Not long ago, a young Ohio woman named Trina Bachtel, who was having health problems while pregnant, tried to get help at a local clinic. Unfortunately, she had previously sought care at the same clinic while uninsured and had a large unpaid balance. The clinic wouldn’t see her again unless she paid $100 per visit — which she didn’t have. Eventually, she sought care at a hospital 30 miles away. By then, however, it was too late. Both she and the baby died. You may think that this was an extreme case, but stories like this are common in America.
Back in 2006, The Wall Street Journal told another such story: that of a young woman named Monique White, who failed to get regular care for lupus because she lacked insurance. Then, one night, “as skin lesions spread over her body and her stomach swelled, she couldn’t sleep.” The Journal’s report goes on: “Mama, please help me! Please take me to the E.R.,” she howled, according to her mother, Gail Deal. “O.K., let’s go,” Mrs. Deal recalls saying. “No, I can’t,” the daughter replied. “I don’t have insurance.” She was rushed to the hospital the next day after suffering a seizure — and the hospital spared no expense on her treatment. But it all came too late; she was dead a few months later.
How can such things happen? “I mean, people have access to health care in America,” President Bush once declared. “After all, you just go to an emergency room.” Not quite. First of all, visits to the emergency room are no substitute for regular care, which can identify and treat health problems before they get acute. . . . Second, uninsured Americans often postpone medical care, even when they know they need it, because of expense. Finally, while it’s true that hospitals will treat anyone who arrives in an emergency room with an acute problem — and it’s wonderful that they will — it’s also true that hospitals bill patients for emergency-room treatment. And fear of those bills often causes uninsured Americans to hesitate before seeking medical help, even in emergencies, as the Monique White story illustrates. . . . According to a recent estimate by the Urban Institute, the lack of health insurance leads to 27,000 preventable deaths in America each year.
But are they really preventable? Yes. Stories like those of Trina Bachtel and Monique White are common in America, but don’t happen in any other rich country — because every other advanced nation has some form of universal health insurance. We should, too.
All of which makes the media circus of a few days ago truly shameful. Some readers may already have recognized the story of Trina Bachtel. While campaigning in Ohio, Hillary Clinton was told this story, and she took to repeating it, . . . She used it as an illustration of what’s wrong with American health care and why we need universal coverage. Then The Washington Post identified Ms. Bachtel, the hospital where she died claimed that the story was false — and the news media went to town, accusing Mrs. Clinton of making stuff up. Instead of being a story about health care, it became a story about the candidate’s supposed problems with the truth. In fact, Mrs. Clinton was accurately repeating the story as it was told to her — and it turns out that while some of the details were slightly off, the essentials of her story were correct. After all the fuss, The Washington Post eventually conceded that “Bachtel’s medical tragedy began with circumstances very close to the essence” of Mrs. Clinton’s account.
And even more important, Mrs. Clinton was making a valid point about the state of health care in this country. . . . And if being a progressive means anything, it means believing that we need universal health care, so that terrible stories like those of Monique White, Trina Bachtel and the thousands of other Americans who die each year from lack of insurance become a thing of the past.
April 11, 2008
Asian American Health
The Kaiser Family Foundation and the Asian & Pacific Islander American Health Forum have released a study entitled, Health Coverage and Access to Care Among Asian Americans, Native Hawaiians, Pacific Islanders." The study shows health insurance coverage for these individuals across the United States. The study revealed a wide variation in insurance coverage and corresponding health status. The study has several helpful charts that present the data clearly. Ketaki Gokhale of Alternet discusses the findings,
National health care studies often treat Asian Americans as a homogenous, and largely healthy group, but a new study analyzing three years of government-compiled data has revealed substantial pockets of poor health and low insurance levels within the population. Korean Americans, Native Hawaiians and Pacific Islanders clock in with lower levels of insurance than African Americans and whites.
The analysis, conducted by the Kaiser Family Foundation and the Asian & Pacific Islander American Health Forum, found that the proportion of non-elderly Asians who are uninsured varies widely, ranging from 12 percent of Japanese and Asian Indians, 14 percent of Filipinos, to 21 percent of Vietnamese and 24 percent of Native Hawaiians and Pacific Islanders.
Koreans have the highest rates of uninsured -- 31 percent. In comparison, 21 percent of African Americans, and 12 percent of non-elderly non-Hispanic whites are uninsured. Hispanics and American Indians and Alaska natives are two groups that have higher levels of uninsured than Koreans, with 34 and 32 percent uninsured respectively.
"If you look at these groups in the aggregate, Asian Americans tend to do well," says Dr. Cara James, a senior policy analyst with the Race, Ethnicity and Health Care Team at the Kaiser Family Foundation. "They are in good health and don't have as many problems with health coverage."
Over 16 percent of the nation's 13 million Asian Americans and half-million Native Hawaiians and Pacific Islanders are uninsured, giving the group a higher overall rate of insurance than African Americans, Hispanics and American Indians and Alaska natives. But look a little closer, James says, and "you have Koreans doing worse than African Americans, and equal to American Indians and Alaska natives."
The low level of insurance in the Korean American community is not the result of poverty, as one might expect, but rather because most Korean Americans -- around 60 percent -- either own or are employed by small companies that can't afford to provide their workers with health insurance.
Among those Koreans with insurance, only 49 percent have employer-sponsored health coverage. Asian Indians, on the other hand, had the highest rate of employer-sponsored coverage among all the Asian sub-groups, with 77 percent. . . . .
Jang hopes the study will drive the direction of the current presidential debate on health care. "The national debate is focused on health care reform, and if your goal is to achieve health care reform that truly reaches everybody, then you need to think of the Native Hawaiian, Pacific Islander, Korean and Vietnamese American communities -- all of them individually," she explains. "We are hoping that this will show the diversity of our communities."
"If you're going to have employer or employee mandates in your reform proposal, the affordability needs to be there. People in the Korean community would purchase insurance if it was affordable. And, for the Asian American populations that are just above the poverty level and don't qualify, maybe those public programs need to be expanded so they can cover more of the working class poor."
Unbelievable Health Care Stories
Paul Krugman in today's New York Times reports on the health care story that recently made the news, not because it is so tragic, but because Senator Clinton got some facts about the story incorrect. I have to agree with article - it is sad when the media focuses on whether a story is completely one hundred percent factually correct - when the underlying story is clearly true and clearly shows that our health care system has huge problems. Paul Krugman writes,
April 10, 2008
Increase in Child Hospitalization Mistakes
The April edition of the journal Pediatrics reports some distressing news - one in fifteen hospitalized children may experience medical harm resulting from medicine mix-ups, overdoses, and bad drug reactions. The purpose of the study, "Development, Testing, and Findings of a Pediatric-Focused Trigger Tool to Identify Medication-Related Harm in US Children's Hospitals" was to "to develop a pediatric-focused tool for adverse drug event detection and describe the incidence and characteristics of adverse drug events in children's hospitals identified by this tool." The authors concluded,
Adverse drug event rates in hospitalized children are substantially higher than previously described. Most adverse drug events resulted in temporary harm, and 22% were classified as preventable. Only 3.7% were identified by using traditional voluntary reporting methods. Our pediatric-focused trigger tool is effective at identifying adverse drug events in inpatient pediatric populations.
The Boston Globe reports further on the studies findings and conclusion,
The new monitoring method developed for the study is a list of 15 "triggers" on young patients' charts that suggest possible drug-related harm. It includes use of specific antidotes for drug overdoses, suspicious side effects, and certain lab tests. By contrast, traditional methods include nonspecific patient chart reviews and voluntary error reporting . . . .
Patient safety advocates said the problem is probably bigger than the study suggests because it involved only a review of selected charts. Also, the study did not include general community hospitals, where most US children requiring hospitalization are treated.
Medical Records Privacy - Not so Private for Celebrities in California
I am hoping that people who work in the health field (or people who wear white coats in attempt to resemble a medical professional) in LA are perhaps a little nosier than the rest of the health care workers in America. It seems that some individuals cannot help but delve into famous people's medical records. The LA Times reports today on California Governor Schwarzenegger and his wife, Maria Shriver's news that their medical records had been accessed by inappropriate individuals multiple times. Oops!
Gov. Arnold Schwarzenegger said this morning that the snooping into his wife's medical records by an unauthorized UCLA Medical Center employee follows a long history of such intrusions on California's first couple. "I have been a victim of this in my own hospital visits," Schwarzenegger said at a news conference to promote volunteerism, "if it was for heart surgery or hip surgery, shoulder surgery, all of those things." Every time he has left an operating room, the governor said, he has been told there were "people going through your file that had white coats on. Obviously, they snuck into the hospital. They had nothing to do with the hospital staff at all. So those things happen."
Really, "those things happen." Isn't there some federal law that requires "covered entities" to place medical files where random people wearing white coats cannot get to them??
The Times reported in today's paper that California first lady Maria Shriver and 1970s TV icon Farrah Fawcett were among 32 celebrities, politicians and other high-profile patients at UCLA Medical Center whose files were improperly viewed by an employee. Schwarzenegger reiterated that his administration will push hospitals to implement new safeguards to stop such snooping.
"It is not just UCLA," he said. "This kind of thing has been happening all over the state, wherever there are celebrities involved. . . . Everyone's medical history ought to be protected. That is the responsibility of the hospital. So we are going to work with them and find a way."
April 9, 2008
Plastic Surgeons See Hard Times - Is that Bad?
Apparently the recession has hit plastic surgeons particularly hard. Slate.com's William Saletan reports,
If your local real estate agent's face is hanging low these days, it might be more than sadness. The recession's latest victim is cosmetic surgery. "Plastic surgeons from the Southland to South Florida said some colleagues are struggling to stay in business," Ricardo Alonso-Zaldivar reports in the Los Angeles Times. A breast implant company disclosed a decline in surgeries late last year; a laser eye-surgery firm has lowered its forecast based on a similar trend early this year. A professional breast augmenter frets that in January and February, business for some of his colleagues was off 30 percent to 40 percent.
Mr. Saletan finds this news to be healthy because it shows that individuals understand the difference between necessary and unnecessary medical care. He continues,
It's not the suffering that gratifies me. It's the reaffirmation of the distinction between necessary and unnecessary procedures. People have always practiced medicine, albeit clumsily. And they've always adorned themselves, to the point of reshaping their heads and bodies, as the Mayans and Chinese did. (Even the Bush administration has yielded to nipple rings.) But despite the occasional overlap, medicine and body art remained two different things. One aimed at health, the other at beauty. One was necessary, the other elective. If your treatment looked really cool but all the patients died, it was a failure.
Modern cosmetic surgery has challenged that distinction. It has done so not in theory but in practice, by making aesthetic procedures so safe and lucrative that people who would otherwise have devoted their careers to medicine turned instead to cosmetic work. . . . Two weeks ago, the New York Times reported that last year, among 18 medical specialty fields, the three that attracted med-school seniors with the highest medical-board test scores were the most cosmetically oriented: plastic surgery, dermatology, and otolaryngology. . . .
More effectively than any bioethicist, the recession is reminding people that cosmetic work isn't medicine. "While healthcare spending as a whole has traditionally moved independently of the economy—a safe haven—that really isn't the case with plastic surgery," a financial analyst tells the Times. In the new, sobered economy, the paper reports, some cosmetic doctors are diversifying into "reconstructive surgery for cancer patients and others that is covered by insurance." Insurance!
Say what you will about coverage-denying bean counters, but they do enforce the essential priority of urgent procedures over elective ones. In a health-care industry controlled by tight budgets and insurers, you might even see the cream of the med-school crop shift back to the kind of work that keeps people alive. I hope they're well-paid for it, and I hope the next rising tide lifts millions more families into the ranks of the insured. But let's never forget what the bad times taught us about what matters and what doesn't.
End of Life Costs: Outcomes v. Spending
The Wall Street Journal Health Blog has a great chart reflecting the data presented by the Dartmouth Atlas of Health Care on health care spending in the United States. The Dartmouth Atlas reviews money spent on Medicare patients across the country. This information is then compared with outcome data for the same area. Basically, the Dartmouth Atlas of Health Care tries to show whether money spent on health care equates to better outcomes. The latest data shows that there does not appear to be a relationship with more money spent and better outcomes. (This fact is also reflected (although in very different data) in another recent study demonstrating that although the United States spends lots of money on health care (more than many other developed nations), the results have not been a healthier population). Theo Francis writes,
The latest edition of the Dartmouth Atlas of Health Care is out today, showing that the cost of individual medical services isn’t the big driver of Medicare spending, at least for chronically ill patients in their last two years. It’s the intensity of care, such as the number of specialist visits and days in the ICU, that matters most, the WSJ reports. Sheer availability of services has a lot to do with how much gets spent.
Nearly as notable as the Atlas’ findings–that Medicare could have saved as much as $50 billion over five years if all U.S. hospitals cared for dying, chronically ill patients the way the most efficient facilities do– are its proposals for change.
Ezra Klein breaks down some of the numbers and the perhaps surprising inefficiencies in our health care system.
April 8, 2008
Ranking Law Schools By Student Quality
Brian Leiter has issued a ranking of law schools based on student quality (calculated by LSAT/GPA percentages with some other factors such as class size taken into account). He provides a discussion of how the rankings were calculated as well as a chart for the top 40 or so schools.
Medicare Future Solvency and Access to Care
AmNews reports on some new numbers for Medicare and its future - it doesn't sound too rosy:
Medicare is facing a long-term financial meltdown, but health policy experts said Congress is not likely in this election year to take the broad actions needed to keep the program sustainable.
Both the physician and hospital portions of the program are in trouble, according to the 2008 Medicare trustees report, released late last month. Part B, of which spending on physician services constitutes about 30%, does not face insolvency because it automatically is funded by general tax revenues and beneficiary premiums.
But it does face rapid growth and will consume an ever-larger portion of the nation's economy, the trustees said. The report predicts that Part B spending will climb from $187 billion this year to $325 billion by 2017, driven in part by the first wave of retiring baby boomers in 2010. . . .
President Bush called for cutting Medicare spending by $12.2 billion in his fiscal 2009 budget plan. Among the proposed reductions were scaling back inpatient hospital care by $4 billion and cutting billions more from other hospitals, home health care, skilled nursing facilities and hospice care . . . .
The trustees report projects that Medicare Part B will increase by an average of 6.2% through 2017. This estimate assumes that scheduled physician pay cuts of about 40% over the next nine years will happen. But the trustees expect Congress again to prevent the reductions from occurring. The first, a 10.6% cut, would take effect July 1. If lawmakers use the same legislative devices to prevent the cuts that they have since 2003, this would add to program spending. Part B expenditures would grow by an annual average of 8%, much faster than the 4.8% growth expected in the U.S. economy, as measured by the gross domestic product.
But physician organizations warn against cuts in doctors' Medicare payments. "Trying to save Medicare money by slashing physician payments will ruin the physician foundation of Medicare for current and future generations of seniors," said Edward L. Langston, MD, chair of the American Medical Association Board of Trustees. An AMA survey found that 60% of physicians say this year's cut alone would force them to limit the number of new Medicare patients they can treat, Dr. Langston noted. "Couple this fact with a physician shortage and the huge influx of baby boomers soon to enter Medicare, and the outlook for Medicare patients' access to care is grim.". . . .
April 7, 2008
Schools Focus On Obesity and Show Positive Results
The Associated Press reports on a successful strategy employed by the Philadelphia School District to reduce childhood obesity. Stephanie Nano of the AP describes the successful plan,
Five Philadelphia elementary schools replaced sodas with fruit juice. They scaled back snacks and banished candy. They handed out raffle tickets for wise food choices. They spent hours teaching kids, their parents and teachers about good nutrition. What have they got to show for it? The number of kids who got fat during the two-year experiment was half the number of kids who got fat in schools that didn't make those efforts.
"It's a really dramatic effect from a public health point of view. That's the good news," said Gary Foster, director of the Center for Obesity Research and Education at Temple University. He is also the lead author of the Philadelphia schools study being published Monday in the April issue of Pediatrics. The bad news: There were still plenty of new overweight kids in the five schools - over 7 percent of them became overweight compared to the 15 percent in the schools that didn't make changes. "That signals to me that we have lots more work to do," said Foster.
Schools are ideal settings for programs that target childhood obesity, the researchers noted. Children spend long hours each day at schools and eat lunch and often breakfast at school. But school-based programs have had mixed results. . . .
For the study, changes were made to the food in vending machines or the cafeteria in five of the schools. Juice, water and low-fat milk replaced sodas. Snacks had to meet limits for fat, salt and sugar. Students who ate healthy snacks got raffle tickets to win prizes such as bikes and jump ropes. "We found when you give children healthy choices, they pick them," said Grace McGinley, school nurse at Francis Hopkinson School, one of the test schools.
Staff and students had lessons on good nutrition. The message was reinforced in other subjects: food labels were used to help teach fractions. And parents were also enlisted: a fundraiser successfully substituted fruit salad for baked goods, said another of the researchers, Sandy Sherman, the Food Trust's director of nutrition education. She said the children were also urged to exercise at activity stations during recess. They were measured and weighed periodically and surveyed about food and exercise.
After two years, besides fewer new overweight children, the overall number of overweight students at the five schools dropped about 10 percent to 15 percent. At the no-change schools, the number of overweight children rose a quarter to 20 percent. There was no difference between school groups in new obese students (6 percent) or the overall number of obese (about 25 percent). Obese children probably benefit more from individually targeted efforts, Foster said. . . . .
Abortion Search on Popline Unblocked . . . .
The New York Times on Saturday reported on the controversy surrounding the government's decision to designate abortion as an "ignored" term when searching the database, Popline. The decision was reversed by Johns Hopkins University. Robert Pear of the Times reports,
Johns Hopkins University said Friday that it had programmed its computers to ignore the word “abortion” in searches of a large, publicly financed database of information on reproductive health after federal officials raised questions about two articles in the database. The dean of the Public Health School lifted the restrictions after learning of them. A spokesman for the school, Timothy M. Parsons, said the restrictions were enforced starting in February. Johns Hopkins manages the population database known as Popline with money from the Agency for International Development.
Popline is the world’s largest database on reproductive health, with more than 360,000 records and articles on family planning, fertility and sexually transmitted diseases. Mr. Parsons said the development agency had expressed concern after finding “two articles about abortion advocacy” in the database. The articles, he said, did not fit database criteria and were removed. Employees who manage the database instructed their computers to ignore the word “abortion” as a search term.
After learning of the restrictions on Friday, the dean, Dr. Michael J. Klag, said: “I could not disagree more strongly with this decision, and I have directed that the Popline administrators restore ‘abortion’ as a search term immediately. I will also launch an inquiry to determine why this change occurred.” . . . . Dr. Klag said the school was “dedicated to the advancement and dissemination of knowledge, and not its restriction.” . . . .
Librarians at the Medical Center of the University of California, San Francisco, expressed concern about the restrictions this week after they had difficulty retrieving articles from Popline. In an e-mail response on Tuesday, Johns Hopkins told the librarians that “abortion” was no longer a valid search term. “We recently made all abortion terms stop words,” Debra L. Dickson, a Popline manager, wrote. “As a federally funded project, we decided this was best for now.” Ms. Dickson suggested that instead of using “abortion,” librarians could use other terms like “fertility control, postconception” or “pregnancy, unwanted.” Gail L. Sorrough, director of medical library services at the medical center in San Francisco, said it was absurd to restrict searches using “a perfectly good noun such as ‘abortion.’ ”
Under the rule, Popline ignored the word “abortion,” just as it ignores terms like “a” and “the.” Ms. Sorrough and a colleague, Gloria Won, reported their experience on an electronic mailing list, and librarians protested the restrictions. . . . .
April 6, 2008
The New York Times has an article today about drug companies and their hopes for complete pre-emption for all tort suits once a drug receives FDA approval. The example provided, however, seems to indicate that the goal of safe drugs may need some support from tort suits and that some drug manufacturers are not quite as open as they should be with the FDA when they submit a drug for approval. The article states,
For years, Johnson & Johnson obscured evidence that its popular Ortho Evra birth control patch delivered much more estrogen than standard birth control pills, potentially increasing the risk of blood clots and strokes, according to internal company documents.
But because the Food and Drug Administration approved the patch, the company is arguing in court that it cannot be sued by women who claim that they were injured by the product — even though its old label inaccurately described the amount of estrogen it released. This legal argument is called pre-emption. After decades of being dismissed by courts, the tactic now appears to be on the verge of success, lawyers for plaintiffs and drug companies say.
The Bush administration has argued strongly in favor of the doctrine, which holds that the F.D.A. is the only agency with enough expertise to regulate drug makers and that its decisions should not be second-guessed by courts. The Supreme Court is to rule on a case next term that could make pre-emption a legal standard for drug cases. The court already ruled in February that many suits against the makers of medical devices like pacemakers are pre-empted.
More than 3,000 women and their families have sued Johnson & Johnson, asserting that users of the Ortho Evra patch suffered heart attacks, strokes and, in 40 cases, death. From 2002 to 2006, the food and drug agency received reports of at least 50 deaths associated with the drug.
Documents and e-mail messages from Johnson & Johnson, made public as part of the lawsuits against the company, show that even before the drug agency approved the product in 2001, the company’s own researchers found that the patch delivered far more estrogen each day than low-dose pills. When it reported the results publicly, the company reduced the numbers by 40 percent.
The F.D.A. did not warn the public of the potential risks until November 2005 — six years after the company’s own study showed the high estrogen releases. At that point, the product’s label was changed, and prescriptions fell 80 percent, to 187,000 by last February from 900,000 in March 2004.
Gloria Vanderham, a Johnson & Johnson spokeswoman, said the company acted responsibly. “We have regularly disclosed data to the F.D.A., the medical community and the public in a timely manner,” Ms. Vanderham said. “Ortho Evra is a safe and effective birth control option for women when used according to the labeling.”
But Janet Abaray, a plaintiff’s lawyer from Cincinnati, said that Johnson & Johnson took advantage of an agency overwhelmed by its many responsibilities. “Johnson & Johnson knew that F.D.A. does not have the funding or the manpower to police drug companies,” Ms. Abaray said. A series of independent assessments have concluded that the agency is poorly organized, scientifically deficient and short of money. In February, its commissioner, Andrew C. von Eschenbach, acknowledged that the agency faces a crisis and may not be “adequate to regulate the food and drugs of the 21st century.”
The F.D.A. does not test experimental medicines but relies on drug makers to report the results of their own tests completely and honestly. Even when companies fail to follow agency rules, officials rarely seek to penalize them. “These are scientists, not cops,” said David Vladeck, a professor at Georgetown Law School. . . . .
Still, lawyers for Johnson & Johnson say that patients should not be allowed to sue the company because the F.D.A. approved the patch and its label. “F.D.A. is responsible for making those decisions,” said John Winter, a lawyer for the company. Judge David A. Katz of Federal District Court for the Northern District of Ohio is expected to rule soon on whether any of the lawsuits against Johnson & Johnson can go forward.
In the fall, the Supreme Court will hear a separate pre-emption case involving Wyeth, another drug company. Chris Seeger, a plaintiffs’ lawyer who has about 125 Ortho Evra cases, said he expected the court to rule in Wyeth’s favor. “Our lawsuits are the ultimate check against the mistake made by the government, or fraud made by the companies against the government, or just an underfunded bureaucracy stretched thin,” he said.