Shake off the post-Thanksgiving blahs and get engaged

Get engaged in the healthcare debate, that is. (We try to avoid relationship directives.)  That debate is now heating up in a national capitol near you.

The D.C. Now blog reports this morning:

"The Senate's post-Thanksgiving debate over healthcare reform gets underway this week against a backdrop of apparent deep public division and slight disapproval.

"With the Senate poised to take up a healthcare overhaul that the Democrats and independent allies have voted to advance to debate and that the Republicans have voted to block, a Gallup poll today reports that 49% of Americans surveyed say they would advise their member of Congress to vote against a bill and 44% say they would recommend a vote for it."

Read more ...

And don't forget The Times' Healthcare Q and A's -- written with the reader in mind -- from our D.C. bureau.

Here's the latest: Breaking down the bills' projected costs: Readers also ask about the penalties for not buying health insurance; changes that veterans would see; interstate insurance plans; and whether the "public option" would cover mammograms.

-- Tami Dennis

Illustration credit: Karen Bleier / AFP / Getty Images

Healthcare must be rationed, including mammograms, doctor says

Yet another doctor has come out with a critique of the new breast cancer screening guidelines released last week by the U.S. Preventive Services Task Force.

Writing in the New England Journal of Medicine, Dr. Robert Truog of Harvard Medical School says routine screening for women between age 39 and 49 has cut the risk of death from breast cancer by 15%: “Clearly, screening mammography does offer an identifiable survival benefit to women in this age group.”

But he doesn’t necessarily oppose the task force’s final result. Though the expert group explicitly left cost out of the equation, Americans as a whole can’t afford the same luxury, Truog writes.

“Screening mammography for women in their 40s is clearly effective. The problem is that the benefit is tiny and expensive. … Statistician Donald Berry has calculated that for a woman in her 40s, a decade’s worth of mammograms would increase her lifespan by an average of 5 days – and this survival advantage would be lost if she rode a bicycle for 15 hours without a helmet (or 50 hours with a helmet).”

The Obama administration – supposed backer of cost-cutting “death panels” – doesn’t want to invoke what Truog calls the “R” word, and neither do Americans. But healthcare reform will never succeed if we don’t own up to the reality of rationing, he writes.

“Rationing is not a four-letter word. No health care system in the world, including our own, is free from the necessity of rationing. As long as a health care system has anything less than an infinite budget, there is a need to decide which types of health care will be funded and which will not.”

Seen in this light, the vitriol directed at the task force is understandable, but misguided, Truog writes:

“The choice is not between health care rationing and some undefined alternative, since there is no alternative. Rather, the choice concerns what principles we will use to ration health care. In the United States, we have traditionally rationed health care in the same way we ration expensive cars: those who can afford to pay for them are those who can have them. The alternative currently being considered in health care reform would involve a shift to other principles, such as those rooted in considerations of fairness, efficiency, and efficacy.”

-- Karen Kaplan

Photo: Are mammograms for women in their 40s with an average risk of breast cancer the best use for limited healthcare dollars? Credit: Rui Vieira/AP Wire

Good and bad preventive health ideas ... and where 'drunken cooking' fits in

In making the world a better place -- or, rather, a healthier place --  some people have a positive effect. Some have a negative effect. And others can only do so much in the face of overwhelming odds ...

Prevention Matters, the blog over at Partnership for Prevention, calls attention to the standouts. Each week, it offers up winners for Best Prevention Idea of the Week and Worst Prevention Idea of the Week.

This week's winner in the "best" category is a tobacco cessation program that managed to cut smoking rates among poor people in Massachusetts. Hard to argue with that choice ...

This week's winner in the "worst" category is radio host Glenn Beck for stating that the federal healthcare bill would offer insurance for dogs. Apparently that wasn't quite true. 

More interesting, however, was last week's winners.

The description of one honoree began: "People should get carryout instead of cooking while drunk, a senior fire officer has warned."

If the headache-inducing obviousness of such a statement elicits an expectation that such advice would handily win the "worst" honor, think again. The judge liked it. 

What the judge didn't like was Health News Review's decision not to rate TV health news for claims of accuracy and responsibility. It was apparently just too overwhelming for reviewer Gary Schwitzer. It's hard to fault the judge for wanting more analysis of TV news. It's impossible to fault Schwitzer for acknowledging he can't hold back the floodwaters. 

-- Tami Dennis

Photo: Not even a working smoke alarm could wake the man who prompted the "never cook after drinking" warning. He was rescued however -- and local fire officials were praised for their sage advice.

Credit: Los Angeles Times

Doctors embrace bariatric surgery as effective treatment for diabetes

Fifty international scientific and medical experts have issued a "consensus statement" declaring that bariatric surgery should be considered a treatment option for patients with Type 2 diabetes, even if they are not extremely obese.

The new guidelines, published today online in the Annals of Surgery, urge surgeons performing bariatric surgery and healthcare insurers reimbursing for such treatment to relax criteria, adopted in 1991, that have restricted such surgery to patients with a body-mass index of 35 or more.

Reviewing more than a decade's worth of studies on weight-loss surgery and diabetes, clinicians and researchers backing the document have concluded that the improved metabolic function that is typical in diabetic patients who undergo bariatric surgery is not merely an incidental effect of weight loss. "Surgery is a specific treatment for diabetes...the effect on diabetes is a direct consequence of the new anatomy created by surgery," said lead author Dr. Francesco Rubino, director of the gastrointestinal metabolic surgery program at New York-Presbyterian Hospital/Weill Cornell Medical College.

The implications, added Rubino in an interview, "are enormous." For starters, that finding should drive a broadening of the patient population offered the option of gastric bypass surgery or less invasive procedures that reduce the capacity of the gastrointestinal tract. Rubino said that patients with Type 2 diabetes that is poorly managed by diet, exercise and medicine should now routinely be assessed as surgery candidates.

Some of those will likely be far less overweight than the bulk of patients who have had the surgery for weight loss. Rubino cited the example of diabetic patients of Asian descent, who rarely reach a BMI of 35 but who might benefit from bariatric surgery.

For the more than 20 million Americans -- and counting -- thought to have Type 2 diabetes, bariatric surgery may offer more than just another treatment option. Research shows that for many patients, diabetes abates dramatically and permanently with surgery. That, said Rubino, makes the possibility of a "cure"--a prospect not discussed until very recently--real for many patients who have been told that "living with diabetes" is the best they can do.

Beyond that, said Rubino, clinicians caring for these patients will need to optimize their pre- and post-operative care to serve a new objective: that of improving metabolic function. Currently, many bariatric surgery patients continue on diabetes medicines after their operation when that might not be optimal or even necessary.

Finally, the consensus finding should guide the search for drugs that can better treat Type 2 diabetes. Those should focus on how metabolic function is changed by an alteration of the gut's anatomy, and whether drugs could be developed or adapted to work in the same way, Rubino said.

-- Melissa Healy

Plavix advertising indirectly cost taxpayers an extra $207 million over five years*

Advertising brand-name prescription medications directly to patients is a uniquely American custom, and a controversial one at that. A study published today in the Archives of Internal Medicine may stir new debate over the practice. In the case of one blockbuster drug, the study found, a major advertising campaign did little to expand the medication's use but brought price hikes that cost taxpayers hundreds of millions over a seven-year period.

Both critics and defenders of direct-to-consumer drug advertising agree on one thing: that the advertising of prescription medications will run up the bill that taxpayers foot to provide healthcare insurance to the elderly, disabled and poor through Medicare and Medicaid. When patients see commercials for a branded drug, they will ask for these medications in greater numbers, and they will get them, the reasoning goes.

But whether that higher price tag buys better healthcare is the point of dispute. Critics charge that advertising allows drug companies to pump up their sales to Medicare and Medicaid patients who might otherwise be treated with safer, cheaper medications. Defenders of the practice argue that drug ads spur more patients to seek treatment for conditions (such as high blood pressure or depression) that are widely under-diagnosed: Sure, it'll cost the taxpayer more, they say, but that's because more Medicare and Medicaid patients will get the treatment they need because they saw an ad.

But what if neither side is right? What if advertising a drug did not spur a rise in a drug's use, just in its price?

That, effectively, is what a pair of Canadians who teamed up with researchers from Harvard University and Kaiser Permanente found when they looked at the cost and use of the drug Plavix,* used to prevent blood clots, from 1999 to 2005. Plavix was on the market for two years, and its use was growing steadily when Bristol-Myers Squibb launched a major advertising campaign for the drug in 2001. Over the next five years, the drug company spent $350 million to promote Plavix in advertisements aimed at consumers.

But according to Michael Law of the University of British Columbia, the advertising campaign did not accelerate the growth in sales of Plavix, which reached $5.9 billion in 2005. While they continued to grow, Plavix sales grew no faster after advertising began than they had before the ads hit the airwaves.

But the cost of the drug certainly accelerated, Law found. Looking at Medicaid expenses in 27 states, Law and his co-authors found that the cost of Plavix shot up from $3.40 per prescription just before advertising began. "Immediately after [advertising] initiation, we found a large, sudden, and statistically significant increase" of 12% in the cost of a Plavix prescription. By the end of 2005, the cost to taxpayers a Plavix prescription filled by a Medicaid patient rose 25% beyond the more modest rate of inflation that would have been expected before advertising began.

Translation: In the Medicaid program alone, just 27 states spent a collective $207 million more on Plavix prescriptions after the big advertising campaign began than would have been expected. If one were to figure in the added cost to Medicare programs and the Medicaid programs of the remaining 23 states, the added cost would look like real money indeed.

Lawmakers in recent years have wrangled over whether and how to rein in drug advertising directed at patients rather than physicians, with no changes made to date. The authors say it's not time to put the debate aside. "Payers and policymakers should appropriately still be concerned about [direct-to-consumer advertising] increasing total drug costs for publicly funded reimbursement programs such as Medicare and Medicaid," they wrote.

--Melissa Healy

* An earlier version of this post incorrectly said that Plavis is a cholesterol drug.

What's another name for a tetanus shot? A 'preventive care vaccine'

Los Angeles Times columnist Steve Lopez takes on emergency room billing in his most recent column.

In describing a local resident's ER visit and aftermath, he begins: "Are you ready to play 'How much was that visit to the ER?'" The full column is here.

Both the fees, and the incomprehensible billing processes, are but symptoms.

-- Tami Dennis

HHS Secretary Kathleen Sebelius wades into the mammogram fray

The reaction to this week's U.S. Preventive Services Task Force recommendation against regular mammograms for women under 50 was swift, emotional and highly public. Today, Health and Human Services Secretary Kathleen Sebelius weighed in, pointing out that, well, the task force is actually just an independent panel offering advice, not setting policy, so ... just do what you've been doing.

Seriously. "My message to women is simple. Mammograms have always been an important lifesaving tool in the fight against breast cancer, and they still are today. Keep doing what you have been doing for years — talk to your doctor about your individual history, ask questions and make the decision that is right for you."

Here's her full statement.

(Enjoy the fallout, task force folks! You're on your own!)

If you want to know more about that panel, check it out here.

By the way, it's sponsored by the Agency for Healthcare Research and Quality, an agency that — we'll say it if few others will — is known for producing excellent work based on science, not emotion. That agency is within, yep, the Department of Health and Human Services.

Here's the original story: Mammogram guidelines spark heated debate

Plus a blog post on the reaction: Don't like those new mammogram recommendations? You're not alone

And here's today's story: Mammography outcry points to trouble for healthcare reform: Some Republicans say the new recommendations are an example of "rationing" that would take place under President Obama's plan to save money by basing treatment on experts' advice.

— Tami Dennis

Photo: HHS Secretary Kathleen Sebelius said she wanted to address recent confusion head on. Address it, she did. Clear it up? Perhaps not.

Credit: Mandel Ngan / AFP / Getty Images

 

The future for older Americans: More disabilities

One of the resounding hopes expressed by the baby boom generation is to change the perception of aging by remaining active, vital and healthy deep into their golden years.

The prospect of achieving that goal isn't promising. A study published today by researchers at UCLA is the first to show that disability trends among older Americans are getting worse. Disabilities were assessed through measures that recorded a person's ability to perform various tasks, such as being able to walk up a flight of stairs, manage personal finances and perform household chores.

In the 1980s and 1990s, studies showed disability rates among older Americans were improving. But the new study compared data from two time periods, 1988 through 1994 and 1999 through 2004, and found that disability rates rose among people ages 60 to 69. The greatest increases were seen among non-whites and people who were overweight or obese.

The study, funded by the National Institute on Aging, found no changes in disability rates among people ages 70 to 79. Among people ages 80 and older, improvements in disability were seen, especially among women.

The study doesn't pinpoint why more people are becoming disabled in their later years, although the obesity epidemic appears to be the major factor, said the lead author of the study, Teresa E. Seeman, a professor of medicine and epidemiology at UCLA's David Geffen School of Medicine.

"Normal-weight individuals do not show a trend of increasing disabilities," she said. "It does seem to be that the increase is restricted to the groups that are overweight and obese. But part of the problem is that more and more people are overweight and obese."
 
The people in their 60s who show increasing rates of disability are likely "harbingers" for the baby boom generation, Seeman said, an observation that should be considered in Washington during the debate over health care reform.

"I think this kind of data highlights the importance of this [health care] debate," she said. "How do we provide health care people need and services that will prevent disability?"

The study is published today in the American Journal of Public Health.

-- Shari Roan

Photo credit: Francine Orr  /  Los Angeles Times

Those medical bills won't just go away; now's the time to get a handle on them

Medical debt doesn't take care of itself. As with a serious illness, ignoring the symptoms will simply ensure more problems down the road.

So today, Families USA offers up tips on what to do about it. The advice from the organization, whose ultimate mission is affordable healthcare for all Americans, is practical and straightforward. It begins with, "Make sure the charges are correct," and ends with links to organizations that can provide additional services.

Here's the complete guide: Your Medical Bills: A Consumer’s Guide to Coping With Medical Debt.

For a general look at medical debt, from the Washington Post and Kaiser Health News, there's this: Americans ensnared by medical debt.

And here's a recent look specifically at California. This report, from the UCLA Center for Health Policy Research, finds that almost 1 in 7 nonelderly Californians has medical debt of one kind or another. It includes breakdowns by region and county.

And here's some more advice, from an article that first appeared in the L.A. Times' Health section: Negotiating Your Medical Bills.

It begins: "Unless you've been rushed to the hospital in an emergency, the time to start thinking about paying the bill for hospital care comes as soon as your doctor says you need to have a test, procedure or surgery."

-- Tami Dennis

Photo: When it comes to costs, and debt, those medical tests can add up.

Credit: John Moore / Getty Images

When making public statements, shouldn't those statements actually state?

When news breaks out, organizations frequently offer up their two cents on the topic at hand. Sometimes these statements clarify the issue or a group's stance -- but only sometimes.

Today, we received this official statement from the American Psychiatric Assn. on the Fort Hood, Texas, shootings:

“The American Psychiatric Association is saddened and shocked by the events at Fort Hood on Thursday, November 5. Our hearts are with the soldiers, the families, and all the members of the Fort Hood and military community affected by this tragedy.”

Couldn't the same be said of most people's reactions -- and the location of their hearts? Here's what the position looked like in its entirety.

And last week, there was this from the National Women's Law Center on the gang rape of a 15-year-old California girl who'd attended a dance:

“The circumstances reported about this brutal assault, as well as the shocking inaction of those who stood by and watched it happen, are shocking – and should be widely condemned."

Again, society didn't seem to need much urging.

If you're going to make a statement, then do so. Here's one this week from the National Right to Life Committee on a legislative move in the House:

"The Ellsworth language is a political fig leaf made out of cellophane -- it directs the federal Secretary of Health to hire a contractor to deliver to abortion providers the payments for elective abortions, payments that are explicitly authorized by the bill [on page 110].  This is a money-laundering scheme -- a federally funded 'bag man' will deliver government funds to abortionists.  This is federal funding of elective abortion."

Here is that statement in its entirety.

Whether you think the statement is an accurate reflection or a grotesque parody of the current political debate, at least there's a point in saying it.

-- Tami Dennis

Photo: Sometimes the point isn't what is said, just that something is said.

Credit: Los Angeles Times