When Treating Cancer Is Not an Option
By JANE E. BRODY
When my husband learned he had advanced lung cancer, he didn't even want to speak to an oncologist about chemotherapy. He saw no point in treatment that could not cure him and might make him feel worse.
Not so, though, for a majority of patients diagnosed with cancers of the lung or colon that have spread well beyond their original site and are currently not curable by any drugs in the medical armamentarium. Most patients with these so-called stage 4 cancers who choose to undergo chemotherapy seem to believe, incorrectly, that the drugs could render them cancer-free.
That is the finding of a recent national study of nearly 1,200 patients with advanced cancers of the lung or colon. Overall, 69 percent of those with stage 4 lung cancer and 81 percent of those with stage 4 colon cancer failed to understand "that chemotherapy was not at all likely to cure their cancer," Dr. Jane C. Weeks, an oncology researcher at the Dana-Farber Cancer Institute in Boston, and colleaguesreported in The New England Journal of Medicine.
When patients do not understand the limitations of such treatment, their consent to undergo it is not truly informed, the authors concluded.
This is not to say that chemotherapy is pointless when cancer is far advanced. Various drugs, some with limited toxicity, can be used as palliatives, perhaps shrinking tumors temporarily to relieve symptoms, slowing the cancer's growth and prolonging the lives of some patients.
But aggressive chemotherapy when death is but weeks or months in the offing can seriously compromise the quality of patients' remaining time and may delay their preparations for the end of life, to the detriment of both patients and their families.
"If you think chemotherapy will cure you, you're less open to end-of-life discussions," Dr. Weeks said in an interview.
When patients pursue chemotherapy under the false belief that they still have a chance for a cure, it often delays their transition to the comfort care of hospice. When patients spend only a few days or a week in hospice, caretakers don't have enough time to get to know them and their families and offer the physical, emotional and practical benefits hospice can provide.
Dr. Weeks said continued chemotherapy involves more trips to the hospital, blood draws and X-rays, whereas hospice attends to patients' symptoms and concerns, and encourages them to leave meaningful legacies. When my husband entered hospice after two miserable weeks in the hospital undergoing palliative radiation, he experienced such relief that he said cheerfully, though in jest, "What if I decide I want to live?" and then enjoyed a treasured last visit with two of his grandchildren.
Cheer up, Papa John’s. Obamacare gave you a good deal.
By Ezra Klein ,
The health-care law’s treatment of larger employers is almost laughably complicated. If you’ve got fewer than 50 employees, nothing is asked of you, and if you’re willing to provide insurance for your employees, you get a giant tax credit, at least for awhile.
But if you’re a business with more than 50 full-time employees, matters become considerably more complex.
If you’ve got more than 50 full-time employees and you already offer them health insurance, you can stop reading now. You’re in the clear.
If you’ve got more than 50 full-time employees and you don’t offer them coverage and you don’t pay them enough to buy coverage on their own without using subsidies, then you have to pay $2,000 for each employee, except for your first 30 employees.
If you’ve got more than 50 full-time employees and you offer some of them coverage but others have to apply for federal subsidies and buy coverage themselves, then you pay the lesser of $3,000 for each employee receiving insurance subsidies or $2,000 for each full-time employee, once again excluding the first 30 employees.
Weird, right? But the complexities of this policy obscure a huge win for employers. In 1974, President Richard Nixon’s health-care plan proposed forcing employers to pay 75 percent of the cost of basic health insurance for their employees, though there would be some assistance for smaller businesses. In 1994, President Bill Clinton proposed forcing employers to pay 80 percent of the cost of basic heath insurance for their employees, though a somewhat confusing series of caps meant that smaller businesses would end up paying much less.
In other words, both Democratic and Republican presidents used to think the proper role for business in the American health-care system was to pay most of the cost of their employee’s health-care insurance.
Under the Affordable Care Act, the principle is different, and much less onerous: Employers don’t need to offer health care, and they don’t need to pay for most of the cost of their employee’s health care, but if their employees are taking advantage of public subsidies, then the employer should have to pay a penalty equal to about 1/8th the cost of the average employer-provided health-insurance plan.
Some employers are still unhappy, and understandably so. The Affordable Care Act will impose new costs on them. Papa John’s, which doesn’t provide most of its employees with health insurance, is warning that it might have to raise prices on its pizza by 11 to 14 cents per pie to offset the penalties.
Medicare agrees to pick up the tab for obesity counseling
Posted Nov. 19, 2012, at 11:19 a.m.
A recent landmark decision by the Centers for Medicare and Medicaid Services (CMS) represents an important first step toward addressing one of the great ironies of American health care.
Insurers have been willing to foot the bill for managing the complications of chronic diseases such as diabetes and heart disease, but most have not been willing to reimburse practitioners for their work in treating obesity, which is often the major risk factor contributing to chronic diseases. Insurers have been willing to pay for costly gastric bypass surgery, but not for intensive medical nutrition therapy that could produce similar results.
Now, Medicare will begin reimbursing primary care physicians and other qualified practitioners for administering face-to-face behavioral counseling to patients with a body mass index of 30 or more.
Some view CMS’ willingness to cover intensive weight loss counseling as an acknowledgment that traditional medicine has been limited in its ability to tackle heart disease and obesity, which account for $550 billion in annual U.S. health spending, according to the federal Centers for Disease Control and Prevention.
There are some reservations, but for the most part the health care community has welcomed this development as long overdue recognition of the medical and behavioral factors underlying costly chronic diseases, and of the need for less traditional preventive measures. It is anticipated that Medicare’s decisions will encourage more private insurers to follow suit, giving physicians and patients the moral and financial boost to do their parts.
“We as a country and certainly as a health care industry have had a fascination with technology, and yet we know from very good research that some of the most significant impact on patients’ health and wellness has to do with lifestyle issues,” said American Academy of Family Physicians President Glen Stream. “Medicare’s recognition of that and willingness to pay for it is also a message to physicians that we need to refocus on the importance of including this in the care of our patients.”
Neither the AAFP nor the American Medical Association have taken positions on the specific coverage initiatives.
A team approach to treatment, often with a physician as team leader, has been shown to work best for the management of chronic diseases. The team usually consists of a registered dietitian, nurse case manager, exercise physiologist and a mental health professional.
“It’s almost impossible for physicians to take care of everything. They don’t have the expertise or the time,” said Shanthi Manivannan, medical director of the Ornish heart disease program at West Virginia University Healthcare’s Ruby Memorial Hospital. She coordinates with patients’ primary care doctors who supervise progress by, for example, setting limits on exercise protocols or adjusting medications.
A Survey Of Primary Care Doctors In Ten Countries Shows Progress In Use Of Health Information Technology, Less In Other Areas
- Cathy Schoen1,*,
- Robin Osborn2,
- David Squires3,
- Michelle Doty4,
- Petra Rasmussen5,
- Roz Pierson6 and
- Sandra Applebaum7
+Author Affiliations
- ↵*Corresponding author
Abstract
Health reforms in high-income countries increasingly aim to redesign primary care to improve the health of the population and the quality of health care services, and to address rising costs. Primary care improvements aim to provide patients with better access to care and develop more-integrated care systems through better communication and teamwork across sites of care, supported by health information technology and feedback to physicians on their performance. Our international survey of primary care doctors in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Switzerland, the United Kingdom, and the United States found progress in the use of health information technology in health care practices, particularly in the United States. Yet a high percentage of primary care physicians in all ten countries reported that they did not routinely receive timely information from specialists or hospitals. Countries also varied notably in the extent to which physicians received information on their own performance. In terms of access, US doctors were the most likely to report that they spent substantial time grappling with insurance restrictions and that their patients often went without care because of costs. Signaling the need for reforms, the vast majority of US doctors surveyed said that the health care system needs fundamental change.
Deadly Fake Medicines
By AMIR ATTARAN and ROGER BATE
THE world’s medicine supply is under attack. From Pakistan, where 120 patients died after taking fake heart medicine, to the United States, where 32 patients died and hundreds were hospitalized because of contaminated steroids, regulators are finding their defenses overwhelmed by shoddy drug companies and organized criminal groups that make fake drugs containing no active ingredients. It is estimated that at least 100,000 people die every year from substandard and falsified medicines for cancer, heart disease, infectious diseases and other ailments.
This week delegates from about 100 member countries of the World Health Organization are meeting in Buenos Aires with the aim of strengthening defenses against substandard and fraudulent medicines. The meeting is extremely important, but to make progress a number of hurdles will have to be overcome. Most of these are commonsensical, as our research team, including professionals in health, law and diplomacy, argued in a paper entitled “How to Achieve International Action on Falsified and Substandard Medicines” just published in the British Medical Journal. (Unfortunately, the authors won’t be able to attend the meeting since the W.H.O. has caved to demands from India that nongovernmental experts should not be admitted.)
In Buenos Aires, the delegates first need to agree which medicines are good and which are bad. Their failure to agree on such matters has impeded progress both in safeguarding the quality of genuine medicines and in criminalizing falsified ones. Rich countries and Western pharmaceutical companies have often seemed interested more in protecting their intellectual property from counterfeiting than the victims of deadly falsified medicines. This has infuriated poorer countries and generic medicine companies, especially when efforts to rein in falsified medicines began targeting genuine generic medicines.
Administration Defines Benefits That Must Be Offered Under the Health Law
By ROBERT PEAR
WASHINGTON — The Obama administration took a big step on Tuesday to carry out the new health care law by defining “essential health benefits” that must be offered to most Americans and by allowing employers to offer much bigger financial rewards to employees who quit smoking or adopt other healthy behaviors.
The proposed rules, issued more than two and a half years after President Obama signed the Affordable Care Act, had been delayed as the administration tried to avoid stirring criticism from lobbyists and interest groups in the final weeks of the presidential campaign.
Insurance companies are rushing to devise health benefit plans that comply with the federal standards. Starting in October, people can enroll in the new plans, for coverage that begins on Jan. 1, 2014.
The rules translate the broad promises of the 2010 law into detailed standards that can be enforced by state and federal officials. Under the rules, insurers cannot deny coverage or charge higher premiums to people because they are sick or have been ill. They also cannot charge women more than men, as many now do.
“Thanks to the health care law, no one will be discriminated against because of a pre-existing condition,” said Kathleen Sebelius, the secretary of health and human services, who issued the rules with Phyllis C. Borzi, an assistant secretary of labor, and Steven T. Miller, the acting commissioner of the Internal Revenue Service.
The rules lay out 10 broad categories of essential health benefits, but allow each state to specify the benefits within those categories, at least for 2014 and 2015. Thus, the required benefits will vary from state to state, contrary to what many members of Congress had assumed when the law was adopted.
http://www.nytimes.com/2012/11/21/us/politics/administration-defines-benefits-under-health-law.html?hpw&pagewanted=print&_r=0
Obama administration unveils long-awaited health law rules
Posted Nov. 21, 2012, at 8:46 a.m.
Long-awaited details on how insurers can structure health benefits and premiums for policies that will cover tens of millions of Americans starting in 2014 were released by the Obama administration Tuesday.
The three proposed rules reaffirm key elements of the 2010 federal health law, including its requirement that insurers accept all applicants, even those with health conditions, and not charge higher rates based on health, gender or occupation.
But the proposals add additional details on how premiums can vary based on age and tobacco use, including allowing tobacco users who enroll in programs aimed at helping them quit to be exempted from extra premium costs set out in the law.
While insurers and consumer groups were cautious about issuing an immediate assessment of the proposals, a quick review showed that no one group won everything it wanted. For example, insurers did not succeed in getting the government to phase-in a requirement that limits their ability to charge older applicants more than younger ones. And consumer groups, which wanted specific details on the benefits required in 10 broad categories, instead saw continued discretion given to state regulators to pick “benchmark” plans and benefits.
“It looks like the Obama administration is continuing to be pragmatic in their approach to the regulations,” said Robert Laszewski, a consultant and former health insurance executive.
Insurers, consumer groups and the public have 30 days to weigh in with comments on two of the proposed rules and will have until Jan. 25 for the third, which outlines how employers can structure wellness programs that offer discounts to workers who participate.
Based on documents posted on HealthCare.gov, here’s a quick look at the new regulations:
Younger Students More Likely to Get A.D.H.D. Drugs
By ANAHAD O'CONNOR
A new study of elementary and middle school students has found that those who are the youngest in their grades score worse on standardized tests than their older classmates and are more likely to be prescribed stimulants for attention deficit hyperactivity disorder.
The findings suggest that in a given grade, students born at the end of the calendar year may be at a distinct disadvantage. Those perceived as having academic or behavioral problems may in fact be lagging simply as a result of being forced to compete with classmates almost a full year older than them. For a child as young as 5, a span of one year can account for 20 percent of the child's age, potentially making him or her appear significantly less mature than older classmates.
The new study found that the lower the grade, the greater the disparity. For children in the fourth grade, the researchers found that those in the youngest third of their class had an 80 to 90 percent increased risk of scoring in the lowest decile on standardized tests. They were also 50 percent more likely than the oldest third of their classmates to be prescribed stimulants for A.D.H.D. The differences diminished somewhat over time, the researchers found, but continued at least through the seventh grade.
The new study, published in the journal Pediatrics, used data from Iceland, where health and academic measures are tracked nationally and stimulant prescription rates are high and on par with rates in the United States. Previous studies carried out there and in other countries have shown similar patterns, even among college students.
Helga Zoega, the lead author of the study, said she had expected there would be performance differences between students in the youngest grades, but she did not know that the differences, including the disparity in stimulant prescribing rates, would continue over time.
"We were surprised to see that," said Dr. Zoega, a postdoctoral fellow at the Mount Sinai School of Medicine in New York and an assistant professor at the University of Iceland. "It may be that the youngest kids in class are just acting according to their age. But their behavior is thought of as symptoms of something else, rather than maturity."
Many Americans unaware of health-care law changes
By Sarah Kliff,
After surviving a Supreme Court decision and a presidential election, the Obama administration’s health-care law faces another challenge: a public largely unaware of major changes that will roll out in the coming months.
States are rushing to decide whether to build their own health exchanges and the administration is readying final regulations, but a growing body of research suggests that most low-income Americans who will become eligible for subsidized insurance have no idea what is coming.
Part of the problem, experts say, is that people who will be affected do not realize the urgency, because the subsidies will not begin for another year. But policy decisions are being made now that will affect tens of millions of Americans, and the lack of public awareness could jeopardize a system that depends on having many people involved.
Low enrollment could lead to higher premiums, health policy experts say. Hospitals worry that, without widespread participation, they will continue getting stuck with patients’ unpaid medical bills. And advocates say the major purpose of the Affordable Care Act — extending health insurance to more Americans — will go unmet if large numbers of vulnerable people don’t take advantage of it.
But because “Obamacare” has been so controversial, and its fate caught up in the presidential campaign, there has been little public discussion about the specifics of putting it into action. States such as Texas and Florida, where opposition to the legislation was strong, have been slow to embrace the law, and critics have been loath to promote it. Initial White House efforts at outreach caused congressional Republicans to accuse the administration of using taxpayer money for political gain.
In mid-November, Ways and Means Committee Chairman Dave Camp (R-Mich.) subpoenaed Health and Human Services Secretary Kathleen Sebelius, demanding information about how her agency has used federal money to promote the Affordable Care Act. The administration is preparing a final budget for an outreach program focused on the opening of the exchanges next October.
“People hear it’s going to come in 2014, which makes it not very relevant to their lives,” said Tevi Troy, a top Health and Human Services official under President George W. Bush. “If you don’t have an understanding of the law, that’s when you’re going to have real take-up problems.”
Obamacare’s Critics Refuse to Give Up
Jonathan Cohn
The New Republic
They lost at the Supreme Court. And they lost at the ballot box. But opponents of Obamacare aren’t giving up yet. Since they don’t have the votes to repeal the law, they’re trying the next best thing: Crippling it.
Their focus, at the moment, is on the development of insurance “exchanges.” Exchanges are basically virtual marketplaces for people buying coverage on their own, because they don’t have access to affordable coverage from an employer. Think of the exchanges as the rough functional equivalent of Expedia or Travelocity, only instead of buying an airline ticket you’d go online to buy health insurance. You’d have full information on what the plans covered, and how much they would cost, so you could shop intelligently. And—this is the important part—you’d have access to these policies, at the prices listed, regardless of any pre-existing conditions. If you couldn’t afford to pay for the policies on your own, you’d be eligible for assistance from the federal government.
California works to get word out on health insurance exchange
The state faces a daunting task in getting enough people — healthy and unhealthy, uninsured and insured — to enroll in the crucial element of the national healthcare overhaul.
By Anna Gorman and Chad Terhune, Los Angeles Times
November 19, 2012
Nearly every day, worried Californians call a Pacoima hotline asking what lies ahead in healthcare reform: Do I have to get private insurance? Will I lose my Medi-Cal? How much will it cost? When does it start?
"There's mass confusion already," said Katie Murphy, managing attorney at Neighborhood Legal Services of Los Angeles County, which runs the call line.
With the presidential election over and the nation's healthcare overhaul moving forward, California officials have less than a year to clear up widespread uncertainty about future medical coverage options.
"We are in our countdown period," said Peter Lee, executive director of Covered California, the state's new health insurance marketplace that opens in October 2013.
Under the federal law, the state-run exchange aims to fundamentally reshape the health insurance market by negotiating with insurers for the best rates and assisting consumers in choosing a plan. The exchange must also help millions of Californians figure out whether they qualify for an expansion of Medicaid, the government insurance for the poor, or federally subsidized private coverage.
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