Thursday, January 31, 2013

Health Care Reform Articles - January 31, 2013

Legislation proposed to help California launch healthcare overhaul

A special session of the state Legislature produces sweeping proposals to help California implement President Obama's healthcare overhaul.

By Michael J. Mishak, Los Angeles Times
2:28 AM PST, January 29, 2013

SACRAMENTO — The state Legislature gaveled in a special session on healthcare Monday, pushing forward with sweeping proposals to help California implement President Obama's healthcare overhaul.
The measures, including a major expansion of Medi-Cal, the state's public insurance program for the poor, would cement the state's status as the nation's earliest and most aggressive adopter of the federal Affordable Care Act. Beginning in January 2014, the law requires most Americans to buy health insurance or pay a penalty.
Gov. Jerry Brown called the special session so healthcare bills that he signs can take effect within 90 days rather than next year.
State lawmakers are racing to pass rules for enrollment in a new state-run insurance market in October. They include a requirement for insurers to cover consumers who have preexisting medical conditions.
Legislative leaders in both houses sponsored bills that would dramatically expand Medi-Cal. Under the proposals, individuals earning up to 138% of the federal poverty level — or $15,415 a year — would be covered, potentially adding more than 1 million Californians to the rolls.
The federal government would subsidize costs for the first three years, phasing down to 90% afterward.
"Ensuring that every Californian has access to quality, affordable healthcare is one of the most important public policy challenges we face," said Assembly Speaker John A. PĂ©rez (D-Los Angeles) at a Capitol news conference. "No Californian should ever face bankruptcy or severe financial setbacks due to illness and injury."
Brown, in his State of the State speech last week, sounded a note of caution even as he embraced the federal law. The long-term costs are unknown, he said, and hold the potential to undermine California's precariously balanced budget.
He called the Medi-Cal expansion "incredibly complex," adding that "it will take more time" to achieve than other parts of the healthcare overhaul. Brown has said the change could allow the state to reduce the roughly $2 billion it gives to counties to care for the uninsured, but county officials and healthcare advocates say that such a move could hurt their ability to help the millions of Californians who will still lack coverage.,0,5364966,print.story

Report: Kaiser tops state health insurance market with 40% share

By Chad Terhune
9:37 AM PST, January 29, 2013

Nonprofit healthcare giant Kaiser Permanente had a 40% share of California's $59-billion health insurance market for employers and individuals, new data show.
A report issued this week by Citigroup analyst Carl McDonald compiled nationwide data on 2011 premiums and enrollment among large and small employers and individuals buying their own policies.
Those insurance markets, excluding government healthcare programs and self-insured employers, totaled more than 80 million people and $317 billion in premiums. McDonald noted these figures don't reflect companies' full market share, but he said these businesses and individual customers account for the vast majority of revenue and profits for most insurers.
In California, Kaiser led the way with $23.3 billion in premiums, or a 40% share, and 5.5 million commercial customers. Overall, the Oakland company has about 6.6 million members in the state and runs 35 hospitals here.
Anthem Blue Cross, a unit of industry giant WellPoint Inc., was second in the state with a 23% commercial market share and $13.7 billion in premiums.
Blue Shield of California came in third with a 14% share, followed by Health Net Inc. at nearly 9% and UnitedHealth Group Inc. at 5%, according to Citigroup.
McDonald said the California market has a significant impact on the entire health insurance industry.
"As California goes, so goes the results of the publicly traded plans, with the California the largest market at four of the six publicly traded plans," he wrote in his report.
Nationwide, WellPoint grabbed the biggest share of this commercial market with 14%. UnitedHealth was second at 12%, and Kaiser was third at nearly 10%, Citigroup data show.
Those companies figure to be among the most affected by the federal healthcare law and the launch of state insurance exchanges for individuals and small businesses in January 2014.

HMO-Like Plans May Be Poised To Make Comeback In Online Insurance Markets

JAN 22, 2013
This story was produced in collaboration with 
It's back to the future for insurers, which plan to sharply limit the choice of doctors and hospitals in some policies marketed to consumers under the health law, starting next fall
Such plans, similar to the HMOs of old, fell into disfavor with consumers in the 1980s and 1990s, when they rebelled against a lack of choice.
But limited network plans -- which have begun a comeback among employers looking to slow rising premiums -- are expected to play a prominent role in new online markets, called exchanges, where individuals and small businesses will shop for coverage starting Oct. 1. That trend worries consumer advocates, who fear skimpy networks could translate into inadequate care or big bills for those who develop complicated health problems.
Because such policies can offer lower premiums, insurers are betting they will appeal to some consumers, especially younger and healthier people who might see little need for more expensive policies.
Insurers, who are currently designing their plans for next fall, "will start with as tight a network control as they can," says Ana Gupte, a managed care analyst with Sanford Bernstein.

During Trial, New Details Emerge About Hip Maker

When Johnson & Johnson announced the appointment in 2011 of an executive to head the troubled orthopedics division whose badly flawed artificial hip had been recalled, the company billed the move as a fresh start.
But that same executive, it turns out, had supervised the implant’s introduction in the United States and had been told by a top company consultant three years before the device was recalled that it was faulty.
In addition, the executive also held a senior marketing position at a time when Johnson & Johnson decided not to tell officials outside the United States that American regulators had refused to allow sale of a version of the artificial hip in this country.
The details about the involvement of the executive, Andrew Ekdahl, with the all-metal hip implant emerged Wednesday in Los Angeles Superior Court during the trial of a patient lawsuit against the DePuy Orthopaedics division of Johnson & Johnson. More than 10,000 lawsuits have been filed against DePuy in connection with the device — the Articular Surface Replacement, or A.S.R. — and the Los Angeles case is the first to go to trial.
The information about the depth of Mr. Ekdahl’s involvement with the implant may raise questions about DePuy’s ability to put the A.S.R. episode behind it.
Asked in an e-mail why the company had promoted Mr. Ekdahl, a DePuy spokeswoman, Lorie Gawreluk, said the company “seeks the most accomplished and competent people for the job.”
On Wednesday, portions of Mr. Ekdahl’s videotaped testimony were shown to jurors in the Los Angeles case. Other top DePuy marketing executives who played roles in the A.S.R. development are expected to testify in coming days. Mr. Ekdahl, when pressed in the taped questioning on whether DePuy had recalled the A.S.R. because it was unsafe, repeatedly responded that the company had recalled it “because it did not meet the clinical standards we wanted in the marketplace.”
Before the device’s recall in mid-2010, Mr. Ekdahl and those executives all publicly asserted that the device was performing extremely well. But internal documents that have become public as a result of litigation conflict with such statements.
In late 2008, for example, a surgeon who served as one of DePuy’s top consultants told Mr. Ekdahl and two other DePuy marketing officials that he was concerned about the cup component of the A.S.R. and believed it should be “redesigned.” At the time, DePuy was aggressively promoting the device in the United States as a breakthrough and it was being implanted into thousands of patients.
“My thoughts would be that DePuy should at least de-emphasize the A.S.R. cup while the clinical results are studied,” that consultant, Dr. William Griffin, wrote.
A spokesman for Dr. Griffin said he was not available for comment.
The A.S.R., whose cup and ball components were both made of metal, was first sold by DePuy in 2003 outside the United States for use in an alternative hip replacement procedure called resurfacing. Two years later, DePuy started selling another version of the A.S.R. for use here in standard hip replacement that used the same cup component as the resurfacing device. Only the standard A.S.R. was sold in the United States; both versions were sold outside the country.
Before the device recall in mid-2010, about 93,000 patients worldwide received an A.S.R., about a third of them in this country. Internal DePuy projections estimate that it will fail in 40 percent of those patients within five years; a rate eight times higher than for many other hip devices.
Mr. Ekdahl testified via tape Wednesday that he had been placed in charge of the 2005 introduction of the standard version of the A.S.R. in this country. Within three years, he and other DePuy executives were receiving reports that the device was failing prematurely at higher than expected rates, apparently because of problems related to the cup’s design, documents disclosed during the trial indicate.

Federal Rule Limits Aid to Families Who Can’t Afford Employers’ Health Coverage

WASHINGTON — The Obama administration adopted a strict definition of affordable health insurance on Wednesday that will deny federal financial assistance to millions of Americans with modest incomes who cannot afford family coverage offered by employers.
In deciding whether an employer’s health plan is affordable, the Internal Revenue Service said it would look at the cost of coverage only for an individual employee, not for a family. Family coverage might be prohibitively expensive, but federal subsidies would not be available to help buy insurance for children in the family.
The policy decision came in a final regulation interpreting ambiguous language in the 2010 health care law.
Under the law, most Americans will be required to have health insurance starting next year. Low- and middle-income people can get tax credits to help them pay premiums, unless they have access to affordable coverage from an employer.
The law specifies that employer-sponsored insurance is not affordable if a worker’s share of the premium is more than 9.5 percent of the worker’s household income. The I.R.S. said this calculation should be based solely on the cost of individual coverage, what the worker would pay for “self-only coverage.”
“This is bad news for kids,” said Jocelyn A. Guyer, an executive director of the Center for Children and Families at Georgetown University. “We can see kids falling through the cracks. They will lack access to affordable employer-based family coverage and still be locked out of tax credits to help them buy coverage for their kids in the marketplaces, or exchanges, being established in every state.”
In 2012, according to an annual survey by the Kaiser Family Foundation, total premiums for employer-sponsored health insurance averaged $5,615 a year for single coverage and $15,745 for family coverage. The employee’s share of the premium averaged $951 for individual coverage and more than four times as much, $4,316, for family coverage.
Under the I.R.S. rule, such costs would be considered affordable for a family making $35,000 a year, even though the family would have to spend 12 percent of its income for full coverage under the employer’s plan.
The tax agency proposed this approach in August 2011 and made no change in the definition of “affordable coverage” despite protests from advocates for children and low-income people and many employers. Employers did not want to be required to pay for coverage of employees’ dependents. But they said that family members should have access to subsidies so they could buy insurance on their own.
However, that would have increased costs to the government, which would have been required to spend more on subsidies.
Paul W. Dennett, senior vice president of the American Benefits Council, which represents many Fortune 500 companies, said: “Individuals who do not have affordable family coverage should be eligible for premium tax credits in the exchange. The final rule does not provide that.”
Under the law, people who go without insurance will generally be subject to tax penalties. In a separate proposed regulation issued on Wednesday, the Internal Revenue Service said that the uninsured children and spouse of an employee would be exempt from the penalties if the cost of coverage for the entire family under an employer’s plan was more than 8 percent of household income.

Maine psychiatric center shortfall may hit $2.3 million

Budget issues mean hundreds of people in the community face long waits for basic services.

By BETTY ADAMS Kennebec Journal
AUGUSTA – An influx of mental patients who are accused of committing crimes is stripping the state's Riverview Psychiatric Center of federal money and adding to a multimillion-dollar budget shortfall.
So says Daniel Wathen, who oversees the consent decree that holds the state mental hospital accountable to certain standards.
Wathen, who files quarterly progress reports on Riverview, told legislators Wednesday that the shortfall could reach an estimated $2.3 million for the five months remaining in this fiscal year. That deficit is not addressed in the governor's proposed supplemental budget.
Even with those budget problems, Wathen said, there's a critical need to increase funding to help people with mental illness who are living in the community.
"More than 400 people are waiting for the most basic mental health service -- caseworkers," he said.
The consent decree calls for anyone who requests a caseworker to get by for at least three days, but Wathen said the wait is typically much longer, sometimes weeks or months.
The Legislature's Health and Human Services Committee took no action on Wathen's concerns, but Rep. Richard Farnsworth, D-Portland, the committee's House chairman, thanked him for "filling us in on some of the holes in the mental health safety net."
Wathen summarized for the panel the conclusions in his latest report on how well the state deals with people hospitalized at Riverview or served by its staff.
The 1990 consent decree requires the state to provide adequate services for those with mental illness. It covers about 4,500 people who were treated at the Augusta Mental Health Institute, Riverview's predecessor, since January 1988.
The state has an obligation to serve others with mental illness by providing similar services, which brings the number of people served to about 12,000.
Earlier this month, Riverview had 51 forensic patients -- those who are accused of committing crimes or have been found not criminally responsible for crimes. There were 57 forensic patients at one point last year.

Tuesday, January 29, 2013

Health Care Reform Articles - January 29, 2013

Single Payer — It Remains The Only Answer

A Crash Course in Playing the Numbers

The chances are that you turn to this part of the newspaper in search of some reliable tools for optimizing your health. The chances are that you periodically visit a doctor for the same reason.
Alas, what you seek cannot be found in either place, not if it’s certitude you’re after. Whether you are healthy, moribund or traversing the stages of decrepitude in between, every morsel of medical advice you receive is pure conjecture — educated guesswork perhaps, but guesswork nonetheless. Your health care provider and your favorite columnist are both mere croupiers, enablers for your health gambling habit.
Staying well is all about probability and risk. So is the interpretation of medical tests, and so are all treatments for all illnesses, dire and trivial alike. Health has nothing in common with the laws of physics and everything in common with lottery cards, mutual funds and tomorrow’s weather forecast.
Thus, no matter how many vitamin-based, colon-cleansing, fat-busting diet and exercise books show up in 2013, the most important health book of the year is likely to remain Charles Wheelan’s sparkling and intensely readable “Naked Statistics,” even though it’s not primarily about health.
A professor of public policy and economics at Dartmouth, Mr. Wheelan earned journalism credentials writing for The Economist and has previously drawn on both careers to produce “Naked Economics” (2002), an accessible guide for the lay reader. “Naked Statistics” is similar, a riff on basic statistics that is neither textbook nor essay but a happy amalgam of the two.
It is not the place to learn for the first time about medians and means, but definitely the place to remember what you were once supposed to know about these and other key concepts — and, more important, why you were supposed to know them.
And that means you. While a great measure of the book’s appeal comes from Mr. Wheelan’s fluent style — a natural comedian, he is truly the Dave Barry of the coin toss set — the rest comes from his multiple real world examples illustrating exactly why even the most reluctant mathophobe is well advised to achieve a personal understanding of the statistical underpinnings of life, whether that individual is watching football on the couch, picking a school for the children or jiggling anxiously in a hospital admitting office.
Are you a fan of those handy ranking systems based on performance data, guaranteed to steer you to the best surgeons in town? If so, you are up to your armpits in descriptive statistics, and Mr. Wheelan has some advice for you: beware. The easiest way for doctors to game those numbers is by avoiding the sickest patients.

Vermont gov wants more time on$1.6B health plan

By By Dave Gram on January 25, 2013
MONTPELIER, Vt. (AP) — After two years of pressure to say how it was going to pay for its single-payer health care plan, Gov. Peter Shumlin's administration on Thursday released a new accounting of what Vermont's universal health care system might cost, but left for later how it would be paid for.
Reports released by the governor's office say Vermonters would have to pay $1.6 billion in new taxes to pay for their share of a single-payer system that can't be implemented until 2017. But that would be more than offset by the fact that most individual and employers would no longer be buying private health insurance, a savings of $1.9 billion, the report said.
Exactly what kinds of taxes would provide that $1.6 billion will be decided in a public discussion process whose details are to be announced next month, administration officials said.
A state law passed in 2011 with strong legislative support called for Vermont to move well beyond the federal health overhaul of 2010 to something closer to what Canada has in place: a universal health insurance system in which the government ensures everyone has coverage. Shumlin's administration estimates the total cost of universal health care to be $3.5 billion, with much of that being covered by federal contributions.

Maine speakers testify against human services cutbacks

Nearly 100 people speak out against Gov. Paul LePage's proposed cuts to the state DHHS budget.

By Kelley Bouchard
Staff Writer
AUGUSTA — Rena Heath, a senior who lives on a fixed income, was the first of nearly 100 people to testify Monday against more than $14 million in proposed cuts to Maine's current health and human services budget.
Heath urged legislators to block a $985,000 reduction in Medicaid prescription drug funding for elderly and disabled Mainers, while other speakers opposed pending cuts to General Assistance, substance abuse services, mental health care and payments to providers.
"Cutting access to prescription drugs will unnecessarily endanger lives and will likely result in higher costs to Maine's already overburdened and costly health care system," said Heath, a volunteer AARP advocate who lives in Hallowell.
The proposed reduction to the Low Cost Drugs for the Elderly and Disabled Program is part of Gov. Paul LePage's effort to address a $90 million shortfall in the Department of Health and Human Services budget ending June 30.
The shortfall has been blamed largely on higher-than-planned costs for MaineCare, the state's Medicaid program, after federal economic stimulus money ran out two years ago. However, MaineCare general fund expenditures are projected to be about $30 million less than in the last fiscal year, said DHHS Commissioner Mary Mayhew.

Doctors say excessive workloads put hospital patients at risk

Posted Jan. 29, 2013, at 9:42 a.m.
NEW YORK — Almost half of hospital doctors said they routinely see more patients than they can safely manage, leading in some cases to unneeded tests, medication errors and deaths, according to a survey by researchers at Johns Hopkins University.
Seven percent of 506 hospital-based physicians surveyed said their heavy workload likely led to a patient complication, and 5 percent reported it probably caused a death over the past year. The findings are published in a research letter released Monday by JAMA Internal Medicine.
Doctors are increasingly taking on more patients to compensate for cuts in payments from health insurers, the researchers said. That workload is projected to increase as the 2010 health law expands insurance coverage to 30 million more Americans. The researchers, based at Johns Hopkins University in Baltimore, said there is a risk that rising patient volumes may increase costs by decreasing quality.
“Excessively increasing the workload may lead to suboptimal care and less direct patient care time, which may paradoxically increase, rather than decrease costs,” the study’s authors wrote.
Forty percent of doctors said they saw an unsafe number of patients at least once a month with 25 percent saying it prevented them from fully discussing treatment options or answering questions, according to the survey.
Researchers electronically surveyed doctors in November 2010 using a physician networking website. The average age of the physicians was 38 with an average salary of $180,000. Doctors said they could safely manage 15 people during a shift if they were able to devote 100 percent of their time to patient care.
Lawmakers have moved to prevent medical errors by putting restrictions on the number of hours doctors in training can work and set standards for nursing staffing levels. There are no similar limits on workloads for physicians who focus primarily on care of hospitalized patients.

Monday, January 28, 2013

Health Care Reform Articles - January 28, 2013

Carrots for Doctors

WITH its ambitious proposal to pay doctors in public hospitals based on the quality of their work — not the number of tests they order, pills they prescribe or procedures they perform — New York City has hopped aboard the biggest bandwagon in health care. Pay for performance, or P4P in the jargon, is embraced by right and left. It has long been the favorite egghead prescription for our absurdly overpriced, underperforming health care system. The logic seems unassailable: Reward quality, and you will get quality. Stop rewarding waste, and you will get less waste. QED! P4P!
If only it worked.
For if you spend a little time with the P4P skeptics — a data-bearing minority among physicians and health economists — you will come away full of doubts. In practice, pay for performance does little to improve outcomes or to control costs. But if you look hard enough at why this common-sense approach doesn’t deliver, you find some clues to what might.
The New York plan would give hospitals bonuses to distribute to their doctors based on such indicators as patient satisfaction, speeding the flow of cases through the system and administering specific therapies. It is an attempt to get ahead of the federal law we all know as Obamacare, which includes rewards for hospitals that peg pay to a list of quality metrics. I’ve said before that I consider Obamacare an important leap forward, mainly for extending the basic safety net to millions of Americans. And there are aspects of the law, notably the Medicare Independent Payment Advisory Board, that may help bring down costs, if Congress can resist the temptation to interfere. But the pay-for-performance provisions are a triumph of theory over experience.

More Using Electronics to Track Their Health

Whether they have chronic ailments like diabetes or just want to watch their weight, Americans are increasingly tracking their health using smartphone applications and other devices that collect personal data automatically, according to health industry researchers.
“The explosion of mobile devices means that more Americans have an opportunity to start tracking health data in an organized way,” said Susannah Fox, an associate director of the Pew Research Center’s Internet and American Life Project, which was to release the national study on Monday. Many of the people surveyed said the experience had changed their overall approach to health.
More than 500 companies were making or developing self-management tools by last fall, up 35 percent from January 2012, said Matthew Holt, co-chairman of Health 2.0, a market intelligence project that keeps a database of health technology companies. Nearly 13,000 health and fitness apps are now available, he said.
The Pew study said 21 percent of people who track their health use some form of technology.
They are people like Steven Jonas of Portland, Ore., who uses an electronic monitor to check his heart rate when he feels stressed. Then he breathes deeply for a few minutes and watches the monitor on his laptop as his heart slows down.
“It’s incredibly effective in a weird way,” he said.
Mr. Jonas said he also used electronic means to track his mood, weight, mental sharpness, sleep and memory.
Dr. Peter A. Margolis is a principal investigator at the Collaborative Chronic Care Network Project, which tests new ways to diagnose and treat diseases. He has connected 20 young patients who have Crohn’s disease with tracking software developed by a team led by Ian Eslick, a doctoral candidate at the Media Lab at the Massachusetts Institute of Technology.

Aging in Brain Found to Hurt Sleep Needed for Memory

Scientists have known for decades that the ability to remember newly learned information declines with age, but it was not clear why. A new study may provide part of the answer.
The report, posted online on Sunday by the journal Nature Neuroscience, suggests that structural brain changes occurring naturally over time interfere with sleep quality, which in turn blunts the ability to store memories for the long term.
Previous research had found that the prefrontal cortex, the brain region behind the forehead, tends to lose volume with age, and that part of this region helps sustain quality sleep, which is critical to consolidating new memories. But the new experiment, led by researchers at the University of California, Berkeley, is the first to directly link structural changes with sleep-related memory problems.
The findings suggest that one way to slow memory decline in aging adults is to improve sleep, specifically the so-called slow-wave phase, which constitutes about a quarter of a normal night’s slumber.
Doctors cannot reverse structural changes that occur with age any more than they can turn back time. But at least two groups are experimenting with electrical stimulation as a way to improve deep sleep in older people. By placing electrodes on the scalp, scientists can run a low current across the prefrontal area, essentially mimicking the shape of clean, high-quality slow waves.
The result: improved memory, at least in some studies. “There are also a number of other ways you can improve sleep, including exercise,” said Ken Paller, a professor of psychology and the director of the cognitive neuroscience program at Northwestern University, who was not involved in the research.

Tips to make sure doctors don’t tune you out

I always admire doctors who can write books criticizing their own profession, including any shortcomings they may have as practitioners, in an effort to improve patient care. In their new book, When Doctors Don’t Listen, Brigham and Women’s Hospital emergency room physicians Leana Wen and Joshua Kosowsky reveal what patients have long suspected: Doctors often tune out a patient’s story when seeking a diagnosis and simply clue in on specific symptoms, which may lead them to over-test and over-treat.
When patients utter the words “chest pain,” doctors may kick into immediate action, giving patients an aspirin to chew, an EKG to monitor their heart’s electrical activity, blood tests, and X-rays, and possibly keeping them overnight in the hospital to confirm or rule out a heart attack.
All too often, patients with muscle strains or heartburn are admitted to the Brigham and elsewhere for a two-day heart work-up — despite having no initial signs of a heart attack. That’s because doctors were following a standard diagnostic protocol for evaluating chest pain — instead of listening to their patients to determine whether something more common was likely to blame.
Today’s doctors, Wen and Kosowsky contend, have failed to practice the art of listening to gain a context in which to place a patient’s symptoms. Wen, who is completing her residency training, admitted that she, at first, stuck to this form of cookbook medicine — ticking off a checklist of symptoms in her head as a patient spoke — in an effort to become an efficient doctor.
Kosowsky, vice chair and clinical director of Brigham’s emergency medical department, called it a “failure in the way doctors are being trained to think,” a result of too much reliance on high-tech imaging tests and blood tests to measure biomarkers that weren’t around a generation ago.“It’s about finding a balance,” he said in an interview. “Neither Leana nor I would say to throw all guidelines out the window, and doctors are well intentioned when they follow these protocols,” Kosowsky said, “but they’ve taken on an oversized role.”

Keeping Blood Pressure in Check

Since the start of the 21st century, Americans have made great progress in controlling high blood pressure, though it remains a leading cause of heart attacks, strokes, congestive heart failure and kidney disease.
Now 48 percent of the more than 76 million adults with hypertension have it under control, up from 29 percent in 2000.
But that means more than half, including many receiving treatment, have blood pressure that remains too high to be healthy. (A normal blood pressure is lower than 120 over 80.) With a plethora of drugs available to normalize blood pressure, why are so many people still at increased risk of disease, disability and premature death? Hypertension experts offer a few common, and correctable, reasons:
¶ About 20 percent of affected adults don't know they have high blood pressure, perhaps because they never or rarely see a doctor who checks their pressure.
¶ Of the 80 percent who are aware of their condition, some don't appreciate how serious it can be and fail to get treated, even when their doctors say they should.
¶ Some who have been treated develop bothersome side effects, causing them to abandon therapy or to use it haphazardly.
¶ Many others do little to change lifestyle factors, like obesity, lack of exercise and a high-salt diet, that can make hypertension harder to control.
Dr. Samuel J. Mann, a hypertension specialist and professor of clinical medicine at Weill-Cornell Medical College, adds another factor that may be the most important. Of the 71 percent of people with hypertension who are currently being treated, too many are taking the wrong drugs or the wrong dosages of the right ones.

An Oil Boom Takes a Toll on Health Care

WATFORD CITY, N.D. — The patients come with burns from hot water, with hands and fingers crushed by steel tongs, with injuries from chains that have whipsawed them off their feet. Ambulances carry mangled, bloodied bodies from accidents on roads packed with trucks and heavy-footed drivers.
The furious pace of oil exploration that has made North Dakota one of the healthiest economies in the country has had the opposite effect on the region’s health care providers. Swamped by uninsured laborers flocking to dangerous jobs, medical facilities in the area are sinking under skyrocketing debt, a flood of gruesome injuries and bloated business costs from the inflated economy.
The problems have been acute at McKenzie County Hospital here. Largely because of unpaid bills, the hospital’s debt has climbed more than 2,000 percent over the past four years to $1.2 million, according to Daniel Kelly, the hospital’s chief executive. Just three years ago, Mr. Kelly added, the hospital averaged 100 emergency room visits per month; last year, that average shot up to 400.
Over all, ambulance calls in the region increased by about 59 percent from 2006 to 2011, according to Thomas R. Nehring, the director of emergency medical services for the North Dakota Health Department. The number of traumatic injuries reported in the oil patch increased 200 percent from 2007 through the first half of last year, he said.
The 12 medical facilities in western North Dakota saw their combined debt rise by 46 percent over the course of the 2011 and 2012 fiscal years, according to Darrold Bertsch, the president of the state’s Rural Health Association.
Hospitals cannot simply refuse to treat people or raise their rates. Expenses at those 12 facilities increased by 15 percent, Mr. Bertsch added, and nine of them experienced operating losses. Costs are rising to hire and retain service staff members, as hospitals compete with fast food restaurants that pay wages of about $20 an hour.
“Plain and simple, those kinds of things are not sustainable,” he said.
Many of the new patients are transient men without health insurance or a permanent address in the area. In one of the biggest drivers of the hospital debt, patients give inaccurate contact information; when the time comes to collect payment, the patients cannot be found. McKenzie County Hospital has invested in new software that will help verify the information patients give on the spot

The fight to defend Britain’s National Health Service

28 January 2013
Britain’s National Health Service (NHS) is suffering death by a thousand cuts and faces wholesale privatisation.
The Conservative-Liberal Democrat coalition has demanded a £20 billion cut by 2015 from an overall budget of £108 billion—a reduction that is impossible without slashing essential life-saving services.
So far, only £6 billion in cuts have been made—mostly one-off savings. Much worse is to follow. But staff levels are already being cut by as much as 20 percent and new labour contracts are being imposed with lower wages and higher workloads.
Accident and Emergency departments (over 30 nationally), children’s units and other wards and facilities are closing—justified by claims that services and medical procedures can be better provided in specialised units. There are no guarantees that such specialised units will not be swamped by demand, or that lives will not be lost due to the distances involved. Yet the medical director of the NHS, Sir Bruce Keogh, dismisses broad opposition to these changes as pressure to “inhibit excellence” and “perpetuate mediocrity.”
The Health and Social Care Act allows private companies to provide health care under the auspices of the NHS and comes in to effect in April 2013. However, this will only escalate a process already underway. The NHS is being bled dry by innumerable private corporations that are fleecing the taxpayer while care is either rationed or denied outright to the chronically ill and the most vulnerable members of society.
On November 13, 2011, Circle Health became the first private corporation to run an NHS hospital. In October 2012, a Freedom of Information request found that in one week alone contracts were signed taking more than 400 community services out of the NHS, including ambulance services, diagnostic testing, podiatry and adult hearing.
Doctors warned that the NHS was being “atomised”, with over 100 health care firms now providing basic care under Any Qualified Provider rules. Some private companies already earn up to £200 million a year each from NHS-funded work.
Sixty NHS Trusts face being declared bankrupt in the next four years, threatening hospitals with “rationalisation” or closure. To fend off this threat, trusts must cut budgets and ration or deny treatments declared to be “of limited clinical value”. Nearly one in five hip replacements and hernia repairs are already handled by private companies. Soon they will have to be paid for.
Cold hard cash is a major factor in the drive to first gut and then privatise the NHS. It will open up massive revenue streams for private medicine, which previously made up just 8 percent of the health sector and was for decades almost entirely parasitic—a form of glorified queue-jumping for the better-off, using NHS taxpayer-funded facilities and doctors trained at public expense.
The NHS is hated by the ruling class as a symbol of everything they were forced to grant the working class in Britain in the post-war period—the “cradle to grave” welfare reforms—in order to placate demands for social change.

Retiring Medicare Actuary Reflects On The Politics Of Spending And Why He Almost Quit

JAN 28, 2013
This story was produced in collaboration with 
Richard S. Foster is retiring this week after 18 years as the chief actuary for the Centers for Medicare and Medicaid Services. His duties included projecting Medicare and Medicaid spending and the cost of health care legislation to help policymakers weigh the impact on the federal budget. Some of those estimates got him into hot water with members of both parties.
Foster recently sat down to discuss the highs and lows of his career with KHN’s Mary Agnes Carey. What follows is an edited transcript of that conversation.

Sunday, January 27, 2013

Health Care Reform Articles - January 27, 2013

Maker Hid Data About Design Flaw in Hip Implant, Records Show

Johnson & Johnson executives knew years before they recalled a troubled artificial hip in 2010 that it had a critical design flaw, but the company concealed that information from physicians and patients, according to internal documents disclosed on Friday during a trial related to the device’s failure.
The company had received complaints from doctors about the device, the Articular Surface Replacement, or A.S.R., even as it started marketing a version of it in the United States in 2005. The A.S.R.’s flaw caused it to shed large quantities of metallic debris after implantation, and the model failed an internal test in 2007 in which engineers compared its performance to that of another of the company’s hip implants, the documents show.
Still, executives in Johnson & Johnson’s DePuy Orthopaedics unit kept selling the A.S.R. even as it was being abandoned by surgeons who worked as consultants to the company. DePuy executives discussed ways of fixing the defect, the records suggest, but they apparently never did so.
Plaintiffs’ lawyers introduced the documents on Friday in Los Angeles Superior Court during opening arguments in the first A.S.R.-related lawsuit to go to trial. The company faces more than 10,000 lawsuits in the United States in connection with the device. An estimated 93,000 patients worldwide received an A.S.R., about one-third of them in the United States.
DePuy executives insisted before the A.S.R.’s recall in mid-2010 that the implant was working well, despite years of complaints from doctors that it was failing early. In late 2009, the company announced plans to phase out the model but said it was doing so because of slowing sales, not safety concerns.
In opening arguments — followed remotely over the Courtroom View Network — a lawyer for DePuy, Alexander G. Calfo, reiterated those positions, telling jurors that DePuy had behaved ethically throughout the A.S.R. episode.
“The evidence will show that DePuy acted as an extremely responsible manufacturer,” Mr. Calfo said.
But a lawyer for Loren Kransky, the plaintiff in the case, painted a far different picture of DePuy’s behavior for jurors in his opening arguments.

Health insurance law debate heats up with GOP praise, Democratic bills to change it

Posted Jan. 25, 2013, at 5:57 p.m.
AUGUSTA, Maine — Lawmakers traded barbs Friday on a 2011 health insurance reform law that Republicans praise for leading to lower premiums in the individual and small-group markets, but Democrats deride for allowing insurers to raise rates without scrutiny.
Democrats made the health insurance reform law a central theme during the 2012 campaign season that ended with them recapturing legislative majorities in both the House and Senate. Now that lawmakers are back at the State House, Democrats already have introduced two bills that target key elements of the law.
Meanwhile, Republicans this week celebrated a new analysis from the state Bureau of Insurance that shows a growing percentage of customers renewing their small-group policies have seen premiums drop since the health insurance reform law passed.
“Some of my Democratic colleagues have said they want to change the law, but in light of the numbers we’re beginning to see as the reform takes effect, we need to be careful about altering this new reform before its potential benefits have been realized,” Rep. Joyce Fitzpatrick of Houlton, the ranking Republican on the Legislature’s Insurance and Financial Services Committee, said in a statement.
The insurance overhaul bill — called Public Law, or PL, 90 — was an attempt to spur more competition in Maine’s health insurance market by making it easier for insurers to offer new plans for small groups and individuals, and by allowing small businesses to band together and negotiate more favorable rates.
The bill also created a high-risk pool — or reinsurance program — to protect insurance companies from the high costs of covering patients who require the most medical care. The law funds the program in part through a $4 assessment on the monthly premium of anyone with private insurance.
In addition, the law allows insurers to charge different rates based on patients’ age, geography and health status. Proponents say that part of the bill is an attempt to woo more young, healthy patients into the marketplace by allowing insurers to charge them less.
Eventually, the law will allow insurers to market plans certified in other states to Maine consumers.
Democrats have said the law does away with important consumer protections and has disproportionately caused premium increases among small businesses in rural areas.

A Flood of Suits Fights Coverage of Birth Control

In a flood of lawsuits, Roman Catholics, evangelicals and Mennonites are challenging a provision in the new health care law that requires employers to cover birth controlin employee health plans — a high-stakes clash between religious freedom and health care access that appears headed to the Supreme Court.
In recent months, federal courts have seen dozens of lawsuits brought not only by religious institutions like Catholic dioceses but also by private employers ranging from a pizza mogul to produce transporters who say the government is forcing them to violate core tenets of their faith. Some have been turned away by judges convinced that access to contraception is a vital health need and a compelling state interest. Others have been told that their beliefs appear to outweigh any state interest and that they may hold off complying with the law until their cases have been judged. New suits are filed nearly weekly.
“This is highly likely to end up at the Supreme Court,” said Douglas Laycock, a law professor at the University of Virginia and one of the country’s top scholars on church-state conflicts. “There are so many cases, and we are already getting strong disagreements among the circuit courts.”
President Obama’s health care law, known as the Affordable Care Act, was the most fought-over piece of legislation in his first term and was the focus of a highly contentious Supreme Court decision last year that found it to be constitutional.
But a provision requiring the full coverage of contraception remains a matter of fierce controversy. The law says that companies must fully cover all “contraceptive methods and sterilization procedures” approved by the Food and Drug Administration, including “morning-after pills” and intrauterine devices whose effects some contend are akin to abortion.
As applied by the Health and Human Services Department, the law offers an exemption for “religious employers,” meaning those who meet a four-part test: that their purpose is to inculcate religious values, that they primarily employ and serve people who share their religious tenets, and that they are nonprofit groups under federal tax law.
But many institutions, including religious schools and colleges, do not meet those criteria because they employ and teach members of other religions and have a broader purpose than inculcating religious values.
“We represent a Catholic college founded by Benedictine monks,” said Kyle Duncan, general counsel of the Becket Fund for Religious Liberty, which has brought a number of the cases to court. “They don’t qualify as a house of worship and don’t turn away people in hiring or as students because they are not Catholic.”

What We Don’t Know Is Killing Us

In one of the 23 executive orders on gun control signed this month, President Obama instructed the Centers for Disease Control and Prevention and other federal science agencies to conduct research into the causes and prevention of gun violence. He called on Congress to aid that effort by providing $10 million for the C.D.C. in the next budget round and $20 million to expand the federal reporting system on violent deaths to all 50 states, from the current 18.
That Mr. Obama had to make such a decree at all is a measure of the power of the gun lobby, which has effectively shut down government-financed research on gun violence for 17 years. Research on guns is crucial to any long-term effort to reduce death from guns. In other words, treat gun violence as a public health issue.
But that is precisely what the National Rifle Association and other opponents of firearms regulation do not want. In the absence of reliable data and data-driven policy recommendations, talk about guns inevitably lurches into the unknown, allowing abstractions, propaganda and ideology to fill the void and thwart change.
The research freeze began at a time when the C.D.C. was making strides in studying gun violence as a public health problem. Before that, the issue had been regarded mainly as a law enforcement challenge or as a problem of disparate acts by deranged offenders, an approach that remains in sync with the N.R.A. worldview.
Public health research emphasizes prevention of death, disability and injury. It focuses not only on the gun user, but on the gun, in much the same way that public health efforts to reduce motor vehicle deaths have long focused on both drivers and cars.
The goal is to understand a health threat and identify lifesaving interventions. At their most basic, gun policy recommendations would extend beyond buying and owning a gun (say, background checks and safe storage devices) to manufacturing (childproofing and other federal safety standards) and distribution (stronger antitrafficking laws), as well as educating and enlisting parents, physicians, teachers and other community leaders to talk about the risks and responsibilities of gun ownership.
But by the early 1990s, C.D.C. gun research had advanced to the point that it contradicted N.R.A. ideology. Some studies found, for example, that people living in a home with a gun were not safer; they faced a significantly elevated risk of homicide and suicide.
The N.R.A. denounced the research as “political opinion masquerading as medical science,” and in 1996, Congress took $2.6 million intended for gun research and redirected it to traumatic brain injury. It prohibited the use of C.D.C. money “to advocate or promote gun control.” Since then, similar prohibitions have been imposed on other agencies, including the National Institutes of Health.

New insurance tools will let patients discover costs