Wednesday, August 30, 2006
ThinkProgress reports on the latest census data concerning insurance. There are now 46.6 million people without health insurance, an increase from last year's 45.3 million. I have tried to reproduce the graph below but unfortunately I am having some technical difficulties. Thanks to firedoglake for the update.
Friday, August 25, 2006
Ezra Klein points to an interesting article on the KaiserNetwork.Org that reviews a recent study in the August edition of the Journal of General Internal Medicine. The study discusses the unexpected people who are selected to be health care proxies when individuals are asked by their doctors for emergency contacts and proxies. Some of the findings:
28% of participants selected someone other than their emergency contacts;
One-third of married participants did not select their spouses;
Participants selected their daughters three times more often than their sons and their sisters two times more often than their brothers; and
About one-fourth of participants said that physicians had never previously asked them to select a proxy.
Since I don't have any daughters, perhaps I need to start talking to my friends in more detail about my health care wishes . . . . On a more serious note, I did find the comments on Ezra's blog below the article to be very revealing and informative.
Thursday, August 24, 2006
National Public Radio had a thorough report on the recent compromise to permit Plan B to be over-the-counter for those women who are age 18 and over. More information can be found in the New York Times. It reports:
The F.D.A.’s acting commissioner, Andrew C. von Eschenbach, wrote that he decided that 18 was the appropriate cutoff for sales because pharmacies already restrict nicotine and cold medicines sales at that age.
“This approach builds on well-established state and private-sector infrastructures to restrict certain products to consumers 18 and older,” Dr. von Eschenbach wrote in a memorandum.
Dr. von Eschenbach’s predecessor, Dr. Lester M. Crawford, said last year that science supported giving over-the-counter access of the drug to women as young as 17, but that he could not figure out how to ensure that such an age restriction was enforced.
The agency has now decided that it will depend upon Barr to enforce the rules. Barr’s chairman, Bruce L. Downey, said in an interview that the company would rely on pharmacists to abide by the restrictions. Barr will not sell the pills to convenience stores, and the company will conduct surveys to measure whether the restrictions are being followed, Mr. Downey said.
According to the Times article, both sides of the debate over Plan B's availability are not happy with this result. Those who wished for over-the-counter access believe that younger women may be injured by having to obtain a prescription for its use and those who opposed Plan B's over-the-counter availability believe that its increased availability will lead to an increase in sexually transmitted disease.
Wednesday, August 23, 2006
Slate.com's Mickey Kaus has an interesting post concerning universal health care and receives some interesting replies to his proposal. Here is a brief excerpt:
Matthew Yglesias takes issue with my suggestion that a "decent" national health care system, added on top of our current Social Security system, will require a "larger tax burden than citizens are willing to bear." He argues:
The U.S. government currently spends a phenomenal sum of money on health care by world standards ... [W]hen you're talking about universal health care you're not really talking about increasing the aggregate resources poured into American health care. There's already tons of money being spent on it. You're talking about redistributing the spending somewhat from richer to less-rich people and altering the path through which the money flows.
I'm not a health care expert, but it seems to me:
1) If we want a system that reinforces social equality--everyone in the same waiting room-- that means we need basically the bottom 90% to use the same system. The hardest (i.e. impossible) way to do this is by forcing the affluent to get less care than they are willing to pay for ("redistributing the spending somewhat from richer to less-rich people," as Yglesias tactfully puts it.) The easiest way to do that is to offer subsidized universal care good enough so that the vast majority of the affluent will be content to use it. In other words, you can't just "insure" the poor with bare-bones HMO treatment. This will be expensive.
2) Medical technology will offer more and more complex and costly ways to treat illness. Some of these treatments will work. We want to offer them to everyone, with a minimum of rationing--again, in a system that most of the affluent will also sign up for. The alternative seems to be a system in which the upper middle class lives (because they can afford fancy treatments) and the working poor die. Avoiding this will be expensive.
3) We will still want to encourage future medical research and technological advance--or at least we want to retard it as little as possible. That's why I'm skeptical of some plans for realizing huge cost savings. For example, the government could undoubtedly use its monopsony power to lower the price it pays for drugs--maybe lower the price to something approaching the marginal cost of producing additional pills. It's not at all clear, however, that this is the price we should want to pay, because it does little to fund research and development costs of developing both the existing drug and new drugs. See Michael Kinsley's analysis here. Paying medical providers enough to fund future advances will be very expensive.
It is an interesting debate!
Monday, August 21, 2006
This article appeared last week in the New York Times and discusses China's growing mummified body business:
Inside a series of unmarked buildings, hundreds of Chinese workers, some seated in assembly line formations, are cleaning, cutting, dissecting, preserving and re-engineering human corpses, preparing them for the international museum exhibition market.
“Pull the cover off; pull it off,” one Chinese manager says as a team of workers begin to lift a blanket from the head of a cadaver stored in a stainless steel container filled with formalin, a chemical preservative. “Let’s see the face; show the face.”
The mastermind behind this operation is Gunther von Hagens, a 61-year-old German scientist whose show, “Body Worlds,” has attracted 20 million people worldwide over the past decade and has taken in over $200 million by displaying preserved, skinless human corpses with their well-defined muscles and sinewy tissues.
But now with millions of people flocking to see “Body Worlds” and similar exhibitions, a ghastly new underground mini-industry has emerged in China.
With little government oversight, an abundance of cheap medical school labor and easy access to cadavers and organs — which appear to come mostly from China and Europe — at least 10 other Chinese body factories have opened in the last few years. These companies are regularly filling exhibition orders, shipping preserved cadavers to Japan, South Korea and the United States.
Fierce competition among body show producers has led to accusations of copyright theft, unfair competition and trafficking in human bodies in a country with a reputation for allowing a flourishing underground trade in organs and other body parts.
Here in China, determining who is in the body business and where the bodies come from is not easy. Museums that hold body exhibitions in China say they have suddenly “forgotten” who supplied their bodies, police officials have regularly changed their stories about what they have done with bodies, and even universities have confirmed and then denied the existence of body preservation operations on their campuses. . . .
Worried about a growing trade in illegal bodies, the Chinese government issued new regulations in July that outlawed the purchase or sale of human bodies and restricted the import and export of human specimens, unless used for research. But it is unclear how the regulations will affect the factories. . . .
Experts say exhibitions featuring preserved bodies are now among the most popular attractions at American science and natural history museums. While the shows have not appeared at two of the most respected museums — the Smithsonian and the American Museum of Natural History in New York — they have appeared at major museums in Chicago, Houston and Los Angeles. . . .
The industry is dogged by questions about the origins of the corpses. Premier says its exhibition uses unclaimed Chinese bodies that the police have given to medical schools. None of the bodies, it says, are those of executed prisoners or people who died of unnatural causes. . . .
Officials at the Customs Bureau here in Dalian and the Dalian Medical University, however, said they had no records showing the supplier of Premier having acquired bodies and then transporting them to exhibitions abroad.
“I don’t know where the bodies came from,” said Meng Xianzhi, a spokesman for the university.
Dr. von Hagens, who opened the first large-scale body preservation factory here in Dalian in 1999, said he abided by the regulations.
The fierce rivalry between Premier and Dr. von Hagens’s company, the Institute of Plastination, has moved to the courts, over everything from copyright claims to rights to the name “Body World.” They have each publicly hinted that their rival is engaging in unethical behavior in acquiring bodies in China.
Although the exhibitions appear to have some educational value, I am not sure they are worth it when the bodies apparently could have been donated involutarily.
Ezra Klein has an interesting post on the Cuban health care system. Apparently some individuals seem to think it is a system to be copied. However, he provides an educational counterpoint to this view:
I'm always skeptical when I hear good liberals waxing rhapsodic about the wonders of the Cuban health care system. Not only is there a total dearth of decent data on the country's care, but what does exist tends to be agenda-driven and ideologically colored. But it is interesting to read why Hilda Molina, one of the countries most honored and highly placed surgeons, resigned her position and became a hated enemy of Fidel's:
In 1989, Dr. Molina realized a longtime dream by getting the government to establish the International Center for Neurological Restoration. The center conducted research and treated Cubans from all walks of life for maladies such as strokes and epilepsy. Fidel Castro would come for visits, often with foreign dignitaries in tow. "It was a point of pride that Cuba could have such an advanced facility," says Dr. Molina, who was rewarded with a seat in the Cuban Parliament. . . .
But in the 1990s, the collapse of the Soviet Union, which had bankrolled the Castro regime, began undermining the project to which Dr. Molina had dedicated her life. Dr. Molina says authorities ordered her to begin setting aside more beds for paying foreign patients, rather than ailing Cubans. "It was all about earning hard currency for the government," she says.
The entire piece is well worth a read as we wait to see how well Fidel Castro recovers.
Tuesday, August 15, 2006
Monday, August 14, 2006
The truly terrific and now recently graduated Jim Tomasewski points out this article in the New England Journal of Medicine entitled, "Language Barriers to Health Care," by Dr. Glenn Flores.
Here is a brief excerpt:
Inadequate communication can have tragic consequences: in one case, the misinterpretation of a single word led to a patient's delayed care and preventable quadriplegia.1 A Spanish-speaking 18-year-old had stumbled into his girlfriend's home, told her he was "intoxicado," and collapsed. When the girlfriend and her mother repeated the term, the non–Spanish-speaking paramedics took it to mean "intoxicated"; the intended meaning was "nauseated." After more than 36 hours in the hospital being worked up for a drug overdose, the comatose patient was reevaluated and given a diagnosis of intracerebellar hematoma with brain-stem compression and a subdural hematoma secondary to a ruptured artery. (The hospital ended up paying a $71 million malpractice settlement.)
In 1998, the Office for Civil Rights of the Department of Health and Human Services issued a memorandum regarding the prohibition, under Title VI of the Civil Rights Act of 1964, against discrimination on the basis of national origin — which affects persons with limited English proficiency. This memorandum states that the denial or delay of medical care because of language barriers constitutes discrimination and requires that recipients of Medicaid or Medicare funds provide adequate language assistance to patients with limited English proficiency. In 2000, a presidential executive order was issued on improving such persons' access to services. Thirteen states currently provide third-party reimbursement (through Medicaid and the State Children's Health Insurance Program) for interpreter services. Unfortunately, most of the states containing the largest numbers of patients with limited English proficiency have not followed suit, sometimes citing concerns about costs. Although the Office for Civil Rights issued guidelines in 2003 that seem to allow health care facilities to opt out of providing language services if their costs are too burdensome, Title VI provides no such exemption.
Ad hoc interpreters, including family members, friends, untrained members of the support staff, and strangers found in waiting rooms or on the street, are commonly used in clinical encounters. But such interpreters are considerably more likely than professional interpreters to commit errors that may have adverse clinical consequences.1,5 Ad hoc interpreters are also unlikely to have had training in medical terminology and confidentiality; their priorities sometimes conflict with those of patients; and their presence may inhibit discussions regarding sensitive issues such as domestic violence, substance abuse, psychiatric illness, and sexually transmitted diseases.5 It is especially risky to have children interpret, since they are unlikely to have a full command of two languages or of medical terminology; they frequently make errors of clinical consequence; and they are particularly likely to avoid sensitive issues.1,5 Given the documented risks associated with the use of ad hoc interpreters, it is of concern that the 2003 guidance from the Office for Civil Rights states that such use "may be appropriate."
Later this year, the California legislature will consider a bill prohibiting state-funded organizations from using children younger than 15 years of age as medical interpreters. Leland Yee, the California speaker pro tempore, proposed the bill, prompted by his experiences interpreting for his mother and, later, as a child psychologist. The bill requires organizations receiving state funding to establish a procedure for "providing competent interpretation services that does not involve the use of children."
Although this legislation may emerge as a state model, as an unfunded mandate, it will have limited power to improve care. Perhaps the time has come for payers to be required to reimburse providers for interpreter services. The provision of adequate language services results in optimal communication, patient satisfaction, outcomes, resource use, and patient safety.1,5 A 2002 report from the Office of Management and Budget estimated that it would cost, on average, only $4.04 (0.5 percent) more per physician visit to provide all U.S. patients who have limited English proficiency with appropriate language services for emergency-department, inpatient, outpatient, and dental visits. This seems like a small price to pay to ensure safe, high-quality health care for 49.6 million Americans.
The entire piece is well worth a read.
Here is an excerpt from last week's table of contents for JAMA concerning violence and human rights:
> Violence/Human Rights: 2 August 2006; Vol. 296, No. 5
> URL: http://jama.ama-assn.org/content/vol296/issue5/index.dtl?etoc
> This Week in JAMA
> This Week in JAMA
> JAMA 2006;296 477
> Original Contributions
> Neuropsychological Outcomes of Army Personnel Following Deployment to the
> Iraq War
> Jennifer J. Vasterling; Susan P. Proctor; Paul Amoroso; Robert Kane;
> Timothy Heeren; Roberta F. White
> JAMA 2006;296 519-529
> Approaches to Screening for Intimate Partner Violence in Health Care
> Settings: A Randomized Trial
> Harriet L. MacMillan; C. Nadine Wathen; Ellen Jamieson; Michael Boyle;
> Louise-Anne McNutt; Andrew Worster; Barbara Lent; Michelle Webb; for
> the McMaster Violence Against Women Research Group
> JAMA 2006;296 530-536
> Mental Health Problems Among Adults in Tsunami-Affected Areas in Southern
> Frits van Griensven; M. L. Somchai Chakkraband; Warunee Thienkrua;
> Wachira Pengjuntr; Barbara Lopes Cardozo; Prawate Tantipiwatanaskul;
> Philip A. Mock; Suparat Ekassawin; Anchalee Varangrat; Carol Gotway;
> Miriam Sabin; Jordan W. Tappero; for the Thailand Post-Tsunami
> Mental Health Study Group
> JAMA 2006;296 537-548
> Symptoms of Posttraumatic Stress Disorder and Depression Among Children in
> Tsunami-Affected Areas in Southern Thailand
> Warunee Thienkrua; Barbara Lopes Cardozo; M. L. Somchai Chakkraband;
> Thomas E. Guadamuz; Wachira Pengjuntr; Prawate Tantipiwatanaskul;
> Suchada Sakornsatian; Suparat Ekassawin; Benjaporn Panyayong; Anchalee
> Varangrat; Jordan W. Tappero; Merritt Schreiber; Frits van Griensven;
> for the Thailand Post-Tsunami Mental Health Study Group
> JAMA 2006;296 549-559
> Anxiety, Depression, and Posttraumatic Stress in Iranian Survivors of
> Chemical Warfare
> Farnoosh Hashemian; Kaveh Khoshnood; Mayur M. Desai; Farahnaz
> Falahati; Stanislav Kasl; Steven Southwick
> JAMA 2006;296 560-566
Thanks to Jim T. for the link.
Sunday, August 13, 2006
The New York Times has an article on the recent decision to loosen regulations on the use of prisoners to test experimental drugs. The article, entitled"Panel Suggests Using Inmates in Drug Trials"and written by Ian Urbina, states:
An influential federal panel of medical advisers has recommended that the government loosen regulations that severely limit the testing of pharmaceuticals on prison inmates, a practice that was all but stopped three decades ago after revelations of abuse.
The proposed change includes provisions intended to prevent problems that plagued earlier programs. Nevertheless, it has dredged up a painful history of medical mistreatment and incited debate among prison rights advocates and researchers about whether prisoners can truly make uncoerced decisions, given the environment they live in.
Supporters of such programs cite the possibility of benefit to prison populations, and the potential for contributing to the greater good.
Until the early 1970’s, about 90 percent of all pharmaceutical products were tested on prison inmates, federal officials say. But such research diminished sharply in 1974 after revelations of abuse at prisons like Holmesburg here, where inmates were paid hundreds of dollars a month to test items as varied as dandruff treatments and dioxin, and where they were exposed to radioactive, hallucinogenic and carcinogenic chemicals.
In addition to addressing the abuses at Holmesburg, the regulations were a reaction to revelations in 1972 surrounding what the government called the Tuskegee Study of Untreated Syphilis in the Negro Male, which was begun in the 1930’s and lasted 40 years. In it, several hundred mostly illiterate men with syphilis in rural Alabama were left untreated, even after a cure was discovered, so that researchers could study the disease. . . .
Under current regulations, passed in 1978, prisoners can participate in federally financed biomedical research if the experiment poses no more than “minimal” risks to the subjects. But a report formally presented to federal officials on Aug. 1 by the Institute of Medicine of the National Academy of Sciences advised that experiments with greater risks be permitted if they had the potential to benefit prisoners. As an added precaution, the report suggested that all studies be subject to an independent review.
“The current regulations are entirely outdated and restrictive, and prisoners are being arbitrarily excluded from research that can help them,” said Ernest D. Prentice, a University of Nebraska genetics professor and the chairman of a Health and Human Services Department committee that requested the study. Mr. Prentice said the regulation revision process would begin at the committee’s next meeting, on Nov. 2.
The discussion comes as the biomedical industry is facing a shortage of testing subjects. In the last two years, several pain medications, including Vioxx and Bextra, have been pulled off the market because early testing did not include large enough numbers of patients to catch dangerous problems.
And the committee’s report comes against the backdrop of a prison population that has more than quadrupled, to about 2.3 million, over the last 30 years and that disproportionately suffers from H.I.V. and hepatitis C, diseases that some researchers say could be better controlled if new research were permitted in prisons. . . .
The Institute of Medicine report was initiated in 2004 when the Health and Human Services Department asked the institute to look into the issue. The report said prisoners should be allowed to take part in federally financed clinical trials so long as the trials were in the later and less dangerous phase of Food and Drug Administration approval. It also recommended that at least half the subjects in such trials be nonprisoners, making it more difficult to test products that might scare off volunteers. . . .
TalkLeft has some serious concerns about this potential regulatory change and his piece also provides helpful links to the recent federal report "Ethical Considerations of Research Involving Prisoners." Thanks to TalkLeft for pointing me to this article.
Friday, August 11, 2006
During these rather stressful times, cutting off the funding for the federal suicide hotline does nont seem to make much sense. Here is the website discussing the hotline and a plea for readers to help save it:
1-800-SUICIDE is in danger of being shut off or worse falling into the hands of the Federal Government. With teenage suicide being the 3rd leading cause of death between 18 to 24 year olds - our government should not be duplicating prevention efforts but helping fund the many local organizations and non-profits with proven track records on prevention. In addition our government should not be in the business having access to this private and sensitive information!
No other crisis hotline is owned by the federal government! Read more...
Despite the fact that almost 2 million callers have reached help and hope over the last 8 years, and a government funded evaluation stating the benefits of 1-800-SUICIDE, the Substance Abuse & Mental Health Service Administration (SAMHSA), a division of Health & Human Services, has decided to create their own government run system where they would have direct access to confidential data on individuals in crisis.
Click on the link above to find out how you can do more to help protect this resource.
Wednesday, August 9, 2006
Carson Palmer, the Cincinnati Bengals quarterback who suffered a terrible knee injury at the end of last season, has an organ donor to thank for his re-built leg. The Cincinnati Enquirer reports,
Julie De Rossi spent the last night of her life passing out fliers for bands she was managing. As she drove home on a Houston freeway, a BMW traveling at twice the speed limit slammed her from behind.
The collision hurtled De Rossi's Volvo into a concrete barrier, crunching the car like an accordion and leaving the 44-year-old mother with only a faint pulse. She died later that day, the victim of a drunken driver.
De Rossi didn't become a meaningless traffic statistic in the early hours of March 17, 2004. An organ donor, she has since helped mend more than 50 people, including Bengals quarterback Carson Palmer, 26, the National Football League's top-paid player.
The knee that Palmer heard snapping apart after a crushing hit during January's playoff game is now held together by Julie De Rossi's Achilles' tendon.
"It's amazing to think that somebody else is inside me," Palmer says.
"You look at the scar. You stare at it. You rub it. It's given me a second chance at life. And I'm extremely grateful to this person." . . . . .
When her life was taken, De Rossi left behind much of value. More than 92,000 people in the U.S. are awaiting organ transplants, according to Richmond, Va.-based United Network for Organ Sharing. Viable transplants can include the heart, kidneys, lungs, pancreas, ligaments, tendons and skin.
Edison, N.J.-based Musculoskeletal Transplant Foundation, the biggest U.S. tissue bank, eventually received De Rossi's donations for processing. As is customary, her tissue was returned to the part of the country where the donation took place. Her tendon was stored in a specialized freezer at the Baylor College of Medicine.
On Jan. 10, Palmer was in surgery at Baylor, and Paulos selected the tendon. He attached it to Palmer's knee joint using screws that will eventually dissolve.
Carson Palmer has now signed up to be an organ donor himself. Perhaps others will be encouraged to follow his lead. [bm]
Saturday, August 5, 2006
The great Ezra Klein points to an article in the Seattle Times that discusses a study reported in the New England Journal of Medicine concerning why people may have problems losing weight. He states their conclusion rather succinctly:
Because we're a bunch of liars:
It's been reported in the New England Journal of Medicine that people attempting to lose weight tend to underestimate the amount they eat by as much as 47 percent and to overestimate their physical activity by as much as 51 percent. When scientists at the USDA's Beltsville Human Nutrition Research Center in Maryland asked 98 men and women how much they ate in a 24-hour period, they found that 6 out of 7 women underreported by an average of 621 calories, and 6 out of 10 men underreported by an average of 581 calories.
Well, I guess people are doing more than just lying to the Department of Motor Vehicles about their weight - looks like it might be time for everyone to start a food journal just to keep us honest. I wonder how much of this results as well from the way that food is packaged and marketed and from a lack of knowledge about serving sizes. I know that I tend to think that I can eat more chocolate mini-bars and still feel that I am not overeating. Indeed, I perhaps would answer a question about my chocolate consumption with a statement that I have had only a few pieces of chocolate when I probably ate a sufficient number of mini-bars to equal two king size candy bars.
Thursday, August 3, 2006
Professor Daniel Solove of Concurring Opinions has an interesting post concerning the use of the internet to blacklist plaintiffs who file medical malpractice suits. He states,
"In a disturbing development, websites are emerging to create blacklists of individuals who file medical malpractice claims. According to an article at Law.com:
In 2004, a group of Texas physicians launched DoctorsKnowUs.com. The site listed the names of plaintiffs, attorneys and expert witnesses in medical malpractice cases. That site did not make any distinction between cases that ended in plaintiff verdicts and those that ended in defense verdicts or settlements.
According to the New York Times, a North Texas man had trouble finding a physician for his 18-year old son after his name was posted on the site. He had filed a medical malpractice suit after his wife died from a missed brain tumor, and had won an undisclosed settlement.
DoctorsKnowUs.com was shut down four days after the Times article was published.
A new website to blacklist medical malpractice plaintiffs has emerged, called LitiPages.com. According to the Law.com article:
In the latest effort to enable doctors to shun patients who sue, an offshore company has launched an Internet site that lists the names of plaintiffs who have filed medical malpractice cases in Florida and their attorneys.
The site, LitiPages.com, encourages doctors to consider avoiding patients who are listed in the database, and it strongly encourages plaintiffs who have lost their cases at trial to turn around and sue their plaintiffs attorney. . . .
Unlike the Texas site, LitiPages.com plans to list only plaintiffs who filed cases that ended in a defense verdict, a settlement, or a plaintiff verdict on only one count while other counts were dismissed.
The overwhelming majority of med-mal cases that go to trial result in defense verdicts. A large percentage of claims never go to trial, and many of those result in settlements. Some experts say that it's not possible to say that cases are "frivolous" just because they don't result in a plaintiff verdict.
He goes on to note the lack of websites that list physicians who have been sued for malpractice and states that such a website, if accurate, would not raise the same issues as the LitPages website.
I believe a distinction can be made. Physicians are professionals, and they have higher duties and responsibilities than the patients they treat. Indeed, one of the duties of the profession is to police itself, to weed out the bad apples. Sadly, I'm not sure that the medical profession does a good enough job of this (lawyers aren't much better at policing their own profession). In distinction, a blacklist of malpractice plaintiffs discourages them from exercising their legal rights and inhibits the legal system from redressing wrongs by errant physicians. Moreover, even to the extent to which plaintiffs bring frivolous suits, these are often the fault of the lawyers, not the plaintiffs.