Diabetes and the Cherokee
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
Elderly visitors may overwhelm emergency rooms
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
Doctors debate Medicare rules
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
Opting out
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.
Some hope for health care costs?
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.
