December 1, 2007
World AIDS Day
Thinkprogress reports some depressing numbers on this World AIDs Day. It states,
There are 33.2 million people in the world currently infected with HIV, and 2007 saw 2.5 million new infections. But as Matt Foreman, Executive Director, National Gay and Lesbian Task Force, notes: “Here in the United States, the attitude of so many within our own community is that there’s not a lot more to be done.”
House Speaker Nancy Pelosi (D-CA) states, “Recently reported increases in both new HIV infections and new AIDS cases in the United States call out for stronger leadership domestically as well.” Right outside the U.S. Capitol, a “modern epidemic” is raging.
The cite also has a helpful map to illustrate the spread of this disease.
November 28, 2007
District of Columbia HIV Study
The Washington Post reported this week on a depressing study on HIV in the District of Columbia. THe Post report states,
The first statistics ever amassed on HIV in the District, released today in a sweeping report, reveal "a modern epidemic" remarkable for its size, complexity and reach into all parts of the city.
The numbers most starkly illustrate HIV's impact on the African American community. More than 80 percent of the 3,269 HIV cases identified between 2001 and 2006 were among black men, women and adolescents. Among women who tested positive, a rising percentage of local cases, nine of 10 were African American.
The 120-page report, which includes the city's first AIDS update since 2000, shows how a condition once considered a gay disease has moved into the general population. HIV was spread through heterosexual contact in more than 37 percent of the District's cases detected in that time period, in contrast to the 25 percent of cases attributable to men having sex with men.
"It blows the stereotype out of the water," said Shannon Hader, who became head of the District's HIV/AIDS Administration in October. Increases by sex, age and ward over the past six years underscore her blunt conclusion that "HIV is everybody's disease here."
The new numbers are a statistical snapshot, not an estimate of the prevalence of infection in the District, which is nearly 60 percent black. Hader, an epidemiologist and public health physician who has worked on the disease in this country and internationally, said previous projections remain valid: One in 20 city residents is thought to have HIV and 1 in 50 residents to have AIDS, the advanced manifestation of the virus.
Almost 12,500 people in the District were known to have HIV or AIDS in 2006, according to the report. Figures suggest that the number of new HIV cases began declining in 2003, but the administration said the drop more likely reflects underreporting or delayed reporting. A quarter-century into the epidemic, the city's cumulative number of AIDS cases exceeds 17,400.
"HIV/AIDS in the District has become a modern epidemic with complexities and challenges that continue to threaten the lives and well-being of far too many residents," the report states.
District health officials have long been faulted for the lack of HIV information and lagging AIDS data. Not until forced by federal funding requirements did the health department start tracking HIV. . . .
The District's AIDS rate is the worst of any city in the country, nearly twice the rate in New York and more than four times the incidence in Detroit, and it has been climbing faster than that of many jurisdictions. . . .
Illegal Immigrants and Health Care Costs
The LA Times contains a story discussing a recent study on the use of health care by illegal immigrants. It turns out - they aren't using that as much health care as people seemed to have thought.
Illegal immigrants from Mexico and other Latin American countries are 50% less likely than U.S.-born Latinos to use hospital emergency rooms in California, according to a study published Monday in the journal Archives of Internal Medicine.
The cost of providing healthcare and other government services to illegal immigrants looms large in the national debate over immigration. In Los Angeles County, much of the focus of that debate has been on hospital emergency rooms. Ten have closed in the last five years, citing losses from treating the uninsured, and those that remain open are notorious for backlogs.
By federal law, hospitals must treat every emergency, regardless of a person's insurance -- or immigration -- status. Illegal immigrants, who often work at jobs that don't offer health insurance, are commonly seen as driving both the closures and the crowding.
But the study found that while illegal immigrants are indeed less likely to be insured, they are also less likely to visit a doctor, clinic or emergency room. "The current policy discourse that undocumented immigrants are a burden on the public because they overuse public resources is not borne out with data, for either primary care or emergency department care," said Alexander N. Ortega, an associate professor at UCLA's School of Public Health and the study's lead author. "In fact, they seem to be underutilizing the system, given their health needs."
Ira Mehlman, media director for the Federation for American Immigration Reform, a group that lobbies for tougher immigration controls, said that usage rates are just one measure of illegal immigrants' effect on healthcare. The other factor, he said, is the cost to taxpayers, which Ortega's study did not examine. . . .
November 27, 2007
Financing Health Care - Consumer Debt
Frank Pasquale at Concurring Opinions has another interesting piece on who opposes universal health care coverage. He writes,
Businessweek has been covering the medical debt industry in depth, and this week's installment newly demonstrates how eager financial interests are to advance "the transformation of medical bills into consumer debt:"
The pool of self-pay patients is mammoth: Some are among the nation's 47 million uninsured; others are among the 16 million whose plans offer scant coverage or have deductibles as high as $10,000. . . . .General Electric's powerful financial arm markets its CareCredit card to dentists, plastic surgeons, and some hospitals, with loan volume expected to hit $5 billion this year, up 40% from 2006. . . . "Everybody is saying [medical finance] is the next horizon—whether it is lines of credit or credit cards," says June St. John, a senior vice-president at Wachovia. . . .
Below the fold: a hidden TILA issue?:
At Spectrum Health, a nonprofit group of seven hospitals in Grand Rapids, Mich., self-pay patients who can write a check within 30 days receive a 20% discount; those who pay within six months get 10% off. Patients who charge their debts to CarePayment get no discount. Referring to CarePayment, Kathleen Engel, an associate professor at Cleveland-Marshall College of Law, asserts: "This is a markup, not a markdown." Engel, a consumer law expert, says that because hospitals effectively charge more when patients use CarePayment, the hospitals should disclose the price difference as the equivalent of an interest rate under the federal Truth in Lending Act.
Joseph Fifer, Spectrum's vice-president of finance, said its disclosure is legally sufficient. Steven M. Wright, Aequitas' senior managing director for health markets, agreed. Wright said Aequitas complies with the law by disclosing its payment terms when it sends CarePayment charge cards to new customers.
I guess so long as it's all disclosed, they may as well open payday lending branches in ERs. But here's a last word from the chief financial officer of Methodist Le Bonheur Healthcare:
"If we heal somebody medically, but we break them financially, have we really done what is in the best interest of the patient?"
Charming Hospice Story in the NY Times
The New York Times reports on hospice providers losing money - the attention grabbing and rather depressing headline reads: "In Hospice Care, Longer Lives Mean Money Lost." The article states,
Hundreds of hospice providers across the country are facing the catastrophic financial consequence of what would otherwise seem a positive development: their patients are living longer than expected.
Over the last eight years, the refusal of patients to die according to actuarial schedules has led the federal government to demand that hospices exceeding reimbursement limits repay hundreds of millions of dollars to Medicare.
The charges are assessed retrospectively, so in most cases the money has long since been spent on salaries, medicine and supplies. After absorbing huge assessments for several years, often by borrowing at high rates, a number of hospice providers are bracing for a new round that they fear may shut their doors.
One is Hometown Hospice, which has been providing care here since 2003 to some of the most destitute residents of Wilcox County, the poorest place in Alabama. The locally owned, for-profit agency, which serves about 60 patients, mostly in their homes, had to repay the government $900,000, or 27 percent of its revenues, from its first two years of operation, said Tanya O. Walker-Butts, a co-owner. Its profits were wiped out in the time it took to open the demand letters, Ms. Walker-Butts said. . . .
In the early days of the Medicare hospice benefit, which was designed for those with less than six months to live, nearly all patients were cancer victims, who tended to die relatively quickly and predictably once curative efforts were abandoned. But in the last five years, hospice use has skyrocketed among patients with less predictable trajectories, like those with Alzheimer’s disease and dementia. Those patients now form a majority of hospice consumers, and their average stays are far longer — 86 days for Alzheimer’s patients, for instance, compared with 44 for those with lung cancer, according to the Medicare Payment Advisory Commission.. . . .
Studies have reached various conclusions about whether hospice care actually saves money, especially for long-term patients. But a new study by Duke University researchers concluded that it saved Medicare an average of $2,300 per beneficiary, calling hospice “a rare situation whereby something that improves quality of life also appears to reduce costs.”
November 26, 2007
Antidepressants and Lifespan
"An antidepressant drug lengthens tiny worms' lives and offers hope of humans living longer too, US scientists say.
In the study, detailed in journal Nature, nematode worms were exposed to 88,000 chemicals in turn and mianserin extended lifespan by almost a third.
The drug seems to mimic the effects on the body of the only known animal long-life regime - virtual starvation. [BBC]"
The researchers don't know why worms exposed to mianserin lived about 30% longer than their untreated counterparts. The researchers took an empirical approach, exposing worms to thousands of different small molecules and noting the effects on survical. Head researcher Linda Buck of the Howard Hughs Medical Institute shared some preliminary hypotheses with Science Daily:
Buck said it was a surprise to find that a drug used to treat depression in humans could extend lifespan in worms. The researchers in Buck's lab found that in addition to inhibiting certain serotonin receptors in the worm, it also blocked receptors for another neurotransmitter, octopamine.
A number of observations support the idea that serotonin and octopamine may complement one another in a physiological context, Buck explained, with serotonin signaling the presence of food and octopamine signaling its absence or a state of starvation. C. elegans, for instance, usually only lays eggs when food is on hand. But serotonin stimulates egg laying in the absence of food, while octopamine inhibits egg laying even when food is nearby. Another example of interplay between the two chemicals is that pharyngeal pumping, the mechanism by which worms ingest food, is jump-started by serotonin and thwarted by octopamine.
"In our studies, mianserin had a much greater inhibitory effect on the serotonin receptor than the octopamine receptor," she said. "One possibility is that there is a dynamic equilibrium between serotonin and octopamine signaling and the drug tips the balance in the direction of octopamine signaling, producing a perceived, though not real, state of starvation that activates aging mechanisms downstream of dietary restriction." [SD]
Find out who your Daddy is - Brought to you by Rite Aid
The New York Times reports on the spread on genetic testing to your local drugstore. It reports,
Genetic testing is now available at the drugstore. A company called Sorenson Genomics has started selling a paternity test kit through Rite Aid stores in California, Oregon and Washington. It appears to be the first time a DNA test is being sold through a major pharmacy chain. The move into the pharmacy is another in the spread of genetic testing directly to consumers. Many genetic tests, for health and diet advice, ancestry and paternity, are already available directly to consumers through the Internet. But Sorenson hopes the corner drugstore will appeal to different customers, including those who do not want to wait three or five days for a kit to arrive in the mail after ordering it over the Internet. . . .
The test, sold under the brand name Identigene, has a suggested list price of $29.99, though a reporter purchased one at a Rite Aid in Santa Monica, Calif., for $19.99. There is an additional laboratory fee of $119 to have the samples analyzed.
The spread of genetic testing directly to consumers has alarmed some doctors and genetic counselors, who said some tests were not valid or that consumers might not be able to understand the results without counseling. Myriad Genetics recently caused some controversy by advertising its test for breast cancer risk directly to women in the Northeast. And the Government Accountability Office, among others, has criticized a plethora of tests now available for advising on health risks and recommending diet and lifestyle changes. “Just because something’s available does not mean it’s safe or effective or worth your money,” said Kathy Hudson, director of the Genetics and Public Policy Center at Johns Hopkins University. She said most genetic tests available directly to consumers had not been reviewed by the Food and Drug Administration.
Still, drugstores already sell various non-DNA diagnostic tests, including those for pregnancy, drug use, cholesterol, blood sugar and H.I.V. When some of these were introduced there was also controversy about whether consumers could perform the tests or understand the results themselves. The results of a paternity test, unlike some of the medical tests, are pretty easy to understand.
The box contains three sets of cotton swabs to collect cheek samples from the child, the alleged father and the mother. (The mother is optional but helps strengthen the results, the company says.) The swabs are put into separate packets and mailed to Sorenson’s laboratory in Salt Lake City. Results are provided by mail, fax or on a password-protected Web site within five days of the laboratory receiving the samples.
Sorenson said the test was for peace of mind and that the results would probably not stand up in court because questions could be raised about whose samples were submitted. The kit advises people wanting to test for legal purposes to call the company and set up a chain of custody for the samples, which would cost an additional $200.
At least one other genetic test is sold in a drugstore. Sciona sells a $269 service that provides dietary advice based on genetic analysis through Pharmaca Integrative Pharmacy, a chain of 19 stores mainly in California and Colorado. Rosalynn Gill, chief science officer of Sciona, said that Pharmaca, unlike most pharmacies, had dietitians on staff to help explain the purpose of the test to customers. “It’s far too early to expect people to walk into a store and buy a genetic test directly off the shelf without some guidance or counsel,” she said. Still, Sciona gets most of its sales from the Internet and from multilevel marketing.
Wellness Programs and Employer Liability
Some types of employer-based wellness programs make me a little nervous - perhaps the employer has a little too much control over the way that people spend their precious free time. Law.com has a brief overview of some of the recent wellness program litigation. Some of these programs seem a bit agressive - even the ones that provide bonuses to employees for meeting certain health goals. The article reports,
Employers are increasingly mandating that employees have healthy lifestyles, or face repercussions. Mandatory wellness programs are popping up everywhere, lawyers say, requiring everything from cholesterol screening to weight-loss plans and yoga classes.
Several employers are starting to reward employees with extra cash for meeting certain company health goals. Others are fining those who refuse to take part in programs such as health screenings or opt not to follow a health coach's plan to get in shape. Some are even firing, or refusing to hire, those who test positive for nicotine use. These tactics have labor and employment attorneys predicting a barrage of discrimination and privacy lawsuits. . . .
Legal challenges to mandatory health checkups and screenings are already creeping their way into the courts. In Massachusetts, a man is suing Scotts Miracle-Gro Co. for firing him after he tested positive for nicotine, violating a company policy banning smoking on and off the job. Rodrigues v. The Scotts Co., No. 1:07-cv-1014-GAO (D. Mass.). Last year, a federal court in Michigan was the first to address mandatory wellness programs in a case in which firefighters challenged the city of Taylor Fire Department over a mandatory blood draw to detect cholesterol. The plaintiffs claimed that taking the blood violated their constitutional rights. The court denied the city's motion for summary judgment and the blood draws were abandoned. Anderson v. City of Taylor, 2006 U.S. Dist. Lexis 38075 (E.D. Mich.).
But some companies are aggressively moving ahead with such plans, despite new federal Health Insurance Portability and Accountability Act rules that prohibit charging employees different rates for health coverage based on wellness, and ADA rules that prohibit employers from asking too many questions about an employee's health.
Maryville, Ohio-based Scotts Miracle-Gro, the national lawn care retailer, has a large-scale mandatory wellness program that includes an outright ban on all smoking. It also charges employees $40 a month more in premiums if they refuse to take part in a health-risk assessment, and $67 a month if they fail to comply with a health coach's plan to address various health problems. . . .
"The fact remains that many employers are cognizant of the epidemic that is the health care crisis," said Greg Keating, co-chairman of the health care practice group at Littler Mendelson. "Some large national employers are even willing to face legal challenges in an effort to reverse the rising tide of health care costs." Littler Mendelson recently conducted a comprehensive study on employer-mandated wellness programs that looked at the potential legal pitfalls and benefits, and the effect of rising health care costs on employers. . . . .
But is that justification for mandating a healthy lifestyle for employees?
"The waters are murky here," said labor and employment attorney Neil Martin of the Houston office of Dallas-based Gardere Wynne Sewell. "Mandatory wellness programs — they sound good, but to me it's an issue of managing the unmanageable. They are fraught with all sorts of 'gotchas.' " According to Martin, the numerous legal risks associated with mandatory wellness programs include running afoul of the ADA, the Health Insurance Portability and Accountability Act and Title VII of the Civil Rights Act of 1964, which prohibits age, race and sex discrimination. Additionally, 29 states have so-called "lifestyle discrimination statutes," which prohibit employers from taking adverse action against employees for lawful off-duty conduct. Those states include Colorado, Illinois, Nevada and New York. . . .
But employers will run into trouble if they penalize those with genetic traits or medical predispositions, he said. "It's one thing to punish people or penalize them for lifestyle choices," Martin said. "It's a another if you're taking punitive action against them and they have a biological disposition or immutable characteristic . . . .Sometimes someone's health is beyond their control."