HealthLawProf Blog

Sick Reviewed

Kevin Drum highlights a review by Phil Longman of Sick, Jon Cohn's new book about America's rather inefficient and expensive healthcare system.  Longman disagrees with Cohn's conclusion that the main problem with our health care system is money.  Longman believes that "Money can't really be our core problem, he says, since the evidence indicates that the more you spend, the worse your treatment is likely to be:"

According to a recent RAND study published in the New England Journal of Medicine, uninsured patients receive only 53.7 percent of the care experts believe they should get — that is, appropriate, evidence-based treatment. But according to the same study, patients with private, fee-for-service insurance are even less likely to receive the proper care. Indeed, among Americans receiving acute care, those who lack insurance stand a slightly better chance of receiving proper treatment than patients covered by Medicaid, Medicare, or any form of private insurance.

....[Dr. Elliot Fisher] found that in America's highest-spending hospitals, only 74.8 percent of heart attack victims receive aspirin upon discharge from the hospital, as opposed to 83.5 percent in lower-budget competitors. This may be one reason why survival rates for heart attack victims are actually higher in low-spending hospitals than in high-spending hospitals.

What's more, these spendthrift hospitals often skip other routine preventative care such as flu vaccines, Pap smears, and mammograms. This general lack of attention to prevention and follow-up care in high-spending hospitals helps to explain why not only heart attack victims but also patients suffering from colon cancer and hip fractures stand a better chance of living longer if they stay away from "elite" hospitals and choose a lower-cost provider instead. Given this reality, it is perhaps not surprising that patient satisfaction also declines as a hospital's spending per patient rises.

Longman has his own book to sell, entitled, "Best Care Anywhere:  Why VA Care is Better than Yours?"
Perhaps the answer to all of our health care problems is contained in one of these books.  For the New York Times Book Review of "Sick"  click here.

FDA: Not Exactly Keeping the US Food Supply Safe

Well, the FDA has apparently taken action against those pet food distributors - but not before some pigs and chickens were fed the tainted food.  oops!  I find it rather discouraging and frightening that the FDA has become either overly trusting of companies to clean themselves or so overworked that they cannot keep upwith all the issues facing food and drugs in the US.  As someone with neither the talent or the time to grow all my own food, I tend to agree with Christy Hardin Smith from Firedoglake who writes:

As the mother of a healthy, growing preschooler — who also happens to be a bit of a picky eater, but loves peanut butter toast — this is not only infuriating, it is downright terrifying:

The Food and Drug Administration has known for years about contamination problems at a Georgia peanut butter plant and on California spinach farms that led to disease outbreaks that killed three people, sickened hundreds, and forced one of the biggest product recalls in U.S. history, documents and interviews show.

Overwhelmed by huge growth in the number of food processors and imports, however, the agency took only limited steps to address the problems and relied on producers to police themselves, according to agency documents….  (emphasis mine)

They knew — KNEW! — for years that there was a problem but relied on the companies to "police themselves"??!!?? Are they completely daft? (Don't answer that.)

As a mother, the thought that the FDA knew that my child, and every other peanut butter eating child in America, could potentially contract salmonella poisoning from a plant with a history of contamination issues but just kept right on allowing that company to manufacture the peanut butter without ensuring the safety of the product?  Even after the contamination was discovered? That is beyond incompetent and negligent.  Especially when you consider just how deadly salmonella can be to a small child.  And if you consider how many kids with compromised immune systems could be added into the mix with a food substance that kids eat by the jar on a weekly basis?  Or how many poor kids whose families can afford peanut butter as a staple for these kids, and who depend on this as a means of feeding the family several days a week for lunch and/or dinner?  Uh.  Mah.  Gawd.

As a former prosecutor, the words that I'm looking for are alleged criminal negligence and/or manslaughter. This is beyond infuriating and, as a parent, I am now asking myself "what else?" Beyond tainted peanut butter and spinach, what else is getting into our food supply that the FDA knows is a problem but isn't bothering to tell the public about it?  And, here's a question, if the FDA knew that there was a problem — then did these manufacturing and processing facilities also know and just keep right on churning this tainted food into the grocery stores anyway?

Here's a clue: you know of a problem in the food supply that could kill my child, the answer is not to keep your mouth shut and hope that the problem magically disappears on its own because the corporation might just be run by some good citizen who will shut down production, not worry about immediate bottom line profits and do the right thing. Nuh uh. You shut down production immediately, you fix the problem and you do not endanger my child. Is that clear enough for you?

As for some good news, the FDA's idea to permit chocolate manufactures to sell chocolate that doesn't contain cocoa butter has caused such an uproar that the FDA has extended the comment period.

Ezra Klein claims to have discovered worst OP-ED ever!

I have to agree that Douglas Shoen's op-ed, "A Health Care Agenda for America," is not very good but I will let you be the judge,  Here is Ezra Klein's take:

There's this wonderful moment in the Simpsons, where Burns goes into the doctor for a check-up, and the doctor explains that the only reason he's alive is that there are so many diseases trying to kill him that none can get through. They're all crowded at the door, struggling to enter. That's sort of describes my reaction to Doug Schoen's health care op-ed. I feel virtually incapable of engaging with it, paralyzed by the infinite expanse of logical holes, self-serving omissions, and political hackery riddling the article. But I shall soldier on.

"According to a Kaiser Family Foundation poll in March," Schoen writes, "after Iraq, healthcare is the single most important issue among American voters today." I've read that poll.  And I've read Doug Schoen's op-ed.  And the two have nothing to do with each other. 

Schoen's op-ed mentions the word "partisan" four times. It tells us that "[Americans] want to see healthcare needs and issues addressed in a spirit of partnership, not partisanship," that [w]hat is clear is that America wants everyone to work together in a constructive manner," that "[h]ealthcare should not become a partisan issue," that Medicare Part D "marked a huge bipartisan step forward" and that "working together, the members of the two parties were able to bring together the best ideas from both sides of the aisle to create a broad-based program that succeeds in achieving many critical goals."

Want to know the final vote tally on Medicare Part D was in the House of Representatives? 216-215. Want to know how long Tom DeLay extended the vote to dragoon and intimidate more members? Three hours. Want to know the Senate margin? 55-44. There was nothing bipartisan about it. It's widely acknowledged to possess huge failings owing entirely to drug company giveaways. George W. Bush is currently threatening to veto an overwhelmingly popular bill that would empower Medicare to bargain down drug prices -- a bill that Democrats made into a core part of their 2006 platform. Schoen mentions none of this.  He paints one of the most grotesquely partisan votes in history, a vote that literally led to ethics investigations against DeLay, as a bipartisan triumph. He ignores the overwhelmingly popular reform that Democrats have long been touting. He spins, he misrepresents, and he lies in order to strengthen the Republican bargaining position. . . .

Job Opening

From:   Richard A Goodman, MD, JD, MPH Anthony D. Moulton, PhD Co-Directors, Public Health Law Program Office of the Chief of Public Health Practice, CDC

JOB OPENING:   Medical Officer with the CDC Public Health Law Program. Among other qualifications, an applicant must be a physician and should have extensive experience in public health as well as thorough understanding of the role law plays in public health. The person in this position leads development and execution of our strategy to improve information about public health law and makes many other contributions to the Program's mission of improving understanding and use of law as a public health tool. A substantial focus is on legal preparedness for public health emergencies. Applications must be received by Friday, April 27. The full job announcement and application guidelines appear at the following website: http://jobsearch.usajobs.opm.gov/getjob.asp

Cost-Sharing and Health Care

Ezra Klein posts some thoughts on why cost-sharing in our health care system should be something that all people support.  Not sure I completely agree but he does raise some interesting points.  He says,

Progressives tend to focus, rightly, on the access question. It makes sense for a number of reasons. One is that the worst of the cost crises won't materialize for decades, while the uninsured lack health coverage now. Another is that cost control is only possible within an integrated, more centralized system, and such a system is better sold on grounds of access than on overall cost.

But how to best control costs should be considered, even if it never becomes a preeminent political talking point. It must be considered not only because the health system will collapse unless spending growth slows, but because we spend too much on health care in the United States. We spend more than we need to, first of all, because our prices are so high and our system is so inefficient. But even if we could purchase care at wholesale rates and construct the most effective delivery system in the world, we would still be spending more than we probably should. On this, the data is clear: We purchase more care than really benefits us. . . .

In their zeal to beat back universal health care, conservatives have argued that the primary problem with America's health care system is, indeed, overuse. We're all so heavily insured and totally insulated from health care costs, the argument goes, that we overuse care and thus make the system more expensive. And so if we exposed individuals to more of the cost of care -- if we paid for our actual health care, rather than paying premiums for our health insurance -- we'd use less of it. This is why conservatives love health savings accounts, which have high deductibles, forcing individuals to pay more for their care and, as the thinking goes, eventually use less of it. . . .

That's what makes cost-sharing so tricky. You don't want to disproportionately penalize the poor, or keep them from seeking necessary care. You don't want to decrease the use of cost-effective treatments. You don't want diabetics to abandon their treatment regimens and require amputations, or for patients to drop their hypertensive medications and suffer heart attacks. Not only is it bad for the patient, it's costly for the system.  .. .

So the question is how to create a cost-sharing system that is not merely progressive, but smart. And some of the most exciting thinking on the subject comes from a new paper by the economist Jason Furman on "The Promise of Progressive Cost Consciousness in Health-Care Reform."

Furman proposes a health system in which households making about 200 percent of the poverty line would pay 50 percent of health costs until they reached 7.5 percent of income. Above that, all expenses would be covered. Below 150 percent of the poverty line, there would be no cost-sharing, and between 150 percent and 200 percent, the limit would be 5 percent of income. Furman estimates that his plan would reduce health spending by an astonishing 30 percent.

That's a lot of money. And I'm a bit skeptical that any achievable plan could trigger such dramatic reductions. But there's no doubt that moving money from premium payments to point-of-care payments would reduce the amount of health care purchased. And that's largely to the good: As discussed, the money can then be freed for other priorities, and the best evidence that we have suggests health outcomes would remain unharmed. And, if we do it right, they could even be improved.

The trick would be exempting certain conditions and treatments from the cost-sharing. For instance, it's cost-effective and medically important to encourage adherence to statin regimens (cholesterol-lowering drugs), and the evidence shows that co-pays compel some to stop taking the medication. So statins shouldn't be subject to cost-sharing. Indeed, the French system provides a useful model here, as it erases cost-sharing for various chronic conditions (like diabetes) and cost-effective medications (like hypertension treatments) where it's cheaper and more healthful to encourage health care use.

In order to do that, you need an integrated system capable of setting system-wide priorities. As Furman, in fact, says, in a surprising admission for an economist associated with the centrist Hamilton Project, "The simplest and cleanest way to implement income-related cost sharing would be as part of a far-reaching fundamental health reform. For instance, a single-payer system could easily incorporate [it]." Such a system would not only save money, it would likely improve outcomes as well. And there'd be nothing catastrophic about that success.

Dietary Supplements

CNN.com reports, not surprisingly, that dietary supplements have not been proven scientifically to provide health benefits.  What was surprising to me was what a large number of these supplements some people take and how much money Americans spend on them each year.  CNN.com states,

Every morning, Dr. Frank Pinto pops not one or two vitamins, not just a handful, but more than two dozen dietary supplements, washing each one down with a sip of water.

When afternoon rolls around, he takes 20 more: all told, nearly 50 pills, every day. Pinto, a dermatologist, and his wife, Rosemary, a family therapist, are chasing life with a vengeance under the guidance of Dr. Ana Casas, an Atlanta-based specialist in "age management."

Like millions of Americans, the Pintos, who live in Tifton, Georgia, take supplements in hopes of gaining energy, warding off disease and slowing down the aging process. The federal government says Americans spend at least $5.8 billion a year on dietary supplements.

To look at the labels, you would think that vitamins and supplements are powerful medicine. Yet for all the money spent, and growing interest from mainstream physicians, virtually no evidence exists that supplements can improve your health.

Mmm, now why isn't this something that a consumer protection agency should be all over -- ooo -- thanks to Congress, these supplements are exempt from FDA coverage.  As CNN notes,

Under the 1994 Dietary Supplement and Health Education Act, nutritional supplements do not have to be tested for safety or effectiveness before going on the market. As long as the manufacturer doesn't claim that a product treats or cures a specific disease, it can advertise any health benefit whatsoever. The next time you're in a health food store, just count the bottles that promise to "strengthen your immune system."

Perhaps Congress should revisit this decision to not regulate the supplement industry.

Stem Cell Funding Vote in Congress

Congress will vote again to approve federal funding for stem cell research this week according to Scientific American.com. The website reports,

Stem cells will be at the top of the agenda for the U.S. Senate when it returns on Tuesday with supporters of the research hoping they can change the president's mind on the issue and opponents hoping to have a say about their stand.                               

The Senate will consider two bills, one virtually identical to a bill vetoed by President George W. Bush last year that would have expanded and encouraged federal funding of human embryonic stem cell research.                               

The other is a compromise measure worked out by Republicans Sen. Johnny Isakson of Georgia and Norm Coleman of Minnesota. It would encourage stem cell research on embryos that have naturally lost the ability to develop into fetuses, such as those that have died "naturally" during fertility treatments.

The compromise bill also would support the creation of a bank of stem cells taken from amniotic fluid and placentas -- two recently discovered potential sources.                            

This bill replaces last year's alternative sponsored by Kansas Republican Sam Brownback, which would ban human embryonic stem cell research and encourage research using other types of stem cells.                              

The House of Representatives passed a bill in January that would expand federal funding of stem cell research, which is now restricted by Bush to batches available as of August 2001. But the bill does not have enough supporters to override a second presidential veto.                              
It is not clear how much support there is for either Senate bill, although opponents of human embryonic stem cell research, such as Brownback, have signaled they will vote for the compromise bill. They also said they were looking forward to making use of up to 20 hours of scheduled debate. . . .

In other news relating to stem cells, an article in Science Daily discusses recent findings by researchers at Children's Hospital of Pittsburgh, that "female stem cells derived from muscle have a greater ability to regenerate skeletal muscle tissue than male cells, according to a study," published in the April 9th issue of the Journal of Cell Biology. Science Daily reports,

This finding could have a major impact on the successful development of stem cells as viable therapies for a variety of diseases and conditions, according to the study's senior author, Johnny Huard, PhD, director of the Stem Cell Research Center at Children's and the Henry J. Mankin Professor and Vice Chair for Research in the Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine.

"Regardless of the sex of the host, the implantation of female stem cells led to significantly better skeletal muscle regeneration," said Dr. Huard, also the deputy director of the McGowan Institute of Regenerative Medicine. "Based on these results, future studies investigating regenerative medicine should consider the sex of the stem cells to be an important factor. Furthermore, investigations such as ours could lead to a better understanding of sex-related differences in aging and disease and could explain, at least partially, the high variability and conflicting results reported in the literature on stem cell biology."

Dr. Huard's team, and the study's first author, Bridget Deasy, PhD, director of the Live Cell Imaging Lab at Children's Stem Cell Research Center, made the discovery while working with a population of stem cells they isolated in the lab while searching for a cure for Duchene muscular dystrophy (DMD). DMD is a genetic disease estimated to affect one in every 3,500 boys. Patients with DMD lack dystrophin, a protein that gives muscle cells structure. Using an animal model of the disease, his laboratory is using stem cells to deliver dystrophin to muscles.

 

Morality and the Mind

William Saletan writing at Slate.com has an interesting piece on the brain and morality.  He writes,

Imagine that killers have invaded your neighborhood. They're in your house, and you and your neighbors are hiding in the cellar. Your baby starts to cry. If you had to press your hand over the baby's face till it stopped fighting—if you had to smother it to save everyone else—would you do it?

If you're normal, you wouldn't, according to a study published last week in Nature. But if part of your brain were damaged—the ventromedial prefrontal cortex—you would. In the study, people were given hypothetical dilemmas: Would you throw a fatally injured person off a lifeboat to save everyone else? Would you kill a healthy hostage? Most normal people said no. Most people with VMPC damage said yes. . . .

The article discusses why people may be making these different choices.  It then concludes with a rather frightening discussion concerning controlling those choices:

Five years ago, in a government report, scientists proposed using microscopic technology to screen the brains of soldiers for emotional interference. Today, the Neurotechnology Industry Organization is lobbying for a federal initiative to study the ethics as well as the mechanics of brain science. "Right now, we're discovering the seat of morality," warns NIO President Zack Lynch. "In 10 to 15 years, we'll have the technologies to manipulate it."

But there's the other catch: Once technology manipulates ethics, ethics can no longer judge technology. Nor can human nature discredit the mentality that shapes human nature. In a utilitarian world, what's neurologically fit is utilitarianism. It'll become the norm, the standard of right and wrong. Sure, a few mental relics of our primate ancestry will be lost. But it'll be worth it. I think.

More Fun Ways to Increase Organ Donation

If you were thinking educational efforts or presumed consent laws, think again, South Carolina has another potential answer to the organ shortage  (no need for those scary half-human donors), we can use prisoners.  The Associated Press reported earlier this month that South Carolina's state legislature is considering a bill that encourages organ donations from prisoners by cutting time (180 days) off their prison sentence.  The AP reports:

A state Senate panel on Thursday endorsed creating an organ-and-tissue donation program for inmates. But legislators postponed debate on a measure to reduce the sentences of participating prisoners, citing concern that federal law may not allow it.

"I think it's imperative that we go all out and see what we can do," said the bills' chief sponsor, Democratic Sen. Ralph Anderson. "I would like to see us get enough donors that people are no longer dying."

The proposal approved by the Senate Corrections and Penology Subcommittee would set up a volunteer donor program in prisons to teach inmates about the need for donors. But lawmakers want legal advice before acting on a bill that would shave up to 180 days off a prison sentence for inmates who donate.

South Carolina advocates for organ donations said the policy would be the first in the nation.

Federal law makes it illegal to give organ donors "valuable consideration." Lawmakers want to know whether the term could apply to time off of prison sentences. . . .

Some further thoughts from the Daily Kos webblog

 

Frontline

Tomorrow night's Frontline, "So Much So Fast" looks worth watching:

When he was 29 years old, Stephen Heywood was diagnosed with ALS -- also called Lou Gehrig's disease -- and told he had two to five years to live. But Stephen and his family refused to accept the doctors' death sentence. So Much So Fast follows the Heywoods' passionate, acerbic, and relentlessly hopeful reaction to a disease that transforms their lives. Stephen's older brother, Jamie, starts a foundation dedicated to finding a cure through fast-paced guerrilla science that attracts both praise and controversy. Stephen gets married and he and his wife, Wendy, have a son. They confront the encroaching paralysis of ALS with a mix of courage and humor, and, surrounded by friends and family, upend the clichés of their situation. From Oscar-nominated (Troublesome Creek) filmmakers Steven Ascher and Jeanne Jordan, So Much So Fast tells a haunting story of one family's unexpected answers to some of life's biggest questions.

Government Health Care

Kevin Drum of the Washington Monthly posts an interesting question about government and its involvement in the health care system.  He refers to a recent LA Times article by Chairman of the Committee to Reduce Infection Deaths Betsy McCaughey discusses favorably the VA health system.  Mr. Drum focuses on the use of computer physician  (CPOE), which involves "a doctor enters the prescription at a computer terminal instead of scribbling it on a pad. The computer identifies incorrect doses or a medication that conflicts with other meds the patient is taking. If the computer sounds an alarm, the physician has to override it."  Not surprisingly, hospitals in many countries have adopted this technology but the article not in the United States with the exception of the VA.   This lack of adoption causes Mr. Drum to ask: 

Question for the free market crowd: if you oppose national healthcare because you think it will reduce the pace of medical innovation, how do you explain this? Why is it that the VA and the national healthcare systems in Europe have all adopted this plainly useful innovation but American hospitals mostly haven't?