January 31, 2009
Unpaid Taxes Delay Daschle
The New York Times' Robert Pear discusses some of Tom Daschle's tax issues that might disrupt plans for his confirmation as Secretary of Health and Human Services. He writes,
President Obama’s pick for secretary of health and human services, Tom Daschle, filed amended tax returns and paid more than $100,000 in back taxes on Jan. 2, administration officials said on Friday. (Related news article.) Mr. Daschle concluded that he owed the taxes for free use of a car and driver that had been provided to him by Leo Hindery Jr., the founder of a private equity firm known as InterMedia Advisors, the officials said.
Mr. Daschle was chairman of the firm’s advisory board. In a financial disclosure statement filed this month with the Office of Government Ethics, Mr. Daschle reported that he had received large amounts of income from InterMedia, including more than $2 million for consulting and $182,520 in the form of “company-provided transportation.” The belated tax payments help explain delays in the confirmation of Mr. Daschle, a former Senate Democratic leader who had been expected to win swift approval from the Senate. . . .
The official said that Mr. Daschle’s failure to pay the taxes was “a stupid mistake,” but should not derail the nomination. The confirmation of Treasury Secretary Timothy F. Geithner was held up only briefly following the disclosure that he had failed to pay more than $34,000 in taxes owed to the federal government. . . .
January 30, 2009
Fertility Treatments Under Scrutiny Again
I am sure that most of you heard about the successful births of octuplets last week. The birth of so many children at one time does raise some, ok many, issues. The LA Times reports,
Even as the birth of octuplets at Kaiser Permanente Bellflower Medical Center drew attention and applause from around the country, questions arose Tuesday about whether the mother's doctors did enough to prevent such a risky pregnancy.
The chances that the eight babies born Monday were conceived naturally are infinitesimal, infertility specialists and doctors in maternal-fetal medicine say. Today's reproductive experts have the tools and the know-how to avoid such high-risk pregnancies -- and often try desperately to do so."When we see something like this in the general fertility world, it gives us the heebie-jeebies," said Michael Tucker, a clinical embryologist in Atlanta and a leading researcher in infertility treatment. Tucker added that in his opinion, "if a medical practitioner had anything to do with it, there's some degree of inappropriate medical therapy there." . . .
The American Society for Reproductive Medicine and the American College of Obstetricians and Gynecologists say "doctors should be making efforts to curb these higher-order multiple gestations," said Dr. Geeta Swamy, an assistant professor of obstetrics and gynecology at Duke University. "But it really is still up to the individual physician. There aren't any laws or legal ramifications to it."
The babies could have been conceived through in vitro fertilization, in which eggs and sperm are combined in the lab and a specified number of the healthiest-looking embryos are transferred to the uterus. That scenario seems unlikely because fertility doctors are asked to adhere to strict guidelines that limit the number of embryos transferred. As a result, higher-order multiple births resulting from in vitro fertilization are uncommon.
A more likely scenario is that the mother of the octuplets received infertility drugs in a procedure called controlled ovarian hyperstimulation. The treatment, which is typically used to achieve pregnancy in women who do not ovulate, stimulates the ovaries to produce a number of eggs. As the eggs near maturity, the patient usually has artificial insemination. An oral drug, clomiphene, can be used to stimulate the release of one or two mature eggs. But more powerful, injectable medications may produce eight to 10 mature eggs, said Dr. David Diaz, medical director of West Coast Fertility Centers in Orange County. "That's the most common way these higher-order multiples occur," he said.
Some patients with infertility problems opt to try controlled ovarian hyperstimulation instead of in vitro fertilization because it is far less expensive -- about $2,000 to $3,000 instead of $10,000. Kaiser Permanente does not cover in vitro fertilization for its members. Although the octuplets were born in a Kaiser hospital, it's not known whether the mother is a Kaiser member. Ovarian stimulation is far less controllable than in vitro fertilization, Swamy said, "because you can't control how many embryos you put back."
Even so, doctors typically go to great lengths to monitor treatments involving infertility drugs, Diaz said. If tests show too many eggs have been stimulated, doctors often will not follow through with a second medication that releases the eggs. They can also drain some of the follicles to reduce the number of eggs released.
If patients choose to proceed with the treatment -- even facing the potential of a large number of eggs being released -- they can later abort some of the embryos if a higher-order pregnancy occurs. Many patients dislike this practice, called selective reduction, said Dr. Harold Henry, director of maternal-fetal medicine at Kaiser Permanente. Some have religious or ethical objections to aborting any of the fetuses; others don't want to risk losing the entire pregnancy.
Infertility experts generally try to prevent multiple births because of the myriad potential health problems for mother and babies and because such births consume enormous financial resources for hospitals, health insurers and families . . . .
Senate Passes SCHIP
The Senate passed a bill on Thursday to provide health insurance to more than four million uninsured children, as a newly empowered Democratic majority brushed aside Republican objections. The vote was 66 to 32, with nine Republicans joining Democrats to support the bill.
The Senate debate showed the outlines of what promises to be a much larger political fight over universal coverage. While Democrats championed expansion of the child health program, many Republicans, including Senator John McCain of Arizona, said they worried that it was part of a long-term effort to replace private health insurance with government programs. The House passed a nearly identical bill two weeks ago, by a vote of 289 to 139, with 40 Republicans joining nearly all Democrats in support of the measure. . . .
One of the most significant sections of the child health bill would allow states to use federal money to cover children and pregnant women who are legal immigrants. Under existing law, legal immigrants are generally barred from Medicaid and the State Children’s Health Insurance Program for five years after they enter the United States. “The bill would end an inequity that we have been trying to eradicate for more than a decade,” said Jennifer M. Ng’andu, a health policy specialist at the National Council of La Raza, a Hispanic rights group.
The Congressional Budget Office said the bill would enable states to cover more than four million uninsured children by 2013, while continuing coverage for seven million youngsters. The bill would increase tobacco taxes to offset the increase in spending, estimated at more than $32 billion over four and a half years. . . .
January 29, 2009
Food Safety - Peanuts and More . . .
Tom Laskawy, writes about the lack of food safety here in the United States, and informs us of all the problems we are having right now. He states,
It's been a bad week for food safety. First, it was the peanut butter, then it was the High Fructose Corn Syrup and now it's deadly antibiotic-resistant staph bacteria (aka MRSA) in CAFO pigs (and their minders). And of course, as Bill Marler - litigious scourge of the food industry - reminds us, we're continuing to lose the fight against E. coli.
Much has been written about the efforts to track down the sources of contamination. And invariably the companies involved quickly close the their doors (which is how we lost one of the largest ground beef distributors in the country virtually overnight and why the Peanut Corporation of America is no more). But what's truly worrisome is that in each case, the USDA and the FDA (who have joint responsibility for food safety) had information at hand about all of these problems. . . .
It's understandable then, that USDA chief Tom Vilsack is less concerned with creating whole new regulatory structures for food safety and more concerned with making the ones that we have actually work. But continuing to mix boosterism and regulation - as many of our federal agencies including the FDA and the USDA do - will inevitably lead to these kind of breakdowns. And though you can come up with laundry list after laundry list of changes to penalties, enforcement, inspections and agencies that would improve matters, the frequency and seriousness of each outbreak suggests good intentioned reform may not be enough.
That the output of one contaminated peanut processing plant could require the recall of hundreds of varied and unrelated products and could kill 8 and sicken over 400 in more than 40 states across the country suggests we may have reached the limits of consolidation in the food industry. You'd think that such centralization of food production would make regulation easier. Indeed, the ease of regulation, along with low cost, was one of the prime alleged advantages of consolidation. But we're seeing not just production failures, but the wholesale failure of the regulatory structures themselves. Well, food is cheap anyway.
Eliminating Waiting Period for Medicare
Harold Pollack writing at Ezra Klein's blog discusses another way to help stimulate the economy - elimination of the two-year waiting period for disabled people to receive Medicare. He explains,
This waiting period goes back to 1972, when Congress expanded Medicare eligibility to include the disabled. Under current policy, people with disabilities must receive Social Security Disability Insurance (SSDI) for 24 months before becoming Medicare-eligible. Exceptions have been added for end-stage renal disease and ALS. Some states step in to fill the gap. Yet this policy imposes severe problems on many people. According to the Congressional Budget Office (CBO), roughly 1.8 million SSDI beneficiaries are now in the waiting period for Medicare coverage. (See Option 19 in their huge report.)
There are policy-analytic arguments to support current policies—Medicare does not want to assume burdens rightfully borne by private insurers or to finance care for temporary disabilities. The program did not want to strengthen perverse incentives to remain uninsured. A nice Commonwealth Fund report by Stacy Berg Dale and James Verdier details these issues. (In one of those small-world moments, I was Verdier’s teaching assistance nearly two decades ago.) As we move into a world aspiring to universal coverage, increased protection for people with preexisting conditions, and perhaps even some flavor of individual mandate for insurance coverage, original arguments for the waiting period seem outmoded, and outweighed by the resulting human cost.
Berg and Verdier’s 2003 report is now a bit dated, but it remains the best single information source. Their work suggests that up to 400,000 uninsured people with serious disabilities might be helped by changes in this policy.
The National Multiple Sclerosis Society and pretty much every similar advocacy group have spoken out against the waiting period. Pending House and Senate bills propose to phase out the waiting period over the next decade and to grant more exceptions for people with life-threatening illnesses. The House version, HR 154, has 104 cosponsors. The Senate version, S2102, has 23 cosponsors. I am especially heartened that the issue is raised in Senator Baucus’s vaunted white paper on health reform.
CBO has sussed out various proposals to reduce or eliminate the waiting period. Eliminating the waiting period entirely would increase federal outlays by about $41 billion between 2010 and 2014, and would cost about $12 billion per year once it is fully implemented. This calculation reflects a shift in federal spending from Medicaid onto Medicare of about $32 billion between 2010 and 2019, because Medicaid plays an important role in filling the current gap. (This calculation nicely illustrates CBO’s essential role in getting complicated numbers right. Don’t try this at home.)
CBO doesn’t report the billions of dollars that states would save by reducing this Medicaid burden. My perilously rough calculation based on Dale and Verdier’s work suggests that states would save in the neighborhood of $2.4 billion annually, were SSDI recipients made immediately Medicare-eligible. . . .
January 28, 2009
Medicare Reform in the Stimulus Bill
The Wall Street Journal's Health Blog reports on some of the proposed changes in Medicaid currently being discussed as part of a stimulus bill.
You might mistake the economic stimulus package slated for a House vote today for a health-reform bill, if weren’t sprinkled with some goodies for other sectors of the economy. Take a look at the changes to Medicaid policy, in particular, the New York Times reports. If it becomes law, the bill would temporarily allow unemployed workers to qualify for Medicaid regardless of their income or assets. Medicaid is typically for the poor.
The bill also increases federal funding for Medicaid and subsidizes laid-off workers who are paying for Cobra insurance coverage through their former employers, NYT says. Here’s how the paper quotes the Congressional Budget Office on the costs: $87 billion to increase the federal share of Medicaid; $29 billion to subsidize private insurance and $11 billion to fund Medicaid for unemployed workers who wouldn’t otherwise qualify. . . . .
One casualty of congressional horsetrading is an expansion of contraceptive coverage under Medicaid, the WSJ reports. That one had been blasted by Republicans, and Democratic leaders late Tuesday agreed to remove it.
Meanwhile, on the health information-technology funding in the bill, National Public Radio caught up with John Halamka, chief information officer at Beth Israel Deaconess Medical Center in Boston. He argues that the $20 billion dedicated to increasing doctors’ use computers will create about 200,000 jobs .. . . .
Learning from Banks?
Slate.com's Zachary Meisel and Jesse Pines have a cautionary tale for health care workers and reformers from those who work in the banking industry. They write,
The condition of the U.S. economy can be described generously as bleak. But while unemployment is on the rise and the Big Three automakers struggle to remain afloat, the business of making people well seems relatively insulated. While some discretionary health care sectors are not growing, such as LASIK eye procedures and plastic surgery that patients pay for out of pocket, most health care workers still have jobs and can afford the occasional $4 latte.
But the health care industry is no oasis. The very problems that brought our country to its financial knees are still at work today in health care. It comes down to the disordered competition that exists in both the mortgage and health care industries.
If you pick up your college econ textbook, you'll read all about Adam Smith and how competition is fundamentally good. When companies compete, it results in a better product for the consumer: McDonald's competes with Burger King to make a better, cheaper hamburger. Problem is, in both the old, defunct mortgage business and current health care industry, the "invisible hand" fails to produce low-cost, high-quality, sustainable products.
In the mortgage industry, this competition failure produced the banking crisis. During the housing bubble, banks competed with one another to sell risky mortgages that had a high likelihood of default. Now, entire neighborhoods have been left nearly deserted because of waves of foreclosures. In health care, competition similarly fails to produce better community health. Instead of competing with one another for the best outcomes, providers compete for patients with the most profitable diseases. Hospital care for cancer and heart surgery makes more money than hospital care for diabetes, pneumonia, or mental health. While all these services get reimbursed, some bring in more cash than others—in effect, cancer care is like gold while diabetes is like silver.
As a result, form follows finance: Gilded diseases get the best care while the silver diseases are given lesser priority. (Ever notice that hospitals have hardwood floors in some areas, like the cancer units, while general medicine gets linoleum?) Mining gold generally means doing high-volume elective procedures and state-of-the art care—the stuff patients think will make them better in a short period of time. Mining silver involves primary and preventive care, like managing blood pressure. Because it's less lucrative to mine silver, even patients with comprehensive insurance are made to wait for doctors' appointments and often get bumped to E.R.s for regular care. In Redefining Health Care, economists Michael Porter and Elisabeth Teisberg detailed how this gold-mining scheme interferes with creating the best health outcomes because it devalues certain treatments and marginalizes patients with particular diseases. Improperly treated diabetes can be just as lethal as untreated cancer, but while hospitals roll out the red carpet for cancer patients, diabetics get the shaft.. . . .
Neither medical care nor mortgages are fundamentally bad. But there are too few checks in the system to prevent people from getting the equivalent of a crappy burger.
How can health reformers learn from the mortgage industry? One solution is paying for health care outcomes instead of health care services. Under this system, if the doctor makes you better, he gets paid—otherwise, no dough. But reimbursing on outcomes is problematic because it is difficult to know who should have gotten better but didn't, and who would have gotten better even without treatment. Doctors who take harder cases would look like they were bad at their job and maybe get paid less, possibly creating incentives for refusing harder cases.
January 27, 2009
Mercy Killing: No Further Jail Time
The LA Times provides an update on an attempted mercy killing and the final determination of whether to prosecute the individual who made the attempt. Catherine Sailant reports,
James Wheeler, the 85-year-old Carpinteria man who attempted to kill his dementia-stricken wife and himself in September, won't be going back to jail after all.In a recent sentencing hearing, Ventura County Superior Court Judge George Eskin ruled that the seven days Wheeler spent in a Santa Barbara jail after his Sept. 17 arrest was enough. He'll also serve three years of probation and 100 hours of community service, Eskin decided at the sentencing Thursday. . . .
Wheeler's story galvanized people in Carpinteria and beyond. Many were incensed that the retired engineer could spend the rest of his life behind bars for what they saw as not a crime but an act of love. Wheeler told investigators that he had lost hope because his wife, in her fifth year of battling Alzheimer's, no longer recognized him. His plan to die with her by pumping car exhaust into their weathered beach cottage was interrupted by a neighbor who saw the exhaust hose and called police. . . .
"He realizes now there were probably other ways to deal with the situation,'' she said.
Sadly, his beloved wife, Betty, died Nov. 12. Wheeler eulogized his wife of 64 years in a memorial service in Carpinteria and wrote her obituary for the local paper, which took up nearly a quarter of a page.
Kidney Transplant Recipients - Gender Gap
The New York Times reports on a new Johns Hopkins showing that older women are less likely to end up on the kidney transplant waiting list. Roni C. Rabin writes,
Women are less likely to receive kidney transplants than men, and researchers at Johns Hopkins have found that this gap primarily affects older women — even though they fare as well or better than men their age after a transplant. . . .
They found that women 45 and younger were as likely as men to be placed on a transplant waiting list. But as women aged, their chances of getting on the list dropped, getting worse with each decade, said the lead author, Dr. Dorry Segev, a transplant surgeon at Johns Hopkins.
By the time women were 46 to 55, they were 3 percent less likely to be put on the transplant list. They were 15 percent less likely to be placed on the list at ages 56 to 65; 29 percent less likely at 66 to 75; and 59 percent less likely to be listed by the time they were 75 or older, Dr. Segev said. The study was published in The Journal of the American Society of Nephrology.
Dr. Segev suggested that caregivers, family members and maybe the patients perceived older women to be more frail than they really are. “A lot of older women die without having an opportunity to get on the transplant list,” he said.
January 26, 2009
Vaccine Study Shows Safety
Newsweek reports on a recent Italian study that demonstrates the safety of vaccines. Carla Johnson writes
In the early 1990s, thousands of healthy Italian babies in a study of whooping cough vaccines got two different amounts of the preservative thimerosal (pronounced thih-MEHR'-uh-sawl) from all their routine shots. Ten years later, 1,403 of those children took a battery of brain function tests. Researchers found small differences in only two of 24 measurements and those "might be attributable to chance," they wrote in the February issue of the journal Pediatrics, which was released Monday.
Only one case of autism was found, and that was in the group that got the lower level of thimerosal. Autism is a complex disorder featuring repetitive behaviors and poor social interaction and communication skills. Scientists generally believe genetics plays a role in causing the disorder; a theory that thimerosal is to blame has been repeatedly discounted in scientific studies.
"Put together with the evidence of all the other studies, this tells us there is no reason to worry about the effect of thimerosal in vaccines," said the new study's lead author, Dr. Alberto Tozzi of Bambino Gesu Hospital in Rome. . . .
Pfizer-Wyeth Pharmaceutical Merger
The Wall Street Journal's Health Blog has many pieces today on the merger of Pfizer and Wyeth Pharmaceuticals. Sarah Rubenstein of the Health Blog writes,
Pfizer has agreed to acquire Wyeth in a $68 billion deal that’s the largest merger in the pharmaceutical industry in nearly a decade. In announcing the deal, the companies made clear that Pfizer has in mind to cut its reliance on traditional pills.
“With its broad and diversified global product portfolio and reduced dependence on small molecules, the new company will be positioned for improved, consistent and stable top-line and [earnings] growth and sustainable shareholder value in the short and long term,” the companies say. “It is expected that no drug will account for more than 10 percent of the combined company’s revenue in 2012.” That’s putting the best face on the loss of patent protection for cholesterol-fighter Lipitor in late 2011, we suppose. Last year Pfizer registered $12.7 billion in Lipitor sales, or a quarter of company revenue.
As Credit Suisse analyst Catherine Arnold put it in a note this morning, a Pfizer-Wyeth deal could “mark the beginning of a year of sector consolidation and could trigger other pharma-pharma or pharma-biotech deals.” Big deals often haven’t gone well for the industry, but the combination of lots of cash sloshing around and looming patent expirations may make deals impossible to resist.
She cites Bristol-Myers Squibb as a possible target. Then again, everybody always cites Bristol as a target — including Deusche Bank analyst Barbara Ryan, who in a note this morning mentioned both Bristol and Schering-Plough, whose stock has yet to recover from last year’s Vytorin imbroglio. . . . .
January 25, 2009
Global Gag Rule Overturned
President Obama overturned the rule banning federal funds to international family planning groups that either offer abortions or provide information about them. The Guardian U.K. reports,
President Barack Obama today made the most contentious move of his young administration with an order, overturning a ban on federal funds to foreign family planning organisations that either offer abortions or provide information or counselling about abortion. The rule change continues the dismantling of George Bush's conservative policies. It is likely to encounter fierce criticism from the still robust anti-abortion movement.
It will allow US aid, usually through the US agency for international development, to flow to HIV/Aids clinics, birth-control providers and other organisations that advocate or provide counselling about abortion across the world. It is known as the "global gag rule" because it denies US taxpayer dollars to clinics that even mention abortion to women with unplanned pregnancies. . . .
Family planning groups in America and the UK cheered the rule change. Dr Gill Greer, director general of London-based International Planned Parenthood Federation, estimated the gag rule had cost the group more than $100m for family planning and sexual and reproductive health programmes during the eight years of the Bush administration, which she said amounted to 36 million unplanned pregnancies and 15 million induced abortions. . . .
While both Clinton and Bush used the Roe v Wade anniversary to change US policy on abortion, Obama declined yesterday. He instead issued a statement reaffirming his commitment "to protecting a woman's right to choose". "On the 36th anniversary of Roe v Wade, we are reminded that this decision not only protects women's health and reproductive freedom, but stands for a broader principle: that government should not intrude on our most private family matters," he said.
The rule comes as no surprise. During the president campaign Hillary Clinton, who as secretary of state will oversee foreign aid, pledged to end the rule. . . .