Friday, July 3, 2009

Health Care Hopes and Realities - Room for Debate Blog -

This week, President Obama took his case for a public health insurance plan to the voters, campaign-style. On Capitol Hill, the war over the costs, details and philosophy of health care proposals has grown more intense by the day. The Congressional Democrats are deeply split over how to pay for more coverage, and the Republicans are attacking the Democrats for supporting a public health plan.

Most Americans say they want substantial changes in the current system, as even the insured face soaring costs and diminishing coverage. When Room for Debate published two forums on the health care issue — on the call for mandatory insurance and on ways to change doctors' pay — hundreds of readers, including many in medical professions, wrote in to describe how they manage (or don't) to live with this system. Here are excerpts from their comments.

Thursday, July 2, 2009

The Patients Doctors Don’t Know -

As they do every July, hospitals across America are welcoming new interns, fresh from medical school graduation. Given how much these trainees have yet to learn, common wisdom holds that it's not a good time of year to get sick. This may be particularly true for older patients, because American medical schools require no training in geriatric medicine.

Often even experienced doctors are unaware that 80-year-olds are not the same as 50-year-olds. Pneumonia in a 50-year-old causes fever, cough and difficulty breathing; an 80-year-old with the same illness may have none of these symptoms, but just seem "not herself" — confused and unsteady, unable to get out of bed.

She may end up in a hospital, where a doctor prescribes a dose of antibiotic that would be right for a woman in her 50s, but is twice as much as an 80-year-old patient should get, and so she develops kidney failure, and grows weaker and more confused. In her confusion, she pulls the tube from her arm and the catheter from her bladder.

Instead of re-evaluating whether the tubes are needed, her doctor then asks the nurses to tie her arms to the bed so she won't hurt herself. This only increases her agitation and keeps her bed-bound, causing her to lose muscle and bone mass. Eventually, she recovers from the pneumonia and her mind is clearer, so she's considered ready for discharge — but she is no longer the woman she was before her illness. She's more frail, and needs help with walking, bathing and daily chores.

This shouldn't happen. All medical students are required to have clinical experiences in pediatrics and obstetrics, even though after they graduate most will never treat a child or deliver a baby. Yet there is no requirement for any clinical training in geriatrics, even though patients 65 and older account for 32 percent of the average doctor's workload in surgical care and 43 percent in medical specialty care, and they make up 48 percent of all inpatient hospital days. Medicare, the national health insurance for people 65 and older, contributes more than $8 billion a year to support residency training, yet it does not require that part of that training focus on the unique health care needs of older adults.

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Tuesday, June 30, 2009

When the Time Comes - WNYC podcast and book

There are currently 45 million Americans caring for family members,
and as the 77 million boomers continue to age, this number will only
go up. Journalist Paula Span shares the stories of several families
who've had to deal with older family members to frail to live alone
but to healthy for a nursing home. She's joined by Debbie Drelich,
President of the Greater New York Chapter of Professional Geriatric
Managers, and Ilze Earner, who has had personal experience caring for
an aging parent. In When the Time Comes: Families with Aging Parents
Share Their Struggles and Solutions, Span writes about the emotional
challenges and practical discoveries about elder care options.

When the Time Comes: Families with Aging Parents Share Their
Struggles and Solutions

What will you do when you get the call that a loved one has had a
heart attack or a stroke? Or when you realize that a family member is
too frail to live alone, but too healthy for a nursing home?

Journalist Paula Span shares the resonant narratives of several
families who faced these questions. Each family contemplates the
alternatives in elder care (from assisted living to multigenerational
living to home care, nursing care, and at the end, hospice care) and
chooses the right path for its needs. Span writes about the families'
emotional challenges, their practical discoveries, and the good news
that some of them find a situation that has worked for them and their
loved ones. And many find joy in the duty of caring for an older
loved one.

The Family Doctor: A Remedy for Health-Care Costs?

The primary-care doctor is gaining new respect in Washington. Battles may be breaking out left and right over the various health-care bills emerging from Congress, but reformers on both sides agree that general practitioners should be given a central role in uniting the fragmented U.S. medical system.

This vision has a name: the "patient-centered medical home." The "home" is the office of a primary-care doctor where patients would go for most of their medical needs. The general practitioner would oversee everything from flu shots to chronic disease management to weight loss, and coordinate care with nurses, pharmacists, and specialists. A 2004 study estimated that if every patient had such a home, the resulting efficiencies might reduce U.S. health-care costs by 5.6%, a savings of $67 billion a year.

Instead, most patients today get a scant seven minutes with a general practitioner, who has time to do little more than ask cursory questions and focus on the problem at hand. The patient rushes to specialists for chronic conditions that could be managed by a regular doctor. (Today, these different physicians rarely coordinate.) Last-minute appointments are almost unheard of -- one reason patients with minor complaints flock to already crowded hospital emergency rooms.

This medical home may sound like the "gatekeeper" model of the 1990s, a managed-care creation that was all about holding down costs. But advocates say the new concept is designed to help patients, not insurers. It's more like doctoring 1950s-style, when a Marcus Welby figure handled all the family's medical needs. This time it's juiced up with digital technology.

It also represents a politically painless way to streamline a disorganized and wasteful system that chews up a crippling 18% of the U.S. gross domestic product. That burden is felt particularly by private industry, which covers 60% of the nation's insured. Since most businesses try to ferret out waste and disorganization in their own operations, the medical home is a concept they can embrace in good conscience.

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Sunday, June 28, 2009

Is there really much tension between quality and efficiency in health care? - By Christopher Beam - Slate Magazine

At the White House's health care town hall on Wednesday, an epilepsy specialist named Orrin Devinsky asked a question that haunts proponents of reform:

"President Obama, if your wife or your daughter became seriously ill, and things were not going well, and the plan physicians told you they were doing everything that reasonably could be done, and you sought out opinions from some medical leaders and major centers, and they said there's another option that you should—should pursue, but it was not covered in the plan, would you potentially sacrifice the health of your family for the greater good of insuring millions? Or would you do everything you possibly could as a father and husband to get the best health care and outcome for your family?"

That question—the health care equivalent of asking Michael Dukakis whether he would still oppose the death penalty if his wife were raped and murdered—lays out a disturbing scenario. Fortunately—for the White House as much as for anyone with a sick spouse or child—it's not very realistic.

The logic behind the question is clear enough. It's easy to talk about cost cutting in macro terms: As much as 30 percent of health care spending goes to unnecessary treatments. Eliminate those, and we're good. But on an individual level, who defines "unnecessary"? Who is going to decide not to order the extra test or the extra treatment? When it's your life or your child's at stake, are you really going to turn down a long-shot treatment just because it's too expensive?

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Grant System Leads Cancer Researchers to Play It Safe

Among the recent research grants awarded by the National Cancer Institute is one for a study asking whether people who are especially responsive to good-tasting food have the most difficulty staying on a diet. Another study will assess a Web-based program that encourages families to choose more healthful foods.

Many other grants involve biological research unlikely to break new ground. For example, one project asks whether a laboratory discovery involving colon cancer also applies to breast cancer. But even if it does apply, there is no treatment yet that exploits it.

The cancer institute has spent $105 billion since President Richard M. Nixon declared war on the disease in 1971. The American Cancer Society, the largest private financer of cancer research, has spent about $3.4 billion on research grants since 1946.

Yet the fight against cancer is going slower than most had hoped, with only small changes in the death rate in the almost 40 years since it began.

One major impediment, scientists agree, is the grant system itself. It has become a sort of jobs program, a way to keep research laboratories going year after year with the understanding that the focus will be on small projects unlikely to take significant steps toward curing cancer.

"These grants are not silly, but they are only likely to produce incremental progress," said Dr. Robert C. Young, chancellor at Fox Chase Cancer Center in Philadelphia and chairman of the Board of Scientific Advisors, an independent group that makes recommendations to the cancer institute.

The institute's reviewers choose such projects because, with too little money to finance most proposals, they are timid about taking chances on ones that might not succeed. The problem, Dr. Young and others say, is that projects that could make a major difference in cancer prevention and treatment are all too often crowded out because they are too uncertain. In fact, it has become lore among cancer researchers that some game-changing discoveries involved projects deemed too unlikely to succeed and were therefore denied federal grants, forcing researchers to struggle mightily to continue.

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