Unintended consequences of insuring the uninsured
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
Oklahoma ranks last again
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
Should angioplasty fall out of favor?
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:
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The number of annual procedures performed each year has declined by 10% to 15% over the last two years.
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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
A new way of looking at diabetes
Researchers have seen that weight-loss surgery appears to cure type 2 diabetes, which they have attributed to the huge drop in pounds. After all, being overweight is a risk factor for diabetes, and losing weight can effectively take care of the problem.
An article that appeared in a supplement to last month’s issue of Diabetes Care argues that the bowel is the site of mechanisms that lead to diabetes.
The study’s author, Dr. Francesco Rubino of New York-Presbyterian Hospital/Weill Cornell Medical Center, presents evidence on the mechanisms of diabetes control after surgery.
“Clinical studies have shown that procedures that simply restrict the stomach’s size (i.e., gastric banding) improve diabetes only by inducing massive weight loss. By studying diabetes in animals, Dr. Rubino was the first to provide scientific evidence that gastrointestinal bypass operations involving rerouting the gastrointestinal tract (i.e., gastric bypass) can cause diabetes remission independently of any weight loss, and even in subjects that are not obese,” according to a press release.
Rubino’s previously has shown that the main way gastrointestinal bypass controls diabetes is by skirting the upper small intestine — the duodenum and jejunum.
“It has become increasingly evident that the gastrointestinal tract plays an important role in energy regulation, and that many gut hormones are involved in the regulation of sugar metabolism,” according to the release.
Rubino’s findings suggest bypassing the upper intestine may work by reversing abnormalities of blood glucose regulation.
He guesses the upper intestine of diabetic patients may be the site where an “abnormal signal” is produced that causes or predisposes one to diabetes.
Gastrointestinal surgery offers the possibility of complete disease remission. This is a major shift in the way we consider treatment goals for diabetes. It is unprecedented in the history of the disease,” he said.
What do you think of using surgery to treat diabetes? Have you had an experience with it? Leave me a comment at http://blog.newsok.com/health.
Jeff Raymond, Medical Writer
The cost to retire
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
Chest pain
I worked for six months or so in the emergency room at Saint Francis Hospital and saw a number of interesting things while I was there. Among them were patients who repeatedly visited the ER complaining of chest pains but who weren’t having heart attacks.
The Agency for Healthcare Research and Quality today reported that such chest pain accounted for 16 million ER visits in 23 states in 2005. I’m not sure if Oklahoma was one of the surveyed states, but it’s nonetheless interesting. About one-fifth of the patients — 345,000 of them — were admitted for observation or treatment.
“Non-specific” chest pain was the fourth most common cause of visits to the ER. The top three were sprains and strains, bruises and other superficial injuries, and abdominal pain.
AHRQ also found:
- ER visits were almost twice as likely among those from the poorest communities compared with those from the wealthiest communities.
- Uninsured patients accounted for about 18 percent of visits.
If you ran a hospital, how would you handle an uninsured person who isn’t having a heart attack but may need observation? Visit The Medicine Bag blog at http://blog.newsok.com/health to leave a comment.
Jeff Raymond, Medical Writer
Going to dust
We Oklahomans know dust — perhaps better than anyone. Like it or not, the hardscrabble Joad family is as much a part of our cultural heritage as Curly, Laurey and Jud.
The Dust Bowl completely destroyed the state, and some would argue it took us a half-century to recover.
I mention this because University of Colorado researchers have found the West has become 500 percent dustier in the past 200 years because of human activity.
My first thought was how they measured such a thing. Turns out the researchers used sediment records from dust blown into lakes in Colorado’s San Juan Mountains. Co-author Jason Neff, an assistant professor of geological sciences at CU-Boulder, attributed the “sharp rise” in dust deposits to the railroad, ranching and livestock of western expansion.
“From about 1860 to 1900, the dust deposition rates shot up so high that we initially thought there was a mistake in our data,” Neff said in a press release. “But the evidence clearly shows the western U.S. had it’s own Dust Bowl beginning in the 1800s when the railroads went in and cattle and sheep were introduced into the rangelands.”
A paper on the research was published in the Feb. 24 issue of Nature Geoscience. In it, the scientists described a “dust fall” that exceeded that of the previous 5,000 years. Because of the size of the dust particles, the authors concluded the dust particles came from the Southwest.
Neff said the West’s increasing dustiness isn’t drought-related. Instead, he said, it is because of “intensive land use, primarily grazing.” Researchers used radiocarbon dating and lead isotope analysis of soil cores to determine this.
“There were an estimated 40 million head of livestock on the western rangeland during the turn of the century, causing a massive and systematic degradation of the ecosystems,” he said in the release.
The five-fold increase in nitrogen, phosphorus, potassium, calcium, magnesium and other byproducts of ranching, mining and agriculture can affect ecosystems.
Then, of course, there’s dust’s effect on allergies.
“There seems to be a perception that dusty conditions in the West are just the nature of the region,” Neff said. “We have shown here that the increase in dust since the 1800s is a direct result of human activity and not part of the natural system.”
For more health and medical news and commentary, read The Medicine Bag blog at http://blog.newsok.com/health.
Jeff Raymond, Medical Writer
Holding on a heart attack
We Oklahomans know heart attack signs about as well as our peers. What we don’t do so well is call 911.
What gives?
A recent issue of the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report compared how much 71,994 residents of 14 states knew about heart attack symptoms and whether they knew to call 911.
Overall, awareness of all five warning signs was 31 percent. Eighty-six percent of respondents reported they would first call 911 if someone were having a heart attack. Among Oklahomans, only 81 percent would do so.
In 2005 approximately 920,000 people had heart attacks; approximately 157,000 were fatal. Fewer people would die from heart attacks if they sought medical care more quickly.
“Although emergency care and medical therapies for acute events have improved, studies have shown that the time from symptom onset to treatment overall has not decreased,” according to the report.
I’m guessing that awareness of heart attack is lacking, and people’s first reaction is to call a loved one or drive the victim to the hospital. Maybe loved ones don’t recognize what’s happening or downplay the seriousness of it. Or maybe people in some parts of the state have to wait for an ambulance to respond, making driving the heart attack victim to the hospital more of an option.
Jeff Raymond, Medical Writer
C-section stats
Almost 1 in 3 American woman had babies delivered by C-section in 2005, the Agency for Healthcare Research and Quality reports.
The number of C-sections was 38 percent less in 1995.
AHRQ also found:
- -Vaginal deliveries declined from about 3 million in 1995 to 2.9 million in 2005.
-Vaginal deliveries among women who previously had given birth via C-section dropped 60 percent –157,200 in 1995 to 62,300 in 2005.
-Hospitals charged $17.4 billion for deliveries by C-section in 2005.
The Oklahoman’s Heather Warlick wrote this story about C-sections in September.
Jeff Raymond, Medical Writer
Waiting for a liver
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
