In the things-to-consider-for-the-sake-of-considering-them category, take a gander at this story from the May 27 edition of The Boston Globe: 

After healthcare reform was made law in Massachusetts in 2006, the number of newly insured patients in the state started to grow, and so did the demand for care. The demand, coupled with a longstanding shortage of primary-care physicians, is creating a real crunch for community clinics, say advocates of healthcare reform as well as area medical professionals.

About 80 percent of the new patients at a community health clinic who are covered under the state’s new health insurance program were formerly uninsured, a clinic supervisor told the newspaper. The result is a lengthy waiting list.

Clinics the newspaper contacted have had difficulty recruiting doctors.

‘What Chapter 58 has done is highlighted the crisis and the problem that we have with the primary-care workforce,’ said Dr. Bruce Auerbach, president of the Massachusetts Medical Society. According to a study conducted in 2006 by the society, 53 percent of patients who had an appointment with a primary-care physician were able to see a doctor within a week of initiating contact. Last year, only 42 percent were able to see a doctor within a week. …

Critics have said healthcare reform should not have been attempted without first addressing the workforce shortages, said John E. McDonough, executive director of Health Care for All, an advocacy group that helped craft the healthcare law. …

Healthcare advocates and providers say that the real problem is that the state underestimated the number of residents without health insurance. …

According to Jon Kingsdale, executive director of the Commonwealth Health Insurance Connector Authority, which administers the new health law, 340,000 people who had been mostly uninsured were covered through the state’s program as of Jan. 1. Of that number, about 110,000 have bought private insurance through Commonwealth Choice. But, he said, the remaining 230,000 people have MassHealth or Commonwealth Care, the state’s subsidized health insurance programs.

One thing that’s unclear is why the formerly uninsured choose the types of clinics mentioned in the story when it looks although they could go to any doctor. Maybe they can’t, or maybe the story didn’t address it.

Either way, the unintended consequences of insuring hundreds of thousands of people are worth considering.

Thoughts? Leave a comment on this blog.

Jeff Raymond, Medical Writer

After taking a hiatus from The Medicine Bag, I have returned … with a question.

Do you think it’s fair and/or accurate to see Oklahoma ranked at or near the bottom of, well, just about every study of health that comes our way? We can’t be worst in everything health-related, can we?

I say this after reading about Wednesday’s report from The Commonwealth Fund. The nonprofit ranked children’s health in states on 13 indicators that included access to and quality of care, outcomes, equity and cost.

Oklahoma pulled up the rear. Fifty-first. Behind the District of Columbia and Mississippi. Leading the rankings were Iowa, Vermont, Maine, Massachusetts and New Hampshire.

Now, I know the devil’s in the details, and I admit I haven’t looked at the methodology of this report. I usually do, however, which is why I ask about the fairness of all this. I imagine this report would pass muster if you agree what it measures accurately sums up the state of children’s health.

Ah, here’s where it gets tricky: Are the measures used fair? Are small differences in rates or percentages blown out of proportion? Is the information current, or as current as possible?

See the state’s “scorecard” for yourself here.

The interesting thing about these reports is they are all largely slicing and dicing the same data. Sometimes it gets hard to tell them apart.

Anyone who honestly assesses the state’s health will find huge problems. But last or near-last every time? Perhaps I’m becoming desensitized, but my reaction is getting to be “C’mon!?!”

What’s yours? Tell me what you think by posting a comment on this blog.

Jeff Raymond, Medical Writer

USA Today had an interesting story yesterday about how the popularity of angioplasty, a commonly performed procedure in which doctors use a balloon to open blocked coronary arteries, may be eroding.

“The rise of angioplasty procedures has leveled off and appears to be on the decline,” Duke University’s Eric Peterson, who reviewed results of the analysis by the National Cardiovascular Data Registry, told the newspaper.

Three studies in the last two years that indicate that angioplasty may be no more beneficial than medication, and may be riskier. According to the newspaper, the research suggests angioplasty is used too often and its benefits don’t justify the procedure’s $10,000 to $12,000 cost.

The newspaper’s analyses found:

• The number of annual procedures performed each year has declined by 10% to 15% over the last two years.

• Angioplasty and stent use began dropping in June 2006, after two “landmark” studies cast doubt on them. Doctors often implant stents — both bare metal and drug-coated — after angioplasty to keep the artery open.

Angioplasty is used to treat the terrible chest pain, called angina, that comes from a heart without enough oxygen.  The slight decline is important because Centers for Medicare and Medicaid Services guidelines seek to have angioplasty available within 90 minutes of a patient’s arrival at the hospital. This is often called door-to-balloon time.

Many medical authorities tout the benefits of angioplasty.

Because hearts suffer from an inadequate blood supply, Bonnie Weiner, president of the Society for Coronary Angiography, told the newspaper, “(Angioplasty) is very effective at achieving more blood flow to the heart.” 

“I personally wasn’t surprised by the results,” says Michael Rich, a cardiologist at Washington University School of Medicine in St. Louis who will debate the study at the heart meeting.

Michael Rich, a cardiologist at Washington University School of Medicine in St. Louis, said angioplasty won’t prolong a person’s life or decrease the risk of a heart attack but will decrease the symptoms of one.

“The analyses conducted for the newspaper also reflect what may be the beginning of a broader change in medicine: a move toward ‘evidence-based’ care drawing on reams of data from medical research and patient treatment,” USA Today reported.

Jeff Raymond, Medical Writer

 Is retirement going to be a luxury for thirty- and forty- something workers? I increasingly think it will be, and a new estimate from investment giant Fidelity does nothing to dispel that.

A 65-year-old-couple retiring this year will need approximately $225K to cover medical costs in retirement, Fidelity estimates. Let’s not lose sight of the fact that this is in addition to the coverage available under Medicare, which may itself not be available when I and others retire.

The hypothetical retirees will still have to have enough money to live, either independently or in long-term care.

Perhaps what’s even more sobering than the estimate is its growth since 2002 — 41 percent.

The roughly 6 percent annual growth in the Fidelity projection about matches the growth of my 401K fund during a slow year. I know that doesn’t take into account contribution matching and interest compounding, but I think it raises a worthwhile point nonetheless.

And health care costs show no signs of flattening or decreasing.

Does paying for retirement terrify you as much as it terrifies me? Leave me a comment at http://blog.newsok.com/health.

Fidelity recommends:

- Creating an individual retirement plan

- Starting early and maximizing opportunities to save

- Assessing health status and becoming a smarter consumer of health care

- Determining details of any employer-sponsored coverage

- Understanding the financial impact of health care costs on Social Security income

Jeff Raymond, Medical Writer

 The need for donor livers outstrips their supply. Each year, about one-third of those with end-stage liver disease who need an organ will receive one. Some die while on the waiting list.

The February issue of Mayo Clinic Proceedings examines how the current system for allocating organs in the United States affects recipients’ outcomes.

The United Network for Organ Sharing (UNOS) oversees organ allocation. With the goal of giving organs to the most critically ill transplant candidates, UNOS adopted the MELD — Model for End-Stage Liver Disease — scoring system in 2002. The score is calculated from the results of three lab tests.

“Unlike past evaluation systems, the MELD score de-emphasizes the length of time a patient has been waiting for a donor organ. … Research has shown that although the donor liver shortage persists, implementing this allocation system has decreased the number of patients who die while waiting for donor organs,” according to a Mayo Clinic press release.

The study looked at the evaluation practices and acceptance criteria for liver transplant used by the Mayo Clinic Jacksonville Transplant Center after implementation of MELD scoring. Researchers examined medical records from 555 patients referred for liver transplants at the Jacksonville center from Jan. 1 through Dec. 31, 2005. Of these patients, 53 percent were denied for a transplant. Half of those denied were considered too early to have the procedure, while the rest were excluded because of medical conditions and psychosocial issues — poor support systems or continuing substance abuse problems, for example.

Many were subsequently accepted.

“Patients seeking referral often undergo repeated assessments by selection committees, as their eligibility can change over time or following treatment and/or changes in conditions that led to their initial exclusion,” according to the release.

Data suggest a “broad range” of patients could benefit from early referral to a transplant center, according to the release.

Basically, management of their disease and other medical and psychosocial conditions could make them transplant candidates sooner.

To read the report, click here.  

People seldom realize transplant waiting lists are anything but static: They constantly change, depending on organ availability and patients’ medical states. They’re definitely moving targets. People move up, they move down; they drop off, they’re added back.

“Our study suggests that early referral for LT (liver transplant) evaluation is beneficial for reasons unrelated to the time patients spend on the LT waiting list. If patients too early for LT were evaluated but not listed, LT centers could initiate management of ESLD (end-stage liver disease) and address psychosocial issues in a sub-group of patients who could also ultimately benefit from LT,” the authors wrote.

Although not exactly the same thing, last month I wrote about this man, Dr. Ludvik Artinyan, left, who registered on organ waiting lists in California and Oklahoma. He was able to receive a liver transplant quicker by traveling to Integris Baptist Medical Center to have the procedure performed rather than having it done in Los Angeles. Because patients’ MELD scores typically are higher in California for various reasons, double-listing likely allowed the Armenia-born physician to shave months off his wait time and perhaps saved his life.

UNOS allows potential transplant recipients to be listed in multiple regions – they must meet each site’s criteria and be ready to respond to the phone call or page when an organ becomes available.

Is the current organ allocation system fair? E-mail me at jraymond@oklahoman.com or post your thoughts at http://blog.newsok.com/health.  

Jeff Raymond, Medical Writer

I spent a recent Monday in Tahlequah talking to Cherokee Nation staff about diabetes. As is often the case, I had to leave out a lot of stuff. So I thought I’d share some of it here.

If you need a refresher, the story is here.

Dr. David Randall, chief of podiatry for the tribe, estimated 5 to 10 percent of diabetics are at risk of developing foot ulcers, about one-fifth of which lead to amputation.

Randall also said he thinks many people in the tribe’s 14-county jurisdictional area see others undergo procedures related to diabetes or suffer from its complications, increasing awareness of the disease and how to take care of oneself. He pointed out the tribe’s employee wellness program and the positive signs he has seen among his patients, most notably a “significant decrease” in amputations.

Diabetes Program Director Teresa Chaudoin said practically every Cherokee has a diabetic in the family. When she came to work for the tribe in 2001, her focus was largely clinical — after all, it was the most pressing. Later, she dove into prevention. Now the tribe has dietitians at each of its clinics and reports more people are able to manage their blood sugar.

“We’ve worked here to build a comprehensive, integrated program,” she said.

Lisa Pivec, director of community health promotion for the tribe, emphasized that losing weight, stopping smoking, eating well and taking appropriate medications worked to reduce chronic illnesses other than diabetes.  One of the tribe’s wellness initiatives, called Wings, began with walking and running but now includes bowling, stickball, dancing and other activities.

Wings members, of which there are more than 1,000, receive admission to 24 races a year. Members have reported a one-point drop in body mass index over nonmembers. Sounds like very little, but big health improvements can be in small numbers. Planned activities often suit the tribe’s rural citizens.

“A lot of our communities are very rural and they may need structured events,” Pivec said.

For health and medical news and commentary, visit The Medicine Bag blog at http://blog.newsok.com/health.

Jeff Raymond, Medical Writer

Rates of visits by the elderly to emergency rooms are outpacing those of other groups, which could lead to “catastrophic overcrowding,” according to a study this week in the Annals of Emergency Medicine.

“Seniors are using the emergency department more and more frequently, and given the needs of this population and the nature of their medical problems, the current state of overcrowding is likely to continue to escalate dramatically,” Dr. Mary Pat McKay of The George Washington University Medical Center said in a press release.  “These patients tend to be sicker and are more likely to be admitted from the emergency department to the hospital, but with many hospitals running a deficit of inpatient beds, I don’t see where these patients are going to go.”

Researchers studied ER visits from 1993 to 2003, and found that visits per 100 people 65 and older increased faster than the visit rate for any other age group, with an overall increase of 26 percent during the study period.

“People aged 65 and older are the fastest growing segment of the U.S. population. As emergency patients, they use the most resources, stay the longest, and are the most likely to be admitted to the hospital of all emergency patients.  Researchers conclude that emergency department visits in the United States for patients between 65 and 74 could nearly double from 6.4 million in 2003 to 11.7 million by 2013,” according to the release.

AARP Policy Director John Rother called on elected officials to “heed the warnings” of the report and recognize that the health care system must deliver appropriate, affordable care.

 “The trends released today underscore the need to make sure emergency departments can meet the demand for care by older people, but we also need a better understanding of why emergency room use by older people is on the rise and why these patients may not be getting care from their personal physicians,” he said in the release.

The study suggests older Americans are having more genuine emergencies, rather than increasingly visiting the emergency department.

For health and medical news and commentary, visit The Medicine Bag blog at http://blog.newsok.com/health.

Jeff Raymond, Medical Writer

When the Centers for Medicare and Medicaid in August announced it wouldn’t pay for hospital mistakes and infections, I expected discussion and debate.

Today’s issue of The New England Journal of Medicine delivered as promised. In it, Meredith Rosenthal, an associate professor of health economics and policy at the Harvard School of Public Health, provided a good, balanced overview of the change’s likely effects.

The rule change, she noted, implemented a congressionally mandated change in hospital reimbursement. It makes the agency’s payment policies “far less passive” than they once were. She further pointed out an interesting — albeit perverse — phenomenon: Hospitals that have improved patient safety and addressed problems such as “nosocomial” (hospital-acquired) infections have seen their Medicare revenues reduced. This she attributed to quirks in the payment system.

I don’t want to go into specifics, and I imagine you’d prefer I don’t.

“The new rule will result in hospitals seeing substantial reductions in payment for the care of individual patients with preventable complications,” Rosenthal wrote. She predicted, however, that the change wouldn’t substantially affect total payments to hospitals because they would be reduced only when the preventable complications were the only factors causing an illness to be reclassified under a more expensive diagnostic code.

Translation: It must be clear that additional problem was related entirely to the hospital stay, and the conditions covered are limited. I imagine proving fault will be a challenge.

The importance of the change is that it tip-toes toward “pay for performance.”

“Hospitals may therefore view the new policy as a harbinger of things to come and act in anticipation of more substantial reimbursement changes,” Rosenthal wrote, predicting hospitals may adopt further quality measures as a result of the new rules and improve reporting.

This began in earnest with reporting a limited number of measures, which the public can view at http://hospitalcompare.hhs.gov.

Today it’s pressure ulcers, bed falls and other things that shouldn’t happen. Tomorrow it’s more complicated stuff.

According to Medical News Today, starting in 2009 Medicare won’t cover “preventable” conditions. Because rules don’t allow hospitals to pass on the cost, they must shoulder the burden. Because Medicare and Medicaid participants make up a large percentage of hospital visitors, the agency has tremendous clout nationally to force changes in the health care system.

The commentary in the medical journal and this week’s news on the prevalence of hospital-acquired infections make this a particularly interesting time. I’ll be curious to see how hospitals respond to the change and if there is an effect on the bottom line.

Because information on hospital-acquired infections isn’t publicly disseminated (at least nowhere I’ve found) or reported to the state, determining the extent of the problem is nearly impossible. Maybe this will shed some light on it.

Jeff Raymond, Medical Writer

I spoke to Steve Anderson, a research fellow with the Oklahoma Council of Public Affairs, today about Census data released this morning that showed an increase in Oklahoma’s poverty rate.

Part of the American Community Survey, which, to my understanding, replaced the Census ”long form” so many Americans loathed, the “poverty report,” as one Tulsa advocacy group called it, is an annual assessment of cities and states’ income. A related report included statistics on health insurance.

Anyway, if you read Wednesday’s paper, or check the Web, you’ll get all this.

What interested me most about the conversation with Anderson, a certified public accountant with a wide knowledge of state government, was his assertion that the rate of uninsured Oklahomans may not be as accurate as is normally portrayed — either numerically or qualitatively.

Anderson said the Census didn’t count American Indians who receive tribal health care. Nor did it reflect those who choose not to have health insurance — the young and fearless, for example. Or those who just aren’t responsible.

I haven’t been able to research his tribal health care claims, and if I have run across statistics on people shunning health plans they can afford, I have long since lost them. However, the bigger picture is more important: Are we making a public-policy crisis out of a problem? If so, to what end?

I’m not weighing in one way or the other. I just think it’s wise to consider things we repeat and take as truth sometimes have shaky foundations. The more we repeat them, the more ingrained they become.

That many Americans are uninsured is undeniable. That they cost a lot of time, money, efficiency and are less healthy than those with insurance is also, in my opinion, undeniable. What is debatable are the scope of the problem and its solution.

On an unrelated note, if you have ever had trouble managing your cholesterol but tried to make a real effort to do better nonetheless, I’d like to talk to you. Please e-mail me by clicking on my name or call me at (405) 475-3364.

Jeff Raymond

I don’t want to announce victory in the earliest stages of a long fight, but I’m encouraged by the steps taken so far to deal with the uninsured in Oklahoma.

Baby steps, to be sure, but steps nonetheless.

The Oklahoma Department of Insurance is soliciting input from around the state about health care priorities and needs to present to a task force that may draft a core benefits plan for residents.

I know, I know … reports, task forces, blue ribbon committees … shuffle paper here, shuffle paper there, talk a lot and change little — at least that’s how I often perceive them.

 Under the clever name of Oklahoma CHAT (Choosing Healthplans All Together), Insurance Commissioner Kim Holland plans to collect information from 31 communities across the state using the CHAT computer simulation.

“The CHAT program will assess how people prioritize what health benefits are important to them when the resources are insufficient to purchase every type of coverage,” according to a news release.

I imagine the research has already been done to some extent, but the way this appears to be designed looks genuine to me.

Now, maybe I’m uncritically giving up my skepticism. After all, solving the problem of the social and economic toll of the state’s 600,000 uninsured won’t happen over night. But, I figure, from where else  than a state with a glaring, vexing problem will an innovative solution arise?

OK, Massachusetts notwithstanding.

They have beaten us to common-sense health insurance reform, but I consider the South more of a peer group.

I guess I’ve concluded that philosophical differences should not keep us from doing something; that what we do doesn’t have to break the bank and may even save money, again, philosophical differences aside; and that some sort of mandatory enrollment in some sort of plan, while it goes against my libertarian sympathies, will be needed.

Just like with 401K plans, people, even those of adequate means, won’t choose to participate in sufficient numbers for society at large to gain unless at least nudged that way, if not pushed.

At this point, I know the reform movement is more of a Doolittle Raid than an Iwo Jima, but acknowledging something must be done, even if we can’t agree on what, is a step in the right direction. And the sponsors of Holland’s project are an impressive bunch that includes Integris Health, the OU College of Public Health, the Oklahoma Hospital Association, the Oklahoma State Department of Health and The State Chamber of Oklahoma.

Strange bedfellows? Maybe. Or maybe not. It depends how you look it at.

The press conference is Tuesday at 10:30 a.m. in the Governor’s Blue Room at the Capitol.

In March, a group called Health Alliance for the Uninsured bemoaned the number of uninsured who turn to emergency rooms because free clinics were full. Or just turned to emergency rooms for basic care, which is costly in time and money and is hugely wasteful in terms of hospital utilization.

“Our 16 free clinics are overwhelmed and do not have the resources they need,” Dr. Murali Krishna, chairman of the alliance and president of Integris Mental Health, said at the time. “That leaves the uninsured with no choice but to go to the emergency room for routine medical care.”

A study presented then showed 53 percent of emergency room visits in Oklahoma County were for nonemergency symptoms.

Among clinics’ problems are getting specialists to volunteer, finding free- or low-cost drugs and locating radiology services.

Because of its location, St. Anthony Hospital deals with a number of poor, transient patients. As such, it has received assistance to put together a system to find these people a “medical home” so that they visit a general practitioner for routine care rather than the emergency room. For a patient with an HMO policy, this is a given. For the uninsured, it’s innovative, at least for Oklahoma.

I haven’t followed up on the project for some time, but it has intrigued me from the start. Will it work? I aim to find out.

As always, please e-mail me or comment on this blog. If you agree, disagree or think I’ve gone off the deep end, let me know one way or the other.

Jeff Raymond