HealthLawProf Blog

Editor: Katharine Van Tassel
Concordia University School of Law

Friday, May 9, 2008

Health of U.S. Hospitals

Firedoglake posts an interesting piece on the state of our nation's hospitals and it isn't pretty.   hospitals.  Isaiah Poole writes,

What I don't get is how all of McCain's free-market fundamentalism on health care is supposed to help make sure my neighborhood hospital is up and running when I need it.

McCain didn't address the health of our nation's hospitals when he rolled out his health care plan last week. Perhaps that's because the issues are complex and many of the proposed solutions don't fit neatly into ideological lines. Perhaps it's because if he started delving into our health care infrastructure, he'd have to admit that the conservative mantra that we have "the best health care system in the world" is false.

A report this week by the House Government Reform and Oversight Committee looked at just one consequence of the dysfunction in our health care delivery system.

Committee staff members surveyed hospital emergency rooms in seven major cities on one Tuesday afternoon to get a snapshot of emergency room capacity, with the goal of determining if emergency rooms in these cities were capable of handling a disaster of the scale of the March 2004 terrorist train bombing in Madrid, Spain. In that attack, 15 Madrid hospitals handled a surge of nearly 1,000 injured people.

The bottom line:

The results of the survey show that none of the hospitals surveyed in the seven cities had sufficient emergency care capacity to respond to an attack generating the number of casualties that occurred in Madrid. The Level I trauma centers surveyed had no room in their emergency rooms to treat a sudden influx of victims. They had virtually no free intensive care unit beds within their hospital complex. And they did not have enough regular inpatient beds to handle the less severely injured victims. The shortage of capacity was particularly acute in Los Angeles and Washington, D.C.

Almost 60 percent of the hospital emergency rooms surveyed were operating above capacity at the time of the survey. The closest hospital to my home, Washington Hospital Center, happened to be "the single most overcrowded hospital surveyed." Its emergency room was already operating at 286 percent of capacity at the time of the survey.

In essence, this survey doesn't tell us anything that especially those of us who live in big cities don't already know: Our hospital system is badly strained on a calm day. And if that's the case, God help us if any sort of major disaster hits. . . .

May 9, 2008 | Permalink | Comments (0) | TrackBack (0)

Elizabeth Edwards on Lack of Health Insurance in America

Thinkprogress has a great story on Elizabeth Edwards and her continued attempt to educate everyone about the need for health reform and greater access to health care for all Americans.   The story includes testimony from her recent appearance before the Senate Health Committee and states the following,

. . . Center for American Progress Senior Fellow Elizabeth Edwards told the Senate Health Committee today, “It doesn’t matter what kind of services we have if we don’t have access to them”:

Health insurance matters. The quality of coverage, of course, matters, but health insurance itself is really crucial part of this. Probably the most preventable cause of unnecessary suffering in our health care system is the lack of adequate health insurance. … We know how to lengthen and improve the lives of people with cancer. But we’ve chosen as a nation to turn our backs on some of us who have the disease. I urge you to reform health care responsibly, morally, and aggressively. . . .

Edwards also mentioned the disturbing disparities in access faced by minorities. FamiliesUSA writes, “Although racial and ethnic minorities constitute one third of the total U.S. population, they comprise more than one half (52 percent) of the uninsured population. In fact, in 2003, 23 million of the 45 million uninsured were racial and ethnic minority Americans.” Rather than cover these people, McCain’s plan could result in 158 million more Americans losing their health insurance.


May 9, 2008 | Permalink | Comments (0) | TrackBack (0)

Thursday, May 8, 2008

Politics of Health Reform

Ezra Klein has a great piece entitled, "The Elusive Politics of Reform," and writes about the various options to reform our health care system.  He starts with a brief statement on why the United States should be focused on reforming health care and then describes the plans currently set forth.  He writes,

If health insurance were cheap, we could all buy it. If universal health care could get 60 votes in the Senate, we'd all have it. But these two imperatives -- the need to control costs and the need to attract the 60 Senate votes required to overcome a filibuster -- point in opposite directions. This is the central paradox of health reform.

The most intractable policy problem is not, fundamentally, the 47 million uninsured or the fact that insurers have a business model right out of Dickens. It's cost. In 2006, the average family policy cost $13,600. This is why one out of six Americans are uninsured; they can't afford the premiums. An October 2007 Kaiser Family Foundation poll found that more Americans were "very worried" about being priced out of their health insurance than feared losing their job, their house, or being in a terrorist attack. And with good reason: Premiums have gone up 98 percent since 2000. Wages have not.

Corporate America's outlook is similarly grim. Better Health Care Together, a health-reform coalition that includes Intel, Wal-Mart, and General Mills, recently issued a report, Health-Cost Crossroad: Why American Businesses Urgently Need Health Care Reform. The paper warns that "health care cost growth threatens businesses, workers, and the overall health of the American economy," and frets that "if trends continue, health benefit costs will exceed profits in Fortune 500 companies in 2008."

Likewise government. Absent reform, government health spending would be 37 percent of gross domestic product by 2050. (The entire federal government now consumes about 20 percent of GDP.) David Walker, the U.S comptroller general, warns that "we have been diagnosed with fiscal cancer, and we need to start treating it." At the Congressional Budget Office, the normally staid Peter Orszag gives an Al Gore-esque slideshow on the looming threat of health costs that risk bankrupting government finances.

The question, then, is how to limit heath-care costs while still surviving the legislative process. A single-payer system would increase efficiencies, but critics fear that it would control costs excessively, limiting care. Politically, single-payer would mean restructuring about 17 percent of our economy and eliminating multibillion-dollar industries that provide tens of thousands of jobs. It would have to be legislated over the fierce objections of the Republican Party and all conservative Democrats. Conversely, many Republicans, John McCain included, advocate a radical shift of costs onto individuals, controlling spending by pricing care out of reach for tens of millions. Few Democrats or moderate Republicans -- or voters -- favor this course. . . .

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

Who Uses the ER?

The New York Times reports today on a study showing that the overcrowding that occurs in emergency rooms does not result from an increasing number of insured patients.   

It is often said that emergency rooms are crowded because of the disproportionate number of uninsured people using them. But data based on telephone surveys and in-person interviews, published on April 14 in The Annals of Emergency Medicine, tell a different story. The number of uninsured people nationwide rose to 15.7 percent in 2004 from 15.4 percent in 1995. Yet in that period, the proportion of uninsured people using emergency rooms declined.

The 26 percent increase in the number of visits in the period was largely caused by an increase in the number of people with private doctors who sought emergency room care. The authors suggest several reasons, among them an aging population, a growing number of time-sensitive medical treatments that can be performed only in an E.R., complications from medical and surgical treatments and the difficulty of obtaining a timely appointment with a private physician. . . .

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

Wednesday, May 7, 2008

McCain's Rhetoric on Health Care

The New York Times reports and critiques on McCain's discussion of the two Democratic presidential candidates. MIchael Cooper and Julie Bosman write,

Senator John McCain has been repeatedly suggesting that his Democratic rivals are proposing a single-payer, or even a nationalized health care system along the lines of those in countries like Canada and Britain.  The suggestion is incorrect. While both Senator Barack Obama of Illinois and Senator Hillary Rodham Clinton of New York are calling for universal health care and an expanded role for government, they stop well short of calling for a single-payer plan.

Mr. McCain has made the assertion several times in recent days, even as he and the Republicans have made repeated calls for accuracy on the campaign trail. They have been complaining indignantly that the Democrats were grossly distorting his position by suggesting that he favors a “100-year war” in Iraq, when he has simply said that he would be fine with stationing troops there for 100 years as long as there were no more American casualties.

Yet on repeated occasions, Mr. McCain, of Arizona, has inaccurately described the Democrats’ health care proposals, using language that evokes the specter of socialized medicine . . . .

“But before you decide to sign on to that kind of a program, go to Canada, or go to European countries that have government-run health care systems,” he continued. “My friends, they don’t work, they’re inefficient, and they end up in a two-tiered system where the wealthiest can afford to pay for their own health care and those with low income sometimes wait six or eight months for a routine kind of treatment. And that’s what I’m not going to let happen to the United States of America.” . . .

Language, of course, is a potent weapon in the battle to shape policy. And Mr. McCain’s effort to cast the Democrats’ plans as a government takeover is just the latest example in a long tradition of using similar language to characterize proposals to change the health care system, said Robert J. Blendon, a professor of health policy and political analysis at Harvard.

“In the campaign, what Senator McCain tries to appeal to is a general antigovernment feeling, a sense that we shouldn’t be doing things too big,” Professor Blendon said. “In a sense he’s appealing to a value that may or may not relate to the policies being discussed by either of the candidates.”

The only Democratic presidential candidate to propose a true single-payer, Medicare-for-all type of health plan in this election cycle was Representative Dennis J. Kucinich of Ohio. Mr. Obama’s and Mrs. Clinton’s plans do not call for a single-payer system like Canadians have, or a government-run national health system like the British have.  Both candidates have called for universal health coverage, with Mrs. Clinton saying she would require everyone to have insurance and Mr. Obama saying he would mandate coverage for children. Both would maintain the existing private insurance system, providing government subsidies or tax credits to help the low-income uninsured afford premiums. And they would give consumers a new option to buy insurance from the federal government, with policies along the lines of Medicare. . . . 

Mr. Bounds said that Mr. McCain’s characterization of the Democrats’ plans was completely reasonable. “While their proposals may not outline one to the finite extent, they clearly suggest that the movement toward a single-payer system is in their overall interests,” he said.

Democrats and Republicans view health care differently, polls suggest. Surveys have found that the most significant health concern voiced by Democrats is expanding coverage for the uninsured, while Republicans and independents are more focused on bringing down health care’s cost.

Even the phrase “socialized medicine” means different things to members of each party. A telephone survey conducted earlier this year by the Harvard School of Public Health and Harris Interactive found that 70 percent of Republicans thought that “socialized medicine” would be worse than the current system, while 70 percent of Democrats thought that it would be better.

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

Bipolar Disorder Overdiagnosed

In a bit of a surprise, Eurekalert reports on a recent study by Rhode Island Hospital and Brown University researchers that bipolar disorder may be overdiagnosed by quite a lot (close to 50%).  The study is published in the Journal of Clinical Psychiatry.  Nancy Cawley writes,

A new study by Rhode Island Hospital and Brown University researchers reports that fewer than half the patients previously diagnosed with bipolar disorder received a diagnosis of bipolar disorder based on a comprehensive, psychiatric diagnostic interview--the Structured Clinical Interview for DSM-IV (SCID).

The study concludes that while recent reports indicate that there is a problem with underdiagnosis of bipolar disorder, an equal if not greater problem exists with overdiagnosis. The study was published online by the Journal of Clinical Psychiatry. Principle investigator Mark Zimmerman, M.D., will present the findings at the annual meeting of the American Psychiatric Association on Wednesday, May 7.

The study method involved 700 psychiatric outpatients who were interviewed using the SCID and completed a self-administered questionnaire between May 2001 and March 2005. The questionnaire asked patients whether they had been previously diagnosed with bipolar or manic-depressive disorder by a health care professional. Family history of bipolar disorder was used as an index of diagnostic validity.

Of the 700 patients, 145 reported they had been previously diagnosed as having bipolar disorder; however, fewer than half of the 145 patients (43.4 percent) were diagnosed with bipolar disorder based on the SCID. Further, the study showed that patients diagnosed with bipolar disorder based on the SCID had a significantly higher morbid risk of bipolar disorder in first-degree relatives.

Unnecessary side effects are a significant concern of overdiagnosis. Because mood stabilizers are the treatment of choice for bipolar disorder, overdiagnosing can unnecessarily expose patients to serious medication side effects, including possible impact to renal, endocrine, hepatic, immunologic and metabolic functions.

Lead author Mark Zimmerman, M.D., director of outpatient psychiatry at Rhode Island Hospital and associate professor of psychiatry and human behavior at The Warren Alpert Medical School of Brown University, notes, “Clinicians are inclined to diagnose disorders that they feel more comfortable treating. We hypothesize that the increased availability of medications that have been approved for the treatment of bipolar disorder might be influencing clinicians who are unsure whether or not a patient has bipolar disorder or borderline personality disorder to err on the side of diagnosing the disorder that is medication responsive.” He continues, “This bias is reinforced by the marketing message of pharmaceutical companies to physicians, which has emphasized the literature on the delayed and underrecognition of bipolar disorder, and may be sensitizing clinicians to avoid missing the diagnosis of bipolar disorder.”

Zimmerman concludes, “The results of this study suggest that bipolar disorder is being overdiagnosed and we recommend that clinicians use a standardized, validated method in diagnosing bipolar disorder.” . . .

Last night, National Public Radio's All Things Considered also presented a story on this study. 

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

Tuesday, May 6, 2008

Suregon's Criminal Case Continues

AmNews reports on the Dr. Roozrokh's criminal case.  He is the surgeon who has been charged with several felonies after allegedly hastening a patient's death to obtain that patient's organs for transplantation.  Bonnie Booth writes,

A California Superior Court judge recently ruled that charges could move forward against a transplant surgeon for, in effect, hastening a man's death so his organs could be harvested more quickly. With this action, the judge authorized the first criminal charge related to an organ transplant procedure. What happens to the doctor he ordered to stand trial is likely to figure quite prominently in whether it also will be the last.

Superior Court Judge Martin J. Tangeman held that Hootan Roozrokh, MD, could be charged with one felony count of dependent adult abuse in the death of a patient at the Sierra Vista Regional Medical Center in San Luis Obispo, Calif.   But he dismissed two other related charges that focused on the administration of drugs to the patient. His mid-March ruling came after a preliminary hearing in which the prosecutors were required to show that their evidence was sufficient to take Dr. Roozrokh to trial.

The charges stemmed from events at the medical center on Feb. 3 and Feb. 4, 2006. Patient Ruben Navarro, who had adrenoleukodystrophy for several years, was admitted Jan. 29, 2006. Upon arrival, he was in a coma after a heart attack. His prognosis was diagnosed as poor.

On Feb. 1, 2006, Navarro's mother consented to withdrawing life support and to make her son an organ donor. Navarro was not brain dead, so doctors decided to use the donate-after-cardiac-arrest method for transplantation. This requires that the withdrawal of life support lead to death before organs can be recovered.

In his ruling letting the case go to trial, Tangeman acknowledged that Dr. Roozrokh did not participate in those decisions. Dr. Roozrokh was there because his employer, Kaiser Permanente, wanted him to perform the transplant surgery after the steps leading up to organ recovery had been completed. The felony charge is based on the prosecution's theory that Dr. Roozrokh ordered too much morphine to be given too quickly.

The judge based his ruling on the fact that the physician witnesses at the preliminary hearing all testified that the administered doses were clearly excessive; that they would have expected doses of that amount to cause Navarro to stop breathing; and that Dr. Roozrokh ordered the last three doses of morphine about 10 to 15 minutes apart after Navarro had been extubated while all the participants were waiting for him to die. Several witnesses also testified that there were no visible signs of distress or any other need that might call for "comfort care" medications.

M. Gerald Schwartzbach, Dr. Roozrokh's attorney, said the surgeon is prepared to fight the charge. At AMNews press time, Schwartzbach said he would move to have the remaining charge dismissed at the next court date, set for May 7.  . . . .

The definition of criminal negligence is set by state statute. The California Supreme Court interpreted that statute to define it as "such a departure from what would be the conduct of an ordinary prudent or careful person under similar circumstances as to be incompatible with a proper regard for human life."  But Dr. Filkins, who is also a lawyer, noted that it is difficult to recognize criminal negligence. The law of negligence usually requires an objective standard, which applies to physicians as well. That would mean anyone judging guilt or innocence would look to what a reasonable physician would do in the same circumstances. . . .

In addition, he said, the judge or jury likely would stray from an objective standard and attempt to look into the mind of the defendant physician through the evidence to decide whether the conduct rose to criminal negligence. If a physician had "corrupt motive," he said, the trier of fact is liable to be more ready to find a culpable mental state.

From the way the San Luis Obispo District Attorney's Office has positioned the case as one in which the physician wanted to get the organs more quickly, it might be looking at the corrupt-motive line of reasoning to prosecute Dr. Roozrokh. San Luis Obispo County Deputy District Attorney Karen Gray declined to comment.   While it might seem like a good strategy for the district attorney, using a corrupt-motive theory is likely to taint a transplant community that already struggles for donors. Indeed, many people who refuse to sign up to be an organ donor do so because they are afraid that less-than-heroic measures would be taken to save them if their organs were salvageable.

At the time of Dr. Roozrokh's arrest, the American Society of Transplant Surgeons released a statement saying they couldn't comment on his arrest but that "the sensationalism of this case in the media will unfortunately result in a decrease in organ donation." Schwartzbach said the threat of criminal prosecution is likely to chill a physician's desire to practice transplant surgery as well. . . .

For now, Dr. Roozrokh is still licensed in California and employed by The Permanente Medical Group. He is on paid leave while working on his defense.

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

10 Million Children Worldwide Die from Lack of Health Care

My Way's Teresa Cerojano reports on the ten million children wordwide who die from lack of health care.  She writes,

More than 200 million children worldwide under age 5 do not get basic health care, leading to nearly 10 million deaths annually from treatable ailments like diarrhea and pneumonia, a U.S.-based charity said Wednesday.  Nearly all of the deaths occur in the developing world, with poor children facing twice the risk of dying compared to richer children, according to Save the Children's global report. 

Sweden, Norway and Iceland top the ranking in terms of well-being for mothers and children in 146 countries surveyed, while Nigeria ranks last.  Eight out of 10 bottom-ranked countries are in sub-Saharan Africa, where four out of five mothers are likely to lose a child in their lifetime, Save the Children said. The top three among the 55 developing countries ranked in the survey are the Philippines, Peru and South Africa - all surveyed for the first time. Indonesia and Turkmenistan tied for fourth.  Laos, Yemen, Chad, Somalia and Ethiopia were found doing the worst among developing countries, the report said. . . .

An alarming number of countries are failing to provide the most basic health services that would save lives, with 30 percent of children in developing countries not getting basic health intervention such as prenatal care, skilled assistance during birth, immunizations and treatment for diarrhea and pneumonia.  Wide disparities in health care for the poorest and best-off children are seen even in the highest-ranked countries, the report said.  In the Philippines and Peru, for example, the poorest children are 3.2 times more likely to go without essential health care than their best-off counterparts.  The poorest Peruvian children are 7.4 times more likely to die than their richest counterparts, while the chances are 3.2 times higher for poor Filipino children . . . .

Use of existing, low-cost tools and knowledge could save more than 6 million of the 9.7 million children who die yearly from easily preventable or curable causes, the report said.  They include antibiotics that cost less than $0.30 to treat pneumonia, the top killer of children under 5, and oral rehydration therapy - a simple solution of salt, sugar and potassium - for diarrhea, the second top killer.

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

Monday, May 5, 2008

Medical Debt

The Cincinnati Enquirer reports on the explosion of medical debt and how individuals are dealing with it.  Peggy O'Farrell writes,

Vicki Mauch had a choice after she lost her health insurance in December: Pay for her medicine or pay for her mortgage.  Mauch, 47, decided to go without the prescriptions she needs to control her asthma and glaucoma.  Her finances were already shaky when a hospital stay in March added to her debt. She fell behind on her mortgage.  She's been too sick to work since then because of a seizure disorder. Now, she has another hard choice: Come up with almost $5,000 in back payments on her $125,000 house by May 7, or go into foreclosure.

Medical debt is a major problem for American families - even for families with health insurance.  Studies from the Access Project, a non-profit organization that focuses on expanding access to health care, cites medical debt as a factor in growing credit card debt, foreclosures and bankruptcy.Mauch has applied for disability and Medicaid coverage, but it's almost certain that her applications won't be approved before she loses her house. . . .

Trey Daly III, a senior attorney at the Legal Aid Society of Greater Cincinnati, hears stories like Mauch's every day.  "We typically hear from people because they've been sued or because they're being contacted by collections agencies over medical debt," Daly said. "That's when they come to us for help."  Most, like Mauch, are uninsured, but a growing number have health insurance, he said.  When families like Mauch juggle bills, most with high interest rates and late fees, it's not hard for medical debt, like credit card debt, to pile up.  Even for families with insurance, a hospital stay can add up to thousands in out-of-pocket expenses. . . .

For people with illnesses that need constant management, skipping preventive care can lead to costly emergencies down the road.  Mauch can't help but wonder when that emergency will arise.  If things get worse, she could get treatment at the closest emergency room, since it would be illegal for the hospital to deny her treatment.  But, Mauch explained, "That's a Band-Aid. I need health care," she said. "And I can't get it."

May 5, 2008 | Permalink | Comments (0) | TrackBack (0)

Health Insurance Costs Up

The New York Times had a front page article yesterday on the high cost of health insurance and the fact that employers are covering less and less of these costs.  Reed Abelson and Milt Freudenheim write,

Many of the 158 million people covered by employer health insurance are struggling to meet medical expenses that are much higher than they used to be — often because of some combination of higher premiums, less extensive coverage, and bigger out-of-pocket deductibles and co-payments.

With medical costs soaring, the coverage many people have may not adequately protect them from the financial shock of an emergency room visit or a major surgery. For some, even routine doctor visits might now take a back seat to basic expenses like food and gasoline.

“It just keeps eating into people’s income,” said James Corbin, a former union official who works for the local utility in Tucson.  Mr. Corbin said that under their employer’s health plan, he and his co-workers are now obliged to pay up to $4,000 of their families’ annual medical bills, on top of about $1,600 a year in premiums. Five years ago, they paid no premiums and were responsible for only about $2,000 of their families’ medical bills. “That’s a big jump,” Mr. Corbin said. “You’ve just lost a month’s pay.”

Already, many doctors say, the soft economy is making some insured people hesitant to get care they need, reluctant to spend a $50 co-payment for an office visit. Parents “are waiting longer to bring in their children,” said Dr. Richard Lander, a pediatrician in Livingston, N.J. “They say, ‘The kid isn’t that sick; her temperature is only 102.’ ”

The problem of affording health care is most acute for people with no insurance, a group expected to soon exceed 48 million, but those with insurance say they too are feeling the pain.

Since the recession of 2001, the employee’s average cost of an annual health care premium for family coverage has nearly doubled — to $3,300, up from $1,800 — while incomes have come nowhere close to keeping up. Factor in other out-of-pocket medical costs, and the portion of the average American household’s income that goes toward health care has risen about 12 percent, according to the consulting and accounting firm Deloitte, and is now approaching one-fifth of the average household’s spending.  In a recent survey by Deloitte’s health research center, only 7 percent of people said they felt financially prepared for their future health care needs. . . . .

“There’s a real shift in the burden of health care to people who happen to be sick,” said Paul B. Ginsburg, the president of the Center for Studying Health System Change, a research group in Washington.  Companies and policy makers have yet to focus on what the faltering economy means for employees’ medical care, said Helen Darling, president of the National Business Group on Health, a Washington association of about 200 large employers.  “It’s a bad-news situation when an individual or household has to pay out-of-pocket three, four or five times as much for their health plan as they would have at the time of the last recession,” she said. “Americans have been giving their pay raise to the health care system.” . . . .

May 5, 2008 | Permalink | Comments (0) | TrackBack (0)