Study Adds New Doubts About Value of Mammograms
One of the largest and most meticulous studies of mammography ever done, involving 90,000 women and lasting a quarter century, has added powerful new doubts about the value of the screening test for women of any age.
It found that the death rates from breast cancer and from all causes were the same in women who got mammograms and those who did not. And the screening had harms — one out of five cancers found with mammography and treated was not a threat to the woman’s health and did not need treatment like chemotherapy, surgery or radiation.
The study, published Tuesday in The British Medical Journal, is one of the few rigorous evaluations of mammograms conducted in the modern era of more effective breast cancer treatments. It randomly assigned Canadian women to have regular mammograms and breast exams by trained nurses or to have breast exams alone.
Researchers sought to determine whether there was any advantage to finding breast cancers when they were too small to feel. The answer was no, the researchers report.
The study seems likely to lead to an even deeper polarization between those who believe that regular mammography saves lives, including many breast cancer advocates and patients, and a growing number of researchers who say the evidence is lacking or, at the very least, murky.
“It will make women uncomfortable, and they should be uncomfortable,” said Dr. Russell P. Harris, a screening expert and professor of medicine at the University of North Carolina. “The decision to have a mammogram should not be a slam dunk.”
The findings will not lead to any immediate change in guidelines for mammography, and many advocates and experts will almost certainly dispute the idea that mammograms are on balance useless, or even harmful.
Dr. Richard C. Wender, chief of cancer control for the American Cancer Society, said the society has convened an expert panel that is reviewing all studies on mammography, including the Canadian one, and would issue revised guidelines later this year. He added that combined data from clinical trials of mammography showed it reduces the death rate from breast cancer by at least 15 percent for women in their 40s and by at least 20 percent for older women.
That means that one woman in 1,000 who starts screening in her 40s, two who start in their 50s and three who start in their 60s will avoid a breast cancer death, Dr. Harris said.
Dr. Wender added that while improved treatments clearly helped lower the breast cancer death rate, so did mammography, by catching cancers early.
But an editorial accompanying the new study said that earlier studies that found mammograms helped women were done before the routine use of drugs like tamoxifen that sharply reduced the breast cancer death rate. In addition, many studies did not use the gold-standard methods of the clinical trial, randomly assigning women to be screened or not.
http://www.nytimes.com/2014/02/12/health/study-adds-new-doubts-about-value-of-mammograms.html?emc=edit_tnt_20140211&tntemail0=y&_r=1
For Women, a More Complicated Choice on Mammograms
For women who dutifully keep their mammogram appointments year after year, the latest results from a long-term trial in Canada, which found no difference in death rates from breast cancer among women who had regular mammograms and those who did not, are bound to sow confusion, perhaps even anger.
For decades now, the annual mammogram has been promoted vociferously and continuously as an essential way to protect oneself from breast cancer. Many women feel they are being irresponsible if they do not get a regular scan, said Dr. Lisa Schwartz, a professor at the Dartmouth Institute for Health Policy and Clinical Practice.
“For so long, we have been trying to convince people that you’re irresponsible or not taking care of yourself if you don’t do this,” Dr. Schwartz said. “People were hit over the head with that message.”
But attitudes have been changing as evidence accumulates of the hazards of intensive cancer screening. The American Urological Association has loosened its prostate cancer screening guidelines for men, for instance, because of the potential for unnecessary, invasive treatment that often leads to incontinence and impotence.
Millions Trapped in Health-Law Coverage Gap
Earning Too Little for Health-Law Subsidies but Ineligible for Benefits Under Existing Medicaid Programs
BIRMINGHAM, Ala.—Ernest Maiden was dumbfounded to learn that he falls through the cracks of the health-care law because in a typical week he earns about $200 from the Happiness and Hair Beauty and Barber Salon.
Like millions of other Americans caught in a mismatch of state and federal rules, the 57-year-old hair stylist doesn't make enough money to qualify for federal subsidies to buy health insurance. If he earned another $1,300 a year, the government would pay the full cost. Instead, coverage would cost about what he earns.
"It's a Catch-22," said Mr. Maiden, an uninsured diabetic. Without help, he said, he must "choose between paying the bills and buying medicine."
The 2010 health law was meant to cover people in Mr. Maiden's income bracket by expanding Medicaid to workers earning up to the federal poverty line—about $11,670 for a single person; more for families. People earning as much as four times the poverty line—$46,680 for a single person—can receive federal subsidies.
But the Supreme Court in 2012 struck down the law's requirement that states expand their Medicaid coverage. Republican elected officials in 24 states, including Alabama, declined the expansion, triggering a coverage gap. Officials said an expansion would add burdensome costs and, in some cases, leave more people dependent on government.
The decision created a gap for Mr. Maiden and others at the lowest income levels who don't qualify for Medicaid coverage under varying state rules. The upshot is that lower-income people in half the states get no help, while better-off workers elsewhere can buy insurance with taxpayer-funded subsidies.
Obamacare study bodes well for health insurance market
AS THIS year’s congressional elections approach, voters are sure to hear ads about a recent Congressional Budget Office study about the potential effects of the Affordable Care Act. The authors of the report computed that Obamacare, by 2024, would reduce the size of the workforce by perhaps 2.5 million people. Critics have seized on the study as evidence of the health law’s destructive power, which among some executives has become an all-purpose excuse for layoffs and cutbacks in employee benefits; last week America Online CEO Tim Armstrong blamed Obamacare — coupled with “two AOL-ers that had distressed babies” — for his long-troubled company’s decision to scale back 401(k) matches. (Armstrong later reversed himself.)
But in fact, the budget office’s report foretells something that corporate America ought to applaud: Over time, workers will be less likely to look to their employers as the only route to obtaining health coverage.
It’s an accident of history that most Americans gained access to health insurance through their jobs. In certain ways Obamacare reinforces that link: Employers with 50 or more full-time employees must offer health coverage to employees who work more than 30 hours per week. (The administration just delayed that requirement to 2015.) Some companies either have or will cut employee hours to fall below that line. But the law does something much more important: It forces the creation of more affordable insurance plans that are available to independent contractors, unemployed people, and those without coverage at work. This change has a powerful real-world effect: People will no longer stay at jobs that they dislike just to keep their coverage. Indeed, the Congressional Budget Office finds that voluntary decisions to leave the workforce account for most of the predicted employment decline.
Will Saving on Health Care Hurt the Economy?
WASHINGTON — LOST in all the debate last week about whether or not the Affordable Care Act will hurt the economy is the fact that health care is already imposing a drag on growth.
The health care sector has repeatedly helped to pull the economy from recession in recent decades, but this time around it is lagging behind the recovery.
Health care spending grew more slowly than the economy in 2011 and 2012 and will probably be found to have done so again in 2013. Meanwhile, health care employment also expanded more slowly than overall employment last year — and the government estimates that in January employment actually shrank for only the second time since 1990.
The reasons for this slowdown are not well understood. The Great Recession is clearly part of the story. Experts also point to changes in technology and in the way care is delivered and paid for. It seems likely that the landmark 2010 legislation is playing at least a small part, but the magnitude of its impact is hotly disputed.
What Goes Up Finally Comes Down
Percent of gross domestic product going to national health care spending:
18%
15
12
Health costs peaked
in 2009 and 2010
at 17.4 percent.
9
6
They fell to 17.2
percent in 2012.
3
’60
’70
’80
’90
’00
’10
The consequences are easier to see, though: Lower health care spending isn’t helping the economy to heal.
Spending less on health care is a longstanding goal of pretty much everyone who doesn’t work in the health care industry. The United States spends much more on health care than do other countries, and it seems likely that some of the money could be put to better use elsewhere. Also, making the health care sector more efficient not only frees up people, money and office space in places like Boston’s hospital district, but it also cuts labor costs in other industries by cutting insurance premiums.
No Sex, Please, We’re on Medicare
By PAULA SPAN
What could be more likely to draw international headlines, and jokes on late-night talk shows, than a government report that includes both an alleged waste of Medicare money and erectile dysfunction?
Even without dopey jokes about swelling costs and rising whatevers, this story was bound to get attention: The federal Department of Health and Human Services dispatched its Office of Inspector General to review Medicare payments for vacuum erection systems, less formally known as penis pumps. Its recent report revealed that Medicare was paying “grossly excessive” prices for these devices (which draw blood into the penis, creating an erection that allows a man to have intercourse).
From 2006 through 2011, the investigators found, Medicare paid on average $451 per pump. Medicare beneficiaries were responsible for a $90 co-pay; Medicare put up the remaining $361. That was more than twice what the Department of Veterans Affairs paid per pump: $186. Searching online, the investigators found that consumers could buy similar pumps for even less.
And Medicare paid for a whole lot of these items — more than 473,000 pumps over six years. Had it paid what others paid, the Inspector General’s report concluded, taxpayers could have saved more than $14 million and beneficiaries almost $4 million each year.
States Meld Medicare and Medicaid
By Christine Vestal, Staff Writer
They are a diverse group of low-income people who are disabled or elderly. Many have multiple chronic illnesses, or are battling depression or substance abuse. Most will need long-term care at some point in their lives.
In the nearly 50 years since Medicaid and Medicare were enacted, the two health care programs – one for the poor and the other for the elderly and disabled – have remained separate, with different rules, duplicative benefits and conflicting financial incentives. The result has been wasted money and disjointed care for more than 10 million “dual eligibles,” the Americans who qualify for both programs.
Massachusetts, which provided the model for the Affordable Care Act, is the first state to take advantage of an Affordable Care Act initiative designed to give dual eligibles better care at a lower cost. In 2011, the new Medicare-Medicaid Coordination Office began awarding $1 million planning grants to participating states and made critical Medicare data available to them for the first time. Now, instead of carrying separate cards for Medicare and Medicaid, dual eligibles in Massachusetts who are enrolled in the state’s One Care program will get a single health plan and a case manager to coordinate their care.
Other states are preparing to follow. California will begin participating in May, and these states will join later this year and in 2015: Colorado, Connecticut, Idaho, Illinois, Iowa, Michigan, Minnesota, Missouri, New York, North Carolina, Ohio, Oklahoma, Rhode Island, South Carolina, Texas, Virginia and Washington.
Arkansas' Medicaid Experiment, Key To Obamacare Expansion, On Ropes
Maine Medical Center gets state OK for $40 million expansion
The project will expand existing operating space and add new operating rooms.
Maine Medical Center said Tuesday it has received final state approval for its $40 million expansion, which will add five new operating rooms as well as create a special cardiac operating room for the most critically ill patients.
The cardiac hybrid operating room will better accommodate large surgical teams and support personnel. The area for patient preparation and recovery also will be improved, the hospital said.
The 40,000-square-foot expansion will help ease a space crunch at the Portland hospital. Its existing operating rooms run at a utilization rate of up to 94 percent, which is substantially higher than national averages in the mid-80s.
“Alleviating some of these capacity pressures will allow us to provide emergency interventions without having to move or delay scheduled procedures,” said Dr. Brad Cushing, chief of surgery. “People across the region have come to count on Maine Medical Center for procedures that they can’t find elsewhere in the state or even in Boston. We know our patients want to be home, so being able to treat them near their homes is important to us.”
Single Payer Rises Again
As the ACA takes effect, an alternative gains ground at the state level.
'We often limit ourselves tremendously by not talking to people that we fear or that we have been told won’t agree.'
When Sergio Espana first began talking to people, just over a year ago, about the need for fundamental changes in the U.S. healthcare system, confusion often ensued. Some people didn’t understand why, if the Affordable Care Act (ACA) had passed, people still wanted to reform the system; others thought organizers were trying to sign them up for “Obamacare.”
Healthcare is a Human Right Maryland, the group to which Espana belongs, is in pursuit of something else: a truly universal healthcare system that would cover everyone and eliminate insurance companies once and for all. Espana and many others in the growing movement see opportunity in the renewed discussion around healthcare reform as the ACA’s insurance exchanges go into effect.
They believe that the ACA’s continued reliance on (and subsidies of) private insurance simply aren’t good enough. People are still falling through the cracks, employers are trying to dodge the requirement that they provide insurance for their workers, and many states refused federal subsidies to expand their Medicaid programs. What these activists want is a program that would replace existing insurance programs, cover everyone regardless of their employment status, and be funded by the government, with tax dollars. Such a plan had strong support when the national healthcare overhaul was being crafted in 2009—including initial backing by President Obama—but the president and Congress decided it wasn’t politically possible and passed the ACA as a compromise.
Now, the rocky launch of the healthcare exchanges that form the cornerstone of the Affordable Care Act has helped revive interest in single-payer, says Ida Hellander, director of policy and programs for the advocacy group Physicians for a National Health Program. New York State Assemblymember Richard Gottfried, the author of a 20-year-old single-payer bill that is receiving renewed support, points out that single-payer would avoid many of the issues of the ACA’s launch. “When you don’t have means testing and you don’t have to make guesses about who’s going to cover your doctor or your ailment, it’s very simple.”
While Republicans on the national stage have been grandstanding about “repealing and replacing” the ACA, grassroots activists are on the ground in many states organizing their neighbors around the idea of real universal healthcare. A national program remains the end goal, but Nijmie Dzurinko of Put People First! Pennsylvania believes that state efforts could have a domino effect. “Our job is to change what’s politically possible,” says Drew Christopher Joy of the Southern Maine Workers’ Center, which is leading the effort in that state.
Lobstermen take health insurance plunge
Study in 2006 found 25 percent of lobstermen uninsured
by Craig Idlebrook
Even though the state's fishermen work in physically demanding and dangerous conditions, a sizable number go without health insurance. The seasonal nature of lobstering and the cost of insurance often make coverage prohibitive.
A 2006 Gulf of Maine Research Institute study on the economic well-being of lobstermen found that nearly a quarter carried no health insurance, which is more than double the rate of those without insurance among the rest of the New England population.
In the Downeast region, that figure climbs to some 50 percent of lobstermen, says Patrice McCarron, executive director of the Maine Lobstermen's Association (MLA). That means many Maine lobstermen live one accident away from losing their livelihood, and many others forgo even basic health care because of the cost, she said.
"A lot of lobstermen live in pain," McCarron said.
The Affordable Care Act (ACA), also known as Obamacare, represents an opportunity to expand insurance coverage for the state's fishermen by mandating everyone buy insurance and offering subsidies for those who can't afford it. The MLA won a grant to train a staff-member, April Gilmore, to help lobstermen navigate the logistics of signing up for coverage.
Though the association takes no position on the mandate, McCarron says she and others have long believed that access to insurance coverage is a good thing for lobstermen.
"We see a huge benefit to that, and if we didn't we would never have taken on this role," she said.
But the signup effort has presented unique logistical challenges. While the association's office is in Kennebunk, Gilmore is charged with reaching out to lobstering communities throughout the coast. And some lobstermen had gotten used to not having insurance, so much so that they didn't really understand what the law did or the ins and outs of coverage.
The association knew it had to ramp up to answer member questions, and in this it may have been aided by a quirk of the calendar. When the Obamacare website opened for business, many lobstermen were still finishing up the season, and few tried to sign up. That proved to be fortuitous, as they avoided the anxiety brought about by the website headaches that derailed other signup efforts throughout the country. It also bought the association time to get up to speed.
"We were really, really climbing the learning curve," McCarron said.
The association sent out a postcard to every member in December and received a deluge of phone calls. Gilmore often had to field 30 calls a day. Eventually, the association was able to do triage with the calls, sending out basic information on health insurance to those beginning to think about the process and walking others through the signup that were ready.
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