Yesterday I appeared on a four-person health care panel that was televised in New Hampshire.  The panel included a conservative who surprised me by arguing that the difference between the progressive candidates’ proposals for health care reform and the conservatives’ position on health care just isn’t that great.

Looking at the candidates’ proposals, I disagreed.  Put simply, the conservatives would like to make government smaller. They want to “outsource” many of government’s jobs to the private sector. They tried to privatize Social Security, and they have partially succeeded in privatizing Medicare by paying private insurers a steep premium to take care of seniors under Medicare Advantage. (See my post about the high cost of the program here).

Finally, the vote on SCHIP split along conservative/ progressive lines, with conservatives voting against expanding SCHIP. As President Bush explained, more funding for SCHIP would expand the government’s role in our health care system.

Continue reading →

I promised to return with more information about who halted the use of life-saving checklists in Intensive Care Units in Michigan and at Johns Hopkins. (For my earlier posts on this shocking story, click here and here).

The Office of Human Research Protections (OHRP) is the agency that has nixed the use of checklists. Who runs the OHRP?  Until his recent resignation (as of Sept. 30), Bernard Schwetz was the director of OHRP. Who is Schwetz? He is a veterinarian (DVM). That’s right, he’s vet, not a M.D.

What’s even more surprising is that from January 20, 2001 to February 2002, Schwetz, who is also a toxicologist (Ph.D.), was Acting Deputy Commissioner of the FDA. This was not a bright period in the FDA’s history. During Schwetz’s tenure, the FDA’s counsel, Dan Troy, was running the agency from behind the scenes. Troy, a Bush appointee, was well-known as a long-time foe of FDA regulation. In the 1990s, he represented Brown & Williamson Tobacco Corp. in its effort to fend off the FDA, and just months before joining the agency, he had defended Pfizer in another battle with regulation. As a U.S. News & World Report headline summed up his career change: “Mr. Outside Moves Inside: Daniel Troy Fought the FDA for Years; Now He’s Helping to Run it.” (I have documented Troy’s power in my book, Money-Driven Medicine).

As for Schwetz, what can one say about a vet/toxicologist who becomes temporary deputy commissioner of the FDA? “Political appointee” is the phrase that comes to mind.

I’m told that the OHRP is a “strange creature.” It was created in 2000 to replace the small, underfunded Office of Protection from Research Risks. That office reported to the NIH. OHRP, by contrast, reports directly to the Assistant Secretary of Health, putting it under the White House’s control.

OHRP began sending what only can be described as threatening letters to Michigan and Johns Hopkins last summer—on Schwetz’s watch. He announced his resignation at the beginning of August. I haven’t been able to find an explanation for the resignation or whether it is in any way connected to OHRP’s decision about the checklist.

Continue reading →

One of the most infamous records the U.S. holds is that of the world’s incarcerator. As of 2006, 2.2 million Americans were incarcerated, more than even China—which has over four times the population of the U.S.

California is the most cell-happy state in the union, with its prison population in midyear 2006 at over 175,000, or 11.3 percent of the total prisoners in the country.  The Golden State’s 175,000 inmates are held in 33 prisons—meaning there’s roughly 5,307 inmates per prison.

Put differently, every prison health care system has 5,307 potential patients, day in and day out. That’s quite a caseload, and it’s made much worse by the fact that prisoners are in much poorer health than the general population. Indeed, the California prison system is in the throes of a health care crisis—one that highlights why we should all care about the quality of medical services for inmates.

As you might guess, prison is an unhealthy place. Prisoners are more than eight times as likely to be infected by HIV, four times as likely to have active tuberculosis, and more than nine times as likely to have hepatitis C. According to the National Commission on Correctional Health Care, about 3 percent of the U.S. population spends time in prison or jail—but between 12 and 35 percent of the total number of people in the nation with some communicable diseases (like AIDS and Hepatitis B) pass through a correctional facility.

Commission data shows similar trends occur for mental illnesses (see the table below). Prison inmates have rates of schizophrenia and other psychotic disorders that are three to five times greater than the general population. Their incidence of bipolar disorder is up to three times greater than people outside prisons. And prisoner rates of drug and alcohol abuse are also higher.

Continue reading →

Perhaps you saw the headlines over the holidays:

• “CIGNA Defends Decision To Let Teen Die—On Christmas Eve”
• “As CIGNA Insurance Waffles on Liver Transplant, Girl Dies”
• “Lawyer: CIGNA’s refusal to pay for liver transplant ‘killed’ teen”
• “Teenage Girl Dies So CIGNA Execs Can Get Richer”
• Metroblog: "Merry ******* Christmas, From  CIGNA Healthcare "

Without question, this is a tragic story. Here are the bald facts: Nataline Sarkisyan, a 17-year-old who had been battling leukemia for three years, received a bone marrow transplant from her brother the day before Thanksgiving. She then suffered complications; her liver failed, and she went into a coma. At that point her doctors at the UCLA Medical Center recommended a liver transplant, saying that the transplant would give her a 65 percent chance of living another six months.  Within four days, a matching donor was found.

But on December 11th her insurer, CIGNA, refused to cover the transplant on the grounds that for a patient this sick, the transplant would be an “experimental procedure.” And her insurance policy "does not cover experimental, investigational and unproven services.” 

The doctors told the family that their only alternative would be to make a $75,000 down payment on the operation. Unfortunately, the family didn’t have $75,000. 

Observers both in the mainstream media and in the blogosphere were outraged when they heard that CIGNA had denied coverage.  Daily Kos led the protest with “Murder By Spreadsheet: CIGNA  Denies Claim and 17-Year-Old Will Die.” Responding to the firestorm, on December 20 CIGNA relented, saying that  "despite a lack of medical evidence regarding the effectiveness of such treatment,” it would cover the transplant.

The letter from CIGNA came too late. That same day, the hospital called to say that Nataline’s condition was deteriorating and her family was forced to make the decision to take her off life support.  She died within the hour.  The next day the Sarkisyan’s lawyer announced that the family planned to sue CIGNA for “malicious” murder.

This is both a tragic tale and a complicated story—far more complicated than the headlines suggest.  As Dr. John Ford, an assistant professor at UCLA’s medical school observed on his blog, California Medicine Man, “While I’m not surprised at the intensity of emotion that has arisen from this case, the utterly inflammatory and often mindless rhetoric being propagated is sobering. It seems that nuance has taken a hike, never to reveal itself.” 

Here are just a few of the questions that this vexed and vexing case raises:

Continue reading →

Today (Sunday, Dec. 30) the New York Times published a shocking op-ed by Dr. Atul Gawande revealing that a U.S. government agency has stopped an enormously successful "checklist" program that was being used to reduce infections in intensive care units at Johns Hopkins and throughout the state of Michigan. (To see my original piece  on checklists, scroll down to my Dec. 14 post below.)

Below, an excerpt from today’s op-ed:

" In Bethesda, Md., in a squat building off a suburban parkway, sits a small federal agency called the Office for Human Research Protections. Its aim is to protect people. But lately you have to wonder. Consider this recent case.

"A year ago, researchers at Johns Hopkins University published the results of a program that instituted in nearly every intensive care unit in Michigan a simple five-step checklist designed to prevent certain hospital infections. . .

"The results were stunning. . . . Over 18 months, the program saved more than 1,500 lives and nearly $200 million

"Yet this past month, the Office for Human Research Protections shut the program down. . .

Continue reading →

I hope everyone has a wonderful holiday.  Health Beat will be taking a vacation—but we’ll be back January 2. And sometime early in the New Year, we’ll have a new design—with the larger typeface that some of you have asked for.  Be well.

Thanks to Merrill Goozner at GoozNews for calling attention to Doctors Without Borders’  list of the ten most underreported humanitarian stories of 2007.

The global humanitarian physician’s group (Doctors Without Borders/Medicine Sans Frontieres, or MSF) zeroes in on ten horrifying examples of suffering so extreme that it is difficult imagine. At this time of year, it seems appropriate to try to take in at least two examples.

The first story below focuses on the tuberculosis epidemic that, as the New York Times explained last year, “is outrunning us. In the last few months, 53 patients in the South African province of KwaZulu-Natal were found to have a form of the disease resistant to enough existing drugs that it is virtually incurable. All but one of those patients has died. Airborne and deadly, extensively drug-resistant TB is a nightmare disease. It has been found worldwide, including in the United States. . .

“The development of antibiotics had allowed wealthy nations to dismiss TB as a disease of the past. But H.I.V and AIDS have changed that calculus. In Africa, active TB cases are rising by 4 percent a year, largely because H.I.V. activates latent TB infection. TB is the leading cause of AIDS-related deaths. Every patient tested in the KwaZulu-Natal study was H.I.V.-positive and more than a quarter of those who died were taking antiretroviral therapy.

“African health officials gathered in South Africa last week to discuss extreme tuberculosis, but they are hobbled by the world’s indifference . . .

“Money for clinical trials would speed things. But donors have always slighted tuberculosis. According to a new report by Results International, an advocacy group, the World Bank spent only $3.5 million directly on TB in Africa in 2005. The Global Fund to Fight AIDS Tuberculosis and Malaria and the Bill and Melinda Gates Foundation are big donors, but much more is needed. Stinginess created this problem. Generosity is needed to fix it.”

Continue reading →

You can comment on posts in Health Beat by Maggie Mahar directly by clicking on the "Comments" link below the introduction portion of each post. Please do join the discussion when something interests you–we’lll be responding.

In response to the questions I raised in two posts below about the hospital
building boom and whether we need—or can afford—hotel-like amenities, Dr. Terry
Bennett sent HealthBeat the story below. It’s a provocative insider’s look at
how a local hospital is raising the money for an “expansion” that, according to
Bennett, seems to have very little to do with improving the health of its
patients or the local community. Part problem is that CEO’s of non-profit
hospitals have begun to think like CEO’s of for-profit corporations: growth is always
good.

“If you own all of the doctors’
practices that refer to a community hospital—as the CEO of our local hospital does–
you can dictate where, when and for how much every single patient is seen,”
Bennett writes.” For example, you can make sure that all urgent cases are seen
in your hospital’s ER at $1000 a head. (Medicare and Medicaid pay less than a
grand for a "bare bones" ER visit, but if you order an EKG, an x-ray
or two, and a few lab tests, you can push the visit up to over $1000).

“Do that 100 times a day
and you have millions [of dollars] which you need to cause to vanish as quickly
as possible. [Otherwise the Centers for Medicare and Medicaid services may
question how a not-for-profit could be making such rich profits, and start to
examine your books.] Thus the Atria, the waterfalls,the new facades, the many
other flashy dashy add-ons, the services no body really needed.

“The CEO of our local hospital hates me.
Because my patients can reach me 24/7, I have the lowest ER admission rate
of any physician on the staff at my local hospital. I treat over the phone, see the next day, am always on the prevention line of
chatter, etc. [In other words Dr. Bennett is not helping the CEO fill the
hospital’s coffers].

“Meanwhile, our hospital, is in the midst of a $45 Million ‘expansion’— no
new beds, no new services, but $45 million is being buried, and ‘non profit
status’ is preserved. It is happening in almost every community across the USA.
Such antics make any healthcare budget, Medicare, Medicaid, or HMO, completely
unpredictable and are bankrupting the entire present system and all of its
budgeting assumptions—and will continue to do so until forcibly stopped.”

Dr. Bennett also included a copy of an Op-ed which originally appeared in two
New Hampshire newspapers, the
Portsmouth Herald and the Rochester Times. Below, an edited version:

Health care issues in the new millennium
By Dr. Terry M. Bennett

It seems like only yesterday, but it was in fact 16 years ago, 1992, when I
ran for a New Hampshire Senate seat proposing a single-payer Medicaid-based
national health care plan using our Social Security numbers for identification.

Continue reading →

(To see my original post on cutting back on healthcare spending, scroll down and click on “September 2007”under “Archives” on the left-hand side of the page. You will find my September 12 post a little more than halfway down the page.)

Barbara—

In some cases, patients can and should actively share in decision as to what kind of care they need. For instance, in the case of elective surgery like a knee implant,  the surgeon and  the patients should discuss the risks and benefits. How long will it take to convalesce? How much pain will the patient experience after surgery?  What can he or she expect in terms of improved function?
Is physical therapy an alternative to sugery? I’ll be writing more about “shared decision-making” for elective surgery in the future.

On the other hand, when it comes to picking a particular knee implant, this is a decision that you want your surgeon to make. Research shows that you are most likely to be satisfied with the outcome if your surgeon uses a device that he has used many times  in the past. Practice makes perfect.

Moreover, too often consumers are influenced by misleading advertising. See my post on “Bespoke Knees” below.  Often drug-makers and device-makers advertise a product “directly to the consumer” because they know they would have a hard time persuading physicians of their claims. They just don’t have the medical evidence to back up what they’re saying.

Continue reading →