Friday, April 4, 2008
The New Yorker has a piece this week by Michael Kinsley on living a long life. He tells movingly about his struggle with Parkinson's Disease and the desire by many for a longer life. He writes,
. . . . What’s more, of all the gifts that life and luck can bestow—money, good looks, love, power—longevity is the one that people seem least reluctant to brag about. In fact, they routinely claim it as some sort of virtue—as if living to ninety were primarily the result of hard work or prayer, rather than good genes and never getting run over by a truck. Maybe the possibility that the truck is on your agenda for later this morning makes the bragging acceptable. The longevity game is one that really isn’t over till it’s over.
Between what your parents gave you to start with—genetically or culturally or financially—and pure luck, you play a small role in determining how long you live. And even if you add a few years through your own initiative, by doing all the right things in terms of diet, exercise, sleep, vitamins, and so on, why is that to your moral credit? Extending your own life expectancy is the most selfish motive imaginable for doing anything. Do it, by all means. I do. But for heaven’s sake don’t take a bow and expect applause.
This is the game that really counts. Perhaps you imagine that, as eternity approaches, the petty ambitions and rivalries of this life melt away. Perhaps they do. That doesn’t mean that the competition is over. It means that the biggest competition of all is about to start. Do you doubt it? Ask yourself: what do you have now, and what do you covet, that you would not gladly trade for, say, five extra years? These would be good years, of cross-country skiing between fashionable Colorado resorts, or at least years when you could still walk and think and read and drive. You would still be a player in whatever game you spent your life playing: still invited to faraway conferences about other people’s problems, if you ever were; still baking your famous chocolate-chip banana bread for the family if your life followed a less McNamarish course. What would you trade for that? Or, rather, what wouldn’t you trade? O.K., you’d give up years for the health and happiness of your children. What else? Peace in the Middle East? A solution to global warming? A cure for AIDS? These negotiations are secret, mind you. No one will know if you selfishly choose a few extra years for yourself over an extra million or two for Planet Earth. We’ll posit that you’re a good person, though, and that to spare the earth from a couple of the Four Horsemen you’d accept a shorter span for yourself. . . .
Anyway, back to you. Children, country, future of the world are off the table. And, yes, these are the important things. But there are other things that make life sweet. The baby-boom generation in America is thought to have found something approaching genuine happiness in material possessions. A popular bumper sticker back in the nineteen-eighties read, “He Who Dies with the Most Toys Wins.” This was thought to be a brilliant encapsulation of the baby-boom generation’s shallowness, greed, excessive competitiveness, and love of possessions. And it may well be all of these things. It’s also fundamentally wrong. Is there anything in the Hammacher Schlemmer catalogue—or even listed on Realtor.com—for which you would give up five years? Of course not. That sports car may be to die for, but in fact you wouldn’t. What good are the toys if you’re dead? “He Who Dies Last”—he’s the one who wins. . . .
Today the Wall Street Journal has an article discussing the money made by non-profit hospitals and how it is being spent.
There’s big money in health care, even for institutions that aren’t chartered to make a profit. The combined net income of the 50 largest nonprofit hospitals in this country was more than $4 billion in 2006, up from less than $1 billion in 2001, the WSJ reports. . . . .
Some nonprofits have also started acting like profit-hungry businesses, demanding upfront payments from patients, hiking list prices, selling patients’ debts to collection companies and focusing on expensive procedures, the WSJ says.
Sen. Charles Grassley (R-Iowa) says, “Some nonprofit hospitals seem to forget that their operations are subsidized with generous tax breaks. They allow their priorities to get out of whack.” The senior Republican on the Senate Finance Committee threatened last year to introduce legislation that would require nonprofit hospitals to deliver minimum levels of charity care to maintain their tax benefits.
Take a look at Northwestern Memorial Hospital in Chicago, which has rebuilt its entire campus in the last few years, including a new women’s hospital with marble in the lobby and flat-screen TVs in birthing rooms. The hospital’s former CEO received a $16.4 million payout in 2006, the WSJ says. The hospital says much of that payment was deferred compensation and retirement benefits accrued during his long career at the hospital. . . .
Ezra Klein has some thoughts here:
Gross stuff. I'm going to outsource this bit of commentary to Maggie Mahar and her excellent book, Money-Driven Medicine:
As health care became increasingly sophisticated, neither government nor a philanthropy could keep up with the levitating costs of a high-tech industry. Meanwhile, in the early 1970s, Washington began to question what many saw as runaway hospital spending. Luckily, at about this time, the bond market decided that it would be more than happy to provide the capital that non-profits needed -- for much the same reasn that the stock market was eager to finance the first for-profit hospitals. With revenues pouring in from both Medicare and the private-sector employers who financed commercial health insurance, hospitals seemed a sure thing...By the late 1970s, nearly 50 percent of hospital financing was done through tax-exempt bonds. Ten years later, 80 percent of construction funds for not-for-profit hospitals would come from borrowing -- up from 40 percent 20 years earlier. By 1981 philanthropy and government grants funded less than 8 percent of hospital construction.
The change meant that not-for-profit hospitals had to redefine their mission. The expectations and demands of a bond investor who entrusts his savings to a hospital are, after all, quite different from the hopes and goals of a philanthropist who bids only for immortality: the bond investor expects a return on his money...This changes a hospital's priorities. In the past, when a hospital board decided how to allocate its resources, board members saw themselves as running a social service. When they looked in the mirror, they didn't see a crew of savvy entrepreneurs; they saw pillars of the community...[So] the economic reality is this: 45 years ago, the market did not set a hospital's priorities because hospitals did not rely on the market in order to survive. Today not-for-profits rely on borrowed money for more than half of their capital. And the cost of much of that money pivots on how well rating agencies like Standard & Poor's view a hospital's balance sheets.
Thursday, April 3, 2008
I hope that this survey is perhaps a late April Fool's joke, if not, we have some teens who are in lots of trouble. Here is the story from Local 6 News in Orlando, Florida:
A recent survey that found some Florida teens believe drinking a cap of bleach will prevent HIV and a shot of Mountain Dew will stop pregnancy has prompted lawmakers to push for an overhaul of sex education in the state.
The survey showed that Florida teens also believe that smoking marijuana will prevent a person from getting pregnant.State lawmakers said the myths are spreading because of Florida's abstinence-only sex education, Local 6 reported.They are proposing a bill that would require a more comprehensive approach, the report said.It would still require teaching abstinence but students would also learn about condoms and other methods of birth control and disease prevention.The bill just passed its first vote in a committee, Local 6 reported.
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USAToday has an article concerning the rapidly rising costs of prescription drugs. Julie Appleby reports,
People with health insurance are having more trouble paying for prescription drugs as higher out-of-pocket costs for medications and a slowing economy strain family budgets, according to surveys and health care analysts.
The Virginia-based National Patient Advocate Foundation, which helps people struggling to pay medical bills, found that 31% of the 44,729 people it aided last year cited drug co-payments — the patient's portion of the drug's cost — as their top medical-debt problem.
"Incomes aren't going up, but co-payments are," says Gary Claxton of the Kaiser Family Foundation, which studies health policy. In some cases, the patient's share of drug costs is no longer a flat dollar amount, but a proportion that can range from 20% to 70%. "Some families that have to deal with chronic or critical illness are not in a position to maintain that," says Nancy Davenport-Ennis, who heads the patient foundation.
Among evidence of increasing problems:
•13% of insured Americans report paying for drugs is a serious problem, says a recent poll by USA TODAY, the Kaiser Family Foundation and Harvard School of Public Health. That's up from 9% in a foundation survey in 2000. The latest poll of 1,695 adults had a margin of error of +/-3 percentage points.
•The 31% reporting drug payments as their top medical-debt problem to the patient foundation rose from 26% of people in 2006 and 17% in 2005. . . .
In the Kaiser survey of 68 million workers with job-based prescription-drug benefits, about 7% had coverage requiring special payments for a few costly types of drugs, including some treatments for cancer and multiple sclerosis. For those drugs, the average 2007 cost was $71 per prescription, up 20% from 2004. . . .
Wednesday, April 2, 2008
Elizabeth Edwards has been reviewing Presidential-candidate John McCain's health plan (you can see it here) and she isn't too happy about what she finds in it. She also wonders whether John McCain would be covered under his own plan? She sets forth some of her concerns here. She has posted a few questions for him at Thinkprogress. She asks,
What I am not confused about is John McCain’s health care proposal. Apparently Douglas Holtz-Eakin, a senior policy advisor to McCain, thinks I do “not understand the comprehensive nature of the senator’s proposal.” The problem, Douglas, is that, despite fuzzy language and feel-good lines in the Senator’s proposal, I do understand exactly how devastating it will be to people who have the health conditions with which the Senator and I are confronted (melanoma for him, breast cancer for me) but do not have the financial resources we have. In very unconfusing language: they are left outside the clinic doors.
Senator McCain likes to start speeches with a litany of questions that, presumedly, less plain-spoken politicians would refuse to answer. Well, here are some questions he does not ask but, as that plain-spoken politician, he might want to answer:
1. Under your plan, Senator McCain, would any health insurer be required to sell you or me (or those like us with pre-existing conditions) a health insurance policy?
2. You say your plan is going to increase competition to the point that it actually lowers costs. Isn’t there competition today among insurance companies? Haven’t costs continued to go up despite that competition?
3. You say that under your plan everyone is going to pay less for health insurance. Nice words, I admit, but they are words we have heard before. You must know when American families calculate the actual cost of health care, they have to include those deductibles and co-pays and not just the cost of the insurance. Are you talking about cheaper overall or just a cheap policy that doesn’t kick in until after thousands of dollars of deductibles have been paid?
4. Isn’t the type of competition you are talking about really a rush to the bottom? As long as you allow insurers to underwrite and deny access, you encourage insurers to offer plans that may be cheap, but that get that way by avoiding people with cancer or other high-cost diseases or by limiting benefits and treatments, particularly if the treatment is expensive or might be needed for a long time. We all live in the real world; those of us lucky enough to have health insurance have seen how insurers cut coverage and up co-pays or deny particular treatments. The insurance company makes money when it doesn’t have to pay for our health care. (I suspect that if they could, they would write obstetrical-only policies for nuns.) Doesn’t your plan really encourage insurers plans to compete to avoid people with cancer or other high-cost diseases? Don’t you think that the kind of competition that starts with a decent level of required coverage, that doesn’t exclude the care we actually need, would be better?
I am not confused about your reputation: you are the straight-talker, you like to say. This is about health care, Senator McCain. Doesn’t the American voter deserve some straight answers to these questions? As one of those with a pre-existing condition, I sure would like some straight talk.
– Elizabeth Edwards
Daily Kos' Dr. Steve B. and ThinkProgress report on a new survey of over 2000 doctors showing that 59% of them "support legislation to establish a national health insurance program. This number is higher than surveys taken five years ago. Ezra Klein says that we should be somewhat suspicious of this number. Here is why:
Sadly, the normal caveats about health care polling all apply. We don't establish health plans in principle, we establish them with specifics. And that tends to be where you lose a lot of stakeholders, as the specifics often threaten to deprive them of revenue. Moreover, this is a very vague question. Steve thinks it's an endorsement of single payer, but it's rather unclear what's actually being agreed to here. Single payer? Socialized medicine? Private insurance paid for by the government? Who knows?
That said, doctors regularly come into contact with Medicare, Medicaid, and the VA -- if those systems were really as bad as some like to pretend, you'd have something less than six-in-ten clamoring for broader government involvement. In the past, the American Medical Association has been a powerful opponent of reform. More recently, they've basically been silent. But if doctors were to actually organize in favor of change, it would be tremendously powerful. Constituencies who want to see reform need to be as aggressive as those who wish to block it.
Tuesday, April 1, 2008
rSlate.com has an article discussing new technologies that help patients remember to take their medications or provide a record of when they do take them. The article also discusses a recent study appearing in Health Affairs on dialysis patients and their compliance with treatment regimes in 12 different countries. Apparently it wasn't just that Americans must pay more for their medications that led to greater noncompliance, there exist some cultural factors as well. Jessica Wapner writes,
Earlier this month, scientists at Georgia Tech announced their invention of a necklace that records the date and time at which a person swallows his prescription medicine. The device (which looks more like a dog collar than jewelry) responds to a tiny magnet in the pill as it travels down the esophagus. Other recently developed similar technologies include a drug-filled prosthetic tooth that slowly drips medicine into the mouth and a pill bottle that sends a wireless message to your pharmacist every time it's opened.
Are we so bad at taking medicine that we need false teeth to do it for us and pill bottles that tattle on us when we don't? It would seem so. About 50 percent of patients fail to correctly follow prescriptions: We forget to take pills, we alter doses, we take breaks. Nonadherence—the medical term for neglecting to abide by a doctor's orders—is rampant, resulting in up to one-quarter of all hospital and nursing home admissions. It's also expensive. The problem persists despite monumental efforts to prevent it. Why? For one thing, it's impossible to predict which patients are likely to deviate from their orders. And while the problem seems like it should have a simple solution, it doesn't. Nonadherence, it turns out, is one more reason to heed the call for better American health care.
Blowing off a doctor's instructions might seem like the act of a basically healthy person. Who hasn't neglected to take that last antibiotic or exercised less than the doctor said to? But treatment drop-off rates are high among the seriously ill, too. About half the people who undergo kidney transplants do not adequately adhere to the regimen necessary to thwart rejection of their new organ. A 1970s study found that 43 percent of glaucoma patients refused to take the doctor-ordered measures necessary to prevent blindness, even when that refusal had already led to blindness in one eye.
Cost of medication is an obvious consideration. A recent study in Health Affairs reported that 29 percent of patients with chronic kidney failure in the United States did not purchase needed drugs because they were too expensive. It's understandable: Their co-pay of $114 for a month of medication was the highest of all 12 countries included in the analysis. By contrast, British patients, who had the lowest out-of-pocket costs, were the best at sticking with treatment.
But cost wasn't the only factor that determined whether patients took their medicine. Swedish patients also had high monthly co-pays, but they were great at following their prescriptions. And good adherence among Japanese patients was only partially explained by low costs. The authors of the Health Affairs study wondered about the influence of cultural factors but also pointed to the health system structure: Since Japanese doctors earn income by selling medicine directly to patients, they have an incentive to make sure prescriptions get filled . . . .
As it turns out, there is one predictive factor: experience with the health care system. A study of 186 doctors and their patients with diabetes, heart disease, and hypertension found that whether patients got their questions answered correlated strongly with whether they would stick with treatment. Other factors that mattered included the doctor's level of job satisfaction, how many patients he or she sees per week, and whether patients scheduled a follow-up appointment. As health care consultant Kip Piper explains, the average doctor's visit clocks in at less than 20 minutes, leaving little time for discussion. And when patients do ask questions, they are usually interrupted within 18 seconds. With little explanation, tricky regimens may not be followed correctly, or a person may take a break from a drug, not understanding the importance of completing the regimen. Many times, patients simply don't understand the doctor's orders. Requiring patients to use mail-order companies to order some drugs, as health insurers are increasingly doing, will probably make matters worse.
The legion of gadgets helps some patients but doesn't make a big enough dent because the contraptions don't address these underlying issues. Concierge medicine is a more successful fix: For an annual fee, doctors promise to limit the number of patients they treat and provide a higher level of care. But, while effective, this approach is inherently limited. The fee of up to $1,500 is prohibitive for many people, and in any case, there aren't that many VIP doctors out there. Adherence, then, is unlikely to improve much unless something changes dramatically in the health care system. Or else, we need to invent a drug for nonadherence. If only anyone would take it.
The Diane Rehm show has an interesting discussing planned for 11am EST concerning personal genetic testing. The brief overview states,
A growing number of people are turning to personalized genetic testing to learn about possible predisposition to some diseases, inherited behavioral traits, and clues to their family heritage. We'll talk about what these tests can tell us and some of the new questions they raise.
Dr. Francis Collins, director of the National Human Genome Research Institute
Beth Peshkin, senior genetics counselor, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center
Linda Avey, co-founder, 23andMe, a personalized genetic testing company
Earlier this morning, Morning Edition had an interesting discussion with Ms.Jessica Queller about her book. Pretty Is What Changes: Impossible Choices, The Breast Cancer Gene, and How I Defied My Destiny," Here is a brief summary of the book:
Eleven months after her mother succumbs to cancer, Jessica Queller has herself tested for the BRCA “breast cancer” gene mutation. The results come back positive, putting her at a terrifyingly elevated risk of developing breast cancer before the age of fifty and ovarian cancer in her lifetime. Thirty-four, unattached, and yearning for marriage and a family of her own, Queller faces an agonizing choice: a lifetime of vigilant screenings and a commitment to fight the disease when caught, or its radical alternative—a prophylactic double mastectomy that would effectively restore life to her, even as it would challenge her most closely held beliefs about body image, identity, and sexuality. . . . Without flinching, Jessica Queller answers a question we may one day face for ourselves: If genes can map our fates and their dark knowledge is offered to us, will we willingly trade innocence for the information that could save our lives?
Monday, March 31, 2008
The New York Times has an editorial today by Paul A. Offit, chief of the infectious diseases division of the Children’s Hospital of Philadelphia, who is highly critical of the recent Poling vaccine award. He views the case as one of compassion winning out over the science and is highly critical of the court's failure to require that the evidence meet not only scientific standards but the preponderance of evidence standard. He writes,
On March 6, Terry and Jon Poling stood outside a federal courthouse in Atlanta, Ga., with their 9-year-old daughter Hannah and announced that the federal government had admitted that vaccines had contributed to her autism. The news was shocking. Health officials at the Centers for Disease Control and Prevention and at the American Academy of Pediatrics have steadfastly assured the public that vaccines do not cause autism. Now, in a special vaccine claims court, the federal government appeared to have said exactly the opposite. What happened?
The answer is wrapped up in the nature of the unusual court where the Poling case was heard. In 1986, after a flood of lawsuits against vaccine makers threatened the manufacture of vaccines for children, Congress created the National Vaccine Injury Compensation Program, financed by a tax on every dose of vaccine. . . .
If, at a trial in a special court, a preponderance of scientific evidence suggested that a vaccine caused one of these problems, a family would be compensated quickly, generously and fairly. Because no one could sue vaccine makers without going through this special court, the number of lawsuits against vaccine makers fell drastically.
The system worked fine until a few years ago, when vaccine court judges turned their back on science by dropping preponderance of evidence as a standard. Now, petitioners need merely propose a biologically plausible mechanism by which a vaccine might cause harm — even if their explanation contradicts published studies. . . .
In 2000, when Hannah was 19 months old, she received five shots against nine infectious diseases. Over the next several months, she developed symptoms of autism. Subsequent tests showed that Hannah has a mitochondrial disorder — her cells are unable to adequately process nutrients — and this contributed to her autism. An expert who testified in court on the Polings’ behalf claimed that the five vaccines had stressed Hannah’s already weakened cells, worsening her disorder. Without holding a hearing on the matter, the court conceded that the claim was biologically plausible.
On its face, the expert’s opinion makes no sense. Even five vaccines at once would not place an unusually high burden on a child’s immune system. The Institute of Medicine has found that multiple vaccines do not overwhelm or weaken the immune system. And although natural infections can worsen symptoms of chronic neurological illnesses in children, vaccines are not known to.
“There is no evidence that children with mitochondrial enzyme deficiencies are worsened by vaccines,” Salvatore DiMauro, a professor of neurology at Columbia who is the nation’s leading expert on the disorder, told me. Indeed, children like Hannah Poling who are especially susceptible to infections are most likely to benefit from vaccines.
Supporters of the Vaccine Injury Compensation Program argue reasonably that the program should err on the side of overcompensation — a relief valve that is needed in a society that mandates vaccines. But there is a price for this largesse. In the past few years, parents of 4,800 autistic children have filed claims to the vaccine court which have yet to be heard. And average awards in other recent vaccine cases have been more than $800,000. Furthermore, because uncompensated claims in vaccine court can spill into state courts, the Poling decision will likely draw more personal-injury lawyers to the fray. “It’s a beginning,” said Kevin Conway, a Boston-based lawyer who represents more than 1,200 families with vaccine injury claims.
The vaccine court should return to the preponderance-of-evidence standard. But much damage has already been done by the Poling decision. Parents may now worry about vaccinating their children, more autism research money may be steered toward vaccines and away from more promising leads and, if similar awards are made in state courts, pharmaceutical companies may abandon vaccines for American children. In the name of trying to help children with autism, the Poling decision has only hurt them.
The UK Independent reports on the results of several new studies on long-term cell phone use - the headline says that they could be more dangerous than smoking. The newspaper reports,
Mobile phones could kill far more people than smoking or asbestos, a study by an award-winning cancer expert has concluded. He says people should avoid using them wherever possible and that governments and the mobile phone industry must take "immediate steps" to reduce exposure to their radiation. The study, by Dr Vini Khurana, is the most devastating indictment yet published of the health risks.
It draws on growing evidence – exclusively reported in the IoS in October – that using handsets for 10 years or more can double the risk of brain cancer. Cancers take at least a decade to develop, invalidating official safety assurances based on earlier studies which included few, if any, people who had used the phones for that long.
Earlier this year, the French government warned against the use of mobile phones, especially by children. Germany also advises its people to minimise handset use, and the European Environment Agency has called for exposures to be reduced.
Professor Khurana – a top neurosurgeon who has received 14 awards over the past 16 years, has published more than three dozen scientific papers – reviewed more than 100 studies on the effects of mobile phones. He has put the results on a brain surgery website, and a paper based on the research is currently being peer-reviewed for publication in a scientific journal.
He admits that mobiles can save lives in emergencies, but concludes that "there is a significant and increasing body of evidence for a link between mobile phone usage and certain brain tumours". He believes this will be "definitively proven" in the next decade.
Noting that malignant brain tumours represent "a life-ending diagnosis", he adds: "We are currently experiencing a reactively unchecked and dangerous situation." He fears that "unless the industry and governments take immediate and decisive steps", the incidence of malignant brain tumours and associated death rate will be observed to rise globally within a decade from now, by which time it may be far too late to intervene medically. . . .
Late last week, the Mobile Operators Association dismissed Khurana's study as "a selective discussion of scientific literature by one individual". It believes he "does not present a balanced analysis" of the published science, and "reaches opposite conclusions to the WHO and more than 30 other independent expert scientific reviews".