How Doctors Die
By Ken Murray, MD
Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds—from 5 percent to 15 percent—albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.
It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.
Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen—that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).
The Good News on Insurance Premiums
How Doctors Die
By Ken Murray, MD
Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds—from 5 percent to 15 percent—albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.
It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.
Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen—that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).
The Good News on Insurance Premiums
By THE EDITORIAL BOARD
Individuals and families who buy health insurance on their own will pay significantly lower premiums next year in New York and many other states. It is the most impressive evidence yet that the Affordable Care Act, through its mandates and competition-promoting health insurance exchanges, can hold previously rising premiums in check.
The encouraging news underscores the vital importance of the health law’s “individual mandate,” which requires most people to buy health insurance next year or pay a penalty. The provision is designed to bring in a flood of young, healthy people into insurance pools, which helps reduce the cost of coverage for older and sicker enrollees.
In a symbolic vote designed purely for the campaign trail, Republican leaders pushed a bill through the House on Wednesday to repeal the individual mandate. Fortunately, Democratic control of the Senate and the White House will block that folly before it can harm the very people whose interests the Republicans claim to champion.
Before the House vote, officials in New York State said they had approved premium rates for 2014 that are at least 50 percent lower on average than those currently available. In New York City, individuals who now pay $1,000 a month or more will be able to find policies on the health exchanges — online marketplaces where they can comparison shop for plans — for as little as $308 a month.
The Obama administration followed with an analysis on Thursday showing that individual premiums in 10 states — including California, New York, Ohio, Colorado, Virginia and Washington — and the District of Columbia will be 10 percent to 18 percent less, on average, than projections the administration derived from estimates by the nonpartisan Congressional Budget Office. (Because these are averages, some people in these may pay more.) The costs for most individuals buying coverage on the new exchanges will be reduced even further by federal premium subsidies available on a sliding scale, for those with incomes up to $94,200 for a family of four.
Premiums will be held down by several elements of the Affordable Care Act. Competition among insurers to sign up customers in the exchanges is expected to keep premiums as low as possible. The administration is counting on the mandate, the subsidies, vigorous marketing, the ease of comparing policies and demand for good coverage to bring in young people to make the system work.
Low Vitamin D Tied to Aging Problems
By NICHOLAS BAKALAR
A new study has found that low vitamin D levels in people over 55 are associated with an inability to perform ordinary tasks of daily life.
Dutch researchers studied two groups of older people — one of 725 men and women aged 55 to 65, and another of 1,237 older than 65 — to see if they could walk up or down a 15-step staircase, dress and undress, stand from a sitting position, cut their toenails, walk outside unaided for five minutes, and use their own or public transportation. Then they did blood tests for vitamin D levels.
After controlling for factors including age, physical activity and chronic diseases, they found that in both groups, a vitamin D level below 20 nanograms per milliliter was associated with an increased number of disabilities compared with those with a normal level (above 30). The study was published online in The Journal of Clinical Endocrinology and Metabolism.
The lead author, Dr. Evelien Sohl of the VU University Amsterdam, said that the study does not establish that low vitamin D is the cause of disability. “Maybe vitamin D supplements would be of benefit,” she said. “But before we can assume this, we have to test it in randomized controlled trials.
http://well.blogs.nytimes.com/2013/07/19/low-vitamin-d-tied-to-aging-problems/?emc=tnt&tntemail0=y&pagewanted=print
In the Doctor’s Office, a Neglected Resource
By PAULA SPAN
When it comes to providing health care for an aging nation, the bad news is no longer news. We already lack sufficient numbers of geriatricians and other professionals — nurses, social workers, pharmacists, aides — trained to care for the elderly, and the shortage is projected to increase.
The good news, confirmed by a study in the Journal of the American Geriatrics Society, is that nurse practitioners can markedly improve the quality of care for older patients.
Say you have recently begun to experience troubling urinary incontinence. Your primary care doctor should offer you “behavioral/lifestyle treatment,” like Kegel exercises (which men as well as women can do). So says an evidence-based practice model, called ACOVE 2, developed to help guide health professionals through complex geriatric conditions.
How closely care hews to the model’s recommendations is expressed as a percentage. “It’s like a report card,” said Dr. David Reuben, director of geriatrics at the University of California, Los Angeles, and lead author of the new study. Behavioral treatments, not drugs, should be the first line of defense against incontinence, he said, because for most people, “it’s been shown over and over that it’s at least as effective and without the side effects.”
In his team’s study of 500 people over age 75, patients with incontinence at two primary care practices were either seen by a physician alone or managed jointly by a primary care doctor and a nurse practitioner. What percentage were treated according to the ACOVE 2 quality indicators? The report card, please.
Of the patients seen only by a physician, not one was told about Kegel exercises or other non-drug methods for reducing incontinence.
Of the patients treated by a physician and a nurse practitioner, 95 percent were offered non-drug approaches.
The U.C.L.A. researchers looked at four common conditions: urinary incontinence, falls, depression and dementia.
All four tend to receive lousy scores on ACOVE report cards, meaning patients with those conditions receive a small percentage of the recommended assessments and treatments — even though they are problems with serious consequences. “People who fall break hips,” Dr. Reuben said. “People with incontinence are limited in going out and participating in social life. These are major reasons for institutionalization.”
When it came to treating depression, patients seeing a doctor and a nurse practitioner received about the same care as those treated by doctors alone. In both groups, patients received 60 percent to 63 percent of recommended care.
But when patients showed up with one of the other three conditions, the addition of nurse practitioners meant much higher scores. Patients who saw a nurse practitioner along with a doctor received 80 percent of the recommended assessments and treatments for falls (compared with 34 percent for those who only saw a doctor), 59 percent for dementia (versus 38 percent) and 66 percent for incontinence (versus a particularly dismal 19 percent).
Anthem Blue Cross shuns insurance market for small businesses
Anthem is the first big insurer in California to publicly pass on the small-business health insurance pool.
By Chad Terhune
5:57 PM PDT, July 19, 2013
Anthem, a unit of WellPoint Inc., is California's largest insurer for small employers. The company's surprising move raised concerns about the state's ability to offer competitive rates and attract businesses to its new Covered California exchange that opens Jan. 1.
The federal Affordable Care Act left it up to health insurers to decide whether they wanted to sell in these government-run marketplaces.
Friday's disclosure made Anthem the first big insurer in California to publicly pass on the small-business pool. Some other big names, such as UnitedHealth Group Inc. and Aetna Inc., have already opted out of California's larger exchange for individual consumers.
Overall, most industry experts have not expressed alarm about the handful of big companies so far that have chosen to sit on the sidelines. They say insurer participation has been fairly solid across the country thus far and next year's premiums have come in lower than expected in California and other states.
The level of insurer competition "has been a pleasant surprise in a number of states and in other places it's been more mixed," said Sabrina Corlette, a research professor at Georgetown University's Center on Health Insurance Reforms.
Anthem's decision in California underscored that the small-business exchanges are the most susceptible to a lack of interest among insurers.
The state's largest for-profit health insurer isn't abandoning the small employer market, which is limited to firms with 50 or fewer workers. It said it would keep selling coverage to small companies outside the exchange, and it also remains one of 13 health insurers that will offer policies to individuals in Covered California.
Anthem led California with 31% of the small-employer market in 2011, according to the most recent Citigroup data. Kaiser Permanente was a close second with a 28% share, followed by Blue Shield of California with 18% of small firms. Both Kaiser and Blue Shield are expected to participate in the small-group exchange.
Nonetheless, Anthem's move caught many observers off guard.
Maine insurer wants its rates kept private
Maine Community Health Options says releasing the data now might give its insurance exchange rival an unfair edge.
A co-op, one of two insurers offering coverage on Maine's health insurance exchange, has asked the state Bureau of Insurance to keep its proposed health insurance rates a secret temporarily.
On Oct. 1, individuals can begin signing up for insurance on the exchange, a key part of the federal Affordable Care Act. The act is designed to allow people who don't have access to affordable insurance to purchase individual coverage on the exchange. Those earning 100 percent to 400 percent of the federal poverty level can qualify for subsidies to help them buy insurance on the exchanges.
The state insurance bureau, in a July 5 letter, ruled that the rates are a public record but agreed to delay releasing them to allow Maine Community Health Options co-op a chance to argue its case for keeping them private. In any event, the rates would be public by July 31, when the insurance bureau submits them to the federal government, which will give the final OK.
Republicans, Obama waste time in health care squabbling
Posted July 19, 2013, at 4:33 p.m.
President Barack Obama’s remarks this week on the Affordable Care Act had the trappings of importance: members of Congress in the audience, ordinary citizens on stage. All that was missing, as is too often the case in the health care debate, was anything important to say.
The president made a show of saying that, thanks to the law, 8.5 million Americans will get 2012 premium rebates from their insurance companies, averaging $100 a family. That amounts to less than 5 percent of all Americans with health insurance, he neglected to note, and the checks aren’t a lot of money, given that the average annual worker contribution for employer-provided family coverage last year was $4,316.
In his defense, Obama was responding to an even more farcical bit of political theater staged by House Republicans, who voted to delay the health law’s mandate that individuals buy insurance. It was the 38th time the House has voted, futilely, to stop or slow Obamacare.
Such posturing only contributes to public confusion over the law — and keeps Republicans and Democrats alike from addressing essential steps toward health-care reform.
Instead, it seems, the closer the law gets to fully taking effect, the more misleading and irrelevant the political arguments become.
Supports and detractors of the law alike have, for example, made an issue of how much insurance plans sold on the new state exchanges will cost. Republicans argue that premiums in California will be higher than what people now pay for individual coverage; Democrats say premiums in New York will be lower.
Both are half right. Premiums for individuals probably will be higher in some states, and for good reason — insurance plans sold on exchanges will be required to provide good coverage, and insurers will be prohibited from turning away people with pre-existing medical conditions.
And yes, some New York premiums will be 50 percent lower, but only for people who buy insurance on their own — a group that now includes just 17,000 people, according to the New York Times. Even this limited success probably won’t be replicated elsewhere, because few other states have placed the same requirements on insurers that have made coverage so expensive in New York.
In any case, there’s little point in trying to predict state-by-state premium prices when much larger issues loom. The exchanges themselves still need to be set up, and half the states have yet to agree to expand Medicaid coverage under the law. Republicans and Democrats should address their differences over how to make both these programs work.
TIAA-CREF shareholders meeting hears call to divest from ‘unethical’ private health insurers
Shareholder’s comments provoke response from company’s president
News release, Healthcare-NOW!, July 17, 2013CHARLOTTE, N.C. – Having suffered an earlier rejection by the leadership of TIAA-CREF of a shareholders resolution calling on the huge, nonprofit investment company to divest its funds from private health insurance firms because of the latter’s “unethical behavior,” a spokesperson for the divestment group took the microphone at the organization’s annual meeting Tuesday and urged just such a course of action.
Shareholder Sandra Fox, speaking on behalf of herself and others who have appealed to TIAA-CREF to divest its holdings in WellPoint and other giant health insurers, said such firms are not managed in an “exemplary and ethical manner” – a criterion for inclusion in the company’s portfolio – and therefore should be scrapped.
Going into to the meeting, Fox said: “The practices of these companies are anything but socially responsible. They make money by denying coverage, raising premiums, and increasing co-pays and deductibles, deterring patients from seeking care. Their everyday operations result in high overhead expenses, spiraling health care costs, worsening health, premature loss of life, and bankruptcy of countless Americans.”
Speaking from the floor to her fellow shareholders, she reiterated those points and stressed that the big health insurers have been repeatedly cited and fined by regulatory bodies and the courts for improper, unethical conduct.
Roger Ferguson, president and CEO of TIAA-CREF, who chaired the meeting, acknowledged Fox’s comments and said her group’s efforts had already made an impact. Ferguson said MSCI, its vendor for rating companies, had downgraded the stock of two health insurance companies based on the information her group had provided. He did not name which two companies they were.
Ferguson also said the dialogue on this issue would continue.
http://www.pnhp.org/print/news/2013/july/tiaa-cref-shareholders-meeting-hears-call-to-divest-from-‘unethical’-private-health-i
Problems with Affordable Care Act show need for single-payer system
By Toni Vafi
St. Louis Post-Dispatch, July 11, 2013
As promises of the Affordable Care Act continue to wither, the delay of the employer mandate is cause for more disappointment. Initially there was promise of average savings of $2,500 per family annually and visions of a public option. Universal coverage was assured and the oft-stated “if you like your employer based insurance, you can keep it” was evidence that we weren’t going socialist. These were a few of the goodies we expected under the Patient Protection and Affordable Care Act.
What happened? Gone are the $2,500 savings and the public option. Cost control wasn’t part of the ACA. The public option bothered insurance companies, so it was out. Of 60 million uninsured, the ACA will leave at least 30 million still without coverage, and the employer mandate delay will now surely increase the implementation burden on the exchanges, which might not be ready to go by Oct. 1.
Not to worry. Employers that have been unable to come up with a plan over the past four years are mainly employers of lower wage and temporary workers. These workers might receive subsidized plans on the exchanges. According to the Post-Dispatch ("Delay in health care law raises questions," July 4), some employers expect to save millions during this one-year delay, millions to be picked up by the taxpayers. Most of the 30 million newly insured will be exchange or Medicaid clients, also to be funded in full or subsidized by the federal government. While I never begrudge the use of federal funds for health care, I do begrudge this elaborate plan giving insurance companies a third of those federal funds to shuffle paper and deny care, while earning huge profits for themselves.
If medical care is to be funded by tax dollars, let’s skip the hogwash and go directly to a single-payer system, which saves billions and provides equitable care for all.
http://www.pnhp.org/print/news/2013/july/problems-with-affordable-care-act-show-need-for-single-payer-system
St. Louis Post-Dispatch, July 11, 2013
As promises of the Affordable Care Act continue to wither, the delay of the employer mandate is cause for more disappointment. Initially there was promise of average savings of $2,500 per family annually and visions of a public option. Universal coverage was assured and the oft-stated “if you like your employer based insurance, you can keep it” was evidence that we weren’t going socialist. These were a few of the goodies we expected under the Patient Protection and Affordable Care Act.
What happened? Gone are the $2,500 savings and the public option. Cost control wasn’t part of the ACA. The public option bothered insurance companies, so it was out. Of 60 million uninsured, the ACA will leave at least 30 million still without coverage, and the employer mandate delay will now surely increase the implementation burden on the exchanges, which might not be ready to go by Oct. 1.
Not to worry. Employers that have been unable to come up with a plan over the past four years are mainly employers of lower wage and temporary workers. These workers might receive subsidized plans on the exchanges. According to the Post-Dispatch ("Delay in health care law raises questions," July 4), some employers expect to save millions during this one-year delay, millions to be picked up by the taxpayers. Most of the 30 million newly insured will be exchange or Medicaid clients, also to be funded in full or subsidized by the federal government. While I never begrudge the use of federal funds for health care, I do begrudge this elaborate plan giving insurance companies a third of those federal funds to shuffle paper and deny care, while earning huge profits for themselves.
If medical care is to be funded by tax dollars, let’s skip the hogwash and go directly to a single-payer system, which saves billions and provides equitable care for all.
http://www.pnhp.org/print/news/2013/july/problems-with-affordable-care-act-show-need-for-single-payer-system
Consumers In Most States Unlikely To See N.Y.’s 50 Percent Reduction In Premiums In Individual Market
New York’s announcement this week that insurance premiums would drop 50 percent next year for individuals buying their own coverage in new online marketplaces made good talking points for proponents of the health law, but consumers in most states are unlikely to see similar savings.
That’s because only a handful have New York’s rules, which like the federal law bar insurers from rejecting people with health problems. Unlike the federal law, however, New York does not require consumers to purchase coverage, so over time, mainly older, sicker people, have purchased coverage. That drove up prices and discouraged younger, healthier people from buying policies, as did a requirement that insurers charge the same rates regardless of age or health status.
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