Wall Street Journal, 12/25/08

Feeling a tad listless? Perhaps your DNA is insufficiently activated. You may want to consult the healers at Oughten House Foundation, specializing in “tools and techniques for self-empowerment . . . through DNA Activations.” Oughten House recommends regular therapy as part of its DNA Activation Healing Project, at $125 per hour-long session.

The foundation isn’t as far from the mainstream as you might think. A survey of 32,000 Americans by the National Center for Health Statistics, released earlier this month, suggests that 38% of adults use some form of “complementary and alternative medicine,” or CAM — now aggressively promoted for everything from Attention Deficit Disorder to the Zoster virus. The survey polled consumers on 10 provider-based therapies — for example, acupuncture — and 26 home remedies, such as herbal supplements.

Hundreds of colleges operating in all 50 states offer coursework in sundry CAM disciplines. Many more advertise online. Typical is the Global College of Natural Medicine, which is somewhat more welcoming than traditional medical schools: Its literature cheerfully advises that even “if you do not hold a high school diploma or equivalent you can still enroll online today.” A 60% grade on an admission exam puts you on the path to becoming a nutritional consultant, master herbalist or holistic chef for animals.

This should be a laughing matter, but it isn’t — not with the Obama administration about to confront the snarling colossus of health-care reform. Today’s ubiquitous celebration of “empowerment,” combined with disenchantment over the cost, bureaucracy and possible side effects of conventional care, has spurred an exodus from medical orthodoxy. As a result, what was once a ragtag assortment of New Age nostrums has metastasized into a multibillion-dollar industry championed by dozens of lobbyists and their congressional sympathizers. Among the most popular therapies are acupuncture, at $50 to $100 per session; reflexology, which involves massaging various parts of the hands and feet, starting at $35 an hour; and aromatherapy, which relies on the supposed healing properties of about 40 “essential oils,” with treatments at $30 to $90 an hour.

The largest well-documented study of CAM’s financial footprint, a decade ago in the Journal of the American Medical Association, estimated that Americans spent $36 billion to $47 billion on CAM in 1997, depending on how one defined the category. Since then, at least 40 states have begun licensing CAM practitioners. Major hospital systems, notably Baltimore’s Johns Hopkins and New York’s Sloan-Kettering Cancer Center, incorporate CAM-based programs like aromatherapy and therapeutic touch, often bracketed as “integrative medicine.”

Indeed, one of the great ironies of modern health care is that many of the august medical centers that once went to great lengths to vilify nontraditional methods as quackery now have brought those regimens in-house. “We’re all channeling East Indian healers along with doing gall-bladder removal,” says Arthur Caplan, director of the University of Pennsylvania’s Center for Bioethics. Mr. Caplan harbors no illusions about what’s behind the trend: “It’s not as noble as, ‘I want to be respectful to Chinese healing arts.’ It’s more, ‘People are spending a fortune on this stuff! We could do this plus our regular stuff and bill ‘em for all of it!’”

Fees for CAM services are increasingly passed on to insurance through a creative — some might say fraudulent — interpretation of the Current Procedural Terminology codes that govern reimbursement for authorized services. (Various tutorials, some online, guide practitioners through the reimbursement maze.) Such creativity may soon be unnecessary if the alternative medicine proponents have their way. For example, ABC Coding Solutions, a medical-software company, has been promulgating a set of 4,000 treatment codes that cover “nearly every healing modality practiced by alternative healthcare providers,” to quote one report. If such codes are fully absorbed by the health-care industry, CAM will have been mainstreamed — while bypassing all the customary peer review, controlled studies and other hallmarks of sound medicine.

Not by coincidence is CAM most avidly touted by a loose alliance of self-help gurus (Andrew Weil, Deepak Chopra, et al.) and veteran hucksters like erstwhile infomercial king Kevin Trudeau. Mr. Trudeau has been sued for deceptive business practices several times by the Federal Trade Commission. In 2004, the agency deemed his sins so egregious that it barred him from “appearing in, producing, or disseminating future infomercials that advertise any type of product, service, or program to the public.” Undaunted, Mr. Trudeau reinvented himself as a health-care expert and, the following year, published the runaway best seller “Natural Cures ‘They’ Don’t Want You to Know About.” The book continued to sell briskly even after the New York State Consumer Protection Board warned that it “does not contain the ‘natural cures’ for cancer and other diseases that Trudeau is promising.”

Meanwhile, CAM has secured its own beachhead within the National Institutes of Health in the form of the National Center for Complementary and Alternative Medicine (NCCAM). “Special commercial interests and irrational, wishful thinking created NCCAM,” writes Wallace Sampson, a medical doctor and director of the National Council Against Health Fraud, on the Web site Quackwatch.com. And Sen. Tom Harkin (D., Iowa), who credited bee pollen with quelling his allergies, was single-handedly responsible for the $2 million earmark that provided seed money for NCCAM, chartered in 1992 as the Office of Alternative Medicine. Despite the $1 billion spent in the interim, the center has failed to affirm a single therapy that can withstand the rigors of science.

Even the center’s own fact sheets unfold as unintentionally comical. After noting that echinacea is “traditionally used to treat or prevent colds, the flu and other infections,” the center concedes that “most studies to date indicate that echinacea does not appear to prevent colds or other infections.” St. John’s Wort as a natural antidepressant? “Two large studies, one sponsored by NCCAM, showed that the herb was no more effective than placebo in treating major depression.” Evening primrose for hot flashes? “Does not appear to affect menopausal symptoms.” And so forth. “It is the only entity in the NIH devoted to an ideological approach to health,” writes Dr. Sampson, who has called for the center to be defunded.

Is there anecdotal evidence that unconventional therapies sometimes yield positive outcomes? Yes. There’s also anecdotal evidence that athletes who refuse to shave during winning streaks sometimes bring home championships. It was George D. Lundberg, a former editor of the Journal of the American Medical Association, who said: “There’s no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data.” We’d do well to keep that in mind as we plot the future of American health care. It’s not like we’ve got billions to waste.

Mr. Salerno is the author of “SHAM: How the Self-Help Movement Made America Helpless.” He blogs at www.shamblog.com.

Source reference:
Hutson H, et al “Excessive use of force by police: a survey of academic emergency physicians” Emerg Med J 2008; 26: 20-22.

ABSTRACT

Objective: To determine the clinical experience, management and training of emergency physicians in the suspected use of excessive force by law enforcement officers.

Methods: Surveys were mailed to a random sample of academic emergency physicians in the USA.

Results: Of 393 emergency physicians surveyed, 315 (80.2%) responded. Of the respondents, 99.8% (95% CI 98.2% to 100.0%) believed excessive use of force actually occurs and 97.8% (95% CI 95.5% to 99.1%) replied that they had managed patients with suspected excessive use of force. These incidents were not reported by 71.2% (95% CI 65.6% to 76.4%) of respondents, 96.5% (95% CI 93.8% to 98.2%) had no departmental policies and 93.7% (95% CI 90.4% to 96.1%) had not received training in the management of these cases.

Conclusions: Suspected excessive use of force is encountered by academic emergency physicians in the USA. There is only limited training or policies for the management of these cases.

AP, 12/27/08

Gainesville’s first community hospital has been on life support since the Shands Healthcare system in northern Florida bought it a dozen years ago.

Now, because of the recession, the plug is being pulled on 80-year-old, money-losing Shands AGH. Next fall, its eight-hospital not-for-profit parent company will shut the 220-bed hospital and shift staff and patients to a newer, bigger teaching hospital nearby as part of an effort to save $65 million over three years across the system.

Like many U.S. hospitals, Shands is being squeezed by tight credit, higher borrowing costs, investment losses and a jump in patients — many recently unemployed or otherwise underinsured — not paying their bills.

All that has begun to trigger more hospital closings — from impoverished Newark, N.J., to wealthy Beverly Hills, Calif. — as well as layoffs, other cost-cutting and scrapping or delaying building projects.

More closings and mergers are on the way, industry consultants predict.

“They’ll get swallowed up by somebody else, if they need to exist, and if they don’t, they’ll just close,” said Tuck Crocker, vice president of the health care practice at management consultant BearingPoint.

Most endangered are rural hospitals and urban ones in areas with excess hospital beds and a lot of poor, uninsured patients.

Hospitals, which employ 5 million people, are reporting that donations and investment returns are down, patient visits are flat and profitable diagnostic procedures and elective surgeries are declining as people with inadequate insurance delay care. But those patients are turning up later at ERs, seriously ill, making it tough for hospitals to lay off nurses and doctors.

All those problems are aggravating long-standing stresses: stingy reimbursements from commercial insurers, even-lower payments that generally don’t cover costs for Medicare and Medicaid patients, and high labor and technology costs.

Hospital executives and consultants say the growing number of people with high-deductible health plans is boosting unpaid patient bills. Many worry health reform efforts by the Obama administration could bring cuts in Medicare reimbursements, and many cash-strapped states already have begun cutting payments for poor people covered by Medicaid.

In the past few months, patients and insurers have been paying hospital bills more slowly. As a result, some think hospitals will start demanding up-front payments for elective procedures.

In November, Moody’s Investors Service changed its 12- to 18-month outlook from “stable” to “negative” for nonprofit and for-profit hospitals, citing “prospects of a protracted recession,” bad debt and the credit crunch.

“Looking forward, the cost of borrowing will likely be higher — and may be nonexistent for lower-rated hospitals,” Moody’s noted, a problem because hospitals borrow for everything from expansions and equipment to payroll and supplies.

Since October, there’s been “a dramatic slowdown” in plans for new wings and building upgrades, with many delayed indefinitely, said Paul Keckley of the Deloitte Center for Health Solutions.

“It probably means we won’t have as many new things in the hospital,” he predicted.

Tim Goldfarb, CEO of Gainesville-based Shands Healthcare, said his system, Florida’s second-largest provider of charity care, this year has seen bad debt jump 20 percent from patients with no insurance.

“We write them off,” Goldfarb said. “It’s a burden that we cannot carry any longer.”

Florida started cutting Medicaid reimbursements two years ago, when its economy started to slow, Goldfarb said. He fears another huge cut next year.

Shands already has paid off variable-rate bonds to avoid higher interest rates, deferred roughly $25 million in equipment purchases, shifted management meetings to church halls and adopted employee suggestions to save millions more.

Goldfarb believes closing Shands AGH will save nearly $100 million over seven years, mainly by avoiding costly renovations, but some administrative jobs will go.

Around the country, while some hospitals still are doing well, closings and bankruptcies seem to be picking up.

In New Jersey, where 47 percent of hospitals posted losses in 2007, five of the 79 acute-care hospitals closed this year, and a sixth may close soon. In Hawaii, nearly every hospital is in trouble, with two filing for bankruptcy and one nearly closing recently.

All over, hospitals are cutting costs by outsourcing services like housekeeping and security and trimming staff through layoffs, hiring freezes and attrition. Most are trying not to touch patient care jobs — nurses, pharmacists, therapists and X-ray technicians — as those already have staff shortages.

“The last thing we can do is skinny down our staffing right where we need it the most,” said Mike Killian, marketing vice president for the three Beaumont Hospitals in suburban Detroit.

There, auto industry job losses and other factors now equal fewer patients with commercial insurance. The system expects a $22 million loss, its first in at least 40 years, Killian said.

So Beaumont this fall announced a $60 million restructuring program that includes 4-10 percent pay cuts for doctors and managers, reducing overtime for some employees and eliminating 500 jobs, 200 already vacant, mostly outside of patient care. Rich Umbdenstock, chief executive of the American Hospital Association, said some of the hardest-hit hospitals began reducing staffing and services as early as last spring and more will follow. He expects some to eliminate services — money-losers such as behavioral health treatment, or those with high operating costs such as burn units — rather than weaken their entire operation.

An association survey of more than 700 hospitals found two-thirds have seen elective procedures and overall admissions fall since July, and half have seen moderate or significant jumps in nonpaying patients.

An industry database on more than 550 hospitals found their third-quarter investment results amounted to a combined loss of $832 million, down from a $396 million gain a year earlier. During the quarter, those hospitals paid 15 percent more in borrowing costs and swung to a 1.6 percent average loss, from an average 6.1 percent profit margin a year ago.

“They’re having serious problems getting the capital they need for needed renovations and upgrading their facilities,” said Mike Rock, a lobbyist at AHA, which is seeking increased federal reimbursements from Medicaid and Medicare.

At Exempla Healthcare, with three hospitals in Denver and its suburbs, Chief Executive Jeff Selberg said there’s usually a 5-7 percent annual profit margin, but this year investment losses wiped that out. He’s scaled back a $200 million plan to upgrade facilities, information technology and clinical equipment and may halt construction of a new maternity unit and operating rooms at one hospital.

Selberg has seen a slight increase in bad debt and expects more problems.

“We feel like the wave is coming, but it hasn’t hit yet, and we don’t know how big this wave is going to be,” he said.

An observational, prospective study comparing tibial and humeral intraosseous access using the EZ-IO
Pages 8-15 in Amer J Emerg Med (1/09) by
Marcus Eng Hock Ong, Yiong Huak Chan, Jen Jen Oh, Adeline Su-Yin Ngo  

Original Contribution

Chicago Tribune, 12/29/08

Heart disease is the leading cause of death for women in the U.S., yet a wealth of data shows female cardiac patients receive inferior medical care compared with men.

Too many physicians still discount the idea that a woman could be suffering from heart disease, delaying or denying needed medical interventions, experts note. Most community hospitals in the U.S. still are not following guidelines for treating women with heart attacks. And primary care doctors don’t do as much as they could to emphasize prevention.

As a result, women are failing to reap the full benefits of enormous advances in cardiovascular medicine.

The point was underscored this month by a study published in the journal Circulation finding that women who have heart attacks receive fewer recommended treatments in hospitals than men, including aspirin, beta blocker medications, angioplasties, clot-busting drugs and surgeries to re-establish blood flow. Women with the most serious heart attacks, known as STEMIs, were significantly more likely to die at a hospital than men.

“We need to do a better job of defining women’s symptoms and treating them aggressively and rapidly, as we do for men,” said Dr. Hani Jneid, the study’s lead author and assistant professor of medicine at the Baylor College of Medicine in Houston.

In Israel, when guidelines have been applied much more rigorously, the mortality difference between the sexes all but disappeared, according to a July study in the American Journal of Medicine.

Outside hospitals, too few internists, family doctors, obstetricians and gynecologists are implementing recommendations for preventing heart disease in women, experts say. Eighty percent of heart attacks in women could be prevented if women changed their eating habits, got regular exercise, managed their cholesterol and blood pressure, and followed other preventive measures.

Although death rates from cardiovascular disease have fallen, the condition killed 455,000 women in 2006, according to data from the American Heart Association. Heart disease causes about 72 percent of cardiovascular fatalities; the rest are strokes and other related conditions.

The next decade could see major advances as scientists better understand how the biology of heart disease differs in women, said Dr. Joan Briller, director of the Heart Disease in Women program at the University of Illinois Medical Center at Chicago.

Already, for example, researchers have learned that plaque deposits tend to be spread more widely in women than in men, resulting in fewer big blockages in the arteries. That means standard therapies such as angioplasty are often less effective in women. Also, woman metabolize certain heart drugs at a different rate than men.

Women should learn about the symptoms of acute heart disease—which can differ from those in men—respond promptly if they sense something is wrong, and “find physicians who care about them,” said Dr. Annabelle Volgman, medical director of the Heart Center for Women at Rush University Medical Center.

“Ask your doctor: Are you familiar with the guidelines for the prevention of heart disease in women published in 2007? Do you follow them? If they say ‘no,’ find yourself another doctor,” she said.

NY Times, 12/30/08

Wall Street Journal (12/30/08)

Obama Will Ration Your Health Care

Think of his health plan as a federal HMO.

By Sally Pipes

People are policy. And now that President-elect Barack Obama has fielded his team of Tom Daschle as secretary of Health and Human Services and Melody Barnes as director of the White House Domestic Policy Council, we can predict both the strategy and substance of the new administration’s health-care reform.

The prognosis is not good for patients, physicians or taxpayers. If Mr. Daschle meant what he wrote in his book “Critical: What We Can Do About the Health-Care Crisis,” Americans can expect a quick, hard push to build more federal bureaucracy, impose price controls, restrict medicines and technology, boost taxes, mandate the purchase of health insurance, and expand government health care.

In his book, Mr. Daschle proposes a National Health Board to regulate the way health care is provided. This board would have vast powers in regulating the massive federal health-care system — a system that includes Medicare, Medicaid, and other programs. Under Mr. Obama, it is likely that that system will be expanded and that new government insurance for the nonelderly, nonpoor will be created.

Given the opportunity, Mr. Daschle would likely charge the board with determining which treatments and drugs are cost effective and therefore permissible to use for patients covered by the government. And because the government is such a big player in the health-care market (46% of health-care spending comes from the government), the board would effectively set parameters for private insurers.

It is nearly certain that the process of determining which drugs and which treatments would be approved for use would be quickly politicized. The details of health-care policy may not be kitchen table conversation, but the fact that a Washington committee can deny grandma a hip replacement due to her age, or your sister a new and expensive drug, is. Health care is personal and voters will pressure lawmakers on access to care.

Liberal experts, Mr. Daschle included, believe that America needs to ration new technology and drugs. In his book, Mr. Daschle complains about overuse of new technology and praises the United Kingdom’s National Institute for Health and Clinical Excellence (NICE), a rationing system that controls government costs. NICE’s denial of care is legendary — from the arthritis drug Abatacept to the lung cancer drug Tarceva. These drugs are effective. It’s just that the bureaucrats don’t consider them cost effective.

Americans will not put up with such limits, nor will our elected representatives. Mr. Daschle himself proves this. He punts the hard decisions about rationing to an unelected board. Yet his main proposals are not only about expanding subsidized programs to cover more people but about adding the massively expensive benefit categories of mental health, which has a strong lobby behind it, and long-term care, which is important to the broad middle class.

One of the great myths in health care is that the uninsured are responsible for driving up private premiums by shifting costs. Uncompensated care certainly shifts some costs to private payers. Yet these costs are actually quite manageable in the aggregate, akin to what retailers lose due to shoplifting. The major cost shift is from government programs — Medicare and Medicaid — to private plans. The government pays doctors to treat Medicare and Medicaid patients. But the rates it pays, on average, are less than the cost for providing care to these patients. This is why Medicaid patients, and increasingly Medicare patients, struggle to find doctors. Putting more people on these programs will destabilize the remaining private system and create a coalition for price and wage controls.

Americans will never tolerate this. Remember our managed-care experiment in the 1990s. It succeeded in its main goal of controlling costs without an aggregate reduction in health quality. But in asking Americans to limit their choices, it prompted a bipartisan act of Congress to provide patients with a Bill of Rights. Now Mr. Daschle proposes nothing less than a giant HMO with a federal bureaucracy setting the benefit plan.

Mr. Daschle’s model is Massachusetts. But Massachusetts’s plan is an unfolding disaster and demonstrates how Mr. Daschle’s private/public model is merely a stalking horse for government-dominated health care.

The headline claim is that the program has signed up 442,000 more people for health insurance. The reality is that 80,000 of these were simply put on Medicaid and 176,000 more on the taxpayer-subsidized plans. Costs have exploded, requiring additional tax hikes and the entire system is only possible due to sizable transfers from the federal government. The plans are so unaffordable that in 2007, 62,000 people were exempted from the individual mandate. So much for universal coverage.

The only way the Massachusetts plan will survive is with continued and increasing federal subsidies — that is, tax revenue from the residents of other states. The only way Mr. Daschle’s proposed plan would survive is with massive deficit spending — that is, with taxpayer money from future Americans, many of whom are not yet born.

Mr. Daschle and the Democrats have spent years developing both the policy and political strategy to make the final push for taxpayer-financed universal health insurance. They have the players on the field, a crisis providing a sense of urgency, and a playbook filled with lessons learned from years of health policy reform disasters — most recently that of HillaryCare in 1994.

The big questions for believers in private medicine are at this point political and strategic. With employers and most insurers reportedly on board with the new administration’s desire for radical overhaul, who will step in to ask the tough questions? Will these issues get raised in time to provoke a meaningful, fact-based debate? Americans could easily find that Mr. Obama’s 100-day honeymoon ends with a whole new health-care regime they hadn’t quite bargained for.

Ms. Pipes, president and CEO of the Pacific Research Institute, is the author of “The Top Ten Myths of American Health Care: A Citizen’s Guide” (Pacific Research Institute, 2008).