18, co-payments are not allowed.
The panel, known as the Medicaid Commission, is considering an option that would allow states to charge higher co-payments, $5 for adults and $3 for children.
Michael J. O'Grady, a member of the panel who is also an assistant secretary of health and human services, said the higher co-payments would make beneficiaries more "price-sensitive" and would not impose an undue burden.
"We are talking about the price of a pack of cigarettes," Mr. O'Grady said. He noted that the maximum co-payments had not been changed since the early 1980's.
This doesn't look good for the future of Medicaid . . . . [bm]
The L.A. Times recently ran some interesting pieces on need for tort reform. Although not specifically focused on medical malpractice, it does provide an overview of some of the efforts by business to "reform" our tort system and points out that these reforms are based on a number of urban legands. The article states,
Merv Grazinski set his Winnebago on cruise control, slid away from the wheel and went back to fix a cup of coffee.
You can guess what happened next: The rudderless, driverless Winnebago crashed.
Grazinski blamed the manufacturer for not warning against such a maneuver in the owner's manual. He sued and won $1.75 million.
His jackpot would seem to erase any doubt that the legal system has lost its mind. Indeed, the Grazinski case has been cited often as evidence of the need to limit lawsuits and jury awards.
There's just one problem: The story is a complete fabrication.
It is one of the more comical tales in an anthology of legal urban legends that have circulated widely on the Internet, regaling millions with examples of cluelessness and greed being richly rewarded by the courts. These fables have also been widely disseminated by columnists and pundits who, in their haste to expose the gullibility of juries, did not verify the stories and were taken in themselves.
Although the origins of the tales are unknown, some observers, including George Washington University law professor Jonathan Turley, say their wide acceptance has helped to rally public opinion behind business-led campaigns to overhaul the civil justice system by restricting some types of lawsuits and capping damage awards. . . .
The LA Times has further articles on this topic available here and here (with registration). The ever-helpful Ezra Klein posts a link to the story with commentary as well as to an earlier piece that he wrote concerning de-bunking the medical malpractice aspects of tort reform. [bm]
August 17, 2005
Medical Marijuana Ruling Analyzed
There's a decent summary of Gonzales v. Raich in Thursday's issue of the New England Journal of Medicine, which -- in a rare departure from their usual editorial policy -- is making the article available on-line for free. Despite a rookie error by the physician-author (identifying the court to which the case has been remanded as "California's Court of Appeals for the Ninth Circuit"), the article includes a brief summary of some of the research that shows, contrary to marijuana's classification in the Controlled Substances Act (see 21 USC § 812(b)(1), (c)(Sched. I)(10) , some medicinal value of the drug. [tm]
Deepak Chopra has an article on the Huffington Post concerning spontaneous remission in cancer. He states,
One of the great mysteries in medicine is the phenomenon of spontaneous remission in chronic illness, particularly in cancer. This week the American Cancer Society and Yahoo are presenting a series of blogs on people's struggles with cancer. I will be posting a case report on one such case specifically a woman with breast cancer who had a remission lasting several years.
. . . . Spontaneous remission is a rare but spectacular phenomena. The cancer disappears spontaneously and there is still no adequate scientific explanation that satisfies physicians completely. When I was a medical student, spontaneous remissions were known as "miracle cures." I personally do not like the term because a miracle camouflages our ignorance of what is really happening. When we do not have an explanation for something, we call it a miracle. When we have explanation for the same phenomenon, we call it science. Yesterday's "miracles" are today's science and today's miracles will be tomorrow's science.
Further information and posts by Deepak Chopra on this topic can be found here. [bm]
Indeed, Medicaid stands, at the moment, as perhaps the underreported domestic policy issue of any real political salience. As George W. Bush’s handpicked (and predictably slanted) Medicaid Commission prepares to issue a report next month with recommendations for cutting $10 billion from the federal portion of the program over the next five years, the president has already circulated a draft proposal to Congress with the administration’s own suggestions, which focus largely on hindering state accounting maneuvers that help to bring in more federal financing.
The program, meanwhile, faces more dramatic threats from the states. Long the dumping ground for refugees of the slowly collapsing employer-based healthcare system, Medicaid's ranks follow countercyclical patterns but have consistently expanded over time. (Currently the program covers about 53 million people.) That growth, combined with the general rise in health-care costs, has helped to swamp state budgets and provoke a harsh response from governors. The Bush administration has encouraged such responses by loosening restrictions on states seeking federal waivers to rejigger their programs. The general thrust of recent waiver reforms in the states -- increased cost-sharing with recipients and reduced services -- has been straightforward, and the results have been predictable: reductions in coverage and care (both PDFs). The National Governors Association (NGA) is now calling for (PDF) a series of national Medicaid policy changes along these same punitive lines.
National Public Radio's Morning Edition had a brief discussion of some of the proposed changes at the state level yesterday and you can listen here.
August 16, 2005
Scotusblog has posted the government's brief in the Ayotte v. Planned Parenthood of New England, the challenge to New Hampshire's parental notification law. You can access the brief here. There is more commentary on the Supreme Court's abortion cases here and here. [bm]
Being a Patient - Check Dignity at the Door
The New York Times has an article on the lack of respect for the patient dignity in hospitals today and its impact on how patients view quality of care. The Times reports,
Entering the medical system, whether a hospital, a nursing home or a clinic, is often degrading. At the hospital where Ms. Duffy was a patient and at many others the small courtesies that help lubricate and dignify civil society are neglected precisely when they are needed most, when people are feeling acutely cut off from others and betrayed by their own bodies.
Larger trends in medicine have made it increasingly difficult to deliver such social niceties, experts say. Many hospital budgets are tight, and nurses are spread thin: shortages are running at 15 percent to 20 percent in some areas of the country. Average hospital stays have also shortened in recent years, making it harder for patients to build any rapport with staff, or vice versa.
Some hospitals have worked to address patients' most serious grievances. But in interviews and surveys, people who have recently received medical care say that even when they benefit from the expertise of first-rate doctors, they often feel resentful, helpless and dehumanized in the process.
In a nationwide survey of more than 2,000 adults published last fall, 55 percent of those surveyed said they were dissatisfied with the quality of health care, up from 44 percent in 2000; and 40 percent said the quality of care had gotten worse in the last five years. The survey was conducted by Harvard University, the federal Agency for Healthcare Research and Quality and the Kaiser Family Foundation, an independent nonprofit health care research group.
"The point is that when they talk about quality of health care, patients mean something entirely different than experts do," said Dr. Drew Altman, president of the Kaiser Foundation. "They're not talking about numbers or outcomes but about their own human experience, which is a combination of cost, paperwork and what I'll call the hassle factor, the impersonal nature of the care."
It doesn't look like hospital stays are becoming more pleasant. [bm]
August 15, 2005
Confidential Nursing Home Settlements in Viriginia Are Raising Protests
The Washington Post reports that the U.S. Attorney's office for Eastern Virginia has settled federal allegations for poor care with owners of seven Virginia nursing homes and two management companies. U.S. Attorney Paul McNulty of the this office calls these settlement agreements innovative. Instead of fining the nursing homes and companies, they require that the owners re-invest the money in nursing home improvements, i.e., hiring more employees and a consultant. In return, the settlements become confidential.
David L. Sadowski, executive director of the Crater District Area Agency on Aging, says he is surprised that the U.S. Attorney would make confidential settlements since that practice is "defeating to the public." He insists that all federal actions against nursing homes should be disclosed. The Washington Post reports that "although it is not uncommon for private lawyers to keep settlements secret, the idea that federal prosecutors would withhold information about nursing home quality has confused and angered some advocates."
These settlements with the Alexandria office seem to run contrary to recent federal efforts to make nursing home care and its deficiencies more transparent. Some U.S. attorneys in other states even list nursing home settlements on their Web pages. Medicare also publishes information about staffing levels and deficiencies in care on their website. Even the Senate is pushing for greater transparency in nursing home care. Senator Charles Grassley (R-Iowa) has introduced a bill that would require the Department of Justice to report details of settlements exceeding $100,000.
However Paul McNulty argues that his office has been trying to shift the focus of nursing home cases from paying fines to improving care. He says that "the principal difference between this approach and others . . . is using those monies to improve the facilities themselves." He thinks working with the owners to fix the problems as opposed to putting money into the federal treasury is a better solution. McNulty has made one of the most recent settlements with Beverly Healthcare public. In that case, the owners were required to spend $315,000 to hire five additional caregivers and an outside expert; in exchange, the owners denied any wrongdoing.
Alice H. Hedt, executive director of the National Citizens' Coalition on Nursing Home Reform says that "the public has a right to know if a facility has been sanctioned, what the sanction was and what it was for." She says further that "a fine is one of the few things in our system that is a very clear indicator that the facility has experienced very serious problems." The U.S. Attorney in Pennsylvania, David Hoffman, thinks that "as much information as you can have in making a selection of a nursing home is critical...that's one of the reasons we make public all of our nursing home settlements. It's important for the consumers, who have a stake in this, and to keep the homes honest."
Thanks to Lindley Bain for help with this post. [tm]
Flaws in Medical Studies Discovered
The Boston Globe reports on the some serious potential problems of peer reviewed medical research, i.e., it doesn't seem to be catching flaws in many studies. The Boston Globe reports,
They are two of the most widely publicized pieces of medical research in recent years: Reports in prestigious journals declared that women who underwent hormone replacement therapy, and people who ingested large amounts of Vitamin E, had relatively low rates of heart disease.
But after research contradicted those studies -- frustrating anyone who had followed their recommendations -- some specialists began looking at whether peer review had failed to identify serious flaws in the research.
But the specialists found that it was almost impossible to discover what had happened in the vetting process, since peer reviewers are unpaid, anonymous, and unaccountable. Moreover, their reviews are kept confidential, making it impossible to know the parameters of the reviews.
Now, after a study that sent reverberations through the medical profession by finding that almost one-third of top research articles have been either contradicted or seriously questioned, some specialists are calling for radical changes in the system.
In advance of a world congress on peer review next month in Chicago, these specialists are suggesting that reviewers drop their anonymity and allow comments to be published. Some are proposing that peer reviewers be paid to ensure a more even quality of review and analysis among all journals.
Dr. Drummond Rennie, who relies on review as deputy editor of JAMA, the Journal of the American Medical Association, said of the process, ''The more we look into it, the harder it is to prove whether it does good or bad."
Rennie has called for greater study of whether peer review improves research, and he has a personal policy of disclosing his name when he reviews articles.
''It would be lovely to start anew and to set up a trial of peer review against no peer review," Rennie said. ''But no journal is willing to risk it."
Rennie's journal published the study, which said that subsequent research had found that almost one-third of the top papers that appeared in top journals over a 13-year period from 1990 to 2003, had been either contradicted or found to have potentially exaggerated results. All the articles had undergone vigorous peer review, leading to questions about whether problems should have been caught by reviewers.
Prescription Drug Monitoring
The new law creates a grant program for states to create databases and enhance existing ones in hopes of ending the practice of "doctor shopping" by drug abusers seeking multiple prescriptions. It would authorize $60 million for the program through fiscal 2010. . . . .
A July letter from the American Medical Association in support of the bill called prescription drug abuse "one of the fastest growing public health problems" in the United States. The letter cited a 2002 Substance Abuse and Mental Health Services Administration survey that estimated there were 6.2 million recreational prescription drugs users then.
The bill passed the House by voice vote and the Senate by unanimous consent in July. . . .
Some in Congress worry the law will invade privacy. "This bill lacks fundamental privacy protections, such as notifying patients if their information has been lost or stolen," said Democratic Rep. Edward J. Markey of Massachusetts, whose amendment to add that notification to the bill was defeated in committee. "The lack of such safeguards virtually guarantees that this well-meaning effort to combat drug abuse will become a scandalous invasion of the privacy of innocent bystanders."
Thanks to TalkLeft for the website and information. [bm]
Euthanasia Legal In Colombia
According to the AP, Colombia is the only country in Latin America where the practice of active euthanasia is legal (see also MSNBC). In 1997, the Colombian Constitutional Court ruled 6-3 that an individual may choose to end his life and that doctors can't be prosecuted for their role in helping. The majority opinion said that "no person can be held criminally responsible for taking the life of a terminally ill patient who has given clear authorization to do so." The court defined a "terminally ill" person as someone with diseases such as cancer, AIDS, and kidney or liver failure if they are terminal and the cause of extreme suffering. However, the ruling specifically refused to authorize euthanasia for patients with degenerative diseases such as Alzheimer's, Parkinson's, or Lou Gehrig's disease.
Even though the court urged the Colombian Congress to codify and regulate the practice to prevent abuses, Congress has not taken up the issue. Colombia is a predominantly Roman Catholic country, and lawmakers have been reluctant to tackle such a contentious issue. However, the judge who wrote the majority opinion is now a senator and has submitted a bill to Congress to regulate the practice of euthanasia and establish clear guidelines. The guidelines proposed are similar to those in the Netherlands and Belgium, where doctors must seek second opinions, give patients rigorous mental health tests, and have cases reviewed by government commissions. Currently, the patient and his doctor are the sole decision makers, and there is no legal obligation to report it to authorities.
One Colombian doctor who has practiced euthanasia comments that "it's never easy, but I do it out of respect and affection for my patients."
Thanks to Lindley Bain for help with this post. [tm]