BATON ROUGE – Jul. 15, 2009
– The LSU Health System today announced deployment of the first phase of
LSU’s new Electronic Health Records (EHR) system designed to create a network
of coordinated health care that is safer, more efficient, and less costly.
GE Healthcare has
been awarded a $12.5 million contract to create a filmless and paperless
central database and radiology image repository for securely sharing patient
imaging data among LSU’s 10 public hospitals and more than 500 clinics
statewide.
"The
selection of GE for the implementation of the radiology information system
and picture archiving is the first major building block of the LSU statewide
electronic health record system,” said Dr. Fred Cerise, LSU System Vice
President for Health Affairs and Medical Education. “This system will make digital X-rays
available at any LSU hospital and clinic throughout the state regardless of
where the X-ray was taken, increasing the knowledge about each patient and
making treatments more effective.”
Implementation of
GE’s Centricity RIS/PACS system, expected to take a year, is scheduled to get
underway in late August. Once
operational, LSU doctors and nurses will be able to access critical patient
information regardless of where it was acquired in better diagnosing and
treating cancer, heart disease, neurological disorders and a wide variety of
other illnesses.
“In addition to
patient safety, convenience, and cost benefits,” said Dr. Cerise, “this system
will allow radiologists at our referral centers to support patient care at
smaller hospitals. Similar to LSU's
statewide systems for primary care, chronic disease management, medication
access, and tertiary referral care, this initiative demonstrates the advanced
system of coordinated care that places LSU in the forefront of state,
regional, and national health care reform."
“This agreement
with LSU further demonstrates that GE Centricity is robust for an enterprise architecture, yet scalable to accommodate
different workflows at a variety of institutions in the academic setting, at
community hospitals, and at imaging centers,” said Don Woodlock,
Vice President and Global General Manager of GE Healthcare IT.
Completion of the
entire EHR system is expected to take five years at a projected cost of $116
million. LSU is in the process of
procuring software for the next phase of development, which is scheduled for
completion by March of next year, culminating in a contract with a single
prime vendor for the EHR operation.
The project is expected to be fully operational by December 2015.
On a related note,
the LSU Health Information Exchange (LSU-HIE) will be completed in three
months. The new service will enable
electronic records of all LSU patients to be available at any LSU hospital, a
capability especially important during hurricane evacuations when patients
are dispersed from homes. When the
LSU-HIE goes online this fall, LSU will have the
first statewide health information exchange in Louisiana.
http://www.lsusystem.edu/news/?action=view&id=78
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Advocate Capitol
News Bureau
The LSU Health
System on Wednesday announced the award of a contract for the first phase of
installation of a $116 million electronic health records system.
LSU awarded GE
Healthcare a $12.5 million contract to create a film-less and paperless
central database and radiology image repository for securely sharing patient
imaging data among LSU’s 10 public hospitals and more than 500 clinics
statewide.
The system is
designed to create a network of coordinated health care that is “safer, more
efficient, and less costly,” according to an LSU news release.
Completion of the
entire electronic health records system is expected to take five years.
LSU is in the
process of procuring software for the next phase of development, which is
scheduled for completion by March, culminating in a contract with a single
prime vendor for the health records operation. The project is expected to be
fully operational by December 2015.
“The selection of
GE for the implementation of the radiology information system and picture
archiving is the first major building block of the LSU statewide electronic
health record system,” said LSU System Vice President Fred Cerise in the
release.
“This system will
make digital X-rays available at any LSU hospital and clinic throughout the
state regardless of where the X-ray was taken, increasing the knowledge about
each patient and making treatments more effective.”
Implementation of
GE’s Centricity RIS/PACS system, expected to take a year, is scheduled to get
under way in late August.
Once operational,
LSU doctors and nurses will be able to access critical patient information
regardless of where it was acquired in better diagnosing and treating cancer,
heart disease, neurological disorders and a wide variety of other illnesses.
“In addition to
patient safety, convenience, and cost benefits,” said Cerise, “this system
will allow radiologists at our referral centers to support patient care at
smaller hospitals.
Similar to LSU’s
statewide systems for primary care, chronic disease management, medication
access, and tertiary referral care, this initiative demonstrates the advanced
system of coordinated care that places LSU in the forefront of state,
regional, and national health-care reform.”
http://www.2theadvocate.com/news/50907317.html
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The Associated
Press
(AP) — BATON
ROUGE, La.
- The LSU Health System has awarded a contract for the first phase of
installation of a $116 million electronic health records system.
LSU awarded GE
Healthcare a $12.5 million contract Wednesday to create a film-less and
paperless central database and radiology image repository for securely
sharing patient imaging data among LSU's 10 public hospitals and more than
500 clinics statewide.
LSU says the
system is designed to create a network of coordinated health care that is
"safer, more efficient, and less costly."
Completion of the
entire electronic health records system is expected to take five years.
http://www.nola.com/newsflash/index.ssf?/base/national-36/1247747740279510.xml&storylist=louisiana
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LSU Health
Sciences Center
New Orleans |
07.15.09
New Orleans, LA – Eduardo Davila, PhD, Assistant Professor
of Pediatrics, Microbiology, and Immunology at LSU Health Sciences Center New
Orleans School of Medicine and Stanley S. Scott Cancer Center, has been
awarded a $1.3 million grant over five years by the National Cancer Institute
of the National Institutes of Health to develop new immunotherapies,
including a vaccine, for cancer. Two years of the research will be supported
by the American Recovery and Reinvestment Act (ARRA).
Dr. Davila’s
research lab has been working with T lymphocytes, immune cells, which can
detect cancer. The LSUHSC research team has identified a novel signaling
pathway in T lymphocytes, and they have demonstrated that the stimulation of
specific proteins called toll-like receptors (TLRs)
on the surface of human T lymphocytes boosts the production of molecules
involved in tumor destruction. They have shown that TLRs
can induce potent and long-lived anti-tumor activity against a highly
aggressive melanoma tumor.
“One arm of this grant is looking at
generating/optimizing a cancer vaccine against melanoma and breast cancer,”
notes Dr. Davila. “Our preclinical data have indicated very promising results
showing that we can activate and sustain high numbers of tumor-specific
immune cells. Data using human cells parallel these studies and demonstrate
the ability to activate human cells indicating promise in treating cancer
patients.”
The LSUHSC
researchers are working to increase our understanding of the underlying
mechanisms of TLR activation and to define strategies to maintain potent TLR
signals in T cells with the aim of prolonging antitumor T cell responses.
“We envision these studies will make
possible new approaches for the development of effective T lymphocyte–based
therapies against cancer through a greater understanding of molecular signals
that enhance T cell activation to weakly immunogenic tumors in patients,”
says Dr. Davila. “These are the tumors that grow aggressively because the
body’s immune response to them is weak.”
The ARRA funding
is supporting the retention of a research technician and a postdoctoral
fellow in Dr. Davila’s laboratory, as well as the creation of one new position.
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By JORDAN BLUM
Advocate Capitol
News Bureau
The flagship LSU
campus is only planning to lay off 24 employees because of state budget cuts
to colleges.
Another 176 vacant
positions are also being axed, according to revised budget plans released
Wednesday.
The campus has
almost 3,300 employees. But nearly half could face furloughs — mandatory time
off without pay.
The LSU Board of
Supervisors meets today to approve or reject the budget plans submitted by
the LSU System’s five academic campuses, medical schools, law school,
biomedical research center and agricultural center.
Nearly 600
positions would be slashed systemwide, up from last
week’s estimate of more than 400. Since then, the main LSU campus and the University of New Orleans submitted additional job
vacancy eliminations.
LSU Chancellor
Michael Martin had said last week he anticipated about 100 layoffs.
In the revised
budget plan, Martin says the budget cut “effectively erases” the funding
increase given to LSU two years ago.
The main campus is
managing to only lay off 24 employees by implementing furlough plans for
1,700 employees. The move does not affect tenure-track faculty.
The Baton Rouge campus is
coping with a nearly $20 million cut, about a 9 percent decrease in state
funds. That does not count more than $8 million already slashed in January.
Gov. Bobby Jindal and the Legislature worked out a last-minute
compromise that was finalized June 25 to limit the budget cuts so colleges
could downsize more slowly, preparing for more budget reductions projected
through 2012.
Martin, who
proposed the furlough, has not seen eye-to-eye on the policy with LSU System
President John Lombardi, who has called furloughs a quick fix that fails to
solve long-term financial problems.
Lombardi has not
openly rejected the furlough plan though and the Board of Supervisors will
have the final say today. The LSU flagship is the only LSU campus opting for
a widespread furlough plan.
“I’m studying it
now,” said LSU Board Chairman Jim Roy on Wednesday when asked about the
budget plans. “I’m doing my homework for tomorrow’s (today’s) test.”
Martin did not
respond to a request for additional comment Wednesday.
The LSU Staff
Senate supports the furlough plan, according to LSU’s budget plan. Employees
making less than $30,000 would not be furloughed. Others, depending on their
pay scale, would be furloughed 35 to 69 hours, the equivalent of 2 to 4
percent of annual salaries.
Martin placed an
emphasis on the academic core by protecting that 35 percent of the
university’s total operating budget.
No tenure-track faculty are losing jobs, but a few instructors and
part-time adjuncts would. Also, close to 70 vacant faculty positions on the
main campus would be eliminated. The 70 position cuts include several
associated with LSU’s Multidisciplinary Hiring Initiative focused on hiring
clusters of faculty centered on a handful of nationally prominent faculty.
The biggest single
cut at LSU is to the Center for Advanced Microstructures and Devices on Jefferson Highway,
which would take a 58 percent or $3 million cut. Half of the 24 layoffs would
be at CAMD.
Ancillary units
being cut by 20 percent include the LSU Press, LSU Museum of Art, Rural Life Museum
and the Southern Review.
Individual
academic colleges would be cut from 2 to 5 percent.
The end result
would be some larger class sizes and fewer class options and electives
offered, according to the budget plan.
Fewer graduate
assistant jobs would be available for students. and
the LSU Library would shorten some of its weekend hours.
The LSU School
of the Coast and Environment reported that fewer resources would be available
for critical coastal restoration projects.
LSU’s recruiting
office would have to close its Dallas office,
hampering student recruiting in Texas,
which is a growing LSU market.
http://www.2theadvocate.com/news/education/50908912.html
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Meg Farris /
Eyewitness News
NEW
ORLEANS – After
state budget cuts, 141 people who work at the New Orleans Adolescent
Hospital got pink slips,
while 48 of those were offered a lower position.
Employees were
called in to a 4 p.m. meeting Wednesday afternoon and told who was laid off
and who was being reassigned to Southeast
Louisiana Hospital
in Mandeville.
"They laid myself off,” said a worker who did not want to be
identified. “I've been with the state 26 and a half years and no kind of job
offer, none. They didn't offer me any thing. They said that as of August the
14th, I won't have a job, and no kind of compensation or anything, nothing,
nothing for my years at NOAH.”
The worker said
she was not offered to go to Southeast
Louisiana Hospital
in Mandeville.
"We need this
facility and I've helped a lot of children here,” she said.
Now that NOAH is
closing, a patient’s mother said her son wouldn’t be going to Mandeville for
treatment.
"No indeed
no. I don't even know where that's at," said Michelle Dickens, whose
young son is an out patient at NOAH.
Dickens is hoping
that her son can continue to get his medications from a pediatrician or a
mental health out-patient clinic in town.
http://www.wwltv.com/topstories/stories/wwl071509cbnoah.445168f7.html#
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by Erica Werner,
The Associated Press
AP Photo/Ron Edmonds
President Barack Obama delivers remarks on health
care reform Wednesday in the Rose Garden of the White House in Washington.
WASHINGTON -- House Democrats are preparing to
advance legislation that would deliver on President Barack Obama's promise to
remake the nation's costly health care system and cover some 50 million
uninsured.
On the heels of
the Senate health committee's approval Wednesday of a plan to revamp U.S.
health care, three House committees with jurisdiction over the issue were
shifting into action.
Votes were planned
Thursday in the Education and Labor and Ways and Means committees on a $1.5
trillion plan that majority House Democrats presented this week. The
legislation seeks to provide coverage to nearly all Americans by subsidizing
the poor and penalizing individuals and employers who don't purchase health
insurance.
A third House
committee, Energy and Commerce, also was considering the measure Thursday,
but the road was expected to be rougher there. A group of fiscally
conservative House Democrats called the Blue Dogs holds more than
half-a-dozen seats on the committee -- enough to block approval -- and is
opposing the bill over costs and other issues.
Rep. Mike Ross,
D-Ark., who chairs the Blue Dogs' health care task force, said the group
would need to see significant changes to protect small businesses and rural
providers and contain costs before it could sign on. "We cannot support
the current bill," he said.
The Energy and
Commerce Blue Dogs met Wednesday to consider what amendments they would
offer, and the panel scheduled vote sessions daily through next Wednesday in
what promised to be an arduous process to reach consensus.
Obama was doing
all he could to encourage Congress to act. He scheduled White House meetings
for Thursday morning with two potential Senate swing votes, Sens. Ben Nelson,
D-Neb., and Olympia Snowe, R-Maine. On Wednesday he
met with a group of Senate Republicans in the White House in search of a
bipartisan compromise and appeared in the Rose Garden for the latest in a
daily series of public appeals to Congress to "step up and meet our
responsibilities" and move legislation this summer.
Obama also pushed
his message in network television interviews, and his political organization
launched a series of 30-second television ads on health care.
In an interview on
NBC, the president declared "there is no free lunch" and said again
that the country cannot afford to postpone dealing with the health care
problem.
"I think the
best way to fund it is for people like myself who
have been very lucky, to pay a little bit more," he said on CBS.
Wednesday's Senate
health committee vote "should make us hopeful -- but it can't make us
complacent," Obama said. "It should instead provide the urgency for
both the House and the Senate to finish their critical work on health reform
before the August (congressional) recess."
The health panel's
$615 billion measure would require individuals to get health insurance and
employers to contribute to the cost. The bill calls for the government to
provide financial assistance with premiums for individuals and families making
up to four times the federal poverty level, or about $88,000 for a family of
four, a broad cross-section of the middle class.
But the 13-10
party-line vote on the bill signaled a rift in Congress -- including between
Democrats. Some liberal-leaning Senate Democrats are eager to move forward
with or without Republican support, while some moderates want to hold out for
a bipartisan deal.
Sen. Chris Dodd,
D-Conn., who presided over the health committee vote, said it was more
important to get a good bill than to get GOP votes.
"There is a
value in achieving bipartisanship but I will not sacrifice a good bill for
that. That's not the goal here," Dodd said, noting that Democrats plus
two independents add up to 60 seats in the 100-member Senate -- the number
needed to advance legislation.
But a core group
on the Senate Finance Committee -- which, unlike the health committee, must
come up with a payment mechanism for the bill -- continued to labor toward
bipartisan agreement. Because it might be difficult to secure support from
all Democrats, Finance Chairman Max Baucus, D-Mont., insisted after daylong
meetings Wednesday that a bipartisan bill was needed.
"Nothing's
100 percent but I think it's virtually impossible to get 60 votes on a
partisan bill," Baucus said. He praised the health committee's work but
said of their legislation, "That's a partisan bill."
Obama has made
clear that he wants the Finance Committee to produce legislation by week's
end but Baucus couldn't say whether that would happen.
Finance Committee
members are considering a new proposal from Sen. Charles Schumer, D-N.Y.,
that would raise $100 billion over 10 years by imposing new fees on health
insurance companies.
http://www.nola.com/news/index.ssf/2009/07/house_democrats_move_to_votes.html
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HealthLeaders
Media | 07.16.09
Heather Comak
A significant portion of surgical residents think the hurs imposed on their work schedules inhibit their
surgical education and puts patients' safety at risk, according to a study
published in the July Journal of the American College
of Surgeons. Although not a majority, 41% of surgical residents included in
the study felt that the duty hour regulations implemented by the
Accreditation Council for Graduate Medical Education (ACGME) presented a
"moderate barrier" to their surgical education.
The duty hour regulations were originally put in place by
the ACGME in 2003 in an effort to prevent surgical errors, keep patients
safer, and give residents more time on their own by acknowledging that
overtired residents are more prone to make mistakes. Currently surgical
residents are required to work no more than 80 hours in a week, and have no
less than 10 hours between shifts. The Institute of Medicine is recommending
that residents working any overnight shifts of 30 hours or longer be given
time to nap and that residents work no longer than a 16 hour shift without
sleep.
Because of the ACGME hour restrictions, surgical residents
do report getting more sleep and having more time for their personal lives.
However, a significant of surgical residents percentage are reporting that
they think patients' safety is being negatively affected by the hour
restrictions due to increased patient handoffs and lack of continuity of
care. Forty-three percent of respondents felt that the ideal work week would
be between 80 and 100 hours, while 52% thought that the 60-80 hours was
adequate.
"We were surprised to find that nearly half of
surgical residents believe work-hour restrictions are actually an impediment
to their training," said Jacob Moalem, MD,
Department of Surgery, University of Rochester (NY) Medical Center,
and lead author of the study. "Our current system limits educational
opportunities for surgeons who are expressing a desire and a need to learn
more in a compact timeframe. Senior surgery residents should be given the
chance to control their own schedules as they continue to refine their
technical skills and transition into independent practice."
The study surveyed resident and associate members of the American College of Surgeons electronically, of
which 599 responded. They were asked to rate if the duty hour regulations
affected their surgical education, and also what the appropriate number of
hours per week they think should be worked during their postgraduate year
from the choices of less than 60, 60 to 80, 80 to 100, or more than 100.
Interestingly, residents who were closer to graduation
were those who more strongly felt that the duty hour regulations interfered
with their education as compared with residents in their first and second
years. Seven percent of junior residents reported that the duty hour
regulations did not impede on their education, while 32% of residents in or
post their seventh postgraduate year said they felt the regulations
interfered with their education.
The researchers concluded that having a "one size
fits all" rule for hours may not be the best practice. Instead, finding
a schedule that works for individual residents may result in safer patients
and better educated surgeons.
Although the hour limitations were put in place to promote
patient safety, there has been little evidence published to show that the
reduction in hours actually does improve patient safety. Some hospitals are
finding it difficult to balance the hour limitations while providing safe
care for patients and adequately educating surgeons. However, surgical
programs do strive for compliance and have focused more on promoting well
rested residents since 2003.
http://www.healthleadersmedia.com/content/235994/topic/WS_HLM2_PHY/Many-Surgical-Residents-Say-Current-Duty-Hour-Restrictions-Put-Safety-At-Risk.html
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HealthLeaders
Media | 07.16.09
Keri Mucci
Nearly three-quarters of nurses who participated in an
American Nurses Association (ANA) online poll that drew almost 15,000 responses
reported insufficient staffing at their workplace. Forty-two percent of
respondents also cited inadequate staffing as the reason they were
considering leaving their position—suggesting nurse shortages will worsen.
The results of the anonymous poll that's been live on the
Safe Staffing Saves Lives Campaign Web site since March 2008 were released
last week, illustrating the need for sufficient nurse staffing and nurses'
views on its significance to the delivery of quality patient care.
The majority (84%) of respondents indicated they were
employed at hospitals and most (76%) worked full-time. Nearly 75% were staff
nurses. Furthermore, nurse experience levels varied, with 55% reporting less
than 15 years experience and 45% more than 15 years.
While the number of respondents who reported staff
shortages is high, it isn't necessarily alarming, but concerning that it
still is an issue.
"Staffing has been an ongoing issue for
decades," says Isis Montalvo, MS, MBA, RN,
director of the ANA's National Center
for Nursing Quality. She adds that the ANA recognized concerns related to
sufficient staffing in the early 1990s. "During that time, a lot of
hospitals were reengineering and cutting back positions, and nurses knew that
cutting back positions would affect patient outcomes. The ANA [has since]
funded quite a bit of research and multiple studies to identify the linkages
between staffing and patient outcomes." The work continues with ANA's National Database of Nursing Quality Indicators®.
What may be surprising is nurses' candor about the effects
such staffing are having on patient care.
For example, more than half of the nurses (52%) who took
the poll reported the quality of care on their unit declined in the past
year, and half said they would not feel confident having someone close to
them receive care in their facility.
"By [the respondents] identifying ‘No, I wouldn't
come to this facility,' that says something because they're in that working
environment," Montalvo says. "And while
we want to all take pride in what we do, nurses are first and foremost
patient advocates. So they are being very candid about their work environment
and why they may not want family to come there."
Time—or nurses' lack of—appears to be one factor
influencing care quality.
Sixty-six percent of nurses reported that they
"always" perform non-nursing activities, such as delivering meals,
transporting patients, and drawing labs, while still carrying out their usual
nursing duties. A meager 2% reported "never" performing non-nursing
tasks. In addition, nearly one-quarter said they were "rarely" able
to take a full meal break.
Looking to the future, much needs to be done to keep
nurses from flocking from the profession. "When it comes to retaining
nurses and taking a look at the work environment, there are many aspects that
are very important for nurses," Montalvo says.
"Is there shared decision making? Are they being included in the
decisions that make an impact in their work environment, as for their
patients? Do they have autonomy in their respective roles?"
Montalvo also stresses the need
for collegial relationships, strong nurse leadership, and nurse managers with
the ability to support staff in their work and advocate on their behalf.
http://www.healthleadersmedia.com/content/235991/topic/WS_HLM2_LED/Poll-Finds-Many-Nurses-Believe-Staff-Shortages-are-Affecting-Patient-Care.html
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By RICARDO ALONSO-ZALDIVAR and BEN FELLER
WASHINGTON — President
Barack Obama achieved a milestone Wednesday when a Senate committee approved
a plan to revamp the U.S.
health care system. The Senate panel's action, which attracted no Republican
votes, came as the president's campaign organization rolled out television
ads to build support for his top domestic priority.
Obama met with Republicans at the White House in search of
an elusive bipartisan compromise on his call to expand coverage to the nearly
50 million uninsured Americans as well as restrain spending increases in
health care.
But the 13-10 party-line vote in the Senate health
committee signaled a deepening rift in Congress. While Democrats respond to
Obama's call for action with renewed determination, Republicans are using
harsher words to voice their misgivings.
In the House, Democrats began pushing legislation through
the first of three committees, although moderate and conservative members of
the rank and file were demanding changes. In the Senate, lawmakers were
considering fees on health insurance companies as a new source of potential
financing for a $1 trillion package that's short on funds.
"We have delivered on the promise of real
change," Sen. Christopher Dodd, D-Conn., said as he presided over the
Senate health committee vote, alluding not only to his bill but also to
Obama's campaign promise.
The president was in the Rose Garden for the latest in a
daily series of public appeals to Congress to "step up and meet our
responsibilities" and move legislation this summer. Obama also pushed
his message in network television interviews, telling employers that his plan
would require them to offer benefits or face a fine.
"If you can afford it, either give your employees
health insurance or pay into the pot so that we're not subsidizing you,"
Obama told CBS News.
He also reversed a campaign stance against requiring
everyone to buy health care coverage.
"I'm now in favor of some sort of individual mandate
as long as there's a hardship exemption," he said. "If somebody
truly just can't afford health insurance even with the subsidies that the
government is now providing, we don't want to double penalize them."
Wednesday's Senate health committee vote "should make
us hopeful — but it can't make us complacent," Obama said. "It
should instead provide the urgency for both the House and the Senate to
finish their critical work on health reform before the August recess."
The health panel's $615 billion measure would require
individuals to get health insurance and employers to contribute to the cost.
The bill calls for the government to provide financial assistance with
premiums for individuals and families making up to four times the federal
poverty level, or about $88,000 for a family of four, a broad cross-section
of the middle class.
Obama wants the House and Senate to act on health care
this summer so lawmakers can reconcile differences in their respective bills
after Labor Day and put final legislation on his desk this fall.
Obama's all-out effort since he returned from his overseas
trip last week has "galvanized things," Sen. Charles Schumer,
D-N.Y., said.
Obama met at the White House with Republican Sens. Susan
Collins of Maine, Saxby Chambliss of
Georgia, Bob Corker of Tennessee and Lisa
Murkowski of Alaska.
"I urged him not to rush consideration of the
bill," Collins told reporters later. "This bill is going to affect
virtually every American. If the president tries to rush this through in the
next two weeks ... I fear the process will be very divisive."
Another senior Republican, whom Obama courted only a few
months ago to become his commerce secretary, also sounded alarm bells.
"This supposed health care fix is a health care
failure and a disaster for the American people," Sen. Judd Gregg,
R-N.H., said. "We still have time to turn this process around instead of
steamrolling our country into a sub-par government-run plan, but it will
require serious action from Democrats and Republicans and a pledge to put
politics aside."
The debate is taking on a campaign-like edge. In the
cross-hairs are moderate senators, Democrats and Republicans, whose votes
could make the difference in a closely divided Senate.
Obama's political organization launched a series of
30-second television ads on health care, which were to begin airing Wednesday
in Washington
and on cable TV nationally. A version will run for two weeks on local
stations in Arkansas, Indiana,
Florida, Louisiana,
Maine, North Dakota,
Nebraska and Ohio to prod senators to back the health
care effort.
In the ads, private citizens describe problems they've had
with the medical system and say it's time for action. The sponsor is
Organizing for America,
Obama's campaign organization, which has become part of the national
Democratic Party. The group would not reveal the cost.
Sen. Ben Nelson, D-Neb., one of the lawmakers targeted,
said the ads would not affect his decision. He has concerns that the evolving
Democratic plans would give government too big a role.
Obama supports a government-run insurance plan to compete
with private insurers, but he says he doesn't want to overturn the system of
employer-sponsored health benefits that has served middle-class families for
better than half a century. He wants the legislation to be fully paid for and
the total cost kept around $1 trillion over 10 years.
"The American people have to recognize that there's
no such thing as a free lunch, right?" Obama told NBC News. "So we
can't just provide care to everybody that has no costs whatsoever."
Wednesday's vote in the Health, Education, Labor and
Pensions committee took the Senate only part of the way toward passage of an
overhaul bill. Another panel, the Finance Committee, still has to unveil its
approach. The plan is to combine the two bills for a floor vote.
Senate Finance Chairman Max Baucus, D-Mont., met Wednesday
with committee Democrats to try to settle how to pay for the bill and other
issues.
"We're just not quite there," Baucus said after
the meeting. Obama has pushed Baucus to have a bill ready by week's end, but
Baucus declined to say whether he'd made a timetable commitment to the
president.
Finance Committee members are considering a proposal from
Sen. Chuck Schumer, D-N.Y., that would raise $100 billion over 10 years by
imposing new fees on health insurance companies.
http://www.google.com/hostednews/ap/article/ALeqM5jlMpJGn28kqCcgU-aGcYE_ZHW-ywD99F7LBO0
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The New York Times | 07.15.09
Politics is so
often a salon sport, with its up-and-down arrows, weekly winners and losers,
and reliable hypocrisies providing sustainable entertainment for the
permanent class in Washington.
But every now and then elected officials do something that has deep and
lasting consequences — a generational life-changer.
This happened 44
years ago, with the creation of Medicare, the socialized health care plan for
the elderly. At the time, the poorest Americans were more often the oldest
Americans. And half of all seniors had no health care coverage.
Today, this
country is full of people who may hate everything about government but would
take up arms if you tried to get rid of Medicare. They came to this
conviction out of personal experience: seeing a spouse or parent live another 10 years because of treatment they otherwise
could never have afforded.
Now we have
arrived at an even bigger national moment. Within a few weeks, we will know
whether health care plans designed to eliminate a problem that has vexed
every president since Franklin Roosevelt will make it to this president’s
desk.
Both the House and
a committee in the Senate have just shown their cards in the political poker
game of the decade. The price of near-universal health, the House plan
indicates, will be about $1 trillion, paid for with a surtax on couples who
earn more than $350,000 a year, and a promise of savings in federal programs
and the considerable waste stream of the private system.
The measures would
require everyone to get health care, with subsidies for the poor. Employers,
except for smaller businesses, would have to provide insurance or pay a fee
to the government. And there would be a public option — a plan that would, in
theory, keep insurance companies honest by acting as a legitimate competitor.
The final bill
will likely be the kind of sausage that is never pretty in the making.
Speaking in Michigan
on Tuesday, President Obama tried to move the urgency meter.
“We have no choice
but to change the health care system,” he said, “because right now it’s
broken for too many Americans.”
But is it really
broken for enough Americans? That’s the overarching question behind the what’s-in-it-for-me check list. As with the debate
over care for the elderly, a system first proposed by President Harry Truman,
people will apply their own tests.
On that first
question, Obama will probably win. Polling consistently shows that majorities
of Americans like the quality of their health care ( their
doctors and therapists), but don’t like the coverage (their insurance
companies and H.M.O.’s).
Thus, even as the United States spends more per capita on health
care than any major country, the overall system is not well-loved, placing
the U.S. near the bottom
of countries that have confidence in their medical safety net, according to Gallup polling.
Will that
dissatisfaction trump warnings about the perils of socialized medicine,
waiting lists and the crush on business? Big money is counting that it won’t.
Consider the
campaign underway by a group called Patients United Now, which calls itself
“people just like you.” But unless you’re worth somewhere north of $10
billion — the reported wealth of the one of the men behind this phony
grassroots group, the oilman and right-wing activist David H. Koch — those
people aren’t anything like you.
This time around,
Harry and Louise, no matter how they are scripted in the public relations
battle ahead, may not overcome the anecdotal arguments for change.
About 48 million
Americans have no health care, which means most people are at least one
degree of separation from someone with no coverage. Texas — with nearly one-in-four lacking
coverage — leads the misery parade.
At the other end
are people who have terrific health care, even gold-plated, and will likely
find nothing in the legislative overhaul for them. But dissatisfaction runs
high even among those with good benefits.
We all know
somebody who is sticking with a lousy job because of the health care.
Economists call this “job lock,” and it stifles entrepreneurship and
mobility, among other things.
We may also know
someone who has remained married to the wrong person for the same reason.
Call this “marriage lock.”
Stories are legion
of people who went overseas for a medical procedure because it was cheaper,
or had an injury in Europe and were pleasantly
surprised that they never had to fill out a lengthy insurance form in the
emergency room.
Over the last
decade, the courts have processed millions of former members of the middle
class who lost it all on one catastrophic illness — the leading cause of most
personal bankruptcies.
And plenty of
people have had vital procedures rejected by their insurance company. That’s
one reason why only 4 percent of Americans in a USA Today poll this week said
they trust insurance companies to change health care. Congressional
Republicans, at 10 percent, were not far behind.
Employees with
otherwise adequate coverage complain that they can never get ahead because
salary raises are wiped out by hikes in premiums and co-pays. Over the last
10 years, the average family saw its premiums more than double, the Kaiser
Family Foundation found. This at a time of stagnant wages.
And it hurts small
businesses just as hard, because they carry so much of the nation’s health
care burden.
To change this
system is an enormous gamble, arguably on the magnitude of creating Social
Security. The costs are scary, and coupled with trillon-dollar
deficits, are prompting many independents to doubt the road that Obama has
chosen.
All of this will
make for a fast-round of shouting among all the interests groups, and a
stimulus package for lobbyists. But this time it may not matter: the future
of American health care could be decided by the politics of personal experience.
http://egan.blogs.nytimes.com/2009/07/15/health-cares-historic-moment/?scp=1&sq=Health%20Care%E2%80%99s%20Historic%20Moment&st=cse
[BACK TO TOP]
The New York Times | 07.15.09
By DENISE GRADY
A genetic test
that can find an increased risk of Alzheimer’s disease does no psychological
harm to people who take it, even if they test positive for a risky gene, a
new study finds.
The results
challenge views long held by the medical establishment, which has discouraged
people from being tested, arguing that the test is not definitive, that it
may needlessly frighten people into thinking a terrible disease is hanging
over them and that testing is pointless anyway because there is no way to
cure or prevent the dementia caused by Alzheimer’s.
“There has been
this extraordinary worry that disclosing risk was going to devastate people,”
said Dr. Robert C. Green, a professor of neurology, genetics and epidemiology
at Boston University, and the lead author of the study, which is being
published on Thursday in The New England Journal of Medicine. “This has
upended those assumptions.”
The idea behind
the study was to treat information like a drug, something with risks and
benefits that could be measured, Dr. Green said.
Dr. Green led a
large team in the study, called Reveal, in which 162
adults who had a close relative with Alzheimer’s could find out if they had
the genes that increased their risk for the disease. All participants had
genetic testing, but 51, picked at random, were not told the results. The
other 111 were told, and the two groups were compared.
Six weeks after
test results were given, all of the subjects filled out standardized surveys
for anxiety, depression and distress related to the test. They also filled
them out six months later, and one year later. There were no major
differences between the people who found out their test results and those who
did not.
“We did not find
significant psychiatric distress,” Dr. Green said.
In the study,
people who found out they did not have the risky gene were relieved, even
though they understood that they were still not in the clear. Those who
learned they had the gene were more likely than those who did not, or who did
not know, to regard their risk of Alzheimer’s as higher and to express
negative feelings about receiving the results. But those feelings did not
translate into distress. And those who had the gene were no less likely than
the others to say they would have the test all over again, the researchers
said.
The information
concerns a gene called APOE, for apolipoprotein E.
It is not a yes/no gene that absolutely determines a person’s fate. But APOE
does influence the risk for Alzheimer’s.
People inherit two
copies of APOE, and each copy comes in one of three types, e2, e3 or e4. E4
is unlucky. People with one copy have three to five times the risk of someone
who has no e4, and those with two copies of e4 have 15 times the risk, Dr.
Green said. (In the general population, the average lifetime risk of ever
developing Alzheimer’s is about 10 percent.) Compared to people with no e4,
those who have it also tend to decline more on memory tests as they age, even
without obvious symptoms of Alzheimer’s.
But APOE is not
definitive. Many people with e4 never become demented, and many Alzheimer’s
patients have no e4. That uncertainty helped turn the medical profession
against testing.
In the past, the
Alzheimer’s Association discouraged testing, but it has relaxed its stance in
the past few years, largely because of reports from the Reveal study. Even
so, William Thies, the association’s chief medical
and scientific officer, said that so far there had not been much demand for
the test, and that a direct-to-consumer company specializing in it had gone
out of business. Two authors of the study, but not Dr. Green, provided
consulting services to a company that was marketing APOE testing.
Two study
participants, among a half dozen whose telephone numbers were given to
reporters by Boston
University, said they
were pleased that they had joined the study. Amy Sumner, 45, a social worker
in Simsbury, Conn., said she had sought out the
research because there were several cases of Alzheimer’s in her grandmother’s
generation on her mother’s side. Ms. Sumner thought her test results might
help her mother and aunts (who do not have dementia) decide whether to be
tested. She turned out to have no copies of e4, a relief for her but not much
help for her relatives, who could still carry the gene.
She said her
mother and aunts were concerned about their risk but did not dwell on it,
adding, “All four are very strong, spiritual women and have a lot of peace
about it even though they’re concerned.”
Another
participant, Robert McKersie, 79, said he wanted
the test because his mother died of Alzheimer’s. Dr. McKersie
said he thought the test results might help him and his wife
decide whether to stay in their house or consider moving to an
assisted-living facility, just in case. He learned that he did have a copy of
e4 — but given his high scores on mental tests and the fact that he has
reached 79 with no intellectual decline, the researchers estimated his risk
as fairly low. Although is retired, Dr. McKersie is
still teaching business courses at the Sloan School of Management at the
Massachusetts Institute of Technology.
Despite the
study’s reassuring results, Dr. Green said it did not mean that APOE testing
was right for everybody. Some people who initially wanted to participate
changed their minds after they learned more about the test. Dr. Green also
cautioned that the study was small, participants were given extensive talks
by genetic counselors and they were followed for only one year. It is too
soon to tell whether the knowledge will begin to haunt them later in life. It
is also not clear whether being positive for e4 could hurt people
financially. Although a law enacted last year forbids health insurers and
employers to discriminate based on genetic tests, it does not apply to
insurance for long-term care or disabilities.
Some study
participants have already bought long-term care insurance specifically
because they learned they had an e4 gene, Dr. Green said, adding that this
scares long-term-care insurance companies. He said that when he mentioned
those purchases in a presentation to insurance executives, whom he described
as a staid group, some leapt to their feet and shouted that there would be no
more long-term-care insurance if too many people with risky genes started
buying policies.
http://www.nytimes.com/2009/07/16/health/research/16dementia.html
[BACK TO TOP]
The New York Times | 07.15.09
By PETER SINGER
You have advanced
kidney cancer. It will kill you, probably in the next year or two. A drug
called Sutent slows the spread of the cancer and
may give you an extra six months, but at a cost of $54,000. Is a few more months worth that much?
If you can afford
it, you probably would pay that much, or more, to live longer, even if your
quality of life wasn’t going to be good. But suppose it’s not you with the
cancer but a stranger covered by your health-insurance fund. If the insurer
provides this man — and everyone else like him —
with Sutent, your premiums will increase. Do you
still think the drug is a good value? Suppose the treatment cost a million
dollars. Would it be worth it then? Ten million? Is there any limit to how
much you would want your insurer to pay for a drug that adds six months to
someone’s life? If there is any point at which you say, “No, an extra six months
isn’t worth that much,” then you think that health care should be rationed.
In the current U.S.
debate over health care reform, “rationing” has become a dirty word. Meeting
last month with five governors, President Obama urged them to avoid using the
term, apparently for fear of evoking the hostile response that sank the Clintons’ attempt to
achieve reform. In a Wall Street Journal op-ed published at the end of last
year with the headline “Obama Will Ration Your Health Care,” Sally Pipes,
C.E.O. of the conservative Pacific Research Institute, described how in
Britain the national health service does not pay for drugs that are regarded
as not offering good value for money, and added, “Americans will not put up
with such limits, nor will our elected representatives.” And the Democratic
chair of the Senate Finance Committee, Senator Max Baucus, told CNSNews in April, “There is no rationing of health care
at all” in the proposed reform.
Remember the joke
about the man who asks a woman if she would have sex with him for a million
dollars? She reflects for a few moments and then answers that she would.
“So,” he says, “would you have sex with me for $50?” Indignantly, she
exclaims, “What kind of a woman do you think I am?” He replies: “We’ve
already established that. Now we’re just haggling about the price.” The man’s
response implies that if a woman will sell herself at any price, she is a
prostitute. The way we regard rationing in health care seems to rest on a
similar assumption, that it’s immoral to apply monetary considerations to
saving lives — but is that stance tenable?
Health care is a
scarce resource, and all scarce resources are rationed in one way or another.
In the United States,
most health care is privately financed, and so most rationing is by price:
you get what you, or your employer, can afford to insure you for. But our
current system of employer-financed health insurance exists only because the
federal government encouraged it by making the premiums tax deductible. That
is, in effect, a more than $200 billion government subsidy
for health care. In the public sector, primarily Medicare, Medicaid
and hospital emergency rooms, health care is rationed by long waits, high
patient copayment requirements, low payments to
doctors that discourage some from serving public patients and limits on
payments to hospitals.
The case for
explicit health care rationing in the United States starts with the
difficulty of thinking of any other way in which we can continue to provide
adequate health care to people on Medicaid and Medicare, let alone extend
coverage to those who do not now have it. Health-insurance premiums have more
than doubled in a decade, rising four times faster than wages. In May,
Medicare’s trustees warned that the program’s biggest fund is heading for
insolvency in just eight years. Health care now absorbs about one dollar in
every six the nation spends, a figure that far exceeds the share spent by any
other nation. According to the Congressional Budget Office, it is on track to
double by 2035.
President Obama
has said plainly that America’s
health care system is broken. It is, he has said, by far the most significant
driver of America’s
long-term debt and deficits. It is hard to see how the nation as a whole can
remain competitive if in 25 years we are spending nearly a third of what we
earn on health care, while other industrialized nations are spending far less
but achieving health outcomes as good as, or better than, ours.
Rationing health
care means getting value for the billions we are spending by setting limits
on which treatments should be paid for from the public purse. If we ration we
won’t be writing blank checks to pharmaceutical companies for their patented
drugs, nor paying for whatever procedures doctors choose to recommend. When public
funds subsidize health care or provide it directly, it is crazy not to try to
get value for money. The debate over health care reform in the United States
should start from the premise that some form of health care rationing is both
inescapable and desirable. Then we can ask, What is the best way to do it?
Last year Britain’s
National Institute for Health and Clinical Excellence gave a preliminary
recommendation that the National Health Service should not offer Sutent for advanced kidney cancer. The institute,
generally known as NICE, is a government-financed but independently run
organization set up to provide national guidance on promoting good health and
treating illness. The decision on Sutent did not,
at first glance, appear difficult. NICE had set a general limit of £30,000,
or about $49,000, on the cost of extending life for a year. Sutent, when used for advanced kidney cancer, cost more
than that, and research suggested it offered only about six months extra
life. But the British media leapt on the theme of penny-pinching bureaucrats
sentencing sick people to death. The issue was then picked up by the U.S. news media and by those lobbying against
health care reform in the United
States. An article in The New York Times
last December featured Bruce Hardy, a kidney-cancer patient whose wife, Joy,
said, “It’s hard to know that there is something out there that could help
but they’re saying you can’t have it because of cost.” Then she asked the
classic question: “What price is life?”
Last November, Bloomberg
News focused on Jack Rosser, who was 57 at the time and whose doctor had told
him that with Sutent he might live long enough to
see his 1-year-old daughter, Emma, enter primary school. Rosser’s wife,
Jenny, is quoted as saying: “It’s immoral. They are sentencing him to die.”
In the conservative monthly The American Spectator, David Catron, a health
care consultant, describes Rosser as “one of NICE’s
many victims” and writes that NICE “regularly hands down death sentences to
gravely ill patients.” Linking the British system with Democratic proposals
for reforming health care in the United States, Catron asked
whether we really deserve a health care system in which “soulless bureaucrats
arbitrarily put a dollar value on our lives.” (In March, NICE issued a final
ruling on Sutent. Because of how few patients need
the drug and because of special end-of-life considerations, it recommended
that the drug be provided by the National Health Service to patients with
advanced kidney cancer. )
There’s no doubt that
it’s tough — politically, emotionally and ethically — to make a decision that
means that someone will die sooner than they would have if the decision had
gone the other way. But if the stories of Bruce Hardy and Jack Rosser lead us
to think badly of the British system of rationing health care, we should
remind ourselves that the U.S. system also results in people going without
life-saving treatment — it just does so less visibly. Pharmaceutical
manufacturers often charge much more for drugs in the United States than they charge for the same
drugs in Britain,
where they know that a higher price would put the drug outside the
cost-effectiveness limits set by NICE. American patients, even if they are
covered by Medicare or Medicaid, often cannot afford the copayments for
drugs. That’s rationing too, by ability to pay.
Dr. Art Kellermann, associate dean for public policy at Emory
School of Medicine in Atlanta,
recently wrote of a woman who came into his emergency room in critical
condition because a blood vessel had burst in her brain. She was uninsured
and had chosen to buy food for her children instead of spending money on her
blood-pressure medicine. In the emergency room, she received excellent
high-tech medical care, but by the time she got there, it was too late to
save her.
A New York Times
report on the high costs of some drugs illustrates the problem. Chuck
Stauffer, an Oregon
farmer, found that his prescription-drug insurance left him to pay $5,500 for
his first 42 days of Temodar, a drug used to treat
brain tumors, and $1,700 a month after that. For Medicare patients drug costs
can be even higher, because Medicare can require a copayment of 25 percent of
the cost of the drug. For Gleevec, a drug that is
effective against some forms of leukemia and some gastrointestinal tumors,
that one-quarter of the cost can run to $40,000 a year.
In Britain,
everyone has health insurance. In the U.S., some 45 million do not, and nor
are they entitled to any health care at all, unless they can get themselves
to an emergency room. Hospitals are prohibited from turning away anyone who
will be endangered by being refused treatment. But even in emergency rooms,
people without health insurance may receive less health care than those with
insurance. Joseph Doyle, a professor of economics at the Sloan School of
Management at M.I.T., studied the records of people in Wisconsin who were injured in severe
automobile accidents and had no choice but to go to the hospital. He
estimated that those who had no health insurance received 20 percent less
care and had a death rate 37 percent higher than those with health insurance.
This difference held up even when those without health insurance were
compared with those without automobile insurance, and with those on Medicaid
— groups with whom they share some characteristics that might affect
treatment. The lack of insurance seems to be what caused the greater number
of deaths.
When the media
feature someone like Bruce Hardy or Jack Rosser, we readily relate to
individuals who are harmed by a government agency’s decision to limit the
cost of health care. But we tend not to hear about — and thus don’t identify
with — the particular individuals who die in emergency rooms because they
have no health insurance. This “identifiable victim” effect, well documented
by psychologists, creates a dangerous bias in our thinking. Doyle’s figures
suggest that if those Wisconsin accident
victims without health insurance had received equivalent care to those with
it, the additional health care would have cost about $220,000 for each life
saved. Those who died were on average around 30 years old and could have been
expected to live for at least another 40 years; this means that had they
survived their accidents, the cost per extra year of life would have been no
more than $5,500 — a small fraction of the $49,000 that NICE recommends the
British National Health Service should be ready to pay to give a patient an
extra year of life. If the U.S. system spent less on expensive treatments for
those who, with or without the drugs, have at most a few months to live, it
would be better able to save the lives of more people who, if they get the
treatment they need, might live for several decades.
Estimates of the
number of U.S.
deaths caused annually by the absence of universal health insurance go as
high as 20,000. One study concluded that in the age group 55 to 64 alone,
more than 13,000 extra deaths a year may be attributed to the lack of
insurance coverage. But the estimates vary because Americans without health insurance
are more likely, for example, to smoke than Americans with health insurance,
and sorting out the role that the lack of insurance plays is difficult.
Richard Kronick, a professor at the School of Medicine
at the University of California, San Diego,
cautiously concludes from his own study that there is little evidence to
suggest that extending health insurance to all Americans would have a large
effect on the number of deaths in the United States. That doesn’t mean
that it wouldn’t; we simply don’t know if it would.
In any case, it
isn’t only uninsured Americans who can’t afford treatment. President Obama
has spoken about his mother, who died from ovarian cancer in 1995. The
president said that in the last weeks of her life, his mother “was spending too
much time worrying about whether her health insurance would cover her bills”
— an experience, the president went on to say, that his mother shared with
millions of other Americans. It is also an experience more common in the United States
than in other developed countries. A recent Commonwealth Fund study led by
Cathy Schoen and Robin Osborn surveyed adults with chronic illness in Australia, Canada,
France, Germany, the Netherlands,
New Zealand, the United Kingdom and the United States. Far more Americans
reported forgoing health care because of cost. More than half (54 percent)
reported not filling a prescription, not visiting a doctor when sick or not
getting recommended care. In comparison, in the United
Kingdom the figure was 13 percent, and in the Netherlands,
only 7 percent. Even among Americans with insurance, 43 percent reported that
cost was a problem that had limited the treatment they received. According to
a 2007 study led by David Himmelstein, more than 60
percent of all bankruptcies are related to illness, with many of these
specifically caused by medical bills, even among those who have health
insurance. In Canada
the incidence of bankruptcy related to illness is much lower.
When a Washington
Post journalist asked Daniel Zemel, a Washington
rabbi, what he thought about federal agencies putting a dollar value on human
life, the rabbi cited a Jewish teaching explaining that if you put one human
life on one side of a scale, and you put the rest of the world on the other
side, the scale is balanced equally. Perhaps that is how those who resist
health care rationing think. But we already put a dollar value on human life.
If the Department of Transportation, for example, followed rabbinical
teachings it would exhaust its entire budget on road safety. Fortunately the
department sets a limit on how much it is willing to pay to save one human
life. In 2008 that limit was $5.8 million. Other government agencies do the
same. Last year the Consumer Product Safety Commission considered a proposal
to make mattresses less likely to catch fire. Information from the industry
suggested that the new standard would cost $343 million to implement, but the
Consumer Product Safety Commission calculated that it would save 270 lives a
year — and since it valued a human life at around $5 million, that made the
new standard a good value. If we are going to have consumer-safety regulation
at all, we need some idea of how much safety is worth buying. Like health
care bureaucrats, consumer-safety bureaucrats sometimes decide that saving a
human life is not worth the expense. Twenty years ago, the National Research
Council, an arm of the National Academy of Sciences, examined a proposal for
installing seat belts in all school buses. It estimated that doing so would
save, on average, one life per year, at a cost of $40 million. After that,
support for the proposal faded away. So why is it that those who accept that
we put a price on life when it comes to consumer safety refuse to accept it
when it comes to health care?
Of course, it’s one thing to accept that there’s a limit to how much
we should spend to save a human life, and another to set that limit. The
dollar value that bureaucrats place on a generic human life is intended to
reflect social values, as revealed in our behavior. It is the answer to the
question “How much are you willing to pay to save your life?” — except that,
of course, if you asked that question of people who were facing death, they
would be prepared to pay almost anything to save their lives. So instead, economists
note how much people are prepared to pay to reduce the risk that they will
die. How much will people pay for air bags in a car, for instance? Once you
know how much they will pay for a specified reduction in risk, you multiply
the amount that people are willing to pay by how much the risk has been
reduced, and then you know, or so the theory goes, what value people place on
their lives. Suppose that there is a 1 in 100,000 chance that an air bag in
my car will save my life, and that I would pay $50 — but no more than that —
for an air bag. Then it looks as if I value my life at $50 x 100,000, or $5
million.
The theory sounds
good, but in practice it has problems. We are not good at taking account of
differences between very small risks, so if we are asked how much we would
pay to reduce a risk of dying from 1 in 1,000,000 to 1 in 10,000,000, we may
give the same answer as we would if asked how much we would pay to reduce the
risk from 1 in 500,000 to 1 in 10,000,000. Hence multiplying what we would
pay to reduce the risk of death by the reduction in risk lends an apparent
mathematical precision to the outcome of the calculation — the supposed value
of a human life — that our intuitive responses to the questions cannot
support. Nevertheless this approach to setting a value on a human life is at
least closer to what we really believe — and to what we should believe — than
dramatic pronouncements about the infinite value of every human life, or the
suggestion that we cannot distinguish between the value of a single human
life and the value of a million human lives, or even of the rest of the
world. Though such feel-good claims may have some symbolic value in
particular circumstances, to take them seriously and apply them — for
instance, by leaving it to chance whether we save one life or a billion —
would be deeply unethical.
Governments
implicitly place a dollar value on a human life when they decide how much is
to be spent on health care programs and how much on other public goods that
are not directed toward saving lives. The task of health care bureaucrats is
then to get the best value for the resources they have been allocated. It is
the familiar comparative exercise of getting the most bang
for your buck. Sometimes that can be relatively easy to decide. If two drugs
offer the same benefits and have similar risks of side effects, but one is
much more expensive than the other, only the cheaper one should be provided
by the public health care program. That the benefits and the risks of side
effects are similar is a scientific matter for experts to decide after
calling for submissions and examining them. That is the bread-and-butter work
of units like NICE. But the benefits may vary in ways that defy
straightforward comparison. We need a common unit for measuring the goods
achieved by health care. Since we are talking about comparing different
goods, the choice of unit is not merely a scientific or economic question but
an ethical one.
As a first take,
we might say that the good achieved by health care is the number of lives
saved. But that is too crude. The death of a teenager is a greater tragedy
than the death of an 85-year-old, and this should be reflected in our
priorities. We can accommodate that difference by calculating the number of
life-years saved, rather than simply the number of lives saved. If a teenager
can be expected to live another 70 years, saving her life counts as a gain of
70 life-years, whereas if a person of 85 can be expected to live another 5
years, then saving the 85-year-old will count as a gain of only 5 life-years.
That suggests that saving one teenager is equivalent to saving 14
85-year-olds. These are, of course, generic teenagers and generic
85-year-olds. It’s easy to say, “What if the teenager is a violent criminal
and the 85-year-old is still working productively?” But just as emergency
rooms should leave criminal justice to the courts and treat assailants and
victims alike, so decisions about the allocation of health care resources
should be kept separate from judgments about the moral character or social
value of individuals.
Health care does
more than save lives: it also reduces pain and suffering. How can we compare
saving a person’s life with, say, making it possible for someone who was
confined to bed to return to an active life? We can elicit people’s values on
that too. One common method is to describe medical conditions to people —
let’s say being a quadriplegic — and tell them that
they can choose between 10 years in that condition or some smaller number of
years without it. If most would prefer, say, 10 years as a quadriplegic to 4
years of nondisabled life, but would choose 6 years of nondisabled life over
10 with quadriplegia, but have difficulty deciding between 5 years of
nondisabled life or 10 years with quadriplegia, then they are, in effect,
assessing life with quadriplegia as half as good as nondisabled life. (These
are hypothetical figures, chosen to keep the math simple,
and not based on any actual surveys.) If that judgment represents a rough
average across the population, we might conclude that restoring to
nondisabled life two people who would otherwise be quadriplegics is
equivalent in value to saving the life of one person, provided the life
expectancies of all involved are similar.
This is the basis
of the quality-adjusted life-year, or QALY, a unit designed to enable us to
compare the benefits achieved by different forms of health care. The QALY has
been used by economists working in health care for more than 30 years to
compare the cost-effectiveness of a wide variety of medical procedures and,
in some countries, as part of the process of deciding which medical
treatments will be paid for with public money. If a reformed U.S. health care system explicitly accepted
rationing, as I have argued it should, QALYs could
play a similar role in the U.S.
Some will object
that this discriminates against people with
disabilities. If we return to the hypothetical assumption that a year with
quadriplegia is valued at only half as much as a year without it, then a
treatment that extends the lives of people without disabilities will be seen
as providing twice the value of one that extends, for a similar period, the
lives of quadriplegics. That clashes with the idea that all human lives are
of equal value. The problem, however, does not lie with the concept of the
quality-adjusted life-year, but with the judgment that, if faced with 10
years as a quadriplegic, one would prefer a shorter lifespan without a
disability. Disability advocates might argue that such judgments, made by
people without disabilities, merely reflect the ignorance and prejudice of
people without disabilities when they think about people with disabilities.
We should, they will very reasonably say, ask quadriplegics themselves to
evaluate life with quadriplegia. If we do that, and we find that
quadriplegics would not give up even one year of life as a quadriplegic in
order to have their disability cured, then the QALY method does not justify
giving preference to procedures that extend the lives of people without
disabilities over procedures that extend the lives of people with
disabilities.
This method of
preserving our belief that everyone has an equal right to life is, however, a
double-edged sword. If life with quadriplegia is as good as life without it,
there is no health benefit to be gained by curing it. That implication, no
doubt, would have been vigorously rejected by someone like Christopher Reeve,
who, after being paralyzed in an accident, campaigned for more research into
ways of overcoming spinal-cord injuries. Disability advocates, it seems, are
forced to choose between insisting that extending their lives is just as
important as extending the lives of people without disabilities, and seeking
public support for research into a cure for their condition.
The QALY tells us
to do what brings about the greatest health benefit, irrespective of where
that benefit falls. Usually, for a given quantity of resources, we will do
more good if we help those who are worst off, because they have the greatest
unmet needs. But occasionally some conditions will be both very severe and
very expensive to treat. A QALY approach may then lead us to give priority to
helping others who are not so badly off and whose conditions are less
expensive to treat. I don’t find it unfair to give the same weight to the
interests of those who are well off as we give to those who are much worse
off, but if there is a social consensus that we should give priority to those
who are worse off, we can modify the QALY approach so that it gives greater
weight to benefits that accrue to those who are, on the QALY scale, worse off
than others.
The QALY approach
does not even try to measure the benefits that health care brings in addition
to the improvement in health itself. Emotionally, we feel that the fact that
Jack Rosser is the father of a young child makes a difference to the
importance of extending his life, but his parental status is irrelevant to a
QALY assessment of the health care gains that Sutent
would bring him. Whether decisions about allocating health care resources
should take such personal circumstances into account isn’t easy to decide.
Not to do so makes the standard inflexible, but taking personal factors into
account increases the scope for subjective — and prejudiced — judgments.
The QALY is not a
perfect measure of the good obtained by health care, but its defenders can
support it in the same way that Winston Churchill defended democracy as a
form of government: it is the worst method of allocating health care, except
for all the others. If it isn’t possible to provide everyone with all
beneficial treatments, what better way do we have of deciding what treatments
people should get than by comparing the QALYs
gained with the expense of the treatments?
Will Americans
allow their government, either directly or through an independent agency like
NICE, to decide which treatments are sufficiently
cost-effective to be provided at public expense and which are not? They
might, under two conditions: first, that the option
of private health insurance remains available, and second, that they are able
to see, in their own pocket, the full cost of not rationing health care.
Rationing public
health care limits free choice if private health insurance is prohibited. But
many countries combine free national health insurance with optional private
insurance. Australia,
where I’ve spent most of my life and raised a family, is one. The U.S.
could do something similar. This would mean extending Medicare to the entire
population, irrespective of age, but without Medicare’s current policy that
allows doctors wide latitude in prescribing treatments for eligible patients.
Instead, Medicare for All, as we might call it, should refuse to pay where
the cost per QALY is extremely high. (On the other hand, Medicare for All
would not require more than a token copayment for drugs that are
cost-effective.) The extension of Medicare could be financed by a small
income-tax levy, for those who pay income tax — in Australia the levy is 1.5 percent
of taxable income. (There’s an extra 1 percent surcharge for those with high
incomes and no private insurance. Those who earn too little to pay income tax
would be carried at no cost to themselves.) Those who want to be sure of
receiving every treatment that their own privately chosen physicians
recommend, regardless of cost, would be free to opt out of Medicare for All
as long as they can demonstrate that they have sufficient private health
insurance to avoid becoming a burden on the community if they fall ill.
Alternatively, they might remain in Medicare for All but take out
supplementary insurance for health care that Medicare for All does not cover.
Every American will have a right to a good standard of health care, but no
one will have a right to unrationed health care.
Those who opt for unrationed health care will know
exactly how much it costs them.
One final comment. It is common for opponents of health care
rationing to point to Canada
and Britain
as examples of where we might end up if we get “socialized medicine.” On a
blog on Fox News earlier this year, the conservative writer John Lott wrote,
“Americans should ask Canadians and Brits — people who have long suffered
from rationing — how happy they are with central government decisions on
eliminating ‘unnecessary’ health care.” There is no particular reason that
the United States
should copy the British or Canadian forms of universal coverage, rather than
one of the different arrangements that have developed in other industrialized
nations, some of which may be better. But as it happens, last year the Gallup organization did
ask Canadians and Brits, and people in many different countries, if they have
confidence in “health care or medical systems” in their country. In Canada,
73 percent answered this question affirmatively. Coincidentally, an identical
percentage of Britons gave the same answer. In the United States, despite spending
much more, per person, on health care, the figure was only 56 percent.
Peter Singer is
professor of bioethics at Princeton
University. He is also
laureate professor at the University
of Melbourne, in Australia. His most recent book
is “The Life You Can Save: Acting Now to End World Poverty.”
http://www.nytimes.com/2009/07/19/magazine/19healthcare-t.html
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The New York Times | 07.15.09
By MANDY KATZ
FIVE-FOOT-NINE and
184 pounds, Kathryn Griffith, a retired teacher in Oakland, Calif.,
counted calories for decades, trying everything from the grapefruit diet to a
regimen based on cabbage soup. She also did Weight Watchers — 27 times. “I
knew it wouldn’t be successful, but I went back anyway,” she said.
So earlier this
year, just when Oprah, the nation’s über-dieter,
renewed her resolve to snack on flaxseed, Ms. Griffith went the other way,
joining a tenacious movement that is scorning the diet industry and what one
pair of bloggers labels, “the obesity epidemic booga
booga booga.”
This movement — a
loose alliance of therapists, scientists and others — holds that all people,
“even” fat people, can eat whatever they want and, in the process, improve
their physical and mental health and stabilize their weight. The aim is to
behave as if you have reached your “goal weight” and to act on ambitions
postponed while trying to become thin, everything from buying new clothes to
changing careers. Regular exercise should be for fun, not for slimming.
“Fat acceptance”
ideas date back more than 30 years, but have lately edged into the
mainstream, thanks in part to public hand-wringing by celebrities like Oprah,
Kirstie Alley and the tennis player Monica Seles,
who said she had to “throw out the word ‘diet’ ” to deal with her weight
gain. (Oprah now cites her goal as being not “thin,” but “healthy and strong
and fit.”)
Even television is
bellying up to the bar, with Lifetime’s introduction of a hefty heroine in
“Drop Dead Diva” and a show having its premiere this month on Fox that
stresses the “reality” in reality TV. The show, “More to Love,” matches
plus-size dates with a bachelor boasting “a big waist and an even bigger
heart.” And elbowing the weight-loss guides on “health” bookshelves, is a spate
of new, more diet-neutral books that track the sociology of obesity,
including “The End of Overeating: Taking Control of the Insatiable American
Appetite” (Rodale Books) by David Kessler, the former surgeon general, and
“The Evolution of Obesity” (The Johns Hopkins University Press) by Michael L.
Power and Jay Schulkin.
Adding credence to
the “fat acceptance” philosophy, are recent medical studies that suggest a
little extra fat may not be such a bad thing. Among the latest is a 12-year
Canadian analysis in last month’s Obesity journal that confirmed earlier
findings that overweight “appears to be protective against mortality,” while
being too thin, like extreme obesity, correlates with higher death risk.
Other recent studies have linked weight cycling (or “yo-yo dieting”) to
weight gain, and to medical conditions often attributed to obesity.
Many appetite
warriors have coalesced under the banner of “Health at Every Size” (or HAES),
which is also the title of a book by Linda Bacon, a nutrition professor at
City College of San Francisco. Ms. Bacon ran a federally financed, randomized
trial to compare outcomes for 78 obese women who either dieted or were
schooled in Every Size precepts. The results, published in the Journal of the
American Dietetic Association in 2005, showed that HAES participants fared
better on measures of health, physical activity and self-esteem. Neither
cohort lost weight.
These pro-fat
results are a trickle, admittedly, in a flood of contrary reports that
condemn obesity as a health risk. But that doesn’t worry the online denizens
of the “fatosphere,” dominated by irreverent sites
like fatshionista.com Fat Rant and Big Fat Blog, as well as those of the “booga booga” bloggers, Kate
Harding (Shapely Prose) and Marianne Kirby (therotund.com). “Fat doesn’t
equal lazy or ugly or even, necessarily, unhealthy,” says another blogger,
the Fat Nutritionist.
Find it all too
much of a stretch? You’re not alone. Antidiet
advice defies a $30-billion weight loss industry, a cultural obsession with
thinness and the fundamental public health tenet that it is dangerous to be
fat. In Obesity Guidelines first published in 1998, the government’s National
Heart, Lung and Blood Institute blames obesity for everything from heart
disease to cancer. Within a month of the Canadian mortality report, University of Wisconsin researchers announced in
Science that calorie-restricted rhesus monkeys seemed to be outliving an
amply fed control group.
“Virtually
everyone who is overweight would be better off at a lower weight,” said
Walter Willett, chairman of the nutrition department at the Harvard School of
Public Health. “There’s been this misconception, fostered by the
weight-is-beautiful groups, that weight doesn’t
matter. But the data are clear.”
What remains
undisputed is that no clinical trial has found a diet that keeps weight off
long-term for a majority. “If they really worked, we’d be running out of
dieters,” said Glenn Gaesser, professor of exercise
physiology at Arizona
State University
and author of “Big Fat Lies: The Truth About Your Weight and Your Health.”
Both sides agree
that regular exercise, at any size, improves health. “If you want to know
who’s going to die, know their fitness level,” said Steven Blair, a
self-described “fat and fit” professor of exercise science, epidemiology and
biostatistics at the University
of South Carolina. His
research indicates that “obese individuals who are fit have a death rate one
half that of normal-weight people who are not fit.”
Still, giving up
dieting can be a tough sell in a society besotted with Kate Moss’s skeletal
build. In “Lessons From the Fat-O-Sphere,” a new book by Ms. Harding and Ms.
Kirby, the authors suggest surrounding yourself with nonjudgmental companions
as an antidote, and seeking out fat-friendly media like the “Illustrated BMI
Categories” photo set Ms. Harding assembled on Flickr.
So, if yo-yo
dieting often leads to weight gain, does quitting ever lead to weight loss?
Anecdotal evidence
suggests that many ex-dieters do slim down, especially if they are young.
Even Ms. Griffith, the retired teacher who is 67, lost several pounds after
quitting. Ms. Bacon, 46, ceased dieting in her 20s and wound up quite slim,
as did Susie Orbach, a psychotherapist who, as
author of “Fat Is a Feminist Issue” in 1978, was one of the earliest
intuitive-eating proponents. (Her latest book, “Bodies,” published this year,
addresses Western culture’s growing obsession with reshaping one’s body.)
But many who quit
do not reduce. Ms. Harding, 34, gave up dieting five years ago. “I thought,
‘O.K., maybe I could be a size 10, and it won’t be so bad.’ As it turned out,
I ended up as roughly an 18, which was exactly where I started.”
Yet, more than
size-acceptance may be involved in quitting. For many dieters, “the pursuit
of thinness as a dream is a place holder,” said Deb Burgard,
a clinical psychologist in Los Altos,
Calif., specializing in eating
disorders. “It gets in the way of asking, ‘What is it I am dreaming of?’ “
A dieter may
think, “ ‘If I could just lose weight, all that will
take care of itself,’ so they don’t invest in getting what they want,” she
said. Instead, she said, “they invest in weight loss.”
http://www.nytimes.com/2009/07/16/health/nutrition/16skin.html?bl&ex=1247889600&en=27743f2b8c546417&ei=5087%0A
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