Curative+Palliative=New Hospice?

Prior to health reform, Medicare (federal program for 65+ and disabled) only covered palliative (non-curative) care for individuals on Hospice care.  Hospice is both a type of care and a philosophy for terminally ill patients, focused on management and alleviation of pain symptoms and spending the end of one's life with friends and family in a manner of dignity and peace.  The focus is on quality of life, rather than lengthening duration of life, or providing cures, and occurs on one's home or a hospice facility.   


With health reform becoming law, Medicaid (state-federal program for the poor) must now provide both palliative care and curative care for children with terminal health conditions.  Additionally, Medicare is instructed to start approximately 15 demonstration projects around the US (rural/urban mix) to test this palliative and curative combination.  Basically, the demonstration projects will be 3-year programs allowing individuals to receive all currently covered Medicare services while simultaneously receiving hospice care.  If the demonstration projects show benefits (defined as the impact on patient care and quality of life) without increasing costs, this could become a new policy for Medicare.  It is listed as Section 3140 of the Patient Protection and Affordable Care Act (PPACA) (and its reconciled Healthcare and Education Reconciliation Act) and is called the Medicare Hospice Concurrent Care Demonstration Program.  


What do you think the outcome will be?  Will this combination of therapies work?  Will costs increase?  Does the addition of curative therapies confuse the point of hospice care (to end life peacefully and with dignity)? Will this make the end of life easier or more difficult for families? 

Robots & Quality Health Care

In yesterday's Wall Street Journal, John Carreyou talks about da Vinci (the robot, not the artist).  The da Vinci is a robot used to perform minimally invasive surgeries.  The machine costs between $1.4 million and $2.2 million and is manufactured by Intuitive Surgical.  It's operated by surgeons with joystick controls with the purpose of providing better visibility and greater flexibility and ease in surgeries.  

Tha da Vinci then is argued to be good for patients because leads to: less blood loss, smaller scars, and less infection.  Additionally, one study found da Vinci surgeries to cut hospital stays, thus reducing hospital costs by a third.  Sounds great, but what are the potential problems?


For one, if unexperienced doctors are performing these procedures, there could be harmful outcomes for patients.     


The da Vinci has been marketed as a technological advantage for small hospitals to be competitive with other hospitals.  One such hospital, Wentworth-Douglas Hospital, in Dover, New Hampshire, has been using the da Vinci for years.   The hospital has performed about 300 surgeries in 4 years.  As a comparison, individual robotic surgery experts, like Dr. David Samadi at Mt. Sinai, average 400-600 per year.  Now, Wentworth-Douglas hospital is under investigation for quality concerns with the robotic surgeries.  There have been some complications in surgeries, but the hospital also notes their da Vinci complication rates are below some recently published rates.


There isn't current data to compare the rates of complications across hospitals, comparing high-volume (high number of procedures in a year) to low-volume.  However, there is data on number of procedures and offsetting cots.  One recent study in the Journal of Urology said that doctors need to perform over 500 per year to offset costs of traditional surgery.


So how can we ensure that we can allow for technological innovation while ensuring consistently high quality medical care delivered to patients and keeping costs down?  If it takes continuous experience (i.e. high volume hospitals, specifically the physicians in the hospitals, performing the procedures frequently) to ensure top-notch quality, how do we ensure access to top quality to less-resourced areas?  Can we ensure equality in quality geographically?

The Skinny on Childhood Obesity

Yesterday, Michelle Obama led the White House Childhood Obesity Summit.  The meeting was a follow-up to her (much-needed) Let's Move Campaign she announced in February.  We all know childhood obesity is a problem and the first lady is getting some national discussions started on how to combat this public health epidemic within the next generation.  Both Health and Human Services (HHS) Secretary Kathleen Sebelius and Surgeon General Regina Benjamin have also stated their plans to help Americans stop the obesity epidemic.

One of the leading health policy journals, Health Affairs, released their special March 2010 issue (Vol 29, No 3), with the theme: Child Obesity: The Way Forward. In this issue, there are a number of great articles discussing implications of childhood obesity and potential next steps to combat it.


Regarding costs, John Cawley's article on "The Economics of Childhood Obesity," mentioned two interventions shown to be not just effective, but cost-effective in youth.  One is the Coordinated Approach to Child Health (CATCH) and the other is Planet Health (cost-effective for females).  He argues that we need to use policies and incentives to promote cost-effective interventions and to find other cost-effective measures to stop this problem costing us $14.1 billion in outpatient care and $237.6 billion in inpatient care each year (direct costs).  


So, what can we do and what's being done? Thomas Frieden, director of the Centers for Disease Control and Prevention (CDC) was the lead author on an action agenda, "Reducing Childhood Obesity Through Policy Change: Acting Now To Prevent Obesity," in the Health Affairs issue.  Recommendations include: food and beverage taxes, zoning policies, banning ads, counterads, increasing exposure to healthy foods, increasing physical activity, and decreasing sedentary behavior.  However, the food and beverage taxes would likely need to be pretty high as a study released last week in Health Affairs revealed soda taxes at 4% have no effect on consumption.  However, if the tax revenues are used to fund cost-effective interventions for childhood obesity, there is still potential benefit in these increased taxes, also noted by the authors.    The authors also called to duty: federal, state, and local governments, parents, the food industry, and businesses to act.


Additionally, issue and policy briefs were released in Washington DC.  The Senate Health, Education, Labor and Pensions (HELP) Committee started a series of hearings on child obesity and how to address the epidemic, with the first in the series being the Health Affairs hearing on March 2.  A number of stakeholders convened to begin discussions on what can be done, the built environment, and food policy. You can view the Health Affairs Issue Briefing here.  Aside:  One of the speakers was Debbie Chang, Vice President of Policy & Prevention for Nemours.  I consulted with Dr. Cynthia Minkovitz and the Johns Hopkins Women & Child Health Policy Center (WCHPC) on a policy scan last year regarding current policies practiced by youth-serving organizations to promote healthy eating and physical activity.  It's exciting to be a part of positive change for our nation.


What are your thoughts on the best way to fight childhood obesity?  What is the largest barrier to stopping the epidemic?

Health Affairs, 29, no. 3 (2010): 357-363

The theme issue for Health Affairs was supported by the Robert Wood Johnson Foundation.
Photo of Michelle Obama courtesy of Evan Vucci/Associated Press.

It's National Public Health Week!

We are halfway through National Public Health Week, which runs from April 5th-11th!! I thought I better get a quick post in to promote public health myself!

So what does Public Health do? Click here to find out!

Click here to view the Statement by Assistant Secretary for Health Howard Koh, MD, MPH.

Health Reform Makes History - What Does it Mean?

The House voted late Sunday March 21, 2010 (219-212 vote) in favor of sending the Health Reform Bill to President Obama. In addition, the House Democrats made some changes to the Senate's health reform bill (220-211 vote) which now goes back to the Senate. They must pass word-for-word reconciliation. As I post this blog entry, Obama is signing this long-awaited bill for the health of our nation.

32 million uninsured will now have health insurance. Excluded in this number are: illegal immigrants (who are also banned from purchasing in the health insurance exchanges), those eligible for Medicaid who won't enroll until they seek care, and those choosing to pay the fine instead of purchasing health insurance.

Here is a breakdown of (some of) what is included in this historical piece of health legislation.

Effective Immediately up to 6 Months From Now:
1) Insurers can't deny coverage to sick children (due to preexisting health conditions)
2) Free preventive care--screenings and preventive care must be excluded from annual deductibles on any new plans (all other plans affected in 2018)
3) No caps on lifetime benefits and restrictions on annual limits on coverage
4) Young adults allowed to stay on parent's insurance until the age 0f 26
5) Medicare Advantage (Medicare benefits delivered by private firms) gets cuts in spending in 2011
6) Children on Medicaid or state CHIP can't be dropped from now until 2019
7) Excise tax on tanning beds (10%)--"sin" tax
8) Individuals without coverage because of preexisting conditions can purchase it from high-risk pools (to be combined into exchanges in 2014)
9) Rebate of $250 for Medicare seniors in the "donut hole" for prescription drug benefits. First of incremental steps to close the hole (half-closed next year)

Effective in (or just prior to) 2014:

1) Individual Mandate--Everyone must purchase health insurance or pay annual fine of $95 (rises to $695 in 2016) unless they can prove financial hardship.

2) State health insurance exchanges--marketplace of insurance plans--goes into effect
3) Insurers can't deny coverage to adults with preexisting health conditions
4) Insurers required to cover maternity care same as medical procedures
5) Tax credits will start helping pay premiums for working families with incomes up to $88,000 per year
6) Medicaid expanded to cover more low-income people, up to 133% of federal poverty level
7) Medicare payroll tax increase of 1% for individuals making >$200k and couples making >$250k
8) New Medicare tax on unearned income of 3.8% (in 2013)
9) "Donut Hole" closing--Medicare Part D prescription drug coverage gap to be fully closed by 2020

Other items:

In 2018, "Cadillac health plans" are taxed 40% of value of the plan above thresholds (of $10,200 per individual or $27,500 per family)

The bill maintains longstanding federal funding restrictions (known as Hyde Amendment) on abortions. The exception would be in cases of rape or incest, or when the life of the woman would be endangered.

It is estimated by the nonpartisan Congressional Budget Office to cut federal deficits by $143 billion over the next decade. This bill is a landmark piece of legislation to improve the health of our nation's people. In my eyes, this is an incremental step (and focused on health insurance reform), but an amazing step nonetheless.

What are your thoughts about this this historical event, the passing of health reform?

Grass-Fed Beef: Health Effects for You And the Environment

The provocative documentary, Food, Inc., brings to light some of the environmental and ethical issues with the way we eat. One of the many issues in this Academy Award-nominated documentary, deals with is the farm industry. Cows raised in pastures are raised more humanely and are usually not given hormones or antibiotics. Additionally, the diet for grass-fed cows uses less fossil fuels than corn/soy-fed cows on a feedlot. Grass-fed cows do their own fertilizing and harvesting. Also, although grass-fed cows create more methane, they compensate in a number of ways. Most importantly, pastures reduce greenhouse gas through "carbon sequestration," or carbon capture and storage. They also use less fossil fuels in production and don't emit as much ammonia as feedlots do. The net result, as determined by the Institute for Environmental Research and Education (IERE) is a reduction in greenhouse gases for pastures and significant increases in greenhouse gases for feedlots. See more detail and other environmental benefits of grassfarming at EatWild.

A new report published this week by California researchers in Nutrition Journal shows that meat from grass-fed cows is nutritionally healthier for you too. The article discusses years have research which have shown that grass-fed diets can significantly increase the amount of cancer-fighting antioxidants, Vitamin A and E, and fatty acids in beef. Grass-fed beef is also lower in dietary cholesterol. In sum, grass-fed beef is healthier for your cardiovascular health and lowers your risk of diabetes and other health problems, like obesity as compared to corn/grain-fed cows. However, it's important to note two things. One, the omega-3 fatty acid levels in grass-fed beef are still much lower than in fish, especially salmon. Two, in order to reap the health benefits, you still need to ensure that you choose lean cuts of the beef. The Mayo Clinic has created a guide to the leanest cuts of beef.

For consumers, there are some other issues of interest here. Because the nutrient content is different between the types of beef, the taste is also different, tasting "grassier." Whether that is a good or bad thing is up to you. To read more about the taste difference, check out this article from the NY Times, "There's More to Like About Grass-Fed Beef." Additionally, the cost of grass-fed beef costs more, nearly 3x as much as grain-fed.

Grass-fed beef is sold primarily at local farms and online. If you're interested in purchasing grass-fed meats, EatWild, has a great State-by-State Directory of Farms. You can also take a look at Tallgrass Beef (Kansas), Burgundy Pasture Beef (Texas), and Hedgeapple Farm (Maryland). When shopping in regular grocery stores, be careful of the food labels. Oftentimes, the label will say "grass-fed" when the cows were only fed on grass for the first 6 or 12 months, then transferred to a feedlot. Check out Mother Earth's article, "The Label Says Grass-Fed, but is it?" for more information. As they suggest, the best label to look for is the American Grassfed Association (AGA).

Do you eat beef? If so, what type of beef do you eat? Are you more intrigued by the environmental or the health issues related to beef? Will this information change your behaviors?

Health Reform Passes. Now, The Real Work Begins.

Well, as I'm sure you're well aware, Health Reform has passed both Houses of Congress. The House of Representatives passed their version on November 7th, 2009 with a vote of 220-215. The Senate passed their version of the health care bill on December 24th, 2009 with a clear 60-39 party-line vote. A clear victory for health-reform advocates (and a nice Christmas gift for those advocates whom celebrate the holiday), the battle is far from over.

Step 1 of the battle was passing the bill. Step 2 now is compromising the two forms and agreeing on the bill's provisions, which is no small task. A number of provisions will be hammered out: 1) national versus state health exchanges (no more public option), 2) definition of, and possible taxing of, "Cadillac" health plans, and 3) how to pay for this health care overhaul. Democrats are focusing on some provisions appealing to all consumers, such as: 1) the cutoff age for children to be on their parents' health plan moved to 26, 2) eliminated co-payments for preventive services, and 3) no more denying coverage to children under the age of 18 with preexisting conditions. However, that doesn't mean Republicans are done fighting. As stated by Minority Leader Mitch McConnell (R-KY), "My colleagues [Republicans] and I will work to stop this bill from becoming law."

I think Adam Zyglis' (from the Buffalo News) Charlie Brown cartoon (above) says it all for our next steps. How far will the compromises go and what will our final version of health care reform look like? Will it be enough?

Health Efficiency

It's a fact. The United States is not a "leader" in health information technology. But we are trying to say "goodbye" to our old ways of paper records (see photo). We may be able to learn a lot of Denmark, a country that started using electronic health records (EHRs) a year ago. Telemedicine is also greatly utilized in Denmark (an example of Telemedicine can be found here). If the US wants to focus on efficiency in our health care system (we do), then perhaps we should follow our Scandinavian friends' example (Sweden and Norway are also using EHRs).

To quote the 2008 report by the Healthcare Information and Management Systems Society (HIMSS), "healthcare information technology (IT) is a sleeping giant." On top of that, healthcare IT is significantly behind most other sectors (e.g. banking and telecommunications). The report also mentions that Denmark was able to save roughly $120 million per year by using electronic medical records. The Commonwealth Fund will also be publishing a study later this month, which concludes the Danish information system is the most efficient in the world.

US policymakers are studying the Danish system and seeing if it is possible to follow their example as we overhaul our current healthcare system. Although it is used in some US hospitals and clinics, EHRs only exist in the minority of hospitals--about 10%, or about 17% of physicians use EHRs. Compatibility across and within systems needs significant improvement in the US though. However, last week, two large health systems and users of EHRs--Kaiser Permanente and the Department of Veterans' Affairs--announced communication is possible across the two systems (hooray!).

Of course, electronic health records (EHR) aren't without some concerns. Privacy is one of them. Even though the majority of physicians think EHRS will save time and money while improving patient care, many are still worried about possible security breaches. This is one area HIT policymakers will have to focus on while moving forward with the United States' journey to advanced HIT and EHR.

What do you think about the United States and its expanding role into electronic health records using health information technology? I must say that I, for one, am looking forward to the day that I do not have to fill out my prior medical history (AGAIN) at every doctor's appointment I ever make. Have it all in one electronic record would sure be nice.

Health Nuts & Pregnancy Nuts

Oh nuts. Many people don't fully appreciate all the health benefits we get from them. Nuts are excellent for our heart health by: lowering our LDL (bad) cholesterol, reducing risk of blood clots, and reducing risk of coronary heart disease. They do this by providing a Power 12 List: 1) Omega-3 Fatty Acids, 2) L-arginine, 3) Fiber, 4) Vitamin E, 5) Plant Sterols, 6) Unsaturated Fats, 7) Vitamin K, 8) Vitamin B6, 9) Folate, 10) Vegetable Protein, 11) Calcium, & 12) Magnesium.

In addition to heart health, nuts contribute to health in other ways. They can reduce your risk of diabetes, Parkinson's disease and dementia, macular degeneration, and improve your mood (e.g. walnuts improve serotonin levels in your brain, similar to antidepressant medications).

The best nuts: walnuts, hazlenuts, almonds, cashews, pistachios, pecans, and even peanuts (although not really a nut, but rather a legume). Also, the way in which you eat them matters. Raw or dry-roasted are the best ways and offer equal nutritional value. Oil-roasted nuts have more fat and calories. Try to avoid nuts made with salt--or at minimum, make sure sea salt instead of regular salt is used. If you are a food pyramid follower, nuts belong in the "meat" group.

The nut craze doesn't come without precaution. Please don't go nuts (pun intended) eating these, as just a handful is approximately 200 calories. Everything in moderation. The reason they are so calorically dense is because of nuts' high fat content. These fats are the healthy ones though, polyunsaturated and monounsaturated.

Pregnancy nuts: there is debate about whether consumption of peanuts and other nuts during pregnancy increases the risk that a child will develop a nut allergy or asthma OR conversely, exposure protects a child from developing an allergy or asthma. Be sure to read scientific sources of literature and look at the date of publication. A lot of press came out after the July 15, 2008 article I referenced above and here, but more recent science says the opposite. Be sure to consult with your physician on this.

*photo courtesy of nuthealth.org