The Dallas Morning News has done a wonderful series on end-of-life care. Thanks to 
Annie for pointing it out.

Here are excerpts from part one, written by Lee Hancock, describing an encounter at a Baylor University Medical School ICU unit between Ms. Patel, a palliative care team nurse, and Dr. Edward Taylor, a 36-year-old trauma surgeon.

Like a palliative care doctor, Patel had been specially trained to help patients who may be dying—and their families—confront excruciating questions about how much care they want.   These specialists also are trained to manage pain, a fine art that too many U.S. hospitals do not practice. Finally, palliative care specialists help other doctors and nurses face the fact that they may be losing a patient.
In this case, Hancock explains: “The middle-aged accident victim had been stranded there for weeks, in a high-tech limbo.”

" ‘He looks a mess,’" Ms. Patel told the surgeon. ‘It doesn't seem like we're going to make him better.’

“‘I don't know if we can say that,’ Dr. Taylor said, looking down at the tiny, Indian-born nurse.

“Ms. Patel's gray scrubs would fit a fourth-grader, but her vibrance and her striking British accent drew outsized attention. She was a legend throughout the medical center, where she had worked since coming from England in 1990…

“Dr. Taylor, 36, called in Ms. Patel that Thursday morning because his patient was the sickest in the unit. But the man's relatives didn't seem to get it. In the twilight zone of the ICU, it was hard for bewildered families to grasp that using more drugs and devices wasn't always the best way to show love.

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                           This Thursday, December 18 in New York

Let’s take blogging and reading blogs to another level: let’s try to translate it into communicating with our government.

 President-Elect Obama and Senator Tom Daschle, the new administration’s point-man on health care reform, say that they want healthcare reform that comes “from the ground up.” This is why they are asking Americans to “give us your ideas and input” during this holiday season.

Here is the invitation from the Office of the President-Elect  “Sign up to lead a Health Care Community Discussion in your home, community center, or even a local coffee shop, anytime from December 15th to 31st. (http://change.gov/page/s/hcdiscussion) Senator Tom Daschle, the leader of the Transition's Health Policy Team, will choose some discussions to attend in person.”  

 I’m hoping that HealthBeat readers of all political persuasions in cities around the country will decide to step up to the challenge. If you’re interested in hosting a discussion, sign up at (http://change.gov/page/s/hcdiscussion     and e-mail me at Mahar@tcf.org.  I’ll post your invitation here on HealthBeat so that people in your area can attend. (When you sign up at change.gov, you might want to let them know you’re a HealthBeat reader, and part of the HealthBeat Network.)

NYC HealthBeat reader Dr. Brad Flansbaum at Lenox Hill Hospital in Manhattan already has decided to host a conference at Lenox Hill this Thursday, December 18, from 6:30 to 8:30 p.m.

I’ll  be there, and Brad and I will put our heads together to create a few bullet points for the discussion. But we’re counting on you to drive the conversation. 

The incoming administration has signaled that it is very interested in hearing from informed constituents. Our opinion WILL make a difference.

 Here’s Brad’s invitation to everyone in the NYC area:

Hi All,

President-elect Obama has made it clear that health care reform is one of his top priorities. That's why the Obama-Biden Transition is asking people to give their own thoughts and ideas for how to fix the system at Health Care Community Discussions all across the country.

We have arranged to host a Community Discussion, and we want your voice heard.  Here are the details:

Date and time: Thursday, 12/18 at 6:30 to 8:30.
Location: 130 Black Hall, ER entrance, SW corner of Lexington and E. 77^th Street, and follow signs to Weisner Conference Center.

[BEF1] 
Hope you can make it.”

*****************************************************************

Please let me know if you’re interested in attending the NYC event by e-mailing me at mahar@tcf.org. (We’re just trying to get an idea of how many people will be coming.)

If  you’re in another city and want to host a discussion, send your invitation to the same address—mahar@tcf.org so that I can post it on HealthBeat.  Just remember, you have to host the discussion sometime between December 15  and December 31.

The Wall Street Journal has some of the best health care reporting of any major newspaper, yet its editorial page is often filled with shrill, misleading nonsense—particularly when it comes to health care. Unfortunately, this week some of the rhetoric of the WSJ’s opinion section seems to have leaked into its reporting: on Tuesday, the paper ran a piece warning that “too much information about drug safety—disseminated through media, online alerts from consumer watchdog groups and even by the Food and Drug Administration itself—might overwhelm patients and raise undue alarm.” Essentially, the article suggests that, when it comes to prescription drugs, the less we know, the better.

The story’s author, Shirley Wang, provides little evidence that America is too concerned about drug safety. As evidence to support her argument, she offers a Pfizer survey of 300 medical professionals which “found that 89% of respondents were at least somewhat concerned that patients might stop their medications if potentially negative safety information was released to the public too early.”

I’m not entirely sure why this is news. Of course a drug company is going to release a survey that hints at the dangers of excessive regulation and oversight. And of course doctors are going to be “somewhat concerned” about the science behind drug risks; I’d wager that just as many are “somewhat concerned” about the science behind reputed drug benefits as well. Good doctors will always be concerned about the integrity of data that will affect the behavior and health of their patients. Pfizer’s survey doesn’t tell me anything I don’t already know; nor is it proof that doctors think our health care system in fact does release negative safety information too early

Unfortunately, the rest of Wang’s article is just as speculative. For example, she notes that in 2004 the FDA “required a so-called black-box warning label—the agency's toughest—on antidepressants to caution about the increased risk of suicidal thoughts and behaviors among teenage patients.” Following the re-labeling, “the number of prescriptions for the drugs decreased” and “the rate of teenage suicides went up.” This would be scary except for the fact that it “isn’t clear” whether or not “the higher suicide rate is linked to the lower number of prescriptions.”

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Recently, a somewhat starry-eyed op-ed in the New York Times suggested that a $100 billion annual investment in universal healthcare is just the medicine that our economy needs. The goal, declared Jonathan Gruber, a professor of economics at the Massachusetts Institute of Technology: “covering every American.”

It is an appealing proposition. But let me suggest that we cannot blindly invest billions in an already bloated healthcare system. We need to think through where we want the reform dollars to go.  Which sectors of a $2.3 trillion health care economy should we stimulate to insure that patients receive the safest, most effective care at a price that they can afford?

For example, should we try to create more jobs for those making diagnostic scanning equipment?

Probably not.  As Health Beat recently reported, we’re already experiencing what some call an “epidemic of diagnostic imaging.” In too many cases, patients don’t benefit.  Across the board, 20 to 50 percent of high-tech diagnostic imaging fails to provide information that improves patient diagnosis and treatment.  In some cases, false positives lead to unneeded biopsies and surgeries that harm patients.  Recent research suggests that an explosion of MRI scans for breast cancer is leading to unnecessary mastectomies. In other words, women lose a breast for no good reason.

So while GE might like more business making diagnostic imaging equipment, all of the medical research suggests that we already have more MRI units than we need, and that they are being overused. (Keep in mind, the goal of health care is not to create jobs: it is to improve the nation’s health.)

But if we simply open the door and tell insurers we’ll provide subsidies for health care for all, we can be sure that a nice chunk of the $100 billion that we invest annually will buy more testing equipment and more tests. Insurers will continue to pay for unnecessary testing because it is popular among many patients (who believe, falsely, that it provides benefits without risks) and some physicians (diagnostic imaging can be very lucrative.)  If insurers say “no” to a popular procedure, they risk losing market share.  If they say “yes” they can pass the cost along in the form of higher premiums, and taxpayers, in turn, will have to find the money to fund higher subsidies.

The problem is this: too many proposals for health care reform focus solely on universal access and run the risk of sending good money after bad. The question we need to ask is: “access to what”?

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“Companies are concerned about how their balance sheets are going to look after two down quarters last year, the events of Sept. 11 and the big increases we've been seeing in health care costs,” the U.S. Chamber of Commerce’s Kate Sullivan told the New York Times in 2002. Reading the tea leaves, Sullivan pointed out that “employers are looking at any way they can to shave off some of those costs”—and that one of their biggest targets were company-sponsored health benefits for retired employees.

Today, six years later, the article's headline—“Retiree Health Benefits Dwindle Amid Recession"—should appear in bold type on the front page of the Times.. In many ways 2002 was part of the good old days, before another half-dozen years of health care inflation culminating in our current, brutal recession. If businesses felt inclined to spend less on retirees’ health benefits back then, today they are even more likely to cut back. .

Indeed, in a recent survey, the Commonwealth Fund found that 53 percent of private employers plan on increasing retirees’ shares of their health care premiums over the next two years. Forty-three percent say they will be increasing cost-sharing for drugs; 19 percent intend to drop retiree benefits for new hires, and 20 percent of companies plan to drop company-sponsored health benefits for active workers or existing Medicare-age retirees. In other words, employers are trying to lighten their load.

Retiree health care is a  particularly tempting target because it stands at the center of corporate America’s  most expensive benefits. In November, the Employee Benefits Research Institute (EBRI) reported that, by 2007, retirement benefits accounted for 47.7 percent of the total spending for benefits, while health benefits had increased to 42.8 percent of total benefit spending. Other benefits” (unemployment insurance, life insurance, and workers’ compensation) accounted for just 9.5 percent of companies’ benefit expenses.

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The following tidbit was buried within the Kaiser Daily Health Policy Report a few days ago: “Fewer Patients Using Health Care Provider Quality Ratings Web Sites To Make Decisions.” The headline could just have easily read: “More Bad News for Consumer-Driven Medicine.”

One of the most persistent dogmas of the consumerist crowd is that patients are eager to comparison shop for health care—and that, if they aren’t doing so today, it’s only because they don’t have the necessary information. Supposedly, if we had more resources like the website Carol.com—which allows providers to list their services in a comparative “marketplace of care”—then consumers would empower themselves with information and make rational choices on the cost and quality of care.

But according to an October survey from Kaiser, people just don’t comparison shop for health care. In fact, only one in seven (14 percent) of Americans “say they have seen and used information comparing the quality among different health insurance plans, doctors, or hospitals in the past year.” At the same time, 30 percent of Americans say that they came across comparative quality information over the course of this year—which means less than half of patients who come across comparative data on health care providers actually use it. 

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Maggie Mahar and Niko Karvounis

Last week the New York Times published a story about one of the biggest medical trials ever organized by the federal government,  a study that showed that the newest, most expensive drugs used to treat high blood pressure (a.k.a. hypertension) work no better than inexpensive diuretics—water pills that flush excess fluid and salt from the body. Moreover, the research revealed that the pricier drugs increase the risk of heart failure and stroke. 

The trial was completed in 2002. Why is the story running now? Because six years later, the findings still have had little impact on what doctors prescribe for patients suffering from hypertension.

Allhat –which stands for the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial—demonstrated that when, it comes to preventing heart attacks, the diuretics—which have been used since the 1950s and cost only pennies a day—is just as effective as newer calcium channel blockers and ACE inhibitors that cost up to 20 times as  much.

And the diuretic is safer. Patients receiving Pfizer’s calcium channel blocker (Norvasc) had a 38 percent greater chance of heart failure than those on the diuretic. And those receiving AstraZeneca’s ACE inhibitor were exposed to a 15 percent higher risk of strokes and a 19 percent higher risk of heart failure.
Meanwhile, NYT reporter Andrew Pollack noted, the diuretics cost only about $25 a year, compared with $250 for an ACE inhibitor and $500 for a calcium channel blocker.

In a rational world, the results “should have more than doubled” use of the less expensive drugs, says Dr. Curt D. Furberg, a public health sciences professor at Wake Forest University and the former head of the Allhat steering committee.

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Yesterday Reuters reported that, in comments at a Financial Times conference in London, a top executive at Roche Pharmaceuticals condemned direct-to-consumer advertising as a disaster. “Direct-to-consumer promotion [of drugs] was the single worst decision for the industry," said William Burns, Roche’s head of pharmaceuticals, to conference attendees. "When industry says we're spending all the money on R&D but actually it's spending it on TV advertising to preserve margins, it doesn't get much credibility,” he continued.

Burns’ despondency is understandable: if ever there was a time that the prescription drug industry needed credibility, it’s now. For the first time in recent memory, drug companies are facing the prospects of an end to their free ride of unregulated profiteering. There are already rumblings that both the Obama Administration and the Democratic Congress want to stack up a series of clean legislative victories by going for “low-hanging fruit”—bipartisan, popular initiatives that will pass easily—and there are few juicier targets than Big Pharma. 


A few days ago, The Chicago Tribune reported that President Obama will likely push for “cheaper copies of expensive drugs derived from biotechnology,” will let Medicare “negotiate drug prices directly with drug companies,” and will try to make “it legal for pharmaceuticals to be imported into the U.S.” In other words, Obama wants to make drugs cheaper for patients, and thus impact drug companies’ bottom line. According to David Dranove, professor of health industry management for Northwestern University's Kellogg School of Management, these changes have been “hanging there [in Congress] for some time and will be easy sells and easy to get through."

For its part, the industry knows that it’s got a big, fat target on its back. During the presidential election, drug companies were torn over which candidate to support, mostly because they couldn’t decide who hated them less. Even John McCain boasted—not untruthfully—that he repeatedly “took on the drug industry” over the course of his career.

The comparable distastefulness of both candidates led to a development that hasn’t happened in almost twenty years: the prescription drug industry gave to the Democratic and the Republican presidential candidate in almost equal amounts (usually pharma goes for the GOP). “Both [Obama and McCain] blame big drug companies for high prices and reduced innovation,” sighed one industry insider. “In either case, we should expect more price negotiation and re-importation [of drugs].” Translation: the honeymoon is over. 

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Whatever happened to the characters in the PBS documentary, “Fat: What No One Is Telling You,” that I wrote about here and here?

By the end of the film, the 300-pound 18-year-old who I described in part 1 had his bariatric surgery and, to his delight, lost 147 pounds. “I’m a whole human less in weight,” he exulted.   Indeed, he had lost the equivalent of his skinny twin’s total weight. (It’s worth noting that this surgery is recommended only as a last resort. And even then, a patient should make sure that his physician is an experienced bariatric surgeon who has performed many operations. The risks are real—and harrowing. Nevertheless, for this young man, the procedure was a huge success.)

What about the former tomboy who gained 125 pounds after becoming an executive at Microsoft? Humiliated when she spilled out of her airplane seat—and onto her fellow passengers—and frustrated that she could no longer participate in the sports she loved, she became even more depressed when she had difficulty getting pregnant.  

That’s when she and her over-sized husband signed up for a comprehensive program that includes doctors, nutritionists, and trainers.

They also purchased health cook books, determined to learn how to cook foods that had been foreign to their diet—such as chicken.

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I recently attended a conference where bloggers and print journalists talked about the pros and cons of their respective professions

I noted that as a blogger, I am never censored. As a print journalist I was told, on more than one occasion; “Maggie, you can’t say that!” (even though I had evidence to back up my facts.)  Usually, the editor was concerned that I would “scare the readers” or upset the publisher (and advertisers). 

Of course, the downside to not having an editor is that I’m working without a net. If I get something wrong, no one has my back. On the other hand, my readers are knowledgeable, and are likely to question anything that looks peculiar. I count on you to do that, and at the same time, know that if I make serious errors—or too many small mistakes—I would lose my credibility.

But not all bloggers have alert readers. And because of the lack of editing,   the blogosphere is clogged with posts that are silly, just plain nasty, and, all too often, simply not true.

Nevertheless, I think that the best blogs manage to keep the level of public discourse high, while enjoying first amendment freedoms that are difficult to achieve in mediums supported by advertising and owned by corporations.

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