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Saturday, July 19, 2014

Health Care Reform Articles - July 19, 2014

When Poverty Makes You Sick, a Lawyer Can Be the Cure

by Tina Rosenbert - NYT

By early summer 2010, the temperature had already reached 100 degrees in Cincinnati. At Cincinnati Children’s Hospital Medical Center, doctors were urging the families of children with asthma to use air-conditioning. One mother handed a piece of paper to her doctor: The child’s room did have a window unit, and she was using it. But then the landlord responded — he apparently didn’t want to pay the electric bills. Use that air-conditioner, the letter said, and you will be evicted.
A concerned doctor might have tried to call the landlord to fight the notice. Or, she might have handed the letter over to a social worker. But Cincinnati Children’s had something better — it had lawyers. In 2008, the hospital and the Legal Aid Society of Greater Cincinnati set up a medical-legal partnership, the Cincinnati Child Health-Law Partnership or Child HeLP.
A week later, another family came in with the same letter. And the week after that.
“Our lawyers were getting the same problem referred over and over in a short period of time,” said Elaine Fink, who is the co-leader of Child HeLP. “They looked at the map ­— they were all in the same neighborhood. They looked to see who owned the buildings. In this case we hit bingo ­— the same owner.”

That was the Brooklyn-based NY Group, which held 18 buildings in Cincinnati and one in Dayton. Many tenants in those buildings had ended up at Child HeLP — to get help with mold, water damage, structural perils, rodents or bug infestations.
Child HeLP wrote to NY Group, including in its letters statements by physicians about the health impacts of its legal violations. It sued on behalf of one severely disabled boy with a tracheotomy whose health depended on air-conditioning. The repairs were done in a few weeks.
http://opinionator.blogs.nytimes.com/2014/07/17/when-poverty-makes-you-sick-a-lawyer-can-be-the-cure/?_php=true&_type=blogs&_r=0

At NewYork-Presbyterian Hospital, Its Ex-C.E.O. Finds Lucrative Work

by Anemona Hartocollis - NYT

When Dr. Herbert Pardes retired as president and chief executive of NewYork-Presbyterian Hospital in 2011, the institution honored him at its annual “Cabaret” fund-raiser. More than 1,000 guests dined on wild mushroom soup catered by the restaurateur Danny Meyer and listened to Kelli O’Hara, a star of “South Pacific,” serenade them with Rodgers and Hammerstein, Sondheim and Berlin.
But there were more thanks to come.
The next year, Dr. Pardes earned $5.6 million, which included $1 million in base salary, a $1.8 million bonus for his final year as chief executive and more than $2 million in deferred compensation, according to hospital tax records. That exceeded the amount earned by Dr. Pardes’s successor, Dr. Steven Corwin, who made $3.6 million that year.
Three years after retirement, Dr. Pardes is still employed by the hospital as the executive vice chairman of its board of trustees, a position that compensation experts say is rare in the nonprofit world, though much more common in for-profit companies.
“That’s a nice retirement present,” said Judy Wessler, the former director of the Commission on the Public’s Health System, a New York City patient advocacy group.
How much hospital executives should be compensated has been a matter of debate for several years and across the country. A study last year by researchers at the Harvard School of Public Health found that in general, executive pay bore no relation to patient outcomes, like mortality and readmission rates, and frequently had more to do — at least indirectly — with the bottom line.
Senator Charles E. Grassley, Republican of Iowa, who has been pressing for tax-exempt hospitals to be more accountable for the salaries they pay, said on Tuesday that Dr. Pardes’s compensation was an example of how “major nonprofit hospitals often are indistinguishable from for-profit hospitals in their operations.” The senator added: “It’s not enough to say high compensation is necessary and leave it at that. A nonprofit hospital should show how that compensation benefits its patients.”

The Global Slowdown in Medical Costs

Margot Sanger-Katz - NYT

We tend to think of health care as a local good. Most people use the doctor or hospital in their neighborhood. China does not export medical care. Health and life spans differ from country to country, even county to county.
But when it comes to health care spending, the picture is starting to look more global. After decades when health spending in the United States grew much faster than it did in other Western countries, a new pattern has emerged in the last two decades. And it has become particularly pronounced since the economic crisis. The rate of health cost growth has slowed substantially since 2000 in every high-income country, including the United States, Canada, Britain, France, Germany and Switzerland, according to data from the Organization for Economic Cooperation and Development.
“We used to be different,” said Louise Sheiner, a senior fellow at the Brookings Institution and a former senior economist at the Federal Reserve. “Since about 1990, we’ve looked about the same.”
The synchronized slowdown offers reasons to be skeptical about neat explanations for the trends in any one country, be it local changes in medical practices or Obamacare’s various attempts to slow cost growth. The slowdown has also reduced budget pressures around the world, a welcome development as baby boomers are retiring. Just this week, the Congressional Budget Office reduced its long-term forecasts for spending in the Medicare program, one of several recent reductions that mean the program’s solvency is looking safer than it has in years.
What’s behind the pattern? Economic growth around the industrialized world has been slow for much of the last decade, and the aging of the population in much of the world has also created fiscal pressures to rein in health spending. But these economic and political forces — which in turn leave governments and households with less money to purchase medical care — do not appear to be the only causes.
The world’s health-care systems are also converging in important ways. New drugs and medical advances, which were once adopted locally and spread more slowly, are now experiencing international launches. Medical technology companies are increasingly global, and seeing regulatory approval in many markets at once. Strategies that can reduce the need for expensive hospital stays, such as performing surgeries in outpatient clinics, are expanding around the world.
http://www.nytimes.com/2014/07/17/upshot/the-global-slowdown-in-medical-costs.html?emc=edit_tnt_20140717&nlid=1311158&tntemail0=y&_r=0

Bees and Colony Collapse


By MARK WINSTON



VANCOUVER, British Columbia — AROUND the world, honeybee colonies are dying in huge numbers: About one-third of hives collapse each year, a pattern going back a decade. For bees and the plants they pollinate — as well as for beekeepers, farmers, honey lovers and everyone else who appreciates this marvelous social insect — this is a catastrophe.
But in the midst of crisis can come learning. Honeybee collapse has much to teach us about how humans can avoid a similar fate, brought on by the increasingly severe environmental perturbations that challenge modern society.
Honeybee collapse has been particularly vexing because there is no one cause, but rather a thousand little cuts. The main elements include the compounding impact of pesticides applied to fields, as well as pesticides applied directly into hives to control mites; fungal, bacterial and viral pests and diseases; nutritional deficiencies caused by vast acreages of single-crop fields that lack diverse flowering plants; and, in the United States, commercial beekeeping itself, which disrupts colonies by moving most bees around the country multiple times each year to pollinate crops.
The real issue, though, is not the volume of problems, but the interactions among them. Here we find a core lesson from the bees that we ignore at our peril: the concept of synergy, where one plus one equals three, or four, or more. A typical honeybee colony contains residue from more than 120 pesticides. Alone, each represents a benign dose. But together they form a toxic soup of chemicals whose interplay can substantially reduce the effectiveness of bees’ immune systems, making them more susceptible to diseases.
These findings provide the most sophisticated data set available for any species about synergies among pesticides, and between pesticides and disease. The only human equivalent is research into pharmaceutical interactions, with many prescription drugs showing harmful or fatal side effects when used together, particularly in patients who already are disease-compromised. Pesticides have medical impacts as potent as pharmaceuticals do, yet we know virtually nothing about their synergistic impacts on our health, or their interplay with human diseases.

We Are Our Bacteria

by Jane Brody - NYT

We may think of ourselves as just human, but we’re really a mass of microorganisms housed in a human shell. Every person alive is host to about 100 trillion bacterial cells. They outnumber human cells 10 to one and account for 99.9 percent of the unique genes in the body.
Katrina Ray, a senior editor of Nature Reviews, recently suggested that the vast number of microbes in the gut could be considered a “human microbial ‘organ’” and asked, “Are we more microbe than man?”
Our collection of microbiota, known as the microbiome, is the human equivalent of an environmental ecosystem. Although the bacteria together weigh a mere three pounds, their composition determines much about how the body functions and, alas, sometimes malfunctions.
Like ecosystems the world over, the human microbiome is losing its diversity, to the potential detriment of the health of those it inhabits.
Dr. Martin J. Blaser, a specialist in infectious diseases at the New York University School of Medicine and the director of the Human Microbiome Program, has studied the role of bacteria in disease for more than three decades. His research extends well beyond infectious diseases to  autoimmune conditions and other ailments that have been increasing sharply worldwide.
In his new book, “Missing Microbes,” Dr. Blaser links the declining variety within the microbiome to our increased susceptibility to serious, often chronic conditions,  from allergies and celiac disease to Type 1 diabetes and obesity. He and others primarily blame antibiotics for the connection.

Groups Under Health Act Are Said to Aid Millions

Assisters Helped 10.6 Million With Coverage Under A.C.A.

By
WASHINGTON — More than 4,400 consumer assistance programs created under the Affordable Care Act helped an estimated 10.6 million people explore their new health insurance options and apply for coverage during the initial six-month enrollment period, according to a new Kaiser Family Foundation survey.
But the programs that operated in states with their own online insurance marketplaces got more funding and helped more people than those in states on the federal exchange, the survey found. In the District of Columbia and 16 states that ran or were working toward running their own exchanges, the programs helped about twice as many people, relative to the uninsured population, as they did in 29 states served by the federal exchange.
 Karen Pollitz, a senior fellow at the Kaiser Family Foundation, said she was surprised by the large number of assistance programs, which the survey estimated to employ more than 28,000 full-time-equivalent workers and volunteers. “The size of this infrastructure was something I wouldn’t have predicted when we began,” she said.
These workers, known as assisters, navigators or certified application counselors, were always seen as crucial to the success of the complicated law. But by the time the first enrollment period started last October, it was clear that their impact would vary from state to state, with wide discrepancies in how much was being spent to hire and train them. Many operated in hostile political climates, with some states passing laws restricting what they could do.
Most of the states that did not create their own exchanges — and where assistance groups had less funding — are led by Republican governors or legislatures who strongly oppose the law. The survey found the top reason people sought help from the programs was confusion about the Affordable Care Act and the insurance plans available through the exchanges. Many also encountered technical problems or did not have Internet at home.
About three-quarters of the programs said that “most” or “nearly all” of their clients who considered buying private coverage needed help understanding basic insurance terms, like “deductible” or “in-network service.” And nearly two-thirds of programs said they spent between one and two hours, on average, helping each client. “It’s not like buying shoes or books online,” Ms. Pollitz said. “It’s a lot more complicated, and I think people will continue to need this level of help for a while.”
http://www.nytimes.com/2014/07/15/us/assisters-helped-10-6-million-with-coverage-under-aca.html?module=Search&mabReward=relbias:r,{"2":"RI:15"}&_r=0

The $300,000 Drug

Kalydeco is truly a wonder drug.
Developed by Vertex Pharmaceuticals, it is the first drug that attacks not just the symptoms but the underlying cause of cystic fibrosis, a genetic lung disease that usually kills victims by the time they reach their 40s. It doesn’t work for every sufferer of the disease, but rather for a small subset — probably around 2,000 people — who have a specific genetic mutation that the drug targets. But for those it helps, it is life changing.
“I still pinch myself every day,” says Emily Schaller, 32, who has been taking the drug since she participated in its Phase III trials five years ago. “I can take deep breaths. I can run without coughing.”
Two years ago, as it was coming to market, Dr. Margaret Hamburg, the head of the Food and Drug Administration, described Kalydeco an “an excellent example of the promise of personalized medicine.” Personalized medicine describes drugs that treat so-called orphan diseases — that is, diseases with a small population — or subsets of people with broader diseases. This kind of targeted medicine has been the Holy Grail ever since the genome was first sequenced about a decade ago. Now it is becoming a reality.
There is one other way that Kalydeco is an excellent example of personalized medicine: its cost. It’s more than $300,000 a year. Because patients will likely be taking the drug for the rest of their lives, it could cost millions of dollars to keep just one patient on Kalydeco. That raises another important question about the coming of personalized medicine. How are we, as a society, going to pay for it?
What brings this question to the fore is a fight taking place in Arkansas, where the state’s Medicaid program is balking at paying for Kalydeco for a handful of young patients with cystic fibrosis. Although state officials won’t say so publicly, it is clear that cost is a key issue; The Wall Street Journal got ahold of emails that show Arkansas officials “discussing Kalydeco’s cost, and their worries about the expense of future cystic fibrosis drugs.”
It’s likely that Arkansas will eventually fold. Most state Medicaid programs — and private insurers — are paying Kalydeco’s cost because it works so well, and because the patient population is so small.
What happens, though, when there are 200 such drugs? Or when they are targeted not at cystic fibrosis, which has maybe 30,000 sufferers, but at diabetes or (heaven forbid) cholesterol? A drug called Sovaldi, marketed by Gilead Sciences, takes aim at hepatitis C. It is described as a “breakthrough” drug. But each pill costs $1,000 — and the full regimen costs $84,000. And the hepatitis C population isn’t 30,000 — it is over 3 million. If everyone with hepatitis C took Sovaldi, it would cost something like $300 billion, which is about what the country now pays for all prescription drugs combined.
“This is the future of medicine,” says Barry Werth, “and there’s going to be a reckoning.” Werth is the author of “The Antidote,” a terrific book about Vertex and its race to discover and bring to market these new kinds of drugs. “Everyone wants to see these drugs succeed,” he told me. “Wall Street is all charged up. There really hasn’t been any pushback yet on cost.”
http://www.nytimes.com/2014/07/19/opinion/joe-nocera-cystic-fibrosis-drug-price.html?hp&action=click&pgtype=Homepage&module=c-column-top-span-region&region=c-column-top-span-region&WT.nav=c-column-top-span-region




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