Tag: Healthcare

Trump Pledged to End H.I.V. But His Policies Veer the Other Way.

WASHINGTON — In his State of the Union address, President Trump announced a bold plan to end the scourge of H.I.V. by 2030, a promise that seemed to fly in the face of two years of policies and proposals that go in the opposite direction and could undermine progress against the virus that causes AIDS.

In November, the Trump administration proposed a rule change that would make it more difficult for Medicare beneficiaries to get the medicines that treat H.I.V. infection and prevent the virus from spreading.

Mr. Trump has repeatedly urged Congress to repeal the expansion of Medicaid under the Affordable Care Act, even though Medicaid is the largest source of coverage for people with H.I.V. And he has promoted the sale of short-term health plans that skirt the Affordable Care Act, even though such plans usually exclude people with H.I.V.

To end the spread of the virus, federal health officials say they must reduce the stigma attached to gay men and transgender people who are at high risk so they will seek testing and treatment. But for two years the administration has tried to roll back legal protections for people in those groups.

Those opposing moves by the administration have AIDS activists baffled.

“The president’s announcement comes as a surprise, albeit a welcome surprise,” said Jennifer C. Pizer, the law and policy director at Lambda Legal, a gay rights group. “It represents an about-face on H.I.V. policy.”

The administration describes the plan to end the spread of H.I.V. as one of the most important public health initiatives in history. But the record shows a rather large gap between the administration’s words and deeds.

Since Medicare’s outpatient drug benefit began in 2006, the government has required prescription drug plans to cover “all or substantially all drugs” in six therapeutic classes, including antiretroviral medicines to treat H.I.V.

In November, the Trump administration proposed a new policy to cut costs for Medicare by reducing the number of drugs that must be made available to people with H.I.V.

The proposal would allow certain exceptions to the requirement for Medicare drug plans to cover all drugs in the six “protected classes.”

Insurers could require Medicare beneficiaries to get advance approval, or “prior authorization,” for H.I.V. drugs and could require them to try less expensive medications before using more costly ones, a practice known as step therapy.

People with H.I.V. and doctors have condemned the proposals.

Bruce Packett, the executive director of the American Academy of H.I.V. Medicine, representing doctors who care for H.I.V. patients, said the administration’s proposals “could be catastrophic” for Medicare patients with the virus, as well as for the president’s campaign to end the epidemic.

“At least 25 percent of all people living with H.I.V. who are in care in the United States rely on Medicare as their insurer,” Mr. Packett said.

Those patients are 65 or older or have disabilities and often have other chronic diseases or conditions, so doctors need access to the “full arsenal” of medicines to treat H.I.V., Mr. Packett said.

Many of the Medicare patients with H.I.V. are taking medicines for their other conditions, so doctors have to worry about drug interactions, Mr. Packett said. In addition, he said, some have drug-resistant strains of H.I.V., and different patients often respond to the same drug in different ways.

“It’s important that providers have access to all the available options” among drugs to treat H.I.V., he said.

Requirements for prior authorization and similar restrictions can delay the start of treatment. Studies show that a rapid start to therapy, within a week or even a day of diagnosis, produces better results for patients and reduces the likelihood that they will infect others while waiting for treatment.

READ MORE: https://www.nytimes.com/2019/02/12/us/politics/trump-hiv-plan.html


The Reasonable Way to View Marijuana’s Risks

Cannabis has downsides, but speculation and fear should be replaced with the best evidence available.

Are we underestimating the harms of legalizing marijuana?

Those who hold this view have been in the news recently, saying that research shows we are moving too far too fast without understanding the damage.

America is in the midst of a sea change in policies on pot, and we should all be a bit nervous about unintended consequences.

Vigilance is required. But it should be reasoned and thoughtful. To tackle recent claims, we should use the best methods and evidence as a starting point.

Crime has gone up in Colorado and Washington since those states legalized marijuana. It’s reasonable to wonder about the connection, but it’s also reasonable to be skeptical about causation.

The best method to investigate this may be synthetic controls. Researchers can use a weighted combination of similar groups (states that are like Colorado and Washington in a number of ways) to create a model of how those states might have been expected to perform with respect to crime without any changes in marijuana laws. Benjamin Hansen, a professor of economics at the University of Oregon, used this methodology to create a comparison group that most closely resembled the homicide trends and levels from 2000-12.

“I picked those years because they were after the tremendous crime drop in the early ’90s and most predictive of crime today,” he said. “I ended in 2012 because that’s when Colorado and Washington voted to legalize marijuana.”

This model showed that we might have predicted more of an increasein Colorado or Washington just based on trends seen in comparable states, even without legalization. When he compared the two states with the synthetic control, Colorado and Washington actually had lower rates after legalization than you’d expect given trends.

This is not evidence that legalization lowers crime rates. But it does suggest that we shouldn’t conclude that it increases them. A number of other studies agree.

A potential misperception involves automobile crashes. Drunken drivers are measurably impaired when their blood alcohol level is above a certain level. We can prove this in randomized controlled trials.

READ MORE: https://www.nytimes.com/2019/01/14/upshot/the-reasonable-way-to-view-marijuanas-risks.html

How to Take Charge of Your Medical Care

Screen Shot 2018-11-13 at 4.34.13 AMWalking into a doctor’s office or hospital can be intimidating. But when you go armed with the right tools and frame of mind, you can walk out of that appointment or hospital stay feeling more confident and satisfied. Learn how to ask your questions, either for yourself or a loved one, figure out your various medical options and determine the best course of action. Just having that knowledge in your pocket can help you feel better.

When You’re Healthy

It can be hard to think about dealing with a medical emergency when you are well, but the things you do now can really pay off later.

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Get Your Paperwork in Order

As much as we don’t want to think about the end of our own lives, it’s a good idea to get a head start while you’re still relatively young and in good health. Don’t just assume your partner or family can read your mind about whether or not you’d want to be put on a feeding tube or be resuscitated if something went wrong. Yes, that means having an advance care directive on hand. This also means appointing a proxy granting him or her power-of-attorney to make your medical decisions if you’re not able to do so.

If you are fortunate enough to have some form of health insurance, always have your current policy information handy and organized in case you need it. In fact, keep it in an easily accessible folder, along with an updated list of all the medications you’re taking — prescribed, over-the-counter and supplements — and a record of your personal and family medical history. Regardless of whether you’re going to see your general practitioner about a viral infection or end up in the E.R. with a broken foot, you’re going to be asked about your medical history, so it’s best to come with as much detail as possible.

Know Your Rights

In the United States, we have various sources setting forth our rights as patients. HIPAA, for example, guarantees on a federal level a patient’s right to get a copy of his medical records, as well as the right to keep them private. There is also the Patient’s Bill of Rights that is part of the Affordable Care Act, though it primarily deals with insurance-specific rights, rather than general health care. Some states, like New York, do have a Patients’ Bill of Rights which grants additional protections, like receiving an itemized bill and explanation of all charges, as well as a right to get emergency care if you need it, meaning that hospitals are not permitted  to turn away a patient requiring emergency care, regardless of where they live and regardless of whether they can pay the bill. In addition, some organizations, like the American Hospital Association, have their own guidelines outlining the rights of patients.

All patients also have the right of informed consent, meaning that if you require any sort of treatment or procedure, your physician should explain what will happen to you in a way you understand, which allows you to make an educated decision. Being familiar with informed consent before needing medical treatment can help you achieve the best outcome possible.

Schedule Regular Appointments

It’s important to stay on top of your health, so schedule regular check-ups to ensure everything is in working order. If you live somewhere with numerous options for medical care, you’ll have the task of finding and then selecting a doctor who best serves your needs. This is true when dealing with your physical as well as a mental health. Once you’re at the appointment, make the most of your time with your doctor, by asking any questions you may have about your body and health, and requesting a full blood test workup.

Mammograms, CT scans, X-rays: Assessing the risk of all that radiation

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An X-ray for knee pain. A CT scan for a head injury. Mammograms every other year, starting at age 50. Over a typical lifetime of radiation exposure from medical tests, a person can start to wonder: How much is too much?

There’s no formula for answering that, experts say, in part because the health effects of radiation don’t add up in a linear way. And while massive doses of radiation are known to be harmful, the small doses used in routine tests are usually safe, especially compared with other health-care choices people make without thinking twice.

“Radiation does have some risk,” says Russ Ritenour, a medical physicist at the Medical University of South Carolina in Charleston. “But it is important for medicine. And in most cases, the risk is quite small compared to the risk of taking too much Advil over your life and other things like that.”

Ionizing radiation – the type that can damage cells – is a daily fact of life even for people who never go to the doctor. Rocks and soil contain radioactive materials, which also appear in our food, our bones and the air we breathe. Cosmic rays barrage us with radiation from space, with higher doses at altitude and on airplanes.

Overall, a person in the United States gets an annual average of about 3 millisieverts (mSv) of background radiation. (Millisieverts are units that measure radiation absorbed by our bodies.)

Added exposure, totaling another 3 mSV each year for the average American, comes from such man-made sources as power plants that run on coal and nuclear fuel, and consumer products including TVs and computer screens. But most of the extra radiation we get comes from X-rays and CT scans, Ritenour says.

Most routine diagnostic tests emit extremely small amounts of radiation. A patient will get about 0.001 mSv from an arm X-ray, 0.01 mSv from a from a panoramic dental X-ray, 0.1 mSv from a chest X-ray and 0.4 mSv from a mammogram, according to Harvard Medical School. (Those estimates vary somewhat, depending on the source and on the specific device used, the size of the patient and other factors.)

CT scans, which take multiple X-rays to create cross-sectional images, deliver higher doses: 7 mSv for a chest CT, and 12 mSV for a full-body scan, according to the National Cancer Institute. Studies have found doses of 25 mSv or more from a PET/CT, an imaging test that requires ingesting a radioactive substance.

With the increasing availability and affordability of imaging technologies, people are getting more tests than they used to. Today, Americans receive more than 85 million CT scans each year, compared with 3 million per year in the 1980s.

Many of those tests may be excessive, argue some researchers, who have been trying to quantify the risks of our increasing use of ionizing radiation in medical imaging. A 2009 study by scientists at the National Cancer Institute estimated that 2 percent – or about 29,000 – of the 1.7 million cancers diagnosed in the United States in 2007 were caused by CT scans. In a 2004 study, researchers estimated that a 45-year-old who planned to get 30 annual full-body CT exams would have a nearly 2 percent lifetime risk of dying of cancer. Other studies are underway to clarify risks, including in children.

But evaluating an individual’s chances of experiencing a bad outcome from any given test or a combination of tests is tricky. Some of the most definitive data on radiation’s health effects come from long-term studies of tens of thousands of people who survived the atomic bombings of Hiroshima and Nagasaki in 1945. Sudden exposure to 1,000 mSv, those studies have found, increased the risk of getting cancer by 42 percent and increased the risk of dying of cancer by 5 percent.

Risks of secondary cancers also rise with the high doses of radiation used in some cancer treatment – a trade-off that often makes sense because doing nothing would be even riskier.

Evidence is murkier about health consequences from lower doses. The Food and Drug Administration estimates that 10 mSv of radiation, an amount typical for a CT of the abdomen, increases lifetime cancer risk by 1 in 2,000. But that calculation assumes that risks are proportional to dose, which has not been proved. Below 10 mSv, there is not enough good data to draw clear conclusions.

There is also no absolute number of scans that constitute a tipping point for health, Ritenour says, in part because our bodies have repair mechanisms that can fix cells damaged by radiation. So while every scan adds to the chances that a problem will occur, radiation doesn’t build up in the body. And damage doesn’t accumulate like water poured into a glass. Theoretically, he adds, 10 mammograms in one day would be riskier than one mammogram a year for 10 years.

“All you can really say is that there’s very little chance a problem can happen” at low doses, says Ritenour, who often consults with patients who have questions about radiation. “It is very unsatisfying in a way. You can’t say, ‘You will definitely have no problems.’ ”

Although health risks from most imaging tests are extremely small, fear can be hard for people to rationalize away. There is a one-in-a-million chance of getting cancer from a chest X-ray, Ritenour says, the same tiny chance of getting cancer from toxins in peanut butter.

Making decisions about diagnostic tests ultimately requires comparing their potential benefits with their potential harms. That balance can be easy to measure if someone has a broken leg or a bullet fragment lodged in their body. But decisions become more nuanced for tests such as mammograms, which catch breast cancers in some women but also produce false alarms that cause unnecessary anxiety and follow-up testing that entails even more radiation. Given the trade-offs, the U.S. Preventive Services Task Force offers evidenced-based advice about many screening tests, and those guidelines can be helpful starting points for conversations with your doctor.

Online calculators can also offer food for thought. When I entered my location, estimated miles traveled by airplane and other information into a tool maintained by the Nuclear Regulatory Commission , I learned that I absorb an estimated 318 millirems, or 3.18 mSv, of radiation each year. Each millirem, according to this government agency, equates to a 1.2-minute reduction in life span, the same accrued from eating 10 extra calories (assuming I’m overweight) or crossing the street three times. In other words, I am likely to die 4 1/2 hours sooner than I would if I could avoid radiation altogether.

While some researchers work to better understand and communicate the risks of radiation, others are refining technologies and procedures, adds Louis Wagner, a diagnostic medical physicist at McGovern Medical School at the University of Texas Health Science Center at Houston. And the field has come a long way.

For example, after studies found an elevated risk of breast cancer among women who had received X-rays for childhood scoliosis, experts say, many health centers switched from taking images from the front of the body to taking images from behind to reduce the cancer risk.

Technicians have made mistakes, such as using higher doses of radiation than needed during scans, and some mistakes have led to expensive legal cases, Wagner says. But those cases are rare. And most machines are now equipped with safety features to avoid overexposure.

“The profession has sought to make use of radiation very, very beneficial to patients with minimal and, I believe, unrecognizable risks,” Wagner says. “I want patients to know the medical profession is avidly pursuing better ways to use radiation to increase the benefits-to-risks ratio. I think good progress is being made.”

Uber, Lyft and the Urgency of Saving Money on Ambulances

‘Don’t reflexively call an ambulance,’ a Harvard researcher says. In many cases, a cheaper way makes sense.

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An ambulance ride of just a few miles can cost thousands of dollars, and a lot of it may not be covered by insurance. With ride-hailing services like Uber or Lyft far cheaper and now available within minutes in many areas, would using one instead be a good idea?

Perhaps surprisingly, the answer in many cases is yes.

The high cost of an ambulance isn’t really for the ride. It comes with emergency medical staff and equipment, and those can be very important, of course, even lifesaving.

But they are not things you always need, although you (and your insurer) pay for them with every trip.

“Don’t reflexively call an ambulance,” said Anupam Jena, a physician and researcher with the Harvard Medical School. “Ambulances are for emergencies. If you’re not having one, it’s reasonable to consider another form of transportation.”

READ MORE: https://www.nytimes.com/2018/10/01/upshot/uber-lyft-and-the-urgency-of-saving-money-on-ambulances.html

Pathologists shortage ‘delaying cancer diagnosis’

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Patients are facing delays in diagnosis because of severe shortages among pathology staff, according to a report seen by the BBC.

A survey by the Royal College of Pathologists found only 3% of the NHS histopathology departments that responded had enough staff.

Histopathologists are doctors and scientists who diagnose and study diseases such as cancer.

Hundreds more pathologists are now working in the NHS, health chiefs said.

‘Staffing gaps’

The new report by the Royal College of Pathologists says that demand for pathology services has grown significantly in recent years, but staffing has not increased at the same rate.

It carried out a workforce survey of histopathology departments throughout the UK in 2017.

Of the 158 departments, 103 responded.

Only 3% said they had enough staff to meet current clinical demand.

And 45% of departments had to outsource work while half of departments were forced to use locums.

“The cost of staff shortages across histopathology departments is high for both patients and for our health services.

“For patients, it means worrying delays in diagnosis and treatment,” said Prof Jo Martin, president of the Royal College of Pathologists.

“We estimate the cost of locums and outsourcing work is £27m each year across the UK health service, money that could be better invested in staff and new diagnostic equipment” she added.

READ MORE:https://www.bbc.co.uk/news/health-45497014

Hidden From View: The Astonishingly High Administrative Costs of U.S. Health Care

It takes only a glance at a hospital bill or at the myriad choices you may have for health care coverage to get a sense of the bewildering complexity of health care financing in the United States. That complexity doesn’t just exact a cognitive cost. It also comes with administrative costs that are largely hidden from view but that we all pay.

Because they’re not directly related to patient care, we rarely think about administrative costs. They’re high.

A widely cited study published in The New England Journal of Medicine used data from 1999 to estimate that about 30 percent of American health care expenditures were the result of administration, about twice what it is in Canada. If the figures hold today, they mean that out of the average of about $19,000 that U.S. workers and their employers pay for family coverage each year, $5,700 goes toward administrative costs.

Such costs aren’t all bad. Some are tied up in things we may want, such as creating a quality improvement program. Others are for things we may dislike — for example, figuring out which of our claims to accept or reject or sending us bills. Others are just necessary, like processing payments; hiring and managing doctors and other employees; or maintaining information systems.

That New England Journal of Medicine study is still the only one on administrative costs that encompasses the entire health system. Many other more recent studies examine important portions of it, however. The story remains the same: Like the overall cost of the U.S. health system, its administrative cost alone is No. 1 in the world.

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Using data from 2010 and 2011, one study, published in Health Affairs, compared hospital administrative costs in the United States with those in seven other places: Canada, England, Scotland, Wales, France, Germany and the Netherlands.

At just over 25 percent of total spending on hospital care (or 1.4 percent of total United States economic output), American hospital administrative costs exceed those of all the other places. The Netherlands was second in hospital administrative costs: almost 20 percent of hospital spending and 0.8 percent of that country’s G.D.P.

At the low end were Canada and Scotland, which both spend about 12 percent of hospital expenditures on administration, or about half a percent of G.D.P.

Hospitals are not the only source of high administrative spending in the United States. Physician practices also devote a large proportion of revenue to administration. By one estimate, for every 10 physicians providing care, almost seven additional people are engaged in billing-related activities.

It is no surprise then that a majority of American doctors say that generating bills and collecting payments is a major problem. Canadian practices spend only 27 percent of what U.S. ones do on dealing with payers like Medicare or private insurers.

Another study in Health Affairs surveyed physicians and physician practice administrators about billing tasks. It found that doctors spend about three hours per week dealing with billing-related matters. For each doctor, a further 19 hours per week are spent by medical support workers. And 36 hours per week of administrators’ time is consumed in this way. Added together, this time costs an additional $68,000 per year per physician (in 2006). Because these are administrative costs, that’s above and beyond the cost associated with direct provision of medical care.

In JAMA, scholars from Harvard and Duke examined the billing-related costs in an academic medical center. Their study essentially followed bills through the system to see how much time different types of medical workers spent in generating and processing them.

At the low end, such activities accounted for only 3 percent of revenue for surgical procedures, perhaps because surgery is itself so expensive. At the high end, 25 percent of emergency department visit revenue went toward billing costs. Primary care visits were in the middle, with billing functions accounting for 15 percent of revenue, or about $100,000 per year per primary care provider.

“The extraordinary costs we see are not because of administrative slack or because health care leaders don’t try to economize,” said Kevin Schulman, a co-author of the study and a professor of medicine at Duke. “The high administrative costs are functions of the system’s complexity.”

Costs related to billing appear to be growing. A literature review by Elsa Pearson, a policy analyst with the Boston University School of Public Health, found that in 2009 they accounted for about 14 percent of total health expenditures. By 2012, the figure was closer to 17 percent.

One obvious source of complexity of the American health system is its multiplicity of payers. A typical hospital has to contend not just with several public health programs, like Medicare and Medicaid, but also with many private insurers, each with its own set of procedures and forms (whether electronic or paper) for billing and collecting payment. By one estimate, 80 percent of the billing-related costs in the United States are because of contending with this added complexity.

Read More:https://www.nytimes.com/2018/07/16/upshot/costs-health-care-us.html?hp&action=click&pgtype=Homepage&clickSource=story-heading&module=first-column-region&region=top-news&WT.nav=top-news