Routine pelvic exam should be discontinued, physicians group says
The routine pelvic exam endured by healthy women at their physician's office is a yearly ritual that frequently produces pain, anxiety and embarrassment in return for no documented benefit, and it should be discontinued, an influential physicians group has concluded.
In a new practice recommendation issued Monday, the American College of Physicians said the visual and manual examination of a woman's reproductive organs is not an effective way to detect gynecological cancers, venereal or pelvic inflammatory disease or bacterial infections.
But the annual procedure does cause pain and discomfort to as many as 60% of women of childbearing age, prompting many to avoid regular visits to a gynecologist. And it is particularly likely to cause distress to women who have been sexually abused and those who are extremely overweight.
"The pelvic examination has held a prominent place in women's health for many decades and has come to be more of a ritual than an evidence-based practice," Dr. George F. Sawaya and Dr. Vanessa Jacoby wrote in an editorial published in the Annals of Internal Medicine alongside the new recommendation.
If gynecologists and obstetricians choose to continue performing the exam on healthy women, they should "clarify its goals and quantify its benefits and harms," added Sawaya and Jacoby, both OB-GYNs at UC San Francisco.
The national medical bill for the yearly pelvic exam is estimated to reach $2.6 billion. That does not include the costs and risks of follow-up medical visits, laparoscopic procedures and other invasive tests performed after screenings turn up something suspicious.
Whether the recommendation will change the routine medical care of women is uncertain. The advice from the American College of Physicians is aimed mainly at internal medicine specialists and general practitioners. But pelvic exams are most often performed by OB-GYNs who, citing "expert opinion," have defended their value.
How politics derailed EPA science on arsenic, endangering public health in central Maine and nationwide
By David Heath, The Center for Public Integrity
Posted June 30, 2014, at 11:02 a.m.
This story was published by The Center for Public Integrity, a nonprofit, nonpartisan investigative news organization in Washington, D.C.
MOUNT VERNON, Maine — Living in the lush, wooded countryside with fresh New England air, Wendy Brennan never imagined her family might be consuming poison every day.
But when she signed up for a research study offering a free T-shirt and a water-quality test, she was stunned to discover that her private well contained arsenic.
“My eldest daughter said … ‘You’re feeding us rat poison.’ I said, ‘Not really,’ but I guess essentially … that is what you’re doing. You’re poisoning your kids,” Brennan lamented in her thick Maine accent. “I felt bad for not knowing it.”
Brennan is not alone. Urine samples collected by the Centers for Disease Control and Prevention from volunteers reveal that most Americans regularly consume small amounts of arsenic. It’s not just in water; it’s also in some of the foods we eat and beverages we drink, such as rice, fruit juice, beer and wine.Under orders from a Republican-controlled Congress, the Environmental Protection Agency in 2001 established a new drinking-water standard to try to limit people’s exposure to arsenic. But a growing body of research since then has raised questions about whether the standard is adequate.
The EPA has been prepared to say since 2008, based on its review of independent science, that arsenic is 17 times more potent as a carcinogen than the agency now reports. Women are especially vulnerable. Agency scientists calculated that if 100,000 women consumed the legal limit of arsenic every day, 730 of them would eventually get bladder or lung cancer from it.
After years of research and delays, the EPA was on the verge of making its findings official by 2012. Once the science was complete, the agency could review the drinking water standard.
But an investigation by the Center for Public Integrity found that one member of Congress effectively blocked the release of the EPA findings and any new regulations for years.
It is a battle between politics and science. Mining companies and rice producers, which could be hurt by the EPA’s findings, lobbied against them. But some of the most aggressive lobbying came from two pesticide companies that sell a weed killer containing arsenic.
The EPA had reached an agreement with those companies to ban most uses of their herbicide by the end of last year. But the agreement was conditioned on the EPA’s completing its scientific review. The delay by Congress caused the EPA to suspend its ban. The weed killer, called MSMA, remains on the market.
Turning to a powerful lawmaker for help is one tactic in an arsenal used by industry to virtually paralyze EPA scientists who evaluate toxic chemicals. In 2009, President Obama signed an executive memorandum to try to stop political interference with science. That same year, the EPA unveiled an ambitious plan to evaluate far more chemicals each year than had been done in either the Bush or Clinton administrations.
But in 2012 and 2013, the EPA has managed to complete only six scientific evaluations of toxic chemicals, creating a backlog of 47 ongoing assessments. It’s a track record no better than past administrations. The Center found that a key reason for this is the intervention by a single member of Congress.
The story of arsenic shows how easily industry thwarted the Obama’s administration’s effort to prevent interference with science.
In support of Medicare for all
By Jack Bernard
The Florida Times-Union (Jacksonville), June 30, 2014
My party, the GOP, is running for election this year on the slogan “repeal and replace Obamacare.”
I agree, but the question is “what will be the replacement?” My answer is Medicare for all.
From a moral standpoint, due to expansion of access to health care, the Affordable Care Act is clearly better than what we had previously. The Medicaid expansion provision, which unfortunately was made voluntary by a politicized Supreme Court, does a lot to help very low-income people who cannot afford insurance premiums.
On the other hand, of the 8 million who signed up for Obamacare nationally through the exchanges, many just switched from existing “limited” insurance policies.
In Georgia (my home), 22 percent of the population (one of the highest rates nationally) was uninsured before Obamacare.
Expanding access
Even if all 8 million had been uninsured, tens of millions are still without insurance and will be for the near future. This fact is especially true in red states like ours that have inexplicably chosen to turn back federal money to expand Medicaid, a purely political decision.
Further, because the Affordable Care Act is built on the defective private insurance model, it will never be very effective or efficient.
And with no Affordable Care Act public option, insurance companies will take advantage of consumers. For example, in the Albany, Ga., area, there is only one insurance company available via the exchange, Blue Cross. Incredibly, rates there are higher than they are in Beverly Hills, Calif.
Thus, many experts believe Obamacare does little to contain costs, the “affordable” portion of the Affordable Care Act, because private insurers are at the core of the program.
As opposed to my fellow Republicans, I do not believe that politically we can just repeal it and go back to what we had.
It is also unrealistic to propose simply doing away with Medicare and Medicaid in their current form as the plan by U.S. Rep, Paul Ryan and others in the GOP propose.
Advocating for this policy will just ensure that the GOP becomes a regional party, permanently losing national elections.
As a proven fiscal conservative, I generally do not like high taxes, especially when public money is going to the wrong places and programs.
Reducing costs
So why do I want to see more government involvement in our health insurance system via Medicare expansion to everyone? Because as opposed to many government programs, Medicare works well. Based on their experience, taxpayers (especially senior citizens like me), like Medicare.
And it is efficient, cutting out marketing and overhead expenses. Medicare has overhead expenses of only 3 percent compared to 20 percent-plus for private insurance companies.
Adding a younger and healthier cohort will automatically lower overall Medicare utilization per patient.
Another factor is the strength that being a single payer gives you in the marketplace. This has proven to be true in Canada, which spends much less than we do per capita and has better outcomes.
Obama, by nature a cautious moderate, made a major mistake in abandoning his previous support for Medicare for all. I believe that he should reverse course and establish a presidential commission to determine the exact benefits and costs of converting our current non-system to single-payer.
Before his retirement, Jack Bernard was a senior health care executive with several national firms as well as the former director of health planning for the state of Georgia.
Vermont and its educators lead the way on single payer
By Mary Ellen Flannery
NEA Today, June 27, 2014
The same state that led the nation on same-sex marriage is now tackling another social justice issue: health care coverage for all of its residents.
Led by Gov. Peter Shumlin, with the strong support of VT-NEA and its leaders, the state of Vermont is moving effectively toward becoming the first in the U.S. with a universal, publicly funded healthcare system. Also known as “single payer,” a universal system promises to contain the out-of-control costs of health care while delivering high-quality, comprehensive, and affordable care to all Vermonters, no matter their family income, employment status or background.
“Many people may have been surprised and a little curious (to hear) Vermont-NEA was backing the move toward universal, publicly funded health care,” wrote VT-NEA President Martha Allen this spring. “After all, the thinking goes, members of the state’s largest union already have comprehensive and affordable health insurance, so why on earth would they support Vermont’s efforts to become the first U.S. state to go down this road?
“The answer, of course, is that the creation of Green Mountain Care is good for Vermonters.”
Proponents of universal health care in Vermont, including many doctors and small business owners, began decades ago to pursue a unified health care system. In 2011, they won a key victory: Passage of Act 48, a state law requiring creation of a “universal and unified” health care system for the “public good” of all Vermont residents. Called “Green Mountain Care,” the new program must, by law, cover residents “in a seamless manner regardless of income, assets, health status, or availability of other health coverage.” It also must work to contain costs, provide patients with choices, and preserve and enhance primary care in Vermont’s communities.
“There’s no reason that anybody in Vermont, regardless of who they are, where they work, or what their health status is, should be without comprehensive, affordable health care,” said Mark Hage, VT-NEA’s health-policy expert. “We’ve been a leading player here to expand access to public health care for Vermonters. This has always been important to us as a union. We believe it’s the right thing to do.”
If all goes well with the General Assembly’s next task—finding the money to pay for roughly $2 billion program— Vermonters will be enjoying Green Mountain Care in 2017, the first year that states may be permitted to enact a single-payer system under the federal Affordable Care Act (ACA). At that point, it could be a model for other states interested in following its lead.
“Vermont is a very progressive state,” said Ida Hellender, of the Physicians for a National Health Program. But the essential ingredients of Vermont’s health care system can be found anywhere: “They have doctors, they have hospitals, they have the same kinds of bodies that the rest of us do…”
The Hidden Cliffs in Obamacare
As the Affordable Care Act becomes reality, so do some of its little-known inequities
A hypothetical couple whom we’ll call Barbara and Harry Jones are 52 years old and have two children, and their household income is $94,200. She’s a freelance marketing consultant and he’s a plumber, so neither has health insurance from an employer. They live in Lancaster, Ohio, and they signed up for Obamacare just in time to make the deadline at the end of March.
Great news: based on their income, Barbara and Harry will get an annual $2,904 subsidy from the government to help pay an insurance bill that will be $12,288 a year for moderately good coverage. Obviously, the Joneses are not poor. But health care is now so expensive that President Obama’s law was designed to give even them help buying insurance.
Alice and Bob Smith (another hypothetical couple) and their two children live next door to the Joneses in Ohio. They too work in jobs–day care for her, light construction for him–that don’t provide health insurance. Their income is $94,300–meaning they’re keeping up with the Joneses and, in fact, beating them by $100. The Smiths will get no subsidy at all.
Now that enrollment in Obamacare has ended for the year, some of the quirks–maybe they should be called potholes–embedded in the complicated and heavily lobbied law are going to start to become visible. First among them may be the “cliff” problem that penalizes the Smiths to the tune of $2,904 for making $100 more than the Joneses. I can already see the headline on Fox News: “Obama’s Health Care Bureaucrats Tax Ohio Couple 2,904% for Making $100 More Than Next-Door Neighbors.”
It will be true. That’s because the Smiths’ income is just slightly more than four times $23,550, the amount defined by the government as living in poverty for a family of four. Under the Affordable Care Act, families like the Joneses who earn up to but not more than four times the poverty level get subsidies. After that, there is no subsidy. Sorry, Mr. and Mrs. Smith. Going over $94,200 is like going over a cliff. Unlike the way the federal graduated income tax is calibrated so that the Smiths never lose money by earning more, the subsidy doesn’t decline step by step. It plunges to zero.
The Price of Prevention: Vaccine Costs Are Soaring
SAN ANTONIO — There is little that Dr. Lindsay Irvin has not done for the children’s vaccines in her office refrigerator: She remortgaged her home to afford their rising prices. She packed them in ice chests and moved them when her office flooded this year. She pays a company to monitor the fridge in case the temperature rises.
“The security company can call me any time of the day or night so I can go save my vaccines,” said Dr. Irvin, a pediatrician. Those in the refrigerator recently cost $70,000, she said — “more than I paid for four years of medical school.”SAN ANTONIO — There is little that Dr. Lindsay Irvin has not done for the children’s vaccines in her office refrigerator: She remortgaged her home to afford their rising prices. She packed them in ice chests and moved them when her office flooded this year. She pays a company to monitor the fridge in case the temperature rises.
“The security company can call me any time of the day or night so I can go save my vaccines,” said Dr. Irvin, a pediatrician. Those in the refrigerator recently cost $70,000, she said — “more than I paid for four years of medical school.”
Vaccination prices have gone from single digits to sometimes triple digits in the last two decades, creating dilemmas for doctors and their patients as well as straining public health budgets. Here in San Antonio and elsewhere, some doctors have stopped offering immunizations because they say they cannot afford to buy these potentially lifesaving preventive treatments that insurers often reimburse poorly, sometimes even at a loss.
Childhood immunizations are so vital to public health that the Affordable Care Act mandates their coverage at no out-of-pocket cost and they are generally required for school entry. Once a loss leader for manufacturers, because they are often more expensive to produce than conventional drugs, vaccines now can be very profitable.
Old vaccines have been reformulated with higher costs. New ones have entered the market at once-unthinkable prices. Together, since 1986, they have pushed up the average cost to fully vaccinate a child with private insurance to the age of 18 to $2,192 from $100, according to data from the Centers for Disease Control and Prevention. Even with deep discounts, the costs for the federal government, which buys half of all vaccines for the nation’s children, have increased 15-fold during that period. The most expensive shot for young children in Dr. Irvin’s refrigerator is Prevnar 13, which prevents diseases caused by pneumococcal bacteria, from ear infections to pneumonia.
Like many vaccines, Prevnar requires multiple jabs. Each shot is priced at $136, and every child in the United States is required to get four doses before entering school. Pfizer, the sole manufacturer, had revenues of nearly $4 billion from its Prevnar vaccine line last year, about double what it made from high-profile drugs like Lipitor and Viagra, which now face generic competitors.
http://www.nytimes.com/2014/07/03/health/Vaccine-Costs-Soaring-Paying-Till-It-Hurts.html?hp&action=click&pgtype=Homepage&version=HpSumSmallMedia&module=second-column-region®ion=top-news&WT.nav=top-news
http://www.nytimes.com/2014/07/03/health/Vaccine-Costs-Soaring-Paying-Till-It-Hurts.html?hp&action=click&pgtype=Homepage&version=HpSumSmallMedia&module=second-column-region®ion=top-news&WT.nav=top-news
Vaccination prices have gone from single digits to sometimes triple digits in the last two decades, creating dilemmas for doctors and their patients as well as straining public health budgets. Here in San Antonio and elsewhere, some doctors have stopped offering immunizations because they say they cannot afford to buy these potentially lifesaving preventive treatments that insurers often reimburse poorly, sometimes even at a loss.
Childhood immunizations are so vital to public health that the Affordable Care Act mandates their coverage at no out-of-pocket cost and they are generally required for school entry. Once a loss leader for manufacturers, because they are often more expensive to produce than conventional drugs, vaccines now can be very profitable.
Old vaccines have beenreformulated with higher costs. New ones have entered the market at once-unthinkable prices. Together, since 1986, they have pushed up the average cost to fully vaccinate a child with private insurance to the age of 18 to $2,192 from $100, according to data from the Centers for Disease Control and Prevention. Even with deep discounts, the costs for the federal government, which buys half of all vaccines for the nation’s children, have increased 15-fold during that period. The most expensive shot for young children in Dr. Irvin’s refrigerator is Prevnar 13, which prevents diseases caused by pneumococcal bacteria, from ear infections to pneumonia.
Vaccination issue illustrates degrees in which doctors can sway decisions
KAREN RAVN
Doctors used to make decisions for their patients routinely. These days many of them give their patients a say, but just how much of a say can vary considerably. Does that make a difference in the care patients receive? Consider an article published in the journal Pediatrics last December analyzing 111 conversations that 16 doctors and nurse practitioners had with parents of children who were due to be vaccinated. While the study was not designed to look at decision-making specifically, it may provide some insights.
All of the healthcare providers in the study surely believed the children should have shots. "There are no known medically acceptable alternatives to the CDC's routine childhood immunization schedule," says Dr. Douglas Opel, an assistant professor at the University of Washington School of Medicine and lead author of the study.
True, research associating autism with childhood vaccinations made a big splash when it came out, and many laypeople still believe in those findings. But subsequent research has not found any such link. And according to the Centers for Disease Control and Prevention (CDC), if we stopped vaccinating children, "before long we would see epidemics of diseases that are nearly under control today. More children would get sick and more would die." In other words, the medical community is united in recommending that children get vaccinated.
Research has shown that when only one medically advisable course of action is available, many doctors — hoping to reduce the chances that patients will choose a medically inadvisable action — simply don't give patients any real choice about what to do.
It's not terribly surprising then that about three-quarters of the providers in the study introduced the subject of vaccination in language implying that vaccination was a foregone conclusion — e.g., "We have to do some shots." Thus, they avoided opening the door for parents to choose not to vaccinate.
But the remaining providers in the study did open that door with language implying that vaccination was not a sure thing — e.g., "What do you want to do about shots?" These providers may have believed very strongly that parents should make their own decisions.
The two approaches yielded very different results. When providers acted like not vaccinating was not even a choice, some parents still said they didn't want the shots — but far more did so when providers seemed to indicate that that was a viable option.
Vaccines are safe and problems are 'extremely rare,' study says
Public health experts have taken a fresh look at the safety records of childhood vaccines and once again pronounced them safe.
A systematic review published Tuesday by the journal Pediatrics notes some evidence of “adverse effects” from 11 vaccines. But the authors of the 13-page report emphasize that such problems are “extremely rare” and that the benefits of routine childhood immunizations far outweigh the risks.
“Vaccines are considered one of the greatestpublic health achievements of the 20th century for their role in eradicating smallpox and controlling polio, measles, rubella and other infectious diseases in the United States,” wrote the study authors, a group of experts from Rand Corp. in Santa Monica, UCLA and Boston Children’s Hospital.
However, some parents falsely believe that these vaccines cause autism and other health problems, and they are opting out in increasing numbers. “Parental refusal of vaccines has contributed to outbreaks of vaccine-preventable diseases such as measles and pertussis,” the study authors wrote.
At the request of the U.S. Department of Health and Human Services’Agency for Healthcare Research and Quality, the researchers scoured the medical literature for the most scientifically rigorous studies on vaccine safety in kids. In addition to the studies examined in a comprehensive2011 report from the Institute of Medicine, they identified 67 more studies involving controlled trials. Studies using versions of vaccines that aren’t available in the U.S. were not included in the analysis.
Here’s what the researchers found about each vaccine:
Best state in America: California, for its smooth rollout of the Affordable Care Act
The Affordable Care Act’s size and scope led to some incredible flops in states such as Maryland , Nevada, Hawaii and Oregon , where Web sites intended to help people gain health insurance coverage failed miserably. But other states fared better: Love or hate the ACA, California implemented the complex new law better than every other state. The software worked, red tape was cut, and sign-ups, for the most part, went smoothly.
In the Golden State, more than 2.5 million people signed up for coverage during the first six months of open enrollment. More than 42 percent of those eligible to sign up for care in California did so, a rate second only to Vermont’s. Medicaid enrollment in California jumped almost 16 percent, putting it in the top quartile of states. California was one of only six states to grow their private insurance rolls more than their Medicaid numbers, even after accepting federal dollars to expand Medicaid.
California’s success comes in large part because it broke down barriers between bureaucratic programs, said Edwin Park, vice president for health policy at the left-leaning Center on Budget and Policy Priorities. It was one of five states to simplify Medicaid enrollment for low-income residents who receive federal food stamp benefits. And even before the open-enrollment period began Oct. 1, several California counties expanded their Medicaid rolls, ensuring that about half a million low-income residents would be covered immediately.
Obamacare: Legal aid groups demand answers on Medi-Cal backlog
ERYN BROWN
With low-income Californians continuing to face months-long delays in getting state healthcare coverage, health advocates are calling on the state to explain within 10 days how it will address lingering Obamacare application delays.
In a letter to Gov. Jerry Brown and other officials Wednesday afternoon, the advocates demanded that California's healthcare agency lay out specific plans for eliminating a huge backlog in applications for Medi-Cal, the state healthcare program for the poor.
"This has been a persistent problem for the last six months, and relief has been woefully insufficient so far," said the letter from members of the Health Consumer Alliance, a group of legal aid organizations that help clients get care. "We cannot ... ignore the effect this backlog is having on our clients."
The Affordable Care Act's expansion of Medicaid -- the umbrella federal program that includes the state Medi-Cal service -- has been touted as a huge success in California. The state healthcare department has reported that Medi-Cal enrollment will surge from 7.9 million before ACA implementation to 11.5 million in 2014-15, covering about a third of the state's population.
But hundreds of thousands of new applications for the program have been bogged down by computer problems -- in many cases, for months.
In May, the department reported that900,000 applicants were waiting to hear whether they were eligible for Medi-Cal. On Wednesday, spokesman Anthony Cava said that "the number of pending individuals is decreasing," but did not provide updated statistics.
Katie Murphy, managing attorney at Neighborhood Legal Services of Los Angeles County, which is part of the Health Consumer Alliance, said ongoing bureaucratic delays had prevented many people from seeking needed medical care.
"It's making people think health reform was an empty promise," she said. "This is completely unacceptable."
Health-care exchanges are not properly ensuring applicants’ eligibility, probe finds
The new health insurance marketplaces run by the federal government and some states are not checking carefully enough that Americans who apply for health plans qualify for the coverage and federal subsidies to help pay for it, according to federal investigators.
A pair of reports, issued Tuesday by the Department Health and Human Services’ Office of Inspector General, conclude that “internal controls” for evaluating applications were not always effective at verifying people’s Social Security numbers, their citizenship, and whether they are eligible to buy health plans through the marketplaces because they cannot find affordable insurance elsewhere.
Such deficiencies “may have limited the marketplaces’ ability to prevent the use of inaccurate or fraudulent information” by consumers drawn to the insurance exchanges created under the 2010 Affordable Care Act, one of the reports said.
In the other report, the inspector general evaluated the marketplaces’ ability to verify the accuracy of information that consumers submit when they apply for the insurance and for financial help. By the end of last year, the report said, the federal marketplace alone had 2.9 million “inconsistencies” — gaps between the information applicants provided and various federal records. And 2.6 million of them could not be resolved because the computer system needed to do so “was not fully operational.”
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