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Category: Patients

What Do Women Know About Obamacare That Men Don’t?

Susan DentzerFor the second year running, more women than men have signed up for coverage in health insurance marketplaces during open enrollment under the Affordable Care Act. According to the Department of Health and Human Services, enrollment ran 56 percent female, 44 percent male, during last year’s open enrollment season; preliminary data from this year shows enrollment at 55 percent female, 45 percent male – a 10 percentage point difference.

What gives? An HHS spokeswoman says the department can’t explain most of the differential. Females make up about 51 percent of the U.S. population, but there is no real evidence that, prior to ACA implementation, they were disproportionately more likely to be uninsured than men – and in fact, some evidence indicates that they were less likely to be uninsured than males .

What is clear that many women were highly motivated to obtain coverage under the health reform law – most likely because they want it, and need it.

It’s widely accepted that women tend to be highly concerned about health and health care; they use more of it than men, in part due to reproductive services, and make 80 percent of health care decisions for their families . The early evidence also suggests that women who obtained coverage during open enrollment season last year actively used it.  Continue reading…

The Therapeutic Paradox: What’s Right for the Population May Not Be Right for the Patient

flying cadeuciiAn article in this week’s New York Times called Will This Treatment Help Me?  There’s a Statistic for that highlights the disconnect between the risks (and risk reductions) that epidemiologists, researchers, guideline writers, the pharmaceutical industry, and policy wonks think are significant and the risks (and risk reductions) patients intuitively think are significant enough to warrant treatment.

The authors, bloggers at The Incidental Economist, begin the article with a sobering look at the number needed to treat (NNT).  For the primary prevention of myocardial infarction (MI), if 2000 people with a 10% or higher risk of MI in the next 10 years take aspirin for 2 years, one MI will be prevented.  1999 people will have gotten no benefit from aspirin, and four will have an MI in spite of taking aspirin.  Aspirin, a very good drug on all accounts, is far from a panacea, and this from a man (me) who takes it in spite of falling far below the risk threshold at which it is recommended.

One problem with NNT is that for patients it is a gratuitous numerical transformation of a simple number that anybody could understand (the absolute risk reduction  – “your risk of stroke is reduced 3% by taking coumadin“), into a more abstract one (the NNT – “if we treat 33 people with coumadin, we prevent one stroke among them”) that requires retransformation into examples that people can understand, as shown in pictograms in the NYT article.  A person trying to understand stroke prevention with coumadin could care less about the other 32 people his doctor is treating with coumadin, he is interested in himself.  And his risk is reduced 3%.  So why do we even use the NNT, why not just use ARR?

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A Tale of Two Sore Throats: On Retail Clinics and Urgent Care

Leslie Kernisan new headshotSix years ago, just after arriving in Baltimore for a winter conference, I fell sick with fever and a bad sore throat.

After a night of feeling awful, I went looking for help. I found it at a Minute Clinic in a CVS near the hotel. I was seen right away by a friendly NP who did a rapid strep test, and prescribed me medication. I picked up my medication at the pharmacy there. The visit cost something like $85, and took maybe 30 minutes. They gave me forms to submit to my California insurance. And I was well enough to present my research as planned by day 3 of the conference.

Fast forward to this year. After feeling a bit blah on a Monday evening, I developed a sore throat, headache, and fever overnight.

I figured it was a winter viral pharyngitis, rearranged my schedule, and planned to make it an “easy day.” Usually a low-key day plus a good night’s sleep does the trick for me.

But not with this bug.

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Getting Your Own Health Records Online: The Good and the Not So Good

Lygeia RiccardiMaking Sense of Blue Button, Meaningful Use, and What’s Going on in Washington  …

At the recent Health 2.0 Conference in Santa Clara, co-chair Matt Holt expressed frustration about the difficulty of getting copies of his young daughter’s medical records. His experience catalyzed a heated discussion about individuals’ electronic access to their own health information. Many people are confused about or unaware of their legal rights, the policies that support those rights, and the potential implications of digital access to health data by individuals. The Health 2.0 conference crowd included 2000 entrepreneurs, consumer technology companies, patient advocates, and other potentially “disruptive” forces in healthcare, in addition to more traditional health system players.

Why is this topic so important? Until now, most people haven’t accessed their own health records, whether electronically or in paper, and I believe that making it easier to do so will help tip the scales toward more meaningful consumer/patient engagement in healthcare and in health. Access by individuals and their families to their own health records can empower them to coordinate care among multiple healthcare providers, find and address dangerous factual errors, and take advantage of a growing ecosystem of apps and tools for improving health-related behaviors, saving money on health services, and getting more convenient, personalized care.

A shorthand phrase for this kind of personal empowerment through access to digital health data is “Blue Button,” which is also the name of a public-private initiative in which hundreds of leading healthcare organizations across the US participate. The Blue Button Initiative is bolstered by the electronic access to health information requirements for patients in the “Meaningful Use” EHR Incentive Program, which is administered by CMS (the Centers for Medicare & Medicaid Services) with companion standards and certification requirements set by ONC (the Office of the National Coordinator for Health Information Technology).Continue reading…

Why Public Health Needs a New Gun Doctrine

The Future Looks Like a Girl With a Gun Resized

I am a public health professional, educated at the vaunted Johns Hopkins University Bloomberg School of Hygiene and Public Health. I like guns, and I believe the Second Amendment clearly secures the rights of individuals to own firearms.

You read that correctly. I am a public health professional.

And I like guns.

This make me a heretic in American public health, where embracing firearms and the rights of gun owners is a gross violation of orthodoxy.

As a society, our focus on guns and not gun users derives from the shock of mass killings, such as those in Newtown, CT, Aurora, CO, Virginia Tech, and Norway, which has some of the strictest gun control laws on the planet. Mass killings, however tragic, get distorted by saturation media hysterics and 24-hour political grandstanding. What gun opponents refuse to discuss is the precipitous fall in violent crime and deaths by firearms over the past 20 years, and how it coincides with an equally dramatic increase of guns in circulation in the US.

While that isn’t cause and effect, the association is certainly curious.

In 2013, the Institute of Medicine, at the behest of the Centers for Disease Control, produced a report on firearms violence that has been ignored by the mainstream media. The upshot: defensive use of firearms occurs much more frequently than is recognized, “can be an important crime deterrent,” and unauthorized  possession (read: by someone other than the lawful owner) of a firearm is a crucial driver of firearms violence.

That report went away for political reasons. Translation. Nobody wanted to talk about it because it raised more questions than it answered.

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Why Doctors Shouldn’t Be Healers

Screen Shot 2014-08-16 at 10.04.17 AMIt’s a seductive idea. We doctors possess knowledge and experience which can not only help people, but can save their lives. We get opportunities to be the right person at the right time to offer the right help that makes all of the difference. It’s one of the greatest things about our profession. It’s also one of its greatest traps.

I’ve heard many doctors refer to themselves as “healers,” as if we have some special power to bring about healing in our patients. This idea confers some sort of a higher status and originates, to some, from a “higher calling” to a more noble life. Again, this is a logical step, in that we have opportunities on a regular basis to help and even save the lives of people. It’s natural to believe that somehow the healing power comes from our touch, or even from our knowledge.

It doesn’t. I am not a healer.

Healing is what the patient does, not the doctor. As a physician, I am certainly one who can help the patient find a faster road to healing, but I don’t heal. I help.

Why am I taking the time to talk about this? Why get stressed out over whether I am a helper or a healer? I think that the belief in doctors as healers causes significant harm to both doctors and patients, and that getting a better perspective about the roles of each will greatly improve the care given. Here’s why I believe this is a topic that needs addressing:

1. Doctors Often Fail at Healing (And Will Always Ultimately Fail)

There are many patient problems that do not get better, despite my best efforts. There are countless pains I can’t remove, and many problems I do not solve. Even when I succeed, the success is always temporary, as a new problem will eventually come back. And if healing is our ultimate goal as physicians, we all are total failures, as all of our patients eventually die. If healing is held as our goal, we fight a losing battle. We are the soldiers in the Alamo, offering impotent resistance to an overwhelming force.

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How PCORI’s Research Will Answer the Real World Questions Patients Are Asking

As a physician, I know the challenge of helping patients determine which health care options might work best for them given their personal situation and preferences.

Too often they — and their clinicians — must make choices about preventing, diagnosing and treating diseases and health conditions without adequate information. The Patient-Centered Outcomes Research Institute (PCORI) was created to help solve this problem — to help patients and those who care for them make better-informed health decisions.

Established by Congress through the Patient Protection and Affordable Care Act as an independent research institute, PCORI is designed to answer real-world questions about what works best for patients based on their particular circumstances and concerns. We do this primarily by funding comparative clinical effectiveness research (CER), studies that compare multiple care options.

But more research by itself won’t improve clinical decision-making. Patients and those who care for them must be able to easily find relevant evidence they can trust. That’s why our mandate is not just to fund high-quality CER and evidence synthesis but to share the results in ways that are meaningful to patients, clinicians and others.

We’re also charged with improving the methods used in conducting those studies and enhancing our nation’s capacity to do such research.

We will be evaluated ultimately on whether the research we fund can change clinical practice and help reduce the variations and disparities that stand between patients and better outcomes. We’re confident that the work we’re funding brings us and the audiences we serve closer to that goal.

Recently, some questions have been raised in health policy circles about our holistic approach to PCORI’s work. That view holds that direct comparisons of health care options — especially those involving high-priced interventions — should be the dominant if not sole focus of PCORI’s research funding approach as a path to limiting the use of expensive, less-effective options.

We agree that discovering new knowledge on how therapies compare with one another is a critical mandate of PCORI and is essential to improving the quality and effectiveness of care.  However, ensuring that patients and those who care for them have timely access to and can use this knowledge, so that they can effectively apply it to improve their decisions, is also very important.

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How Doctors Die

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds—from 5 percent to 15 percent—albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.

It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen—that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).
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