Saturday, October 22, 2011

When Doing Nothing Is the Best Medicine -

Don't just do something; stand there!"

It's one of those phrases that attending physicians will spout off to their medical students while on rounds, trying to sound both sagacious and clever at the same time. It sometimes grates, but it does make a valid point, because so much of medicine is about "doing something."

Sore throat? Prescribe an antibiotic.

New headache? Get a CT scan.

P.S.A. at the upper limit of normal? Get a biopsy.

Blood pressure still high? Add on another medication.

Doctors tend to want to "do something" whenever they note something amiss. And patients, by and large, want something done when they have a symptom. Few people like being told just to watch and wait.

Of course, every "thing" a doctor does also has side effects — rampant bacterial resistance from antibiotic overuse; major increases in radiation exposure from unnecessary CT scans; incontinence or impotence from prostate cancer treatments that may do nothing to prolong life; toxic drug interactions from multiple medications, particularly in the elderly.

The admonishment "Don't just do something; stand there!" reminds us that we should stop and think before we act, that there are many instances in which doing nothing is greatly preferable to doing something.

In fact, there are some doctors for whom "doing nothing" is the dominant way of thinking, who are not reflex "do-ers." They tend to lean toward the status quo: If the patient is doing fine right now, why rock the boat?

There's a term for this in the medical literature — clinical inertia — a term with a distinctly negative connotation. It describes the doctor who, for instance, sees a patient with cholesterol levels that are not optimum but who does not prescribe a statin. Or the doctor who notices that a diabetic patient's blood sugar levels are still not normal but refrains from increasing the patient's medication.

Of course, this is not black and white: There is a continuum of practice styles, just as there is a continuum of personalities in general. At one end are doctors who jump on the merest hint of a borderline lab value; at the other are doctors who avoid making changes unless absolutely necessary.

I like to think of myself as perfectly balanced in the precise middle of this spectrum, but if I take a hard look in the mirror I can see that I tend toward the clinical inertia side, always hesitating before I write a prescription or order a test. I tell myself that this arises from the august wisdom of my clinical experience, from having witnessed my fair share of side effects and adverse outcomes due to medical meddling. But I have to be honest and recognize that it reflects my personal tendency to be slow in making major decisions of any sort, to need a strong sense of how things are likely to play out before I act.

Every time I prescribe a medication — or order an invasive test, or refer a patient to a surgeon — it always feels like I'm placing a stone on a balance scale. Intellectually, my goal is to place the stone on the side of the scale that benefits my patient. But in my heart, I fear that it could end up on the other side, the side that harms, and the weight and permanence of the stone give me pause.

Many make the argument that deciding not to act is as momentous as deciding to act. Except that it never feels that way. My hesitation induces guilt; it makes me ask myself if I am harming my patients by not acting as fast or aggressively as some of my colleagues would.

An essay I came across in The Journal of the American Medical Association called "Clinical Inertia as a Clinical Safeguard" offered some food for thought. The authors postulated that doctors who tend toward inertia might actually benefit their patients by protecting them from overzealous medical intervention.

They focused on three common medical conditions — diabetes, elevated cholesterol and hypertension — for which there are established clinical guidelines for doctors to follow and "quality measures" that evaluate medical care. For all three illnesses, "lower is better" is the dominant mantra.

But while "lower is better" is probably true for large populations, that is not always the case for individual patients. In fact, there are some clinical trials in which aggressively lowered blood sugar or blood pressure have been associated with higher rates of dying.

The authors weren't saying that these medical conditions shouldn't be actively treated, but they did caution that standard clinical guidelines tend to favor overaggressive treatment in pursuit of "good numbers." In the stampede toward good numbers, individual patients can be harmed by the side effects of these treatments. Clinical inertia might actually act as a safeguard for such patients.

No one, of course, wants doctors who fail to act when action is necessary. And medical emergencies are a different story altogether. But most chronic illnesses, luckily, are not emergencies, so there is room for deliberation before action. And while insurance companies won't reimburse for deliberation, and report cards pointedly penalize, it's interesting to consider that there are many patients who may have been saved by inertia.

Danielle Ofri is an associate professor of medicine at New York University School of Medicine and editor in chief of the Bellevue Literary Review. Her most recent book is "Medicine in Translation: Journeys With My Patients."

At Walgreen, Pharmacists Urged to Mix With Public -

CHICAGO — As the Walgreen Company pushes its army of pharmacists into the role of medical care provider, it is bringing them out from their decades-old post behind the pharmacy counter and onto the sales floor.

The pharmacy chain, based in Deerfield, Ill., and the nation's largest, has renovated 20 stores in the Chicago area and is converting more than 40 in Indianapolis to get the pharmacist closer to patients. Pharmacists in the revamped stores are being kept away from the telephone, where dealing with insurance coverage questions and other administrative tasks occupy 25 percent of their time, Walgreen says.

"What we are seeing now is pharmacists should be using their knowledge to help consumers manage their medications appropriately," said Nimesh Jhaveri, executive director of pharmacy and health care experience at Walgreen. "It's not about the product but the care we give."

The reinvention of the pharmacist's role comes at a critical time for Walgreen, as it vies to keep its customer base. The company has so far been unable to reach a new contract with the pharmacy benefit giant, Express Scripts. At the same time, Greg Wasson, the chief executive, is trying to remake the company into a national provider of health care services.

This last summer, Walgreen sold its own pharmacy benefit management company for more than $500 million to a Maryland firm in a deal that Mr. Wasson said would help the company focus on becoming the consumer's "most convenient choice for health and daily living needs."

Walgreen braced investors last month for the potential loss next year of more than $3 billion in sales in 2012 if it lost the customers whose prescription coverage was managed by Express Scripts. In the most recent fiscal year for the company, it filled about 90 million prescriptions managed by Express Scripts. The two are parting ways effective Jan. 1 over payment issues, leaving Walgreen scrambling to contract with major employers directly in hopes that they will want to opt out of Express Scripts' pharmacy network. Walgreen's new model resembles the type of service that CVS and other major drugstore chains are trying to achieve by developing deeper relationships with customers and their doctors. Big pharmacy companies are hoping to increase reimbursements from insurers and employers as they become more integral in managing customers' medical care.

At the newly converted Walgreen stores, one of the ways pharmacists hope to develop longstanding relationships with customers is through private or semi-private consulting areas away from the busy pharmacy counter.

On Chicago's North Side, Walgreen has a pharmacy in the Andersonville neighborhood on North Clark Street that dispenses a substantial amount of medications to patients with the AIDS virus, so privacy for patients was critical and figured in the overall idea behind the new store model, company executives said.

Behind the pharmacy counter, the familiar bags of medications are tagged and labeled alphabetically in plastic containers, but they cannot be seen from in front of the pharmacy counter. "Customers want privacy," Mr. Jhaveri said.

The Andersonville neighborhood store includes a 50-square-foot room behind sliding doors where a pharmacist, James Wu, can sit and counsel patients, who sit on a padded bench that has enough room for the patient and a family member or two. Mr. Wu's desk is steps to the right of the private room.

Mr. Wu said he could now spend more time talking to patients or out in the store aisles, and rarely is distracted now by the orders being placed for prescriptions.

"I would take calls, asking 'Is it ready?' 'Is it covered?' " Mr. Wu said. "The phone doesn't ring anymore."

Walgreen said it would route routine questions about insurance coverage and co-payment issues to a call center in Orlando, Fla., that is staffed around the clock by pharmacists and pharmacy technicians. Another new feature is a "health guide," a concierge of sorts who answers questions, markets new services and triages patients who may need other health care services, like treatment at a Walgreen Take Care retail clinic. At 354 of the chain's more than 7,700 stores, nurse practitioners at such clinics are available to handle routine maladies.

There are financial incentives for the more personal approach; some private and government insurers have programs that reward health care providers if they can prove that their services improve the quality of care and save money.

Moreover, insurance companies and the federal government are moving to models that encourage better coordination of medical care service, putting all providers on the same page.

Federal Medicare drug laws allow for payment to pharmacists for "medication therapy management," when patients have multiple chronic diseases like hypertensiondiabetes and asthma and are taking multiple medications. In recent years, Walgreen and other pharmacy chains have lobbied aggressively for reimbursement and changes to rules that allow pharmacists to do more and to get paid for these additional services.

Walgreen already has aggressive lobbying efforts under way to get pharmacists the ability under state rules to administer more vaccines in the pharmacy. And the company is working with doctors and hospitals to develop relationships that include having a pharmacist involved in patient consultations and management of their diseases.

"As we start to prove better outcomes, our reimbursement is going to be more based on how we do that," Mr. Jhaveri said.

Employers are open to Walgreen's idea, citing national studies showing large numbers of Americans, particularly among the elderly, who do not adhere to their treatment regimens or forget to take their medicines.

For example, 2009 research from the New England Healthcare Institute showed that patients who did not take medications as prescribed cost the health system $290 billion in "avoidable medical spending every year."

"There are a variety of reasons why the current medical system is failing to help people stay on their medications," said Larry Boress, president and chief executive of the Midwest Business Group on Health, a coalition of large employers that purchases more than $3 billion in medical care services annually. Among the members are Boeing, Ford Motor and Kraft Foods.

"On filling the script, the pharmacist or pharmacy tech doesn't do much more than ask: 'Do you have any questions?' And then they give you the bag," Mr. Boress said.

Friday, October 21, 2011

Parents Turn To The Internet Before Going To The ER | Fox News

One in eight parents goes online for medical information about their child's condition before taking the child to the emergency room, according to new research.

What's more, many parents would willingly visit sites recommended by their child's doctor—which means pediatricians should be prepared to offer advice on this topic, according to Dr. Purvi Shroff from the University of Louisville in Kentucky.

She presented her findings on Friday at the 2011 national conference of the American Academy of Pediatrics in Boston.

Dr. Shroff and her team interviewed 240 parents or guardians with Internet access who brought their child to the ER.
They found 12 percent of the parents had consulted the Web about their kid's trouble during the past 24 hours, while half said they had used the Internet at least once in the previous three months for a health-related question about their child.

The most common websites were WebMD and Wikipedia, but few parents used the Centers for Disease Control and Prevention website, run by the government, or the American Academy of Pediatrics' Healthy Children website.

The majority of parent Internet users said they were highly likely to visit a website that was recommended by their child's doctor.

"Being invested in your child's health and wanting to learn more and make the best decision for your child is always a good thing. However, when it comes to using the Internet, appropriate use depends on accessing good websites and knowing whether or not the information you find is applicable to your child," Dr. Shroff told Reuters Health.

It is important, she added, that parents be able to talk to pediatricians about what they read on the Internet, and for the pediatrician to place it in context for each child.

Thursday, October 20, 2011

Prenatal testing: Birth defects often come as a surprise. - Slate Magazine

Here's something to freak out expectant parents:Over 2 percent of all American pregnancies are complicated by serious birth defects, and more than 0.5 percent of all fetuses have either a missing or an extra chromosome—a condition that leads to problems like Down or Edwards syndrome. Birth defects are a leading cause of infant mortality in the country, and most problems occur in pregnancies without any obvious risk factors. (For example, most babies with Down syndrome are born to women under 35 years of age.) There are ways to screen fetuses for birth defects like these, but due to a lack of clear guidance from caregivers or policymakers, parents may not find out about them until it's too late.
Knowing about problems before birth is important for at least two reasons. First, it allows doctors to treat the condition. Take heart problems, where a major artery may be connected incorrectly or a pumping chamber may be missing. Prenatal detection and immediate treatment at birth can prevent the sudden oxygen deprivation and shock that might occur if doctors were surprised by the defect. Some types of spina bifida can be surgically fixed before birth, preventing future paralysis.
A second benefit of prenatal screening is that it gives families a chance to decide whether they wish to continue a pregnancy at all. A huge number of women now choose abortion when faced with major birth defects. In Hawaii, which collects comprehensive information on pregnancy outcomes, more than 90 percent of women who learn they have a fetus with Down syndrome choose to terminate their pregnancies. (Other states are likely to have similar proportions.) Roughly one-half of all women whose babies have brain defects or major abdominal defects also elect abortion. To be sure, many families continue their pregnancies, and love and nurture their babies. Such families deserve support from doctors and insurers. But many families choose differently and they also deserve support.
Most of the time, however, expectant parents never realize there might be a problem. Major heart defects go unnoticed until birth an astounding 70 percent of the time. Three-quarters of all babies with missing limbs come as a surprise to both doctors and patients. More than one-half of cases of Down syndrome are overlooked. The list goes on and on.
Why are we missing so many important birth defects during pregnancy? Insurers and advisory groups don't support the necessary procedures. To diagnose the vast majority of problems—such as those related to the heart, lung, gut, and brain—one must visualize the fetus's body by ultrasound during the second trimester. But back in 1993, the New England Journal of Medicine reported results from the so-called RADIUS study (that's "Routine Antenatal Diagnostic Imaging with Ultrasound"). According to its findings, the blanket use of such ultrasounds "clearly indicate" no impact on a baby's outcome; parents would do just as well by letting their doctors decide whether to do the scans on a case-by-case basis. As a result, several insurance companies, such as Aetna, don't cover comprehensive fetal scans for routine pregnancies—a policy that affects roughly one-third of American women. The American Congress of Obstetricians and Gynecologists does not recommend the scan for all women, either. (When my wife was pregnant with our first child, our obstetrician actually advised us to make up a family history of birth defects, since our insurer wouldn't cover the scan in a normal pregnancy.)

More ...

Wednesday, October 19, 2011

Hospital Infection Rates Drop, CDC Says -

Patients were less likely to get certain infections in U.S. hospitals last year thanks to a concerted campaign to prevent them, federal officials announced on Wednesday.

They found a 33 percent reduction in central-line infections – caused when a thin tube is inserted into a patient's neck or chest to deliver medication and check blood. Infections caused by catheters used to collect urine from bed-bound patients fell by 7 percent in 2010; surgical-site infections fell 10 percent; and dangerous methicillin-resistant Staphylococcus aureus, or MRSA, infections dropped 18 percent.

"It is very impressive progress," Dr. Denise Cardo, director of the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention, told a National Journal policy forum where she presented the figures.

The CDC, the Health and Human Services Department, and nonprofit groups such as the Association for Professionals in Infection Control and Epidemiology have been pushing to reduce infections in hospitals.

The CDC estimates that one in 20 patients -- 1.7 million a year -- will get some sort of infection while in the hospital. And 99,000 people die of these infections annually.  GE Healthcare released a report in July estimating that health care-associated infections cost at least $35 billion.

HHS developed its official "Action Plan to Prevent Healthcare-Associated Infections" in 2009, and CDC credits some of its goals with helping hospitals make the 2010 reductions.

"Timely progress has been made toward most targets for which associated data are available. Although this progress is promising, continued efforts are needed to achieve the goals in the Action Plan," the report reads.

One of the main goals is keeping data on hospital-acquired infections so that health care facilities can keep track of where they may be going wrong – and make note of when new practices such a using checklists start to turn things around.

"What gets measured gets managed," Linda Greene, director of infection prevention for New York's  Rochester General Health System, said at the forum.

Under the 2010 health care law, the Centers for Medicare and Medicaid Services will eventually stop paying for treating patients who get infected while in the hospital.

Cardo also credits groups such as Consumers Union, which has pushed for better collection of data on hospital infections and on policy measures to force health care facilities to act. "If it weren't for Consumers Union pushing for public reporting, we wouldn't be here now," Cardo said.

Health insurers are on board, too, trying to lower costs. America's Health Insurance Plans, the largest insurance-industry lobby group, reported in August on success stories in which hospitals were paid for meeting infection-control goals.

One program in Tennessee reduced central-line-associated bloodstream infections by 40 percent, AHIP reported.

Report: U.S. Health Care Not Improving | The Rundown News Blog | PBS NewsHour

America's health care system is not getting any better even as it gets more expensive, according to the third comprehensive scorecard issued by the Commonwealth Fund, one of the country's biggest health care foundations.

After looking at 42 indicators of health care quality, access, cost and other values, the fund gave the United States a score of 64 out of 100 on its performance when comparing the nation to the best performing countries, states, regions or health care plans. That was slightly below the 67 the country scored in 2006, the first scorecard the fund issued, and the 65 score the United States received in 2008.

"Even though the U.S. is spending more than when we first started issuing the scorecard, we're not seeing rapid improvement in health care outcomes," said Cathy Schoen, a senior vice president at the Fund, which is based in New York City.

The scorecard primarily looked at data from 2007 to 2009, before the health care law was adopted last year, and thus is more of a benchmark of where the country was at the end of the last decade than how it is currently doing. Many of its measures have been reported elsewhere or are well known, such as the rising cost of health insurance. Still, the scorecard provides a rare, big-picture assessment of all the ways the country's health care system is failing or underperforming, as well as a few ways it has gotten better and areas where it has the most room to grow.

The scorecard found improvements in how well adults got their high blood pressure under control, and how well hospitals were doing in preventing surgical complications and treating heart attacks, heart failure and pneumonia. But it also found an increase in hospitalizations of nursing home patients and shortcomings in the ability of sick adults to quickly get to a doctor without going to the emergency room. It also concluded that the U.S. does dismally in terms of how efficiently it uses health care resources, avoids wasteful treatments, limits administrative costs and uses electronic medical records.

"As observed in previous scorecards, the U.S. is not achieving the health outcomes or quality that should be possible with the resources the nation invests," the report said.

Tuesday, October 18, 2011

Forget left v. right, it'sthe gender divide - National Post

For years, scientists studying the brain used only male rodents as their subjects, not wanting the females' ovarian cycles - and inconveniently changing hormone levels - to muddy their research.

With women now accounting for 70% of new dementia cases and succumbing to depression twice as often as men, that research bias is starting to crumble, with a growing realization that hormone variations are actually a key factor in why some brain disorders affect women and men so differently.

A conference Tuesday in Toronto is being touted as the first of its kind in Canada, a chance to underscore the neurological divide between the sexes, as the aging population creates an expected tidal wave of Alzheimer's disease.

Understanding those differences and figuring out ways to lessen the number of women who get Alzheimer's and depression is crucial, given the key role they play in caring for dementia patients, says one scientist speaking at the event.

"We need to shine a special light on it, absolutely," said Nasreen Khatri, a clinical psychologist at Baycrest, the brain and aging centre whose charitable foundation is spearheading the conference. (The National Post is a media sponsor of the symposium.)

"As these women get older we don't want them to develop dementia, because who will care for them? We need them to be intact, for their own sake and for the sake of society."

In basic science involving animals and in testing of drugs and other research on humans, subjects have predominately been male for a variety of reasons, said Dr. Gillian Einstein, a University of Toronto psychology professor.

That includes, for humans, a desire to protect women from experimental medicines that might harm pregnancies, and, for animals, the fact that it is cheaper to use lab rats or mice that are male, rather than sacrifice females that breed and produce more subjects, she said.

It was also felt that the menstrual cycle - just four days in a rodent - and its varying levels of hormone could complicate results, said Dr. Einstein.

She argues there are many reasons for scientists to now focus more on the brain's sex distinctions, noting that males are more prone to some neurological problems, such as autism, than women.

The Baycrest conference is focused on Alzheimer's, which already affects 500,000 Canadians and is expected to hit about 1.1 million patients within 25 years, imposing hardship on family caregivers as well as patients and a burden on the health-care system.

What may not be well known is that seven out of 10 new cases are women, ironically the people who more often than not take on the major responsibility for caring for dementia sufferers.

One key factor is likely reduced estrogen levels, one of the effects of menopause, said Dr. Einstein.

Research shows that women who have hysterectomies or ovaries removed before menopause - both operations that would cut estrogen production - are far more prone to dementia.

Though there is no proof yet of a cause-and-effect relationship, it is known that estrogen helps in the connections between neurons and the firing of neurons, she said.

"If you have a vulnerability that predisposes you to Alzheimer's disease, and if you aren't making estrogens, it can kick you over that cognitive cliff," said the researcher. "For lateonset Alzheimer's disease, actually being estrogen-deprived ... is a kind of a risk factor."

Complicating the issue is that estrogen, though good for the brain, is actually considered a risk factor for some forms of breast cancer. A possible answer are drugs that could boost the estrogen level only in the brain, said Dr.

Einstein. But research on hormone-replacement treatments has all but ground to a halt since findings in 2002 that suggested such HRTs increase the risk of breast cancer, stroke and heart attacks.

Almost as striking as the sex differences involving Alzheimer's is that women are twice as likely to develop depression. The higher risk is likely due to a combination of factors, including such biological ones as the effects on the brain of hormonal changes during pregnancy, social factors like the multiple roles women tend to play in modern society and psychological ones like different coping styles, said Dr. Khatri.

Many middle-aged women today are also caring for both their own children and elderly parents, increasing stress levels, which in turn can lead to depression, she said. And depression itself appears to make women two times as susceptible to Alzheimer's, for reasons that are not entirely clear, said Dr. Khatri.

Regardless, it makes successfully treating depression all the more important.

"We don't want them to get depressed again and again in case it makes them more likely to get dementia later on."

Sunday, October 16, 2011

How to fight AIDS: Five of the most effective responses. - Slate Magazine

It is dangerous to believe that the end of AIDS is in sight. About 30 million people around the world live with HIV, and another 30 million are likely to become infected in the next decade if current trends persist. Funding from developed governments is dropping—a trend that must be reversed. But we also need to acknowledge that billions of dollars have been spent on well-meaning attempts to save lives, and there has been an alarming lack of high-quality evaluation of how these investments have performed.
This is true not only of abstinence campaigns, for which there is no evidence of effectiveness, but also for many other mainstays of the AIDS response. On a systemic level, we do not know what works, where, and why—or how to replicate our successes.
In the project RethinkHIV, the Copenhagen Consensus Center and the Rush Foundation asked 30 of the world's top HIV economists, supported by epidemiologists, demographers, and medical professionals to analyze the most promising responses to the epidemic in the world's worst-hit region, sub-Saharan Africa. They were asked to examine what could be achieved with extra investments in six key areas: prevention of sexual transmission, reduction of nonsexual transmission, treatment of those who have the disease, initiatives to use social policy and health-system strengthening to fight HIV/AIDS, and vaccine research.
To spark a dialogue about HIV/AIDS priorities based on the RethinkHIV research, the Copenhagen Consensus Center and the Rush Foundation asked five world-class economists—including three Nobel laureates—to form their own conclusions about how best to spend additional funding. The panel zeroed in on five investments that they believe should be at the top of policymakers' lists.
The resulting research papers offer the first-ever comprehensive attempt at cost-benefit analysis of AIDS priorities. Economics can offer a fresh perspective by showing us the overall value to society of competing spending options. Among worthwhile investments, some are very costly and achieve little good; others are remarkably cheap and incredibly effective. Whether on AIDS or other problems, additional funds should be spent first where we can achieve the highest return for our money.
Most important, they identified an urgent need for increased investment in developing an HIV vaccine. This is clearly a longer-term response to the epidemic: Research by Dean Jamison and Robert Hecht (PDF) for RethinkHIV suggests that we are about 20 years away from large-scale vaccination, and that increasing current funding by around 10 percent, or $100 million a year, would meaningfully shorten that projection. This would save millions of lives and potentially end the epidemic in the long run, while dramatically improving scientific understanding of the disease in the near term. For every dollar spent, it is likely that the benefits would run into the tens of dollars.
As a shorter-term response to the epidemic, the Nobel laureates were convinced by research by the economist Lori Bollinger (PDF) that we could practically wipe out mother-to-child transmission of HIV by 2015 with additional expenditures of just $140 million a year. About 350,000 infants became HIV positive in 2008, through pregnancy, labor, delivery, or breast-feeding, accounting for approximately 20 percent of all new infections. Since we have such cost-effective programs to halt this tragedy, the Nobel laureates concluded, this is a compelling investment.
So, too, is spending more to make blood transfusions safer. Bollinger calculates that annual investment of $2 million over five years would achieve 100 percent safe blood transfusions by 2015 and avert more than 131,000 HIV infections, while alleviating fears of infection for the almost half-billion people who would otherwise receive blood that was not comprehensively screened.
The Nobel laureates also found that male circumcision is an excellent use of funds. They focused particularly on the longer-term benefits of infant-male circumcision, arguing that there is massive untapped potential to introduce this very cheap practice across Africa. We know that adult-male circumcision reduces the odds of transmission from a woman to a man by up to 60 percent. Research by Jere Behrman and Hans-Peter Kohler (PDF) of the University of Pennsylvania makes clear that the real focus needs to be on working out the best ways to broaden adult circumcision efforts across the region, and to convince men that getting circumcised is a good idea. We also need to introduce counseling to ensure that men do not treat circumcision as a vaccine, and engage in riskier behavior as a result.
Finally, the panel of Nobel laureates concluded based on research by Mead Over and Geoffrey Garnett (PDF) that additional resources for treatment should go first to patients who are the sickest and most infectious. Because treatment is very expensive, coverage rates remain woefully inadequate. But treatment is not only an ethical imperative; it also is important in preventing and reducing sexual transmission.

The expert panel did not just identify the top-priority uses for additional funds. It also highlighted promising areas where more research is needed. As Anna Vassall, Michelle Remme, and Charlotte Watts of the London School of Hygiene and Tropical Medicine point out (PDF), gender inequalities and domestic violence are both associated with a significant increase in risk of HIV infection. So, if gender training programs were to piggyback on current income-boosting microfinance and agricultural-support programs, we could undermine norms about gender roles that entrench women's dependence on men or condone domestic violence. It's a proposal that deserves further investigation, as is the proposition from William McGreevey of Georgetown University (PDF) to increase efforts to focus treatment of HIV-positive patients to reduce opportunistic infections of cryptococcal meningitis.

We need to arrest the recent drop in AIDS funding and secure additional resources in order to make further headway against the disease. By highlighting sound investments—including some that are not currently at the top of policymakers' to-do lists—RethinkHIV makes the case in economic terms for doing just that.

This article
 comes from Project Syndicate.

How Medicare Fails the Elderly -

Jane Gross is a former New York Times reporter and the author of "A Bittersweet Season: Caring for Our Aging Parents — and Ourselves." 

HERE is the dirty little secret of health care in America for the elderly, the one group we all assume has universal coverage thanks to the 1965 Medicare law: what Medicare paid for then is no longer what recipients need or want today.

No one then envisioned the stunning advances in medicine that now keep people alive into advanced old age, often with unintended and unwelcome consequences. Indeed, scientific reports have showed the dangers, not merely the pointlessness and expense, of much of the care Medicare is providing.

Of course, some may actually want everything medical science has to offer. But overwhelmingly, I've concluded in a decade of studying America's elderly, it is fee-for-service doctors and Big Pharma who stand to gain the most, and adult children, with too much emotion and too little information, driving those decisions.

In the last year alone, and this list is far from complete, here is what researchers have found both useless and harmful, according to leading medical journals:

• Feeding tubes, which can cause infections, nausea and vomiting, rarely prolong life. People with dementia often react with agitation, including pulling out the tubes, and then are either sedated or restrained.

• Abdominal and gall bladder surgery and joint replacements, for those who rank poorly on a scale that measures frailty, lead to complications, repeat hospital stays and placement in nursing homes.

• Tight glycemic control for Type 2 diabetes, present in 1 of 4 people over 65, often requires 8 to 10 years before it helps prevent blindness, kidney disease or amputations. Without enough time to reap the benefits, the elderly endure needless dietary limits and needle sticks.

Yet Medicare, which pays for all of the above, does not, except in rare instances, pay for long-term care in a supervised, safe place for frail or demented old people, or for home aides to help with shopping, transportation, bathing and using the toilet.

Nationwide, the median annual cost of a nursing home in 2010 was $75,000; room and board in an assisted living facility, with no additional help, was $37,500; and the most basic category of home health aide, who can perform no medical tasks, like the dispensing of medication, was $19 an hour. These expenses are left to the elderly (and their adult children) to pay for out of pocket until their pockets are all but empty.

Then they are eligible for Medicaid, the state-run safety net for the poor. While Medicare, a federal program, is financed by payroll taxes, and thus is an "earned" benefit, Medicaid is "charity," in the minds of the formerly middle class who worked their whole lives and never imagined themselves destitute.

In the case of my mother, who died at 88 in 2003, room and board in various assisted living communities, at $2,000 to $3,500 a month for seven years, was not paid for by Medicare. Yet neurosurgery, which I later learned was not expected to be effective in her case, was fully reimbursed, along with two weeks of in-patient care. Her stay of two years at a nursing home, at $14,000 a month (yes, $14,000) was also not paid for by Medicare. Nor were the additional home health aides she needed because of staffing issues. Or the electric wheelchair after strokes had paralyzed all but the finger that operated the joy stick. Or the gizmo with voice commands so she could tell the staff what she needed after her speech was gone.

She paid for the room. My brother and I paid for the private aides and bought her the chair and the "talking board." What would her life have been like without the skilled care she required and the ability to get around her floor and communicate her needs? I shudder to think. But none of this was Medicare's responsibility.

Yet Medicare would pay for "heroic" care for a woman who was dying of old age, not a disease that could be treated: Diagnostic tests. All manner of surgery. Expensive medications. Trips to the emergency room or the hospital — had she not refused all of them, in the last year of her life. So, in less than a decade, by my low-ball estimate, my mother spent $500,000 of her own money and uncalculated sums from her two children before winding up what she considered, with shame, "a welfare queen."

A recent state-by-state study of long-term care, the first of its kind, by a consortium of researchers, has found that this kind of essential help costs anywhere from 166 percent to 393 percent of the average annual income of America's elderly.

BY now, you may be wondering if your parents have a half million dollars for old age. Or if you or your children do. You may be counting on quick and easy deaths. Shoot me, so many people say. Alas, 70 percent of the elderly will need extended care before they die. Denial is powerful but doesn't pay the bills.

This mismatch between what is covered and what is actually useful is the central flaw in Medicare today, a shock to families who have no clue, until they're smack in the middle of it, about how this system works.

This mismatch tortures our elderly, drains the Medicare trust fund and leaves adult children with depleted retirement reserves. Yet in all the debate about the national debt, medical inflation and the need to pare Medicare costs by such means as raising the eligibility age, why is nobody, outside the insular community of long-term care providers, even mentioning the difference between acute and chronic care and how each is paid for (or not)?

Why is nobody enraged that our taxes are paying for hip replacements, for example, for people with advanced Alzheimer's disease, who are incapable of physical therapy? Why is nobody saying out loud, like it or not, that one of our great challenges is figuring out what to do about our elderly people, our fastest growing-population cohort, which will grow exponentially when 76 million baby boomers join the ranks?

The current system is unsustainable, but the alternative is the third rail of health care policy. President Obama's original legislation included Medicare reimbursement to doctors for discussion of end-of-life issues. These are what Sarah Palin called "death panels"; days later, they were cut from the legislation. An Independent Payment Advisory Board will make recommendations to Medicare about what works and what doesn't, beginning in 2015, but its proposals are not binding, as intended. A long-term-care insurance provision — with an average daily benefit of a mere $50 — is under siege.

Reading the history of the Medicare law, which was not intended for long-term care because today's technology and demographics were unimaginable then, one is struck by the battles and ultimate compromises between President Lyndon B. Johnson and Wilbur Mills, the head of the House Ways and Means Committee, who originally opposed Medicare.

That the crafting of that legislation was so difficult leaves one despairing that this pillar of the Great Society could now be rewritten, given our partisan incivility. But right now, according to the health economist Marilyn Moon, there are 47 million Medicare beneficiaries, costing a half trillion dollars a year, or one-fifth of the nation's health spending. In 2050, the population on Medicare will number 89 million. How scary is that?