Tuesday, April 30, 2013

Health Care Reform Articles - April 30, 2013

Hospitals trying arsenal of superbug-fighting inventions

Mike Stobbe / The Associated Press
NEW YORK — They sweep. They swab. They sterilize. And still the germs persist.
In U.S. hospitals, an estimated 1 in 20 patients pick up infections they didn't have when they arrived, some caused by dangerous 'superbugs' that are hard to treat.
The rise of these superbugs, along with increased pressure from the government and insurers, is driving hospitals to try all sorts of new approaches to stop their spread:
Machines that resemble "Star Wars" robots and emit ultraviolet light or hydrogen peroxide vapors. Germ-resistant copper bed rails, call buttons and IV poles. Antimicrobial linens, curtains and wall paint.
While these products can help get a room clean, their true impact is still debatable. There is no widely accepted evidence that these inventions have prevented infections or deaths.
Meanwhile, insurers are pushing hospitals to do a better job and the government's Medicare program has moved to stop paying bills for certain infections caught in the hospital.
"We're seeing a culture change" in hospitals, said Jennie Mayfield, who tracks infections at Barnes-Jewish Hospital in St. Louis.
Those hospital infections are tied to an estimated 100,000 deaths each year and add as much as $30 billion a year in medical costs, according to the Centers for Disease Control and Prevention. The agency last month sounded an alarm about a "nightmare bacteria" resistant to one class of antibiotics. That kind is still rare but it showed up last year in at least 200 hospitals.
Hospitals started paying attention to infection control in the late 1880s, when mounting evidence showed unsanitary conditions were hurting patients. Hospital hygiene has been a concern in cycles ever since, with the latest spike triggered by the emergence a decade ago of a nasty strain of intestinal bug called Clostridium difficile, or C-diff.

How the 19-year-old brain can both awe and appall us

Posted April 25, 2013, at 12:04 p.m.
Among the most mysterious things on the planet is the brain of a male in his late teens. It has been designed by evolution for purpose without much perspective, passion without much reason, reproduction without much responsibility and performance without caution. If it was a car, it would be a Corvette convertible with 430 horsepower, no seat belts or brakes and a horn that blared, “Hey, babe, wanna go for a ride?”
That’s why we send their owners to goal lines and front lines, but don’t let them drink until they are 21. That’s why we love having them as sons but are reluctant to have them date our daughters. And as we were reminded last Monday in Boston’s marathon, it’s why we should not be surprised that among the millions of teen males growing up around us, one of them seems like a great kid one day and — under the influence of an influential, older ringleader — does something stupid, crazy or appalling the next.
Neuroscientists and other brain experts now know what the rest of us need to understand about brain biology: Those 19-year-old brains, while capable of doing things with some adult capability and many adult consequences, are not the same as fully developed adult brains. The typical brain of the late adolescent has at least three to five more years of development to go before judgment, impulse control, insight, good risk and consequence appreciation, consistent assumption of responsibility and emotional control are fully “wired” and fully functional. Neurons remain to be connected, frontal lobe nerve fibers remain to be coated with myelin so that judgment function routinely and effectively precedes decision function, and the brain wiring for full maturity is completed. (Some of you women would say all that never happens in men.)
Evidence of this incomplete development fills our living rooms with sprawled teenage males about to turn 20 with little sense of what they want to do when they grow up, and our parental lives with wonderful or painful chaos. It fills our legal systems with troubled teenagers on the verge of growing up too fast by being sentenced as adults, and our graveyards with premature deaths of 18- to 24-year-olds by the thousands in America each year. These young “boys-into-men” have among the highest crash, crime and chaos rates of our entire population.
At the same time, they go into battle for us, haul injured comrades out of harm’s way and fill our chests with pride and our eyes with tears because they can be so glorious to behold. Prince or pain; we are not certain which they will be, or when they will be whatever, because they often don’t know either and they often can be both for several difficult years.

Next Big Challenge for Health Law: Carrying It Out

WASHINGTON — This month, a political organization aligned with House Republicans sent an e-mail to reporters attacking President Obama’s health care law.
“Young adults on parents’ plan pay more,” said the organization, the YG Network, citing a new employee benefits study. The e-mail’s subject line read, “So Much for Popularity.”
Actually, the study did not show that those young adults were paying more. It showed that insurance companies were, because they had begun providing health coverage to those young adults, as called for under the law.
The missive, inaccurate though it was, illustrates the immense challenge facing the Obama administration as it puts in place the most significant parts of the landmark 2010 law. Few government initiatives reach so many corners of the American economy and society — and have as much potential to generate trouble for the party in the White House.
Among the complex imperatives: pushing reluctant states to set up insurance marketplaces and expand Medicaid programs, keeping an eye on insurance companies as they issue new rate schedules, measuring the law’s effects on small-business hiring, and coaxing healthy young people to buy coverage so the system works economically for everyone else.
Gail Wilensky, who ran Medicare and Medicaid under President George Bush and supports the new law, said that 2014, when the law will make it mandatory to have insurance, “is going to be quite a bumpy year.”
Austan Goolsbee, a former chief economist to Mr. Obama, predicted “a big messaging headache the whole year.”
A fresh example popped up last week, to the delight of Republican opponents of the law. An article by Politico reported “high-level confidential talks about exempting lawmakers and Capitol Hill aides” from the health law.
In fact, lawmakers said, the talks that the article referred to concerned preserving the same kind of employer-subsidized health coverage for Congressional employees that workers at private companies can receive under the law. Yet the article, which quoted a spokesman for Speaker John A. Boehner as talking about “the ravages of the president’s health care law,” sent White House aides and other Democrats scrambling to avoid the appearance of special treatment.
The law poses some modest potential headaches for the overall economy.

Engaged or Detached?

Let’s say you are a young person beginning to write about politics and policy. You probably have some idea of what you believe, but have you thought about how you believe it? That is to say, have you thought about where you will sit on the continuum that stretches from writers who are engaged to those who are detached?
Writers who are at the classic engaged position believe that social change is usually initiated by political parties. To have the most influence, the engaged writer wants to channel his efforts through a party.
The engaged writer closely and intimately aligns with a team. In his writing, he provides arguments for the party faithful and builds community by reminding everyone of the errors and villainy of the opposing side. For the engaged writer, the writing is often not about persuasion. (Realistically, how many times does a piece of writing persuade someone to switch sides?) It’s often about mobilization. It’s about energizing the people who already agree with you.
The engaged writer often criticizes his own party, but from a zone of trust inside it, and he is usually advising the party to return to its core creed. The engaged writer is willing to be repetitive because that’s how you make yourself an unavoidable pole in the debate. The goal is to have immediate political influence, to provide party leaders with advice, strategy and policy recommendations.
The detached writer also starts with a worldview. If you don’t have a philosophic worldview, your essays won’t even rise to the status of being wrong. They won’t be anything.
But the detached writer wants to be a few steps away from the partisans. She is progressive but not Democratic, conservative but not Republican. She fears the team mentality will blinker her views. She wants to remain mentally independent because she sees politics as a competition between partial truths, and she wants the liberty to find the proper balance between them, issue by issue.
The detached writer believes that writing is more like teaching than activism. Her essays are generally not about winning short-term influence. (Realistically, how many times can an outside writer shape the short-term strategies of the insider politicians?) She would rather have an impact upstream, shaping people’s perceptions of underlying reality and hoping that she can provide a context in which other people can think. She sometimes gets passionate about her views, but she distrusts her passions. She takes notes with emotion, but aims to write with a regulated sobriety.

Advocacy groups put pressure on Maine lawmakers to support Medicaid expansion

Posted April 29, 2013, at 1:07 p.m.
AUGUSTA, Maine — A coalition of advocacy groups, including AARP Maine, the American Cancer Society Cancer Action Network and the American Heart Association, will launch newspaper and radio advertisements Tuesday urging legislators to support a plan that would allow the state to expand Medicaid benefits under the Affordable Care Act.
The ad campaign comes after a weekend in which Republican Gov. Paul LePage and Democratic legislative leaders sparred over the proposal and whether it should be linked to a plan to repay the state’s Medicaid debt to Maine’s hospitals.
LePage and Republican legislative leaders remained more focused Monday on repaying the state’s $186 million share of an overall $484 million Medicaid debt to Maine’s 39 hospitals.
On Monday, the governor issued a statement challenging Democratic legislative leaders to schedule an up-or-down vote on his proposal to use revenue bonds derived from renegotiating the state’s wholesale liquor contract to repay the hospitals.
House Republican Leader Ken Fredette of Newport followed with a statement echoing LePage’s call. “Paying our bills to Maine’s hospitals is the one big issue we’re all in agreement on at the State House and indeed throughout the state,” Fredette said. “It deserves a clean, up-or-down vote.”
“Maine has an opportunity to expand access to health care to thousands of people, while also reducing health care costs and providing a boost to our economy,” Becky Smith, director of government relations for the American Heart Association in Maine, said Monday in a prepared statement. “Our goal is to raise awareness about this important issue and encourage Mainers to let their voices be heard.”
The ads provide a toll-free phone number that Mainers can call to urge their legislators to support the Medicaid expansion. The release announcing the ads cites a Maine People’s Resource Center pollshowing that 68 percent of respondents support the expansion. The Maine People’s Resource Center is affiliated with the Maine People’s Alliance, a liberal advocacy group that opposes many of LePage’s policies.
The group, called the Cover Maine Now! Coalition, also has begun collecting signatures on a petition encouraging legislators to support the Medicaid expansion, according to the release.
Under the Affordable Care Act, President Barack Obama’s 2010 health care reform law, Maine has the option of expanding Medicaid. Under the law, the federal government will cover 100 percent of costs for newly eligible Medicaid recipients for three years. The 100 percent funding will gradually drop to 90 percent in 2020, and states will have to make up the remaining share.
Rep. Linda Sanborn, D-Gorham, has introduced legislation calling for Maine to participate in the expansion. The LePage administration has generally opposed expanding Medicaid, but his administrationbegan discussing the possibility with federal officials after a number of other Republican governors said they would accept the federal Medicaid funds in their states.
Health and Human Services Commissioner Mary Mayhew last month sent a letter to U.S. Health and Human Services Secretary Kathleen Sebelius requesting more flexibility and more funding — 10 years of full federal expansion funding rather than the three prescribed in law — as a condition for Maine to expand Medicaid.
LePage said Saturday that Mayhew is traveling to Washington, D.C., this week discuss details with federal officials.

Paying off the hospital debt and expanding Medicaid eligibility would be good policy.

Gov. LePage has made paying Maine's debt to hospitals his top policy priority. He says that paying for services already rendered is not only the right thing to do, it would be good for the state's economy.
Raising $186 million in state money through the revenue of liquor sales would release $298 million from the federal government. Since hospitals are among the state's biggest employers and economic actors, these funds would reverberate through communities still struggling to recover from the recession.
He's right, but the same arguments can be made for another health care policy that he has chosen to oppose -- accepting federal funds to enroll more people in MaineCare, the state's version of Medicaid.
Expanding access to health care is the right thing to do: People with health insurance live longer and lead healthier lives than those without. And with 69,000 more Mainers insured -- all on the federal government's tab -- millions more dollars would be delivered to Maine hospitals and have the same positive effect on local economies.
And expanding Medicaid would attack one of the biggest cost drivers in Maine's high health insurance costs -- uncompensated charity care, usually in emergency departments.

LePage: Health law to send U.S. 'into a spiral'

Speaking to a crowd of business leaders, he also criticizes President Obama and Maine's wind-energy industry.

By Kevin Miller
Washington Bureau Chief
WASHINGTON — Maine Gov. Paul LePage lashed out against President Obama's health care initiative Monday, predicting the law "is going to put this country into a spiral" and that Obama "is going to ruin the American Dream as we know it."
Speaking to several hundred business owners from across the country, LePage also once again blamed Maine's high energy costs on the growing wind power industry in the state.
LePage, a Republican, said the Obama administration's Affordable Care Act -- commonly referred to as "Obamacare" -- would result in higher health care costs in Maine and is undercutting his own administration's efforts to increase competition in the insurance market.
"I think the ACA is going to put this country into a spiral," said LePage, one of three governors speaking as part of a U.S. Chamber of Commerce panel discussion. "I think the country is partly in a spiral now, but I think this president ... is going to ruin the American Dream as we know it.
"And the reason why is the American Dream is based on earned success. You earn it," LePage said. "Whereas he believes in learned dependency. He believes very, very strongly that every American's American Dream is provided by the government. And it doesn't work that way."

A simple way to improve Maine’s health care delivery

Posted April 29, 2013, at 2:23 p.m.
Maine officials and health care professionals know of ways to make the delivery of health care more efficient and reduce costs, but political agreement is difficult. One preventive approach, however — where health care providers focus on the underlying reason for an illness instead of only treating the illness — should not be a difficult political lift and deserves greater recognition and implementation in health care circles.
The spending problem could rightfully be called a crisis. Maine is fifth in the nation for health care spending per person. Its health care costs per capita exceed the national average and continue to increase at a faster-than average rate. The Maine Economic Growth Council’s “ Measures of Growth in Focus” 2013 report identifies health care spending as having an “enormous impact on Maine’s economy.” Maine businesses identified the cost of health care as being the top obstacle to investment in a 2010 Maine Development Foundation survey.
The state, unfortunately, does not have a long-term strategy to reduce health care costs, though some good efforts are being carried out in parts of Maine. The “ Accountable Care Organization” model has propelled some doctors, hospitals and other providers to work together to avoid the duplication of services under Medicare, for example, and prevention efforts have expanded under the Affordable Care Act.
Another approach worth pursuing more is trauma-informed care. Studies have shown that when doctors identify a patient’s childhood abuse or emotional trauma and recognize that it contributed to the patient’s health concern, patients end up not needing their doctors as frequently. The approach requires physicians to make a change in the way they practice medicine.
In some cases the correlation between childhood trauma and disease is profound, as Vincent Felitti and Robert Anda learned in their Adverse Childhood Experiences Study, which was carried out in Kaiser Permanente’s Department of Preventive Medicine in San Diego, together with the U.S. Centers for Disease Control and Prevention. They studied 17,000 individuals to record the effect that traumatic childhood experiences had later in life.
Two-thirds of the middle-class population surveyed had experienced at least one adverse childhood experience, such as abuse, neglect or growing up with an alcoholic or drug-addicted parent. The researchers found a proportionate relationship between the number of trauma-related categories that people experienced and the following: self-acknowledged chronic depression, hallucinations, smoking, alcoholism, impaired worker performance, drug use, liver disease and chronic obstructive pulmonary disease — all conditions that require expensive treatments and that are partially responsible for continually rising health care costs.
It turned out what was often presenting as the person’s health problem, such as obesity or an addiction, was, in fact, sometimes the person’s attempted solution for dealing with the long-term effects of trauma. As one study subject, who was beaten as a child and later turned to alcohol, cigarettes and drugs, said, “I found a way to block the emotions and the memories.”

Hospitals that pay no taxes must tend to community health

Posted April 28, 2013, at 1:23 p.m.
Consider the tax-exempt hospital.
Traditionally, these hospitals have offered free or subsidized medical treatment for poor patients. Over the past half-century, however, as the federal government has taken to paying for health care — via Medicare, Medicaid and, now, the Affordable Care Act — policymakers have tried to steer the nation’s 2,900 tax-exempt hospitals away from charity medical treatment for individuals and toward the kinds of preventive public-health services that are believed to lower health care costs generally: community blood-pressure and mammography screening, clinics for weight loss and smoking cessation, and so on.
To push this shift, the Internal Revenue Service has required tax-exempt hospitals to report annually on the community benefits they provide. Now, under the Affordable Care Act, they also have to formally assess, every three years, the health needs of their communities and adopt strategies to meet those needs. The idea is to hold the hospitals accountable for the estimated $13 billion in federal, state and local tax breaks they receive.
It’s too soon to tell whether the latest reporting requirement will accomplish the shift policy makers are looking for. What is known is that hospitals have a long way to go to live up to their mandate.
According to a study published last week in the New England Journal of Medicine, only 5 percent of the money that tax-exempt hospitals spent on behalf of their communities in fiscal year 2009 went to public-health programs. The lion’s share went to free and subsidized patient care.

Sunday, April 28, 2013

Health Care Reform Articles - April 28, 2013

If this was a pill, you’d do anything to get it

By Ezra Klein, Updated: 

When Ken Coburn has visitors to the cramped offices of Health Quality Partners in Doylestown, Pa., he likes to show them a graph. It’s not his graph, he’s quick to say. Coburn is not the sort to take credit for other’s work. But it’s a graph that explains why he’s doing what he’s doing. It’s a graph he particularly wishes the folks who run Medicare would see, because if they did, then there’s no way they’d be threatening to shut down his program.
The graph shows the U.S. death rate for infectious diseases between 1900 and 1996. The line starts all the way at the top. In 1900, 800 of every 100,000 Americans died from infectious diseases. The top killers were pneumonia, tuberculosis and diarrhea. But the line quickly begins falling. By 1920, fewer than 400 of every 100,000 Americans died from infectious diseases. By 1940, it was less than 200. By 1960, it’s below 100. When’s the last time you heard of an American dying from diarrhea?
“For all the millennia before this in human history,” Coburn says, “it was all about tuberculosis and diarrheal diseases and all the other infectious disease. The idea that anybody lived long enough to be confronting chronic diseases is a new invention. Average life expectancy was 45 years old at the turn of the century. You didn’t have 85-year-olds with chronic diseases.”
With chronic illnesses like diabetes and heart disease you don’t get better, or at least not quickly. They don’t require cures so much as management. Their existence is often proof of medicine’s successes. Three decades ago, cancer typically killed you. Today, many cancers can be fought off for years or even indefinitely. The same is true for AIDS, and acute heart failure and so much else. This, to Coburn, is the core truth, and core problem, of today’s medical system: Its successes have changed the problems, but the health-care system hasn’t kept up.
Kenneth Thorpe, chairman of the health policy and management school at Emory University, estimates that 95 percent of spending in Medicare goes to patients with one or more chronic conditions — with enrollees suffering five or more chronic conditions accounting for 78 percent of its spending. “This is the Willie Sutton rule,” he says. “If 80 percent of the spending is going to patients with five or more conditions, that’s where our health-care system needs to go.”
Health Quality Partners is all about going there. The program enrolls Medicare patients with at least one chronic illness and one hospitalization in the past year. It then sends a trained nurse to see them every week, or every month, whether they’re healthy or sick. It sounds simple and, in a way, it is. But simple things can be revolutionary.

Doctors Denounce Cancer Drug Prices of $100,000 a Year

With the cost of some lifesaving cancer drugs exceeding $100,000 a year, more than 100 influential cancer specialists from around the world have taken the unusual step of banding together in hopes of persuading some leading pharmaceutical companies to bring prices down.
Prices for cancer drugs have been part of the debate over health care costs for several years — and recently led to a public protest from doctors at a major cancer center in New York. But the decision by so many specialists, from more than 15 countries on five continents, to join the effort is a sign that doctors, who are on the front lines of caring for patients, are now taking a more active role in resisting high prices. In this case, some of the specialists even include researchers with close ties to the pharmaceutical industry.
The doctors and researchers, who specialize in the potentially deadly blood cancer known as chronic myeloid leukemia, contend in a commentary published online by a medical journal Thursday that the prices of drugs used to treat that disease are astronomical, unsustainable and perhaps even immoral.
They suggested that charging high prices for a medicine needed to keep someone alive is profiteering, akin to jacking up the prices of essential goods after a natural disaster.
“Advocating for lower drug prices is a necessity to save the lives of patients” who cannot afford the medicines, they wrote in Blood, the journal of the American Society of Hematology.
While noting that the cost of drugs for many other cancers were just as high, the doctors focused on what they know best — the medicines for chronic myeloid leukemia, like Gleevec, which is enormously profitable for Novartis. Among the critics is Dr. Brian Druker, who was the main academic developer of Gleevec and had to prod Novartis to bring it to market.
Novartis argues that few patients actually pay the full cost of the drug and that prices reflect the high cost of research and the value of a drug to patients.
Gleevec entered the market in 2001 at a price of about $30,000 a year in the United States, the doctors wrote. Since then, the price has tripled, it said, even as Gleevec has faced competition from five newer drugs. And those drugs are even more expensive.
The prices have been the subject of intense debate elsewhere as well. The Supreme Court in India ruled recently that the drug could not be patented, clearing the way for use of far less expensive generic alternatives.
Some of the doctors who signed on to the commentary said they were inspired by physicians at the Memorial Sloan-Kettering Cancer Center in New York, who last fall refused to use a new colon cancer drug, Zaltrap, because it was twice as expensive as another drug without being better.
After those doctors publicized their objections in an Op-Ed article in The New York Times, Sanofi, which markets Zaltrap, effectively cut the price in half.
What impact the new commentary will have remains to be seen. The authors, however, call merely for a dialogue on pricing to begin.

U.S. Sues Novartis Again, Accusing It of Kickbacks

The United States government on Friday announced its second civil fraud lawsuit against the Swiss drug maker Novartis in four days, accusing a unit of the company of paying multimillion-dollar kickbacks to doctors in exchange for prescribing its drugs.
The authorities said that for a decade, the company lavished healthy speaking fees and “opulent” meals, including a nearly $10,000 dinner for three at the restaurant Nobu, to induce doctors to prescribe its drugs.
They said this led to the Medicare and Medicaid programs’ paying millions of dollars in reimbursements based on kickback-tainted claims for medication like thehypertension drugs Lotrel and Valturna and the diabetes drug Starlix.
The charges are described in a whistle-blower lawsuit first filed against Novartis Pharmaceuticals by a former sales representative in January 2011 and which the federal government has now joined.
Twenty-seven states, the District of Columbia and Chicago and New York are also plaintiffs in the lawsuit, which seeks triple damages under the federal False Claims Act.
“Novartis corrupted the prescription drug dispensing process,” Preet Bharara, the United States attorney in Manhattan, said in a statement. “For its investment, Novartis reaped dramatically increased profits on these drugs, and Medicare, Medicaid and other federal health care programs were left holding the bag.”
On Tuesday, the government accused Novartis of inducing pharmacies to switch thousands of kidney transplant patients to its immunosuppressant drug Myfortic in exchange for kickbacks disguised as rebates and discounts.

Another Alleged Drug Kickback Scheme

Two federal lawsuits charging a prominent drug company with making fraudulent kickbacks to promote sales of its drugs raise disturbing questions about how to control fraudulent behavior in the pharmaceutical industry, behavior that appears to be on the rise. The company is Novartis Pharmaceuticals, the American subsidiary of a Swiss-based multinational. Novartis denies any wrongdoing and vows to defend itself in court.
Less than three years ago, Novartis settled criminal and civil investigations into whether it had illegally promoted drugs to health care professionals for uses not approved by the Food and Drug Administration. The company was accused of providing illegal kickbacks to doctors through such mechanisms as entertainment, travel, and appointment to advisory boards or speaker programs. It paid $422.5 million to settle the case and signed a “corporate integrity agreement” to ensure that its promotional functions would comply with a federal anti-kickback statute.
Last week Preet Bharara, the United States attorney for the Southern District of New York, announced the filing of a lawsuit accusing the company of providing even more blatant kickbacks to pharmacies to generate sales of one of its better-selling drugs. The suit charged that Novartis provided illegal rebates and discounts to 20 or more influential pharmacies based on their success in persuading institutions and doctors to switch patients from other drugs to Myfortic, an immune suppressant used to prevent rejection of kidney transplants. (If prosecutors want to send an even stronger message, they should also pursue the corrupt pharmacies, which are suspected of pocketing tens or hundreds of thousands of dollars in illegal kickbacks.)
The federal prosecutors also filed a second suit, charging that Novartis Pharmaceuticals made illegal payments to physicians in the form of honorariums and other benefits to induce them to write prescriptions for various other drugs made by the company. These sound like exactly the kinds of payments that Novartis pledged not to make in the settlement three years ago.

Democratic Senators Tell White House of Concerns About Health Care Law Rollout

WASHINGTON — Democratic senators, at a caucus meeting with White House officials, expressed concerns on Thursday about how the Obama administration was carrying out the health care law they adopted three years ago.
Democrats in both houses of Congress said some members of their party were getting nervous that they could pay a political price if the rollout of the law was messy or if premiums went up significantly.
President Obama’s new chief of staff, Denis R. McDonough, fielded questions on the issue for more than an hour at a lunch with Democratic senators.
Senator Jeanne Shaheen, Democrat of New Hampshire, who is up for re-election next year, said, “We are hearing from a lot of small businesses in New Hampshire that do not know how to comply with the law.”
In addition, Mrs. Shaheen said, “restaurants that employ people for about 30 hours a week are trying to figure out whether it would be in their interest to reduce the hours” of those workers, so the restaurants could avoid the law’s requirement to offer health coverage to full-time employees.
The White House officials “acknowledged that these are real concerns, and that we’ve got to do more to address them,” Mrs. Shaheen said.
Senator Tom Harkin, Democrat of Iowa and chairman of the appropriations subcommittee on health care, said he was extremely upset with Mr. Obama’s decision to take money from public health prevention programs and use it to publicize the new law, which creates insurance marketplaces in every state.
“I am greatly disappointed — beyond upset — that the administration chose to help pay for the Affordable Care Act in fiscal year 2013 by raiding the Public Health and Prevention Fund,” Mr. Harkin said.
The administration said it had transferred $332 million from the prevention fund to pay for “education and outreach” activities publicizing the new insurance markets, or exchanges.
To express his displeasure, Mr. Harkin has blocked Senate action on Mr. Obama’s nominee to be administrator of the Centers for Medicare and Medicaid Services, Marilyn B. Tavenner. By putting a “hold” on the nomination, aides said, Mr. Harkin hopes to draw the White House into negotiations on the future of the prevention fund, which he has championed.
At Congressional hearings this week, Kathleen Sebelius, the secretary of health and human services, said it was necessary to tap the prevention fund because Congress had refused to provide money requested by the president for outreach and education activities.

Maine Democrats offer deal on debt to hospitals

Gov. LePage blasts the proposal, which links repayment of the debt to an expansion of Medicaid.

By Steve Mistler
Staff Writer
AUGUSTA – The Legislature's Democratic leaders have told Gov. Paul LePage that they will pass his plan to pay back Maine's hospitals but they want it directly linked to the state's participation in a federal program to expand health care coverage for low-income Mainers.
LePage blasted the proposal Friday, saying Democrats had "reneged" on their agreement to pay the state's 39 hospitals for overdue Medicaid reimbursements.
House Speaker Mark Eves, D-North Berwick, and Senate President Justin Alfond, D-Portland, told the governor their plan Thursday during a closed-door meeting in the governor's Cabinet Room. It marks a shift in the debate over paying back more than $484 million to the hospitals and a separate policy to expand Medicaid to about 55,000 Mainers. 
The two proposals have been linked because Maine's hospitals, which are influential in state politics, support both. But the Democrats' proposal is their first attempt to directly tie LePage's hospital payback plan to his acceptance of federal dollars to expand Medicaid.
It's also one of the first attempts by Democratic leaders to assert themselves by leveraging their legislative majority to advance one of their primary policy initiatives. 

Why is Maine 5th in US for health care spending?

Posted April 26, 2013, at 2:51 p.m.
AUGUSTA, Maine — The state’s health care costs per person exceed the national average and continue to rise at a faster-than-average rate. But while lawmakers often stress the need to rein in health care spending, they have not settled on a long-term strategy to do so.
Discord among Democrats and Republicans over crafting that strategy emerged on the House floor Wednesday when legislators debated a bill that would form a state Commission on Health Care Cost and Quality and charge it with developing a plan for cutting costs and improving outcomes in Maine’s health care system.
Democrats said the legislation, LD 230, was needed to focus health care reforms in the state on a common goal. Republicans, meanwhile, said the commission would duplicate work already underway at the Department of Health and Human Services — and at a significant cost.
The bill garnered initial approval in the Democratically controlled House with a 90-57 party-line vote. While it sparked partisan tension, members of both parties acknowledged Maine needs a coordinated plan if it stands a chance of improving the health of its population and controlling health care costs.

Above-average costs, growth

In 1993, spending on health care in Maine totaled $3.6 billion, according to the federal Centers for Medicare and Medicaid Services. By 2009, that figure had risen 214 percent, to $11.2 billion. Total property taxes in Maine rose 103 percent during that period, in comparison.
Health care spending today accounts for more than a fifth of Maine’s economy — 22.4 percent in 2009, according to the Maine Development Foundation. And Maine Department of Labor statisticsshow the health care and social assistance sector accounts for one in five jobs in the state.
The underlying figures portend affordability problems for the Maine businesses and residents who pay for health insurance. They also portend problems for the state budget, which needs to fund a Medicaid program that covers 27 percent of the population and is sensitive to spikes in the cost of care.
Maine ranked fifth nationally in 2009 for per-capita spending on health care, according to the Kaiser Family Foundation. The Pine Tree State spent $8,521 per person, 25 percent more than the national average of $6,815.
And Maine’s health care costs keep rising. According to the Centers for Medicare and Medicaid Services, costs in the state rose an average of 7.4 percent annually between 1991 and 2009, compared with 6.5 percent nationally.

Our Feel-Good War on Breast Cancer

I used to believe that a mammogram saved my life. I even wrote that in the pages of this magazine. It was 1996, and I had just turned 35 when my doctor sent me for an initial screening — a relatively common practice at the time — that would serve as a base line when I began annual mammograms at 40. I had no family history of breast cancer, no particular risk factors for the disease.
So when the radiologist found an odd, bicycle-spoke-like pattern on the film — not even a lump — and sent me for a biopsy, I wasn’t worried. After all, who got breast cancer at 35?
It turns out I did. Recalling the fear, confusion, anger and grief of that time is still painful. My only solace was that the system worked precisely as it should: the mammogram caught my tumor early, and I was treated with a lumpectomy and six weeks of radiation; I was going to survive.
By coincidence, just a week after my diagnosis, a panel convened by the National Institutes of Health made headlines when it declined to recommend universal screening for women in their 40s; evidence simply didn’t show it significantly decreased breast-cancer deaths in that age group. What’s more, because of their denser breast tissue, younger women were subject to disproportionate false positives — leading to unnecessary biopsies and worry — as well as false negatives, in which cancer was missed entirely.
Those conclusions hit me like a sucker punch. “I am the person whose life is officially not worth saving,” I wrote angrily. When the American Cancer Society as well as the newer Susan G. Komen foundation rejected the panel’s findings, saying mammography was still the best tool to decrease breast-cancer mortality, friends across the country called to congratulate me as if I’d scored a personal victory. I considered myself a loud-and-proud example of the benefits of early detection.
Sixteen years later, my thinking has changed. As study after study revealed the limits of screening — and the dangers of overtreatment — a thought niggled at my consciousness. How much had my mammogram really mattered? Would the outcome have been the same had I bumped into the cancer on my own years later? It’s hard to argue with a good result. After all, I am alive and grateful to be here. But I’ve watched friends whose breast cancers were detected “early” die anyway. I’ve sweated out what blessedly turned out to be false alarms with many others.
Recently, a survey of three decades of screening published in November in The New England Journal of Medicine found that mammography’s impact is decidedly mixed: it does reduce, by a small percentage, the number of women who are told they have late-stage cancer, but it is far more likely to result in overdiagnosis and unnecessary treatment, including surgery, weeks of radiation and potentially toxic drugs. And yet, mammography remains an unquestioned pillar of the pink-ribbon awareness movement. Just about everywhere I go — the supermarket, the dry cleaner, the gym, the gas pump, the movie theater, the airport, the florist, the bank, the mall — I see posters proclaiming that “early detection is the best protection” and “mammograms save lives.” But how many lives, exactly, are being “saved,” under what circumstances and at what cost? Raising the public profile of breast cancer, a disease once spoken of only in whispers, was at one time critically important, as was emphasizing the benefits of screening. But there are unintended consequences to ever-greater “awareness” — and they, too, affect women’s health.

Diagnosing the Wrong Deficit

IN the spring of 2010, a new patient came to see me to find out if he had attention-deficit hyperactivity disorder. He had all the classic symptoms: procrastination, forgetfulness, a propensity to lose things and, of course, the inability to pay attention consistently. But one thing was unusual. His symptoms had started only two years earlier, when he was 31.
Though I treat a lot of adults for attention-deficit hyperactivity disorder, the presentation of this case was a violation of an important diagnostic criterion: symptoms must date back to childhood. It turned out he first started having these problems the month he began his most recent job, one that required him to rise at 5 a.m., despite the fact that he was a night owl.
The patient didn’t have A.D.H.D., I realized, but a chronic sleep deficit. I suggested some techniques to help him fall asleep at night, like relaxing for 90 minutes before getting in bed at 10 p.m. If necessary, he could take a small amount of melatonin. When he returned to see me two weeks later, his symptoms were almost gone. I suggested he call if they recurred. I never heard from him again.
Many theories are thrown around to explain the rise in the diagnosis and treatment of A.D.H.D. in children and adults. According to the Centers for Disease Control and Prevention, 11 percent of school-age children have now received a diagnosis of the condition. I don’t doubt that many people do, in fact, have A.D.H.D.; I regularly diagnose and treat it in adults. But what if a substantial proportion of cases are really sleep disorders in disguise?
For some people — especially children — sleep deprivation does not necessarily cause lethargy; instead they become hyperactive and unfocused. Researchers and reporters are increasingly seeing connections between dysfunctional sleep and what looks like A.D.H.D., but those links are taking a long time to be understood by parents and doctors.
We all get less sleep than we used to. The number of adults who reported sleeping fewer than seven hours each night went from some 2 percent in 1960 to more than 35 percent in 2011. Sleep is even more crucial for children, who need delta sleep — the deep, rejuvenating, slow-wave kind — for proper growth and development. Yet today’s youngsters sleep more than an hour less than they did a hundred years ago. And for all ages, contemporary daytime activities — marked by nonstop 14-hour schedules and inescapable melatonin-inhibiting iDevices — often impair sleep. It might just be a coincidence, but this sleep-restricting lifestyle began getting more extreme in the 1990s, the decade with the explosion in A.D.H.D. diagnoses.

LePage says Democrats ‘jumping the gun’ on Medicaid expansion

Posted April 27, 2013, at 6:53 p.m.
BANGOR, Maine — Democrats who now want to expand the Medicaid program under the federal Affordable Care Act are “jumping the gun” because not enough is known yet about the program, Gov. Paul LePage said Saturday.
“[Health and Human Services] Commissioner [Mary] Mayhew is going to Washington next week specifically to talk about the expansion,” LePage said at the Four Points Sheraton Hotel at Bangor International Airport. “Why would we jump the gun and not work with the federal government before we expand it?”
The governor and his wife, Ann LePage, were in Bangor on Saturday to attend the state convention of the Maine chapter of Disabled Veterans of America.
At an impromptu press conference in the walkway between the terminal and the hotel, the governor said that he wanted some assurances from officials in Washington, D.C., “that in three years they aren’t going to start reducing reimbursement.”
LePage was reacting to what he called “an ultimatum” delivered Thursday by Democratic legislative leaders. They proposed a deal that would tie the payback of Maine’s $484 million hospital debt to the expansion of Medicaid, according to a previously published report.
House Speaker Mark Eves, D-North Berwick, has said Democrats want to tie the debt payback to health care system reforms that could control costs in the long run.
“Democrats are going to repay the hospitals. It’s a top priority of ours,” he said Thursday. “As we make that final payment on our hospital debt, we’re also going to do things that address cost drivers in our health care system.”