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Health Policy

Doctor Revolt Shakes Disability Program

An interesting article in The Wall Street Journal, for those of us in the disability assessment world. Briefly, earlier this year, senior managers at the Social Security Administration in Baltimore, frustrated by a growing backlog of applications for federal disability benefits, called meetings with 140 of the agency’s doctors. The message was blunt: The number of people seeking benefits had soared. Doctors had to work faster to move cases. Instead of earning $90 an hour, as they had previously, they would receive about $80 per case—a pay cut for many cases which can take 60 to 90 minutes to review—unless the doctors worked faster. Most notably, it no longer mattered if doctors strayed far from their areas of expertise when taking a case.

So  what happened? Some doctors quit following the changes. Others were fired. In all, 45 of the 140 left within months, the agency said. The upheaval, described by current and former doctors and agency officials, is the latest strain on a cash-strapped program struggling to deal with a giant influx of applications. Read more…

The Downside of Doctors Who Feel Your Pain

From an editorial in The New York Times: “Medicine, like education, business and fashion, is subject to fads. Hormone replacement therapy. Radical mastectomy. Bloodletting. The latest? Breeding nice doctors. It’s all the rage.”

The author notes that “proponents of weeding out students who lack interpersonal skills argue that communication errors are at the root of medical mistakes. But we have no data to suggest that medical students who sit close but not too close make any fewer mistakes than their less-communicative colleagues. The awkward student in the corner who obsessively follows a checklist may make fewer procedural mistakes than his charming friend who lights up the room.”

It’s a thought provoking read and a good reminder that medicine, as with everything else, has its trends but unlike other fads is subject to the rigors of scientific investigation. “In a culture that values novel technology above all else, undue emphasis on interpersonal skills may make it only more difficult for patients to discern good medicine from that which makes us feel most understood. ” Read more…

Understanding the Causes of Obesity

MCNtalk has frequently blogged on the national obesity epidemic and approaches to a cure. This pair of articles in The New York Times, “Attacking the Obesity Epidemic by First Figuring Out Its Cause” and “The Numbers Behind an Urgent Fight” offer, in different ways, important insights as to the causes of the situation—and why it must be addressed.

The first article, addressing cause, compares the epidemic to smoking and calls for a multi-level, long-term approach: “…the solution to the nation’s most pressing health problem—the ever-rising epidemic of overweight and obesity at all ages—lies in the answer to this question: Why did this happen in the first place? That is the conclusion of an impressive team of experts who spent the last two years examining obesity-promoting forces globally. They recently published their findings online in a series of reports in The Lancet.

But as has happened with smoking, it will take many years, a slew of different tactics and the political will to overcome powerful lobbying by culpable industries to turn the problem around and begin to bring the prevalence of overweight and obesity back to the levels of the 1970s.

And why is the comparison to smoking so apt for an obesity study? As “The Numbers Behind…” points out, if the trend that, since the 1970s, has led to striking increases in the proportion of Americans who are overweight or obese is not halted, about three of every four Americans will be overweight or obese by 2020.

  • The added treatment costs of obesity, already at $75 billion in 2003, could exceed $66 billion a year, with an even greater cost in lost productivity of up to $580 billion.
  • For every five-point rise in body mass index, men face a 52 percent increase in the risk of esophgeal cancer and a 24 percent increase in colon cancer. Women can expect a 59 percent rise in the risk of both endometrial and gallbladder cancer and a 12 percent rise in postmenopausal breast cancer. 

Food for thought? The cancer statistics alone should be enough to keep one’s mouth from closing on a double cheeseburger and fries.

The Cough That Launched a Hit Movie

And now for something a little different…a movie review. Or, rather, discussion of the new movie Contagion in The New York Times.

As the article notes, “You have to applaud the effort, for the movie does indeed offer a procession of dead-on accurate scenes that not only could happen but, in many cases, have already happened. Still, the whole thing is an improbable caricature, with 100 action-packed Hollywood minutes veering far from reality. You can still be very afraid if you want, if a contagious apocalypse happens to be your thing. But it’s not going to happen this way.” That may sound like good news, but on the other hand The Times piece does walk the reader through how events do play out in widespread contagions. Read more…

Scientists Retreat on Chronic-Fatigue Theory

Articles in the The Baltimore Sun and The Wall Street Journal are significant in a number of ways. With respect to the matter of an infectious cause of chronic fatigue, they would suggest that prior theories and findings in support of this may lack foundation. This would support other etiologies including psychogenic.

 On a broader note, the trail of study as summarized shows how science as a discipline works. Hypotheses are generated. Studies test the hypotheses and support or refute them. Studies are replicated and the process can be repeated in various permutations. Scientists are willing to be disproven and will let the data decide their positions.

Science, while imperfect, is a process and system of inquiry and openness to let the outcomes speak for themselves.  

There are many people who believe they suffer from chronic fatigue. See http://www.cfids.org/. At this site one finds great interest in the research (http://www.research1st.com/2011/09/13/the-x-factor/).One can’t question the suffering of those in pain. It should be interesting to observe how changing scientific views impact individuals’ views and interpretation of the meaning and origins of their  pain.

The Right Way to Help Veterans(?)

This article in The Seattle Times, “Seattle, King County to Set up Special Veterans Courts,” caught our eye as an interesting follow-up to an MCNtalk posting a few weeks ago, “The Wrong Way to Help Veterans.” 

The New York Times op ed piece which inspired our first posting on the subject of veterans and the mental health system noted that “as many as 20 percent of them will suffer from post-traumatic stress disorder, anxiety or depression, while suicide rates have reached tragic new highs among veterans.”

The Seattle  Times article notes that Seattle will open a special court Sept. 20 for military veterans charged with nonviolent crimes, and King County may not be far behind. Veterans Court, part of Seattle Municipal Court, is intended to give some vets charged with misdemeanor offenses a chance to obtain substance-abuse and mental-health treatment while still being held accountable for their actions, according to court officials.

“Providing a specialized court experience for veterans is a logical extension of the services already available in Mental Health Court and Community Court,” City Attorney Pete Holmes said in a news release. “My office is dedicated to ensuring that veterans will be held accountable for misdemeanor crimes, but in the supportive environment they deserve.”

Veterans courts, the latest kind of therapeutic specialty court, have sprung up in 80 jurisdictions since the concept was pioneered by Buffalo, N.Y., in 2008. Four Washington counties — Clark, Pierce, Spokane and Thurston — have such courts.

The comments posted on-line about The Seattle Times article are decidedly mixed, ranging from those who are opposed to separate treatment for veterans to those objecting to soldiers serving multiple tours of duty to those who believe that this type of court is a step in the right direction in addressing the problem. And then there’s the practical view: “Now that’s something which is long over due, is needed and will keep down incarceration costs and other costs of care.”

Read more…

Cuts in Health Care May Undermine Role in Labor Market

Per this New York Times article, “even during months of stubborn unemployment, the health care industry has provided a solid underpinning, reliably adding jobs in an otherwise dismal environment.”

Is this good news? Generally “reliably adding jobs” sounds nice. But the article concludes by quoting Joshua Shapiro, chief United States economist at MFR, Inc. (Global Economic Consultants): “If spending on health care continues at its current pace, it will choke out other vital sectors and end up hurting the rest of the economy. I think the path that we’re on now is clearly unsustainable.”  

One of the justifications for the high cost of health care as a component of GDP in the US is that it creates jobs. On a macroeconomic level, this may be the case, but at what cost. And what will the outcome be if and when costs moderate due to political or budgetary mandates. How many hospitals are built on the funds provided by Medicare and what power does this spending yield? A recent posting  on MCNTalk focused on tremendous discounting and write-off from list price of a Medicare bill. Presumably this example precedes additional pending Medicare cuts under consideration.

Not discussed in the article is the impact of cost shifting  to the private sector, including most significantly the private group health insurance market, as well as other systems including workers’ compensation, accident related care and other areas that are not under Federal pricing guidelines. If cost shifting is inevitable and significant, as we predict it will be, rational employers and payers will continue to decrease their contributions to their employees’ healthcare, leading to a higher likelihood of a national health payment scheme, as many are hoping for but significant constituencies have to date defeated.

Read more…

Who’s really to blame for child obesity?

From time to time MCNtalk has touched on the subject of childhood obesity. Per this article in The Philadelphia Inquirer,  the subject is meriting serious attention, with dramatic solutions being discussed.

Should morbidly obese children be taken from their parents and put into foster care? This was the question discussed in a commentary piece last month by obesity expert David S. Ludwig of Children’s Hospital Boston and lawyer Lindsey Murtagh of the Harvard School of Public Health. They explored this solution at a time when the rates of obesity in U.S. children over the last 30 years have tripled.

“In severe instances of childhood obesity, removal from the home may be justifiable from a legal standpoint because of imminent health risks and parents’ chronic failure to address medical problems,” wrote Murtagh and Ludwig.

But, they added, “the decision to pursue this option must be guided by carefully defined criteria . . . with less-intrusive methods used whenever possible,” and the two are quick to point out that “morbid obesity” is the key point: Imminent risk – where children are really in lethal situations – is the only reason children can be removed from parental custody.

Bill Lawhorn, a supervisor of Court Appointed Special Advocates in Philadelphia, says that, in more than 30 years with the child-welfare system, he has never seen a case of removal based solely on obesity and that to do so would be a logistical challenge.

“Child welfare is hard-pressed to respond to adjudicate matters of abuse and neglect, let alone dietary concerns and lifestyle, or following through on healthy choices,” Lawhorn said.

Reporting laws in a handful of states, including Pennsylvania, could possibly make removals happen, though. Such laws require that doctors contact child services if they think chronic parental neglect has resulted in morbidly obese complications – like failing to comply with doctors’ orders for weight-related diabetes and sleep apnea.

But placing blame solely on parents would be shortsighted, according to Daniel Taylor, a pediatrician at St. Christopher’s Hospital for Children in Philadelphia and the founder of the Children’s Advocacy Project, known as Cap4Kids. Decades of societal neglect are actually to blame for our obesogenic generation, he said, citing the areas of food-industry regulation, investments in safe outdoor play, and portion-control regulation as elements that have been ignored.

Clearly the root causes need to be found and addressed; lifespans in the United States are seriously lagging behind rates in other developed nations, with obesity being one of the main culprits for the gap. Obesity and its complications are a major social, emotional, and economic drain on Americans. Perhaps removing children from their homes is not the actual solution, but it does frame the discussion in drastic terms: which is probably how it should be framed.

Guarding Privacy / Protecting Patients

At MCNtalk we thought this posting in the New York Times “Views,” Guarding Privacy May Not Always Protect Patients, was an interesting read.

“Juggling parental concernwith an adolescent patient’s legal and ethical right to privacy,” the author, Dr. Perri Klaas notes,  “opens up some tricky questions.”

The law varies state by state, but many, including New York, allow minors to consent by themselves to medical care involving such sensitive needs as contraception, pregnancy, sexually transmitted diseases, and mental health.

Clinics for adolescents are keenly conscious that the promise of confidential care is essential to gain and hold their young patients’ trust. But in those same clinics, doctors often try to convince teenagers to bring parents into the conversation. Read more…

Companies Get Tougher with Employees Who Smoke

Smoking costs the U. S. more than $193 billion a year according to the Centers for Disease Control and Prevention, per this Bloomberg Businessweek article.  For employers, a smoker is 18 percent more expensive than a nonsmoker, says Cathy Tripp, a consultant at Aon Hewitt.

That cost gap likely will widen beginning in 2018 when, under a provision of health reform legislation passed last year, companies with health plans that spend way more than average will have to pay an additional federal tax. That may push some to reduce employee coverage. “Employers have two choices: cut benefits or cut the trend” of rising medical costs to avoid the levy, Tripp says. “It has made all of them a lot bossier when it comes to employee lifestyle choices.”

Health-care companies have been among the most active at tackling smoking. The Cleveland Clinic banned the use of tobacco in 2005 and stopped hiring smokers two years later. Job candidates, including doctors, must have their blood tested for nicotine. Says Toby Cosgrove, chief executive officer of the clinic network: “If we want to be a model of health care, then we as an organization need to show our patients what a healthy lifestyle means.” Read more…