The Health Care Blog – Page 246 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Living for Today with Cancer

Nov 1, 2018

By James Salwitz, MD

To have cancer is to change forever. It is a devastating declaration. Each of us copes with the diagnosis differently. How people adjust and move on with their lives are lessons in humanity.

I take care of a patient who explained to me how he deals with incurable cancer. Stan is active and able to enjoy grandchildren, friends and hobbies. He describes himself as happy, despite his terminal diagnosis. The key was both difficult and simple. He said, “that in order to survive with cancer, you need to accept that you are going to die.”

For Stan the obstacle was his struggle against the unstoppable. When diagnosed he responded by attacking the disease. He demanded extra tests, multiple second opinions and became obsessed with an investigation of treatment choices. He threw himself into conventional and alternative therapies. He filled binders with data, radiology reports, tumor markers and medical articles. He cataloged every event. Stan was absorbed in the disease process every moment of every day and with every ounce of his being.

Wherever Stan turned, he found that his cancer was indeed incurable. No matter what he did, he would eventually die. Frustration overwhelmed him. The more time he spent with the disease, the more he became lonely and frightened. He was the prototypic cancer patient…sick, exhausted, isolated and buried in medical care. He fell away from life and started to die.

According to Stan, the answer came as a revelation. In a particularly depressed and forlorn moment, a realization saved him. Stan did not have to fight an opponent he could not defeat. There is no shame in mortal limits. If he stepped back and accepted there were things he could not change, he would be alright. Stan discovered that to be set free, he needed to drop the burden of struggle.

With his family and doctors, Stan put together a basic medical plan. It consists of chemotherapy, nutritional support and exercise. He has set terminal limits. Most importantly, Stan carved out large blocks of time to be away from “health care” and return to his life.

Stan spends most of the days enjoying his family. He has done a little bit of traveling. He has been reading and learning. He is looking forward to spring garden planting. Stan hugs all his grandchildren every single day. He is happy.

Each person needs to find their own way through the challenges of life and those caused by illness. For this man the formula is difficult and simple. Accept what he cannot change and hold on tight to the things he loves. Seize life today, for that may be all there is…but sometimes that is enough.

James C. Salwitz, MD is a Medical Oncologist in private practice for 25 years, and a Clinical Professor at Robert Wood Johnson Medical School. He frequently lectures at the Medical School and in the community on topics related to cancer care, Hospice and Palliative Medicine. Dr. Salwitz blogs at Sunrise Rounds in order to help provide an understanding of cancer.

Crowd-Funding for Research Dollars: A Cure for Science’s Ills?

Nov 1, 2018

By Jai Ranganathan

Science in crisis

Scientists – and science generally – are in a moment of crisis on multiple fronts. The gap between science and society has grown to a chasm, with disastrous consequences for issue after issue. For example, just last month, Tennessee passed legislation permitting creation “science” into classrooms. On another front, the concern of Americans about global warming has dramatically declined over the past decade, despite the scientific consensus on the clear and present danger caused by climate change.

But science illiteracy in the general public isn’t the only crisis in science. Funding for research is becoming increasingly unattainable, with funding rates at their lowest levels in a decade at the National Science Foundation (NSF) and the National Institutes of Health (NIH), the two most important American science agencies (see here and here for details). The situation in many other nations is no better. In Spain, for example, science spending by the central government has fallen by 20% since 2009. Even worse, research funding from traditional sources will likely be even harder to come by in the years to come due to ongoing economic instability around the world.

Kids Today Are Not Inattentive

Nov 1, 2018

By Neuroskeptic

There’s no evidence that children today are less attentive or more distractible than kids in the past, according to research just published by a team of Pennsylvania psychologists: Long-Term Temporal Stability of Measured Inattention and Impulsivity in Typical and Referred Children.

The study gave a large sample of kids the “Gordon Diagnostic System” GDS test of sustained concentration ability. This dates to the 80s and it consists of a box, with a button, and a display with three digits. There are three different tasks but the main one is a sustained attention test. The goal is to watch a series of numbers and quickly press the button whenever a “1” is followed by a “9”. Easy… but it takes concentration to do well.

Over the period of 2000-2006, the researchers gave the GDS to 445 healthy American kids, not diagnosed with any learning or behavioural disorder and not taking medication. They compared their scores to the standardized norms – which were based on a sample of American kids back in 1983.

The results showed that today’s kids scored pretty much the same, on average, as the 1983 kids. The average age-standardized scores were extremely close to the 1983 means, across the board. Children diagnosed with ADHD, as expected, scored much worse. Oddly, kids with an Autism Spectrum Disorder did just as badly as the ADHD ones.

What About Single-Payer?

Nov 1, 2018

By James Burdick, MD

President Barack Obama’s vision for health-care reform could have resulted in a much better law had it not been for congressional decrees at the start that a single-payer system was “off the table.” But guess what has appeared back on the table during the thoughtful pondering of the problem by the Supreme Court?

Justice Anthony Kennedy said on March 27: “Let’s assume that it could use the tax power to raise revenue and to just have a national health service, single payer. How does that factor into our analysis? In one sense, it can be argued that this is what the government is doing. It ought to be honest about the power that it’s using and use the correct power.”

As a doctor viewing the Supreme Court drama unfolding over the Affordable Care Act, I have high hopes that patients will emerge with much more access to the wonders that modern medicine can provide. Being able to treat and perhaps cure patients is essential to the freedoms and entitlements protected by the Constitution and its Bill of Rights. But the constitutional question has been framed as one of interstate commerce — not rights.

Commercial interests dominated during the formulation of the Affordable Care Act. An average of eight lobbyists were at work for each member of Congress, and the insurance companies were delighted when they saw the initial draft.

Patients may get sick and need care without adequate insurance. Doctors have always known this, but the conundrum is now occupying our country’s best legal minds. That and other failures of our insurance-based system of coverage for health care have been highlighted. And the logic is overwhelming: We need to just get on with providing affordable, quality health care coverage for everyone, like every other developed country.

It is easy for the naysayers to prey on fears that a national system must cost too much, must allow people to get too much health care at others’ expense, and must subject patients and doctors to rationing and government interference. But none of this is necessarily so.

If patients understand that their doctors are practicing high-quality medicine when they employ just the right care for a health problem — not less but also not more — we are on the way to solving the problem. Excess care is harmful as well as expensive. The insurance companies profit because they force patients to make unhealthy decisions based on finances, not medical need.

Fear of higher taxes comes from extrapolation of present spending patterns. But the things that would make universal coverage cost too much are bad for patients. In overcoming them, we can save $500 billion by avoiding unnecessary care, more than $150 billion in administrative costs, and billions more in avoidable, excess costs for the uninsured.

Doctors are faced with decreasing incomes and at the same time are beset by a huge proliferation in Medicare billing codes due to fee-for-service payments, and by increasing administrative quality requirements and insurance restrictions. Given the necessary legal responsibility and authority, doctors (not insurers) can define necessary care, which will cut excessive spending and end the fear of unfair, unrestrained use of health care. Doctors tend to resist this proposed responsibility, viewing it as the government again telling them what to do — but many are ready for change. And this would be different: It could work according to rules that would be set by doctors for doctors, doing what federal and insurance company administrators cannot do.

In short: We doctors, along with our patients, need to take over the decision-making and control harmful and unnecessarily expensive practices. Dr. Toby Cosgrove, president of the Cleveland Clinic, recently noted that “health-care overhaul is happening, regardless of what the Supreme Court decides,” with improvements that doctors are already achieving.

The savings from having everyone automatically covered will support better professional incomes. Patients will be safer and healthier, and the deficit will no longer be held hostage to increasing health care costs.

Good sense about what the Constitution means may carry the legal day. But even if the Affordable Care Act is struck down, we must move forward with the intent of the law: to make the purpose of medical coverage to create good health.

Dr. James Burdick, a professor of surgery at the Johns Hopkins University School of Medicine, had a career as a transplant surgeon and served in the Department of Health and Human Services as director of the Division of Transplantation. He is writing a book detailing his doctors’ plan for health reform. His email is jb******@**mi.edu.

What Makes Health Care Different

Nov 1, 2018

By Donna Dubinsky

As best as I can tell, the arguments at the Supreme Court did not touch on a critical part of the discussion about government’s role in health care: the broken market for private insurance. And I think I know why.

A key assumption underlying the arguments, questions and answers was that all uninsured people are uninsured by choice. Sure, some very ill people with preexisting conditions do not qualify. But the implication was clear: Most uninsured people either do not want to pay for insurance or cannot afford it. Justice Samuel Alito said, “You can get health insurance.” Justice Ruth Bader Ginsburg made the point that people who don’t participate are making it more expensive for others, that their “free choice” affects others. The “free rider” problem is thoroughly examined.

It was as if the court forgot that the private insurance market does not function as a normal market. If you are not employed and you want to purchase insurance in the private market, you cannot unilaterally decide to do so. An insurer has to accept you as a customer. And quite often, they don’t. Insurers prefer group plans, with lots of people enrolled to spread the risk. Can you blame them? The individual consumer is a lot of work, is a higher risk and produces relatively little revenue.

States’ Revenue Rising, Spending Not So Much

Nov 1, 2018

By Merrill Goozner

Call it the Scott Walkering of America.

Even though tax revenues are finally rising faster than expenses, governors across the nation are recommending more austerity in the budgets they’re presenting to state legislatures this year, the latest survey from the National Governors Association shows.

For the fiscal year beginning July 1, governors are recommending a 2.2 percent increase to $683 billion in general revenue fund spending. That’s down from the 3.3 percent increase in state spending in 2012. Revenue, meanwhile, is projected to rise four percent during the coming fiscal year.

“The public sector has even more uncertainty at this time than the private sector,” said Dan Crippen, executive director of the NGA and former head of the Congressional Budget Office. Citing the looming Supreme Court decision on health care reform, the uncertain levels of federal aid from the “fiscal cliff” negotiations, and talk of tax reform that could cut tax expenditures that benefit state and local governments, “it’s pretty hard for states to plan,” he said.

Roulette

Nov 1, 2018

By Rob Lamberts, MD

“I want you to get me a new doctor,” she told me, a bit of disgust coming out in the sharp tone in her voice.

“What happened?” I asked.

“He asked me if I was nauseated, and I told him no, I was just vomiting. Then he asked if I was feeling pain in my stomach, and again I told him no, it was just vomiting. He then told his nurse to write down nausea and abdominal pain. When I objected, he just gave me a bad expression and walked out of the room.”

I tried to come up with a plausible explanation for his action, but there was none. ”I’m sorry,” I said. ”There are a lot of people who come back from him feeling really happy and listened-to. It’s obvious that you saw none of that from him.”

“I asked his nurses if he aways acted this way,” she continued, “and they just shrugged and told me that he sometimes did.”

“I’m happy to send you to a different doctor,” I said, shaking my head.

I hate it when this happens.

I send people to specialists for two main reasons:

I am not qualified to offer the treatment or procedures the specialist can give.
The specialist has far more experience with the problem, and so can offer better care.

The Nursing Workforce of 2020: Well Trained, Well Paid, and — Actually, Who the Hell Knows

Nov 1, 2018

By David Glenn

This morning’s wretched jobs report tells a now-familiar tale: Employment has risen nicely in health care (a net gain of more than 340,000 jobs between May 2011 and May 2012). But almost every other sector has been flat or worse.

You might think that would mean that new-graduate nurses are having an easy time finding work. That’s still true in rural areas — but elsewhere, no.

In many U.S. cities, especially on the west coast, there’s real evidence of a nursing glut. The most recent survey conducted by the National Student Nurses’ Association found that more than 30 percent of recent graduates had failed to find jobs.

How is that possible?

While demand for nurses has been rising, it actually hasn’t risen as fast as most scholars had projected. Meanwhile, the supply of nurses has spiked unexpectedly, at both ends of the age scale: Older nurses have delayed retirement, often because the recession has thrown their spouses out of work. And people in their early twenties are earning nursing degrees at a rate not seen in decades. We’re now in the sixth year in which health-care employment has far outshone every other sector, and college students have read those tea leaves.

So what will happen next? Here are crude sketches of two possible futures:

I. THE NURSING SHORTAGE OF 2020

(This scenario draws from a talk that Vanderbilt University’s Peter Buerhaus gave two weeks ago at the U. of Maryland School of Nursing. Buerhaus still sees a shortage coming, though a less severe one than the shortage that he and two colleagues had predicted in a widely-cited 2000 paper.)

In June 2012, the Supreme Court upholds the Affordable Care Act, and Republicans never manage to do much to weaken the law. Tens of millions of Americans gain access to insurance, and the demand for nurses rises in tandem.
Some time around 2014, the general labor market finally recovers. There’s less desperation in the air. Sixty-year-old nurses are more likely to retire, and twenty-year-old college students who aren’t actually that interested in nursing go back to majoring in anthropology or accounting or whatever, because they’re reasonably sure they’ll find jobs.
The millions of soon-to-retire Baby Boomers utilize Medicare at rates similar to previous cohorts of 70-year-olds.
Changes in health care delivery mean that nurses and nurse practitioners are heavily deployed to provide primary care and to coordinate patients’ services.

II. THE NURSING GLUT OF 2020

In June, the Supreme Court strikes down the ACA’s insurance mandate. Mitt Romney wins the 2012 election and pushes his health proposals through Congress. In this scenario, at least 45 million fewer people have health insurance than would have been the case with an intact ACA.
The EU zone goes to hell, and the ensuing financial crisis means that the U.S. labor market stays miserable for years. College students continue to pour into health care fields, because that’s the one sector with better-than-zero growth.
The millions of soon-to-retire Baby Boomers utilize Medicare at significantly lower rates than previous cohorts of 70-year-olds. (Unlike the other items on this list, this one is good news.)
Changes in health care delivery don’t lead to a relative increase in the deployment of nurses and nurse practitioners. Accountable Care Organizations use social workers and other non-nurses to coordinate patients’ care across providers.

What will actually happen? Probably something in between, of course. (Or maybe the Yellowstone volcano will erupt and this will all be moot.)

We had better hope that it is something close to halfway in between. Both shortages and gluts are bad for patients and bad for the nursing profession. Nursing shortages, because patients are even more likely than usual to face understaffed units and overstretched nurses. Nursing gluts, because nurses are so afraid of unemployment that they don’t speak up about problems on their units.

David Glenn is a student at the University of Maryland School of Nursing and author of the blog, Notes on Nursing, where this post originally appeared.

Who Owns Patient Data?

Nov 1, 2018

By Fred Trotter

Who owns a patient’s health information?

The patient to whom it refers?
The health provider that created it?
The IT specialist who has the greatest control over it?

The notion of ownership is inadequate for health information. For instance, no one has an absolute right to destroy health information. But we all understand what it means to own an automobile: You can drive the car you own into a tree or into the ocean if you want to. No one has the legal right to do things like that to a “master copy” of health information.

All of the groups above have a complex series of rights and responsibilities relating to health information that should never be trivialized into ownership.

Raising the question of ownership at all is a hash argument. What is a hash argument? Here’s how Julian Sanchez describes it:

“Come to think of it, there’s a certain class of rhetoric I’m going to call the ‘one-way hash‘ argument. Most modern cryptographic systems in wide use are based on a certain mathematical asymmetry: You can multiply a couple of large prime numbers much (much, much, much, much) more quickly than you can factor the product back into primes. A one-way hash is a kind of ‘fingerprint’ for messages based on the same mathematical idea: It’s really easy to run the algorithm in one direction, but much harder and more time consuming to undo. Certain bad arguments work the same way — skim online debates between biologists and earnest ID (Intelligent Design) aficionados armed with talking points if you want a few examples: The talking point on one side is just complex enough that it’s both intelligible — even somewhat intuitive — to the layman and sounds as though it might qualify as some kind of insight … The rebuttal, by contrast, may require explaining a whole series of preliminary concepts before it’s really possible to explain why the talking point is wrong.”

The Problem Is Relative

Nov 1, 2018

By H. Gilbert Welch

Numerous studies have shown that the general public has exaggerated perceptions of the health risks they face — as well as exaggerated expectations of the benefit of medical care.

Is it because they’re stupid? No. Instead, the problem relates to how various sources of health information — researchers, doctors, reporters, web designers, advertisers, etc. — frequently frame their messages: using relative change.

“Forty percent higher” and “50 percent lower” are statements of relative change. While they are easy to understand, they are also incomplete. Relative change can dramatically exaggerate the underlying effect. It’s a great way to scare people.

For example, research earlier this year found that women with migraines had a 40 percent higher chance of developing multiple sclerosis. That sounds scary.

But the researchers were careful to add some important context: Multiple sclerosis is a rare disease. In fact, for women with migraines, the chance of developing multiple sclerosis over 15 years was considerably less than 1 in 100 — only 0.47 percent. To be sure, that is about 40% higher than the analogous risk for women without migraines — 0.32 percent — but it’s a lot less scary. More importantly, it’s a much more complete piece of information.

What makes it more complete is the context of two additional numbers: the risk of developing multiple sclerosis in women with and without migraines. Epidemiologists call these “absolute risks.” You and I might call them the real numbers.

Relative change also exaggerate effects in the other direction. It’s a great way to make people believe there has been a real medical breakthrough.

A few years ago a study of a cholesterol-lowering statin drug was hailed for big reductions in heart attacks in people with so-called healthy cholesterol levels. The drug led to about a 50 percent reduction in the risk of heart attack. That sounds like a breakthrough.

But the absolute risks — the real numbers — are sure to look a little different. Why? Because in people with healthy cholesterol levels, heart attacks are rare. To get that context, get the two additional numbers: the risk of heart attack in people taking and not taking the drug.

For people taking the drug, the chance of having a heart attack over five years was less than 1 percent. To be sure, that is about 50 percent lower than the analogous risk for those not taking the drug — less than 2 percent — but it sounds a lot less like a breakthrough.

These absolute risks suggest that 100 apparently healthy people have to take the medication for five years for one to avoid a heart attack. And it’s not even clear from the research — or the federal registry of clinical trials — what kind of heart attack: the kind that patients experience (the bad kind) or the kind that is diagnosed by detecting less than a billionth of gram of a protein in the blood (the not-so-important kind). Add in all the hassle factors of being on another drug (filling scripts, blood tests, insurance forms) and the legitimate concerns about side effects, the use of relative change might now strike you as more than a little misleading.

Whatever the finding — harm or benefit — relative change exaggerates it.

Upon learning this, one of my students likened relative change to funhouse mirrors. If you are thin, there is a mirror that can make you look too thin; if you are heavy, there is mirror that can make you look too heavy.

In the case of relative change, it all happens in the same mirror. It provides a potent combo to promote medical care: exaggerated perceptions of risk and exaggerated perceptions of benefit. Can you imagine a more powerful marketing strategy?

Relative change is not the only culprit in misleading health information, but it is an important one. The good news is that more and more researchers, reporters and editors are on to this game. The bad news is that there is an awful lot of information to police and sometimes it can be hard to even find the real numbers.

That’s where a skeptical, numerate public comes in — one that knows to ask for the real numbers. And, if they can’t be found, one that knows to move on.

H. Gilbert Welch is a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice. He is the coauthor of Overdiagnosed: Making People Sick in the Pursuit of Health. This post originally appeared on The Huffington Post.