May 31, 2008
Americans Want Health Reform
The New Republic's Jonathan Cohn reports on a new poll in the International Herald Tribune showing that four out of five Americans would like to see our health care system completely overhauled. He writes,
. . . . On behalf of the International Herald Tribune and France 24 television, Harris Interactive surveyed people in the U.S., Britain, France, Germany, Italy, and Spain. The findings? Four out of five Americans say the system needs fundamental changes or a complete overhaul--the highest of all the countries surveyed.
Just to be clear, the number of dissatisfied people was pretty high in most of the countries. But in the other countries, it's more people calling for "fundamental changes" rather than a "complete rebuilding." And, having just spent some time in these countries, I suspect a lot of that is concern over long-term financing. They want to sustain what they have--and are worried that, given medical care's escalating costs, they will have trouble doing so in the future. It's a valid concern but, of course, one that only makes their systems look even better relative to ours, since they already spend far less than we do.
In any event, the citizens of one country actually did seem pretty satisfied with their health care system. That country is France. But this is hardly surprising. People who follow health care closely--like Ezra Klein, Victor Rodwin, and, yes, me--have been talking up the French system for a while. French national health insurance offers convenience, a high level of services, plus universal coverage--again, all at a significantly lower price tag than in the U.S. The system is far from perfect, but, overall, it seems like a far better deal than what we give our citizens.
May 30, 2008
Obama's First 100 Days: Health Care
Ezra Klein comments on Obama's speech discussing what he would do during his first 100 days in office. He would focus on health care - as well as some other items obviously. Ezra writes,
Speaking at a fundraiser in Denver last night, Obama was asked what he'd do in his first 100 days. The answer? After sitting down with the Joint Chiefs of Staff to figure out a strategy in Iraq, "[G]et our health care plan moving. We need a bill...by March or April to get going before the political season sets in." For those of us into the politics of this issue, that timetable is big news. Doing health care quickly is crucial. You can't lose your momentum. You can't get bogged down in the endless unknown events and unexpected crises of a presidency. You need a strategy and you need momentum and in order to preserve those things, you need to move. This is what Clinton failed to do in 1993. . . .
Global Warming as Public Health Threat
The Washington Post writes about the EPA's report on the impact of global warming and the various health risks it poses to individuals. Andrew Revkin states,
The Bush administration, bowing to a court order, has released a fresh summary of federal and independent research pointing to large, and mainly harmful, impact of human-caused global warming in the United States. The report, released Thursday, is online at climatescience.gov, along with a new report updating the administration’s priorities for climate research.
Most of the findings, like the spread of warmth-loving pests and the inevitable loss of low-lying lands to rising seas, are not new. But the report included new projections of how the poor, elderly and communities with lagging public-health and public-works systems will face outsize health risks from warming.
Among the report’s new conclusions on health: “An increased frequency and severity of heat waves is expected, leading to more illness and death, particularly among the young, elderly, frail and poor.” It added that deaths from cold would decline, but said uncertainties on both projections made it impossible to characterize the overall risk.
It gave high odds (essentially a two out of three chance) that Lyme disease and West Nile virus would have expanded ranges because of warming. The report gave the same odds that some food- and water-borne diseases would also increase among susceptible populations, but said “major human epidemics” were unlikely as long as public-health systems remained effective. . . .
May 29, 2008
Obama's doctor revealed today that Obama is in excellent health. The New York Times reports,
Senator Barack Obama was in “excellent health” at the time of his last examination more than a year ago, according to a letter released today by his physician, and has no known medical problems that would affect his ability to serve as president.
It is the first time Mr. Obama, 46, has publicly released information on his medical history or current health condition. The brief statement summarized the senator’s health for the last 21 years and was signed by Dr. David L. Scheiner , who has been Mr. Obama’s primary care physician for more than two decades.
Mr. Obama’s “family history is pertinent,” according to the doctor, who noted that the senator’s mother died from ovarian cancer and his grandfather died of prostate cancer. Mr. Obama’s smoking history – off and on for at least two decades – also was noted. . . .
The Wall Street Journal Health Blog wanted to know about the cigarettes . . . .
Barack Obama’s doctor just released a one-page letter describing the senator’s health as “excellent.” . . . He exercises and eats well. His blood pressure is 90/60, his LDL cholesterol is 96 and his HDL is 68, says the letter by Dr. David Scheiner, who has treated Obama since 1987. The letter does note that Obama’s history has included “intermittent” cigarette smoking. “He has quit this practice on several occasions and is currently using Nicorette gum with success,” says the letter. But it doesn’t say how much Obama smoked, or for how long. . . .
The letter concludes that Obama is in “overall good physical and mental health needed to maintain the resiliency required in the Office of President.” . . .
Vioxx Verdicts - Score Two for Merck
The New York Times reports on the latest two Vioxx verdicts and they aren't good for plaintiffs. The Associated Press states,
A Texas court reversed a $26 million verdict against Merck from the first trial. The court found no evidence that the patient, Robert Ernst, suffered a fatal heart problem from a blood clot caused by Vioxx. He had been taking the now-withdrawn drug for eight months before being stricken in May 2001. His widow had won a $253 million verdict against Merck in 2005, but caps on punitive damages in Texas later cut that to about $26 million.
Also Thursday, a New Jersey appeals court voided $9 million of the $13.9 million awarded to John McDarby in 2006 by a jury in Atlantic City. The panel found that New Jersey’s Product Liability Act was pre-empted by the federal Food, Drug and Cosmetic Act. Mr. McDarby survived his 2004 heart attack.
In a statement, Merck’s general counsel, Bruce Kuhlik, said the company was gratified that the Texas 14th Court of Appeals found Vioxx did not cause Mr. Ernst’s death. “In addition, the New Jersey court correctly reversed the awards of punitive damages and consumer fraud,” Mr. Kuhlik said. “We intend to seek further review of the portion of the award that remains standing after the New Jersey decision. We continue to believe Merck acted responsibly.”
Mr. McDarby’s lawyer, Ellen Relkin, said that while they were delighted with the affirmation of the $4.5 million compensatory part of the verdict, they would consider appealing the reversal of the $9 million in punitive damages. Ms. Relkin said that “the most important legal finding” from the case is that court found that a drug maker could be found liable for contributory liability even in the case of a person with “underlying cardiac risk factors, such as diabetes, elevated cholesterol and advanced age.”
The New Jersey ruling also upheld a verdict in favor of Merck in the case of Thomas Cona, who survived a heart attack in June 2003. His case was heard simultaneously in Atlantic City with McDarby’s case. Mr. Cona’s lawyer, W. Mark Lanier, called the ruling “unfortunate,” but said the New Jersey panel’s 126-page decision was well-reasoned. Mr. Lanier, who also represented Mr. Ernst, complained that the Texas appellate panel’s ruling failed to interpret the evidence in the light most favorable to the jury verdict. . . . . Mr. Lanier said he would appeal to the Texas Supreme Court if the appellate panel declines to reconsider the ruling.
All three cases were excluded from the settlement Merck reached in November in which it agreed to pay $4.85 billion to end thousands of other Vioxx lawsuits. Thursday’s rulings give Merck 11 victories and 3 losses stemming from the trials that reached verdicts, with the damages now reduced in one of those losses. Retrials are pending in a few cases. . . .
May 28, 2008
Political Donations from Health Care Enterprises
The Wall Street Journal's Health Blog notes today that political contributions have started to flow toward the Democrats and away from the Republicans. While this may partially be the result of the current lack of popularity of the President, it could mean that some sources are hoping to stop aggressive reform and benefit from some insurance reforms. The Wall Street Journal's Jacob Goldstein writes,
From Jan. 1, 2007 through March of this year, people and political action committees in the health sector have contributed $42 million and to Democratic candidates for congress and the presidency, compared with $34.6 million to Republicans, Dow Jones Newswires reports. . . . The figures come from the Center for Responsive Politics, a nonprofit group that tracks this kind of thing. They include gifts from people employed in the sector. The biggest donors are the American Dental Association, the American Hospital Association and PACs and people associated with Pfizer.
One obvious reason for the shift is the fact that the Democrats control Congress and will likely continue to do so after the November elections. And on the presidential level, we’d point out that both Democratic candidates have called for a big expansion of health insurance coverage that would pour an additional $100 billion a year in federal funds into the health sector — plenty of new money to spend on health-care goods and services. John McCain’s health-care proposals, by contrast, wouldn’t put significantly more federal money into health.
Childhood Obesity - Some Positive News - It isn't getting worse
The New York Times reports on some good news on childhood obesity - a plateau. Tara Parker-Pope writes,
Childhood obesity, rising for more than two decades, appears to have hit a plateau, a potentially significant milestone in the battle against excessive weight gain among children. But the finding, based on survey data gathered from 1999 to 2006 by the federal Centers for Disease Control and Prevention and published in Wednesday’s issue of The Journal of the American Medical Association, was greeted with guarded optimism.
It is not clear if the lull in childhood weight gain is permanent or even if it is the result of public anti-obesity efforts to limit junk food and increase physical activity in schools. Doctors noted that even if the trend held up, 32 percent of American schoolchildren remained overweight or obese, representing an entire generation that will be saddled with weight-related health problems as it ages. “After 25 years of extraordinarily bad news about childhood obesity, this study provides a glimmer of hope,” said Dr. David Ludwig, director of the childhood obesity program at Children’s Hospital in Boston. “But it’s much too soon to know whether this is a true plateau in prevalence or just a temporary lull.”
The data come from thousands of children who have taken part in the National Health and Nutrition Examination Surveys — compiled by the National Center for Health Statistics at the C.D.C. since the 1960s — and represent some of the most reliable statistics available on the health of American children. The most recent data is based on two surveys — one in 2003 to 2004 and one in 2005 to 2006 — that included 8,165 children ages 2 to 19. In that group, about 16 percent of children and teenagers were obese, which is defined as having a body mass index at or above the 95th percentile on United States growth charts. For example, a 10-year-old girl who is 4-foot-7 would be considered obese if her weight reached 100 pounds. By comparison, about 5 percent of children and teenagers in the United States were obese in the 1960s and 1970s. As startling as those numbers are, the good news is that from a statistical standpoint, obesity rates have not increased since 1999. Estimates for the number of children who fall into the overweight or obese category also have remained stable at about 32 percent since 1999. Overweight is defined as at or above the 85th percentile. . . .
The researchers did not give reasons for the leveling off of childhood obesity rates. One concern is that the lull could represent a natural plateau that would have occurred regardless of public health efforts. . . .
One worry is that as obesity rates stabilize, financing for childhood health efforts will wane. In Arkansas, the program was a success but a financial crunch prompted the state legislature recently to cut physical activity programs in seventh through 12th grade.
While the latest data suggest the obesity epidemic may have been contained, researchers say the real question is whether it is possible to reverse the obesity trend among American schoolchildren. “We still lack anything resembling a national strategy to take this problem seriously,” said Dr. Ludwig, co-author of an editorial accompanying the obesity report. “The rates of obesity in children are so hugely high that without any further increases, the impact of this epidemic will be felt with increasing severity for many years to come.”
National Public Radio had further information on its Morning Edition Program as well as a discussion of the difficulties of determing a child's BMI.
May 27, 2008
Slate.com's Zachary Meisel questions why doctors are still prescribing so many antibiotics. He writes,
While working a busy night shift in the ER recently, I evaluated a 13-month-old girl. On her chart, the triage nurse had written: "Infant with fever and runny nose. Mother here for antibiotics." The baby was fussy but probably more tired than uncomfortable. Between her squirms, she cooed and smiled at me. Her anxious and upset mother, however, was in far worse shape, repeatedly sticking a rubber bulb syringe up her infant's nostrils in a futile attempt to suck out an endless stream of snot. The mom was also really mad: She had been waiting for more than three hours for a doctor to see her daughter. Now she wanted antibiotics: specifically, a prescription for bubble-gum-flavored amoxicillin.
By my assessment, the child was not acutely ill: She'd had a low-grade fever for two days, her mother said, and a mild cough, but she had clear lungs and appeared well-hydrated. Her eardrum may have had some fluid behind it but wasn't red or bulging. Just as the baby was trying to put my stethoscope in her mouth, paramedics pushed through the ambulance doors with a patient who was having an acute stroke. I had to decide right then if I was going to give this mother the antibiotics she wanted, even though I thought her daughter probably didn't need them. . . .
In the doctor's office or the ER, it's hard to tell the difference between bacterial and viral infections, and so doctors are tempted to prescribe antibiotics whenever they're unsure. That's especially true when doctors think that patients expect to take the medicine home, according to a recent study. Investigators interviewed patients with respiratory infections who went to the ER in 10 hospitals affiliated with medical schools, asking whether the patients expected to receive antibiotics and about whether they were satisfied with the care they received when they were discharged. The researchers also asked physicians why they prescribed antibiotics. The main conclusion was that doctors were significantly more likely to prescribe if they believed that patients expected them to—but did a lousy job predicting which patients those actually were. And the patients most satisfied with their care were the ones who left the ER with a better understanding of their condition, antibiotics or no antibiotics. The take-home message for doctors like me: Spend an extra five minutes talking to your patients about their medical problems, and you can send them away happy and without unnecessary medicine.
So once doctors absorb the result of this study and similar investigations, will they write fewer prescriptions? I bet not. To give out fewer antibiotics, the doctors will have to believe that their patients won't benefit from them. If you look closely at the ER study, 73 percent of the patients who received antibiotics for acute bronchitis had illnesses that were either deemed by their doctors to have likely been caused by a bacteria or to have origins that were in that gray toss-up area between a bacteria and a virus. If the doctors were right, and these were bacterial infections, they would, in fact, warrant antibiotics. Also, in many of these cases, the doctors gave other persuasive reasons for choosing antibiotics, including "ill appearance of the patient" and "concern about follow-up." . . . .
In the end, I did not prescribe antibiotics for the 13-month-old baby. Instead, I took the time to explain thoroughly why I didn't think she needed them (while my colleague took care of the stroke patient). But no matter what that study says, that mother left in a huff— highly dissatisfied, I can assure you. I'm not sure what I'll do the next time I see a similar case. Perhaps I will refuse to write the prescription again, notching another victory for public health. But, for all I know, something intangible will be different: Perhaps the kid just won't look right, or maybe the mother or father will seem too disorganized to be relied on to return if the kid worsens. And that may persuade me to send them home with a bottle of pink-bubble-gum-flavored amoxicillin. It's likely that the fussy kid and his parents won't sleep any better that night. But I will.
Ezra Klein has a few thoughts on what is causing the malpractice crisis - that would be malpractice . . . . He writes,
The medical malpractice problem is not, as some would have you believe, solely in the courts. It's on the operating tables. Take this study from the Harvard School of Public Health (as Maggie notes, "this is not a cabal representing lawyers who should be sitting on the bottom of the ocean. These researchers are interested in our health as a nation."), which found:
• “The great majority of patients who sustain a medical injury as a result of negligence do not sue.” Indeed, the New York Times reports, although “recent studies have found that one of every 100 hospital patients suffers negligent treatment, and that as many as 98,000 die each year as a result . . . only a small fraction of injured patients — perhaps 2 percent—press legal claims.)
• “Just 1.1 percent of all doctors accounted for 30 percent of all malpractice payments made between 1990 and 2002, while only 5.2 percent of doctors were responsible for 55 percent of all payouts.” A very small group of doctors are losing or settling malpractice lawsuits, but they are losing big.
• “Eighty percent of claims involved injuries that caused significant or major disability (39 percent and 15 percent, respectively) or death (26 percent).”
The problem isn't malpractice lawsuits, but the mistakes that lead to them. I'm sympathetic to doctors who don't want to be punished for human error, but I'm also sympathetic to patients who've been grievously injured because they trusted doctors to avoid major errors. In our system, such trust is all too frequently grievously misplaced. But trying to deal with this on the legal end, either by toughening the circumstances under which patients can sue or simply increasing disclosure and easing the path to restitution, is getting it exactly backwards. The suits aren't the problem, the mistakes are the problem. . . . .