Health Business Blog

From the Independent newspaper (Mobile phones ‘more dangerous than smoking’)

Mobile phones could kill far more people than smoking or asbestos, a study by an award-winning cancer expert has concluded. He says people should avoid using them wherever possible and that governments and the mobile phone industry must take “immediate steps” to reduce exposure to their radiation.

The study, by Dr Vini Khurana, is the most devastating indictment yet published of the health risks.

It draws on growing evidence “exclusively reported in the IoS in October“ that using handsets for 10 years or more can double the risk of brain cancer. Cancers take at least a decade to develop, invalidating official safety assurances based on earlier studies which included few, if any, people who had used the phones for that long.

Most others disagree. I don’t know enough to say who is right. He took the unusual step of releasing his work while it is being peer-reviewed.

He has put the results on a brain surgery website, and a paper based on the research is currently being peer-reviewed for publication in a scientific journal.

He fears that “unless the industry and governments take immediate and decisive steps”, the incidence of malignant brain tumours and associated death rate will be observed to rise globally within a decade from now, by which time it may be far too late to intervene medically.

This makes it sound like the incidence has not actually risen.

Late last week, the Mobile Operators Association dismissed Khurana’s study as “a selective discussion of scientific literature by one individual”. It believes he “does not present a balanced analysis” of the published science, and “reaches opposite conclusions to the WHO and more than 30 other independent expert scientific reviews”.

Khurana also contends that “exposure to asbestos is responsible for as many deaths in Britain as road accidents”, which seems surprising.

Thanks to Mickey.

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The big news today is that Hillary Clinton wants universal coverage that will cap health insurance premiums at 5 to 10 percent of a family’s income, regardless of income. Considering that health care represents 16 percent of the GDP (i.e., income) and rising that number doesn’t seem too realistic. From the transcript:

Q: You’ve also said you would cap premiums. But you haven’t said where you would cap them.

MRS. CLINTON: You know, I think we could do it somewhere between five and 10 percent of income.

The median household income in the US is about $50,000 per year. I can tell you that $2500 to $5000 won’t buy much in the way of health insurance for a family.

Of course I’m describing matters in an overly simplistic way. Medicare is where the big money is spent. But of course even low wage earners who lack health insurance already pay into that system through FICA deductions, not to mention the spending that comes out of general taxation revenues.

Health care in the US is expensive. Mandating caps on premium costs won’t solve that problem.

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Lehman Brothers, a big investment bank, may have been swindled out of $250 million, which was supposed to be used to buy medical equipment. From the Wall Street Journal:

Late last year, a unit of the New York-based investment bank issued loans to a fund run by a medical consulting company owned by LTT Bio-Pharma Co., a Japanese biotechnology company based in Tokyo. The funds, which were to be used to help provide trade financing for hospitals buying medical equipment, were secured with certificates from Marubeni Corp., one of Japan’s biggest trading firms.

Lehman grew concerned at the end of February when its funds were not repaid…The LTT Bio-Pharma subsidiary filed for bankruptcy protection on March 19.

Lehman officials acknowledged that the firm has filed a criminal complaint with Japanese police about the situation. A spokesman says the firm believes Marubeni is responsible for repaying Lehman, which is studying how it might proceed.

Oops!

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Benjamin Brewer, a family physician who writes for the Wall Street Journal, points out that the supply of primary care physicians is not up to the task of handling a surge of new patients unleashed by proposals for universal health care. (See Primary Health Care Needs Fixing Before Universal Care Can Work.) In fact, primary care can’t even handle the load it’s under today, and things will get worse anyway as the population ages and the number of primary care docs fails to keep up.

Being a primary care doctor isn’t that enticing. Reimbursement is pretty low, hours can be long, autonomy is limited, and primary care physicians aren’t always well respected by specialists. Some primary care docs are responding by becoming hospitalists, opening concierge practices, or (especially the women) working part time. All of those things squeeze the supply of primary care even further. I’ll resist the urge to repeat my pro-immigration tirade, but let’s face it, primary care physician has become a classic immigrant position: a low-paid, unattractive job that Americans won’t fill.

One of the big pushes in health care right now is to rate the quality of physicians and to get them to be transparent about cost and quality. In theory that could help patients choose the best physician to take care of them. In practice, the only information that’s really relevant to a patient looking for a primary care physician is whether the doc is accepting new patients! It’s hard enough, at least in Boston, to find one who is.

I don’t have any great solutions to this problem. The medical home concept seems worthy enough, and it looks like it will be adopted at least on some scale. I don’t know whether it will make a huge difference. The use of “physician extenders,” i.e., Nurse Practitioners and Physician Assistants holds some promise although personally I’d rather see my doctor. Improving physician office workflow with techniques such as open access scheduling and clinical messaging can help, too, in some cases dramatically. Electronic health records probably won’t help capacity much if at all. There’s a real danger that even a well-implemented EHR will slow things down in a practice by putting more work on the physician.

My primary care doc is nearing retirement. I guess I better start looking around for his replacement.

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From MSNBC (Pronounced dead, man takes “miraculous” turn; Doctors can’t explain why 21-year-old Zack Dunlap recovered from accident)

…36 hours after the accident, doctors performed a PET scan of his brain and informed his parents, along with other family members who had gathered to keep vigil at the hospital, that there was no blood flowing to Zack’s brain; he was brain-dead…

Some four hours after doctors declared Zack dead, a nurse began to remove tubes from Dunlap. His cousins, Dan and Christy Coffin, both of whom are nurses, were also in the room. Something about Zack’s appearance made them think that he wasn’t as dead as the doctors said. On a hunch, Dan pulled out his bone-handled pocket knife and ran the blade up the sole of one of Zack’s feet.

The foot yanked away, but the other nurse said it was a reflex action. So Dan Coffin then dug a fingernail under one of Zack’s nails. Zack yanked his arm away and across his body, and that, the other nurse agreed, wasn’t a reflex action. It was a sign of life.

The problem with the story is that the cousins seem to have done a better job at applying the American Academy of Neurology’s brain death criteria than did the doctors.

If the result of this case is to doubt determinations of brain death that did not meet the AAN criteria, that is a good outcome. If the result is to doubt determinations of brain death that did meet the AAN criteria, that is a bad outcome.

Like I say, bring your own doctor to the hospital if you can, or at least a nurse.

Thanks to Mickey.

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Check out the Cavalcade of Risk blog carnival at InsuranceYak.

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In the relatively good old days of air travel in the mid-90s, one of the pleasures of flying the shuttle between Boston and New York or Washington was the free newspapers and magazines that included titles like the Economist, New York Review of Books, and others that one might willingly pay for. A real gem that I discovered at the time was the Columbia Journalism Review (CJR), which did an excellent job –in those days before blogs– of analyzing how stories were covered in the press. The glory days of the shuttle have long past, so I haven’t read the CJR in a while.

Luckily the magazine started sending me health care stories and they’re quite good. Two recent ones by Trudy Lieberman critique media coverage of health care in the presidential election. In The Missing Genre, Lieberman is surprised that journalists have stuck to making dry comparisons of the candidates’ wonkish proposals without delving into the implications for everyday people.

[T]here have been plenty of stories like the one The Plain Dealer of Cleveland published before the Ohio primary that gave thumbnail sketches of [the] plans. Such stories employ all the buzz words: ”penalties, tax credits, incentives, affordable insurance. But stories about people like Charles and Kevisha [poor, urban African Americans with health problems and poor access to health care] have largely been missing, at least in the context of what the proposals would mean for them.

That’s curious. During the two years that Bill Clinton’s health plan was debated and dissected, people stories populated the news columns, and ordinary Americans could get some idea how they would fare under his proposal. This time, though, reporting has pretty much followed the candidates’ script. Reporters have been stenographers, diligently punching out the words candidates say rather analyzing how those words will affect and even transform people’s lives.

Lieberman also takes McCain to task (McCain’s Health-Care Disconnect) for bragging about the US system being the best in the world and for having unrealistic proposals.

Said McCain to his supporters: “I will campaign to make health care more accessible to more Americans with reforms that will bring down costs in the health care industry without ruining the quality of the world’s best medical care.” Politicians have used such language before in an effort to persuade the public that the system is not broken, and that a fix will damage it. This time, though, voters may well tune out that song. The system’s warts have grown larger.

Too many Americans are uninsured and have ended up in bankruptcy court or are nearly bankrupt because they cannot pay hundreds of thousand of dollars in medical bills. Even those with insurance can end up in bankruptcy, because health coverage no longer necessarily protects against the high cost of illness. A landmark study by Elizabeth Warren, a Harvard law professor, shows that high deductibles, copayments, exclusions, and other loopholes result in bills that many middle-class people cannot pay.

I’m not quite as surprised as Lieberman by the wonkish stories. The reason, I think, is that none of the presidential candidates has a plan that will resolve the Charles and Kevisha stories. It’s not really possible to square the circle of cost, quality and access, and despite the seeming boldness of Clinton’s plan in particular it really isn’t going to make a fundamental change for those at the bottom. If I were Lieberman I would level my criticism at the fact that Medicare is hardly discussed by the candidates or the press, even though growth in that program is the gravest economic threat faced by the US over the next generation, and if we’re to have reform of the health care system overall we will need to tackle Medicare head on.

As for McCain, while he’s certainly pandering to conservatives with talk about the US system being the best, he probably believes it himself. He’s admitted he doesn’t understand economics, so why would we expect him to grasp health care policy, which requires a grasp of economics and a whole lot more? At least McCain has spoken up about costs being an issue, in a way that almost none of the other candidates has. He hasn’t even relied on the old conservative favorite of “waste, fraud, and abuse” as a solution to cost problems.

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Immigrants are key to the US economy, especially in health care. A study of the health care workforce in Massachusetts documents the large percentage of slots filled by foreign-born professionals. Not just doctors, but pharmacists, nurses, home care workers, medical technicians and so on. See Immigrants make mark in health care work force in the Boston Globe.

According to the study, the percentage of foreign-born pharmacists doubled from 20 percent in 2000 to 40 percent in 2005. Physician assistants rose from 11 percent to 28 percent and paramedics increased from 4 percent to 14 percent.

Other occupations with significant numbers of immigrants included foreign-born physicians and surgeons, who were 28 percent of their field in 2005, opticians (22 percent), licensed practical and vocational nurses (21 percent) and dentists (17 percent).

I haven’t seen the methodology for the study (by profs from U Mass, Tufts, and UC Berkeley) and have a feeling that some of the numbers could be a little shaky. It hardly matters, though, to the overall message, which is that immigrants are fundamental. Squeeze off immigration and we’ll be in even more serious trouble than we already are.

Quite a bit of the anti-immigration fervor has focused on how immigrants (legal and illegal) put a strain on the health care system. While I’m sympathetic to the specific communities where this occurs, it’s worth noting that when it comes to health care overall, immigrants provide a lot more than they receive. (That’s something that’s been documented.) Those who want to keep immigrants out should be prepared to wait longer to see a doctor and lose the chance to consult with their pharmacist.

Ironically, the only real beneficiaries of anti-immigration policies for health care workers are the home countries of those workers who would would otherwise be in the US.

We need to make the US more hospitable to health care immigrants rather than less.

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Check out the latest edition of Grand Rounds at Monash Medical Student.

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When Wal-Mart introduced $4 generics, most analysts played down the impact. After all it only affected certain products and wouldn’t matter to people with insurance. I’m happy to say that since the time of the announcement I’ve noted the potential implications (Can Wal-Mart save the American health care system?):

Wal-Mart seems to have a strategy that could fundamentally shift the market: it’s making routine items cheap enough that insurance for them isn’t even worth the hassle. Today’s announcement of $4 generics is an important step in that direction. It makes the cash price lower than the typical co-pay.

Over time the number of $4 products has increased, some competitors have matched Wal-Mart’s prices, and there’s been an increase in the awareness of just how cheap generics can be. So I was interested to see the Drug Benefits News article, entitled Generic Rx Copays Are Steady or Dropping, With Wal-Mart’s $4 Generics Seen as a Factor.

Despite ever-increasing financial pressures to shift more pharmacy costs to consumers, health plan sponsors in 2008 generally are keeping their generic drug copayments low, while lifting copays on preferred and non-preferred brand drugs, say PBMs and health plans surveyed by DBN. The next big trend, in fact, could be “zero-dollar copays” on generics, say pharmacy executives who attribute the interest in reducing members’ financial barriers in part to Wal-Mart Stores, Inc.’s $4 generics program.

So the Wal-Mart policy actually does affect insured patients after all!

Still, not everyone has caught on to the full implications. According to Tom Tran, senior director of pharmacy at Health Care Service Corporation:

“If the member feels that the medication they are taking is essential, you could raise [copays] $4, $10, and they’ll still see the benefit of taking my drug. I’d rather pay $10 a month than to have my diabetes worsen and I lose my vision and I lose my feelings in my legs and my big toe amputated,” Trans says as an example. “If they don’t see the value of why they’re taking their drugs or disease states, they’re going to see a dollar increase in copays as a burden and not take them.”

Of course Tran is right that it’s worth $10 to avoid having one’s toes amputated, but that’s not the only consideration. Another rational reaction to a co-pay increase could be, “How come I’m paying good money for pharmacy insurance but my co-pay is higher than the full price of a Wal-Mart drug, which I don’t even need insurance to purchase?”

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