The NPA’s 2008 Presidential Candidate Health Plan report card grades the candidates on their health care plans according to the IOM Principles stated here.  One of the two most important distinguishing grades was in regards to the principle of “Affordable for Families”, where Obama scores a “Pass” and McCain a “Fail”.  There are growing questions regarding whether Obama’s estimates for savings on “Main Street” (is anyone else sick of this term?) are accurate.

One other concern is that health care has fallen off the map on the CBS/NYTimes Poll as an answer to the question: “What do you think is the most important problem facing the country today?”.  One year ago, 9% of respondants said health care, second only to war (21%).  The most recent poll had health care at a dismal 3%, behind economy (38%), war (10%), Heating Oil/Gas Crisis (7%), and Iraq (4%).  Granted, it is likely that significant health care reform will improve the economy, but can we get people to listen to the debate regarding health care reform at this time?

 What is needed is the political will.  What is needed is a unified voice.

You’ll be hearing more in the coming months about NPA’s specific approach to this problem, but for more reading about this issue check out this one. 

Apart from the regular Board business, focus was on the campaigns for Unbranded Doctor, Rx Vote and equitable affordable health care. Among other things, we celebrated Board Member Judy Zerzan’s birthday.

Happy Birthday!

16 months ago, the American Academy of Pediatrics endorsed a guideline developed with the AHA in 2006 on how to treat children with disorders that have been shown to put them at risk for prematrue coronary artery disease. The highest risk catergory, which would receive medicines early in the course of treatment, featured conditions fairly rare in childhood (including Diabetes Type I). As recently as July 2007, the US Preventive Services Taskforce concluded that

Several key issues about screening and treatment of dyslipidemia in children and adolescents could not be addressed because of lack of studies, including effectiveness of screening on adult coronary heart disease or lipid outcomes, optimal ages and intervals for screening children, or effects of treatment of childhood lipid levels on adult coronary heart disease outcomes (emphasis added)

Now we are reading that children as young as 8 may be candidates for medications if they have a LDL concentration (”bad cholesterol”) above 160 mg/dl. These risk factors include:

obesity, hypertension, or cigarette smoking or a positive family history of premature CVD (cardiovascular disease)

So maybe the above Task Force - and I  - have missed a recent large outcomes trial that shows that treating an overweight child with a Statin (presumably that, because as the article points out most other medicines are poorly tolerated) will prevent adult heart disease. Furthermore, this articles hopefully compared it with the standard of care… if you find it, let me know. What is the standard of care? Here are a few suggestions by the American Heart Association:

Cholesterol and Atherosclerosis in Children

AHA Scientific Position

There is compelling evidence that the atherosclerosis (…) begins in childhood and progresses slowly into adulthood. Then it often leads to coronary heart disease (…)

Elevated cholesterol levels early in life may play a role in the development of atherosclerosis in adults.

Eating patterns and genetics affect blood cholesterol levels and coronary heart disease risk.

Lowering levels in children and adolescents may be beneficial.

(…)

To reduce fatty buildups in arteries in children (and adults):

Cigarette smoking should be discouraged.

Regular aerobic exercise that lasts at least 30–60 minutes on most days of the week should be encouraged.

High blood pressure should be identified and treated.

Obesity should be avoided or reduced.

Diabetes mellitus should be diagnosed and treated.

Children age 2 years and older should be encouraged to eat at least five servings of fruits and vegetables daily as well as a wide variety of other foods low in saturated fat and cholesterol. Doing this will help them maintain normal blood cholesterol levels and promote cardiovascular health.

No mention of drugs…..

I do not doubt that some children, particulary those with extremely elevated LDL (above 500 or so), may benefit from Statin drugs. But every obese child with a LDL above 160? That may be hundreds of thousands if not millions of young people swallowing expensive pills, with rare but serious side effects, and no proven benefit. It may help (prove it!), but the problem of obesity among children is not one of pill deficiency. How about spending the billions of health care dollars that such a treatment program will presumably cost, and getting more education, physical ed and better nutrition to our kids!

 And then when you read that the lead author Stephen Daniels has a conflict of interest (undisclosed by the journal), you may get nauseated… hey, there is a pill for that, too!

Read more in the New York Times, or LA Times.

NPR did a piece on Germany’s health care system, a system which by the way has existed for over 125 years. For some jaw-dropping action, read the whole article, it’s not that long. What really stuck out for me was a fundamental difference in the set of values we hold above all else, in both countries. What we tolerate or praise here would not be tolerated there. What we struggle with here in regards to access to healthcare, bankruptcy from medical bills, huge deductibles, time to see docs, are a non-issue there. Obviously there are problems in every system. Here’s a glimpse, though, of some of the virtues of the German system we’re not exposed to in most of our media sources. Some quotable quotes:

Germany on access to doctors at times of need:

On one particular night, Juergen was the doctor on call for the region. Any German who needs after-hours care can call a central number and get connected to a doctor.

On access to humane and intuitive support services after an operation, as told by a woman who had thyroid surgery:

“Then I came home to my little daughter, who I couldn’t really lift up because of my neck having been cut open,” Sabina says. “So I asked my doctor, ‘What can I do?’ And she said, ‘Well, your health insurance will pay for someone to come help you in the house.’”

They also pay for support services and money to families who want to keep their elderly parents at home and out of nursing homes. Again, a fundamentally different set of values.

On coverage for everyone:

The health care system… is not funded by government taxes. But it is compulsory. All German workers pay about 8 percent of their gross income to a nonprofit insurance company called a sickness fund.

On SOLIDARITY:

Basing premiums on a percentage-of-salary means that the less people make, the less they have to pay. The more money they make, the more they pay. This principle is at the heart of the system. Germans call it “solidarity.” The idea is that everybody’s in it together, and nobody should be without health insurance.

This one really got me. I dream of the day (it is possible!) when Americans routinely use the word solidarity. More after the jump — click here –>

On the cost to employers:

The big difference is that U.S. employers pay far more, on average, than German employers do — 18 percent of each employee’s gross income versus around 8 percent in Germany.

On humanity (FUCK DEDUCTIBLES!)

Moreover, German health insurance has more generous benefits than U.S. policies cover. There are never any deductibles, for instance, before coverage kicks in. And all Germans get the same coverage.

After mentioning they would NEVER move to America STRICTLY because of health care costs for their chronic problems, a couple also notes the embarassing statistic about bankruptcy due to medical costs in America. On DIGNITY:

“It’s also the No. 1 reason in the United States that people personally go bankrupt,” Sabina translates, “which would never happen here … never!”

On family coverage:

Nicole pays a premium of $270 a month for insurance that covers her children, too. Nicole pays a single $15 copayment once every three months to see her primary-care doctor — and another $15 a quarter to see each specialist, as often as she wants. She pays no copayments for her children’s care —-and her insurance even covers her daughter’s orthodontia bill.

If you’re self-employed you have to buy insurance from a private for-profit company (not the non-profit sickness funds). This is also an option if you make more than a certain amount a year. Interestingly…

But most people don’t opt out. Chris says that’s because there’s a fundamental difference in the way Germans view health care and the government’s role — which, in Germany, means refereeing the system and making sure it’s fair and affordable.

The German govt regulates the insurance companies, or in better terms, holds them accountable to a basic set of guidelines:

So Chris’ insurer can’t raise his rates if he gets sick or jack up his premiums too much as he gets older. The government also requires insurers to keep costs down so things don’t get too expensive.

And again, on SOLIDARITY:

Germans really hate any hint of unfairness in health care. The fundamental idea is that everybody must be covered and, preferably, everybody should get equal treatment. So the fact that 10 percent or so can buy some perks is an irritant — something Germans complain about but manage to put up with.

I noted that the article didn’t mention anything about the uninsured in Germany (those who are not employed or are not self-employed, or who are self-employed but cannot afford the monthly premium). And then I realized that NPR had done a piece on the uninsured in Germany. 0.2 of the population there is uninsured, there are only 8 free clinics in the country, and that’s changing for the better as a new law was passed that would allow for the uninsured to be covered. Picking up my jaw again from the floor.

ALSO check out the interactive international health care comparison chart at the NPR site — you can do head to head comparisons of US vs Germany, Britain vs Germany, Switzerland vs Japan, and other such permutations. It’s pretty interesting.

Thoughts on all of this? Cmon, pick up your jaw already!

A 76 year old demented patient is referred to me for a transesophegal echocardiogram (TEE, that is when they take an ultrasound picture of your heart from within your food pipe - although pretty low risk, it’s not the most comfortable experience). He was found to have a moderately leaky valve and a large fluid collection around his heart - 2 months ago! Another cardiologist has referred him, but when speaking to that person, he does not know the patient well, having seen him once. This cardiologist states that the primary care doctor wanted the TEE. That primary care provider also claimed that “he is new to me”.

Now if I do the TEE, although it may not be a great indication, I make ~ $400 for my practice (most from the technical fee), and eventually, some for myself. If I do not, I have spent 30 min reviewing the chart and speaking with the patient and his family, for basically nothing (I cannot charge for a consult as the patient has just been seen by one of my partners). A pericardial effusion may require a follow up ’surface’ echo, for ~ $50. But if I want to do that, I need to spend another 15 to 20 minutes tracking the referring doctor down, changing the order, explaining the whole thing to the patient….. probably as much time as it would take me to do the study.
There is an apparent conflict of interest - patient health (put at risk by the TEE) and his wallet versus my convenience and bank account. It seems to me that this conflict is resolved often in favor of doctors’ income, if you read about the proliferation of heart CT scans for but the most inappropriate indications.

But what else could be going through your mind? Would you do the TEE? Would you be afraid that the referring primary doctor, maybe used to get what he wants, will refer the patient elsewhere? What about if the patient has worsening symptoms? What if the patient’s family wants to have the test because they want to know “what is wrong with him?” Are you afraid the patient is seriously ill and that you will be sued if harm comes to him and you did not do the test? Would he even be a candidate for surgery of the leaking of the valve was found to be severe?

There certainly is not a lot of black and white here. Is defensive medicine justifiable in the current system? Probably, and unfortunately, yes. However we must always consider the patient first. If more harm than good is done, think back to “Primum Non Nocere”. Whoever came up with it (and it seems not to have been Galen, nor Hippocrates, they spoke greek!) had - and made - a point.

And if I may offer some more of my bad Latin: Cura Te Ipsum (de studium percuniae) - Physician, heal thyself first of the striving for money….

“the industry’s science engine has stalled. The century-old approach of finding chemicals to treat diseases is producing fewer and fewer drugs. Especially lacking are new blockbusters to replace old ones like Lipitor, Plavix and Zyprexa.”

According to the FDA’s Janet Woodock, applications for new drugs are down by 1/3. So let’s stop whining, be thankful that we have a lot of generics that work extremely well, and that there are dedicated researchers and companies that bring us truly novel drugs, such as Gleevac.

By the way, one of the recent drugs that was turned down by a 20 to 1 vote, was Arcoxia (etoricoxib) by Merck, Vioxx 2.0 so to speak. The trial meant to approve it, MEDAL, used an old recipe to make drugs look nice and compared etoricoxib to Diclofenac, which is  - as far as I know - one of the NSAIDs with more GI side effects. Do we really need such ‘new’ drugs?

 Writing this is giving me a headache. I’ll just pick up some 5 cent ibuprofen….

The former seems blatantly lacking in the story quoted below.

Every neophyte is owed the opportunity to be taught so long as the teacher recognizes her imperative to teach. Especially in a hospital in July.

New Docs on the Block

According to medical lore, July is the worst time to be hospitalized because that’s when inexperienced med students start clinical training. But is summer really riskier for patients?

A month into Sandeep Jauhar’s medical internship at a prominent teaching hospital in New York City, he was asked to drain fluid from the belly of a patient who was HIV-positive. “I was trying to get out of the hospital to keep a dinner appointment,” he recalls. “I was sort of rushing. I heard a snap and there was all this fluid leaking all over the floor.” Jauher’s gloves were too small, he hadn’t assembled the tubes for the blood correctly, he was new, he was inexperienced and nobody was watching. “[The patient] was totally oblivious to the disaster, but it was a mess,” he says. “These are the mistakes that new, green interns can make.”

According to conventional wisdom, a patient’s chances of encountering a mistake-prone rookie like Jauhar go way up in the summer. That’s because July 1 is the start of the academic year for medical schools: In teaching hospitals around the country, medical students will replace interns, interns will replace residents and residents will move on to fellowships or to become full doctors.

This crucial and sometimes perilous training period can be incredibly difficult for medical students. As Jauhar writes in his recent book, “Intern, A Doctor’s Initiation,” incoming doctors are not only practicing on patients for the first time, they’re also learning the often Byzantine workings of their respective hospitals, new technical language, new procedures and the tedious, yet critical, ways to fill out paperwork. All this learning is packed into 80-hour workweeks and overnight shifts in a busy hospital environment—a far cry from the academic environment they might be coming from. But is it really riskier to go into a teaching hospital during those first few weeks of intern training? Or is the “July phenomenon” a medical myth?

Finish reading at

New Docs on the Block

~casey

(cross-posted at Cure This)

]]> http://npalliance.net/blog/?feed=rss2&p=140 http://npalliance.net/blog/?p=140 http://feeds.feedburner.com/~r/npalliance/~3/322020295/ http://npalliance.net/blog/?p=139#comments Sat, 28 Jun 2008 13:10:59 +0000 BMS high quality health care for all a day in the life of a practicing physician healthcare workforce http://npalliance.net/blog/?p=139 The Senate’s Republicans blocked a vote to avoid a cut in Medicare reimbursement starting next week. I hear part of the problem was that money to pay for avoiding the cut was going to come from funding Medicare Advantage Plans. Basically, this is federally subsidized private health insurance for Medicare elegible people and is generally 10 to almost 20% more expensive for tax payers than traditional Medicare. I see that there a probably some profits from donors to protect…. according to the New York Times, Bush has threatened a veto because

 “… it would finance a small increase in payments to doctors next year by reducing payments to insurance companies that care for some Medicare beneficiaries.”

Go figure. Let’s just say the insurance industry has about a 10% profit while my practice’s has been exactly 0.

OK, so many of you may think: doctors make enough money - what is a 11% cut going to do, they can’t buy there second Porsche? No, my friends. I am not clairvoyant, but here are some facts and what (I am pretty sure) will happen:

• Doctors are already working longer hours for less money than a few years ago. Believe it or not, many doctors already provide some free healthcare (maybe not as much as they want you to believe, but my mechanic doesn’t work for free either). While there has been a small increase in average worker’s wages over the past decade, reimbursment of many doctors has dropped by as much as 20% (or even more). Most doctors are dedicated to their patients, but they are also deeply indebted with school loans, and may not want to sell their home or have their kids drop out of college just to be able to do their job. Money is just a reality.
• Doctors offices will reduce costs, which means cutting down on overhead (firing the assistant, the nurse, the receptionist), which means longer waits and worse care.
• Doctors will avoid seeing new Medicare patients - good luck, Baby Boomers (just remember to vote in November!).
• There is already a severe shortage of doctors in poor and rural areas. As these tend to have more people dependent on Medicare and Medicaid, there will be further exodus from these regions - wouldn’t you be at least considering another job if you salary was cut by 10%? There are plenty of opportuities elsewhere.
• Primary Care doctors, already facing probably the lowest reimbursment, may as well be hanging up their coat and go into more lucrative jobs…  like at McDonalds…. ever tried to get preventive healthcare from a Dermatologist?
• The education of resident doctors is tied to Medicare, so we’ll see cuts there, and thus in a few years, probably a decline in quality.

In other words, please do not make a screwed up system worse. What we truly need is an overall reform, like Universal Healthcare, not a patchwork of legislation and rules that is so intransparent, I am sure many legislators have no clue what is going on, especially that they live in cities with pelnty of physicians to choose from and their healthare is paid for!

 

]]> http://npalliance.net/blog/?feed=rss2&p=139 http://npalliance.net/blog/?p=139 http://feeds.feedburner.com/~r/npalliance/~3/283017241/ http://npalliance.net/blog/?p=137#comments Sat, 03 May 2008 23:39:25 +0000 anjali Uncategorized http://npalliance.net/blog/?p=137 Disclaimer: This post is not intended to be specifically partisan in the 2008 presidential elections — it’s a note about how misinformation about health care and health insurance in America should not be tolerated, and how out of touch some of our presidential candidates are regarding this extremely important issue.

Smintheus at dkos shares two articles from the NYTimes and the Des Moines Register talking about how McCain is twisting the Democratic presidential candidates’ health insurance plans. From the NYTimes:

“There are those that want a massive government takeover of the health care system in America,” Mr. McCain warned Thursday in Des Moines, as he made the case for his more market-based approach…

“But before you decide to sign on to that kind of a program, go to Canada, or go to European countries that have government-run health care systems,” he continued. “My friends, they don’t work, they’re inefficient, and they end up in a two-tiered system where the wealthiest can afford to pay for their own health care and those with low income sometimes wait six or eight months for a routine kind of treatment. And that’s what I’m not going to let happen to the United States of America.”

My dear friend McCain:

ALL YOUR LIFE you have relied on the government to provide top-notch insurance to you. When you were a kid, your father was an Admiral and you received health insurance under the military’s plan. When you were in the military you received health insurance through the military, and in your many years in office you have benefitted from the comprehensive health insurance packages that the state and country have provided for you, on the taxpayer dollar (read: McCain has not experienced private insurance, and if he has, it has been for a very short time).

Mccain, if you seethingly hate government-funded health insurance so much, you should have long opted for private insurance yourself.

And please stop twisting the Democratic health insurance plans as “socialized medicine”. That they are not, to the excitement of many, and to the dismay of many others. There is no room for lies in this very important life-and-death issue facing Americans.

I don’t care for your double-talk. Put your money where your mouth is.

- - - - - -

As a primary care doc at a county hospital, where most folks don’t have insurance or have medicaid, it’s a DAILY REALITY for people with painful gallstones have to wait 9-12 months for a cholecystectomy (surgery to remove the gallbladder), or where people with severe debilitating neurological disorders have to wait 9-12 months for a first appointment to see a neurologist.

A few of us who traveled to Seattle and Vancouver in 2004 interviewed folks who were going about their daily business in the downtowns of both cities. OVER AND OVER again, I heard about stories like the Canadian who was traveling in America and who tore his ACL (a ligament in the knee) and went straight back to Canada for surgery that same week ($0 in out-of-pocket costs); the woman who noted a lump in her breast, who called her primary care doc’s office — saw him within 2 days, and saw a breast specialist within a week, and was under chemotherapy treatment within two weeks after a mammogram, all for free; or the man who had a severe headache, took a cab to the emergency room, had a head CT, saw a neurologist, stayed in the hospital for two days, and left with just a $40 cab bill.

There are many things wrong with the health care systems in other countries, i’m not absolving them of all criticism. But it shows how absolutely out of touch McCain and his cronies are for spewing garbage like this. It really does. And this kind of talk actually incenses more and more Americans on a daily basis, as they increasingly face the harsh realities of the american health care system and its tiered healthcare systems.

Apparently, McCain also wants to destroy the employer-based health insurance system and force millions of Americans to buy individual private health insurance plans. Again, while he’ll never make mention of it, all his life McCain has been provided health insurance through government funding and is COMPLETELY out of touch with the realities of purchasing private health insurance through the uncompetitive markets with no bargaining power and great scrutiny of “pre-existing coniditions”.

Again thanks to Smintheus for the link to the editors’ commentary at the Des Moines Register:

The proposal [by McCain] should scare the heck out of the millions of Americans who rely on employer-based coverage…Buying individual policies means having your health history reviewed. It means not having the bargaining power and protections that come with being part of a plan offered by an employer. And it’s expensive…

The senator is correct that the employer-based system of health insurance in this country isn’t working. Businesses are saddled with the high costs of coverage, putting them at a competitive disadvantage in the global marketplace. Insurance shouldn’t be tied to jobs.

But the more reasonable solution is to offer everyone what Medicare already offers: health coverage financed by a combination of tax dollars and participant contributions, thus allowing the huge bargaining power of millions of Americans to leverage down costs.

That idea is nowhere near as radical as forcing millions of Americans to shop for their own coverage in a profit-driven, private-insurance sector.

Now we’re talking. I like the use of the word “radical” in the editorial, contrasting the radical right wing thoughts on health insurance to the more reasonable solutions on the table (and those that a growing number of Americans are embracing).

(cross posted at Cure This)

]]> http://npalliance.net/blog/?feed=rss2&p=137 http://npalliance.net/blog/?p=137 http://feeds.feedburner.com/~r/npalliance/~3/280499485/ http://npalliance.net/blog/?p=136#comments Wed, 30 Apr 2008 02:14:15 +0000 ChrisPMcCoy high quality health care for all http://npalliance.net/blog/?p=136 This article covers all of the bases in one simple, sad story.

It begins with a ghastly trend — charging patients before they are treated. And goes downhill from there, including such swell tactics as:

• Charging the uninsured many-fold times what insurance companies reimburse for the same services
• Stopping therapy until the payment office gets a check
• Considering a billing administrator part “of the health care team”
• $20 for latex gloves?! Is the patient allowed to bring her own next time?

Apparently, hospitals have decided to take up the motto of the highway robbers of old: “You money or your life.”

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