May 2, 2008
Affordable Dental Care
Matthew Yglesias writes at the Atlantic.com about the problem receiving dental care in this country and some new proposals to promote dental cleanings that have come under fire from dental groups. He states,
Inability to afford basic dental services is a large problem for many poorer Americans, so naturally when an entrepreneur comes along ready to offer basic dental services at a more affordable price dentists' trade organizations leap into the fray to get the operation shut down. It's proprietor, after all, isn't a dentist . . . The focus on America's horrible, horrible system of financing health care tends to obscure the fact that it's layered on top of a horrible, horrible system of delivering health care in which there are all kinds of restrictions on the supply of services that make basic care substantially more expensive than it ought to be.
Professor Elizabeth Warren on Health Care Insurance
Writing at TPM Cafe, Professor Elizabeth Warren writes about our complicated and bizarre health insurance stystem,
. . . . But even those who have health insurance and can afford to pay are knocked around in a broken system. A friend--with insurance--had some minor surgery a while back. She bounced back quickly, but the pain of trying to pay is still not over:
I got a letter from the hospital very nicely demanding payment of over $500 today.The hospital thinks I owe them $438 more than I actually owe them because the insurance company sent that amount to the doctor. The doctor, of course, won't send it to the hospital. Instead, I had to call the insurance company to ask them to recall the payment so they can then send it to the hospital.
This isn't about getting more health insurance. This is about a system that is broken even for those who have health insurance. This is about waste and inefficiency and burning up dollars that should go to medical treatment. Where are the serious proposals to cut through this nonsense and waste?
If I fax the explanation of benefits to the hospital, they won't turn my account over to collections (that, despite the fact that I have already paid $300 and call them about once a week to work on this problem.) And most amusing is the fact that the doctors' group and the insurance company are managed by the same company. . . .
Complicating this is the fact that the hospital keeps a running total of all amounts due, so the fact that I had another expense (bone scan) makes it hard to keep the surgery bill separate. . . . .So today I figured out that I owed only $2.30, to the pathologist (somehow that was my copay!) and about $98 to the hospital after they track down the payment that went to the doctor.
How on earth would a sick person work through this mess? And how would a person who couldn't take an hour a week off for 6 weeks to deal with this ever get payments straight? The worst part is that I am incredibly lucky to be in this situation because I have health insurance.
May 1, 2008
U.S. Experiences Dramatic Increase in Measles Cases
The New York Times reports today on the increase in measles in the United States. The Times article states,
The United States has had 64 cases of measles since January, the highest number reported for this time period since 2001, federal health officials reported Thursday. Nearly all the cases, 63 of the 64, were in people who had not been vaccinated, and 54 resulted from overseas travel. Sixteen cases occurred in families who had refused vaccination for religious or personal reasons. Fourteen patients have been hospitalized. reports on the increase in measles in the United States. . . .
Ezra Klein on McCain's Health Plan and HSAs
Today, Ezra Klein provides some analysis of McCain's proposed health plan. He writes,
. . . "I am convinced," said John McCain at Miami Children's Hospital, "that the wrong way to go is to turn over your lives to the government and hope it will all be fine. It won't." Spoken like a 71-year-old whose government health coverage has kept him healthy enough to run for the presidency.
Government health insurance, like large employer health insurance, is based on a simple concept: Risk pooling. The more of us in this together, the more our health risks will average out among the population. When I'm sick, many more will be well, and so the group will be able to bear the costs of my illness. Moreover, the greater the size of the pool, the greater our ability to negotiate better deals, demand fairer treatment, and generally find market strength in numbers. . . . .
In contrast, McCain would like to take the health-care system in the opposite direction, toward an individual market where individuals seek coverage without the protection of large insurers or the government. Thus, the core of McCain's health-care proposal is a tax credit designed to ease people out of employer insurance and help employers pull away from offering coverage. McCain would give individuals a $2,500 tax credit and families a $5,000 tax credit meant to help them seek cheaper coverage options, such as health savings accounts, in the private market. And it is this cheaper coverage that is truly the point of McCain's health plan. "I would seek to encourage and expand the benefits of [health savings] accounts to more American families."
The benefits of those accounts are simple: low monthly premiums. The drawbacks are similarly clear: very high deductibles, lots of personal financial risk, and relatively sparse coverage. "These accounts put the family in charge of what they pay for," enthuses McCain. But that's not quite accurate. Individuals have no more autonomy under these accounts than in a traditional sense. They are just more acutely sensitive to the price of their care, which means they'll purchase less of it, and overall health spending will fall.
If you're young and unlikely to get sick, these accounts are a good deal, as you'll pay lower premiums. If you're not as demographically and genetically blessed, they're a bad deal, as you'll pay much more out of pocket for your care. They are, in other words, the logical extension of the modern health coverage marketplace: They're health insurance for people who don't need health care. . . . .
Ezra Klein also provides a helpful overview of the HSAs,
. . . HSAs, for those not yet acquainted, are the current conservative panacea for all that ails our health system: They are high deductible, low premium insurance plans that offer a tax sheltered account where folks can sock away money with which to pay their high deductibles. The idea behind them is simple: If we pay directly for more care, we'll buy less of it, either because we can't afford the care or because we decide to spend the money on something else.
Implicit in that argument is the idea that we, as individuals, will know which care is worth buying and which care is worth skimping on. But, of course, we don't know that. So instead, HSAs ask for a much cruder economic calculation: Do you think you'll need care or not? If you do think you'll need care, you're better off with traditional insurance, which pays for you to get care. If you don't think you'll need much care, an HSA might be the way to go, as your premiums will be lower. . . . HSAs are health coverage for people who don't need health care. But I left out one group who also find HSA's useful: The rich. . . . .
According to the report, "the average adjusted gross income for those reporting HSA activity in 2005 was about $139,000, compared with about $57,000 for other filers." To be fair, some of that probably reflects the fact that HSAs are a fairly new product and early adopters are probably high education, well-to-do types. But in a broader sense, this is to be expected. HSAs -- which reduce your financial protection from health costs -- are a perfectly good option if you don't really need financial protection from health costs. So they're more popular among the rich. . . .
April 30, 2008
McCain's Health Plan
McCain, the presumptive GOP presidential nominee, wants everyone to get a tax credit to either buy insurance or offset the taxes on health care coverage obtained through work. The Arizona senator says variety and competition will help bring down costs. Bush has a similar tactic, offering tax deductions for health care costs.
"My approach to transforming health care is to put families in charge," McCain said Monday at Miami Children's Hospital in Florida, a possible swing state this fall.
Reuters news service provides more details on his plan and states,
On a campaign swing to highlight his health care proposals, the Arizona senator said he wanted to put individuals in charge of their health care, foster competition in insurance markets and reduce the prevalence of employer-based plans. "Americans need new choices beyond those offered in employment-based coverage. Americans want a system built so that wherever you go and wherever you work, your health plan goes with you," McCain said at a Tampa cancer research hospital.
At the heart of McCain's plan is a tax credit of $2,500 for individuals and $5,000 for families that could be used to leave an employer-based plan and purchase cheaper, more suitable insurance on the open market -- creating competition that would lower the price.
"Insurance companies could no longer take your business for granted, offering narrow plans with escalating costs. It would help change the whole dynamic of the current system, putting individuals and families back in charge," he said. . . .
Clinton called McCain's approach "radical" and suggested it could force millions to lose their employer-based insurance. "The McCain plan eliminates the policies that hold the employer-based health insurance system together, so while people might have a 'choice' of getting such coverage, employers would have no incentive to provide it," she said in a statement.
McCain said he would not force anyone to leave an employer-based program and would seek solutions for those with pre-existing medical conditions, including creating gap coverage and working with states that create insurance pools for high-risk individuals.
"Those without prior group coverage and those with pre-existing conditions do have the most difficulty on the individual market, and we need to make sure they get the high-quality coverage they need," McCain said. . . .
Elizabeth Edwards responds to McCain's health care plan here. Hint: She is not a big fan.
Future of Health Care Reform - The Lobbyists
According to this CJR report, regarding a series of studies from Health Care Week and other industry groups, the health care industry, drug manufacturers and other related industry groups are doing everything they can to insure there are no changes to their current profit margins:
The insurance companies, of course, think the system is just fine, and they spent heavily to keep the status quo. Health Plan Week, an insurance industry trade pub, took a hard look, revealing that overall health insurance payments to lobbyists soared last year and are likely to grow again in the next couple of years as health reform becomes the biggest issue. A large percentage of that money, the magazine found, was focused on the Medicare Advantage issue, which was front and center last year. Analyzing disclosure forms from the Senate’s public records office, Health Plan Week found that fifteen health plans paid lobbyists more than $22 million in 2007, up from $18 million in 2006, a hefty chunk of change by any measure. WellCare Health Plans, a big seller of Medicare Advantage products that has gotten in trouble with regulators for its questionable sales practices, quadrupled its spending to $320,000 and paid half of that amount to the Washington law firm to plead its case on Medicare issues. Health Net and Tufts Health Plan more than doubled their spending, while insurance biggies like CIGNA and UnitedHealth Group substantially increased their lobbying budgets. Blue Cross and Blue Shield plans spent nearly $10 million....
A press release just issued by the Center for Responsive Politics further reinforces the money and health care story. Its message: Special interests spent $17 million for every day Congress was in session, and the drug industry spent most of all, paying lobbyists 25 percent more than they did last year. Did Harry Reid forget to mention them? Drug companies spent some $227 million on lobbying activities. The insurance industry was right behind with $138 million, and not far down was the hospital and nursing home industry, which spent some $91 million. When the Center pulled apart spending by organization, Pharma, the American Medical Association, and the American Hospital Association ranked three, four, and five on its list of top spenders. It’s too bad that the Center’s latest numbers haven’t gotten more press. For they, too show, the rocky path ahead for health reform. . . .
Health care isn't just about prenatal care and cancer exams, although both are very important. It's also about vaccines and control of dangerous contagions. And we don't have a handle on any of this because we've put profit ahead of care (YouTube)...way ahead. Think it can't be you? Think again...
April 29, 2008
The New Romance: Marrying for Health Insurance
Some people marry for love, some for companionship, and others for status or money. Now comes another reason to get hitched: health insurance. In a poll released today, 7% of Americans said they or someone in their household decided to marry in the last year so they could get healthcare benefits via their spouse.
"It's a small number but a powerful result, because it shows how paying for healthcare is reflected not only in family budgets but in life decisions," said Drew E. Altman, president of the Kaiser Family Foundation, which commissioned the survey as part of its regular polling on healthcare.
On a broader scale, the survey found that healthcare costs outranked housing costs, rising food prices and credit card bills as a source of concern. Twenty-eight percent of those surveyed said they had experienced serious problems because of the cost of healthcare, compared with 29% who had problems getting a good job or a raise. Gasoline prices were the top economic worry, with 44% saying they had serious problems keeping up with increases at the pump. . . . .
Healthcare inflation has been rising at about twice the rate of economic growth, and it's unclear how much of a difference better prevention, computerized medical records and other ideas for containing costs might prove to be.
But with employer-based health insurance averaging $12,000 for family coverage and $4,500 for individuals, the public concern with costs is understandable. Nearly a fourth of Americans said they had decided to keep or change jobs in the last year because of health insurance.
What surprised researchers was that such costs had become a factor in marriage decisions. "We should have asked about divorce," said Altman, joking.
Those who cited health insurance as a factor in deciding to marry tended to have modest incomes. About 6 in 10 were in households making less than $50,000 a year, said Mollyann Brodie, who directs Kaiser's opinion research. They also were younger, with 4 in 10 between 18 and 34.
"We don't know a lot more about them," Brodie said. "Just that they answered that of all the reasons for getting married, [health insurance] was also a reason, was surprising." . . .
The Kaiser polling, conducted April 3-13, surveyed a nationally representative sample of 2,003 adults, and has a margin of error of plus or minus 3 percentage points.
Banning Medical Freebies
The New York Times yesterday reported that the Association of Medical Colleges has recommended a ban on free items, including food, gifts, trips, and "ghost-writing services" from pharmaceutical companies and medical device manufacturers. Gardiner Harris writes
The proposed ban is the result of a two-year effort by the group, the Association of American Medical Colleges, to create a model policy governing interactions between the schools and industry. While schools can ignore the association’s advice, most follow its recommendations. Rob Restuccia, executive director of the Prescription Project, a nonprofit group dedicated to eliminating conflicts of interest in medicine, said the report would transform medical education. “Most medical schools do not have strong conflict-of-interest policies, and this report will change that,” Mr. Restuccia said. The rules would apply only to medical schools, but they could have enormous influence across medicine, said Dr. David Rothman, president of the Institute on Medicine as a Profession at Columbia University. “We’re hoping the example set by academic medical colleges will be contagious,” Dr. Rothman said.
Drug companies spend billions wooing doctors — more than they spend on research or consumer advertising. Medical schools, packed with prominent professors and impressionable trainees, are particularly attractive marketing targets. So companies have for decades provided faculty and students free food and gifts, offered lucrative consulting arrangements to top-notch teachers and even ghost-wrote research papers for busy professors. “Such forms of industry involvement tend to establish reciprocal relationships that can inject bias, distort decision-making and create the perception among colleagues, students, trainees and the public that practitioners are being ‘bought’ or ‘bribed’ by industry,” the report said.
A group of influential doctors decried these practices in a 2006 article in The Journal of the American Medical Association, and said that medical schools should ban them. In the article’s wake, the medical college association created a task force.
With Dr. Roy Vagelos, a former Merck chief executive, serving as the task force’s chairman and the chief executives of Pfizer, Eli Lilly, Amgen and Medtronic on the roster, some who advocate for greater restrictions on industry influence in medicine predicted that the report would be weak. They were wrong. . . . .
It recommended that schools set up centralized systems for accepting free drug samples or “alternative ways to manage pharmaceutical sample distribution that do not carry the risks to professionalism with which current practices are associated.” It suggested that schools audit independently accredited medical education seminars given by faculty “for the presence of inappropriate influence.” And it said the rules should apply to faculty even when off-duty or away from school.
Speakers’ bureaus and drug samples are pillars of the industry’s marketing operations, and many medical school professors have resisted efforts to restrict them. Only a handful of medical schools presently bar faculty members from serving on speakers’ bureaus, so if this recommendation is widely adopted, it could transform the relationship between medical school faculty and industry, and it could change substantially the way medical education is routinely delivered.
Indeed, the chief executives of Pfizer and Eli Lilly dissented from the report’s recommendation regarding speakers’ bureaus. “We continue to believe that these types of programs, which are subject to clear regulations regarding their content, can be worthwhile educational activities,” wrote Jeffrey B. Kindler of Pfizer and Sidney Taurel of Lilly. . . .
Today's Times has an editorial approving of the ban and urging further reform,
Outright bans would be imposed on personal gifts, industry-supplied food and meals, free travel that is not reimbursement for services and payment for attending industry-sponsored meetings. Also outlawed are the notorious ghostwriting services, in which a drug company drafts a journal article and then persuades a respected academic to sign on as the lead author, giving it a gloss of objectivity that it may not deserve.
Free drug samples, though not banned, would generally have to be accepted by a central pharmacy, presumably capable of assessing their value, not by individual doctors more susceptible to sales pitches.
Unfortunately, the task force, appointed by the Association of American Medical Colleges, flinched on some important issues. It urged medical schools to “strongly discourage” faculty from participating in industry speakers’ bureaus, which pay influential doctors to promote the benefits of products, but it stopped short of calling for a complete ban on the highly dubious practice.
Similarly, the group did not call for an end to industry subsidies of continuing medical education programs that doctors must take to retain their licenses. Instead, it simply proposed steps to audit the content of the programs and ensure that they are scientifically objective. It is hard to see why doctors should not pay the full cost of their own continuing education.
April 28, 2008
Reminder Text Messages to Teens for Meds
The Cincinnati Enquirer reports today on a new program by Cincinnati Children's Medical Center to help remind teenagers to take their medications - text messages. Peggy O'Farrell writes,
Tylor Thomas, 16, has never counted how many text messages he gets in a day, but it's a lot. Tucked in among all those shout-outs from friends, one potentially lifesaving message arrives every morning around 9 for the Winton Hills teen. "They just text me and tell me, 'Hi. Don't forget to take your asthma meds,' " Tylor said. He's one of a handful of teens participating in a Cincinnati Children's Hospital Medical Center pilot project to determine how well text-message reminders work to help teens manage their asthma.
If text messages are an effective solution for asthma management, there's no reason they won't work for patients with diabetes or other chronic illnesses, said Maria Britto, an adolescent medicine specialist at Children's. Britto, director of the center for innovation in chronic disease care and assistant vice president for chronic disease programs at Children's, coordinates the pilot project. Whether they're 16 or 60, patients with chronic diseases aren't good about sticking to their treatment regimen, experts say. Only about half take their medicine when they're supposed to, the way they're supposed to, Britto said.
"The longer you have to take the medicine, the lower your adherence rate is. If you have strep throat, the doctor gives you an antibiotic and tells you to take it for 10 days, and it's not a big deal. But if it's a medication you have to take every day for a long time and it has side effects you don't like, you're not going to take it every day," she said. Teens are a tricky patient population, as any parent can attest. Sometimes not taking their medicine is an attempt at independence. More often, they just forget.
"One of the barriers to adherence is the fact that many asthma medications really work over the long term, in that they prevent symptoms from happening," said Dennis Drotar, a psychologist at Cincinnati Children's. "But teenagers live in the short-term, so today and tomorrow are more important than not having an asthma attack six months from now." Tylor was diagnosed with asthma when he was about 3. His symptoms are pretty well controlled, but he uses an inhaler once a day to prevent asthma attacks.
Between school, playing on the basketball team and singing in the Miami Baptist Church choir, it's easy to forget about his inhaler. "Sometimes, like if I'm playing, I'll skip it. If I need it later, then I'll take it," Tylor said. Text messaging teens to take their medicine seemed like a natural fit, Britto said, especially once she and her colleagues noticed their patients were constantly texting, even during office visits. It's a preferred form of communication, and it's so common that their friends won't notice they're getting one more message. . . .
Most texts are medication reminders. But as the new system takes hold, Britto said, the possibilities are endless, including sending appointment reminders and test results.
"We could send out messages about other issues, like avoiding triggers, or not going outside when there's a smog alert or the pollen count's too high. Or if someone is trying to quit smoking or change another behavior, we could send out messages," she said.
Marijuana and Organ Transplants
The Associated Press reports on an individual in need of a liver transplant but who was refused one dur partially to the fact that he used marijuana legally. The AP states,
Timothy Garon’s face and arms are hauntingly skeletal, but the fluid building up in his abdomen makes the 56-year-old musician look eight months pregnant. His liver, ravaged by hepatitis C, is failing. Without a new one, his doctors tell him, he will be dead in days. But Garon has been refused a spot on the transplant list, largely because he has used marijuana, even though it was legally approved for medical reasons. “I’m not angry, I’m not mad; I’m just confused,” said Garon, lying in his hospital bed a few minutes after a doctor told him the hospital transplant committee’s decision Thursday.
With the scarcity of donated organs, transplant committees like the one at the University of Washington Medical Center use tough standards, including whether the candidate has other serious health problems or is likely to drink or do drugs. And with cases like Garon’s, they also have to consider — as a dozen states now have medical marijuana laws — if using dope with a doctor’s blessing should be held against a dying patient in need of a transplant.
Most transplant centers struggle with how to deal with people who have used marijuana, said Dr. Robert Sade, director of the Institute of Human Values in Health Care at the Medical University of South Carolina. “Marijuana, unlike alcohol, has no direct effect on the liver. It is, however, a concern ... in that it’s a potential indicator of an addictive personality,” Sade said.
The Virginia-based United Network for Organ Sharing, which oversees the nation’s transplant system, leaves it to individual hospitals to develop criteria for transplant candidates. At some, people who use “illicit substances” — including medical marijuana, even in states that allow it — are automatically rejected. At others, such as UCLA Medical Center, patients are given a chance to reapply if they stay clean for six months. Marijuana is illegal under federal law. . . . .
Dr. Brad Roter, the Seattle physician who authorized Garon’s pot use for nausea, abdominal pain and to stimulate his appetite, said he did not know it would be such a hurdle if Garon were to need a transplant. That’s typically the case, said Peggy Stewart, a clinical social worker on the liver transplant team at UCLA who has researched the issue. “There needs to be some kind of national eligibility criteria,” she said. The patients “are trusting their physician to do the right thing. The physician prescribes marijuana, they take the marijuana, and they are shocked that this is now the end result,” she said. No one tracks how many patients are denied transplants because of medical marijuana use.
Pro-marijuana groups have cited a handful of cases, including at least two patient deaths, in Oregon and California, since the mid- to late 1990s, when states began adopting medical marijuana laws. Many doctors agree that using marijuana — smoking it, especially — is out of the question post-transplant. The drugs patients take to help their bodies accept a new organ increase the risk of aspergillosis, a frequently fatal infection caused by a common mold found in marijuana and tobacco. . . .
Dr. Jorge Reyes, a liver transplant surgeon at the UW Medical Center, said that while medical marijuana use isn’t in itself a sign of substance abuse, it must be evaluated in the context of each patient. “The concern is that patients who have been using it will not be able to stop,” Reyes said.
Dale Gieringer, state coordinator for the California chapter of NORML, the National Organization for the Reform of Marijuana Laws, scoffed at that notion. “Everyone agrees that marijuana is the least habit-forming of all the recreational drugs, including alcohol,” Gieringer said. “And unlike a lot of prescription medications, it’s nontoxic to the liver.” . . .