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Tuesday, June 9, 2015

Health Care Reform Articles - June 9, 2015

The War on Doctors & Destruction of Healthcare | Medical Blog

by Linda Girgis, M.D.

May 28, 2015
Walking the hospital corridors, many of the comments I overhear patients and others speaking about doctors often amazes me. On this day, I took notice to the conversation of two elderly women who were none too happy with doctors, whom they stated only cared about their computers these days and not about their patients.
Upon hearing this, I wanted to scream out that nothing is further from the reality of what doctors truly feel. In fact, many days, a burning desire to toss my computer out the second floor window consumes me, but I rein it in. Doctors abhor spending time during the patient visit on their computers, documenting in the electronic chart. This decision was foisted on us by governmental mandates much against our wills. EHR (or electronic health record) technology was forced upon us as well as its antecedent meaningful use requirements. If we do not comply, we will be financially penalized, so we have little choice. I have published many articles on the topic.
Patients do not see this, however. They want our time, they need our eye contact, they need to know we care about their health. They do not want us keyboarding away while they open their hearts to us. It makes them feel insecure. It lets mistrust sneak in. This lack of trust is very harmful to the doctor-patient relationship in many ways. Perhaps, most important is that patients are less likely to follow our medical advice when the trust is not there. And, this can lead to unfavorable medical outcomes.

“The doctor is no longer center stage, unless you are watching a puppet show. We are now the supporting cast. Patients no longer have center stage either. The stars are the CEOs, the administrators who are raking in the big bucks…”

Reading or watching the media exemplifies the anti-doctor culture now prevalent in the US. Even in a State of the Union Address, our own POTUS Obama made the suggestion that doctors perform procedures for profit. He completely disregarded the integrity of most doctors who work long hours, studied for many years, and take great strides to give patients our very best care. The media clamors for us to be transparent about our charges, while many of us close our doors because we can no longer afford to practice. We see the stereotype the media portrays of us: greedy doctors driven for profit. Yet, how many of those journalists volunteered to visit our practices or even talk to us and see what it is like in the exam room and what we deal with on a daily basis? Far easier just to perpetuate a stereotype than to investigate the reality. Sure, there exist some greedy doctors out there. But, the truth is, the majority of doctors despise them because they give us all a bad name and cast us in an unfavorable light. Does anyone want to know what the average doctor is like? Or do we just want to hate them all in the same way because it pleases us this way?
The war on doctors flames in board rooms across the country, as healthcare executives discuss how to profit off of our work. They place no value on our expertise but rather calculate how they can reduce our reimbursements and get us to practice medicine in the way they desire to reduce costs and maximize their revenue. Doctors are not judged by clinical skills but rather by how much money they saved the insurance company. I receive these analyses quarterly from many of the insurance companies that I contract with. If I prevent my patients from going to the ED to obtain medical care or only prescribe them the cheapest medications, I earn a higher rating. Do we really want to be treated by doctors who know how to cut costs the most, or by those with the best medical skills and knowledge? Sure, we all need to be conscious of healthcare costs, but not by sacrificing the best care for our patients. Insurance companies see their bottom lines. I, and most physicians, see a patient in front of us in the exam room that we want to help, to cure, to heal, to prevent a bad outcome from happening. But, all too often, the insurance company overrides our medical decisions in order to save costs, not lives. How has the system lost its priority like this?

Unless, we stand up and demand changes, we are facing a future where the doctor no longer has much input into medical care.


Why doctors quit, Chapter 2

by Charles Krauthammer

I rarely do follow-up columns. I’m averaging one every 10 years. And while my last such exercise resulted in a written apology from the White House (for accusing me of making up facts over its removal of Churchill’s bust), today’s is not a complaint. It’s merely a recognition that the huge response elicited by last week’s column, “Why doctors quit ,” warrants both rebuttal and clarification.
Physicians who responded tended to agree with my claim that doctors are being driven out of the profession by the intrusions, interferences, regulations, mandates, constraints and sundry other degradations of their vocation that are the result of the bureaucratization of medicine. Chief among them is the imposition of electronic health records (EHR).
On the other hand, my critics, vocal and many, had two major complaints. First, that I’m just a Luddite unwilling to adapt to the new digital world and looking for excuses not to. Second, that while I might have a point about the bureaucratization of medicine, could I not have made it without satisfying my anti-Obama tic and blaming it all on him, and my other itch and blaming it on liberalism?
First, I don’t oppose going digital. Properly used, it brings many benefits. The gains, however, are coming not from massive databases attempting to cover and extend to all of medicine but from far more narrow and tailored adaptations. In radiology, for example, one is dealing with artifacts — X-rays, CT scans, MRIs — that can be easily categorized, digitized, filed, transmitted and shared in a way impossible in the age of the shadowed X-ray film held up to backlight.
The problem with the EHR, however, is that the pretense of universality leads to information collection that is largely irrelevant to the patient. And, more fundamentally, that the EHR technology, being in its infancy, is hopelessly inefficient. Hospital physicians will tell you endless tales about the wastefulness of the data collection and how the lack of interoperability defeats the very purpose of data sharing.
As for my complaint about President Obama and his fellow liberals: Again, I don’t oppose going electronic. What I oppose is the liberal instinct to impose doing so, giving substance to that old saw that a liberal is someone who doesn’t care what you do, as long as it’s mandatory. Why could they not leave the decision of when and how to go electronic to those who use the technology and can best judge its ripeness and usefulness? Instead, the Obama administration decided arbitrarily six years ago that EHR should be universally in use by 2015. Time being up, doctors who did not conform are now penalizedthrough partial loss of Medicare reimbursement.
In time, we will surely develop more tailored, specific and efficient data-collection systems that doctors and hospitals will adopt if only to keep up with the increasing efficiency of their digitized competitors. Why, then, the punitive mandate?
I was in no way arguing that the bureaucratization of medicine began with Obama. It is the inevitable and inexorable result of the industrialization of everything from cloth making to food service, now extended to health care. My point is that, given the consequent loss of autonomy and authority of doctors, why are we compounding their demoralization by forcing an EHR mandate that robs them of both time and the satisfaction of proper patient care?
Yes, in principle, vast record-collection will create mass databases that in theory could be mined to help administrators, and perhaps even to yield medical insights. But it is somewhat ironic that with incessant complaints about NSA collection of telephone metadata— as of last Sunday, now banned in these United States — as an assault on privacy and civil liberties, we seem not at all disturbed by the current amassing of mountains of medical data about you and your insides, a literal and far more intrusive invasion of the self. 
My argument is simple. If electronic records are such a great boon — as I believe they eventually will be — they will be adopted over time as the benefits begin to exceed costs. Let the market work. Let doctors breathe. And while you’re at it, drop the Medicare penalty.


Bill would limit efforts to recoup Medi-Cal costs from patients' estates

The state's Medi-Cal program has long looked to the estates and heirs of deceased Californians to recoup public money spent on their healthcare in the last years of life.
But the practice — including suing survivors and filing liens against the homes of poor families — is coming under attack in Sacramento.
On Thursday, the state Senate approved, 33 to 0, a bill by state Sen. Ed Hernandez (D-West Covina) to order major changes in the Medi-Cal recovery program. It now goes to the Assembly.
If signed into law, Senate Bill 33 would limit the state's ability to go after homes "of modest value," allowing survivors hardship exemptions for homes with fair market value of 50% or less of the county average. It would also prohibit seeking money from the estates of surviving spouses.
The bill targets California-specific provisions of the recovery program, which are more aggressive than required by federal Medicaid regulations.
Hernandez took interest after learning that many poor families were reluctant to sign up for Medi-Cal because they didn't want the state collecting after they died. Taking from estates and heirs "needlessly prolongs poverty," he said Thursday.
"Californians shouldn't be forced to put their house on the line in order to receive basic healthcare services," he said.
Since 1993, California has recovered more than $1 billion from Medi-Cal recipients' estates — and that number could swell as thousands more low-income people sign up for Medi-Cal as part of the Affordable Care Act. Almost a third of all Californians get some kind of assistance from Medi-Cal.
The $1 billion seized came from the estates of Medi-Cal recipients who died leaving behind assets, often their homes. If heirs do not voluntarily pay off the Medi-Cal debt, or win hardship exemptions, California officials file lawsuits to collect the debt in court.
The state's recovery efforts take many survivors by surprise. Linda Conder, a 67-year-old Whittier woman, said she had no idea she could have taken steps to protect her mother's assets from collection.
The state sued her in March, seeking $120,000 her mother held in a bank account when she died in 2010. Medi-Cal had paid that amount to cover her mother's care between 1999 and 2003.
"If you're wealthy enough, you can set it up in a certain way" to avoid collection, she said. "We didn't know that. We don't have attorneys working for us. That's not the way everyday America works."

Hospital bill is high enough to raise anyone's blood pressure
by David Lazarus

single dose of the anti-anxiety drug lorazepam — the generic version of Ativan — will run you about 14 cents at Safeway or Target.
At Good Samaritan Hospital in Los Angeles, the same pill goes for nearly $2,000.
At least that's the impression Laurie Leigh came away with after being so overcome with grief when her 90-year-old father died at the hospital that she fainted at his bedside. She subsequently received a pill to soothe her nerves.
Leigh's insurer, Blue Shield of California, covered about $200 of the bill, leaving her holding the bag for more than $1,700.
Leigh's experience underlines a problem faced by everyone who interacts with our healthcare system — the inexplicable cost of even the most modest treatment. Patients face a tough challenge in getting a straight answer to the question, "Why so much?"
"Hospitals and doctors don't like to answer that question because there's no good answer," said Jerry Flanagan, staff attorney with the Santa Monica advocacy group Consumer Watchdog. "The answer is that they charge as much as they think they can get away with."
It's worth noting that Leigh's $1,952 bill was aside from the bill for about $100,000 that her father ran up over several weeks, until he was disconnected from a life-support machine.
All things considered, you'd think any hospital would do whatever it could to assist bereaved family members and wouldn't be tempted to reach deeper into their pockets.
Makes you also wonder what part of the Good Samaritan story Good Samaritan Hospital doesn't understand.
Leigh, 57, told me that when her father died in February, she was so stricken that she collapsed briefly into a family member's arms. She came to as she was being moved by wheelchair into Good Samaritan's emergency department.


In the ER, Leigh said, her blood pressure was measured — it was a little high — and she was given the pill to help her relax. She then waited about 90 minutes on a bed until she felt calm enough to leave.
"My blood pressure went down and that was it," Leigh recalled.
The nearly $2,000 hospital bill arrived last month. It didn't itemize any charges. It just said, "Type of service: Emergency."
"I thought, 'You've got to be kidding,'" Leigh said. "This is crazy."
She contacted Good Samaritan. A representative of the billing department said the charge was accurate and offered only to work out a payment plan.
"You'd think they could show at least a little compassion," Leigh said.
Even factoring in the costs of the wheelchair ride down the hall, the nurse who took Leigh's blood pressure and whatever expense can be attached to waiting around for an hour and a half, it's hard to see how a hospital would try to turn the screws on someone whose father had just died in the facility.
Moreover, why wouldn't it break down specific charges on the bill? The only reason, it would seem, is that the hospital doesn't want patients knowing the insane prices they're being charged.
Good Samaritan was more forthright with Leigh's insurer, Blue Shield.
The hospital's insurance claim shows that it charged about $232 for the blood-pressure exam and $19.54 for the pill. The bulk of the bill — $1,700 — was for just setting foot in the emergency room.
The average registered nurse makes $26.66 an hour, according to PayScale.com. It's hard to see how that jibes with charging $232 for a blood-pressure exam that couldn't have taken more than a few minutes.
The price-comparison website GoodRx says 1 milligram of generic lorazepam costs about 14 cents at Safeway and Target, 18 cents at Kroger Pharmacy and 19 cents at Walgreens.
At nearly $20 a pill, Good Samaritan imposed a markup of more than 14,000% — a healthy profit margin by anyone's reckoning.
As for the ER charge, a hospital obviously has fixed costs for maintaining emergency services. But $1,700 just for a routine blood-pressure test, a pill and the use of a bed for 90 minutes? That seems pretty steep.
Katrina Bada, a Good Samaritan spokeswoman, expressed condolences to Leigh and her family. But she said the nearly $2,000 bill was justified because "this was not a 10-minute office visit to receive a simple medicine."
"She was admitted for care in our emergency room, where she was evaluated, and then observed over the course of one and one half hours because of her condition," Bada said. "She did receive medication and was discharged only after her condition improved and she was determined to be safe to discharge."
She said Leigh's bill didn't reflect just having her blood pressure taken or receiving a pill, "but also the staffing, facilities and infrastructure to deliver the items."
The $1,700 ER charge, Bada said, "is consistent with the charges assessed by other hospitals in our area." She said that if patients want itemized bills, they can ask for them.
Flanagan at Consumer Watchdog said hospitals used to hit insured patients with sky-high charges to help subsidize treatment of the uninsured — a practice known as cost shifting.
"They don't have that excuse anymore because we now have the Affordable Care Act," he said, referring to the federal program that requires most people to have coverage and helps pay the monthly premiums of those requiring financial assistance.
"Now it's just straight-up profiteering," Flanagan said.

Much in common, but worlds apart on the issue of vaccinating children

Robin Abcarian

COLUMNIST

We sat outside on a gorgeous spring day here, the four moms and me. Lucia Sciarpa Paxton, a former Spanish teacher and professional photographer, had prepared an impressive lunch. For two hours, as we moved from roasted fennel salad to coffee, the women explained why California should not require vaccinations for schoolchildren.

I had met Paxton, 42, in a hallway outside a state Senate hearing room in Sacramento in April. She had come with hundreds of others to protest SB 277, which would eliminate the state's personal belief exemption. The PBE allows parents to opt out of vaccinating kids against diseases like polio, chickenpox, measles and whooping cough.

The new law, still wending through the Legislature, would not apply to children who cannot be immunized for medical reasons. Nor would it apply to children who are home-schooled independently or under the supervision of public schools, as is the case for Paxton's 14-year-old daughter, Zephyra, who has been selectively vaccinated. Paxton opposes the bill on principle.

Mandatory vaccinations seem like such a no-brainer to me. The personal belief exemption has gotten out of hand, especially in highly educated, mostly white enclaves such as Marin and Santa Cruz counties, imperiling herd immunity. And yes, the bill is a form of coercion. Then again, so are seat belt laws and anti-smoking laws.
Still, I wanted to know more about how these women think. I wanted to listen with an open mind.
Paxton said she'd be happy to talk to me as long as she could include some of her allies in the battle against the bill. As we sat down to lunch, Zephyra left on her skateboard. I could not help but notice she wore a helmet.

Philosophical exemption to vaccines puts Maine children at risk

Sadly, Maine is seeing an increase in preventable childhood illnesses. This week, the news was about chickenpox. Last year, it was whooping cough. Outbreaks of these diseases can be averted or minimized with vaccinations.
Maine has seen twice as many cases of chickenpox this school year than it did last year. State officials say more than two-thirds of the infections were among children who were not vaccinated or were undervaccinated.
From September 2014 through mid-May 2015, 84 cases of the highly contagious virus were reported in children, according to the Maine Center for Disease Control and Prevention. During the same period last school year there were 44 cases.
Chickenpox cases have been reported in every county except Washington.
Sixty-eight percent of the infections were in children who were not vaccinated at all or had not received the recommended two doses of the vaccine. Four of the children were too young to be vaccinated, highlighting the dangers of diminishing herd immunity. Some people, for health reasons or their age, are not able to be vaccinated. They are protected when a large enough percentage of the population is vaccinated against diseases — a concept known as herd immunity. For some illnesses, more than 90 percent of the population needs to be vaccinated for herd immunity to be effective.
But federal data show the percentage of Maine parents choosing to skip their children’s vaccines is on the rise. Maine’s vaccination opt-out rate was the fourth highest in the nation during the 2013-2014 school year.
Without an exemption, kindergarten students in Maine must be vaccinated against pertussis, diphtheria, tetanus, measles, mumps, rubella, polio and chickenpox.
But the problem lies with those exemptions. Maine is among 18 states that allow parents to exempt their children from school-required immunizations for philosophical reasons. Children can also be exempted from the requirements for medical and religious reasons, although these account for a small fraction of Maine’s opt-outs. Mississippi and West Virginia are the only states that don’t allow exemptions for religious or philosophical reasons. Mississippi, not coincidentally, had the highest kindergarten vaccination rate in the country in 2012-13, according to the U.S. Centers for Disease Control and Prevention.
Late last month, Vermont Gov. Peter Shumlin signed a law doing away with that state’s vaccine philosophical exemption. “Vaccines work, and parents should get their kids vaccinated,” Shumlin said in a statement. “We’re not where we need to be to protect our kids from dangerous diseases, and I hope this legislation will have the effect of increasing vaccination rates.”
Washington and California are also consideringeliminating their vaccine exemptions for philosophical reasons. Maine lawmakers had a similar opportunity this year. Unfortunately, they rejected LD 606, sponsored by Rep. Ralph Tucker, D-Brunswick, which would have done away with the philosophical exemption.

Unionized nurses at EMMC vote to authorize strike

By Jackie Farwell, BDN Staff
Posted June 05, 2015, at 10:27 a.m.
BANGOR, Maine — Unionized nurses at Eastern Maine Medical Center voted Thursday to authorize a strike if the hospital fails to better address their patient safety concerns, including “unsafe staffing.”
The registered nurses are working under a contract extended through June 18, after their original contract expired on May 30, according to a news release from the Maine State Nurses Association/National Nurses Organizing Committee. The next bargaining session is scheduled for June 10.
The union represents about 800 nurses at EMMC.
The nurses said the new contract must address “critical issues impacting patient safety,” to reduce injuries, infections and bedsores among patients treated at the hospital. Unionized nurses voted “overwhelmingly” to prepare to strike if “management continues to turn a blind eye to patient safety,” according to the release.
“As nurses, our first priority is our patients,” EMCC nurse Steve Akerley said in the release. “While we would always prefer to be providing care, at the bedside, the reason nurses voted to authorize a potential strike is because management is putting our patients’ lives and health in jeopardy. We cannot stand by and let that happen.”
The nurses union noted that the Medicare program penalized the hospital for high rates of complications and infections. Medicare cut payments to EMMC, along with five other Maine hospitals, by one percent this fiscal year as part of the government’s nationwide crackdown on avoidable medical errors.
Improved staffing would reduce such errors, the union argued. As of late May, 39 registered nurse positions remained open at EMMC. Without a secure contract, the hospital has struggled to recruit and retain nurses, the union said.
Along with staffing, the union is also negotiating with the hospital on wages, benefits and other working conditions.

Short-Term Health Insurance Attracts Many Despite Drawbacks

By 
TEMPORARY, bare-bonesinsurance plans that don’t meet the requirements of the Affordable Care Act are still attracting consumers, online insurancebrokers report. But health experts caution consumers to be wary of the plans.
Ehealth, a publicly traded onlinehealth insurance broker, said on Wednesday that the number of applicants for the short-term plans on its website more than doubled in 2014, to 140,000 people. (EHealth has struggled to compete in the sale of comprehensive health plans since the Affordable Care Act made policies with premium help available on government exchanges, according to an analysis this week by Kaiser Health News.) Short-term plans are also known as “gap” plans because they were originally intended to fill gaps in coverage, as when people were between jobs.
Whether an increase in short-term policies is a national trend is unclear. The policies tend to be lightly regulated, and some insurers don’t disclose sales of specific types of plans, so data is scant. But other web brokers, like GoHealth, also say they have seen increased interest in the plans.
Short-term policies, which offer primarily catastrophic coverage for major injuries, are available outside the Affordable Care Act’s open enrollment period, but come with many caveats. The plans are available in one-month increments of up to 11 or 12 months, although some plans have shorter maximum coverage periods, like three to six months. They generally require medical underwriting, meaning that applicants can be declined based on their health history — something that cannot be done with Affordable Care Act-compliant plans, a crucial protection. (EHealth said 12 percent of its short-term applications were declined in 2014, mainly for medical reasons.)
Plus, short-term plans are “nonrenewable,” which means that once they expire you must reapply for new coverage, and submit to medical underwriting again, said Karen Pollitz, a health policy expert at the Kaiser Family Foundation.
Once you make a significant claim under such a plan, insurers are unlikely to offer you another one, Ms. Pollitz said. Or they may exclude benefits for care related to your previous claim, before issuing you another policy. Some insurers may also conduct “post claim” underwriting, which means that if you make a claim, the insurer can review your past health history to see if the condition predated your policy. If it finds that it did, your claim may be denied.
“It’s tenuous protection at best,” she said.
The plans generally carry lower premiums because benefits are limited. But plan deductibles — the amount you must pay out of pocket before the plan pays — can still be hefty. The average premium for individual short-term plans sold on eHealth was $110 last year, while the average deductible was $3,589. “The premiums are low for a reason,” Ms. Pollitz said.
So, why would someone buy such a plan? Nate Purpura, a spokesman for eHealth, said some buyers were people who missed the open enrollment period for Affordable Care Act plans but then decided they wanted some coverage. Yet they lacked a qualifying event, like a job loss, that would allow them to buy on the government exchanges after the enrollment period. Another group of purchasers includes those who didn’t qualify for the health law’s premium subsidy, but also don’t qualify for coverage under Medicaid, he said. More than half of eHealth’s short-term applicants were 18 to 34 years old.
Here are some questions and answers about short-term health insurance:
http://www.nytimes.com/2015/06/06/your-money/short-term-health-insurance-attracts-many-despite-drawbacks.html?mabReward=CTM&action=click&pgtype=Homepage&region=CColumn&module=Recommendation&src=rechp&WT.nav=RecEngine

Sneaky Ways to Raise Drug Profits

By 

Two devious tactics by manufacturers of brand-name drugs to delay competition from cheaper generic drugs were appropriately slapped down recently by federal and state officials. That should help consumers, insurers and anyone else who foots the bill for prescription medicines. Generic copies, which can enter the market when patents on a brand-name drug expire, typically cost much less than branded versions and are just as safe and effective.
One tactic involves buying off the competition. According to the Federal Trade Commission, the pharmaceutical company Cephalon, which makes Provigil, a drug used to treat sleep disorders, sued four generic drug makers in 2005-2006 for patent infringement and later paid them more than $300 million collectively to drop their challenges to Provigil’s patents and to stop selling their generics for six years, until April 2012.
In a twist, one of the four companies paid off by Cephalon was Teva Pharmaceutical Industries, based in Israel, which later bought Cephalon and now has to answer for Cephalon’s improper scheme. On May 28, the F.T.C. announced that Teva had agreed to settle a lawsuit filed by the government for $1.2 billion, the largest amount ever secured by the agency. That’s probably less than what Teva might have had to pay if the case went to trial as scheduled on June 1, but it might deter other companies from trying to buy off the competition.
The other tactic that suffered a setback, at least temporarily, is known as “forced switching” or “product hopping.” The attorney general of New York, Eric Schneiderman, won a preliminary injunction to stop the drug company Actavis and its subsidiary Forest Laboratories from withdrawing an older version of Namenda, a drug to treat moderate-to-severe Alzheimer’s disease with a patent that expires in July, and replacing it with a newer version covered by a patent that would extend until 2029.

Global Diabetes Rates Are Rising as Obesity Spreads 

By 

WASHINGTON — The global diabetes rate has risen by nearly half over the past two decades, according to a new study, as obesity and the health problems it spawns have taken hold across the developing world.
The prevalence of diabetes has been rising in rich countries for several decades, largely driven by increases in the rate of obesity. More recently, poorer countries have begun to follow the trend, with major increases in countries like China, Mexico and India.
The study, published Monday in the British medical journal The Lancet, reported a 45 percent rise in the prevalence of diabetes worldwide from 1990 to 2013. Nearly all the rise was in Type 2, which is usually related to obesity and is the most common form of the disease.
A major shift is underway in the developing world, in which deaths from communicable diseases like malariaand tuberculosis have declined sharply, and chronic diseases like cancer and diabetes are on the rise. The pattern is linked to economic improvement and more people living longer, but it has left governments in developing countries scrambling to deal with new and often more expensive ways to treat illnesses.
The study, led by the Institute for Health Metrics and Evaluation, a research group, was funded by the Bill and Melinda Gates Foundation. It is the largest analysis of global disability data to date, drawing on more than 35,000 data sources in 188 countries.
The study measured the burden of disability by calculating the proportion of a population living with any given disorder in a year. It found that the numbers of people living with disability have gone up — largely a result of population growth and aging — but that the rate of disability declined slightly, dropping to 110 per 1,000 people in 2013, compared with 114 per 1,000 in 1990.
Nor had the top-ranking disabilities changed much. The top five were lower back pain, major depression, iron deficiency anemia, neck pain, and hearing loss from aging. In a stark illustration of the decline of infectious diseases in many countries, diarrheal diseases fell to 25th place from 15th. But diabetes increased as a share of the overall burden of disability, moving to No. 7 in 2013 from No. 10 in 1990.

Sell a disease to sell a drug

Steven Woloshin and Lisa M. Schwartz are professors of medicine at the Dartmouth Institute for Health Policy and Clinical Practice and co-chairs of the steering committee of Preventing Overdiagnosis, an international conference to be held at the National Institutes of Health in September.
Seven years, at least 25 million prescriptions and $9.7 billion in sales too late, the Food and Drug Administration is finally pushing back against the over-prescribing of testosterone. 
Last month, in response to new FDA rules, testosterone manufacturers released new instructions for doctors making it clear that testosterone is not approved for “low-T” — a marketing term developed by drug companies to describe men with low testosterone levels caused by aging. Companies must now warn doctors about a possible increased risk of heart attack and stroke in men who take these drugs.
The FDA rules came about after the agency announced in March that it “has become aware that testosterone is being used extensively in attempts to relieve symptoms in men who have low testosterone for no apparent reason other than aging. The benefits and safety of this use have not been established.”
Why are so many men taking testosterone for an unapproved use? The nearly tenfold increase in testosterone prescriptions began in 2007 when Abbott Laboratories (now AbbVie) launched its award-winning“Is It Low-T?” disease awareness campaign. The campaign has urged countless middle-age men who would like to become thinner, more muscular, more energetic and more sexually satisfied to ask their doctors whether low testosterone could be the reason they have gained weight, sometimes feel sad or grumpy, or get sleepy after meals.
A quiz on the “Is It Low-T?” Web site — which, perhaps in a positive sign, was taken down for unspecified “upgrades” last month — told men if they should have their testosterone level checked. (A company spokeswoman said last week that she could not answer our questions about the status of the site.) One of us — feeling grumpy, low energy and a little sleepy after dinner — took the quiz in the days before the site was removed and was told to talk his doctor about having a blood test. The Web site even instructed visitors in how to ask. Suggested questions included, “Considering my symptoms, should I be tested for Low T?” — helpful if your doctor is a little slow or happens to read the New England Journal of Medicine, which in 2010 published a study debunking the value of symptoms besides those related to sexual activity, like those covered by seven of the 10 quiz questions, in making a diagnosis (the question on loss of height was not tested). 
Company-funded disease awareness campaigns often blur the line between public health messages that increase awareness about important diseases and infomercials meant to sell a disease to sell a drug. It’s a simple formula: The more diagnoses doctors make, the more prescriptions they can write. The “Is It Low-T?” campaign appears to be about getting as many men as possible diagnosed.

Blue Shield faces more heat over nonprofit status, $1.2-billion deal
Health insurance giant Blue Shield of California is facing more questions over its loss of tax-exempt status as it tries to win state approval of a $1.2-billion acquisition.
A former Blue Shield executive is accusing the San Francisco insurer of giving contradictory answers to state officials about its corporate structure. And consumer advocates are calling on Blue Shield to disclose details of a state audit that examined the company's taxpayer subsidy.
These issues are likely to dominate a hearing Monday in Sacramento held by the California Department of Managed Health Care.
Regulators will hear from Blue Shield and the public about the company's plans to spend about a quarter of its $4.2 billion in financial reserves to acquire Care1st, a Medicaid insurer based in Monterey Park.
Blue Shield Chief Executive Paul Markovich will discuss the merits of the deal and take on his company's critics at the hearing.
Scrutiny of the insurer intensified in March when The Times reported that the California Franchise Tax Board had quietly revoked Blue Shield's tax-exempt status in August 2014 after a lengthy audit. Blue Shield had held the tax break since it was founded in 1939.
To the frustration of Blue Shield's critics, the findings of the audit remain secret — even as the insurer is protesting the tax ruling. The company said it plans to remain a nonprofit regardless of the outcome.
Blue Shield already pays federal income taxes.
The tax board's decision and the big acquisition have prompted debate about whether Blue Shield is serving the public interest as a nonprofit health plan. Many consumers complain about Blue Shield's repeated rate hikes while it holds billions in surplus.

Obama to State His Case for Health Law Before Justices Weigh In

By 

WASHINGTON — Days before the Supreme Court hands down a ruling that could drastically undermine the Affordable Care Act, President Obama will deliver a speech on Tuesday extolling his health care law as a moral and practical victory that was decades in the making.
White House officials said that the speech’s timing was unrelated to the ruling, and that Mr. Obama was not seeking to sway the justices in a case that they probably decided shortly after it was argued in March. But the White House is clearly stating its case for the law before what could be a challenging period if the court invalidates subsidies for millions of people who signed up for coverage through HealthCare.gov.
The justices will issue a ruling by the end of the month. If they strike down the subsidies, millions of people could lose their health insurance, and rates for millions more could rise if the insurance markets collapse in the more than 30 states that use the federal insurance exchange.
Even if the court does not invalidate the subsidies, health care is almost certain to be a central issue in the 2016 presidential campaign.
Speaking on Monday in Germany before returning from a meeting with European leaders, Mr. Obama said he was optimistic that the justices would not invalidate the subsidies. He said doing so would require a “contorted reading” of the Affordable Care Act and the intent of lawmakers.
“This should be an easy case,” Mr. Obama said. “Frankly, it probably shouldn’t have even been taken up.” He said he assumed that the Supreme Court “is going to do what most legal scholars who have looked at this would expect them to.” The case centers on a provision in the law that seems to say that subsidies are available only to people living where the insurance exchanges had been “established by the state.”
In his speech on Tuesday at the annual conference of the Catholic Health Association, Mr. Obama will once again try to make his case that the 2010 law has brought dramatic improvements to the lives of millions of people who had previously been unable to afford basic health care, officials said.
He will cite statistics showing that the law has helped slow the growth of health care costs, and that it has failed to produce the terrible side issues that Republicans had once predicted.
Mr. Obama’s speech is part of a broader effort to shape and define the president’s biggest domestic accomplishment in the face of partisan attacks. The president sent an email to his supporters on Monday urging them to watch the speech, and reminding them of the letter that Senator Edward M. Kennedy of Massachusetts, a champion of broader access to health care, wrote to Mr. Obama a few months before his death in 2009.
“While Teddy didn’t live to see his life’s work signed into law, more than five years after its passage, the spirit of his words ring true,” Mr. Obama wrote. “This is, fundamentally, about the character of our country. Doing right by one another. It’s who we are.”
The White House also unveiled a new website intended to put the Affordable Care Act into a broader historical context. The site features a timeline suggesting that efforts to expand health coverage began more than 100 years ago.

When the Influence of a Patient’s Former Doctor Lingers

By ABIGAIL ZUGER, M.D.
JUNE 8, 2015
When is my patient not my patient? When he is Kevin, for one. I have cared for Kevin in both senses of the word for years now, but he still has his previous provider’s fingerprints all over him: he takes medications I never use and has health-maintainance routines I find somewhat perplexing.
Kevin is doing fine, but even so, I often find myself trying to reorganize him into a more familiar form. Invariably, he makes a sad face: He and his former doctor were very tight. Sentiment prevails, I give in, we move on.
Sometimes, though, in similar situations, patients and I do not move on. Instead, we square off. Former providers have left behind situations I cannot live with: orders for tests I consider unnecessary, medications that strike me as bizarre or prohibitively risky. I can’t refill those for you, I say. The responses vary, but no one is ever pleased.
I dread these confrontations and always feel guilty. After all, does it not verge on fraud of the bait-and-switch variety for two representatives of the same profession to contradict each other with implacable authority, one snatching away what the other has provided, leaving the consumer dangling apparently at the mercy of individual whim rather than clear-cut policy?
Still, no one can make me do what I think is wrong — not the state licensing me, nor the profession credentialing me, nor the patient hollering at me. So when I stumble over a too-high testosterone dose, or magnetic resonance imaging orders for a long-gone headache, or a perplexing combination of drugs that is likely to do more harm than good, it is my absolute right to just say no.

Florida legislators benefit from heavily subsidized health insurance

by Mary Ellen Klas


TALLAHASSEE — One of the chief arguments Florida House Republicans made Friday when they rejected the Senate plan to help 600,000 working poor get health insurance is that it would create a taxpayer-funded entitlement and would be hard to repeal. 
What they didn't mention during the debate is that they are entitled to a very generous health insurance package that costs $22,000 a year — with premiums mostly covered by Florida taxpayers. And, over the years, they have rejected any attempts by Gov. Rick Scott to reduce the benefit.
For many of the 160 members of the Florida House and Senate, the prospect of having to scramble for cash to pay for medication and doctor visits is not something that keeps them up at night. According to financial disclosure statements, 54 legislators are millionaires and 145 of them are enrolled in the taxpayer-financed State Group Health insurance plan, which includes about 80,000 full-time state workers. 
The monthly cost per legislator: $180 a month for a family, or $2,160 a year, and $50 a month, or $600 a year, for individuals. That's only a fraction of the average monthly family premium paid by most Floridians — $1,347 — according to data tabulated by the Kaiser Family Foundation, a nonprofit that focuses on health care issues.
Until last year, House members were part of a group of state workers who got an even better deal: $30 a month for family health insurance coverage, and $8.34 a month for individuals. That group, along with 800 legislative staff, the governor and the Cabinet are among about 17,500 state workers, known as the Senior Management and Select Exempt Service, who pay the lowest costs in the state. 
Of the few legislators who don't accept the subsidized insurance are three senators and 12 House members. Some are veterans, who get health insurance from the federal government, and others retained the employer-paid insurance they had when they were elected.

If Supreme Court rules against Obamacare, few states are ready for the fallout
by Noam Levey
Millions of Americans could soon lose health insurance when the Supreme Court decides the latest challenge to the Affordable Care Act this month, but states have made few concrete plans to deal with the potential fallout, and they may get little help from Washington, President Obama warned Monday.
“If somebody does something that doesn’t make any sense, then, it's hard … to fix,” the president said, suggesting his administration can’t do much if the justices side with the health law’s Republican critics.
When the court rules this month, the justices may eliminate insurance subsidies in as many as 37 states that use the federal HealthCare.gov marketplace established through the health law. The law’s challengers argue that a strict reading of the statute makes those subsidies available only in states that established their own marketplaces, rather than having the federal government operate the marketplace for them.
A state could restore the aid if it runs its own marketplace, as California and 12 other states and the District of Columbia already do.
Just two states whose residents are in jeopardy — Pennsylvania and Delaware — have outlined strategies for preserving subsidies, however.
“I’m afraid the potential for major disruptions is only now starting to dawn on people,” said former Utah Gov. Mike Leavitt, a Republican who served as Health and Human Services secretary under President George W. Bush. Leavitt is working with a group of former federal and state health officials on contingency plans to help states.
In many places, Republican legislators and governors oppose any action to accommodate the federal health law.
But even GOP governors who are looking for ways to protect their residents are struggling to figure out what they can do.
“It’s really bleak,” said a health official from one Southern state, who asked not to be identified out of concern that speaking publicly would make his state a target for conservative political activists. Groups opposed to Obamacare have pressured state legislatures not to expand health coverage under the law.


Some States Make Obamacare Backup Plans, As Supreme Court Decision Looms

by Elana Gordon

Online health insurance marketplaces are central parts of the Affordable Care Act. And HealthCare.gov, the federally run exchange, is where 27-year-old Kathryn Ryan, a restaurant server in Philadelphia, turned for health coverage, as soon as the law took effect. 
"I was excited because if it weren't for Obamacare, I wouldn't be insured at all," she says. "I wouldn't have the ability to go to the doctor." 
She can afford health insurance thanks to a $200 a month subsidy that brings her premium down to $60 a month. 
Ryan, who's also studying social work, is one of nearly 400,000 Pennsylvanians who have qualified for income-based financial assistance. But like a lot of people, she had no idea that a case before the Supreme Court puts at risk the subsidies in states like Pennsylvania that rely on the federally run exchange. 
"You telling me this is, like my heart has sank a bit to the bottom of my stomach, because I was planning on keeping this insurance until I am gainfully employed with an agency that offers benefits," she says. 
The reasons Ryan's subsidy and those going to millions of other people nationwide are in jeopardy has to do with a lawsuit before the Supreme Court. 
The plaintiffs in the case argue that only those with coverage in state-based marketplaces are eligible for subsidies. If the Supreme Court agrees, Trish Riley with the National Academy for State Health Policy, says it could result in something insurance analysts refer to as a death spiral. "The whole individual market in states could collapse," she says. 
Without subsidies, millions of people in the HealthCare.gov states would likely drop coverage. Those most likely to stay would be the really sick people who need expensive care. That change in customers would make insurance "premiums go through the roof," Riley says. 
So how are are the roughly three dozen states with federal marketplaces bracing for this? Not many states are officially declaring they have alternatives. 
But Pennsylvania, for one, has a backup plan. "My biggest concern is, do we have a fallback if we need it?" asks Gov. Tom Wolf, a Democrat who took office in January after defeating an incumbent Republican. The state sent a blueprint of the contingency plan to the feds this month. 
He stresses the plan is nonbinding and would only be set in motion if the court rules rules the subsidies for federally run marketplaces are illegal. 



By Jackie Farwell, BDN Staff
Posted June 08, 2015, at 3:43 p.m.
A highly publicized kidney donation sparked by a South Portland woman’s plea for an organ painted on her car window is scheduled for next week.
Joshua Dall-Leighton of Windham will donate a kidney to waitress Christine Royles on June 16 at Maine Medical Center in Portland, the hospital and the Maine Transplant Program announced Monday.
After learning she needed a transplant, Royles, a 24-year-old mother who suffers from kidney failure, painted a message on the back windshield of her Kia Soul asking for a donor.
Corrections officer Dall-Leighton, 30, spotted the ad in a mall parking lot and stepped forward in early March as a potential donor.
The hospital hit the brakes on the procedure in April after unprecedented fundraising for Dall-Leighton raised concerns about breaking a federal law that prohibits donors from profiting from donating an organ. Royles organized fundraisers to cover Dall-Leighton’s family’s expenses related to the donation, and another individual started an online crowdfunding campaign that raised nearly $50,000.

Our View: Supreme Court puts an end to one LePage health care cutback

The state should finally stop trying to deprive one small group of MaineCare clients – very-low-income young adults.
BY THE EDITORIAL BOARD
Gov. Paul LePage’s plan to save money by dumping 7,000 young adults off MaineCare has been shot down by the U.S. Supreme Court, which refused to hear his appeal. Maybe he’ll listen now.
This is the governor’s third court loss on this issue, in which the state was represented by a private lawyer because Maine Attorney General Janet Mills refused to take the case, stating that the governor’s position lacked legal merit. Too bad the governor didn’t listen before the legal bills started piling up.
His plan to cut health insurance for very-low-income 19- and 20-year-olds has been turned down by the federal Department of Health and Human Services, the U.S. District Court, a unanimous three-judge panel of the U.S. Court of Appeals and now the U.S. Supreme Court.
Maybe now, the administration will consider changing its strategy when it comes to providing health care to people in need. Maybe now, the administration will realize that dumping more people onto the list of the uninsured and forcing hospitals to pick up the slack by driving up their charity care budgets is not reforming the system. Maybe administration officials will admit they wasted state resources running down a legal rabbit hole that they were advised to avoid.
It could happen, but it hasn’t happened yet.
Maine DHHS Commissioner Mary Mayhew expressed disappointment with the court’s decision in a prepared statement that again referred to the young adults who will keep their health care as “able-bodied” – a code word in the LePage administration for “undeserving.”
She said the state would continue to fight to deny them coverage, which she described as a matter of prioritizing “our elderly and severely disabled neighbors.”
There is no dispute that older and disabled Mainers deserve the best care we can afford, but it should be clear to Mayhew and LePage by now that taking coverage away from others who are also in need is not the way to pay for it. It’s not necessary to pit one group against the others, and it is not legal, either.



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