HealthLawProf Blog

Editor: Katharine Van Tassel
Akron Univ. School of Law

A Member of the Law Professor Blogs Network

Monday, February 11, 2008

Flu Pandemic Preparation for Hospitals

DailyKos has a great article by DemFromCt on the preparation or lack of preparation that hospitals have undertaken for the next flu pandemic - complete with lots of helpful charts and graphs.  The article is an eyeopening read on how much strain such emergencies would put on our health care system.  DemFromCt writes,

Problems like pandemics, surge capacity and disaster preparation do not go away by ignoring them. Hopefully, by putting some of these issues in perspective, we can better appreciate the time, dollars and energy spent on mitigating that which cannot be stopped. At the same time, we can appreciate the efforts being made by your public health people which, if invisible, are still none the less remarkable. And finally, we can appreciate how strained the current health system is... it would not take much these days to push things over the edge, despite the remarkable resilience the health system has shown.

Discussion

The Washington Post had an interesting story last week about the challenges hospitals face in preparing for the next flu pandemic:

The federal government's voluminous plans for dealing with pandemic flu do not adequately account for the overwhelming strain an outbreak would place on hospitals and public health systems trying to cope with millions of seriously ill Americans, some public health experts and local health officials say.

The Bush administration's plans, which run more than 1,000 pages, contemplate the nightmare medical scenarios that many experts fear, but critics say federal officials have left too much of the responsibility and the cost of preparing to a health-care system that even in normal times is stretched to the breaking point and leaves millions of people without adequate access to care.

"The amount going into actually being prepared at a community level is not enough," said Patrick Libbey, executive director of the National Association of County and City Health Officials. "We are still talking about rearranging with little additional resources the assets of a system that are built on such a thin margin now that you have significant amounts of people without access to care, and hospitals that are periodically shutting down their ERs and the like."

These concerns aren't just reflected in news stories quoting public health officials. At a recent emergency management conference I attended, I heard the same concerns expressed by hospital representatives from all over the country. There's a reason for this... despite the great work by creative people trying to figure out how best to cope, there's just not enough of the three components that make up what's called surge capacity, the ability to flex up hospital care quickly to meet the needs of the population it serves (.pdf link). Those components can be thought of as "staff" (nurses and other health care workers and caregivers, "stuff" (from intravenous medicines to bedsheets to actual beds) and "space" (everything needs to be housed somewhere). California alone is spending hundreds of millions of dollars on this (good that they are), and given the efforts on the one hand and the concerns on the other, it's worth spending a Sunday essay reviewing what the big deal is. It's your tax dollars, and (for one disaster or another), your community (click this link).

Dr Eric Toner (from the University of Pittsburgh Medical Center's Center for Biosecurity) has been working on these issues for some years. Two of his slides illustrate the problem that an influenza pandemic would cause. In the first, the total US hospital beds availability is presented, and contrasted with what would be needed for both a mild moderate (similar to the 1968 pandemic) and a severe (based on 1918) pandemic. SNS is the strategic national stockpile, set aside for grave emergencies and under the control of HHS and DHS.

The second slide represents the same numbers looked at in terms of projected demand, and what would be required from hospitals to cope.

Using FluSurge 2.0 and inputting variables from the HHS planning assumptions results in projections that indicate that hospitals would be severely stressed in the best case scenario and completely overwhelmed in the case of a severe pandemic

What Hospitals Should Do to Prepare for an Influenza Pandemic
Eric Toner and Richard Waldhorn . . . . .

February 11, 2008 | Permalink | Comments (0) | TrackBack (0)

The Canadian Health Care MythBuster

Here is a great link to a website that discusses the Canadian Health Care system and de-bunks some of the myths surrounding it.  Here is just a brief sample:

1. Canada's health care system is "socialized medicine."
False. In socialized medical systems, the doctors work directly for the state. In Canada (and many other countries with universal care), doctors run their own private practices, just like they do in the US. The only difference is that every doctor deals with one insurer, instead of 150. And that insurer is the provincial government, which is accountable to the legislature and the voters if the quality of coverage is allowed to slide.

The proper term for this is "single-payer insurance." In talking to Americans about it, the better phrase is "Medicare for all."

2. Doctors are hurt financially by single-payer health care.
True and False. Doctors in Canada do make less than their US counterparts. But they also have lower overhead, and usually much better working conditions. A few reasons for this:

First, as noted, they don't have to charge higher fees to cover the salary of a full-time staffer to deal with over a hundred different insurers, all of whom are bent on denying care whenever possible. In fact, most Canadian doctors get by quite nicely with just one assistant, who cheerfully handles the phones, mail, scheduling, patient reception, stocking, filing, and billing all by herself in the course of a standard workday.

Second, they don't have to spend several hours every day on the phone cajoling insurance company bean counters into doing the right thing by their patients. My doctor in California worked a 70-hour week: 35 hours seeing patients, and another 35 hours on the phone arguing with insurance companies. My Canadian doctor, on the other hand, works a 35-hour week, period. She files her invoices online, and the vast majority are simply paid -- quietly, quickly, and without hassle. There is no runaround. There are no fights. Appointments aren't interrupted by vexing phone calls. Care is seldom denied (because everybody knows the rules). She gets her checks on time, sees her patients on schedule, takes Thursdays off, and gets home in time for dinner.

One unsurprising side effect of all this is that the doctors I see here are, to a person, more focused, more relaxed, more generous with their time, more up-to-date in their specialties, and overall much less distracted from the real work of doctoring. You don't realize how much stress the American doctor-insurer fights put on the day-to-day quality of care until you see doctors who don't operate under that stress, because they never have to fight those battles at all. Amazingly: they seem to enjoy their jobs.

Third: The average American medical student graduates $140,000 in hock. The average Canadian doctor's debt is roughly half that.

Finally, Canadian doctors pay lower malpractice insurance fees. When paying for health care constitutes a one of a family's major expenses, expectations tend to run very high. A doctor's mistake not only damages the body; it may very well throw a middle-class family permanently into the ranks of the working poor, and render the victim uninsurable for life. With so much at stake, it's no wonder people are quick to rush to court for redress.

Canadians are far less likely to sue in the first place, since they're not having to absorb devastating financial losses in addition to any physical losses when something goes awry. The cost of the damaging treatment will be covered. So will the cost of fixing it. And, no matter what happens, the victim will remain insured for life. When lawsuits do occur, the awards don't have to include coverage for future medical costs, which reduces the insurance company's liability. . . .

February 11, 2008 | Permalink | Comments (0) | TrackBack (0)

Friday, February 8, 2008

Book Quiz: Just for Fun on a Friday

Here is fun Book Quiz by BluePyramid for you to take to learn which book best represents you and your future.  It is only six questions.

I ended up as, "The Lion, The Witch and the Wardrobe," by CS Lewis (a book that I greatly enjoy).  I am not so sure about my future though . . .

You were just looking for some decent clothes when everything changed quite dramatically. For the better or for the worse, it is still hard to tell. Now it seems like winter will never end and you feel cursed. Soon there will be an epic struggle between two forces in your life and you are very concerned about a betrayal that could turn the balance. If this makes it sound like you're re-enacting Christian theological events, that may or may not be coincidence. When in doubt, put your trust in zoo animals.

February 8, 2008 | Permalink | Comments (0) | TrackBack (0)

10 Ways to Change our Health Care System

LiveSmarter has an interesting post detailing ten different ideas to help improve our health care system from 10 experts.  Here is a brief selection:

1. Mend the medical schools

Dr. Julie Gerberding, director of the Centers for Disease Control and Prevention (CDC), thinks the country needs more medical schools and that doctors, nurses, vets need to learn together. Beginning their education at once, Gerberding says, can encourage healthcare professionals to cooperate and develop a shared mission.

“If we are seriously thinking about building a health system, then we need to be training professionals in a collegial and collaborative manner,” Gerberding told reporters at the annual meeting of the American Veterinary Medical Association earlier this year.

2. Single-payer insurance

Dr. Michael Ozer, a San Antonio-based pediatrician and a member of Physicians for a National Health Program (PNHP), says that the country needs to expand health coverage and lower its costs at the same time. The only way to do this, he asserts, is through single-payer national health insurance, or NHI. The approach is similar to healthcare programs in Canada and Britain.

According to PNHP estimates, U.S. insurance companies spend more than a third of health care dollars on administration and marketing, which subtracts money from patient care. A national system, Ozer states, would facilitate long-term cost controls on the pharmaceutical industry to ensure that new benefits are sustainable. Such a system would equal overhead savings possibly to the tune of as much as $350 billion a year. He goes on to cite federal legislation currently under consideration in Congress called the United States National Health Insurance Act (HR 676) which, if passed, would extend Medicare to more people.

3. Individual, not company, plans

Michael F. Cannon, director of health policy studies at the Cato Institute and co-author of the forthcoming 2nd edition of Healthy Competition: What’s Holding Back Health Care and How to Free It, says market forces bear no consequence on rising healthcare costs. Doctors and insurance companies get away with charging high prices because government programs encourage employer-controlled insurance. More people could benefit if they kept the same insurance plan even if they didn’t keep the same job.

The government is at least taking a step in that direction, Cannon says. President George Bush and GOP presidential candidate Rudy Giuliani have endorsed reforms that would extend the tax break applying to employer-controlled coverage to individual coverage. Those measures could result in families controlling more of their healthcare money and the expansion of coverage to 7 million people, according to the Congressional Budget Office.

4. Divert the dollar to the doc

Orthopedic surgeon and sports medicine specialist Neil Thomas Katz, on the other hand, says that the dollar needs to go to the doctors, not the patients, the insurance companies or the government.

“The solution is simple. Doctors and hospitals need to be paid at least as much as it costs to take care of you. We should not be losing money,” Katz states.

America’s healthcare funds, he claims, go toward paying high executive salaries and to maintaining insurance company staff whose primary job is “to find ways not to pay for your healthcare.” In addition, workers’ compensation and no-fault premiums create a cycle of litigation against doctors and employees. The current system enables a government health bureaucracy to thrive.

5. Pay for the care of populations, not events

Donald Berwick, a Massachusetts pediatrician and the president of the Institute for Healthcare Improvement, touches upon several ways to transform healthcare. One area he focuses on involves making healthcare a pattern, not a response to a particular occurrence.

Berwick thinks that individuals rely on random health events like hospital stays and office visits for care. A better system would treat patients on a regular basis and aim for high quality preventive care. This method would address “the real needs of patients over time and place, guiding them through the technological thicket of modern medicine, and making sure that they get exactly what they want and need, exactly when and how they want and need it,” Berwick says. . . . .


Thanks to Ezra Klein for the link.

February 8, 2008 | Permalink | Comments (0) | TrackBack (0)

Thursday, February 7, 2008

Rating Your Doctor: Cost v. Quality of Care

The Wall Street Journal's Health Blog reports on Tennessee BlueCross BlueShield's adoption of doctor rating.  Jacob Goldstein reports,

The debate over insurers rating doctors encapsulates a lot of what people are fighting over in health care these days: Who should have access to what information, how to determine quality of care, and the roles insurers and doctors should play. But even as the debate continues, it’s clear that consumers will get more information about their doctors, and insurers are starting to dish it out.

The latest example comes courtesy of  the Nashville Tennessean, which reports today that BlueCross BlueShield of Tennessee, the state’s largest insurer, will soon start rating doctors based on whether patients get appropriate tests and treatments. The insurer’s private customers will also be able to get info on how much doctors charge.

The insurer will stop short of recommending particular doctors. And, the article reports, it will follow the rating model established by negotiations between the New York AG’s office and several big insurers. One key element is disclosing the criteria that go into rating doctors, and allowing doctors to appeal their ratings.

Docs have argued that insurers have an incentive to send patients to the cheapest — but not necessarily the best — doctors.  Dr. William Edwards, a vascular surgeon who served on an advisory panel to the Blues on the ratings, said that doctors who see sicker patients could be at a disadvantage because their costs would be higher. “If you publish that data, you run the risk that those doctors could become averse to taking on those risky patients because it makes them look bad,” he told the Tennessean. . . . .

February 7, 2008 | Permalink | Comments (0) | TrackBack (0)

Modern Music: Your Parents Were Right!

The New York Times reports this week on the "dangers" of modern music which our children spend hours a day listening today.  The story says,

Teenagers listen to an average of nearly 2.5 hours of music per day. Guess what they’re hearing about?  One in three popular songs contains explicit references to drug or alcohol use, according to a new report in The Archives of Pediatrics and Adolescent Medicine. That means kids are receiving about 35 references to substance abuse for every hour of music they listen to, the authors determined.

While songs about drugs and excess are nothing new, the issue is getting more attention because so many children now have regular access to music out of the earshot of parents. Nearly 9 out of 10 adolescents and teens have an MP3 player or a compact disc player in their bedrooms.  Studies have long shown that media messages have a pronounced impact on childhood risk behaviors. Exposure to images of smoking in movies influences a child’s risk for picking up the habit. Alcohol use in movies and promotions is also linked to actual alcohol use.

Researchers from the University of Pittsburgh School of Medicine studied the 279 most popular songs from 2005, based on reports from Billboard magazine, which tracks popular music. Whether a song contained a reference to drugs or alcohol varied by genre. Only 9 percent of pop songs had lyrics relating to drugs or alcohol. The number jumped to 14 percent for rock songs, 20 percent for R&B and hip-hop songs, 36 percent for country songs and 77 percent for rap songs. . . .

The study authors noted that music represents a pervasive source of exposure to positive images of substance use. The average adolescent is exposed to approximately 84 references to explicit substance use per day and 591 references per week, or 30,732 references per year. The average adolescent listening only to pop would be exposed to 5 references per day, whereas the average adolescent who listens just to rap would be exposed to 251 references per day. . . .

Although music lacks the visual element of film, adolescent exposure to music is much more frequent, accounting for an average of 16 hours each week for music compared with about 6 hours each week for movie images, according to the study authors. But frequency of exposure is not the only factor. Unlike visual media, music is a powerful social force that also taps into an individual’s personal identity, memories and mood.

February 7, 2008 | Permalink | Comments (0) | TrackBack (0)

Wednesday, February 6, 2008

Costly People to Cover -- Healthy People

PLoS Medicine published a study by Dutch scientists whichprovides an overview of how much obesity costs the nation.  It has received some (see AP article here) because its conclusions about the cost of the obese are not quite what people expected.  It turns out that obese people are not as costly as one might assume - it is those with slighly lower BMIs and a history as a non-smoker who tend to live longer and those consume more health care dollars. 

The researchers used their model to estimate the number of surviving individuals and the occurrence of various diseases for three hypothetical groups of men and women, examining data from the age of 20 until the time when the model predicted that everyone had died. The “obese” group consisted of never-smoking people with a BMI of more than 30; the “healthy-living” group consisted of never-smoking people with a healthy weight; the “smoking” group consisted of lifetime smokers with a healthy weight. Data from the Netherlands on the costs of illness were fed into the model to calculate the yearly and lifetime health-care costs of all three groups. The model predicted that until the age of 56, yearly health costs were highest for obese people and lowest for healthy-living people. At older ages, the highest yearly costs were incurred by the smoking group. However, because of differences in life expectancy (life expectancy at age 20 was 5 years less for the obese group, and 8 years less for the smoking group, compared to the healthy-living group), total lifetime health spending was greatest for the healthy-living people, lowest for the smokers, and intermediate for the obese people.

Darn those healthy people - I think I will go eat some more chocolate and consider some unhealthy habits I can adopt just so that I won't be adding to our nation's health care costs.

February 6, 2008 | Permalink | Comments (0) | TrackBack (0)

Climate Change and the Spread of Disease

Slate.com has an interesting piece discussing the what impact, if any, climate change may have on the spread of various diseases.  Maria Said writes,

Before the summer of 2007, Castiglione di Cervia, Italy, was known as a quiet village near Ravenna. In July, however, doctors noticed complaints of excruciating joint pain, fever, headaches, and rash. Their patients were experiencing a fever called "chikungunya"; the word originates in the Makonde language in Tanzania and Mozambique and means "to dry up or become contorted." This epidemic had two years previously raged unexpectedly through islands in the Indian Ocean. But it was new to Europe.

And so Castiglione found itself at the center of scientists' efforts to map the effect of climate change on the spread of infectious disease. In December, at a Washington, D.C., conference sponsored by the Institute of Medicine, scientists and doctors wrestled with these questions: Did global warming bring chikungunya to Italy? Will it lead to a return of scourges like malaria, pushed out of Europe and the United States in the mid-20th century? Will epidemics worsen in poorer countries? . . . .

While they readily accept the associations between climate and infectious agents, scientists balk at stating exactly what a change in climate might cause. This reluctance lies both in the complexity of disease and in the nature of science, in the need to build a case incrementally, fact by fact. Asking a scientist to predict the spread of disease is like asking him or her, while standing in the midst of a tornado, to predict how the landscape will change by measuring the direction and amount of debris flying by.

Take the chikungunya debate: Initially hailed as a clear example of how warmer weather can lead to new epidemics, some experts pointed out that it was not global warming but a new mutation of the virus that made the fever increasingly infectious. Others argued that the reasons for the chikungunya epidemic lay in new routes for disease opened up by the global economy; in the 1990s, imported tires carried into Italy a mosquito known as "the Asian tiger," which can serve as a vector for chikungunya as well as dengue fever. . . . .

What is the alternative to endless discussion? Recent editorials in the New England Journal of Medicine and the Lancet call for accepting, even without 100 percent certainty, the accumulating body of evidence that climate change will affect infectious diseases. Doctors regularly make recommendations to patients based on what they think might happen. Gina Solomon, a physician and senior scientist for the Natural Resources Defense Council, points out that not knowing whether hypertension will hurt an individual patient does not stop a doctor from trying to bring his or her blood pressure down.

A different slant, put forth by Peter Schwartz and others at the consulting agency Global Business Network, sidesteps the need for scientific proof. Their "systems vulnerability approach" does not try to predict what will happen to the climate; rather, it identifies existing vulnerabilities in our world that could easily tip a region toward a new epidemic given the additional stress of climate change. A damaged Iraqi town without a clean water source is more vulnerable to a cholera outbreak if waters there warm, as they did in Peru. An unusually hot summer in a sprawling slum in Mexico City becomes the breeding ground for an epidemic of infectious diarrhea. We may not know precisely what causes what. But we don't have to sit back and wait to see what the weather will do.

February 6, 2008 | Permalink | Comments (0) | TrackBack (0)

Monday, February 4, 2008

Bush Budget: Cuts for Medicare and Medicaid

The Wall Street Journal's Health Blog provides a concise overview of the Bush budget for Medicare and Medicaid.  Ms. Wang writes,

Medicare spending needs to be reigned in, the Bush administration makes clear in its budget proposal for fiscal year 2009. The $3 trillion proposed federal budget cuts Medicare and Medicaid funds by $14.2 billion, reports the Washington Post.

The plan would shave $560 billion from Medicare and Medicaid over the next decade but leaves alone subsidies to insurers totaling an estimated $150 billion, notes the WSJ. The Bush administration estimates the changes will result in a $10 trillion decrease in spending over the next 75 years. . . .

A bipartisan discussion of federal entitlements are being called for by some congressional leaders, says the WSJ, but most think the chasm between President Bush and the Congress is too wide to be bridged.

February 4, 2008 | Permalink | Comments (0) | TrackBack (0)

SEIU Puts Money Behind Universal Health Care

Ezra Klein updates us on the push for universal health care - writing about the recent decision of the SEIU to spend $75 million promoting universal health care (Take that Harry and Louise!).  He writes,

It's a really big deal that SEIU has committed to a $75 million campaign for universal health care. More important, by far, than the opinions and strategies of the individual presidential candidates is the strength, commitment, and ferocity of the coalition pushing for reform. Politicians are, at the end of the day, politicians, and they will do only what they believe to be possible given the realities of the moment. SEIU's efforts, along with those of the many other groups I reported on in this article, will shape the moment.  And they, not the candidates, are why we actually have a chance.

February 4, 2008 | Permalink | Comments (0) | TrackBack (0)

Friday, February 1, 2008

Bad Public Health Initiative

The blog, JunkFood Science reports on a Mississippi legislator's attempt to combat the obesity epidemic: banning restaurants from serving food to anyone who is "obese" (a term defined by the State of Mississippi).  If the restaurants fail to comply, their permits to serve food will be revoked.   Sandy Szwarc at JunkFood Science provides further information: 

House Bill 282 was introduced in the 2008

Mississippi

legislative session on Friday by Representative W.T. Mayhall, Jr., a retired pharmaceutical salesman with DuPont-Merk. Its co-authors are Bobby Shows, a businessman, and John Read, a pharmacist.

The full text reads:

HOUSE BILL NO. 282

An act to prohibit certain food establishments from serving food to any person who is obese, based on criteria prescribed by the state department of health; to direct the department to prepare written materials that describe and explain the criteria for determining whether a person is obese and to provide those materials to the food establishments; to direct the department to monitor the food establishments for compliance with the provisions of this act; and for related purposes. Be it enacted by the legislature of the state of Mississippi:

SECTION 1.

(1) The provisions of this section shall apply to any food establishment that is required to obtain a permit from the State Department of Health under Section 41-3-15(4)(f), that operates primarily in an enclosed facility and that has five (5) or more seats for customers.

(2) Any food establishment to which this section applies shall not be allowed to serve food to any person who is obese, based on criteria prescribed by the State Department of Health after consultation with the Mississippi Council on Obesity Prevention and Management established under Section 41-101-1 or its successor. The State Department of Health shall prepare written materials that describe and explain the criteria for determining whether a person is obese, and shall provide those materials to all food establishments to which this section applies. A food establishment shall be entitled to rely on the criteria for obesity in those written materials when determining whether or not it is allowed to serve food to any person.

(3) The State Department of Health shall monitor the food establishments to which this section applies for compliance with the provisions of this section, and may revoke the permit of any food establishment that repeatedly violates the provisions of this section.

SECTION 2. This act shall take effect and be in force from and after July 1, 2008.

Perhaps we need to re-think whether obesity should be viewed as a disability - discrimination based on weight in our society seems to be on an upswing.  Thanks to the blog, Feministe for the link. 

February 1, 2008 | Permalink | Comments (0) | TrackBack (0)

More News on Chocolate . . .

Slate.com's Medical Examiner's "Your Health This Week" column concerns whether chocolate is bad for women's bones.  (Yikes - say it isn't so!)   Slate reports: 

Question: One of the plusses of chocolate is that it contains materials called flavonoids. These are known to enhance bone health. But does chocolate do more harm than good to the bones?

Research: Jonathan M. Hodgson and his associates looked at whether calcium supplements might prevent the loss of minerals from the bones of older women, which leads to weakness and risk of fractures. As part of their study of about 1,000 randomly selected elderly women, these scientists examined the effects of diet. One of the foods they studied was chocolate, both as a solid and as cocoa. Given chocolate's flavonoids, they expected that it would improve calcium absorption into bone, which they measured using the standard method: X-ray densitometry.

Findings: To the great surprise of the researchers, the women who ate a lot of chocolate—on average, more than one portion a day (a cup of cocoa, say, or a bar of chocolate)—had lower bone density five years after the experiment began than the women who didn't. The chocolate-eaters and -drinkers were also, unexpectedly, more energetic and leaner.

Explanation: The authors speculate that the lower bone density may be due to another natural ingredient in chocolate: oxalic acid. Oxalic acid can bind the calcium in our diet (from leafy green vegetables and dairy products) and block its absorption, so its presence in chocolate might prevent some calcium from ever reaching the bones. But, as always, we need to keep in mind that association doesn't necessarily imply causation. It may be that some other factor, having nothing to do with chocolate, controls the intake and absorption of calcium.

Speculation: Here's another thought, or really speculation: The chocolate-eaters in the study were somewhat lower in weight and body fat than the women who avoided chocolate. Especially in older women, body fat contributes to estrogen level, which, in turn, promotes increased bone calcium. Perhaps the slightly heavier post-menopausal women in the study, who ate less chocolate, had higher levels of calcium in their bones, on average, because of the additional estrogen produced by their body fat.

Conclusion: So, does this study also apply to younger women or to men? It's hard to say, since we don't know the true mechanism which leads to lower bone density in older women who like chocolate. But we do know one thing which helps maintain and increase bone density and strength: exercise. Which certainly seems preferable to giving up chocolate.

I must admit that I tend to be rather picky as to which of these scienfic studies on dietary issues I believe; i.e.,  Dark chocolate good for you - completely scientifically sound.  A glass of wine good for you - again completely scientifically sound.  Chocolate potentially not so good - I am suspicious about the scientific method used in this study  . . . .

February 1, 2008 | Permalink | Comments (0) | TrackBack (0)