Why Discussing Limiting Medicare Benefits for the Elderly Is Worthwhile

While browsing the opinion section of the New York Times, I came across an interesting editorial about limiting benefits for senior citizens in order to make health care more effective. The article, by Daniel Callahan, can be found here: http://newoldage.blogs.nytimes.com/2008/11/13/heart-surgery-how-old-is-too-old. Callahan, in essence, argues that we should limit expensive treatment given to the elderly in order to cut costs upon the Medicare system and avoid otherwise necessary increases in taxes.
Callahan succinctly explains the burdens levied upon the Medicare system by expensive treatments for the elderly. While I believe some will find that assessing life-saving treatments as “burdensome” or perhaps “wasteful,” as Callahan certainly implies, the cold numbers are extremely persuasive. And they should at the very least not be overlooked. So let’s examine the numbers. The Medicare program cost $429 billion in 2007, and has a 7% annual cost increase. Thus, by 2017, it should cost $884 billion. Most importantly, by 2017, the Medicare program will be bankrupt.
Now, how do expensive treatments for the elderly factor in? While Old age itself is certainly not a barrier to coverage. In fact, the average age of those undergoing heart surgery, organ transplantation, kidney dialysis, and cancer treatment is continually rising, Callahan explains. Essentially, science is finding ways of keeping the sick or weak alive longer. It is important not to forget that just a few decades ago, the methods used to keep people alive were not even dreamed of. Significantly, not only are people staying alive longer, but many elderly people are opting for expensive, aggressive treatments, even when the likelihood of success is dismal. I personally do not blame anyone for this decision; if your life is on the line, wouldn’t you opt to try to extend it? But the fact remains: people aren’t likely to simply roll over and die. If treatment is available, they’ll want it.
Thus, the effect on the system is significant. Callahan writes that the average Medicare recipient has to spend between $5,000 and $10,000 for treatment not covered by the program. Doctors are becoming reluctant to take on elderly patients because they are often poorly reimbursed. Out of pocket costs for drugs and co-payments are expected to jump anywhere from 31 to 60 percent in 2009 alone. Therefore, if I interpret the numbers correctly, it seems that not only is the system going bankrupt, but recipients are facing significant price increases or will have to pay out-of-pocket because the system itself cannot afford to treat them.
In light of these numbers, Callahan argues that limiting benefits based on age should be done, because it is not likely that the other possible fix (raising taxes) will be seriously considered in the near future. I thought the most important part of Callahan’s argument was the simple fact that he acknowledges that age-based rationing will not be accepted. Thus, I think he effectively removes that contention from the argument. However, his point is that we can’t completely factor out cost and age from the equation. Congress has refused to allow Medicare to take costs into account in its coverage decisions. But should it play some role? Should age? Callahan’s answer is emphatically yes. I agree with Callahan’s sentiment that our society “can not, and should not, promise open-ended, progress-driven medical care that is indifferent to costs.” Because in the real world, age does matter. It matters in that there are more and more elderly people undergoing expensive care, putting increasing burdens on a system that is already on the brink of collapse. This is a practical way to save money. This is not a proposal to eliminate access to benefits for the elderly altogether. It's a proposal that cuts extremely expensive treatments that likely either won't work or won't work for long. And freeing up cash helps the system. And, although now I am editorializing, I wonder: at the end of the day, what is better? A functioning system that, admittedly has its flaws and is imperfect? Or no system whatsoever? I say an imperfect system.
Keep in mind, age isn’t the only factor. Likelihood of success, cost, and patient wishes should all weigh in. Perhaps a government-regulated healthcare system would solve ALL of these problems? But we’re not there yet, and I think it is important to try to make our system work until we get there. I think Callahan’s point is that we need to consider solutions that may not be popular or pleasant, not because they will ultimately be implemented, but because they are often realistic and therefore, a reasonable starting point to formulate serious solutions.

America Shrugs at Being Fat

The fattest city in America has just been named, and apparently it "shrugs" at that moniker. This makes me think long and hard about how a city in America, a country so weight-obsessed, can be as nonchalant about being called The Fattest. Professor Pasquale's lecture about image-obsession reminded me of how beauty throughout history has been paralleled with wealth. Huntington, West Virginia, the aforementioned unhealthiest city in America, also has a poverty level worse than the national average. With the economy in the state it is, will the future of America's health suffer as dramatically as the stock market? And if so, how will the health care system adapt? The economy is sickening the hospitals in the U.S. Decline in elective procedures and admissions, and patients who cannot pay for care have left hospitals in an economic slump. Poor times call for cheap measures, for sure. Kentucky Fried Chicken's $10 Challenge is no help. A KFC commercial challenged a family in a grocery store to put together a dinner for $10 or less that was comparable to the KFC $9.99 7-piece value meal. Access to health seems to be as big of an issue as access to health care.

Huntington leads the nation in a half dozen other ailments too, including diabetes, heart disease, and tooth loss. I wonder how a city that is so evidently health-poor can just not seem to care? When did being healthy become associated with being rich? When did health become a luxury? Americans pine after having the newest thing, and despite the economic situation, people will keep shopping. KMart reinstated layaway just in time for the holidays. But people don't seem to want to spend that money on healthier foods -- the apathy is there, and it doesn't seem to be going anywhere. Not even the mayor of the fattest town in America seems to want to do anything about it.

In Mauritania, fatter women are considered beautiful. Young girls in rural areas are forcefed until they vomit in order to attain this goal. This, on a continent with with 50% of the population living below the poverty line, seems reflective of the trend that wealth equals beauty. In India, even in the most rural areas, the poorest of women wear a piece of jewelry because that represents her beauty. However, even with America's economy plummeting as it has, that desire for beauty in the U.S. seems to fade. Priorities change, and rightly so, but the desire to preserve one's health, the most basic human instinct, has seemed to vanish from the American psyche. One would think being called the fattest city in the entire country would be a wakeup call, but when the reaction is no more than a shrug, I worry.

Please Make Me Look White?

An issue was raised in class a couple weeks ago regarding the trend that in an effort to appear more white, Asians were demanding plastic surgery. I’ve often questioned this idea and wondered if it wasn’t instead a misperception perpetrated by the media.

Consider for example the argument which posits that the reason Asians flock to plastic surgeons for double eyelid blepharoplasty is to achieve larger, rounder, Caucasian eyes. It seems like a post hoc argument to me (hearkening back to the LSAT, it’s a necessary but not sufficient condition). Associating the rise in blepharoplasty procedures with the rise in Western media influence is certainly plausible, but it’s not an entirely sound argument.

I’m not discounting the fact that the media plays an enormous role in shaping perceptions of beauty, but I think that it’s just as important to look to the underlying evolutionary basis (that crosses cultural lines) behind plastic surgery trends. Obviously there’s much interplay between these two, but when it comes to this debate I often see the focus on the aforementioned cultural imperialist notion rather than on evolutionary reasons.

It seems almost universal that humans are drawn to big eyes—notice our penchant for babies, puppies, and kittens. Big eyes are associated with youthfulness, as evidenced by the popularity of brow lift procedures in older American woman seeking to “open up” their eyes. And seeing that there are almost four billions Asians in the world there are obviously those with varying eye sizes.

After college, I lived in Taiwan for a couple years and traveled extensively throughout Asia. I met a few people with plastic surgery, but none would say that getting their eyes done made them look more Caucasian. In fact, the surgery allowed them to look more like other Asians who had relatively larger eyes. Naturally occurring double eyelids are prevalent in those from the southern part of China and Southeast Asia, and to a lesser extent (but not uncommon) in Northern Chinese, Koreans, and Japanese.

Another issue that is often discussed is the fixation with skin lightening. Again, I’m wary of the media’s conclusions that it’s just another example of Asians desiring to look more Caucasian. Throughout the centuries in Asia, dark skin has been frowned upon because of its association with toiling under the sun and menial labor—thus, the reason fair skin is generally desirable.

I just had to throw it out there, but there are plenty of other reasons Asians prefer bigger eyes or lighter skin and it may be due to reasons other than trying to look like their Western counterpart. It’s more likely that their reasons for doing so are more similar to the reason Westerners prefer bigger eyes.

When two cultures collide there’s bound to be misperceptions. As someone who embodies both Asian and American cultures and has lived on both sides of the world, I think it’s important to take what you read with a grain of salt-- there are obvious reasons which needn’t be mentioned here why the Western media’s portrayal of the East is skewed (as with the East’s portrayal of the West).

Ellie

Misleading Research From Industry?

By John Tierney
http://tierneylab.blogs.nytimes.com/2008/10/30/misleading-research-from-industry/
In 2005, The Journal of the American Medical Association cited “concerns about misleading reporting of industry-sponsored research” to justify its stricter standards for any such research to be considered for publication. The new policy, requiring researchers with no financial connections to the sponsor to vouch for the data and perform statistical work, was promptly criticized in an editorial in The British Medical Journal as “manifestly unfair” because it created a “a hierarchy of purity among authors.”
Now some researchers have looked to see what kind of hierarchy actually exists. After analyzing weight-loss research conducted over four decades, they’ve found that the quality of data reporting in industry-sponsored research does seem to be different from that in other research: It’s better.
The researchers found that the quality of data was significantly better in industry-supported research than in nonindustry-supported research, particularly in studies involving drug treatments. The researchers conclude:
This suggests that, while continued efforts to improve reporting quality are warranted, such efforts should be directed at nonindustry-funded research at least as much as at industry-funded research. A benefit of the greater funding offered by industry, the greater scrutiny of industry, or perhaps greater concern or training of industry personnel for rigorous reporting may be an enhancement of the overall reporting quality in the literature, at least for long-term weight-loss studies.
The author’s colleague Gina Kolata recently reported that some prominent medical researchers are starting to shun any financial support from industry — not because they think it leads to bad research but because they’re tired of having their integrity impugned. These ad hominem attacks have become routine against anyone or any group receiving industry money. In light of the new study, the author worries what will happen if the best scientists become afraid to work with the sponsors that can afford to pay for the most thorough studies. What happens to the quality of future research? And should this new study give pause to JAMA’s editors? By stigmatizing industry-sponsored research, is their “hierarchy of purity” doing more harm than good?
This article only mentioned obesity studies, but it seems to suggest that other industry funded studies are superior to their non-industry funded counterparts. It shouldn’t come as a surprise that well funded research provides better results regardless of who’s footing the bill - even organizations with an agenda value solid research. Maybe articles like this will help lessen the stigma of working for “the man.”
EEM

Woman who got HIV from kidney transplant sues University of Chicago Hospital

A woman who contracted HIV and hepatitis C from a kidney transplant sued the University of Chicago Medical Center and one of its doctors on Monday, saying they should have told her the organ donor was gay.  In November, she was asked to come back to the hospital because 3 other people who had received organs from the same donor had tested positive for HIV.  She said she was not told at the time of the transplant that the donor who was killed in an automobile accident had engaged in male-to-male activity, but that had she been told of this, she would not have gone ahead with the operation.

The U.S. Centers for Disease Control and Prevention guidelines say that gay men who are sexually active should not be organ donors unless the patient is in imminent danger of death.  The guidelines also say patients should be informed if a donor had engaged in homosexual activity.  I wonder how fair this policy is.  I understand that high-risk activity is not to be taken lightly, but what about gay men in monogamous relationships with people who are not HIV-positive?  

I know of the patient who received the heart from this same donor.  He was on the verge of death prior to the transplant.  His quality of life after the transplant was far better than it was prior to receiving the heart, and he believed he would not have had the opportunity to feel better again and to live longer without the operation.  He did not have sex with his wife between having the operation and finding out he was HIV positive.  He did not blame the hospital or the physicians and he did not intend to sue them.  

HIV tests require one week to get the results back, and organs would be dead by that time, and therefore useless to the recipients.  What if a hospital has no way of knowing if a donor has engaged in high risk activity?  I know many physicians who find this scenario horrifying -- the potential of being sued for yet another situation that they may not be responsible for.  

This situation is unprecedented for hospitals and physicians alike.  Nothing like this has ever happened before, there are no studies or lawsuits regarding this scenario, and its results are potentially devastating, both for the hospitals as well as for the patients and their families.  There is a question of what the patients' quality of life will be, since many of the medications that donor transplant recipients will be on stimulate white blood cells, which HIV medications do as well.  HIV drugs have become quite effective, and the lifespans of infected persons are longer now than ever before.  The patients potentially could feel well and live another ten to twenty years because of the medications, which they may not have had the potential for prior to receiving their organs.  For the heart recipient, the infected heart gave him more time to live. 

I am curious to see how many millions of dollars this woman will make...

Implications of BRCA1 gene mutation as it relates to In The Family and otherwise...

In preparation for our screening of Joanna Rudnick's documentary, In The Family, I wanted to pass along some information and links to recent articles written on the subject. Although the film is centered around a female of jewish descent, it bears mentioning that surprising new studies have shown the BRCA mutations to have revelance to a wide range of ethnicities, and affects men with prostate and breast cancer as well. On an even larger scale, the documentary points to the dilemmas associated with gene patenting, disclosure, and genetic mutations in general-whether it be a BRCA mutation, or otherwise. The following list of links are by no means all-inclusive, and I invite any and all to add and expand upon those attached below as we try to better understand the gene mutation before Thursday. Thanks.

WHAT YOU NEED TO KNOW ABOUT BRCA1:

BRCA1 stands for "breast cancer 1, early onset," and belongs to a class of genes known as tumor suppressors. Like most tumor suppressors, the protein produced by the BRCA1 gene helps prevent cells from dividing too rapidly or erratically. Specifically, the BRCA1 gene is essential for providing instructions for producing proteins involved in repairing damaged DNA. To date, researchers have identified more than 1,000 mutations of the BRCA1 gene, most of which are associated with an increased risk of breast cancer.

IN THE FAMILY INDEED:

http://news.yahoo.com/s/ap/20081117/ap_on_he_me/med_breast_cancer

As the article linked above asserts, a family's medical history may be a more accurate indicator than genetic screening for breast cancer. Although BRCA1 and BRCA2 are considered aggressive hereditary mutations, the problem emerges when female relatives test free of the mutation in the belief they are not still at risk. Dr. Steven Narod stresses, "family history is a much stronger predictor regardless of what gene tests show." Of 1,500 women tested from 365 cancer-prone families who had nonetheless tested negative for both mutations, the group still had a four-fold higher risk thatn average women of developing breast cancer. The report goes on to remind that the $3,000 BRCA tests are still generally well accepted but newer tests will be available soon that will be more available, less expensive, and hopefully, more accurate.

In the meantime, I would argue that the importance of sitting down with one's family and hashing out the good, the bad and the ugly of shared medical history cannot be over- emphasized.

WHO SHOULD GET TESTED:

Traditionally, the BRCA1 mutation has been to known to be more prevalent for Ashkenazi Jews, and recent studies have shown that Ashkenzi women with breast cancer had the highest BRCA1 mutation of the ethnic groups studies, at around 8.3%. However, the same study (cited below) also showed the mutation is widespread among Hispanics and young black women as well. A research scientist at the Northern California Cancer Center in Fremont and assoc. professor of health research/policy at Stanford, Ester John reported that Hispanic women had a higher chance of carrying the BRCA1 mutation than caucasian women, but that young black women carried the most alarming rate. For all black women the rate of the BRCA1 mutation was 1.3%, however of that subsection under 35 who had breast cancer, the rate skyrocketed to 16.7%.

John's research appears to be backed up by Dr. Christine Pellegrino (NYC) who said that the findings mirror what she's seen in her clinical practice. Pellegrino supports a widespread program of genetic counseling for young patients and genetic screening for all women and female relatives who develop breast cancer at an early age.

http://health.usnews.com/usnews/health/healthday/071226/brca1-mutation-prevalent-among-hispanic-younger-black-women.htm

Given that the 2007 findings were surprising to even the specialists, it might not be overly presumptive to encourage screening for women with known, higher than usual rates of risk for breast cancer. In realizing that option is more or less taking the easy answer, I still would rather error on the side of caution and too much data, rather than not enough.

AND THIS FROM MYRIAD:

http://www.myriadtests.com/provider/brca-mutation-prevalence.htm

BRCA NEWS FOR MEN:

Men with a strong family history of prostate or breast cancer also experience BRCA related dangers. As cited by the attached link below, prostate cancer caused by a BRCA2 gene mutation are more than twice as likely to die from the genetic disease than those carrying the fault BRCA1 gene mutation. The study found that carriers of the BRCA2 gene were found to live for an average of four years compared to an average of eight years for BRCA1 carriers. While the information is unsettling, it does help to tailor future therapies and treatments, especially in treating the lethal BRCA2 mutation.

http://www.news-medical.net/?id=39490

Again, the above articles and information is a slim fraction of what is available on the BRCA mutations and I invite anyone to supplement this thin offering. Thanks, JWD.

Specialty Hospitals

After class the other evening, I was wondering about the specialty hospitals we spoke of briefly and had some questions about their existence. From what I have read, the only types of specialized hospitals that exist are ones that specialize in cardiac, orthopedic, and general surgery. There are very few of these hospitals and are typically geographically located in a small area (Kansas, Oklahoma, South Dakota, and Texas). The major issue surrounding these hospitals is the fact that many claim they are taking away the most profitable and generally easier cases from community hospitals. This argument relies on the fact that patients at these hospitals are generally insured on other policies than Medicare and are not in highly emergent situations. While I definitely understand that community hospitals rely on insured patients for much of their funding to cover uninsured patients and patients with Medicare that does not pay as much, specialized hospitals really do not seem to have anything to do with this problem other than they are taking some of the insured patients away. Therefore, it seems that the overall complaint with specialty hospitals is not going to be addressed by not allowing them, but by correcting the payment problems at community hospitals.

I think that patients should have a choice in where they receive their care and not be forced to make up for losses that are incurred elsewhere. As I was reading this article, I could not help but think of nationalized healthcare. A nationalized healthcare system would correct the problem of uninsured patients and also presumably help Medicare type insurance pay more money. However, a nationalized healthcare system is bound to have a privatized option that will take the same form as a specialty hospital.

A further issue that is raised in the article is the one of conflict of interest of a doctor’s who own hospitals. However, with this point, the article cites statistics that state the doctors individually only own very small parts of these hospitals, 1% per physician. Also, with cardiac specialty hospitals, physicians only own 34% of the hospital on average. These seem like small numbers to be creating conflicts of interest. A further point is that it seems like a far stretch to be saying that physicians are performing surgeries that they otherwise would not be because they own a small part of the hospital. This argument would make much more sense in a different field like dermatology (which by the way is a specialized practice usually that is owned by physicians). To me, it makes more sense that a dermatologist might prescribe is different medication that they profit more off of rather than a different option that is cheaper well before a cardiac surgeon performs a procedure on someone’s heart that is unnecessary. While the cardiac surgeon might also prescribe a different medication, that is a different point and will exists no matter where the physician is working.

In the end, I definitely do not know much about specialty hospitals, but these were just a few thoughts I had. The last thing that I thought was interesting was a website for a specialty hospital that claims:
"Some day all hospitals wil be like this."