Health care reform needs a do-over
By Arnold Relman, M.D.
USA Today, July 10, 2012
USA Today, July 10, 2012
The Affordable Care Act narrowly escaped death at the hands of the Supreme Court, but its troubles are far from over. Stability in how Americans will get their health care in the future is now just as much threatened by the ACA's internal flaws as it is by Republican opposition and fresh lawsuits.
Republican presidential candidate Mitt Romney's plan to undermine the Obama administration's health care reform effort if elected is well-known. But even if President Obama is re-elected and Democrats regain control of both houses of Congress, the ACA's problems will not disappear.
Dispelling Myths About Emergency Department Use: Majority of Medicaid Visits Are for Urgent or More Serious Symptoms
HSC Research Brief No. 23
July 2012
Anna Sommers, Ellyn R. Boukus, Emily Carrier
July 2012
Anna Sommers, Ellyn R. Boukus, Emily Carrier
Contrary to conventional wisdom that Medicaid patients often use hospital emergency departments (EDs) for routine care, the majority of ED visits by nonelderly Medicaid patients are for symptoms suggesting urgent or more serious medical problems, according to a new national study by the Center for Studying Health System Change (HSC). About 10 percent of nonelderly Medicaid patient ED visits are for nonurgent symptoms, compared with about 7 percent for privately insured nonelderly people. Nonetheless, there are clearly opportunities to develop less-costly care options than emergency departments for both nonelderly Medicaid and privately insured patients.
Lines Are Drawn Over Opting Out of Medicaid Plan
By ABBY GOODNOUGH
MIAMI — In the weeks since the Supreme Court ruled that states could opt out of a plan to vastly expand Medicaid under President Obama’s health care law, several Republican governors have vowed to do just that, attacking the expansion as a budget-busting federal power grab.
But it may not be so easy. A battle is brewing here in Florida, where Gov. Rick Scott took to national television soon after the ruling to announce that he would reject the expansion. Advocates for the poor and some players in the health care industry — especially hospitals, a powerful political lobby — intend to push back.
Hospital associations around the country have already signed off on cuts to reimbursement rates under the health care law on the assumption that the new paying customers they would gain, partly through the Medicaid expansion, would more than cover their losses.
“If we’re going to walk away from that coverage, we’ll simply see those dollars we contributed through cuts in hospital payments go to covering people in other states,” said Bruce Rueben, president of the Florida Hospital Association. “It’s a bad deal for people in Florida if it plays out that way.”
Two Medical Students Navigate the Health Care Maze
By PAULINE W. CHEN, M.D.A burly Midwesterner in his mid-20s, he had entered medical school determined to become a primary care physician. But over the last two years, despite encouragement from mentors and good experiences helping patients at the local free clinic, the resolve of the young doctor-to-be had wavered. On the eve of his third year of medical school, he had become more apprehensive than ever.
One recent afternoon, seeing his eyes turn glassy and his smile freeze, I realized that my own attempt to encourage him was failing to restore his determination.
"I appreciate what you're trying to tell me," he said. "But there's a big difference between your experiences and mine." He paused to search for words to explain, then smiled when the television down the hall began blasting the latest news on health care reform.
"You knew what you were getting into when you started, but us," he said, gesturing toward the television, "we have no idea of what health care or our futures will look like."
For several years now, doctors and patients have been struggling to reimagine the future of health care. Policy makers, health care experts and pundits have been eager to help, churning out well-meaning op-eds and essays and cobbling together exhaustive blogs and books. Trying to help the rest of us understand, for example, they have described how Medicare will rely increasingly on "accountable care organizations" and "bundled payments" and eventually eliminate "the doughnut hole."
Unfortunately, there's been one problem with these earnest and well-intentioned attempts to help: It's hard to understand what they are saying. In fact, few of us fully understand how the health care system works in the first place, let alone what these august experts are trying to say.
A threat to modern medicine
Posted July 13, 2012, at 6:03 p.m.
One of the great medical advances of the last century, the invention of antibiotics, is at risk of being lost. Increasingly, microbes are becoming untreatable. Margaret Chan, director general of the World Health Organization, warned in March of a dystopian future without these drugs. “A post-antibiotic era means, in effect, an end to modern medicine as we know it,” she said. “Things as common as strep throat or a child’s scratched knee could once again kill.”
Since the 1940s, antibiotics have greatly reduced the amount of human illness and death and transformed modern medicine, making possible such sophisticated interventions as hip replacements, organ transplants, cancer chemotherapy and care of premature infants. But evidence is mounting that antibiotics are losing efficacy. Through the relentless process of evolution, pathogens are evading the drugs, a problem known broadly as antimicrobial resistance.
Some bacteria, such as those causing tuberculosis and gonorrhea, have become resistant to multiple antibiotics. In the past few years, researchers discovered a new enzyme known as NDM-1 that can confer resistance to antibiotics on bacteria and can easily jump among different species. As the first-line antibiotics are lost, the replacement treatments are often more expensive, and more toxic.
http://bangordailynews.com/2012/07/13/opinion/a-threat-to-modern-medicine/
Since the 1940s, antibiotics have greatly reduced the amount of human illness and death and transformed modern medicine, making possible such sophisticated interventions as hip replacements, organ transplants, cancer chemotherapy and care of premature infants. But evidence is mounting that antibiotics are losing efficacy. Through the relentless process of evolution, pathogens are evading the drugs, a problem known broadly as antimicrobial resistance.
Some bacteria, such as those causing tuberculosis and gonorrhea, have become resistant to multiple antibiotics. In the past few years, researchers discovered a new enzyme known as NDM-1 that can confer resistance to antibiotics on bacteria and can easily jump among different species. As the first-line antibiotics are lost, the replacement treatments are often more expensive, and more toxic.
http://bangordailynews.com/2012/07/13/opinion/a-threat-to-modern-medicine/
Scientists Weigh In on Fall Prevention
By SUSAN SELIGERWho would have thought that popping a pill could help prevent falls in the elderly? According to a new report on fall prevention, published in Annals of Internal Medicine, vitamin D, of all things, may help adults age 65 and older stay steady and upright.
Falls are the leading cause of injury in adults 65 and older, and preventing them is much more effective than treating them. Thirty percent to 40 percent of the elderly fall at least once a year; many who had been living independently never regain their previous functioning, ending up in assisted living and nursing homes.
Many Governors Are Still Unsure About Medicaid Expansion
By MICHAEL COOPER
WILLIAMSBURG, Va. — How well the new health care law succeeds in covering millions of the poorest Americans will depend largely on undecided governors of both parties, who gathered here this weekend and spoke of the challenges of weighing the law’s costs and benefits in a highly charged political atmosphere and a time of fiscal uncertainty.
The Supreme Court’s ruling last month that the states should have the choice of whether to expand their Medicaid programs has set the stage for a frenzied year and a half in which governors will have to analyze their options, devise plans, negotiate with the federal government and successfully navigate the thorny statehouse politics that often accompany any big change. Much of the law is set to take effect in 2014, when many governors will be facing re-election.
The initial reaction to the court’s ruling split along party lines. More than half a dozen Republican governors — including those of Texas and Florida, which have the nation’s largest populations of poor uninsured residents — said they would not expand their programs because Medicaid already eats up an unsustainable share of their budgets. A slightly bigger number of Democratic governors said they would move swiftly to expand coverage in their states, with the federal government pledging to pick up all the costs at first and 90 percent of them after 2020.
The New Tug of War Over Medicaid
By TYLER COWEN
THE new health care law’s individual mandate — the provision pushing people to buy insurance, and upheld last month by the Supreme Court — has garnered huge attention. But about half the planned expansion of insurance coverage under the new law comes from another source entirely: growth of the Medicaid program.
Yet Medicaid has never been especially popular, and when its expanded role becomes more widely understood, it is likely to become less popular still.
Medicaid beneficiaries have limited means, and their low incomes usually translate into below-average political influence. The joint federal-state financing of Medicaid reflects its lack of broad support among the more affluent. Neither the federal government nor the states wish to pick up the entire tab, and many state governments — and not just Republican administrations — would prefer to spend more on education, roads and other programs. Yet the federal subsidy for Medicaid expenditures keeps many states locked in — the Feds usually pick up at least half the cost — at levels they would not have chosen on their own.
Those are signs of a program ripe for cuts, and yet the law is bringing a major Medicaid expansion. Will it stick? The additional federal subsidy is probably high enough to induce most states to expand Medicaid in the short run. (Under the Supreme Court decision, states can back out of the Medicaid expansion and lose only the new federal subsidy rather than all of their Medicaid funds.)
The greater likelihood is that, over time, American voters will rebel against Medicaid and dismantle the subsidies that keep the states locked in, and will prefer instead to spend the money on other programs.
The Boy Who Wanted to Fly
By MAUREEN DOWD
RORY STAUNTON was always looking up.
As soon as he could walk, he wanted to fly. The exuberant freckle-faced redhead from Sunnyside, Queens, yearned to be up in the romantic night sky where, as the French pilot and poet Antoine de Saint-Exupéry wrote, the stars are laughing.
His parents told him he’d have to wait until he was 16 to take flying lessons. But it’s hard to tell a determined 5-foot-9, 169-pound 12-year-old what to do.
He dreamed of being the next Captain Sullenberger, practicing on a flight simulator on his computer and studying global routes. He read and reread Sully’s memoir, thrilled to learn that the flier’s hair had once been red. He found a Long Island aviation school that would teach 12-year-olds.
On his 12th birthday, his parents shuddered and let Rory fly with an instructor.
How could you resist that sweet Irish face? Sure, Rory drove his parents nuts, sneaking downstairs late at night to gorge on episodes of “Family Guy,” and pretending to do his homework when he was really devouring political stories in The Times.
Don’t Get Sick in July
By THERESA BROWNIt's one of those secrets you normally don't learn in nursing school: "Don't go to the hospital in July." That's the month when medical residents, newly graduated from medical school, start learning how to be doctors, and they learn by taking care of patients. And learning means making mistakes.
There's disagreement in the medical literature about whether a so-called July Effect, where medical error rates increase in the summer, actually exists. But a 2010 article in the Journal of General Internal Medicine and a 2011 article in the Annals of Internal Medicine both found evidence of it. In an interview, Dr. John Q. Young, lead author of the latter review, likened the deployment of new residents to having rookies replace seasoned football players during "a high-stakes game, and in the middle of that final drive."
From what I've experienced as a clinical nurse, whether or not the July Effect is statistically validated as a cause of fatal hospital errors, it is undeniably real in terms of adequacy and quality of care delivery. Any nurse who has worked in a teaching hospital is likely to have found July an especially difficult month because, returning to Dr. Young's football metaphor, the first-year residents are calling the plays, but they have little real knowledge of the game.
This experience deficit plays out in ways large and small, but I remember an especially fraught situation one July when a new resident simply did not know enough to do his job and a patient quite literally suffered as a result.
Health cost bill may not attack key problem
Market clout of top doctors, hospitals drives up premiums
Five Obamacare Myths
By BILL KELLER
ON the subject of the Affordable Care Act — Obamacare, to reclaim the name critics have made into a slur — a number of fallacies seem to be congealing into accepted wisdom. Much of this is the result of unrelenting Republican propaganda and right-wing punditry, but it has gone largely unchallenged by gun-shy Democrats. The result is that voters are confronted with slogans and side issues — “It’s a tax!” “No, it’s a penalty!” — rather than a reality-based discussion. Let’s unpack a few of the most persistent myths.
OBAMACARE IS A JOB-KILLER. The House Republican majority was at it again last week, staging the 33rd theatrical vote to roll back the Affordable Care Act. And once again the cliché of the day was “job-killer.” After years of trying out various alarmist falsehoods the Republicans have found one that seems, judging from the polls, to have connected with the fears of voters.
Some of the job-killer scare stories are based on a deliberate misreading of a Congressional Budget Office report that estimated the law would “reduce the amount of labor used in the economy” by about 800,000 jobs. Sounds like a job-killer, right? Not if you read what the C.B.O. actually wrote. While some low-wage jobs might be lost, the C.B.O. number mainly refers to workers who — being no longer so dependent on employers for their health-care safety net — may choose to retire earlier or work part time. Those jobs would then be open for others who need them.
Troubled New York Hospitals Forgo Coverage for Malpractice
By ANEMONA HARTOCOLLIS
Every hospital makes mistakes. But some New York City hospitals may not have enough money to pay for them.
Several of the city’s most troubled hospitals are partially or completely uninsured for malpractice, state records show, forgoing what is considered a standard safeguard across the country.
Some have saved money to cover their liabilities, but others have used up their malpractice reserves, meaning that any future awards or settlements could come at the expense of patients’ care, and one hospital has closed its obstetric practice, in part out of fear of lawsuits.
Executives of these hospitals, most of which are in poor neighborhoods, say their dire financial circumstances and high premiums make it impractical to pay millions of dollars a year for insurance.
But insurance experts say that though dropping coverage may make economic sense in the short term, it is hardly in the best interest of patients, and in the long term it may be costly to hospitals and their bondholders, including some bonds backed by the state, should large judgments force them into bankruptcy.
“From a kind of self-interest of the hospital, it seems if you’re a marginally capitalized hospital barely making it, it would be perfectly rational not to buy insurance,” said Tom Baker, a law professor at the University of Pennsylvania who has written about malpractice insurance.
“From a social perspective, it’s very irresponsible. They’re taking in these people knowing they’re not able to make good on the harm they caused. Even a really good hospital is going to have a certain amount of medical malpractice. It’s inevitable.”
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