An analysis by The New York Times found that in the first full year of the Affordable Health Care Act there were historic increases in coverage for low-wage workers and those in other demographics previously less represented in the health care system. The article from The New York Times illustrates the findings with a series of charts and graphics showing the scope of changes. As noted, the expanded coverage has had a significant impact for many Americans. Read more…
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Health Policy
The Link Between Life Expectancy and Geography for the Poor
by Jen Jenkins
Geography matters for the poor when it comes to life expectancy rates in the United States. While the rich live longer regardless of where they live, in some parts of the country, adults with the lowest incomes have lifespans that match that of people in much poorer nations around the world. However, in some large cities like New York and Los Angeles, as well as a few smaller cities, the poor are living as long as the middle-class and are seeing rising life expectancy. New research shows that improving habits and public health can help people live longer regardless of income. This New York Times article discusses the new research published this month in The Journal of the American Medical Association.
According to Stanford economist Raj Chetty, who is the above-mentioned study’s lead author, “You want to think about this problem at a more local level than you might have before. You don’t want to just think about why things are going badly for the poor in America. You want to think specifically about why they’re going poorly in Tulsa and Detroit.” Adopting local policies to help the poor maintain healthier habits may succeed in extending lifespans despite what the future may bring as far as income inequality. The New York Times article states:
It could be as simple as this: Wealth buys higher-quality medical care, which allows people to live into old age. But a long line of evidence, including the new work, suggests it’s less obvious than it might seem. The affluent seem to live in healthier ways. They exercise more, smoke less, feel less stress and are less likely to be obese.
Quality medical care is important and carries a high value but research has long established that behavioral factors, such as smoking or exercising, have a larger effect on life span than health care interventions.
It is important to know that poor Americans are living longer in some places in the country but it’s even more important to understand how these places are making that possible. For example, in Jefferson county, Alabama, the chief executive of the health department, Mark E. Wilson, believes that the following measures have helped to raise the lifespan in that area: expanding availability of preventative health care, allocating local taxes to hospital care for those that cannot afford to pay, banning smoking in restaurants and workplaces, and establishing philanthropic foundations to fund campaigns to make people in the area healthier. “These aren’t all huge-scale projects, but there is still an alignment of getting resources moving in the same direction around health,” Dr. Wilson said. “We’re trying to establish a culture of health and get it more and more on the radar screen of our community.”
Establishing a “culture of health” in our communities to help make people healthier regardless of income – could this be a factor that helps to positively effect the radical gap in longevity between income levels in this country?
Please share your thoughts with us in the comments section!
Finding Relief with Mind-Based Therapies
By Jen Jenkins
According to national health figures, one in four adults in the United States has experienced back pain within the past month. Back pain is the second most common cause of disability for American adults and is a leading cause of disability worldwide. Sufferers have tried it all, from painkillers and shots to physical therapy. In our previous post on MCNTalk we discussed chronic pain in the United States and the growing concerns surrounding opioid painkillers, their addictive nature, and the rise in opioid-related deaths. Amid this evolving crisis, a new study is now reporting that many people may find relief with a form of meditation called mindfulness-based stress reduction. This technique harnesses the power of the mind to help manage pain and involves a combination of meditation, body awareness and yoga.
“This new study is exciting, because here’s a technique that doesn’t involve taking any pharmaceutical agents, and doesn’t involve the side effects of pharmaceutical agents.”
– Dr. Madhav Goyal
Dr. Madhav Goyal of Johns Hopkins University School of Medicine co-wrote an editorial accompanying the paper published on the study of mindfulness-based stress reduction. Participants in the study were assigned to meditation or cognitive behavior therapy and they received eight weekly two-hour sessions of group training in the techniques. Six months later, those learning meditation had an easier time with activities such as getting up out of a chair, climbing stairs, or putting on socks; a year later, they were still doing better and expressed meaningful improvement. The sheer size of this study is considered one of its strengths – it included 342 participants ranging from age 20 to age 70. However, Dr. Goyal does warn, “It may not be for everybody.” Some people with back pain might find yoga and certain movements too painful, but Dr. Goyal thinks that this technique is very empowering for people who want to do something using their own mind to help their pain.
Mindfulness-based stress reduction was developed in the 1970s by scientist Jon Kabat-Zinn, who used Buddhist meditation practices as a template for his technique. Dr. Cherkin explained that the goal is for pain sufferers to increase their awareness of their experience through meditation. They are meant to understand how their pain is affecting them and more importantly, how they respond to it. The idea is for participants “to change their mindset and, in a way, almost befriend the pain, and not feel it’s oppressing them.”
It is important to be able to offer a lot of options for chronic pain because while some treatments may help some people, they may not work well for others. Dr. Cherkin believes that mindfulness-based stress reduction is helpful because even if someone does not use it all the time, it is a skill they will never forget and it is something that can be used anywhere. Currently, the downsides for those who are interested in mindfulness-based stress reduction revolve around getting access to is, which is problematic without certified instructor training available everywhere; and, as an alternative remedy, receiving instruction in it may not be covered by health insurance.
View this New York Times article on mind-based therapy and back pain. Also, please share your comments with us!
Limiting Opioids for Patients with Chronic Pain
By Jen Jenkins
Pain is one of the main reasons people go see their doctor. Although it was once overlooked or often dismissed, it is now a standard vital sign in a patient’s work-up. However, unlike other tests administered in a medical setting, pain is difficult to measure because among other factors, pain tolerance is highly individual. The United States has had a long and complex history with chronic pain management. In the 1990s, doctors were reproached for under-treating pain and were told that opioids, including OxyContin, could not only bring unmitigated relief to patients but do so in a safe way. Today, doctors are again being admonished but for a very different reason. Politicians and policy makers continue to publicly denounce what has been labeled as the “opioid crisis,” due in part to doctors over-prescribing medication, namely opioids.
A growing number of states are enacting measures to limit prescription opioids and the federal government has issued the first national guidelines to help reduce the use of these highly addictive medicines. Dr. Robert L. Wergin, chairman of the board of the American Academy of Family Physicians, said he doesn’t want to stop prescribing opioids altogether but that he can see why some doctors have gotten to that point. Dr. Wergin has taken professional and personal risks in prescribing opioids. Closely monitored by state and federal officials, he must go through an elaborate prescription checklist. He has also been threatened by addicts, desperate for pills. His patients now sign “pain management contracts” and must agree to random drug tests before receiving an opioid prescription. “You don’t want to become so jaded that you assume everyone in the E.R. is a drug-seeker,” Dr. Wergin said, but he has seen firsthand a growing number of overdoses and opioid-related deaths during his emergency room shifts.
Collectively, primary care physicians write the greatest volume of opioid prescriptions and these same doctors are now scrambling to find alternatives for their patients dealing with chronic pain. Prosecutors and medical review boards closely scrutinize physicians who prescribe controlled substances. Many medical associations now offer doctors training about chronic pain, urging the use of other remedies such as physical therapy, acupuncture, anti-inflammatories, antidepressants, or counseling before prescribing opioids. Unfortunately, alternatives are unrealistic for some patients for a variety of reasons: physical therapy may be too expensive; anti-inflammatories cannot be taken by those with a compromised liver.
Some state medical boards have recommended limiting the number of opioid doses per month while others have recommended limiting the strength of daily dose. Dr. Wergin is careful not to promise patients a prognosis of being “pain-free” and chooses instead to talk with them about setting realistic goals to manage their pain. Although opioids help to alleviate severe pain, they are highly addictive. The epidemic of overdoses and death is real and the responsibility of monitoring patients for potential abuse falls largely on prescribing doctors.
Take a moment to read the following New York Times article and learn more about Dr. Wergin and what he is doing for his patients.
The Upward Trend in Health Care Advertising
by Jen Jenkins
Around a decade ago health care advertising was not something likely to turn up on prime-time television or in elite magazines. Generally, hospitals and doctors considered the advertising of health care tacky and questionable from an ethical standpoint. Nowadays, however, this type of advertising is targeting patients with either good insurance or those who are able to afford the priciest drugs out-of-pocket. Patients are no longer seen as simply patients to hospitals and clinics, but rather as a customer base to which it is necessary to market what they are selling: drugs.
In 2014, the health care industry spent $14 billion on advertising, jumping 20 percent since 2011. In this same time frame, although magazine advertising saw a decline along with the publishing industry, television advertising rose 55 percent for hospitals and 30 percent for prescription drugs. Drug companies once focused on promoting products that could be prescribed to millions of people, such as pain killers. Now, the focus is on niche medicines that are much more expensive and prescribed to far fewer people.
According to Holly Campbell, a spokeswoman for the pharmaceutical manufacturers trade association, PhRMA, drug makers are “designing their advertising to provide scientifically accurate information to help patients better understand their health care and treatment options” and ultimately to help patients make better decisions. However, health economists and doctors alike are raising concerns about the advertising trend which they say increases prices and influences patients to seek out treatment that may be inappropriate or too expensive. Last year, the American Medical Association recommended a ban on this type of advertising due to concern over “the negative impact of commercially driven promotions.” The United States and New Zealand are the only countries that even allow drugs to be advertised to consumers in this way.
Research is showing that rather than helping consumers make better or more informed choices, advertising instead tends to drive patients to patented drugs and more expensive treatments. This New York Times article provides more information on this research and extensively compares different drugs that are heavily promoted along with their pricing. Federal regulations do not require advertisements to say how much medicines cost, how well they work or if there is a cheaper option available. Overall, that means that patients are not getting nearly as much beneficial information from these advertisements as they think. In fact, doctors say that most patients come in asking for medicines and treatments that are far more expensive than alternatives or that are not necessary in the first place.
Share with us what you think of this trend in advertising, we love to hear from you.
A Growing Gap in Life Spans of the Rich and Poor
by Jen Jenkins
A disturbing new pattern is emerging from a growing body of data. Although experts have long been aware that people of affluence live longer people than people who are poor, this recent New York Times article delves into the widening longevity gap between high-income and low-income Americans. In their newest research, economists at the Brookings Institution found when looking at the top ten percent of earners and the bottom ten percent for men born in 1920 there was a six-year difference in life expectancy; for men born in 1950 that difference skyrocketed to fourteen years. The causes for this growing chasm are still under investigation but one explanation may be the significant declines in smoking among the educated and affluent populations. Although it is hard to point to any one cause, smoking is known to be the single biggest cause of preventable death and has definitely played a role in the widening gap. The article goes on to discuss other possible factors and the potential weight they may or may not carry. These include obesity, the prescription drug epidemic, and limited access to health care.
Elizabeth H. Bradley, a professor of public health at Yale, believes that economic and social inequities are at the heart of this disparity, which is something that high-tech medicine cannot fix. Last summer, after convening a panel of experts to study the implications of the growing longevity gap, the National Academy of Sciences concluded that disparate life expectancies are making programs such as Social Security and Medicare unfair to the poor. More information on what this means for the promise of Social Security can be found in this research report published by the Brookings Institution.
The New York Times article wraps up with a quote from Christopher J.L. Murray, director of the Institute for Health Metrics and Evaluation in Seattle.
“There are large swaths of the population that are not enjoying the pretty impressive gains the rest of us are having in life spans. Not everybody is sharing in the same prosperity and progress.”
Policy makers are now expressing concern over shortening life spans for some Americans, especially since the United States has slipped down to some of the lowest rankings of life expectancy among rich countries.
We are interested in your thoughts on this subject – please share with us in the comments section.
Deductibles: A Significant Component of Health Insurance
Until recently, health insurance deductibles have proven to be quite a catch 22. On one hand, Americans would rather not have to pay a deductible or co-payment before receiving healthcare; however, it’s simultaneously impossible to ignore that deductibles have helped to make health insurance more affordable and, for some Americans, possible to have at all. Bernie Sanders recently released his proposed health care plan featuring the promise that no American would have to pay a deductible again. Although light on the details, this part of the plan would mean removing something that has been working its way into the health care market since the early 1990s. Deductibles can be significant for some when an average out-of-pocket cost of around $1000 required before coverage kicks in. This is something that has been tolerated due to the standing argument that it makes health care more affordable overall. But is this actually the case? The truth behind the purpose of deductibles is something we do not often get to see up front. The fact that most Americans can’t afford steep deductibles has been one reason to reassess the system but the main question now appears to be: Are deductibles actually helping with health care spending, or deterring it?
In this article featured in the New York Times, Michael Chernew, a professor of health policy at Harvard, stated “If you make something free, people will spend a lot on it.” Recent research is now supporting this idea as studies have shown that more required out-of-pocket costs may be responsible for a downturn in health care spending altogether. Researchers are now beginning to agree that high deductible plans are not what they have been thought to be in the past. Multiple randomized experiments are showing that over time, people who pay more health care bills out of their own paychecks choose to use less health care, while people who have everything covered by insurance tend to utilize healthcare more because they have insurance available. Another important factor is that in comparing these two groups of people, those who were choosing to receive less health care were no less healthy than those taking advantage of using more. What could this mean about the future of health care deductibles? No one is sure at this point. According to some health economists, including Michael Chernew, it may require “smarter” albeit more complicated forms of health insurance. These plans would utilize economic incentives to reduce unnecessary health care spending without deterring necessary care for patients.
We are interested to hear what you think about the possible new direction of health care and the role that deductibles and co-pays have. If you have a moment to read the more in depth New York Times article on this subject please leave us your thoughts in the comment section.
The Shkreli Problem
by Jen Jenkins
Martin Shkreli dominated headlines last year as the villain of the pharmaceutical industry. We blogged on MCNTalk about the drug Daraprim, which his company, Turing Pharmaceuticals, purchased, subsequently raising the price per pill from $13.50 to $750. The Internet immediately labeled him the “Most Hated Man in America,” but despite all the criticism, Mr. Shkreli forged ahead and even defended his actions by saying, “I could have raised it higher and made more profits for our shareholders. Which is my primary duty. Again, no one wants to say it. No one’s proud of it. But this is a capitalist society, capitalist system and capitalist rules. My investors expect me to maximize profits.” Comments such as these are a very small glimpse into the reason why big pharma’s problem with price hikes can be called “the Shkreli problem.”
It has become commonplace for drug companies to raise the prices of old drugs by any percentage that they please. Although the percentage of these price bumps may not be as exaggerated as what Shkreli did with Daraprim, it still raises the question: why should they be able to raise prices of old drugs with no justification? This Forbes article shares some of Martin Shkreli’s background and discusses how he went from simply talking about inventing new drugs to dramatically raising the prices of existing ones, as well as some of his other disreputable deeds in between. One of the biggest differences between Shkreli’s acts and those of other pharmaceutical companies is the publicity. Everyone else avoids the press when exercising price hikes while Shkreli unabashedly promotes and defends what he is doing. Respectable drug companies have, for the most part, distanced themselves from this ludicrous display of behavior. Although they essentially all follow the same practices, they want it to be clear that their reasoning surely does not align with that of Shkreli.
The fact is, 80% of drugs in the United States are generic, thus our current system highly encourages drug companies to either focus on making money off of drugs that serve a smaller population of people or raise the prices on existing drugs. Another problematic side effect of this is that new drugs, research, and innovation are falling by the wayside. Martin Shkreli’s behavior is an exaggerated, albeit disturbing outlook on big pharma and decisions that are being made largely out of the public eye.
The Vaccine War
by Angela Sams
Many of us likely saw or at least heard about the picture that Mark Zuckerberg, co-founder of Facebook, posted on the social media site recently. Though perhaps it appeared innocent on the surface, the photo of his two-month-old daughter getting vaccinated surely ruffled some feathers amongst the anti-vaccination community. A recent Time article discusses the fact that this isn’t the first public statement that Zuckerberg has made regarding vaccinations. He recently used Facebook to publicize a book called On Immunity, by Eula Bliss. “The science is completely clear: vaccinations work and are important for the health of everyone in our community,” he wrote.
Despite the fact that links between vaccines and autism have been discredited, there are still many who believe that vaccines are harmful. But what about the harm caused by unvaccinated individuals who are spreading diseases that were once a thing of the past? Indeed, if Zuckerberg wanted to, he could shut down the Facebook pages of the “antivaxxers.” This does not violate any First Amendment rights, due to the fact that Facebook is a private company.
Another article on the Time website discusses the dangers of “tolerating” those who refuse to vaccinate their children. Recently, at a school in Melbourne, Australia, approximately a quarter of the school’s student body contracted chicken pox. Only 73.2 % of the students had been vaccinated. Apparently, the school does not require students to receive vaccinations, and instead wrote that “staff respects the right of every family to make choices about immunisation,” in a school newsletter back in May.
While tolerance is often a good thing, even called “the social and intellectual flexibility that allows a society to function at all,” at what cost does it come? Will our society eventually see a dangerous return of diseases that until recently have been kept at bay due to vaccines? The line has to be drawn somewhere, especially when the beliefs of certain individuals (despite the scientific facts) negatively impact those around them.
Skin in the Game – Hospitalists Resisting Outsourcing
by Jen Jenkins
There was a time not long ago, circa the mid-1990s, when the term “hospitalist” did not exist. Doctors worked in hospitals only periodically, attending to their patients when necessary. It wasn’t until economic pressures and a push for efficiency in healthcare created “the hospitalist boom” that we started seeing doctors working in hospitals full-time. It became clear that having doctors based at every hospital was significantly better for both efficiency and for hospital profits. According to this article in the New York Times, the discipline grew rapidly from 2003-2011, jumping from 11,000 hospitalists nationwide to 50,000 respectively. Doctors began enjoying the additional time they were now afforded to spend with their patients and for a time hospitals were so happy with the advantages in efficiency that it all seemed too good to be true. And sure enough, the initial advantages began to wear off. A huge consequence of the constantly changing healthcare market is the necessity for more and more efficiency. In yet another shift, doctors began having their quality time with patients limited due to a push for a focus on metrics, documentation, and hospital management.
Dr. Rajeev Alexander is a hospitalist at PeaceHealth Sacred Heart Medical Center in Springfield, OR. In his practice, Dr. Alexander believes in taking the time to go through every minute detail with his patients and he dislikes the style of medicine so carelessly flaunted in pop culture television. “Real life is all about the narrative,” he said. “It’s sitting down and talking about bowel movements with a 79-year-old woman for 45 minutes. It’s not that interesting, but that’s where it happens.” His method of treating patients happened to be negatively juxtaposed against the new direction his hospital wanted to take. In 2014, Sacred Heart announced that they planned on requesting bids to outsource their hospitalists to a management company. Outsourcing has recently become more popular across the country as hospitals realize it may be an excellent way for them to measure quality without being responsible for the complicated data collection that is involved. Working in our modern hospitals means being preoccupied with money constantly; this new shift was targeting that bottom line.
Here, the overarching problem for Dr. Alexander’s group is that hospitalists are not a “profit center” for hospitals. Dr. Alexander and his colleagues at Sacred Heart were outraged by the very idea of outsourcing, convinced that this would mean seeing many more patients per shift in the interest of profits. They did not want to lose their jobs by resisting this change but they also knew that it would be the patients that were significantly affected. Then, the idea of unionizing was brought up. It is rare, but there are hospitals around the country whose doctors are unionized, although no union is composed of a single group of specialists. Feeling increasingly bitter after seeing no better options, the group shed their doubts and held a union election. The decision to form a union was voted in overwhelmingly. They had won a battle but not the war. Although the industry has seen a retreat in outsourcing for the time being, that does not mean that hospitals aren’t still keen on getting more out of their doctors. Just how they do so, we shall continue to see.
