Last week I wrote about the President’s Cancer Panel Report which highlighted the “grievous harm” caused by environmental carcinogens and urged action that included removing the toxins from our food, water, and air that “devastate American lives.”

Achieving this is will be no easy task for a nation whose primary tool for regulating chemicals, the Toxic Substances Control Act (TSCA), was added last year to a list of government programs at “high risk” of failure by the Government Accounting Office. The Cancer Panel authors write that TSCA, passed in 1976, is a weak law that doesn’t provide the Environmental Protection Agency with enough authority and “may be the most egregious example of ineffective regulation of environmental contaminants.”

When the Act was passed, some 62,000 chemicals already on the market were declared “safe”, even though there was little or no data to support this policy. Every year another 1,000 chemicals are introduced onto the market—usually with little toxicity testing. The net result: Only 2% of the 80,000 to 100,000 chemicals currently in use have been tested for carcinogenicity and other toxicity.

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Summary:  A startling study published in the New England Journal of Medicine reveals that just as doctors in some towns are more aggressive in treating their patients, physicians in some places are more likely to send patients for tests, and to subspecialists. As a result, their patients are diagnosed with more diseases. Thus, if a Medicare patient who was living in Phoenix (and feeling perfectly healthy), moves to Miami, he may suddenly discover that he suffers from two or three chronic conditions.  
This creates a problem, not only for the patient (am I really sicker?), but for health care reformers who hope to pay hospitals and doctors more for higher quality care. To do that they have to adjust for risk: Providers caring for sicker patients should still be eligible for bonuses, even if their outcomes  aren’t as stellar as the results achieved by hospitals that treat more robust patients. But if the majority of Medicare patients in Miami have been diagnosed with one disease or another, does that mean that Medicare should pay Miami’s hospitals more than hospitals in Phoenix because their patients appear more vulnerable– at least on paper? The researchers conclude: “risk-adjustment is going to be tougher than we thought.”
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At a dinner party in Manhattan, someone mentions the problems he has been having with his sinuses, and his doctor’s diagnosis. Since everyone at the table is over 40, his comment quickly leads to a lively discussion of back pain, rotator cuffs, high blood pressure, skin cancer, and diverticulitis. It seems that everyone in the room has been diagnosed with something. Finally, someone asks “Are we really that old? Can’t we talk about something else?” Everyone laughs and the conversation turns to politics.

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Over on Kevin M.D. Dr. Vineet Arora  writes about what she learned while touring hospitals and a med school in China: http://www.kevinmd.com/blog/2010/05/china-medical-school-residency-training.html

“My husband and I recently traveled to Wuhan Medical School in the Hubei Province in central China,” she reports. “Our medical school [University of Chicago] has partnered with Wuhan to help inform their curricular reform efforts. We spent 4 days touring the hospitals and teaching facilities, meeting students and faculty, going on rounds, and giving talks. Although the language barrier was challenging, we had incredible translators who worked to translate every slide we spoke into Chinese. We also had the opportunity to observe and talk to students, residents, and faculty through translators to better understand their experiences.”

Unfortunately, Chinese medical students are getting a somewhat skewed view of medical education in the U.S.  “The preclinical students told me they watch Grey’s Anatomy and House, MD and wonder if that is what medicine is like. I told them that U.S. medical students and premeds have wondered that too!”

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The recent report from the President’s Cancer Panel, entitled “Reducing Environmental Cancer Risk,”  took the bold step of focusing on environmental toxins and their role in causing cancer. In it, the authors charge that “the grievous harm from this group of carcinogens has not been addressed adequately by the National Cancer Program” and they urge the President “to use the power of your office to remove the carcinogens and other toxins from our food, water, and air that needlessly increase healthcare costs, cripple our nation's productivity, and devastate American lives.”

Much of the media chose to highlight the “personal responsibility” aspects of the panel’s recommendations for reducing cancer risk: Eating organic foods, avoiding toxic cleaning products, buying phthalate-free toys, filtering drinking water and avoiding unneeded medical scans, among other suggestions that are practical mostly for an upper-middle-class, educated audience–the media's target group.

But the Panel’s welcome—if surprising—endorsement of “green” living is not what makes the 200-plus page report so groundbreaking. What the authors have dared to do is call for a fundamental shift in direction for cancer research and prevention; away from the relentless pursuit of chemotherapy drugs and other treatments that provide incremental benefits—weeks or months of survival for a limited group at enormous cost—and toward an approach that focuses on taking meaningful steps toward reducing risk and preventing disease in the first place. They write:

“Environmental exposures that increase the national cancer burden do not represent a new front in the ongoing war on cancer. However, the grievous harm from this group of carcinogens has not been addressed adequately by the National Cancer Program. The American people—even before they are born—are bombarded continually with myriad combinations of these dangerous exposures.”

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Summary: If hospitals pay more attention to how they discharge patients, and what happens to them after they leave, Medicare could save billions. Under the reform legislation, beginning in 2011 Medicare will refuse to pay for an excessive number of preventable readmissions. Over at the New American Foundation’s “Health Care Dialogue” Joanne Kenen reports on research that shows that we do know how to reduce “bounce-backs.”  And hospitals aren’t waiting for 2011, they are already finding creative solutions to the problem.
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In a post titled “Slowing Down that Revolving  Readmissions Door" the New America Foundation’s Joanne Kenen writes about avoidable readmissions. “I once interviewed a patient who literally could  not remember how often he had been hospitalized within just a few months,” Kenen recalls, referring to a story published in the Washington Post last year.

There, she reported that “one of five Medicare hospital patients returns to the hospital within 30 days–at a cost to Medicare of $12 billion to $15 billion a year—and by 90 days the rate rises to one of three, according to an analysis of 2007 data by Stephen Jencks.”  Within a year, two out of three are back in the hospital—or dead—says Jencks who consults on this issue for the Institute for Healthcare Improvement (IHI).

This is money that health care reformers could use as we expand care to the uninsured. It’s worth noting that what many call “Medicare cuts” are really “Medicare savings”—billions that could be reclaimed if we rescued patients from that revolving door.

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Summary-Not long ago, a New York Times editorial repeated a statistic that you may have heard before: "one in four Americans are projected to die of cancer."  Fortunately, this is a complete fabrication. For most Americans–including the vast majority of Times' readers– the risk is far lower.

A recent New York Times editorial announced that the war on cancer is reaching "a state of crisis."   Citing the Institute of Medicine (IOM), the Times called for boosting funds that support cancer trials while also raising the academic rewards to encourage researchers to run clinical trials. Appealing to readers' pre-dawn terrors, the editorial concludes by declaring that "Nearly one in four Americans are projected to die from cancer. It is vitally important to find the best treatments for them."

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Over on “Movin’ Meat,” an ER doctor living in the Pacific Northwest tells a true story titled “Where romance and medicine collide.”

 I suspect that many readers will view this tale as a welcome  respite from the details of health care legislation.  But I should warn that  some might find it in questionable taste. The opening should help you decide: 

“A patient was brought in around midnight as a ‘possible stroke.’ She was a sixty-something woman who had suddenly become unresponsive.  She and her husband had been making love at the time, and he noticed that she was no longer conscious.” [Good For Him!- mm]

Many thanks to the “Happy Hospitalist” for calling attention to this post

You can find the full post here.

Summary: In Part 3 of “Myths & Facts about the Impact of Reform on Hospitals and Patients Who Need Hospital Care,”  I addressed the fear that  cuts in Medicare spending will threaten the financial health of the nation’s hospitals. Reform’s critics argue that hospitals already lose money on Medicare patients, and that if the government tightens its belt, they will lose revenues that they sorely need if they are going to provide high quality care. The truth is that, today, more efficient hospitals make money or at least break even on Medicare beneficiaries. The Medicare “cuts” will not affect needed care; they aim only at reducing waste, infections and inefficiencies that hurt patients. I also explain how Medicaid’s expansion will help hospitals.

Here, in Part 4, I respond to rumors that because government pays less than private insurers, hospitals will continue to shift costs to insurers, and thus, insurance premiums will rise. The truth is that private insurers are over-paying some hospitals, not because Medicare pays too little, but because large brand-name hospitals have more clout in the marketplace than insurers, and can force them to accept high charges. As reform regulations put insurers under financial pressure, it’s likely that they will begin to fight back. Meanwhile, states will follow Massachusetts in taking a closer look at “marquee hospitals” that charge more for basic services, without providing better care.

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Summary: I’m crossing posting this piece from Dr. Len’s Cancer Blog http://www.cancer.org/aspx/blog/Comments.aspx?id=353

because it seems to me a very wise and balanced assessment of what Provenge means—and doesn’t mean—for patients, for Medicare and for society as a whole. I’ve highlighted some sentences, and inserted a few comments in italic. Many thanks to HealthBeat reader Greg Pawelski for calling attention to this piece.

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Today’s announcement by the Food and Drug Administration (FDA)   (FDA) that they approved Provenge for the treatment of advanced, hormone resistant prostate cancer is significant for several reasons, not the least of which that it offers new hope to men with advanced prostate cancer where progress in treatment has been very slow in coming.

Equally important, it closes the door on decades of unfulfilled hopes that tumor vaccines and immunotherapy would eventually play a significant role in cancer treatment.  We now have a demonstrated success, which is especially important given the many near-misses that have occurred over the years.  This reinforces for many the dream that one day we would be able turn on the body’s own defense mechanisms as one more approach to treat (or one day—perhaps—prevent) certain cancers.

As exciting as this announcement is, and with all of that hope it brings to patients, their families and the physicians who treat them, it is important that we keep this development in perspective for what it is: one small step in an otherwise complex and still difficult situation.  It is not a miracle cure, especially for men with very advanced, symptomatic disease.

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For a compendium of some of the most provocative healthcare posts of the past two weeks, see Health Wonk Review, hosted this time by Health Care Economist Jason Shafrin.  For instance:

• The Incidental Economist wonders whether the Affordable Care Act is just an excuse for income redistribution.
• Georgians for a Healthy Future analyzes the Illinois Supreme Court’s decision to strip not-for-profit Provena Covenant Medical Center of its exemption from property tax, stating that the hospital did not provide enough charity care to justify that exemption. [Note under health reform legislation non-profit hospitals will have to justify their tax-exempt status every three years–mm ]
• The Health Affairs Blog has a way to add some teeth to the health reform mandate: tying your credit score to whether or not you have health insurance [They are going to have to do something to stiffen the penalty or young, healthy people won’t join the pool and insurance will be extremely expensive.—mm]—
• HealthCare Renewal says that fining large health care companies for criminal activities will not change the firms’ behavior. An idea to convince health care executives to follow the rules is to allow for the prosecution of these corporate leaders. –
• Will the FDA begin regulating medical software? The Health Blawg says the answer may be yes as the FDA has asserted the right to “regulate software as a device, not only in the context of radiology, but also in the context of electronic health records.

These are just highlights. Click here for the full review.