Status and Stress
By MOISES VELASQUEZ-MANOFF
Although professionals may bemoan their long work hours and high-pressure careers, really, there’s stress, and then there’s Stress with a capital “S.” The former can be considered a manageable if unpleasant part of life; in the right amount, it may even strengthen one’s mettle. The latter kills.
What’s the difference? Scientists have settled on an oddly subjective explanation: the more helpless one feels when facing a given stressor, they argue, the more toxic that stressor’s effects.
That sense of control tends to decline as one descends the socioeconomic ladder, with potentially grave consequences. Those on the bottom are more than three times as likely to die prematurely as those at the top. They’re also more likely to suffer from depression, heart disease and diabetes. Perhaps most devastating, the stress of poverty early in life can have consequences that last into adulthood.
Even those who later ascend economically may show persistent effects of early-life hardship. Scientists find them more prone to illness than those who were never poor. Becoming more affluent may lower the risk of disease by lessening the sense of helplessness and allowing greater access to healthful resources like exercise, more nutritious foods and greater social support; people are not absolutely condemned by their upbringing. But the effects of early-life stress also seem to linger, unfavorably molding our nervous systems and possibly even accelerating the rate at which we age.
The British epidemiologist Michael Marmot calls the phenomenon “status syndrome.” He’s studied British civil servants who work in a rigid hierarchy for decades, and found that accounting for the usual suspects — smoking, diet and access to health care — won’t completely abolish the effect. There’s a direct relationship among health, well-being and one’s place in the greater scheme. “The higher you are in the social hierarchy,” he says, “the better your health.”
Dr. Marmot blames a particular type of stress. It’s not necessarily the strain of a chief executive facing a lengthy to-do list, or a well-to-do parent’s agonizing over a child’s prospects of acceptance to an elite school. Unlike those of lower rank, both the C.E.O. and the anxious parent have resources with which to address the problem. By definition, the poor have far fewer.
So the stress that kills, Dr. Marmot and others argue, is characterized by a lack of a sense of control over one’s fate. Psychologists who study animals call one result of this type of strain “learned helplessness.”
Medical Procedures May Be Useless, or Worse
By NICHOLAS BAKALAR
We usually assume that new medical procedures and drugs are adopted because they are better. But a new analysis has found that many new techniques and medicines are either no more effective than the old ones, or worse. Moreover, many doctors persist in using practices that have been shown to be useless or harmful.
Scientists reviewed each issue of The New England Journal of Medicine from 2001 through 2010 and found 363 studies examining an established clinical practice. In 146 of them, the currently used drug or procedure was found to be either no better, or even worse, than the one previously used. The reportappears in the August issue of Mayo Clinic Proceedings.
More than 40 percent of established practices studied were found to be ineffective or harmful, 38 percent beneficial, and the remaining 22 percent unknown. Among the practices found to be ineffective or harmful were the routine use of hormone therapy in postmenopausal women; high-dose chemotherapy and stem cell transplant, a complex and expensive treatment for breast cancer that was found to be no better than conventional chemotherapy; and intensive glucose lowering in Type 2 diabetes patients in intensive care, which not only failed to reduce cardiovascular events but actually increased mortality.
In some instances, doctors routinely refused to give beneficial therapies despite a lack of evidence that they were harmful. Vaccines were unnecessarily withheld from multiple sclerosis patients in the belief that they increased flare-ups; women with lupus were denied oral contraceptives for fear they increased the severity of the disease; and epidural anesthesia was delayed during childbirth on the theory it increased the rate of Caesarean sections. Yet good studies showed that none of these fears was justified..
“Contradicted practices don’t disappear immediately,” said the lead author, Dr. Vinay Prasad. “There’s an inertia, a 10-year period of time when the contradicted procedure continues to be practiced.”
Dr. William E. Boden, chief of medicine at the Stratton VA Medical Center in Albany, who was not involved in the work, found the study useful and provocative. “It’s challenging us to look at things we’ve done and attempt to find whether there’s evidence to support their use,” he said. “There’s going to be increasing pressure to come forward with making sure that the health care dollars we’re allocating are being well utilized.”
The Charitable-Industrial Complex
By PETER BUFFETT
I HAD spent much of my life writing music for commercials, film and television and knew little about the world of philanthropy as practiced by the very wealthy until what I call the big bang happened in 2006. That year, my father, Warren Buffett, made good on his commitment to give nearly all of his accumulated wealth back to society. In addition to making several large donations, he added generously to the three foundations that my parents had created years earlier, one for each of their children to run.
Early on in our philanthropic journey, my wife and I became aware of something I started to call Philanthropic Colonialism. I noticed that a donor had the urge to “save the day” in some fashion. People (including me) who had very little knowledge of a particular place would think that they could solve a local problem. Whether it involved farming methods, education practices, job training or business development, over and over I would hear people discuss transplanting what worked in one setting directly into another with little regard for culture, geography or societal norms.
Often the results of our decisions had unintended consequences; distributing condoms to stop the spread of AIDS in a brothel area ended up creating a higher price for unprotected sex.
But now I think something even more damaging is going on.
Because of who my father is, I’ve been able to occupy some seats I never expected to sit in. Inside any important philanthropy meeting, you witness heads of state meeting with investment managers and corporate leaders. All are searching for answers with their right hand to problems that others in the room have created with their left. There are plenty of statistics that tell us that inequality is continually rising. At the same time, according to the Urban Institute, the nonprofit sector has been steadily growing. Between 2001 and 2011, the number of nonprofits increased 25 percent. Their growth rate now exceeds that of both the business and government sectors. It’s a massive business, with approximately $316 billion given away in 2012 in the United States alone and more than 9.4 million employed.
Philanthropy has become the “it” vehicle to level the playing field and has generated a growing number of gatherings, workshops and affinity groups.
As more lives and communities are destroyed by the system that creates vast amounts of wealth for the few, the more heroic it sounds to “give back.” It’s what I would call “conscience laundering” — feeling better about accumulating more than any one person could possibly need to live on by sprinkling a little around as an act of charity.
Posted July 25, 2013, at 11:08 a.m.
A new approach to health care under the federal health reform law that rewards hospitals financially for keeping patients healthy at less cost is beginning to yield results in Maine.
Under the model, outlined in the Affordable Care Act, health systems throughout the U.S. are forming alliances of doctors and hospitals called “accountable care organizations.” ACOs are a cornerstone of the federal law that many hope will slow the ever-rising health care costs eating up more and more of Americans’ paychecks.
The experimental approach rewards health providers with financial incentives for keeping patients healthy and happy rather than steering them toward more visits and procedures. If providers reduce costs while providing high-quality care for a certain population of patients, they can share in the savings with the health insurer. Likewise, if they fail to cut costs or miss certain quality targets, hospitals may get pinched financially.
Several health organizations in Maine are experimenting with the new model, and two shared early results this week.
Eastern Maine Healthcare Systems of Brewer partnered with Medicare for its ACO. The health system, parent to Bangor’s Eastern Maine Medical Center, was one of 32 organizations nationally chosen by Medicare, the government health insurance program for seniors, to pioneer the new model.
On Wednesday, EMHS released early data on its “Pioneer ACO” effort.
To be eligible for the incentive payments, ACOs must demonstrate their progress by tracking the health of participating patients through quality measures, such as the number of avoidable hospital admissions and how well providers monitor patients with high cholesterol.
During 2012, EMHS improved its readmission rate — which reflects how many patients wind up back in the hospital a month after being discharged — by 13.2 percent. Its readmission rate — 14.97 percent — was lower than the average rate of 15.42 among all the other Pioneer ACOs throughout the country, according to EMHS.
EMHS also touted another measure that tracks whether nurses follow up with patients to ensure they’re taking the right medications after being discharged from the hospital. That follow-up occurred 91 percent of the time among Medicare patients participating in the ACO, according to EMHS. The average among the other ACOs was much lower, about 72 percent.
As for savings, the EMHS ACO reduced the cost of caring for Medicare patients by 4.9 percent, placing it among the top five of the Pioneer ACOs, according to the health system. EMHS declined to release the dollar amount saved.
The ACO included 9,200 Medicare patients in its first year, and since has expanded to about 14,000 patients.
Maryland Regulators Slash Rates For Obamacare Insurance Policies - Kaiser Health News
Citing what they called flawed data and unreasonable assumptions, Maryland insurance regulators on Fridaysharply reduced prices for health plans that will be sold to individuals and families through the state's insurance marketplace starting Oct. 1.
In some cases, the final premiums were cut by a third for the Maryland Health Connection exchange, pleasing advocates of affordable coverage but prompting others to question whether such low prices can be sustained.
Regulators reduced prices for all nine carriers filing to sell policies in the marketplace.
"People are going to have access to plans at reasonable prices," said Maryland Health & Mental Hygiene Secretary Joshua Sharfstein, whose department is not involved in insurance regulations. "Plus people are going to have access to tax credits on top of that. So we think that's good news."
While Oregon, Rhode Island and other states have also lowered insurers' proposed prices for new insurance policies, Maryland's move is one of the most aggressive, analysts said.
IOM Finds Differences In Regional Health Spending Are Linked To Post-Hospital Care And Provider Prices
Big health spending variations throughout the country are largely driven by differences in the use of post-acute services such as skilled nursing homes and home health care by Medicare beneficiaries, and by higher prices that some hospitals and doctors charge commercial insurers, according to an Institute of Medicine report released Wednesday.
The report recommended that Medicare push ahead with using its financial might to make hospitals, doctors and other providers work more closely and reap rewards or lose money based on how well and efficiently they care for their patients. The IOM panel – which telegraphed this in an interim report, rejected an idea that has been promoted by some members of Congress to pay more to medical providers in areas of the country where Medicare spending is lower, such as Rochester, N.Y., and less in places where it is high, such as Fort Lauderdale, Fla.
The 178-page document represents the government's most thorough effort to dig into one of the great questions in health research: Why does it cost more to treat patients in some areas of the country than in others? The topic has led to feuds among researchers amid a decades-long disagreement about whether overly aggressive or greedy doctors and facilities are to blame, or whether the true culprits are patients in places that have excessive obesity or other widespread health problems or patients who demand more medical services.
The Hype Over Hospital Rankings
By ELISABETH ROSENTHAL
LAST week U.S. News and World Report released its annual list of “Best Hospitals.” Web sites are being updated to celebrate victories. (Johns Hopkins ranks No. 1!) Magazines will be plump with advertising. (NewYork-Presbyterian is first in New York and tied for seventh nationally!) And, because I am a reporter covering health care, my in-box is accumulating e-mails from the “Honor Roll” of the Top 18 hospitals.
But what does this annual exercise mean for patients? And what does it say about American health care?
After all, Harvard and Princeton, which tied for No. 1 in the magazine’s 2013 Top 10 national universities list, didn’t take out ads to proclaim their triumph; they will fill their classrooms no matter. And as in the college ratings, there are no big surprises in the top hospital group: they are the big academic medical centers — the Mayo Clinic, Massachusetts General Hospital, the Cleveland Clinic. More to the point, even though you might well fly across the country for four years of schooling, you are far more likely to stay near your home for medical care. No one’s flying to Mayo in Minnesota to get inhalers for asthma, even though it ranks No. 1 for pulmonary medicine.
But American hospitals are a bit like restaurants, competing for your business (and donations). As such they go all out to promote their brand, even though hospitals and doctors are not permitted to advertise in many other countries.
For American hospitals large and small, it clearly pays to advertise, particularly in these tough economic times and with the Affordable Care Act poised to throw tens of millions of newly insured patients into the market. But for patients the rankings and, especially, the subsequent promotions generally have limited benefit, experts say.
“Nearly every hospital has a banner out front saying they’re a ‘top hospital’ for something in some rating system,” said Dr. Nicholas Osborne, a Robert Wood Johnson Clinical Scholar at the University of Michigan. “Those ratings have become more important for hospital marketing than for actually helping patients find the best care.”
Obama Intends to Let Health Care Law Prove Critics Wrong by Succeeding
By MICHAEL D. SHEAR and JACKIE CALMES
GALESBURG, Ill. — President Obama waved aside persistent Republican criticism of his signature health care law last week, saying in a New York Times interview that the overhaul would become vastly more popular once “all the nightmare scenarios” from his adversaries proved wrong.
The president accused Republicans of “all kinds of distortions” about the legislation. He said bluntly that his administration had a simple plan to build support for the law, which continues to be viewed with suspicion by large numbers of Americans. “We’re going to implement it,” he said.
Mr. Obama said he decided to delay a requirement that businesses provide insurance to their employees because of concerns expressed by executives about its administrative burdens. Some companies that already provide insurance had balked at provisions requiring them to show proof. The president said delaying that part of the law for a year would give the Treasury Department and other agencies a chance to make it “a little bit simpler” for companies to comply.
But he rejected criticism that by delaying the provision he had exceeded his constitutional authority.
“This is the kind of routine modifications or tweaks to a large program that’s starting off that in normal times in a normal political atmosphere would draw a yawn from everybody,” Mr. Obama said. “The fact that something like this generates a frenzy on Republicans is consistent with the fact that they’ve voted to repeal this thing 38 times without offering an alternative that is plausible.”
Mr. Obama said members of Congress who questioned his power to delay the provision should “make that case.” But he pointedly suggested that the criticism had less to do with the substance of the issue and more to do with political efforts to undermine his presidency.
'Critically Ill' author Frederick Southwick on what ails our healthcare system
By Judy Mandell
3:35 PM PDT, July 26, 2013
Her physician husband interceded and transferred her care to a trusted cardiologist. Because her lungs filled with fluid, she had to be intubated and placed on a respirator. She also suffered kidney failure. While a tube was being placed to filter her blood to remove fluid, Southwick had two cardiac arrests. Remarkably, she made a full recovery.
Frederick Southwick, chief of infectious diseases at the University of Florida in Gainesville, says his wife's trauma motivated him to write the book "Critically Ill: A 5-Point Plan to Cure Healthcare Delivery." Here he offers some guidance to negotiate the healthcare system.
Boothbay region 'full of fear' as hospital closing looms
Posted:TodayUpdated: 7:36 AM
MaineHealth officials call it the best path forward, but a community with many older residents worries about having no ER nearby.
By Colin Woodard cwoodard@pressherald.com
Staff Writer
Staff Writer
BOOTHBAY HARBOR - They come to Jane Good's beauty shop in Southport nearly every day to have their hair done and share their fears that the pending closure of the St. Andrews Hospital emergency room could mean their death.
"They just want to be able to be taken to St. Andrews in five minutes if something goes wrong," says Good, one of the leaders in the fight to stop the closure. "This whole community is so full of fear, fear that somebody they know is going to die because they can't get to the hospital in time."
But on Oct. 1, St. Andrews, located five minutes up the road and over the swing bridge in Boothbay Harbor, will cease to be a hospital. Its emergency department will close and 25 hospital beds will disappear. A 10-hour-a-day urgent care center will take its place, but ambulances and emergency cases will be directed another half-hour north to Miles Memorial Hospital in Damariscotta, which is itself being downsized from 38 beds to 25.
http://www.pressherald.com/news/boothbay-region-full-of-fear-as-hospital-closing-looms_2013-07-28.html?pagenum=full
Proposal Challenges TIAA-CREF on For-Profit Health Insurance
by Robert Kropp
by Robert Kropp
Advocacy groups urge the pension fund to divest its holdings in private health insurance companies, arguing that the industry has a well-documented history of unethical behavior and abuses.
SocialFunds.com -- Should sustainable institutional investors hold the stocks of private health insurance companies in their portfolios?
It's a question that advocates for a single-payer healthcare system is asking theTeachers Insurance and Annuity Association - College Retirement Equities Fund (TIAA-CREF), the financial services organization and one of the nation's largest pension funds. A signatory to the United Nations' Principles for Responsible Investment (PRI), TIAA-CREF states in its investment philosophy that it seeks "to invest in areas that affect social change and environmental stewardship while also producing competitive financial returns."
There's no doubt that private health insurance companies such as CIGNA, Humana, Aetna, Coventry, and WellPoint help TIAA-CREF's portfolio produce competitive financial returns. According to Healthcare-NOW!, an organization advocating for the passage of single-payer healthcare legislation, average profits for the five companies increased by almost 50% during the fiscal year that ended in July, 2011. Meanwhile, 3,700 families file for bankruptcy every day in the US, and cite illness and medical bills as the primary causes. Sixty percent of those filing for bankruptcy had private insurance.
A 2012 study by physicians associated with Physicians for a National Health Program (PNHP) found that Medicare had overpaid private insurance companies in the amount of $282.6 billion since 1985, most of which occurred in the last eight years.
In 2011, Healthcare-NOW! and PHNP launched the Divestment Campaign for Health Care, which in 2012 informed TIAA-CREF of its intention to file a shareowner resolution calling for divestment from private health insurance companies. The Campaign withdrew the proposal for one year after TIAA-CREF and MSCI, its vendor for environmental, social, and corporate governance (ESG) ratings, agreed to dialogue.
There's no doubt that private health insurance companies such as CIGNA, Humana, Aetna, Coventry, and WellPoint help TIAA-CREF's portfolio produce competitive financial returns. According to Healthcare-NOW!, an organization advocating for the passage of single-payer healthcare legislation, average profits for the five companies increased by almost 50% during the fiscal year that ended in July, 2011. Meanwhile, 3,700 families file for bankruptcy every day in the US, and cite illness and medical bills as the primary causes. Sixty percent of those filing for bankruptcy had private insurance.
A 2012 study by physicians associated with Physicians for a National Health Program (PNHP) found that Medicare had overpaid private insurance companies in the amount of $282.6 billion since 1985, most of which occurred in the last eight years.
In 2011, Healthcare-NOW! and PHNP launched the Divestment Campaign for Health Care, which in 2012 informed TIAA-CREF of its intention to file a shareowner resolution calling for divestment from private health insurance companies. The Campaign withdrew the proposal for one year after TIAA-CREF and MSCI, its vendor for environmental, social, and corporate governance (ESG) ratings, agreed to dialogue.
Detroit Looks to Health Law to Ease Costs
By MONICA DAVEY and ABBY GOODNOUGH
As Detroit enters the federal bankruptcy process, the city is proposing a controversial plan for paring some of the $5.7 billion it owes in retiree health costs: pushing many of those too young to qualify for Medicare out of city-run coverage and into the new insurance markets that will soon be operating under the Obama health care law.
Officials say the plan would be part of a broader effort to save Detroit tens of millions of dollars in health costs each year, a major element in a restructuring package that must be approved by a bankruptcy judge. It is being watched closely by municipal leaders around the nation, many of whom complain of mounting, unsustainable prices for the health care promised to retired city workers.
Similar proposals that could shift public sector retirees into the new insurance markets, called exchanges, are already being planned or contemplated in places like Chicago; Sheboygan County, Wis.; and Stockton, Calif. While large employers that eliminate health benefits for full-time workers can be penalized under the health care law, retirees are a different matter.
“There’s fear and panic about what this means,” said Michael Underwood, 62, who retired from the Chicago Police Department after 30 years and has diabetes and Parkinson’s disease. Mr. Underwood, who says he began working for the city when employees did not pay into future Medicare coverage, is part of a group suing Chicago over its plan to phase many retirees out of city coverage during the next three and a half years. “I was promised health care for myself and my wife for life,” he said.
Unfunded retiree health care costs loom larger than ever for localities across the country, and the health law’s guarantee of federal subsidies to help people with modest incomes afford coverage has made the new insurance markets tantalizing for local governments. A study issued this year by the Pew Charitable Trusts found 61 of the nation’s major cities wrestling with $126 billion in retiree health costs, all but 6 percent of that unfunded.
“The Affordable Care Act does change the possibilities here dramatically,” said Neil Bomberg, a program director at the National League of Cities. “It offers a very high-quality, potentially very affordable way to get people into health care without the burden falling back onto the city and town.”
But if large numbers of localities follow that course, it could amount to a significant cost shift to the federal government. Authors of the health care law expected at least some shifting of retirees into the new insurance exchanges, said Timothy S. Jost, a law professor at Washington and Lee University who closely follows the law. “But if a lot of them do, especially big state and local programs,” he said, “that’s going to be a huge cost for the United States government, and it’s mandatory spending.”
Obamacare Canvassers Seek Out Florida's Uninsured
BOCA RATON, Fla. – Tammy Spencer did a double take when she read the address on her paper and looked at the house in front of her.
Spencer, a volunteer with the nonprofit Enroll America, was spending a hot and humid Saturday morning knocking on doors in this mostly posh South Florida city looking for people without health coverage. She wanted to let them know about new online insurance marketplaces that open for enrollment Oct. 1.
After two hours of canvassing, she found one uninsured woman and got contacts for three others. "It was worth it," said the 51-year-old insurance agent. "But next time, we need to go to a poorer area, or set up a table in the mall."
Spencer is one of hundreds of volunteers for Enroll America's "Get Covered America" campaign, which canvassed neighborhoods across Florida, New Jersey, Ohio and several other states Saturday to kick off several months of outreach efforts. The group, which is funded by health insurers, hospitals, philanthropies and others, has close ties to the Obama administration. It's trying to educate consumers about new insurance options and drive enrollment in the new marketplaces opening this fall for coverage that takes effect in January.
http://www.kaiserhealthnews.org/Stories/2013/July/29/Obamacare-Enroll-America-Florida.aspx
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