Jim was at his desk, looking weary.
The last few weeks had been brutal. Despite working twelve-hour days, he felt that he had little to show for it. His annual board meeting was to take place the next day, and he expected it to be tense.
With a replacement bill for the ACA about to be voted on, and with Trump in the White House, the situation seemed particularly precarious. The board members had asked him to present a contingency plan, in case things in DC didn’t go well.
As CEO of a major health insurance company, Jim was well aware that business as usual had become unsustainable in his line of work. No matter what insurers had tried to do in the last few years—imposing onerous rules, setting high deductibles, pushing for government subsidies—prices had been going up and up.
Premiums, of course, had had to do the same but, evidently, the limit had now been reached. The horror stories being told at town hall meetings across the country were all too real. People were fed up, and politicians were feeling the heat.
Something needed to be done to change course, but what? He did not have any good plan to propose to the board.
As GOP lawmakers grapple with the “replace” aspect of Obamacare and seek to overhaul the subject “nobody knew could be so complicated,” we must remember that one of the best ways to reduce spiraling healthcare costs is to improve health through preventive measures.
For instance, increased participation in youth sports would help control rising obesity and sedentary rates which are responsible for 21% of annual medical spending – a staggering $190.2 billion a year. Inactivity among youth spiked from 20% in 2014 to 37.1% in 2015. But while the NIH identifies preventing weight gain in childhood as critical to warding off lifelong obesity outcomes and playing sports as one of the strongest weapons against teen obesity, participation rates have declined nearly 10% since 2009. A number of factors have been attributed to this trend, but with the biggest losses in contact sports like football and wrestling, it’s impossible to ignore the long-standing elephant in the stadium – concussions.
Current polls show 94% of U.S. adults believe sport concussions constitute a public health concern and a full 100% of parents are affected by them. But do the risks of playing contact sports really outweigh their myriad physical, mental, and social benefits? After decades of research, why do we still not know what to do about concussions?
Eric Lindros, who retired from the NHL after suffering 6 concussions and donated millions to the cause, hit the nail on the head in lamenting the lack of tangible results and guidance from concussion research: “It seems like there are so many groups trying to do the right thing, but our voice would be stronger through consolidation. Are we sharing all the information? Let’s get people working together.”
Lindros’ frustrations are best illustrated by disagreement about what a concussion even is. Google defines it as “temporary unconsciousness caused by a blow to the head.” But only a small minority of medical “consensus statements” (of which there are more than 42) even require a loss of consciousness and most sources say indirect impacts are also sufficient to cause concussion. These differences aren’t just academic – accounting for sport concussions that did not involve loss of consciousness made the prevailing incidence rate jump from 300,000 to 1.8 – 3.6 million annually. Failure to agree on how to define the problem has created a snowball effect, contributing to inconsistent diagnostic standards and unreliable incidence and prevalence data that cannot be aggregated or compared.
The Ketamine Papers serves as an essential window into the rapidly accelerating application of the anesthetic cum party drug ketamine to individuals with disorders such as treatment-resistant depression and post-traumatic stress disorder (PTSD). In addition, the book’s release coincides with other psychedelics, MDMA (aka ‘Ecstasy’) and psilocybin, being cleared for late-phase clinical trials as therapeutic adjuncts for the treatment and – dare we say – cure of those and related disorders, a process that will still take some years. Given what seems to be an increasing explosion of interest in the use of psychedelics for everything from therapy to micro-dosing of LSD to fuel creativity, The Ketamine Papers offers a range of views into how the psychiatric and psychotherapeutic communities are putting to use what amounts, for now, as the only legal psychedelic drug left standing, and for a group of people who very much struggle and suffer, at a significant cost to themselves, their relationships, and society.
The recurrent leitmotif of The Ketamine Papers is that of stubbornly lingering psychological illness – with feelings and behaviors ranging from sadness and stuckness to suicidality – that doesn’t just happen. It is often the function of trauma, childhood and otherwise, and lack of attachment not offset by a resilience that some develop and many do not. Those statements won’t be surprising to anyone who has read the works of psychiatrists and psychologists who have rooted depression – by far the most common form of mental illness – in unresolved childhood conflicts.
Barely one month after a stinging and stunning legislative defeat, President Donald Trump has committed to revising the AHCA and potentially resubmitting it for Congressional approval.
In addition to Democrats and widespread popular opinion against ACA repeal, the AHCA may face another obstacle – international law.
This week the Washington Post’s Dana Milbank reported that the United Nations Office of the High Commission on Human Rights forwarded a four-page letter to the Acting Secretary of State, Thomas A. Shannon, to express the Commission’s “serious concern” that the US was in danger of violating its obligations under international law if the U.S. ratified legislation repealing the ACA.
The letter authored by Dainius Puras, a Lithuanian with the somewhat remarkable title of UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, argues that repealing core elements of the ACA would negatively impact almost 30 million Americans’ right to the “highest attainable standards of physical and mental health”, particularly those in moderate and low income brackets and those suffering from poverty or social exclusion.
Texas should call itself The Granny State. That’s because it’s a nanny state in which the public officials who run the place have the values of a tea-totaling, Bible-thumping biddy who knows how God wants everyone to live and can’t resist telling them. No buying liquor on Sundays when people are supposed to be at church. No gambling ever. No whacky-weed for medicinal uses or recreation, even in the privacy of one’s home. No gay marriage, preferably no gays, and no transgender folk deciding which restrooms to use. And, of course, no sex, sex education, birth control, or abortions. Women should have sex only in marriage and then only to reproduce, and those who get pregnant must carry their babies to term, regardless of the consequences for themselves or anyone else.
These religion-inspired policies have served Texans poorly. The state’s maternal mortality rate nearly doubled in just two years after Texas cut its budget for family planning by two-thirds and eliminated funding for Planned Parenthood clinics. It’s now the worst in the developed world, not just in the US. Texas ranks 8th from the bottom in the frequency of STDs and has the 5th highest teen pregnancy rate too. Its 35 births per 1,000 girls aged 15-19 are nearly double the national average. Meanwhile, Colorado and other states have achieved miraculous reductions in teen pregnancy rates and abortion rates by providing young women with long-acting contraceptives, like implants and IUDs. If Texas is following God’s plan, then God’s plan is a bust.
Now Granny is once again sticking her nose where it doesn’t belong. Currently before the Texas legislature is Senate Bill 25, which would eliminate the wrongful birth cause of action that the Texas Supreme Court recognized four decades ago in Jacobs v. Theimer. The facts were as follows. While traveling, Dortha Jacobs became ill. Upon returning home, she consulted a physician, Dr. Louis Theimer, who discovered that she was newly pregnant. Fearing that the illness was rubella—also known as the German measles—Jacobs asked Dr. Theimer if there was reason for concern. Rubella can injure a gestating fetus severely. Dr. Theimer told her not to worry, but he did so without performing an available diagnostic test. In fact, the disease was rubella and the child “was born with defects of brain, speech, sight, hearing, kidneys, and urinary tract,” among others. The medical expenses were extraordinary.
Nonprofit hospitals have higher profit margins than most for-profit hospitals after accounting for their tax obligations. 3900 (62%) of U.S. Hospitals are non-profit and therefore tax-exempt: they pay no property tax, no federal or state income tax, and no sales tax. An article published in Health Affairs found seven of the nation’s 10 most profitable hospitals were of the non-profit variety, each earning more than $163 million from patient care services. Revoking their property tax-exempt status for not functioning as a charitable entity could return billions in healthcare dollars to local government, communities, and citizens, struggling to afford quality health care.
The idea of exempting nonprofits from paying taxes in the first place is based on the belief these entities provide charity for the underserved and underinsured who would otherwise require the government to lend a helping hand. As the percentage of uninsured declines as a result of the ACA, the justification for tax exempt status is being called into question.
Recently, the Harvard Chan School of Public Health, in their press release, reported about the effect of surgical checklists in South Carolina. The release was titled, “South Carolina hospitals see major drop in post-surgical deaths with nation’s first proven statewide Surgical Safety Checklist Program.”
The Health News Review, for which I review, grades coverage of research in the media. Based on their objective criteria, the Harvard press release would not score highly.
The title exudes certainty – “nation’s first proven.” The study, not being a randomized controlled trial (RCT), though suggests that checklists are effective, far from proves it. At least one study failed to show that surgical checklists improve outcomes.
The press release’s opening line is “South Carolina saw a 22 percent reduction in deaths.” It reports relative risk reduction (RRR). Reporting RRR is now considered a cardinal sin in healthcare journalism, because RRR inflates therapeutic optimism by making the intervention sound more efficacious than it is.
Healthcare providers, medical institutions, local pharmacies and pharmaceutical companies generally set the price of their products/services well above the payment they expect to receive from all insurers. These healthcare vendors set their fee schedule at 150%, 200% or 1,000% of the maximum payment they expect to receive from their most generous payor.
Here in Massachusetts, when a healthcare product or service is consumed and the patient has health insurance, the vendor submits a bill to the insurance company who specifies the “allowed fee,” which is considerably less than the “billed fee,” and the vendor “writes off” the balance of the “billed fee” from their books.
For example, I recently had some blood tests done at Quest Diagnostics. Quest Diagnostics sent a bill to my insurance company for $660. The “allowed payment” was $110, so Quest wrote-off $550 and the “allowed payment” of $110 was divided between me and my insurance company.
I’ve been quite vocal about supporting only wellness done for employees and not to them…but what if there could be a “conventional” wellness program – even including screening, HRAs etc. – that both you and I could love?
People manage what’s measured and what’s paid for. If employers want people to stay healthy in the long run, why not measure and pay for health in the long run?
Why not give people the incentive to stay healthy during their working years, instead of giving them the incentive to pretend to participate in programs of no interest, just to make a few bucks? Or, worse, give employees the incentive to learn how to cheat on biometrics, and how to lie on health risk assessments. Attempts to create a culture of health often create a culture of resentment and deceit.
Short-term incentives haven’t changed weight, as noted behavioral economist Kevin Volpp has shown. Nor have they changed true health outcomes – it is easily provable that wellness has almost literally never avoided a single risk-sensitive medical event. So-called outcomes-based programs, ironically, are more about distorting short-term outcomes than achieving long-term outcomes. They have more in common with training circus animals to do tricks in exchange for treats than they do with helping employees improve long-term health.
After missing an appointment with a physician recently, one of us was tongue-lashed by a medical assistant who explained that the practice has a months-long waiting list for new patients. The dressing-down included a threat. Another no-show and the miscreant would be discharged from the doctor’s practice and have all medications cut off.
Wondering if patients really wait months to see this doctor, the delinquent called back, pretended to be a new patient, and asked how quickly he could get in. The first available appointment at the closest location was, in fact, 2 months out. (The wait could have been cut in half by driving to an office that was farther away.)
Two months is a long time to wait to see a doctor. If your auto mechanic or air conditioner repairman told you that it would take a week to fit you in, you’d find someone else to take care of the problem and you’d never go back to the person who told you to wait. Given the transcendent importance of health, why do patients who need medical assistance routinely wait far longer? And if patients with good insurance wait for two months, how long is the queue for those who rely on Medicaid or who have no insurance at all?Continue reading…