At Harvard, heroes and villians, sugar and supplements

screen-shot-2017-01-16-at-9-04-30-pmGary Taubes’ sugar takedown continued in the NYTimes SundayReview, including reference to the late Fred Stare, founder of the nutrition department at the Harvard School of Public Health. In the 1970s Stare was  reportedly paid to exonerate sugar in journal supplement, “Sugar in the Diet of Man,

STATNews refers to the case of another Harvard doctor, this one who found himself on the wrong side of a supplement maker. 

The jury trial had momentous implications for the future of research into the safety of weight-loss and muscle-building pills; for the freedom of academics to speak out about matters of public health; and for our ability to learn what’s in the supplements on our kitchen counters.

 

Massachusetts #universal health coverage effort carries on

Here in Massachusetts, life goes on in terms of universal coverage.From The Boston Globe:

Health-insurance sign-ups are running ahead of expectations as the Massachusetts Health Connector wraps up the second month of the three-month open-enrollment period, according to Louis Gutierrez, executive director.

The Connector, a state agency that serves people who don’t obtain health insurance through an employer, has drawn in more than 27,600 new enrollees since open enrollment began Nov 1. And Gutierrez expects to see many more before the sign-up period ends on Jan. 31.

WBUR reports that coverage may change:

imgrese head of the Massachusetts Health Connector, Louis Gutierrez, says no matter what happens with the ACA, the Connector is committed to providing affordable coverage, as it has since the state’s own health care overhaul went into effect in 2006. Since then, the ACA has helped the state expand its Medicaid and Medicare programs.

Gutierrez is hesitant to guarantee enrollees will get to keep the exact coverage they signed up for this year, regardless of what happens in Washington. “I can’t make commitments about things I can’t personally control,” he said.

Kaiser Health News: Increase in health insurance exchange enrollment mirrors some state programs, including Massachusetts

Phil Galewitz of Kaiser Health News reports that enrollment increases for federal exchanges  mirror “activity on several state-run Obamacare exchanges, according to figures obtained from states independently by Kaiser Health News. Minnesota, with more than 54,000 enrollees as of Monday, capturedoubled the number of sign-ups it had at the same time last year. Colorado, Massachusetts and Washington had enrollment growth of at least 13 percent compared to a year ago.

“Because of the new administration and the high likelihood of changes coming to the ACA, it is creating a sense of urgency” for people to enroll, said Michael March and, director of communications for the Washington Health Benefit Exchange. Enrollment exceeded 170,000 customers on the Washington exchange as of this week, up 13 percent compared to same time a year ago.

Other state exchanges saw moderate increases: Connecticut, 3 percent; Idaho, 4 percent; Maryland, 1 percent. California’s enrollment is about same as a year ago. Rhode Island’s enrollment dropped to 27,555 from 31,900 for the same period last year. State exchange officials cited a drop in customers who were automatically renewed because UnitedHealthcare dropped out.

About 12.7 million people enrolled in the state and federal exchanges for 2016 coverage at the end of the previous enrollment season. HHS predicted in October that an additional 1.1 million people would sign up for 2017 coverage. Burwell said Wednesday that her department is sticking with that projection, even though “the headwinds have increased” since the election.

Obamacare, now in its fourth open enrollment season, took some heavy blows this year after several big insurers — including UnitedHealthcare, Humana and Aetna — withdrew from many marketplaces for 2017 because of heavy financial losses. At the same time, remaining insurers increased premiums by 25 percent on average.

All of that, plus a changed political climate in Washington, was expected to dampen enrollment. While the surprise presidential election outcome may have been the primary force for changing those expectations, other factors also have fueled enrollment growth this fall, state officials pointed out in interviews.

More people who don’t qualify for government subsidies are buying health plans on the exchanges because it’s an easier way to compare available plans in one place. Noting that trend, Premera Blue Cross in Washington recently stopped selling individual coverage off the exchange.

In Minnesota, higher government subsidies — which reduce premiums for people with lower incomes — is the main reason why more people have signed up, according to Allison O’Toole, CEO of MNsure, the state-run exchange. The subsidy amount is tied to the cost of the second-lowest silver plan on the exchange, so as premiums rise for that plan, the subsidy rises too. Premiums soared by an average 50 percent in Minnesota for second-lowest silver.

Another factor driving earlier enrollment in that state was caps set by several Minnesota insurers on the number of new enrollees they would accept. People signed up earlier to make sure they could get the plan they wanted, according to O’Toole.

Minnesota’s growth is surprising because one of its biggest carriers, Blue Cross and Blue Shield of Minnesota, stopped selling its most popular health plan on the exchange. That forced about 20,000 people to change insurers or switch from Blue Cross’ PPO, which has a broad provider network, to its HMO plan with a narrower network.

In Colorado, the 18 percent increase in enrollment so far has exceeded officials’ expectations, said Luke Clarke, the spokesman for Connect for Health Colorado, the state exchange. “We had an office pool and no one picked a number that high,” he said. “It was a healthy surprise,” particularly because premiums increased in the state by about 20 percent on average.

Conservatives warn it’s still too early for Obamacare supporters to celebrate.

“I suspect that some states saw big increases because local advocacy groups were able to tell their constituents that they should enroll before Trump is sworn in and Republicans take over Congress — thereby pretty much guaranteeing that they get a full year’s coverage regardless of what Republicans might do on repeal,” said Joe Antos, a health economist with the American Enterprise Institute, a conservative think tank.

Under that scenario, large enrollment increases this fall might be followed by a dropoff in January over the 2016 numbers and the final enrollment tally could end up similar this year’s, he said. Antos noted the true enrollment figures will be known once people pay for their coverage and stay enrolled for the full year.

“As with everything related to ACA,” Antos said, “it’s easy to find a happy story if you squint hard enough and don’t wait for the enrollment process to complete — or the plan year to end.”

Boston Globe: Sachs, Angell, weigh in on health care reform

Jeffrey  Sachs of  Columbia University is not a health care guy; he’s a big picture guy. One in  a series of lengthy columns in The Boston Globe offered this:

captureOBAMACARE INCREASED health care coverage but did not solve the crisis of sky-high prices, and may well have exacerbated it by adding government subsidies into a system marked by pervasive market power and lack of competition.

I therefore recommend the following policies to address America’s urgent health care crisis.

First, as I’ve suggested in previous articles in this series, America should adopt policies to reduce income inequalities, end the over-incarceration of the poor, empower workers, clean and green the environment, and raise the social status of working-class families. Over time, such measures would help to reverse the epidemics of drug abuse, mental illness, obesity, and other diseases exacerbated by poverty and low social status.

Second, America should move toward universal health care coverage through public financing, as in Canada and Europe, with health providers (both private and not-for-profit) supplying coverage on the basis of capitation rather than fee-for-service. Capitation would encourage and enable health providers to offer supportive services (nutrition counseling, social support, health advising) that help to prevent, treat, and manage chronic conditions such as cardiovascular disease and adult-onset diabetes.

Third, the government should move to a system of price ceilings for medicines under patent through rational guidelines that balance the incentives for R&D with drug affordability and access. Economists have long argued that today’s patent law does not do an adequate job of balancing the needed incentives for innovation with the assurance of access to affordable medicines. The situation became intolerable after the advent of Medicare Part D, with the government now spending vast sums for drugs and drug companies grossly abusing the system by setting outrageous markups on the cost of production.

None of this is a dream or a utopian vision. These reforms would simply put the United States on the path toward improved health care coverage, affordability, and outcomes already enjoyed by the citizens of Canada, Japan, and many countries in Europe.

To which Dr. Marcia Angell, a former NEJM editor vocal critic of health care profiteering, had this to say:

JEFFREY D. SACHS has written an excellent overview of what makes the American health system so inadequate, inequitable, and expensive, compared with other advanced countries, and he recommends some important reforms. But one of them — paying providers a set yearly amount for each patient covered (capitation), instead of paying on a fee-for-service basis — would not work in this country, because, unlike other countries, our providers are largely for-profit (or behave that way).

Will genetic advances address health disparities? Not much unless they are accessible.

The new issue of Health Affairs looks at health policy and health disparities. Many local researchers represented.

Of interest: Using Genetic Technologies To Reduce, Rather Than Widen, Health Disparities

The authors include two local researchers: Katherine L. Tucker is a professor in clinical laboratory and nutritional sciences at the University of MassachuseCapturetts, in Lowell…José M. Ordovás is director of the Nutrition and Genomics Laboratory at the Human Nutrition Research Center on Aging at Tufts University

Evidence shows that both biological and nonbiological factors contribute to health disparities. Genetics, in particular, plays a part in how common diseases manifest themselves. Today, unprecedented advances in genetically based diagnoses and treatments provide opportunities for personalized medicine. However, disadvantaged groups may lack access to these advances, and treatments based on research on non-Hispanic whites might not be generalizable to members of minority groups. Unless genetic technologies become universally accessible, existing disparities could be widened. Addressing this issue will require integrated strategies, including expanding genetic research, improving genetic literacy, and enhancing access to genetic technologies among minority populations in a way that avoids harms such as stigmatization.

And, a team from Harvard offers this :

Across US Hospitals, Black Patients Report Comparable Or Better Experiences Than White Patients

Patient-reported experience is a critical part of measuring health care quality. There are limited data on racial differences in patient experience. Using patient-level data for 2009–10 from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), we compared blacks’ and whites’ responses on measures of overall hospital rating, communication, clinical processes, and hospital environment. In unadjusted results, there were no substantive differences between blacks’ and whites’ ratings of hospitals. Blacks were less likely to recommend hospitals but reported more positive experiences, compared to whites. Higher educational attainment and self-reported worse health status were associated with more negative evaluations in both races. Additionally, blacks rated minority-serving hospitals worse than other hospitals on all HCAHPS measures. Taken together, there were surprisingly few meaningful differences in patient experience between blacks and whites across US hospitals. Although blacks tend to receive care at worse-performing hospitals, compared to whites, within any given hospital black patients tend to report better experience than whites do.

 

 

 

Is response time the best way to judge ambulance services?

Tom Kimball, described as a Boston-area paramedic who will be  attending medical school this fall posed that question in a Boston Globe opinion piece this weekend. ambulances

Many cities and towns in Massachusetts still judge the performance of their ambulance services using metrics like response times, which can miss the point. An additional two minutes waiting for an ambulance will rarely make a difference for a trauma patient facing emergency surgery that may take hours.

Patient outcome is a more valuable measure of whether a medical service is doing right by people. In many areas of health care these days, it is the gold standard, a key factor in determining how much insurance companies pay service providers. Changing the terms of ambulance companies’ contracts to make good patient outcomes the goal could greatly improve the quality of medical care across the state — and save lives.

Boston health interviews: Spotlight on surgery, Lown and Berwick

You correspondent has been tooling around the city lately asking a lot of questions. Three recent Q&A column in Health Leaders with Boston, Brookline and Cambridge, Mass. links.

Also, the staff at the Brigham had a few questions when a VIP guest make some special requests. Check out the story from the Sunday Globe

When state investigators interviewed an employee identified as “nurse director #1’’ in the report, she said the patient interpreted the use of protective gowns as an indication they thought he was “dirty’’ and asked that staff not wear them. A physician told inspectors that he visited the patient five to seven times a week and did not wear protective gear because the patient “found it offensive.’’ And the hospital had no infection control policies in place for the patient’s personal staff, it told the state. 

sox win 07
Go Sox!

Concurrent Surgery Gets the Spotlight treatment: The editor of The Boston Globe’s investigative reporting unit discusses his team’s series raising questions about the practice of concurrent surgeries and patient safety.

 

Vikas Saini, MD, president of the Lown Institute:”There really needs to be an alliance among patients, families, and communities. At the end of the day, they get to decide what is the right care,”

 

Donald Berwick: The former head of CMS says “we will never solve the problem of cost and finance by focusing on cost and finance.” Instead, it will be resolved “by focusing on the design and redesign of healthcare and the improvement of its quality.”  Part 2