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Archive for April, 2011

Is end-of-life care getting better and worse?

April 30, 2011 Leave a comment

Medicare patients who have severe chronic diseases are becoming less likely to die in a hospital and more likely to receive hospice care, according to a new report from the Dartmouth Atlas of Health Care. This indicates that patients’ preferences for treatment are being honored more frequently — but there are also contradictory findings.

The number of seriously ill patients who see 10 or more doctors during their last six months of life is also increasing, as is the use of specialist MDs, the Dartmouth researchers found. These trends drive up spending, while use of hospice drives costs down.

Data show the same patterns for the Rochester, NY, area (where I live) as for the U.S. as a whole. So the Beatles may be partly right: it could be getting better…and worse…all the time.

Read more…

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Canadian govt muzzles scientists, too

April 29, 2011 Leave a comment

Borrowing a trick from the Bush 43 regime, the (Conservative) Canadian government leadership is refusing media access to scientists employed by the government, in the apparent belief that news it doesn’t like can be made to disappear if experts are not permitted to share their findings and interpretation with the public.

According to CBC News, the Canadian Science Writers Association sent an open letter to the government, saying

“We urge you to free the scientists to speak. Take off the muzzles and eliminate the script writers and allow scientists — they do have PhDs after all — to speak for themselves.”

In one instance, the govt denied access to an expert at the Dept of Fisheries and Oceans who had been lead author of an article about salmon mortality that was published in Science in January. Recently, Health Canada refused access to data from Canadian radiation monitors following the Japanese power plant failure.

Paul Raeburn at Knight Science Journalism Tracker comments: “Here’s a story American science writers might want to match. Then again–why worry? This could never happen in the U.S., right?

Oh, that’s right, it already did.

Health-care reform won’t stop, analysts insist

April 26, 2011 Leave a comment

Health care reform “has left the station and is not likely to be turned back,” no matter what happens to the Affordable Care Act, according to economists and health policy experts at a recent Univ. of California-Irvine Health Care Forecast Conference.

Even though repealing ACA will probably be a top GOP issue in 2012, the likelihood of it actually happening is slim, at best, according to former White House aide Chris Jennings. “And even if repeal were somehow successful, the market will have changed so much, repeal wouldn’t alter it,” he added.

Fundamental changes are underway in insurance coverage, access, payment, and delivery system organization, explains Jon Stewart of Kaiser-Permanente’s Institute for Health Policy.

Even Wall Street is inclined to agree that these “reforms” are acquiring their own momentum, Denver hedge-fund manager Ted Shannon told the UCI confab, noting that drug-makers and device-makers’ excessive profits are unsustainable. A $100 price tag for a brand-name drug that may be little better than its rivals will become a thing of the past, he declared.

Read more…

The costly American way of dying

April 26, 2011 Leave a comment

The ER doc who posts at “Movin’ Meat” tried to address how expensive it is to die in the US: it’s estimated that 25% of Medicare spending goes to pay for health care services during peoples’ last year of life, even though the outcome is death.

So — simple solution, right? cut down on the futile care, and we’re good to go. Only problem — as a doctor, I sometimes have a hard time telling when someone is in their last DAY of life, let alone last year.

Nobody knows the hour of their death, he writes, and who could disagree? The real issue here is the dramatic under-use of advance care planning, and the reluctance of families to fulfill their loved one’s stated preferences for what medical treatments they do or do not want.

Consider what happens when families actually do what the patient wants, even when that means declining surgery or some other aggressive treatment: the example of Mike Mikula’s father, as reported on cnn.com:

Dad was adamant: “Do not cut me.” He was unwilling to take the considerable chance of stroking out on the table and spending the rest of his life incapacitated and unaware. “I want to go home.” His voice was stern and strong. “I want hospice, and I don’t want to be in pain anymore.”

Mikula’s account of the advance of his dad’s terminal illness does not sugar-coat what happened, especially during the final days, even with the assistance of skilled hospice caregivers. It wasn’t all ‘skittles and beer,’ he declares. He also recognizes how fortunate his family was: both elderly parents knew and said what they wanted, and he and his siblings respected those wishes.

Some doctors indulge themselves and their patients into thinking that over an endless timeline, with unlimited finances, humanity’s losing streak against death can be snapped. But every gambler knows the house always wins. Lots of luck went into my Dad’s “good death,” but luck favors the prepared.

Bill Sez: I hope shadowfax at Movin’ Meat and every other doctor reads and takes to heart the Mikula family story — not only because it will reduce the amount Medicare spends on futile care, but also because it establishes that families are capable of positive, life-affirming experiences even when the outcome is death.

‘Skin in the game’ cannot reduce US health spending

April 22, 2011 Leave a comment

GOP Rep. Paul Ryan’s mendacious proposal to end Medicare and Medicaid as we know them enshrines bad policy, but it is a foundation built on sand: the notion that the free market can reduce health care costs.

As the blog of an ER physician points out, “people who believe that passing along the cost of health care to consumers will promote cost savings are wrong, and health reforms which are predicated on this concept will not work.”

Doc Shadowfax explains by referencing a powerful graphic drawn from a Kaiser Family Foundation report: 20% of the US population accounts for 80% of annual health-care spending, with the worst-off 5% tallying 49% all by itself. Meanwhile, the relatively healthy 50% of the population is responsible for only 3% of spending. Says the doc:

Once you are told that you need a bypass/chemo/stent/dialysis/NICU etc, etc, etc, the costs are so overwhelming that a consumer cannot possibly pay them out of pocket. Since, by definition, these catastrophic costs are paid by some form of insurance, the consumer cannot have much financial interest in cost containment.

On the other hand, no matter how informed and price-sensitive the healthy half may be, they can only affect a very small piece of total health-care spending. Even when they become sick, there’s little they can do, as shadowfax explains in recounting the choices he and his wife are making regarding treatment for her stage II breast cancer.

I can afford to pay $20,000 or more out of pocket if I need to, and it STILL wouldn’t make a difference. If families with more limited means were obligated to pay the same $10-20K, if would mean financial ruin, or inability to access the lifesaving care, but it wouldn’t allow the invisible hand to guide the market towards cheaper, more efficient care.

Read the whole thing…it establishes the fraudulence of the Ryan proposal beyond a doubt. The charts it references are worth the price of admission. H/t The Incidental Economist and Kaiser Family Foundation.

Medical tests don’t always ‘make it better’

April 22, 2011 Leave a comment

Have you ever heard of an “incidentaloma”? According to family physician Kenny Lin, the increasing use of CT scans often results in detection of incidental findings that could be — but usually are not — cancer.

The problem? When an “incidentaloma” turns up, doctors usually recommend more tests. And incidental findings happen a lot.

A study published last year in the journal Archives of Internal Medicine found that nearly 40 percent of CT and MRI scans performed for research purposes at the Mayo Clinic from January through March 2004 turned up at least 1 incidental finding.

Even the American College of Radiology worries about this, Lin says. ACR recently published guidelines that warn

“Subjecting a patient with an incidentaloma to unnecessary testing and treatment can result in a potentially injurious and expensive cascade of tests and procedures.”

Note the subhead of Lin’s article: Why to Think Twice Before Getting a CT Scan. The U.S. spends so much more than other countries on health care partly because doctors order so many tests, and tests too often yield false positives, and even false positives require treatment or more testing….

Thanks to Gary Schwitzer at Health News Blog for this quote from an essay called “The Last Well Person.”

“[F]alse positives are the arithmetically certain result of applying a disease-defining system to a population that is mostly well. … If the behavior of doctors and the public continues unabated, eventually every well person will be labeled sick. Like the invalids, we will all be assigned to one diagnosis-related group or another. How long will it take to find every single lesion in every person? Who will be the last well person?”

Categories: Health care

“Broadie” Brizard’s claims questioned in Chicago

April 21, 2011 Leave a comment

Chicago mayor-elect Rahm Emanuel is already under fire for selecting Rochester school superintendent Jean-Claude Brizard to take over the helm of the Windy City’s public schools, based in part on some questionable claims Brizard made about his tenure in Rochester.

Brizard departs after completing less than three years in Rochester. He’s an alumnus of the Broad Superintendent’s Academy, a training program funded by a leader of the Billionaire Boys’ Club that bankrolls most of the education “reform” crowd. Broad and his pals believe public schools should be run as a business and advocate for charter schools, despite little or no evidence that charters achieve better results.

Meanwhile, readers of the Rochester Business Journal are in full boo-hoo-hoo mode over Brizard’s departure — about what you’d expect from wealthy white Republican suburbanites who tend to be fond of education “reform” leadership that does nothing to challenge established power. More on that later.

Out west in Chi-town, Tribune columnist Eric Zorn cast a jaundiced eye on Brizard’s “achievements” in Rochester:

Can Rochester, N.Y., superintendent Jean-Claude Brizard pad a payroll? Skirt the rules? Spend frivolously? Distort statistics to make himself look good? Infuriate his constituents with a high-handed style? Check, check, check, check and check.

Read more…

Categories: Education "reform"