Tuesday, March 12, 2013

Health Care Reform Articles - March 12, 2013

MARCH 12, 2013, 6:00 AM

Too Many Colonoscopies in the Elderly

Bill Fullington doesn’t remember exactly where he read that all adults over age 50 should be screened for colon cancer. A magazine? Maybe the local paper?
In any case, Mr. Fullington, a retired teacher in Birmingham, Ala., takes excellent care of his health; he never smoked, doesn’t drink, hits the gym daily. “Everybody thinks I’m 30 years younger than I am, because of my zip,” Mr. Fullington said in an interview. So he dutifully arranged to have a colonoscopy in 2008, when he was 80.
The doctor removed two small polyps — “the size of BBs,” Mr. Fullington said — and sent him home to recover. The next day, “I woke up screaming in pain.”
At the emergency room at Brookwood Medical Center, tests showed that the procedure had perforated his colon. Mr. Fullington underwent a colostomy and spent a week in intensive care — and that was just the beginning.
March is Colorectal Cancer Awareness Month, so you may be reading and hearing a lot about the importance of screening. You may even get to walk through the eight-foot-high inflatable simulated colon that makes appearances around the country — and see what polyps look like from the inside. But you may not hear much about when colon cancer screening should stop.
Even the Fight Colorectal Cancer Web site, from the major advocacy group working to make Americans aware of the disease and its prevention, says that all adults over age 50 should be screened. “Don’t wait. Talk to your doctor,” it urges.
But in 2008, just a few months after Mr. Fullington’s colonoscopy, the United States Preventive Services Task Force reviewed years of research and recommended against routine screening for colorectal cancer in adults over age 75 and against any screening in those over 85.
Let’s be clear: Screening those over age 50, the group most at risk, makes complete sense. Removing the polyps that may become cancerous years later (but also may not) can prevent the disease. But while colonoscopy is underused by the poor and uninsured, it’s overused by the elderly.

For the Elderly, Medical Procedures to Avoid

The Choosing Wisely campaign, an initiative by the American Board of Internal Medicine Foundation in partnership with Consumer Reports, kicked off last spring. It is an attempt to alert both doctors and patients to problematic and commonly overused medical tests, procedures and treatments.
It took an elegantly simple approach: By working through professional organizations representing medical specialties, Choosing Wisely asked doctors to identify “Five Things Physicians and Patients Should Question.”
The idea was that doctors and their patients could agree on tests and treatments that are supported by evidence, that don’t duplicate what others do, that are “truly necessary” and “free from harm” — and avoid the rest.
Among the 18 new lists released last week are recommendations from geriatricians and palliative care specialists, which may be of particular interest to New Old Age readers. I’ve previously written about a number of these warnings, but it’s helpful to have them in single, strongly worded documents.
The winners — or perhaps, losers?
Both the American Geriatrics Society and the American Academy of Hospice and Palliative Medicine agreed on one major “don’t.” Topping both lists was an admonition against feeding tubes for people with advanced dementia.
“This is not news; the data’s been out for at least 15 years,” said Sei Lee, a geriatrician at the University of California, San Francisco, and a member of the working group that narrowed more than 100 recommendations down to five. Feeding tubes don’t prevent aspiration pneumonia or prolong dementia patients’ lives, the research shows, but they do exacerbate bedsores and cause such distress that people often try to pull them out and wind up in restraints. The doctors recommended hand-feeding dementia patients instead.
The geriatricians’ list goes on to warn against the routine prescribing of antipsychotic medications for dementia patients who become aggressive or disruptive. Though drugs like Haldol, Risperdal and Zyprexa remain widely used, “all of these have been shown to increase the risk of stroke and cardiovascular death,” Dr. Lee said. They should be last resorts, after behavioral interventions.
The other questionable tests and treatments:

A New Commission: Time to Cheer or Yawn?

The fate of the Class Act, which would have established the nation’s first voluntary public long-term care insurance program, was sealed in 2011 when the Obama administration shut it down, essentially calling it unworkable.
As long as the language remained part of the Affordable Care Act, supporters allowed themselves to hope, or perhaps fantasize, that the administration might return to the subject. How to care for an aging population, and who pays for that and how, are questions that won’t go away.
But Congress quietly administered the coup de grâce last month, during the fiscal cliff negotiations. The budget deal stripped the Class Act language from the Affordable Care Act. R.I.P.
In its place — thanks to the intervention of Senator Jay Rockefeller, Democrat of West Virginia — the negotiators created a Commission on Long-Term Care, charged with developing plans for “a comprehensive, coordinated and high-quality system” ensuring long-term care for older adults and people with disabilities.
Its 15 members — three picks each for the president, the Senate majority and minority leaders, and the House speaker and minority leader — face a tight deadline. Within six months, they are supposed to recommend legislative or administrative actions, including actual legislative language. Then bills are to be introduced in both houses of Congress on the very next day they are in session.
Which sounds like urgency, but is it? Even Connie Garner, the longtime Kennedy staff member who directs the advocacy group called Advance Class, was skeptical. “What can you really do in six months?” she said. Actuaries and policy types had been working on the Class plan for 19 months before the plug was pulled. “And so what if you introduce a bill?” she went on. “You can introduce stuff and nothing happens.”
So when Advance Class held its monthly board meeting a few days after the Class Act officially bit the dust, Ms. Garner figured this push for a national long-term care approach was dead, along with her organization. She had prepared a valedictory, praising the group for at least putting the issue on the national agenda.
“But they said, ‘No, we’re going to keep Advance Class going; we’re going to fight the long fight,’ ” she recalled. So on we go.

For Women, Reduced Access to Long-Term Care Insurance

“This was a very, very good business for a short time, with people buying long-term care insurance like it was candy in a candy store,’’ said Michael Perry, a vice president at the Opus Advisory Group, a strategic financial planning firm in Purchase, N.Y.
No more. Mr. Perry has sold only one long-term care policy in the last six months and is “backing off from marketing’’ them as he watches this corner of the insurance business contract, raise premiums, tighten eligibility requirements and reduce key benefits. Long-term care insurance is a comparatively new product, launched in the late ’80s, and only now, as claims begin to pour in, have the actual costs to insurers become apparent.
Companies like MetLife, Prudential Financial, Allianz and Berkshire Financial (a subsidiary of Guardian) have stopped selling new policies and are hiking premiums for the ones already in place — up 37 percent, by one estimate, in 2011. Insurers are increasing elimination periods — the period during which a beneficiary must cover his or her own costs — and reducing inflation protection to 3 percent from 5 percent, once customary. They are requiring home visits instead of phone interviews from new applicants, as well as blood tests and a thorough examination of their medical records.
But the change that has generated the most public attention is so-called gender-distinct pricing, a new strategy that will raise rates for single women by as much as 40 percent beginning in April. Genworth Financial, the nation’s largest long-term care insurance provider with more than a million policy holders, is the first to win approval by state insurance commissions to raise rates for single women purchasing new policies. Women, most of them single by the time they reach advanced age, cost the company $2 of every $3 in benefits paid so far, according to Steve Zabel, Genworth’s senior vice president for long-term care insurance.
The company also will introduce what Mr. Zabel called “enhanced underwriting,” or more stringent qualifying standards, including blood testing to check for nicotine, drugs and markers of cardiovascular disease for all new applicants, regardless of gender or marital status.
Now permitted in all states except Montana and Colorado, gender-distinct pricing will not affect Genworth’s current policyholders, only new applicants. But all other carriers are likely to follow, according to Jesse Slome, executive director of the American Association for Long-Term Insurance, a trade group in Westlake Village, Calif. With the entire industry headed toward higher rates, Mr. Slome recently warned women that “the window is closing” and that now is the time to grab a policy while the price is still manageable.

Widespread Flaws Found in Ovarian Cancer Treatment

Most women with ovarian cancer receive inadequate care and miss out on treatments that could add a year or more to their lives, a new study has found.
The results highlight what many experts say is a neglected problem: widespread, persistent flaws in the care of women with this disease, which kills 15,000 a year in the United States. About 22,000 new cases are diagnosed annually, most of them discovered at an advanced stage and needing aggressive treatment. Worldwide, there are about 200,000 new cases a year.
Cancer specialists around the country say the main reason for the poor care is that most women are treated by doctors and hospitals that see few cases of the disease and lack expertise in the complex surgery and chemotherapy that can prolong life.
“If we could just make sure that women get to the people who are trained to take care of them, the impact would be much greater than that of any new chemotherapy drug or biological agent,” said Dr. Robert E. Bristow, the director of gynecologic oncology at the University of California, Irvine, and lead author of the new study presented on Monday at a meeting of the Society of Gynecologic Oncology in Los Angeles.
The study found that only a little more than a third of patients received the best possible care, confirming a troubling pattern that other studies have also documented.
Karen Mason, 61, from Pitman, N.J., had been a nurse for 28 years when she was found to have ovarian cancer in 2001. She scheduled surgery with her gynecologist, who was not a cancer surgeon.
But her sisters would not allow it. They had gone on the Internet, and became convinced — rightly, according to experts — that she should go to a major cancer center.
“They took the reins out of my hands,” Ms. Mason said.
She wound up having a long, complicated and successful operation performed by a gynecologic oncologist, which she does not believe her gynecologist could have done.

Medicaid Expansion Is Rejected in Florida

MIAMI — Rebuffing Gov. Rick Scott’s support of Medicaid expansion, a Florida Senate committee on Monday rejected the idea, all but ending the possibility that the state would add more poor people to Medicaid rolls.
But the Senate panel debating the expansion proposed a compromise: to accept the federal money but use it to put low-income people into private insurance plans. Accepting the money would please the governor and a number of Floridians, while steering people away from Medicaid, which many lawmakers and residents view as troubled.
The committee vote to reject a Medicaid expansion under President Obama’s health care overhaul was 7 to 4, with Democrats voting for the expansion.
Last week, a Florida House committee voted to reject Medicaid expansion altogether, saying that the system was broken and that adding people to the rolls would cost taxpayers too much money in the long run. The House speaker, Will Weatherford, a Republican, said it was the wrong approach, calling it a “dangerous path.”
From the start, Mr. Scott knew it would be difficult for the Florida Legislature to embrace Medicaid expansion, even for only three years, which is what he proposed. The governor had staked his political career on derailing what he calls “Obamacare,” and his abrupt reversal did not endear him to conservatives in Florida or in the Legislature.
Last week, he made it clear he was not going to lobby the Legislature on Medicaid, preferring to use his influence to push through raises for teachers and eliminate a manufacturing sales tax.
“I am confident that the Legislature will do the right thing and find a way to protect taxpayers and the uninsured in our state while the new health care law provides 100 percent funding,” Mr. Scott said in a statement Monday after the vote.
A Senate committee will convene to develop a plan that would use federal dollars under the law to expand Florida Healthy Kids, a well-established, well-liked health care exchange for low-income children. The proposal would allow the one million uninsured adults who qualify under the health care law to join and choose among various insurance plans. They would pay on a sliding scale, depending on income.

Guest Voice: Business owner says Pa. needs single-payer health plan

Health care, its delivery, quality, coverage and cost is the most perplexing and challenging issue facing the business community today. There is nothing more important to a business in managing its operations than knowing the cost of each component of those operations.

When it comes to health-care protection for employees, however, those costs are difficult to understand and to control, especially for small-business owners who wear many hats and must deal with day-to-day challenges while still finding time to ensure that the long-term plan is also in place. As a small-business owner, my struggle to find a balance between those responsibilities is ever present.

Since World War II, health care has principally fallen upon the shoulders of business. It was discretionary for business owners to provide or not provide health care to employees. Frequently, that meant a hardworking individual had to depend on the employer's health-care plan being a major beneficial component of the business cost and competitive structure. When the plan failed to be beneficial, the employer was free to drop employee health care. As costs rose and competitive conditions changed, many business owners did just that. Often such action was imperative for the business to remain viable.

With the passage of the Affordable Care Act in 2010, businesses are, for the first time, required to provide health care to their employees. Businesses smaller than 50 employees are exempt but their individual employees must now buy insurance to cover themselves and their families. The total impact of these changes to the health-care system is not yet known to business owners, but are much feared.

More and more business owners are asking: Why is health care still our responsibility? Why do we continue to perpetuate a 70-year-old system that is costly and leaves many hardworking people without health protection of any kind? Business owners know their products and services. They are not schooled in health-care administration.

Statins keep cholesterol in check, but they can affect memory and strength

By Christie Aschwanden, Published: March 11

A lawyer contacted Beatrice Golomb, a physician at the VA San Diego Healthcare Center, because he could no longer follow a normal conversation with his clients. A radiologist told Golomb that he found himself suddenly unable to distinguish left from right. A third person told her he had grown so forgetful that his doctor assumed he had Alzheimer’s.
All three had developed their memory problems after taking a cholesterol-lowering statin drug, and the symptoms improved after they stopped the medication.
The statin revolution began in 1987, when lovastatin was approved by the Food and Drug Administration. Since then, this class of drugs has transformed cardiac medicine, says Allen Taylor, chief of cardiology at MedStar Georgetown University Hospital. “Cardiovascular disease affects one in two people. This is the one drug that works.”
But these drugs are not without risks. Golomb has amassed thousands of reports at her Web site, detailing adverse reactions from statins. She says that cognitive problems are the second-most-common side effect reported in her database, after muscle pain. In a 2009 report in the journal Pharmacotherapy, Golomb described 171 patients who’d reported cognitive problems after taking statins.
The idea that a cholesterol-lowering drug could make your brain fuzzy might sound crazy, and Golomb says the notion was greeted with suspicion at first. But eventually the FDA received enough such reports that last February it ordered drug companies to add a new warning label about possible memory problems.

Paul Ryan’s make-believe budget

By Published: March 11

If Rep. Paul Ryan wants people to take his budget manifestos seriously, he should be honest about his ambition: not so much to make the federal government fiscally sustainable as to make it smaller.
You will recall that the Ryan Budget was a big Republican selling point in last year’s election. Most famously, Ryan proposed turning Medicare into a voucher program. He offered the usual GOP recipe of tax cuts — to be offset by closing certain loopholes, which he would not specify — along with drastic reductions in non-defense “discretionary” spending.
If the plan Ryan offered had been enacted, the federal budget would not come into balance until 2040. For some reason, Republicans forgot to mention this detail in their stump speeches and campaign ads.
Voters were supposed to believe that Ryan was an apostle of fiscal rectitude. But his real aim wasn’t to balance the budget. It was to starve the federal government of revenue. Big government, in his worldview, is inherently bad — never mind that we live in an awfully big country.
Ryan and Mitt Romney offered their vision, President Obama offered his, and Americans made their choice. Rather emphatically.
Now Ryan, as chairman of the House Budget Committee, is coming back with an ostensibly new and improved version of the framework that voters rejected in November. Judging by the preview he offered Sunday, the new plan is even less grounded in reality than was the old one.
Voters might not have focused on the fact that Ryan’s original plan wouldn’t have produced a balanced budget until today’s high school students reached middle age, but the true deficit hawks in the House Republican caucus certainly noticed. They demanded a budget that reached balance much sooner. Hence Ryan’s revised plan, which claims to accomplish this feat of equilibrium within a decade.
It will, in fact, do nothing of the sort, because it appears to depend on at least one ridiculous assumption and two glaring contradictions. That’s for starters; I’m confident we’ll see more absurdities when the full proposal is released soon.

Consensus to expand Medicaid in Maine seen as likely

Posted: March 11
Updated: Today at 9:01 AM

The governor's willingness to consider Medicaid expansion is noteworthy because of the deep opposition he expressed just a few months ago.

AUGUSTA — Republican Gov. Paul Le-Page and the Democratic-controlled Legislature appear to be moving toward a consensus that would expand Medicaid in Maine and end a month-long political standoff over debt payments to the state's hospitals.
LePage signaled Monday that he's open to participating in the federal health care law's Medicaid expansion program, but will seek the "best deal for Mainers."
At the same time, Democratic legislative leaders released a plan to pay Maine hospitals the $484 million that they're owed.
LePage has been urging lawmakers to dedicate revenue from a new wholesale liquor contract to the hospital payments. But Democrats have not acted on his bill, making it clear that they want Medicaid expansion before they support the hospital reimbursements.

LePage administration talking with feds about Medicaid expansion

Posted March 11, 2013, at 1:28 p.m.
AUGUSTA, Maine — Gov. Paul LePage’s administration is starting conversations with officials in the Obama administration about a potential expansion of Maine’s Medicaid program under the federal Affordable Care Act.
LePage spokeswoman Adrienne Bennett said Monday that members of LePage’s administration began internal discussions about the Medicaid expansion within “the last couple of weeks,” after announcements from a number of other Republican governors that they would accept funds from the federal government to expand their Medicaid programs. Conversations with the U.S. Department of Health and Human Services were to begin Monday, according to Bennett.
“We’ve seen the deals struck by other states — and that’s not to say that Medicaid expansion is the right thing to do,” Bennett said. “It’s just that the right thing to do right now is begin a dialogue with the federal government and find out where Maine’s at.”
The LePage administration has so far remained opposed to expanding the state’s Medicaid program, saying Maine already has a generous Medicaid program it can’t afford and the state can’t count on a promise from the federal government to stick to increased Medicaid funding rates.
“What we want to ensure is that we have a minimal, quality safety net for our most needy and one that is affordable for Maine people,” Bennett said.
Over the past few months, a growing number of Republican governors who, like LePage, staunchly opposed the Obama administration’s health care reform bill have said they would sign their states up for a Medicaid expansion, citing the potential for additional federal funds to provide more of their residents with health insurance.

A start toward health care solutions

Posted March 11, 2013, at 6:28 p.m.
The political winds shifted on Monday in surprising and encouraging fashion. Gov. Paul LePage’s office said it has started talking with the Obama administration about potentially expanding Maine’s Medicaid program under the federal Affordable Care Act. And Democratic legislative leaders unveiled their plan to pay the debt the state owes its hospitals.
Both announcements represent positive steps and possibly a way for political opposites to meet in the middle. Lawmakers would be wise, as they dig into the details and debate both Medicaid reform and paying the debt to hospitals incurred for their Medicaid services, to keep the wider health care picture in mind. The two topics — Medicaid expansion and a debt repayment plan for the hospitals — are part of the same larger issue concerning how to provide good care for all while reducing costs over time.
Debt owed to hospitals — for their services provided under the state’s Medicaid program — ballooned during the last decade, after Maine expanded Medicaid eligibility, health care costs increased, and the state had to pay a legal settlement to 21 hospitals. Medicaid expenses are a major cost driver for the Department of Health and Human Services and have caused many of the state’s unfortunate supplemental budgets. A new approach was needed long ago.
There may be relief if the state expands Medicaid under Obamacare. Until Monday, Maine was among the minority of states that had rejected or leaned toward rejecting the expansion, which would extend Medicaid coverage to those not traditionally covered under the public health insurance program. LePage had argued that expanding Medicaid would not be affordable, but financial analyses from the Kaiser Family Foundation and the conservative Heritage Foundation have showed that Maine would be one of 10 states to see the amount of money it spends on Medicaid decrease during the next decade, while the federal share would increase.
In choosing to expand Medicaid, the state would be committing to improving public health and reducing health differences linked to economic disadvantages. Democratic legislative leaders articulated that fact on Monday when they unveiled their plan to repay the hospitals. They called for more transparency in medical billing, a shift toward a system of care in which doctors are paid for improving health, and a willingness to accept federal dollars to expand Medicaid.
Of course, the past must be dealt with, too. How can the state pay $484 million in hospital debt while retaining the greatest possible value from a renegotiated liquor contract? Answering that question will require Maine lawmakers to analyze the financial projections of two competing proposals, from LePage and Sen. Seth Goodall, D-Richmond.

Because the governor would rather fight than lead, he is missing an opportunity to govern, and Maine people are missing out on solutions that can improve their lives. That is too high a cost to pay whether you are a Republican, a Democrat or independent.
Consider the current debate at the State House, which seems to be heading toward a stalemate. However, a closer look at the competing priorities suggests an opportunity to take a comprehensive approach to solving our state’s challenges.
First, Gov. Paul LePage wants to pay off the debt owed to hospitals. Both Democratic and Republican lawmakers agree that the debt should be paid. Democrats in the Legislature have also offered a plan to expand Medicaid — known as MaineCare in Maine — by accepting $300 million from the federal government while also reforming hospital billing to reduce costs and improve outcomes. If we reject the federal offer, then all those tax dollars — our tax dollars — would simply go to another state.
Why not bring that money to Maine where it can strengthen our health-care system, improve the care of our elderly, children and families and make a real difference? Republican governors across the country, from Arizona to New Jersey, are eagerly accepting their share of new funds to expand health care. Why not our governor?

'Bitter pill' should prompt lawmakers to back Medicare for all

By Timothy Shaw, M.D.
The Capital Times (Madison, Wis.), Letters, March 11, 2013
Steven Brill’s recent Time magazine article “Bitter Pill: Why Medical Bills Are Killing Us,” rightly portrays our American health care system as a mess. Health care has become an unaffordable business monopoly that benefits the medical community and corporations the most, and patients the least.
But before the right-wing media starts spinning the fantasy that this mess is “Obamacare,” I want to emphasize that this is NOT Obamacare. Speaking at an AFL-CIO event in 2003, then Sen. Obama advocated for a single-payer plan. But in 2010, President Obama had to settle for the Patient Protection and Affordable Care Act. While it has some excellent provisions in it, it still leaves in place a dysfunctional, employer-based, for-profit health care system which is the cause of the problems elucidated in Brill’s article.
PPACA, as written, was influenced by over 3,000 special-interest lobbyists — doctors, health insurers, big PHARMA, hospital systems, etc. Influenced by special-interest money, Congress dropped the public option, and when eight caring doctors and nurses rose to speak at a congressional hearing in favor of an affordable single-payer system, they were arrested.
Some of our elected leaders speak in disfavor of labor unions, but encourage and are funded by the excessively greedy and profitable union of doctors, insurers, hospitals and big PHARMA.
Our elected leaders should live up to their oath of office and “promote the general welfare” by expanding our Medicare system to ALL citizens equally by voting for H.R. 676 “Expanded and Improved Medicare for All Act.”
Dr. Timothy Shaw resides in Fitchburg, Wis.

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