HealthLawProf Blog

Balancing the Budget through Medicare and Medicaid Cuts

The New York Times reports today on President Bush's announcement that he will "call for large cuts in the growth of Medicare, far exceeding what he proposed last year, and he will again seek major savings in Medicaid."

Health care savings are a crucial part of Mr. Bush’s plan to put the nation on track to achieve a budget surplus by 2012. But before then, the officials said Wednesday, the White House anticipates higher deficits in 2008 and 2009, reflecting the current weakness of the economy and the cost of a stimulus package. . . .

Mr. Bush has repeatedly said that the costs of Medicare and Medicaid, which dwarf spending for lawmakers’ pet projects, are unsustainable. The two health programs account for nearly one-fourth of all federal spending, and their combined cost — $627 billion last year — is expected to double in a decade.

Budget documents show that Mr. Bush will propose legislative changes in Medicare to save $6 billion in the next year and $91 billion from 2009 to 2013. In his last budget, by contrast, his legislative proposals would have saved $4 billion in the first year and $65.6 billion over five years.

The president’s budget also takes aim at Medicaid, the insurance program for low-income people. He would pare $1.2 billion from it next year and nearly $14 billion over five years.  Those figures do not include tens of billions of dollars that Mr. Bush wants to save through new regulations. Such rules are not subject to approval by Congress, but could be revised by a future administration.

Congressional Democrats often pronounce Mr. Bush’s budget dead on arrival, and they have no reason to make unpopular cuts in this election year.  But lawmakers say they feel obliged to pass a Medicare bill in the first half of this year, to spare doctors from a 10 percent cut in Medicare fees that would otherwise take effect on July 1. . . .

Most of the Medicare savings in the budget would be achieved by reducing the annual update in federal payments to hospitals, nursing homes, hospices, ambulances and home care agencies.  The budget would not touch payments to insurance companies for private Medicare Advantage plans, even though many Democrats and independent experts say those plans are overpaid.

In the next five years, the largest amount of Medicare savings, by far, would come from hospitals: $15 billion from an across-the-board reduction in the annual updates for inpatient care; $25 billion from special payments to hospitals serving large numbers of poor people; and $20 billion from capital payments for the construction of hospital buildings and the purchase of equipment.  In addition, the president’s budget would reduce special Medicare payments to teaching hospitals, including many in the New York area, by $23 billion over the next five years.

This sounds like a terrific way to save money . . . .

Lifetime Benefit Caps

TPM Cafe's Cindy Zeldin has a great discussion of today's Washington Post article on the issues and problems surrounding lifetime benefit caps on insurance spending.  She writes,

Today’s Washington Post explores lifetime benefit caps, provisions of most private health insurance policies that limit the total amount of expenditures an insurer will pay, with these limits typically falling in the one- to two-million dollar range. These lifetime caps and other insurance gaps like high out-of-pocket maximums and uncovered medical services are colliding with escalating health care costs to force questions about just what it means to have health insurance anyway. . . .

A few years back, the Institute of Medicine released a series of reports that painstakingly analyzed the importance of health insurance in accessing health care, highlighting the myriad problems that result from uninsurance, both to individuals and to society. We know that health insurance matters. Thanks to a growing body of research, at the heart of which is Professor Warren's findings on medical bankruptcies, we also know that, while insurance is crucial, it isn't always enough. Even the insured can face barriers to care and bills that exceed their ability to pay. The Washington Post article notes that the National Hemophilia Foundation is embarking on a lobbying effort to increase the amount of health insurance caps. If we move down the road of health reform in '09, we're going to wrestle with questions about how much individuals should be expected to pay and how much insurance should cover--questions we haven't exactly built a consensus around as a society but which threaten to fracture the public support that is building for health reform if left unaddressed.

Volunteer Opportunity for ACS

The American Constitution Society has requested volunteers to help with their "Constitution in the Classroom" program.  From their website: 

CALLING ALL CLASSROOM VOLUNTEERS!

ACS is pleased to announce the expansion of one of our signature programs: Constitution in the Classroom, which will include an ACS-wide volunteer effort this Spring!

Our expanded Spring 2008 Constitution in the Classroom project will include a national volunteer effort, placing ACS volunteers in classrooms across the country. As a volunteer, ACS will help you find a classroom and provide you with grade-specific lesson plans.

Get Involved

If you are interested in participating in Constitution in the Classroom, either by volunteering in a classroom or becoming a Project Coordinator to implement an effort on behalf of your chapter, please sign up online HERE, or email us at classroom@acslaw.org. For more information about Constitution in the Classroom, please visit us at www.acslaw.org/conclass.

Death Without Dignity

Ezra Klein points us toward a post by Andrew Kline about his father and his father's cancer.  Mr. Kline writes about his frustration and concern he experiences as he deals with the medical treatment his father has received.  He provides a moving statement that may sound familiar to those who have experience when dealing with end-of-life situations at the hospital.  He states,

I'm back home, a thousand miles away from my father. But he had another setback, and he is back in the main hospital.

I am not expecting any miracles. I know that the clock has been ticking ever since his cancer diagnosis. My frustration is with trying to get the system to share my goals. . . . .  Similarly, what I want for my father is the best possible combination of dignity, lucidity, and absence of pain. The operative word is possible, because what is attainable is limited. Moreover, there are trade-offs among these goals.

But what you deal with are people who are doing their job. For example, the cardiologist's job is to make sure his heart does not give out, even if it means he lies on his back for so long that the prospects for restoring diginity recede. Everyone wants to shunt him around, giving him more Hansonian medicine, which detracts from his ability to remain lucid.

For the larger goal of trying to do the best with his remaining life, nobody is in charge and nobody is empowered. Particularly in that big hospital. I'll probably be back there soon, but I don't know what medical decisions would best serve our goals and I don't know how to get the system to work for us.

I hope that he finds his answers.

The NewsHour and Health Care

This week the NewsHour is running a series on the upcoming primary states and issues that are important to voters in each state.  The first state under review was New Jersey and the focus was health care.  It was a panel discussion with Judy Woodruff and it really brought home how much we need to reform our health care system.  The audio and transcript are available here.

The Upcoming Silver Tsunami and Medical School Training

Reuters reports on medical schools responding to an increasing aging population by adding more courses in geriatric care.  The article reports,

Just a few years ago, a graduate from Brown University medical school had just an inkling about how to care for the elderly.  Now, Brown and other U.S. medical schools are plugging geriatric courses into their curricula and adding specially trained faculty members as they respond to an imminent boom in the number of older Americans and the need to better understand how to properly care for the elderly.

The U.S. Census Bureau projects the number of elderly Americans will nearly double to 71 million by 2030, leaving one physician trained in geriatric care for every 7,665 seniors. 
The first members of the Baby Boomer generation, so named for the explosion in births in the years after World War Two, turn 65 in three years. In addition, people are living longer than ever.

"The first ripples of the silver tsunami are lapping at the shores of our country, but there is not a coordinated or strategic response taking place in America," said Richard Besdine, who is director of the geriatrics division at Brown University medical school in Providence, Rhode Island, and past president of the American Geriatrics Society.

Geriatrics has never been a field of choice for young doctors. Elderly care doctors are paid less than most other physicians and surgeons and the aged can be hard to treat. . . .

I haven't heard much attention paid to the aging of our population beyond the social security/medicare issues on payment and costs.  Obviously other concerns will need to be addressed and it is interesting to see how medical schools are responding and encouraging graduates to consider a different specialty.

Junk Food Diet and Violence

The Independent (UK) reports on a new Oxford University study of British prisons that reviews prison diets and prisoner behavior to determine whether a link exists between diet and behavior.  The Independent reports,

Some of Britain's most challenging young prisoners are to be given food supplements in a study aimed at curbing violent behaviour.  Scientists from Oxford University say the effect of nutrition on behaviour has been underestimated. They say increases in consumption of "junk" food over the past 50 years have contributed to a rise in violence.  The university will lead the £1.4m study in which 1,000 males aged 16 to 21 from three young offenders' institutions in England and Scotland will be randomly allocated either the vitamin-and-mineral supplements or a placebo, and followed over 12 months.

In a pilot study of 231 prisoners by the same researchers, published in 2002, violent incidents while in custody were cut by a more than a third among those given the supplements. Overall, offences recorded by the prison authorities fell by a quarter.

John Stein, professor of physiology at Oxford University, said: "If you could extrapolate from those results you would see a reduction of a quarter to a third in violent offences in prison. You could reduce violent offences in the community by a third. That would have a huge economic benefit."

"Our initial findings indicated that improving what people eat could lead them to behave more sociably as well as improving their health. This is not an area currently considered in standards of dietary adequacy. We are not saying nutrition is the only influence on behaviour but we seem to have seriously underestimated its importance." . . .

The theory behind the trial is that when the brain is starved of essential nutrients, especially omega-3 fatty acids, which are a central building block of brain neurons, it loses "flexibility". This shortens attention spans and undermines self-control. Even though prison food is nutritious, prisoners tend to make unhealthy choices and need supplements, the researchers say.

Bernard Gesch, a senior research scientist in the department of physiology and the director of Natural Justice, a charity that investigates the causes of offending, said the prisoners would be given the supplement containing 100 per cent of the recommended daily amount of more than 30 vitamins and minerals plus three fish-oil capsules totalling 2.25g on top of their normal diet.  "We are trying to rehabilitate the brain to criminal justice. The law assumes crime is a matter of free will. But you can't exercise free will without involving your brain and the brain can't function properly without an adequate nutrient supply. It may have an important influence on behaviour." . . .

The Ministry of Justice is backing the three-year study, which will start in May. David Hanson, the Prisons minister, said he hoped it would shed further light on the links between nutrition and behaviour.  The Food Standards Agency says there is not enough evidence to show harm from additives or benefit from fish-oil supplements.

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That Kinoki FootPad Ad --

I don't know how many of you have seen the ad for the Kinoki footpad detoxication system but Revere- at Effect Measure viewed the ad and posts how just watching it makes him feel -- well -- perhaps we should hear it in his own words. . . .

[E]very time I see this piece of [. . . .] advert for something called the Kinoki footpad detoxification system. I want to scream when it comes on television. I mean really SCREAM. Mrs. R. has to restrain me from yelling at the TV. This ad pushes all my buttons. It pushes buttons I didn't even know I had. It pushes buttons I don't want to have and no one should have.

Now Wired has noticed it (hat tip Boingboing), calling it The Biggest Medical Scam Since Alex Chiu's Immortality Device. Since I'm not a quackery aficionado I don't know about Alex Chiu's live long and prosper technology, but I am an environmental epidemiologist and I know something about chemical toxins in general and some of them I know quite a lot about, as in being an expert knowing a lot about them. Like asbestos. Asbestiform fibers are minerals, variously composed calcium and magnesium silicates. When you breathe them they can cause a fatal scarring of the lungs (asbestosis) or one of a number of kinds of cancer. Because they are mineral fibers, they don't move around much once they get lodged wherever they get to. In particular, they won't leach out onto a foot pad over night. Nor, unfortunately, will your cellulite. Or lead. Or parasites. Mucous?!?! Holy Mother [. . . . ] (I will grant it is pretty effective at removing that green stuff from your wallet).

In case you have missed this ad, the Effect Measure website provides a helpful video.

SuperBowl Pepsi Ad by EnAble

While you are waiting for next weekend's Superbowl festivities, Shakesville helpfully highlights a youtube of the new Pepsi ad that will be aired during that primetime event.  EnAble a group within PepsiCo which supports diversity and the inclusion of persons with different abilities, made the ad. It is terrific!  And no, there isn't any sound . . . .

Medicinal Marijuana and the Workplace: The Drug is Still Illegal

Today, the California Supreme Court ruled that the California Compassionate Use Act of 1996 did not prevent an employer from firing a new employee who failed a preemployment drug test.  The case is Ross v. Ragingwire Telecommunications, Inc., S138130 (CA Jan. 25, 2008),   Workplace Prof Bog reports further and provides excerpts from the opinion, Plaintiff, whose physician recommended he use marijuana to treat chronic pain, was fired when a preemployment drug test required of new employees revealed his marijuana use. The lower courts held plaintiff could not on that basis state a cause of action against his employer for disability-based discrimination under the California Fair Employment and Housing Act . . . We conclude the lower courts were correct: Nothing in the text or history of the Compassionate Use Act suggests the voters intended the measure to address the respective rights and duties of employers and employees. Under California law, an employer may require preemployment drug tests and take illegal drug use into consideration in making employment decisions . . . . Plaintiff’s position might have merit if the Compassionate Use Act gave marijuana the same status as any legal prescription drug. But the act’s effect is not so broad. No state law could completely legalize marijuana for medical purposes because the drug remains illegal under federal law (21 U.S.C. §§ 812, 844(a)), even for medical users (see Gonzales v. Raich, supra, 545 U.S. 1, 26-29; United States v. Oakland Cannabis Buyers’ Cooperative, supra, 532 U.S. 483, 491-495).  Instead of attempting the impossible, as we shall explain, California’s voters merely exempted medical users and their primary caregivers from criminal liability under two specifically designated state statutes. Nothing in the text or history of the Compassionate Use Act suggests the voters intended the measure to address the respective rights and obligations of employers and employees. . . .

Ownership of the Body

The Ohio Supreme Court heard arguments yesterday in the case, Albrecht v. Treon, involving the issue of whether an individual has a legal right to a relative’s body parts and organs. In May 2006, after an autoposy to determine how and why Chrisopher Albrecht and his car ended up in a pond.  The county coroner's office failed to inform the family that it had removed his brain and not replaced it.  The parents are now suing.  The case has attracted lots of attention.  Here is a good overview of the legal background and the Cincinnati Enquirer reports on some of the factual issues as well as the interesting differences in litigation strategies,

During an autopsy to determine why Christopher Albrecht had suddenly plunged his vehicle into a pond and drowned, the Hamilton County coroner removed Albrecht's brain and never put it back.  Though the practice is standard for coroners, Albrecht's parents didn't know for years that they had buried their son without his brain.  When they found out, they filed a lawsuit that raises sweeping ethical, moral and religious questions.

The case, to be argued Wednesday before the Ohio Supreme Court, has drawn international attention for its ramifications to coroners, crime investigators, EMTs, funeral directors and followers of religions that espouse the importance of burying the whole body.  The lawsuit is a class action against coroners and commissioners in 87 of Ohio's 88 counties covering cases dating to 1991.  Under Ohio law, brains, hearts and other body parts and fluids removed during an autopsy are classified as medical waste, which generally means they are incinerated.

"What this case really comes down to is, for the convenience of the government, are we Ohioans, we humans, supposed to give up our most basic rights to the human remains of our loved ones?" said John Metz, an attorney who brought the Albrechts' suit. "I am absolutely amazed to have to be standing in front of the highest court in our state to defend against such a socialist view."

Defenders of the coroners, including the Ohio State Coroners Association, Ohio State Medical Association and the National Association of Medical Examiners, contend that establishing property rights for families to the organs, tissue, blood and other fluids extracted during an autopsy could jeopardize timely autopsies and risk the resulting criminal evidence. . . .

Mason anticipates an onslaught of litigation against counties if the Albrechts prevail, as relatives - often upset by an autopsy in the first place - negotiate what to do about body parts that have been removed, perhaps disagree and communicate conflicting directions to coroners.

Metz and co-counsel Patrick Perotti have been taken to task before the court for making a legal question too emotional. Perotti's briefs contain references to Achilles' slaying of Hector in "The Iliad," the drowning of Shakespeare's Ophelia and poet Walt Whitman's "I Sing The Body Electric."  Lawyers for the coroners at one point tried and failed to get one particularly verbose submission - which traced the history of death from ancient to modern times - stricken from the record.  "We don't dispute that it is a cultural norm for us to accord that kind of respect for our dead," Mason said. "But that doesn't mean that when they went out to get Hector's body back, they scraped up every drop of blood to make sure they got everything."

Pathologists and others fighting the Albrechts argue that what happens in an autopsy is common knowledge because of television if nothing else, and families must know that bodies that have undergone an autopsy are not returned entirely intact.  In its brief, the Medical Examiners Association said biologic material from a dead body can't help but be lost. Bodies lose fluids at accident scenes and parts of some bodies are never found, the group said.It argued that material taken by coroners is being singled out unfairly in this case.

Metz said there is evidence to suggest that people care deeply about retrieving such items, including the expense and effort taken by the U.S. military to identify and return remains to the loved ones of fallen soldiers.  Hamilton County, the one county not named in the suit, began calling families after autopsies as part of a court settlement, Metz said, and has encountered few problems with the new system. Franklin County took similar steps voluntarily - in part in an unsuccessful attempt to be removed from the lawsuit - with little negative impact, he said. . . .

Diabetes and Surgery

The New York Times reports today on a new study showing that "Weight-loss surgery works much better than standard medical therapy as a treatment for Type 2 diabetes in obese people, the first study to compare the two approaches has found."  The story continues and states,

The study, of 60 patients, showed that 73 percent of those who had surgery had complete remissions of diabetes, meaning all signs of the disease went away. By contrast, the remission rate was only 13 percent in those given conventional treatment, which included intensive counseling on diet and exercise for weight loss, and, when needed, diabetes medicines like insulin, metformin and other drugs.

In the study, the surgery worked better because patients who had it lost much more weight than the medically treated group did — 20.7 percent versus 1.7 percent of their body weight, on average. Type 2 diabetes is usually brought on by obesity, and patients can often lessen the severity of the disease, or even get rid of it entirely, by losing about 10 percent of their body weight. Though many people can lose that much weight, few can keep it off without surgery. (Type 1 diabetes, a much less common form of the disease, involves the immune system and is not linked to obesity.)

Zuzu at Feministe responds by looking behind the articles and getting the bottom of the report on diabetes and weight loss surgery - it doesn't appear to be quite the easy fix to diabetes that the New York Times and Associated Press reports present.  Zuzu writes,

Patients who have lap band surgery can, once they heal, go on to eat a fairly wide variety of foods in small amounts. As for gastric bypass patients? (AP):

Gastric bypass is even more effective against diabetes, achieving remission in a matter of days or a month, said Dr. David Cummings, who wrote an accompanying editorial in the journal but was not involved in the study.

Yeah. And yet somehow the AP article, like the Times article, mentions this without also mentioning what gastric-bypass patients face after surgery. From the Mayo Clinic:

You won’t be allowed to eat for one to three days after the surgery so that your stomach can heal. Then, you’ll follow a specific progression of your diet for about 12 weeks. The progression begins with liquids only, proceeds to pureed and soft foods, and finally to regular foods.

With your stomach pouch reduced to the size of a walnut, you’ll need to eat very small meals during the day. In the first six months after surgery, eating too much or too fast may cause vomiting or an intense pain under your breastbone. The amount you can eat gradually increases, but you won’t be able to return to your old eating habits.

SCHIP Veto Override Fails Again

The Gavel reports that the House Republicans "have again narrowly sustained President Bush’s veto, with a vote of 260 in favor of passage and 152 against, (15 votes short) despite the veto-proof margin in the Senate."  The Gavel also has a handy list of newspaper editorials nationwide that urged Congress to override President Bush's veto. 

The Daily Kos blog's DemFromCt reports on what might be the likely political fall-out for the two parties from the SCHIP veto.  It also provides a rather eye-opening review of where both sides stand on SCHIP and health programs provided by the federal government. 

Updates on Flu Preparation: ACLU weighs in

DemFromCt writes at the Daily Kos blog and has an update on preparations for a flu pandemic.  The story reports on the ACLU report on issued last week and drafted by the illustrious George Annas and Wendy K. Mariner from the Boston University School of Public Health and Wendy E. Parmet of Northeastern Law School.  The story provides a brief summary of the report as well as a link to the full version.  It states,

. . . .  the ACLU issued a strongly-worded report entitled Pandemic Preparedness: The Need for a Public Health — Not a Law Enforcement/National Security — Approach, co-authored by George Annas, the same author of the Boston Globe editorial from 2005 . . .

Here's a summary from CIDRAP, which also includes reactions to the plan:

The American Civil Liberties Union (ACLU) this week charged that federal pandemic planning efforts rely too heavily on law enforcement and national security approaches, in effect making people, not disease, the enemy.

The ACLU aired its concerns in a report authored by three prominent public health law attorneys and released Jan 14 at a press conference in Washington, DC. The authors are George Annas and Wendy K. Mariner from the Boston University School of Public Health and Wendy E. Parmet of Northeastern Law School.

The report discusses a wide range of privacy protections and other civil liberties that the ACLU believes might be threatened in a pandemic setting. The authors include a list of recommendations intended to focus pandemic planning efforts more toward community engagement, as well as an appendix that covers a number of constitutional issues that could surface during a pandemic.

"A law enforcement approach is just the wrong tool for the job when it comes to fighting disease," said Barry Steinhardt, director of the ACLU's technology and liberty program, in a Jan 14 press release. He said history shows that a coercive approach to pandemic that treats sick people as enemies is ineffective from a public health perspective.

But a spokesman for the US Department of Health and Human Services (HHS) says the group has mischaracterized the government's efforts. Also, other critics with expertise in public health and the law say the ACLU report is marred by a misunderstanding of government response plans.

Health Care Plans of the Candidates: Now in Handy Graphic Form

Ezra Klein points out Health Care Central's helpful (if perhaps slightly imprecise) and super cool looking chart showing where the various health care plans of the current Presidential candidates line up in terms of access, coverage etc.  Click here for the chart.

Regulating Genetic Tests or Not

The New York Times reported last week on a federal panel, Secretary’s Advisory Committee on Genetics, Health and Society, which submitted a report demonstrating its concerns over the increasing use of genetic tests without the appropriate regulation and oversight.  The Times article states,

The science of genetic tests is marching ahead and so are efforts to sell them directly to consumers who are willing to send in a check and a bit of saliva to learn whether they are at risk for a disease.  What is not keeping up is regulation and oversight, according to a federal advisory panel. The panel concluded that a growing number of the tests are being marketed with claims that are unproved, ambiguous, false or misleading.

      

Millions of people have already taken the tests, a relatively new tool that even many doctors have yet to master. Test results can provide information to help prevent, detect and treat hundreds of conditions including cancer, heart disease, diabetes, cystic fibrosis and blood disorders.  The results can lead to momentous decisions. For example, women with a family history of breast cancer rely on them in deciding whether to have surgery to remove breasts or ovaries as a preventive measure.

With use of the tests growing at an explosive rate, the panel concluded that patients could be harmed. In most cases, the tests do not pose a direct physical risk; but, the panel said, if a test is inaccurate, patients may be given risky, unnecessary treatments or denied treatments that would be highly beneficial.   In addition, the panel said, most doctors lack the training and expertise needed to interpret genetic tests, and many are unfamiliar with professional guidelines for their use. Although professional societies play an important role in making sure their members get up-to-date information, the panel said, “they cannot keep up with the pace of development of genetic tests.”

The panel went on to discuss some of the regulatory morass that is supposed to helping approve and oversee these genetic tests.  It doesn't make one feel overly comfortable.

Addressing Conflicts of Interest . . .

The Associated Press reports on some steps hospitals are taking to address conflicts of interest that may arise in the pharmaceutical and medical device areas  - purging trinkets!

When a Duluth-based operator of hospitals and clinics purged the pens, notepads, coffee mugs and other promotional trinkets drug companies had given its doctors over the years, it took 20 shopping carts to haul the loot away.

The operator, SMDC Health System, intends to ship the 18,718 items to the west African nation of Cameroon.  The purge underscored SMDC's decision to join the growing movement to ban gifts to doctors from drug companies.

SMDC scoured its four hospitals and 17 clinics across northeastern Minnesota and northwestern Wisconsin for clipboards, clocks, mouse pads, stuffed animals and other items decorated with logos for such drugs as Nexium, Vytorin and Lipitor.  Trinkets, free samples, free food and drinks, free trips and other gifts have pervaded the medical profession, but observers say that's starting to change.  "We just decided for a lot of reasons we didn't want to do that any longer," Dr. Kenneth Irons, chief of community clinics for SMDC, said Friday.

So SMDC put together a comprehensive conflict-of-interest policy that, among other things, limits access to its clinics by drug company representatives. Employees suggested the "Clean Sweep" trinket roundup, Irons said. . . . .

SDMC's effort was motivated by a desire to show patients that its 450 doctors were serious about keeping prescription drug costs down and making unbiased medical decisions, Irons said.

The backlash against the cozy relationships between doctors and drug makers gained steam from article in the Journal of the American Medical Association in 2006. It said research had shown that even cheap gifts, such as pens, can affect doctors' prescribing decisions.  The Prescription Project, funded by the Pew Charitable Trusts, was founded to promote the JAMA article's recommendations for countering aggressive marketing to physicians by the pharmaceutical and medical device industries. . . .

Kaiser Permanente, the country's largest HMO, Veterans Affairs hospitals and medical centers at several universities have recently adopted strict conflict-of-interest policies, such as gift bans, Hams said.

Many of SMDC's items will be going to the health system of the Evangelical Lutheran Church of Cameroon, which has three hospitals, and several rural health centers.  Irons said there shouldn't be a conflict of interest in Cameroon because the advertised drugs aren't available there.

The Music Genome Project is Here!

I don't know how many of you suffer from the frustration of trying to find a radio station that plays only music that you like - and perhaps you are a bit tired on all the songs on your ipod . . . .   Well, the solution is finally here - the music genome project from Pandora.com.  You type in your favorite list of songs and viola - it matches those songs to music that is similar and creates a radio station just for you.  I haven't played around with it too much but it does seem like a fun tool and perhaps can introduce to some fun new music.

Here is the website's overview of its mission:

When was the last time you fell in love with a new artist or song?

At Pandora, we have a single mission: To play music you'll love - and nothing else. 

To understand just how we do this, and why we think we do it really, really well, you need to know about the Music Genome Project®. 

Since we started back in 2000, we have been hard at work on the Music Genome Project. It's the most comprehensive analysis of music ever undertaken. Together our team of fifty musician-analysts has been listening to music, one song at a time, studying and collecting literally hundreds of musical details on every song. It takes 20-30 minutes per song to capture all of the little details that give each recording its magical sound - melody, harmony, instrumentation, rhythm, vocals, lyrics ... and more - close to 400 attributes! We continue this work every day to keep up with the incredible flow of great new music coming from studios, stadiums and garages around the country.

With Pandora you can explore this vast trove of music to your heart's content. Just drop the name of one of your favorite songs or artists into Pandora and let the Genome Project go. It will quickly scan its entire world of analyzed music, almost a century of popular recordings - new and old, well known and completely obscure - to find songs with interesting musical similarities to your choice. Then sit back and enjoy as it creates a listening experience full of current and soon-to-be favorite songs for you. . . .

Wow - what will people think of next.  Enjoy!

Patent on Feelings

The Wall Street Journal's Health blog reports on one of Microsoft's latest patent attempts.  The story states,

Say you’re sitting at your computer, typing away, and suddenly you see something — an ominous email from the boss, maybe — that makes you nervous. Your heart races, and you lose focus on your work. A minute later, a colleague IMs you and offers to lend a hand. Creepy? Useful? Both?

We pose the question because Microsoft has applied for a patent on a system for “monitoring group activities” that could automatically keep an eye on people’s vital signs as a way to see how everybody’s doing and to send help when it’s needed.

The system could use sensors to “detect at least one of heart rate, galvanic skin response, EMG, brain signals, respiration rate, body temperature, movement, facial movements, facial expressions, and blood pressure,” the application says.

Those signs could allow a system of the future to “automatically detect frustration or stress in the user via physiological and environmental sensors and then offer or provide some type of assistance accordingly.”

The patent application is posted on the Web site of the U.S. Patent & Trademark Office, and was described in a recent story in the Times of London.  The application (which refers not only to desktop computers but also to mobile devices) “does not relate to any of Microsoft’s current product plans,” Microsoft VP of Intellectual Property and Licensing Horacio Gutierrez said in a statement. . . .

Hey sounds great to me -  it sure would be fun to have this technology available at the next faculty meeting.  Those meetings could use some extra spark .    Ok, on a serious note, I find it rather troubling for a number of reasons - doesn't the technology sound a bit like a lie detector test (i.e., perhaps a bit unreliable).   Plus, my e-mail box still contains a lot of spam.  I am sure that my co-workers will want to know my response to yet another ad for an impotence cure. . . . .    I can hardly wait for their assistance . . . .

Health Stories

Just in time for my Health Law class, Ezra Klein helpfully points to a website that has started a video collection which provides first person accounts of numerous experiences with low-quality health care in the United States.  The website is "Health Care for All" and can be accessed here.

Drug Studies Suppressed - but only the negative ones

The New England Journal of Medicine reports this week on a report showing that a majority of studies that get published about antidepressants are positive, while negative studies remain unpublished.  The article is entitled: "Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy." Here is the abstract: 

Background Evidence-based medicine is valuable to the extent that the evidence base is complete and unbiased. Selective publication of clinical trials — and the outcomes within those trials — can lead to unrealistic estimates of drug effectiveness and alter the apparent risk–benefit ratio. 

Methods We obtained reviews from the Food and Drug Administration (FDA) for studies of 12 antidepressant agents involving 12,564 patients. We conducted a systematic literature search to identify matching publications. For trials that were reported in the literature, we compared the published outcomes with the FDA outcomes. We also compared the effect size derived from the published reports with the effect size derived from the entire FDA data set. 

Results Among 74 FDA-registered studies, 31%, accounting for 3449 study participants, were not published. Whether and how the studies were published were associated with the study outcome. A total of 37 studies viewed by the FDA as having positive results were published; 1 study viewed as positive was not published. Studies viewed by the FDA as having negative or questionable results were, with 3 exceptions, either not published (22 studies) or published in a way that, in our opinion, conveyed a positive outcome (11 studies). According to the published literature, it appeared that 94% of the trials conducted were positive. By contrast, the FDA analysis showed that 51% were positive. Separate meta-analyses of the FDA and journal data sets showed that the increase in effect size ranged from 11 to 69% for individual drugs and was 32% overall. 

Conclusions We cannot determine whether the bias observed resulted from a failure to submit manuscripts on the part of authors and sponsors, from decisions by journal editors and reviewers not to publish, or both. Selective reporting of clinical trial results may have adverse consequences for researchers, study participants, health care professionals, and patients. 

In response to this article and its findings, Dr. Steven Nissen recommends legislation that would require all drug studies to be placed in a public registry. To hear more about his proposal, listen here.

Childhood Cold Medicines and Cloned Food: Your FDA at Work

The FDA announed today that cold medicines are too risky for very young children age 2 and under.  They will decide later about the safety of such cold medicines for slightly older children.  From the Associated Press,

Parents may be left with only love and lots of liquid to give their sniffling babies and toddlers now that the government is declaring over-the-counter cough and cold medicines too risky for tots.  The Food and Drug Administration was issuing that warning Thursday to parents of children under 2.

It's a move expected for months: Drug companies last October quit selling dozens of versions of nonprescription cold remedies targeted specifically to babies and toddlers. That month, the FDA's scientific advisers also voted that the drugs don't work in small children and shouldn't be used in preschoolers, either — anyone under age 6.

The FDA still hasn't decided if OTC decongestants, antihistamines and cough suppressants are appropriate for older children, officials told The Associated Press. Expect a decision on that by spring, the deadline necessary to notify manufacturers before they begin production for next fall's cold season.

For now, FDA's first official ruling focuses on youngsters under 2, warning that "serious and potentially life-threatening side effects can occur."

The good news - well that "lots of liquids" can now included milk from cloned animals!! Woo!!  In a brief article yesterday, the New York Times noted that the FDA had found that food and milk from cloned animals and their progeny is safe.  I know that I trust them completely.

Also, further good news as an earlier story by the New York Times indicates that parents will be saving lots of money by not purchasing these drugs:   "There are about 800 pediatric cold products sold in the United States that use one or more of 39 different drugs. Parents spend around $500 million every year buying nearly 95 million boxes containing 3.8 billion doses of medicine."

As I have mentioned before - drugs for parents of sick children (something non-drowsy that makes one feel happy about the fact that they will be up all night  - perhaps singing soft songs) might be a lucrative nitch market. (Plus, you maybe need report only the positive clinical trials for these drugs - oo - the New England Journal of Medicine may have just squashed that as well, see here for brief overview of story).

State of Health Care: We're Number 19!!

The Washington Monthly's Kevin Drum reports on the state of our health care system: 

A pair of researchers has just published an update that compares various countries on their rates of "amenable mortality," defined as deaths that are "potentially preventable with timely and effective health care." In 1997, the United States ranked 15th out of 19 industrialized countries. So how are we doing now?

Answer: we're now 19th out of 19. The rest of the countries have improved their performance by an average of 16%, while the U.S., that well-known engine of healthcare innovation, has improved by only 4%. So now we're in last place. . . . .

New Health Care Ad

ThinkProgress shows us the latest in health care advertising:  CheneyCare.  ThinkProgress reports,

Last month, the California Nurses Association and the National Nurses Organizing Committee ran ads in Iowa newspapers advocating for a single-payer health-care bill, highlighting the fact Vice President Dick Cheney has benefited from his government-provided coverage. “If he were anyone else, he’d probably be dead by now” due to his long history of health problems, claimed the ad. . . .

The ad “asks readers to go to CheneyCare.org and sign a petition in support of CheneyCare for all Americans”:

Cheney’s office “did not respond to a request for comment” by the Washington Examiner, but in December, when the original ads ran, Cheney spokesperson Megan Mitchell said that “something this outrageous does not warrant a response.”

As ThinkProgress noted at the time, what is actually outrageous is the fact that there are roughly 47 million people in America without health insurance, including 3.2 million children, but President Bush twice vetoed legislation that would have expanded coverage to 4 million more children.

Child Support from Sperm Donor

Interesting case from Pennsylvania concerning the right of a private sperm donor to contract away his right to make child support payments.   From the Associated Press,

The Pennsylvania Supreme Court ruled that a woman who promised a sperm donor he would not have to pay child support cannot renege on the deal. The 3-2 decision overturns lower court rulings under which Joel L. McKiernan had been paying up to $1,500 a month to support twin boys born in August 1994 to Ivonne V. Ferguson, his former girlfriend and co-worker.

“Where a would-be donor cannot trust that he is safe from a future support action, he will be considerably less likely to provide his sperm to a friend or acquaintance who asks, significantly limiting a would-be mother’s reproductive prerogatives,” Justice Max Baer wrote in the majority opinion issued last week.

Arthur Caplan, chairman of the Department of Medical Ethics at the University of Pennsylvania, said the decision runs counter to the pattern established by similar cases, where the interests of the progeny have generally been given great weight.  “It sounds like the Pennsylvania court is trying to push a little harder into the brave new world of sperm, egg and embryo donation as it’s evolving,” Caplan said.

McKiernan’s lawyer, John W. Purcell Jr., said Wednesday an adverse decision against his client would have jeopardized the entire system of sperm donation.  “That wouldn’t just include Pennsylvania, because we found out in the course of this trial that many doctors order their sperm for their artificial inseminations out of state,” he said. . . . .

Courts found that the two agreed McKiernan would not have to pay child support and would not have visitation rights, but Ferguson later changed her mind and sued.  A county judge said it was in the twins’ best interests that McKiernan be required to support them. In addition to monthly payments, McKiernan also was ordered to come up with $66,000 in back support. The appeal reverses that order. . .

Justice J. Michael Eakin, in a dissent, said a parent cannot bargain away a child’s right to support. “The children point and say, ’That is our father. He should support us,”’ Eakin wrote. “What are we to reply? ’No! He made a contract to conceive you through a clinic, so your father need not support you.’ I find this unreasonable at best.”

The case is: IVONNE  V. FERGUSON v.  JOEL L. MCKIERNAN, [J-60-2005], which is available on the Pennsylvania Supreme Court website.

Intensive Care Revamped

Atul Gawande has a great article in the December 10th New Yorker (ok, yes, I am a little behind on my reading - something about grading . . . ) concerning the use of checklists in intensive care and the impact such helpful lists may have on improving the quality of health care in general.  He writes,

                                                    

                                                                                                                                                                                                               

The damage that the human body can survive these days is as awesome as it is horrible: crushing, burning, bombing, a burst blood vessel in the brain, a ruptured colon, a massive heart attack, rampaging infection. These conditions had once been uniformly fatal. Now survival is commonplace, and a large part of the credit goes to the irreplaceable component of medicine known as intensive care.

It’s an opaque term. Specialists in the field prefer to call what they do “critical care,” but that doesn’t exactly clarify matters. The non-medical term “life support” gets us closer. Intensive-care units take artificial control of failing bodies. Typically, this involves a panoply of technology—a mechanical ventilator and perhaps a tracheostomy tube if the lungs have failed, an aortic balloon pump if the heart has given out, a dialysis machine if the kidneys don’t work. When you are unconscious and can’t eat, silicone tubing can be surgically inserted into the stomach or intestines for formula feeding. If the intestines are too damaged, solutions of amino acids, fatty acids, and glucose can be infused directly into the bloodstream. . . .

On any given day in the United States, some ninety thousand people are in intensive care. Over a year, an estimated five million Americans will be, and over a normal lifetime nearly all of us will come to know the glassed bay of an I.C.U. from the inside. Wide swaths of medicine now depend on the lifesupport systems that I.C.U.s provide: care for premature infants; victims of trauma, strokes, and heart attacks; patients who have had surgery on their brain, heart, lungs, or major blood vessels. Critical care has become an increasingly large portion of what hospitals do. Fifty years ago, I.C.U.s barely existed. Today, in my hospital, a hundred and fifty-five of our almost seven hundred patients are, as I write this, in intensive care. The average stay of an I.C.U. patient is four days, and the survival rate is eighty-six per cent. Going into an I.C.U., being put on a mechanical ventilator, having tubes and wires run into and out of you, is not a sentence of death. But the days will be the most precarious of your life.

                                            

                   

A decade ago, Israeli scientists published a study in which engineers observed patient care in I.C.U.s for twenty-four-hour stretches. They found that the average patient required a hundred and seventy-eight individual actions per day, ranging from administering a drug to suctioning the lungs, and every one of them posed risks. Remarkably, the nurses and doctors were observed to make an error in just one per cent of these actions—but that still amounted to an average of two errors a day with every patient. Intensive care succeeds only when we hold the odds of doing harm low enough for the odds of doing good to prevail. This is hard. There are dangers simply in lying unconscious in bed for a few days. Muscles atrophy. Bones lose mass. Pressure ulcers form. Veins begin to clot off. You have to stretch and exercise patients’ flaccid limbs daily to avoid contractures, give subcutaneous injections of blood thinners at least twice a day, turn patients in bed every few hours, bathe them and change their sheets without knocking out a tube or a line, brush their teeth twice a day to avoid pneumonia from bacterial buildup in their mouths. Add a ventilator, dialysis, and open wounds to care for, and the difficulties only accumulate. . . .

Substantial parts of what hospitals do—most notably, intensive care—are now too complex for clinicians to carry them out reliably from memory alone. I.C.U. life support has become too much medicine for one person to fly. 

Yet it’s far from obvious that something as simple as a checklist could be of much help in medical care. Sick people are phenomenally more various than airplanes. A study of forty-one thousand trauma patients—just trauma patients—found that they had 1,224 different injury-related diagnoses in 32,261 unique combinations for teams to attend to. That’s like having 32,261 kinds of airplane to land. Mapping out the proper steps for each is not possible, and physicians have been skeptical that a piece of paper with a bunch of little boxes would improve matters much.

In 2001, though, a critical-care specialist at Johns Hopkins Hospital named Peter Pronovost decided to give it a try. He didn’t attempt to make the checklist cover everything; he designed it to tackle just one problem, the one that nearly killed Anthony DeFilippo: line infections. On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting a line in. Doctors are supposed to (1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a sterile mask, hat, gown, and gloves, and (5) put a sterile dressing over the catheter site once the line is in. Check, check, check, check, check. These steps are no-brainers; they have been known and taught for years. So it seemed silly to make a checklist just for them. Still, Pronovost asked the nurses in his I.C.U. to observe the doctors for a month as they put lines into patients, and record how often they completed each step. In more than a third of patients, they skipped at least one.

The next month, he and his team persuaded the hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask them each day whether any lines ought to be removed, so as not to leave them in longer than necessary. This was revolutionary. Nurses have always had their ways of nudging a doctor into doing the right thing, ranging from the gentle reminder (“Um, did you forget to put on your mask, doctor?”) to more forceful methods (I’ve had a nurse bodycheck me when she thought I hadn’t put enough drapes on a patient). But many nurses aren’t sure whether this is their place, or whether a given step is worth a confrontation. (Does it really matter whether a patient’s legs are draped for a line going into the chest?) The new rule made it clear: if doctors didn’t follow every step on the checklist, the nurses would have backup from the administration to intervene.

Pronovost and his colleagues monitored what happened for a year afterward. The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from eleven per cent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths, and saved two million dollars in costs. . . .

The checklists provided two main benefits, Pronovost observed. First, they helped with memory recall, especially with mundane matters that are easily overlooked in patients undergoing more drastic events. (When you’re worrying about what treatment to give a woman who won’t stop seizing, it’s hard to remember to make sure that the head of her bed is in the right position.) A second effect was to make explicit the minimum, expected steps in complex processes. Pronovost was surprised to discover how often even experienced personnel failed to grasp the importance of certain precautions. In a survey of I.C.U. staff taken before introducing the ventilator checklists, he found that half hadn’t realized that there was evidence strongly supporting giving ventilated patients antacid medication. Checklists established a higher standard of baseline performance. . . .

I called Pronovost recently at Johns Hopkins, where he was on duty in an I.C.U. I asked him how long it would be before the average doctor or nurse is as apt to have a checklist in hand as a stethoscope (which, unlike checklists, has never been proved to make a difference to patient care).

“At the current rate, it will never happen,” he said, as monitors beeped in the background. “The fundamental problem with the quality of American medicine is that we’ve failed to view delivery of health care as a science. The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is insuring those therapies are delivered effectively. That third bucket has been almost totally ignored by research funders, government, and academia. It’s viewed as the art of medicine. That’s a mistake, a huge mistake. And from a taxpayer’s perspective it’s outrageous.” We have a thirty-billion-dollar-a-year National Institutes of Health, he pointed out, which has been a remarkable powerhouse of discovery. But we have no billion-dollar National Institute of Health Care Delivery studying how best to incorporate those discoveries into daily practice.

Year's Top Ten Science and Tech Stories

Will Saletan at Slate.com presents his list of the top ten "Human Interest" stories of 2007.  Quite frankly, some of them were a little scary and some do provide hope for the future.  For example, these two I found quite hopeful -

1. Cellular rejuvenation. Say goodbye to the stem-cell war. In November, two research teams announced that they had turned regular body cells into the equivalent of embryonic stem cells just by injecting four genes. Everyone agrees this is better than conventional embryonic stem-cell derivation or cloning: It's easier, avoids the human egg shortage, kills no embryos, is eligible for federal funding, and can produce tissue customized to each patient. Now the fight is over whether conservatives deserve credit for pushing the idea of nondestructive stem-cell derivation—or blame for impeding the original stem-cell research that made this breakthrough possible. (Related: Human Nature's previous takes on the new method.)

3. Regeneration. In November, doctors announced that they had restored amputees' sensations of lost limbs by relocating the severed nerves to other parts of the body. They concluded that through mechanical transmission of stimuli to re-innervated skin, "An amputee may one day be able to feel with an artificial limb as although it was his own." Meanwhile, the U.S. military is trying to go beyond artificial limbs altogether. It's testing a way to regrow lost body parts using "extracellular matrix," the material that tells cells where to go and what to become. One man photographed his finger's regrowth (after losing the last three-eighths of an inch) over four months. (Related: regeneration through embryo farming.) .
. . . .

These next two - not so much hopeful as why are we trying this??  I, for one, will not be purchasing a talking hamster for my son anytime soon . . .

4. Humanized animals. In September, British regulators approved the creation of human embryos with animal DNA. The usual method is to substitute a human cell nucleus for an animal cell nucleus in an animal egg, thereby cloning embryos for stem-cell research without having to get human eggs. Britain's Academy of Medical Sciences reported that scientists have created "thousands of examples of transgenic animals" carrying human DNA, largely to study the effects of diseases and drugs on human systems without involving actual human beings. In a separate experiment, researchers improved eyesight in mice by inserting a human gene. Everyone agrees that these mixtures are scientifically useful. But the moral complications are drawing concern, including from Catholic bishops, who are now demanding human rights for "interspecies embryos." (Related: Humanized animals are the future of medicine.)

5. Cyborgs. First U.S. military researchers put computer chips into moths, allowing them to be remotely controlled. Then Chinese scientists remotely controlled a flying pigeon. By implanting electrodes in its brain and activating them from a computer, they operated the bird as though in a video game. Another research team immobilized a moth and attached an electrode to its brain so that the moth's eye movements steered the robot. Now the U.S. military is merging artificial intelligence with humans, including a helmet that, according to its manufacturer, delivers "a visual readout for combat commanders showing the cognitive patterns of individual soldiers." In humans, unlike animals, the cybernetic component hasn't become internal or dominant. Yet. (Related: Voluntary cyborgs.)