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Monday, August 31, 2015

Health Care Reform Articles - August 31, 2015

Steroid Shots No Better for Back Pain Than Placebo

By NICHOLAS BAKALAR
AUGUST 24, 2015
Steroid shots are commonly used for back pain, but evidence that they work no better than placebos is mounting.
In a review published Monday in Annals of Internal Medicine, researchers combined data from 30 placebo-controlled studies of epidural steroid injections for radiculopathy (back pain that radiates to the legs) and eight studies of spinal stenosis (back or neck pain caused by narrowing of the spinal canal).
The study showed that for radiculopathy, injections provided some short-term pain relief, but over time were no more likely to be helpful than placebos, and they did not reduce the need for later surgery.
The pooled data showed similar results with injections for spinal stenosis — some moderate temporary pain relief, but no differences between treatment and placebo in pain intensity or functional ability lasting six weeks or longer after the shot.
The authors acknowledge that most of the trials had methodological shortcomings, and that some analyses were based on small numbers of patients.
Dr. Roger Chou, the lead author and a professor of medicine at Oregon Health & Science University, said there was probably some financial motivation for continuing to use the procedure despite the lack of evidence for its effectiveness. “The professional societies are concerned because they worry about the implications for insurance coverage,” he said. “We don’t say anything about that in the study.”



Living With Cancer: Collateral Damage

By SUSAN GUBAR
AUGUST 27, 2015
When I was invited to attend a prostate cancer group called “Us Too” in my town, its members were meeting in a private room in our public library. About eight men, some accompanied by their wives, had great difficulty communicating their discomfort about urine leaks and diapers. They wanted to know what strategies my gynecological cancer group used to talk about sexual issues. To alleviate their daily problems, the participants needed professional help that I could not furnish.
Sexual dysfunction and incontinence in prostate cancer survivors underscore a quandary that shadows oncology. As we all realize, procedures that prolong lives also impair them. Yet cancer patients who must forfeit quality of life to gain quantity of life rarely receive adequate warning before treatment or guidance afterward.
A vigorous defender of conventional medicine, the British journalist John Diamond nevertheless admitted that the impairments he faced had nothing to do with his throat cancer but were instead produced by efforts to cure him of it: a missing lump of tongue, a hole in his throat from a tracheotomy, shooting pains in the neck and jaw, the loss of voice and saliva glands and tastebuds, a limp, edema, overproduction of mucus and saliva, ulcers, a frozen shoulder, toothache, constipation, diarrhea, and radical weight loss. The surgery, radiation, and chemotherapy that inflicted these damages gave him four years of a compromised existence. 
The initial operation for ovarian cancer certainly disabled me. A debulking operation led to a perforated intestine and infections that in turn led to an ileostomy: a bit of intestine brought out of the body and attached to the belly for the purpose of excretion. Another woman in my support group had to have an ileostomy when an experimental drug caused a fistula, an abnormal duct or passage.
http://well.blogs.nytimes.com/2015/08/27/living-with-cancer-collateral-damage/

No Social Security increase in 2016 at substantial cost to most older adults

August 28, 2015
by Diane Archer

Every year but two for the last 40 years, people have seen a cost-of-living increase in their Social Security checks, an inflation adjustment. But, they will see no increase at all in their Social Security benefit in 2016. To make matters worse, a new report from the Center for Retirement Research, reveals that, unless there is a work-around, some people with Medicare will see almost a 50 percent increase in their Medicare Part B monthly premium. And, most people with Medicare will have less disposable income for non-health care related expenses.
Significant Medicare premium increase for about 15 million people: About three in ten people with Medicare will have to absorb the full 25 percent of Medicare Part B program costs in their premiums that the other 70 percent of people with Medicare will be exempt from paying. Under the law, Medicare premiums cannot increase for most older adults and people with disabilities if their Social Security benefits do not also increase.
However, people who are just joining Medicare, have an income-adjusted Medicare premium, or have Medicare and Medicaid, can face premium increases. And, because the law requires Medicare Part B premiums to cover 25 percent of program costs, the 30 percent of people with Medicare for whom premiums can rise will have monthly premiums of at least $159.30, up from premiums as low as $104.90. Couples with incomes of more than $428,000 will have monthly premiums of $509.80.
Less disposable income for non-health-related expenses for most people receiving Social Security benefits: Because health care costs are rising faster than non-medical costs, people with Medicare who rely on Social Security for some or all of their income, receive lower net Social Security benefits after health care expenses each year. (People with Medicare spend an average of $5,000 on health care costs Medicare does not pay for.) Also, Medicare premiums have been rising more than twice as fast as the Social Security benefit, even with the cost-of-living adjustment. As a result, each year, people with Medicare have less disposable income for non-health-related expenses.

New Alternatives to Statins Add to a Quandary on Cholesterol


By 
ROCHESTER, Minn. — Doctors have long faced a conundrum in prescribing statins to lower cholesteroland heart attack risk: The drugs are cheap and effective for most people, and large, rigorous clinical trials have found minimal side effects. But as many as 25 percent of those who try them complain of muscle pain. Others stop taking the drugs because, they say, they cause a hazy memory or sleep problems, among other side effects not documented in studies.
Now, with the approval on Thursday of the second in a powerful — and very expensive — new class of cholesterol-lowering drugs, the dilemma confronting doctors just got trickier. Should the people who need to lower their cholesterol, but say they cannot tolerate statins, be prescribed new drugs that cost more than $14,000 a year, potentially adding billions of dollars to the nation’s medical bill?
Doctors say their first responsibility is to patients, but it is hard for them or their patients to forget the price of drugs meant to be taken for a lifetime. The new drugs are approved for use by people with heart disease who cannot control their LDL, the dangerous cholesterol, by other means. Doctors say they try to work with patients to ensure that all who can safely take statins, many of which cost pennies a day, do so, but a substantial portion of patients insist the side effects are too severe.
At the Mayo Clinic here, Dr. Stephen L. Kopecky, who directs a program for statin-intolerant patients, says he is well aware that middle-age and older adults who typically need statins may blame the drugs for aches, pains and memory losses that have other causes. He also knows his patients peruse the Internet, which is replete with horror stories about the dangers of statins.
Yet he, like other doctors, also thinks some statin intolerance is real despite what clinical trials have shown. The problem: In the vast majority of cases, there is no objective test to tell real from imagined statin intolerance.
So what is he to do when patients insist they cannot take statins and he can find no other reason for the symptoms they attribute to the drugs?
“How can I not believe them?” he asks.
Experts say there is a pressing need for new cholesterol-lowering treatments. Coronary heart disease accounts for one in seven deaths in the United States or 375,000 a year. About one in four American adults takes statins, pills that block an enzyme needed to make LDL. The drugs are credited with helping save many lives, but even among those taking statins, only 20 percent to 26 percent of high-risk patients have LDL cholesterol levels below 70, a goal many doctors strive for. And that does not count the many high-risk patients who cannot or will not take statins. Estimates of their number range from one million to three million.
Before the advent of the new drugs, injected antibodiesthat block an enzyme involved in regulating levels of LDL, doctors had few options for statin-intolerant patients other than suggesting lower doses or different and less effective drugs. But now they will be able to offer the two new drugs — Praluent, made by Sanofi Regeneron and approved by the Food and Drug Administration last month, which costs $14,600 a year, and Repatha, made by Amgen and approved Thursday, at $14,100 a year.
The medicines can slash LDL to levels almost never before seen in adults. Although the drugs seem remarkably safe and free of side effects, large studies to test their safety and efficacy in preventing heart attacks, strokes and cardiovascular deaths are still underway. Results are not expected until 2017.
The looming bill for the new drugs, said Peter J. Neumann, a health economist at Tufts Medical Center in Boston, “raises questions about how much we are willing to pay for effective innovation in the face of uncertainty about long-term effects and questions of affordability.”
Insurers are also worried about higher drug costs pushing up premiums, economists say.
“We’ve reached a point where patients are increasingly facing five- and six-figure price tags for medications that they will take over the course of their lifetimes,” said Matthew Eyles, an executive vice president for America’s Health Insurance Plans, the national trade association for the insurance industry. “If this is the new normal to treat common and chronic conditions, how can any health system sustain that cost?”
Doctors with patients who maintain they are intolerant to statins say they are confronted with a clash between the art and the science of medicine.




Maine's High Vaccination Rate Applauded, but Experts say Job Not Done 


By  • AUG 28, 2015

AUGUSTA, Maine - New data from the federal Centers for Disease Control and Prevention shows that Maine's rate of vaccination for kids between 19 and 35 months was the highest in the nation in 2014.
According to the new numbers, almost 85 percent of those Maine toddlers got vaccinated last year - that's an increase of nearly 17 percent over 2013. The national average is 71.6 percent.
State officials and others are saying the numbers are a reason for celebration.  And given Maine's well-known policy of allowing parents to opt their kids out of vaccines on philosophical grounds, some are saying it's something of a surprise. The state's opt-out rate has dropped in the last couple of years, but it's still higher than the national average.
The new data would seem to indicate that the tide may be turning against anti-vaccine sentiment. But it's a complicated picture. Maine Things Considered host Nora Flaherty gets the details from Dr. Lawrence Losey, a Brunswick pediatrician and a member of the state's Immunization Task Force. 

Desperate Maine Opiate Addicts Face Long Waits and Few Options for Treatment 

By  • AUG 28, 2015
AUGUSTA, Maine - Like so many states, Maine is in the grip of an opiate epidemic that shows no signs of slowing down. While other states have expanded drug treatment as part of the response, Maine has not. 
There are fewer treatment options than just a few years ago. Republican Gov. Paul LePage is pursuing a drug enforcement strategy instead. Critics say that's taking a heavy toll.
A major blow came in May when one of Maine's largest treatment providers announced it was closing. Mercy Recovery Center placed much of the blame on cuts in state funding. There was already a shortage of long-term residential treatment beds. And then, last week, a methadone clinic in southern Maine also announced it was shutting its doors.
For those who want to safely get off heroin the first step toward recovery is often detox - if you can get in. "Yesterday we had someone count and we had turned away 113 people this month because the program was full," says Lauren Wert.
Wert is the director of nursing at Milestone Foundation in Portland. This is the epicenter of the heroin crisis in Maine, and Milestone is the only residential detox around. It has just 16 beds available for three-to-seven-day stays.
At the small nurses station, Wert says she and her staff gently inform a steady stream of callers that they can't help them out. "Often times people cry," she says. "Sometimes the client is so frustrated that they've given up calling, but the family member will continue to call for them. They're asking questions like, 'Where else do we go? What do I do? He feels like he's going to die.' "
Wert says there used to be places to refer clients, but now all the staff can say is, "I'm so sorry." 

Would the GOP's healthcare ideas work? It depends on your definition of 'work.'

by Larry Levitt
Just like in the 2012 election, every Republican candidate for president wants to repeal the Affordable Care Act. Some of the candidates have even come forward with ideas for replacing it, and we are beginning to get a sense of what Republican healthcare reform might look like.
Judging from rhetoric alone, Republicans seem to want to achieve what Obamacare has already accomplished.
For example, in a recent op-ed, Florida Sen. Marco Rubio wrote that "we need to make affordable, quality healthcare accessible in the 21st century." Wisconsin Gov. Scott Walker, for his part, wants to "provide refundable tax credits to individuals who do not have employer-based coverage to make health insurance more affordable," and to "protect all Americans with preexisting conditions."
However, Republicans' policy ideas are quite different from what's in the ACA — in expected ways. Republicans want less regulation and lower federal spending. They also want to provide less help for those with low incomes.
Consider, for instance, the various concepts for protecting people with preexisting health conditions — an idea everyone wants to get behind. The ACA requires insurers to accept all consumers regardless of their health during annual open enrollment periods and prohibits premium surcharges for people who are sick. To discourage people from waiting until they're ill to buy insurance, the law also takes the unpopular step of requiring most people to buy insurance or pay a tax penalty.
The emerging Republican plans, by contrast, eschew federal regulation of the insurance market. Walker, Rubio and Louisiana Gov. Bobby Jindal have all discussed using state-based high-risk pools, which would theoretically provide affordable coverage to people with serious health problems.
Historically, however, high-risk pools haven't been effective. Thirty-four states had high-risk pools before the ACA went into effect, and they typically charged premiums 50% to 100% above prevailing rates for people who were healthy and could get private insurance. Making high-risk pools work requires adequate government funding. So far, candidate proposals have not been specific on how much money would be provided.

LePage administration may press for second psychiatric hospital

The state’s top health services officer says creating a new, separate treatment facility for mentally ill patients who have committed crimes may be the only way for the Riverview Psychiatric Center to regain federal certification and preserve an estimated $20 million in annual funding.
The idea of a new facility was first brought up by the LePage administration in May but failed to get support in the Legislature. Mary Mayhew, commissioner of the Department of Health and Human Services, said last week that the administration still sees it as a solution to satisfy the federal agency that oversees Riverview funding.
The decertification of Riverview has loomed over the 92-bed Augusta hospital and DHHS since a 2013 federal audit found numerous problems, including the use of stun guns, pepper spray and handcuffs on patients, improper record-keeping, medication errors and failure to report progress made by patients.
Mayhew said the hospital quickly moved to correct the deficiencies but that a new facility for so-called forensic patients – those who have killed, assaulted or committed other offenses but been found criminally insane – is the only certain way to obtain certification.
Given the guidance from the federal government, Mayhew said, “we’re challenged by the dual roles that Riverview plays in providing services to both forensic patients and civil patients.”
However, the LePage administration’s solution worries advocates for the mentally ill, who fear that a new facility will operate more like a prison and less like a treatment center. And some are concerned about indications that DHHS may privatize mental health services for a group of patients who garner little sympathy from the public and a health care system that has long stigmatized their illness.


Maine's Hidden Public Health Crisis: Suicide 

By  • AUG 28, 2015
AUGUSTA, Maine - Maine Attorney General Janet Mills says the number of drug overdose deaths for 2015 is on track to be similar to last year - the worst on record. She calls that a crisis. But while the state battles drug overdoses, another public health issue is taking even more lives in Maine: suicide.
It was February, two years ago, when Tonya Bailey-Curry of Lewiston found out:  Her 21-year-old son Dante had killed himself.
"I absolutely thought, you know, this can't be," Bailey-Curry says. "Maybe somebody murdered him. Just the thought that I would think that instead, like that's the better option. But just the thought that you could have a child who has unfortunately made a decision to end their own life, what does that say about you as a parent?"
When Dante died, he left behind a family filled with grief and unanswered questions. As Curry tries to piece together what led to Dante's death, she remembers he changed some habits. He stayed up all night and slept all day. He cared less about his appearance.
At the time those changes seemed small. But in hindsight, Curry says they were warning signs. "We talk about suicide as a reactive measure a lot, not as a proactive measure. I don't think we think about it as parents until it affects someone close to us or ourselves."
The year that Dante died - 2013 - marked the highest number of suicide deaths in Maine in recent years - 245 people. 


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