Worth Checking Out

For worthwhile information concerning health care costs, see:

http://www.nchc.org/facts/cost.shtml

What's Threatening Our Healthcare System?

No, it's not an epidemic or an earthquake or another hurricane Katrina. It's health care cost inflation, which in 2007 (the year before the US government really started to run the Treasury's money printing presses overtime at full speed) was about twice the general inflation rate. The Medicare population is a prime inflation victim, as its members observed when their Federal Medicare premium and private (i.e., AARP) Medigap premiums increases wiped out their Social Security inflation adjustments robbing resources from food, clothing, shelter and donut hole prescriptions.

The health care inflation rate, at 6.9% was double the general inflation rate; employers paid an increase of 6.1% for health insurance benefits with typical insurance family insurance premiums of about $12,000 per. Our bill for all health care products and services is heading towards 3 trillion dollars.

As our citizens, in increasing numbers, age and become ill, the cost of their care will be reflected in health care inflation. As new technologies, pharmaceuticals and advanced biologic products are introduced, their costs will be reflected in health care inflation. And as the numbers of those needing expensive new services increase, insurers and other intermediaries will elbow their way up to the trough to demand their share of resources as a reward for their roles in "managing" health care.

When resources are devoured by wasteful programs and unnecessary bureaucracies, food, mortgages, education, defense, transportation will be shortchanged. That will not be sustainable.

This Thanksgiving, let us be grateful for our country's world leadership, the affirmative role it plays in our lives, our ability to meaningfully participate in government, prosperity (for many), and the opportunities Americans enjoy to enjoy freedom of thought, action and religion. And let us resolve to provide appropriate health care to all Americans in a kind, humane, efficient system which alleviates pain and suffering and extends valuable life.

Something Was A Little Strange

Medical school hadn't officially started: we were being oriented with cheerleader speeches from faculty and a memorable talk the by the student body president who told it the way it was, ending with the thought that nowhere in the medical school catalog was there any statement that we would be treated fairly.

That afternoon, as we gathered quietly in an auditorium, the student to my left introduced himself as "Sam" (not his real name). And then, as inkblot patterns flashed on the white screen in rapid succession, he whispered an offer to help me with the inkblot interpretations because he had a lot of experience with inkblots. I ignored him.

A few weeks later we had become intense experienced students, soaking up new words, concepts and information. Neuroanatomy was difficult, the exam notorious, and each person's semester grade depended on correct identification of the brain structures in which our instructor had inserted small numbered pin-flags. But there was a problem - at the front of the line named "Sam." As he came to each test specimen, he systematically removed each flag, replacing it within an inch of its original site. Bedlam ensued. Somehow, Sam escaped without being physically assaulted.

A week later, "Sam" didn't show up for class. The next day we learned that he had murdered his mother-in-law. The details were supplied by a national magazine a few days later. The informal consensus was that at least no-one would move the little numbered exam identification flag

HIV and Male Healthcare Workers

At New York's Downstate Medical School, one of the pathology professors delighted in asking students what US persons were (in recent times) most likely to die of smallpox. His answer, hospital laundry workers, was my introduction to health care workers as victims of work-transmitted diseases.

When researching my chapter concerning HIV infected health care workers in Clark, Boardman, Callaghan's "Health Law Practice Guide," I was puzzled by the lack of evidence of widespread transmission of HIV to health care workers. There were a few lawsuits by individuals who claimed to have contracted HIV infection during the course of their duties, but they were relatively uncommon and there were confounding factors: was the appearance of HIV transmitted from a patient, or the result of lifestype exposure?

As noted in Kaisernetwork.org Daily HIV/AIDS Report , the CDC has published a study in the American Journal of Industrial Medicine suggesting that male health care workers face a more than twofold risk of dying from HIV/AIDS related causes, as well as other bloodborne diseases (Hepatitis B and C). Female nurses were at lower risk of dying from HIV - related causes than women who did not work in health care.

So, we are back to the old questions: is it private personal lifestyle or decreased immunity or increased risk of work-related infection which accounts for these findings. Because there are confounding issues, such as workers' compensation insurance payments and employer liability payments which may be at play, it will take a large, well funded and staffed, and deep study to figure this one out.

Final Regulation to implement and enforce the Patient Safety and Quality Improvement Act of 2005

http://edocket.access.gpo.gov/2008/pdf/E8-27475.pdf

The final regulation to implement and enforce the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) has been published in the Federal Register today. In April 2006, Secretary Leavitt delegated to OCR the authority to implement and enforce the confidentiality protections of the Patient Safety Act in conjunction with the Agency for Healthcare Research and Quality (AHRQ), which is responsible for administration of the Patient Safety Organization (PSO) requirements. On February 12, of this year, AHRQ and OCR published the proposed regulation for public comment. On October 8, of this year, AHRQ and OCR published interim guidance to permit AHRQ to begin listing PSOs prior to the effective date of the final regulation. On January 19, 2009, the final regulation will be effective and supersede the interim guidance.



The final regulation establishes the procedures and requirements for the listing and operation of PSOs, as well as the privilege and confidentiality protection for patient safety work product. The final rule makes several modifications to the proposed rule, in particular adding new requirements for PSOs and clarifying how information is collected to allow efficiencies in provider operations when collecting similar information for different purposes.



OCR’s enforcement responsibility includes the imposition of a civil money penalty for a knowing or reckless impermissible disclosure of patient safety work product. A civil money penalty may be imposed in an amount up to $10,000 for each violation.



The Patient Safety Act recognizes certain provisions of the HIPAA Privacy Rule are implicated by covered entity providers seeking the protections of the Patient Safety Act. The preamble to the final regulation describes how the HIPAA Privacy Rule disclosure permissions operate in conjunction with the patient safety disclosure permissions.



You may review the final regulation in the Federal Register (http://edocket.access.gpo.gov/2008/pdf/E8-27475.pdf).

Was There A Free Lunch?

Early Monday morning, I had an office visit with a physician who had a "No Free Lunch" sign prominently posted next to the sliding glass reception window. The notice said that the doctor would not accept free lunch, samples, sales/educational information or other materials from pharmaceutical companies.

Two days later I attended a no-charge all-day continuing medical education program for approximately a thousand physicians, nurses and related professionals, conducted by a national medical education company which has been funded by pharmaceutical companies, an insurer and a local medical society. Subjects included incretin hormones for management of type 2 diabetes, osteoporosis prevention, reducing cardiovascular risk by focusing on HDL, the beneficial blood component, asthma, new Beta blockers for hypertension treatment, fibromyalgia and actinic keratoses/squamous skin cancer. These are all relevant medical subjects and just happen to be conditions for which medications may be prescribed.

While several pharmaceutical companies had tables with representatives, the number was smaller than in previous years. Other than a speaker who (to me suspiciously) grandly extolled the virtues of sitagliptin, the obvious and indirect commercial message was subdued compared to past years. The speakers were professional, competent qualified and (except as described above) appropriately restrained.

And my lunch - half of a plain turkey sandwich, diet coke and an apple. Healthy, but not necessarily "free."

Maybe We Can Help The Auto Industry?

It takes a crisis to end our lethargy, a crisis which convinces us that aggressive lifesaving, previously unthinkable, action is needed.

We have our crisis. GM, Ford and Chrysler are moribund, in part, because of crushing health care costs. The Big 3, and its entire American supply chain, is burdened by excessive health care costs, adding to inflation in the price of American automobiles and automobile related services paid by American consumers. America's auto industry is emblematic of our lack of competitiveness in the global economy.

It's time for the multifaceted approach described in my October 10, 2008 blog . Bail out American industry, including but not limited to the auto manufacturers, by giving them a level playing field in global commerce: remove their burden of crushing health care costs by enrolling the entire auto industry's workforce in a plan which is equivalent to that available to Congresspeople, preferably one which has a federal component which (on an even-playing field) competes with major health insurers and systems. Will the public lose? Not if American automakers can sell "green" reasonably priced cars; not if plummeting employment begins to rise again; not if Americans can pay their mortgages and send their kids to college because they are working and optimistic; not when hope is restored to capital markets; not when America is already paying for health care costs which include a 25% wasteful administrative overhead for some insurers; not when millions of Americans have no health care insurance and either don't pay or become public charges; and not when appropriate regulatory oversight of the American automobile production industry is included.

We have a crisis which may soon reach epidemic proportions. We have reasonable solutions at hand which may remediate the health care financial drain on our collapsing economy. Before the patent's eyes close and rigor mortis sets in, let's take action.

Believe The Brown Journal

Although the New England Journal of Medicine (NEJM) now comes every week by mail without any cover, it used to come in a tan paper wrapper.

One day, as a colleague and I discussed a NEJM article, we discovered that each of us would let the NEJM stack up until the wrappers turned from tan to brown. Then, as with ripe bananas, it would be time to open them and digest the contents. Until the wrapper was brown, there had not been enough scientific scrutiny to trust claims made in the journal's articles.

On Monday November 11, the NEJM article on the use of a particular statin in a "low risk" population with satisfactory cholesterol levels but high CRPs (C-reactive Protein, a marker of inflammation) attracted a great deal of media attention. Experienced physicians will probably wait for several months before letting the article provoke them into prescribing the statin in question for the reasons promoted in the article. By the time the "brown journal" has matured in four or six months, the data will have been scrutinized carefully, appropriate questions will have been asked, biases will have been exposed, the drug company sponsor's biases will have been evaluated, the issue of possible conflicts of interest among the investigators will have been considered, and conflicting medical-scientific questions and issues will have been brought forward.

If you ask most young physicians about the "brown journal" they won't know what you are talking about. If they believe today's news, without paying attention to the information about the study that is still to come, they do you, the patient, no favor. And if you are dubious about my hypothesis, go to any medical library, take a ten year old journal from the shelf, read the drug advertisements, and ask yourself why those drugs disappeared and are no longer used.

Dear President-Elect Obama

You have staked your political and personal reputation on your promise to reform health care, make it more effective and more cost efficient. My guess is that you have surrounded yourself with experts who tell you that the federal government can save enormous amounts by managing and coordinating disease care for high risk people. These high-cost patients, many of them poor, elderly and not well educated, with multiple diseases, use enormous amounts of government funds for their care. Obviously, your experts will say, spending money on managing disease care through insurers or other plans, telephonically or by personal contact (with such interventions as providing transportation, medication or social service support), makes sense.

As a lawyer and former President of the Harvard Law Review, you know very well that all that is in print is not true, that experts can honestly hold to strong but incorrect opinions, and that one should be skeptical of claims by anyone that he or she has "the" solution. Please use those skills in evaluating the hype about disease management.

The managed disease care solution falls apart under close scrutiny. The Fall, 2008 Health Care Financing Review, in an interesting series of papers growing out of disease management studies conducted by Medicare and Medicaid, shows that savings, if any are negligible. Brown and Peikes (15-Site RAndomized Trial of Coordinated Care in Medicare FFS") found that after two years, the treatment group experienced no gross or net expenditures savings when compared to the control. Esposito and Brown reported that a primarily telephonic patient monitoring and education service "show virtually no overall impacts on hospital or emergency room . . . .use" although for a subset of patients with congestive heart failure program reduced Medicare expenditures by 9.6 percent. In the paper "Evaluation of Medicare Health Support Chronic Disease Pilot Program," Cromwell and McCall's conclusions were consistent with the cited authors' interpretation of their data. Goldfield and McCullough's paper, "Identifying Potentially Preventable Readmissions" unsurprisingly showed that "readmission rates increase with increasing severity of illness and increaasing time between admission and readmission, vary by the type of prior admission, and are stable within hospitals over time."

Treating elderly individuals with near end-stage severe chronic disease and mental health illness, will absorb enormous resources with very limited benefits. Providing a significant portion of those resources to young Americans, and using less expensive culture-changing methodologies, may yield better long-term results. America needs to resolve its ambivalence over tobacco, alcohol, addicting substances, unhealthy food intake, exercise and work habits. It should facilitate education for all of our young people and devote adequate resources to building a healthy life foundation for our country.

Good luck, Mr. President-elect. My grandchildren's well-being will depend on the decisions you make.

A Brave New World - But Who Can Afford It?

The doctors' lunch table discussion on Thursday, Nov. 7, was a little different. Since the only oncologist in the group had left practice, we did not discuss the inability of oncologists to pay for an office stockpile of expensive chemotherapy drugs for their patients and the difficulties this caused for patients, oncologists, hospital and infusion centers to which these patients were referred for treatment. The difference yesterday that the complaint came from a new source, an experienced community nephrologist who described an insured kidney failure (not on dialysis) patient who need erythropoietin to produce blood. Because the doctor's practice was not generating sufficient income for him to stockpile a supply a erythropoietin, he gave the prescription to the patient whom he told to procure the drug and bring it in on the next visit. The patient came, but without the drug, saying that he couldn't afford the $500 prescription charge. This doctor went ahead and took care of the patient's need, giving him the medically appropriate dose of erythropoietin, but sent letters to the rest of his patients informing them that he will be unable to do this for them.

Recently, there have been studies and journal articles about the risks of giving too much erythropoietin. But less dramatic information about the difficulties patients are having in getting, paying for and benefiting from standard accepted medical therapies grab no headlines. As we move into a period of extraordinarily effective biologic products which relieve pain, suffering and premature death, our health system will have to grapple with the high costs of these products and their unavailability to many who need them.

What Is The Lesson of Obama?

The election of Obama teaches us, not only that a well-organized, dedicated and competent electorate will respond to an articulate smart and sensible leader, but that it will recognize its legitimate self-interest and take forceful action.

That lesson is applicable to our health care system. The Clintons tried to design a hierarchical system from the top down: it didn't work. Let our united voices help build a system, from the bottom up, which provides affordable appropriate necessary health care to all Americans. See my blog dated November 6, 2008,write your letters, and make your voices heard.

Voters: Set The Health Care Agenda

When Congressman Norman Mineta and I had a discussion about health care reform at his annual barbecue in the mid-90s, Norm, a very smart, seasoned and common-sensed San Jose Democrat, felt that neither Congress nor the Administration at the time was ready to act. As usual, he was right

Although health care has even greater public importance today, unless it's a high profile item on the national political agenda, nothing substantive will happen. Partisan politics, budgetary priorities and shortfalls, and our economic woes will block reform of our health systems. Major donors (i.e., insurers, hospitals, pharmaceutical manufacturers, chiropractors organizations, nursing homes, nursing associations and unions, physicians' lobbies, various unions and many others) will preserve their privileged positions. The public, patients and their families, will once again be ignored or stalled.

It's time for voters to use some of their chips - to write brief clear letters (especially the kind that go in the Post Office mail) to our Representatives, Senators, the Administration, and national political parties, making it very clear what we expect them to accomplish for health care. (If you can't write a letter, send an email, but note that email is not as effective at influencing political judgment.)

If you choose not to use your political chips, those major donors to the Republican and Democratic parties, candidates and functionaries, will be at the health policy table in a no limit to the stakes game. Setting an agenda in which health care needs are trivialized, they will divvy up the health care pot, and the public will once again be screwed. You can make a difference by writing a one page letter to your Congresspeople, the Republican and Democratic national parties, the Obama Administration, and your local newspaper:

!. First short paragraph: tell the recipients who you are, where you live, and that you are a voter in their districts (use your zip code); briefly describe the single most serious health system problem you have found.
2. Second short paragraph: describe a solution to the problem you have identified and describe the single most important thing that you want them to do.
3. Third paragraph: picture for them how your proposed solution will help.
4. Fourth paragraph: tell them why their advocacy for your solution to the problem you have identified will be in their best interests.

Politicians count numbers. If enough of us write to our politicians they will notice and respond. If we set their agenda, they will follow. After all, they work for us.