Interesting New HIV/AIDS Potential Treatment Report

In the early 1980s, as a physician and volunteer professional chair of a local Red Cross Blood Services advisory committee, and later as the Chair of  Northern California Red Cross Blood Service's Board (and subsequently, for the Western United States), I had the chance to experience the impact of  HIV on patients, my community and on national blood transfusion programs. As a practicing clinical hematologist, I sat through many meetings about HIV and AIDS, most of which highlighted highly pessimistic views about preventive measures such as  education, pharmacologic measures and vaccines. As a healthcare attorney, and author of a chapter concerning HIV-infected health care workers in the Health Law Guide, I was able to sound a more optomistic note as effective treatments evolved, allowing HIV infected people to experience dramatically improved qualities of life and survivals. But no approach suggested cure.

In an AIDS RESEARCH AND THERAPY abstract from a recently published report from Israel, Aviad Levin and others, at The Hebrew University of Jerusalem, state:

"A correlation between increase in the integration of Human Immunodeficiency virus-1 (HIV-1) cDNA and cell death was previously established. Here we show that combination of peptides that stimulate integration together with the protease inhibitor Ro 31-8959 caused apoptotic cell death of HIV infected cells with total extermination of the virus. This combination did not have any effect on non-infected cells. Thus it appears that cell death is promoted only in the infected cells. It is our view that the results described in this work suggest a novel approach to specifically promote death of HIV-1 infected cells and thus may eventually be developed into a new and general anti-viral therapy."

The report does not promise cure, but does describe a serious advance in the potential for treatment of HIV infection. It is worth reading.

"Shifting the Health Cost Burden"

On 9/3/2010 The New York Times editorial page discussed shifting the health cost burden.  The editorial noted that 2010 health care premiums went up a "modest" 3% for family plans but that workers' shares soared by 14% and expressed what I interpret as "unhappiness"about the cost shift from employers to workers in the form of increased workers' contributions, reduced benefits, increasing deductibles and increasing copayments.

Employers don't take these actions in a vacuum. Insurers structure their plans and premiums to encourage employers to remain with them by manipulating benefits, deductibles and copayments to remain competitive.  Struggling employers, including those who "shop," have few real choices, as health insurance underwriting restricts insurance company willingness to accept high risk business, particularly business which involves demonstrably sick or older employees.  Paradoxically, the longer an employer stays with an insurer, the greater the risk that long-term employees and employees loyal to the employer because of personal or family illness insurability issues, drive up health insurance risk and the premiums. Perhaps health reform will change this picture, but perhaps not.

The Times said nothing about reducible costs of health care, such as (1) eliminating large duplicative professional, business and government bureaucracies which officiously pass paper (and digital data) back and forth and spend endless hours in defining policies and procedures intended to trace, identify, categorize and restrict reduce health services utilization while increasing administrative overhead (2) reducing technology barriers, such as requiring physicians to be data entry clerks for office visits rather than use their time and skills evaluating, diagnosing and treating their patients, (3) finding ways to increase and maintain the skills  and efficiency of all categories of health care professionals free of contributions from pharmaceutical companies and other vendors, (4) providing appropriate subsidies, expertise and legal authority to government and professional entities (including the FDA, Department of Agriculture among others) active in the public health arena, (4) eliminating subsidies which make our citizens fat, physically  inactive and ignorant of how to recognize and deal with their own health needs, and (5) admitting that health care reform focuses on access to and financing of  health care and not the extent and quality of appropriate and necessary health services.

It's easy to complain about the cost shift burden. But focusing on the reasons for excessive health care costs will step on many vested interest toes. Will true reform even drive down some of the high-flying health invested mutual funds?

What About My Child Who Was Cured of Cancer?

For several days, radio and televisions broadcasts have said it: beginning September 23, 2010, under the Affordable Care Act applying to grandfathered group health plans, health insurance enrollees who are younger than 19 years of age cannot be excluded from benefits or denied coverage because a condition was present before the date coverage became effective (or denied).

The hype sounds good, but what if your 19-26 year old child was treated for heart disease, lung disease, cancer, leukemia, Hodgkin Disease, Wilson's Disease or any other serious condition and the insurance company says "no" to someone age 19-26 with a pre-existing condition under the grandfathered plan?  (A grandfathered plan was one existing on March 23, 2010 and a new plan is one established after that date.) While minors must be covered, not until 2014 will the  pre-existing prohibition for adult children be eliminated.

Sophisticated advisers stress the importance of keeping a close eye on employers' grandfathered plans.  When new insurance is written or major revisions to existing plans take place,  "grandfathered" plans may become new plans and work under a whole new set of more consumer- protective rules.  Pay attention.

Health Reform: Upset WIth Democrats, Afraid of Republicans

My take, based on conversations with professionals and just plain people, is public apprehension about the impact of the 2010 health reform package. On the one hand, people complain about the threat of federalization of health care and on the other, they demand that their Medicare program not be affected by health reform.  While there is recognition of the need to clean up the the old inefficient expensive system which provided economic rationing of care, there is a sense that the political parties are at odds, and that any gains made since passage of health reform in March, 2010 will be undone by Republicans should they gain control of Congress. The uncertainty created by Democratic passage of reform is threatened by the fear that - if the Republicans can control health care - it will be the bad old days again and people will sit in movie theaters (or in front of their big home TVscreens) booing insurance companies, HMOs and any theatrical reference to institutions that control of health care.

The Democrats haven't exactly made it easy for the public to understand what is happening and what will happen under health reform. A recent posting of a letter from Kathleen Sebelius  calling on Health Insurers to Stop Misinformation and Unjustified Rate Increases, said

"Any premium increases will be moderated by out-of-pocket savings resulting from the law.  These savings include a reduction in the "hidden tax" on insured Americans that subsidizes care for the uninsured.  By making sure insurance covers people who are most at risk, there will be less uncompensated care, and, as a result, the amount of cost shifting to those who have coverage today will be reduced by up to $1 billion in 2013.  By making sure that high-risk individuals have insurance and emphasizing health care that prevents illnesses from becoming serious, long-term health problems, the law will also reduce the cost of avoidable hospitalizations.  Prioritizing prevention without cost sharing could also result in significant savings: from lowering people's out-of-pocket spending to lowering costs due to conditions like obesity, and to increasing worker productivity - today, increased sickness and lack of coverage security reduce economic output by $260 billion per year."

Walk into any hospital Emergency Department and you may observe terribly sick and injured people who, because they are not insured American citizens, may still run up substantial costs which will be shifted to the insured population making the Secretary's claim of dubious validity. We need the facts to substantiate claims of savings as an offset to the doubts proclaimed by the political and corporate opponents of health reform.

Otherwise we will have more upset which will outweigh fear.

Who Will Judge Your Health Care Coverage?

Two articles in today'[s New York Times referenced health care costs on the reform bill. Stating that the reform bill  focused on health care access, rather than cost-control. Jonathan Bush opined that health reform will be cost-expansionary. But Andrea Sisko, the main author of a government report predicted modest effects on the  growth of health care cost to accompany a marked increase in access as more than 30 million people gain insurance coverage, although the article citing her report notes that growth in health care spending will increase from its 17.3 percent of the gross domestic product to 19.6 percent in 9 years.

Will our government be forced - by economic realities - to make new changes to health care coverage, limiting benefits for conditions now covered, imposing age barriers to obtaining palliative or even curative therapies, or barring individuals from health care coverage for conditions which they developed  as a result of damage which they self-imposed, such as the use of drugs, high risk sexual behavior, abuse of alcohol, and perhaps even consuming types and quantities of foods known to increase the risk of diabetes, heart disease, hypertension, obesity related joint disease and other conditions? Will government move towards pragmatic limits which will reduce scientific research, impose restrictions which favor the young and healthy, and make individuals primarily responsible for the consequences of lifestyle decisions which end-up costing society money?

Who will judge and who will be judged?  Who will live and  who will die?

Who by Fire?

Highly Sensitive Information

When I practiced internal medicine, asking a patient to go through psychological testing usually meant that the patient would never return to my office.  The issue was too sensitive for many reasons, including the possibility that someone related to the patient socially or through a business connection  (i.e., a spouse, employer or insurance company) would gain access to that information with serious consequences for the patient.

The sensitivity of psychological records remains an issue under federal privacy laws.  Following, is a notice I received today (9/7/2010) which may be of interest to my readers:

Before You Drink That 6-Pack . . . .

As I walked into my local supermarket to buy some flowers for the weekend, I saw the 6-packs of beer leaving the store, tightly clutched in customers' hands.  It made me wonder:
1. Do you believe that drinking the Labor Day weekend 6-pack will make your "crowd" like you?
2. Do you believe that drinking the Labor Day weekend 6-pack will make you more sexually attractive?
3. Do you believe that drinking the Labor Day weekend 6-pack and driving does not increase your risk of an  auto accident, a DUI citation, large hospital bills resulting from that auto accident, loss of auto insurance, lawyers' bills, and grief?
4. Do you believe that drinking the Labor Day weekend 6-pack will bring you joy?
5. Do you believe that drinking the Labor Day weekend 6-pack will absolve you of responsibility for an unwanted pregnancy?
6. Do you think that drinking the Labor Day weekend 6-pack and others, doesn't increase your risk of alcoholic liver disease, esophageal cancer, mouth and throat cancer (especially if you smoke) and gastrointestinal bleeding?
7. Do you think that the only friends worth having are the ones that will consume their own Labor Day weekend 6-packs followed by lots more?
8. Do you think that drinking 6-packs has an effect on your weight?
9. Do you think that drinking 6-packs has an effect on your school or job performance?
10. Do you really believe what the brewery ads imply, that the only way to have fame, fortune, friends, sex and happiness is to find it in the bottles they sell?


Ask any doctor or nurse who works in an emergency room what he or she thinks based on real life experience.

Don't Rush To The Newest Drug

In its September/October 2010 edition of  the American Society of Hematology's The Hematologist, Pete Lollar, M.D. reviews a report by Dutton, Wayman and Wei describing previously unknown actions by the anticoagulant warfarin (proprietary name - Coumadin)  used to combat abnormal venous and in-heart clotting which can produce strokes and pulmonary emboli with catastrophic results. Warfarin is also used as rat poison.

The report notably reports that vitamin K-dependent proteins involved in clotting involve vitamin K epoxide reductase ("VKOR") which is inhibited by warfarin. Humans are not the only life form which uses takes advantage of VKOR, since some bacteria including the one causing tuberculosis partially share VKOR activity.

There is a great deal of interest in new drugs which are being proposed to replace warfarin, a product which has been available since 1948 and, in addition to preventing strokes and pulmonary emboli, may be responsible for serious bleeding, particularly in women above age 80.  We are only beginning to understand the subtleties of the biologic action of warfarin.  When presented with the newcomer anticoagulants, how long will it take for us to understand how they work, and how many patients will experience serious unanticipated consequences of their adoption which we do not fully understand? Serious unanticipated consequences which rival the monitoring, cost savings and bleeding episodes now experienced with warfarin.