Dr. Buttery's Public Health BLOG

ScienceDaily — California's state tobacco control program saved $86 billion -- in 2004 dollars -- in personal healthcare costs in its first 15 years, according to a study by researchers at the University of California, San Francisco. California’s state tobacco control program saved $86 billion--in 2004 dollars--in personal healthcare costs in its first 15 years, according to a study by researchers at the University of California, San Francisco. During the same period, the state spent only a total of $1.8 billion on the program, a 50-to-1 return on investment, according to study findings. The study is the first that has been able to quantifiably connect tobacco control to healthcare savings, say its authors.

Posted by at 10:44 AM | Permalink | Comments (0)

A study in this week's Annals of Internal Medicine reported on data from the 1999-2004 NHANES survey of US Households. The study identified at least 11 million uninsured people with chronic diseases. the most common being heart disease, high blood pressure, and diabetes. Lack of insurance meant that such individuals were far less likely to attempt to obtain medical care, and unlikely to be able to afford medicines to control their diseases. As a result they were more likely to be unproductive workers, and to be disabled or die early from their conditions. All this increasing the cost of the nation's medical care system.
[Ann Intern Med. 2008;149:170-176.]

Posted by at 10:46 AM | Permalink | Comments (0)

From Harvard School of Public Health, researchers found that 30% of the recent decline in cigarette sales may be offset by the robust sale of small cigars, snuff and roll-your-own products. The major factor in the apparent switch to non-cigarette products by smokers appears to be price -- with the federal tax on other forms of tobacco 1/10th that of cigarettes -- and the heavy attention given to campaigning against cigarette use but not against other forms of tobacco products in recent years. Price increases have proven to be the single most effective form of curbing tobacco use in the U.S. population. Tobacco kills, no matter if it's in a cigarette, a cigar, a snuff can or a roll-your-own.

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From "Rite of Passage? Why Young Adults Become Uninsured and How New Policies Can Help, 2008 Update," Commonwealth Fund we find that Almost 14 million young adults lacked coverage in 2006. Young adults often lose insurance when they age out of eligibility for their parents' coverage or public insurance, or when they graduate from college. Jobs available to this population frequently are low-wage or temporary and often don't offer health benefits. Young adults from low-income households are most at risk for going without coverage.

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From the Wall street Journal we learn that an increasing array of Americans, many with health insurance, are delaying or forgoing medical care because of concern about cost, according to a report from the Center for Studying Health System Change. About 20% of the respondents in a 2007 survey of 18,000 people said that they had put off or gone without needed medical treatment at some point in the year earlier, up from 14% in a 2003 survey. Comment: The longer we wait to fix our disabled health care system the worse the problem will get. The experience in Massachusetts shows we cannot do this state by state, or just by increasing the reimbursement system.

Posted by at 9:35 AM | Permalink | Comments (2)

A study reported in the Dartmouth Atlas of Health Care 2008 decsribes The remarkable variation in the way academic medical centers manage chronic illness is testimony to the weakness in the scientific basis of medicine. The neglect of the evaluative sciences— those sciences whose mission is to evaluate medical theory, understand patient preferences, and establish the cost-effectiveness of clinical practice—has left the nation unprepared to deal with unwarranted variation. The consequences for public policy should be obvious. Further the authors of the sudy say "the nation needs a crash program to transform the management of chronic illness to a rational system where what happens to patients is based primarily on illness severity, medical evidence, and the patient’s wishes, and where resource allocation and Medicare spending can be guided more and more by knowledge of what is needed to produce cost-effective, high-quality care".
However the country cannot focus just on the cae of chronic disease without also changing the entire system to a focus on affordable, accessible, coordinated primary care. This will require different teaching goals in academic centers which must turn away from a focus on basic research and move toward a focus on patient care and effective efficient outcomes of care.

Posted by at 12:06 PM | Permalink | Comments (0)

The Wall Street Journal today highlights a report from PricewaterhouseCoopers putting the value of the waste sloshing around in the health care system at a whopping $1.2 trillion a year, or 50% of the total spending.. However the "waste" may be more in the eyes of the auditors than real. For example waste includes such items as missed appointments, medicines not taken, Dr's recommendations not followed, diseases associated with adverse behaviors. It also believes there is much administrative waste in the way medical services are delivered. There are many deficiencies in the system , much of it due to illogical legislation and federal laws, or services delivered that are usually unecessary but are used to prevent lawsuits. The headlines in The Journal make good copy. Probably 50% of the "waste" could be averted, Even $600 billion dollars a year are well worth saving. This will not happen without a major overhaul of our broken system.

Posted by at 10:29 AM | Permalink | Comments (0)

A wonderful presentation on how to make data useful and translate it into understandable form.

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Yesterday I noted the potential impact of gastric banding for all obese persons. Today the Diabetes Association tells us that Diabetes costs $174 billion a year. When you add each special disease interest group's prognostication the costs are far more than the total spent for disease care each year.

Posted by at 9:17 AM | Permalink | Comments (0)

From the AMA's American Medical News today, we find that the cost of immunizing a child less than 18 years old was $11.68 in 1975, while in 2006 it was $668.81. The cost has risen as more shots are recommended, as the cost of making new vaccines increases, as safety concerns arise, and as protection from adverse events is included in the cost.

Posted by at 10:29 AM | Permalink | Comments (0)

The United States continues to spend the most on health care when compared to other Organization for Economic Cooperation and Development (OECD) countries. Health care prices and higher per capita incomes are major factors for higher U.S. spending, according to a study by researchers at the Johns Hopkins Bloomberg School of Public Health and Princeton University.
U.S. health care spending per capita was 2.5 times greater than the median OECD country.
The United States spent 15.3% of our gross domestic product on health care, which is substantially higher than any other OECD country.
Despite the fact that:
The United States had fewer physicians, nurses and hospital beds per capita than the OECD median.
The United States also had lower utilization rates than the OECD median for physician visits per capita, acute care bed days and average length of inpatient stay.

Posted by at 10:45 AM | Permalink | Comments (0)

In the NYT today is an article about Alzheiner's disease which among other items, notes that most "researchers say no breakthrough is around the corner, and it could easily be a decade or more before anything comes along that makes a real difference for patients." The numbers associated with the condition "are staggering." About 4.5 million Americans have Alzheimer's, one-in-10 over 65 and nearly half of those over 85. "Taking care of them costs $100 billion a year, and the number of patients is expected to reach 11 million to 16 million by 2050.

Posted by at 11:31 AM | Permalink | Comments (0)

From the Wall Street Journal "The dearth of primary-care providers threatens to undermine the Massachusetts health-care initiative, which passed amid much fanfare last year. Newly insured patients are expected to avail themselves of primary care because the insurance covers it. And with the primary-care system already straining, some providers say they have no idea how they will accommodate an additional half-million patients seeking checkups and other routine care."

Posted by at 10:57 AM | Permalink | Comments (0)

The report, "Health Coverage Proposals in California: Impact on Businesses," which was authored by researchers at UC Berkeley's Center for Labor Research and Education, analyzes Gov. Schwarzenegger's health care reform proposal and Assembly Bill 8 (AB 8). The researchers also say that the state could see an infusion of between $1.2 billion to $3.7 billion in new federal Medicaid matching funds to expand coverage to children and low-income parents, as well as a reduction of between $1.4 billion and $3.4 billion in employee and employer federal tax payments. Their report says both health reform packages would boost productivity as workers take off fewer sick days.

Posted by at 10:29 AM | Permalink | Comments (0)

In just the first year of a special effort organized by the federal agency that runs the Medicare system, the University of Michigan Health System was able to significantly improve both the quality and efficiency of care that Medicare beneficiaries received at its hospitals and health centers, while also saving the Medicare system millions of dollars.
All 10 physician groups improved quality of care for Medicare beneficiaries who have diabetes, by achieving nationally recognized benchmarks for diabetes care quality. The U-M Faculty Group Practice, which includes all the physicians on the U-M Medical School faculty who treat patients at U-M facilities, achieved 95 percent of its targets for providing specific, proven treatments and preventive measures to people with diabetes.

Posted by at 11:34 AM | Permalink | Comments (0)

Yesterday the Kaiser Family Foundation had an excellent webcast on the issues of the cost of maternity care. The webcast is worth listening to. Look carefully at the newest buzz phrase "Consumer Driven Health Plans" which is an insurance company 'weasel' phrase to suck people into an expensive insurance program. Note that today JAMA has a commentary on 'value based' insurance which is another weasel phrase used by insurance sponsors to suck people into expensive insurance. Caveat Emptor is still well and thriving. It needs replacement by a universal access system not support from the AMA!

Posted by at 11:08 AM | Permalink | Comments (0)

Colon cancer survival rates are worse for blacks than whites, and that may largely be due to social and economic factors, according to a new research review. The reviewers, who work in Houston at the University of Texas Health Science Center, included Xianglin Du, MD, PhD. They note that colon cancer killed 27 per 100,000 blacks compared with 19 per 100,000 whites from 2000-2003 in the U.S. During the same period, the five-year colon cancer survival rate was almost 55% for blacks, compared with 65% for whites. Adjusting for socioeconomic factors and for colon cancer treatment erased much of the black-white race gap in colon cancer survival rates.
The reviewers conclude that closing the social and economic gaps may narrow the colon cancer survival race gap.

Posted by at 2:10 PM | Permalink | Comments (0)

What information should be found in a Personal Health record(PHR)? The issue is being debated on many fronts but I see little interest from public health groups. For those interested in population health and prevention why is this not a major topic today? The Robert Wood Johnson Foundation is taking a lead in defining the elements to be found in such a record, see today's business section of the AMA-NEWS This includes a summary of 15 pieces of data that insurance companies, rather than doctors, are expected to update . Who will monitor these pieces of data? Will it be as difficult to find and question as one's credit history? What is wrong with the current plan listed in Amednews? What about the uninsured? Do you really trust insurance comanies to be concerned for the population's health? How much of this current move is driven by profit rather than good health care? Much to think about. Make a New Year's resolution to become more knowledgeable about the topic.

Posted by at 10:31 AM | Permalink | Comments (0)

How much money do we waste that could be spent to improve the public's health, that is diverted to useless nostrums, because of media attention to media stars without any science background. Now we find one more 'complementary medicine', Black Cohosh, supposedly used to treat postmenopausal symptoms has been found worthless. According to USAToday sales of black cohosh supplements soared after an NIH-sponsored study in 2002 reported that hormone therapy — the most effective treatment for menopause symptoms — raised users' risk of heart attacks, breast cancer, blood clots and stroke. U.S. black cohosh sales rose 26% from 2002 to 2003 to $15.7 million, according to the Natural Foods Merchandiser, a trade magazine.

Posted by at 9:35 AM | Permalink | Comments (0)

A major national survey of people affected by cancer provides an in-depth examination of how families cope with cancer and highlights problems of health insurance and health care costs through the lens of those who have experienced this major illness. The results show how health care and health insurance systems can fail to protect people when they are most in need.
The survey found that one in four families affected by cancer say the experience led the person with the disease to use up all or most of their savings, and one in eight say they borrowed money from relatives. The illness also made it harder for some to find and keep health insurance – with about one in 10 saying they couldn’t buy health insurance because they had been diagnosed with cancer, and 6% saying they lost their coverage as a result of the disease.

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Posted by at 10:40 AM | Permalink | Comments (1)

Today we had a major article in our newspaper about the elderly loosing health insurance. Today from the Mayo Clinic we get an article about spending on intensive care, which today comprises 30-40 percent of hospital costs, may go even higher as the population ages, according to a new Mayo Clinic study.

Published in the July issue of Mayo Clinic Proceedings, the study found that older people and those with chronic illnesses have the highest rates of end-of-life intensive care unit (ICU) use. Given that the country's aging population has an increasing prevalence of chronic diseases, the ICU may be treating more and more people at the end of life, the study's authors say.

But, what about prevention?

Posted by at 12:15 PM | Permalink | Comments (0)

We have learned this year of the financial disasters of the NHS. Now we learn that the German Health System is in deep financial trouble although for some what different reasons. Too many hospitalizations, too many prescriptions, and too many people failing to pay their insurance. As we worry about our spiralling costs, which are much worse than in countries that provide universal coverage, we should learn, although that may not be possible, how to avoid the same traps, We continue to react rather than plan long term.

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Once again, we learn that unnecessary medical tests are costing the U.S. health care system millions—and potentially billions— of dollars per year, and add unnecessary patient stress, say researchers from Georgetown University Medical Center and Johns Hopkins University in the June issue of the American Journal of Preventive Medicine.
The uathors say that among the many reasons that diagnostic interventions which lack evidence of benefit in asymptomatic patients are used are:

Studies have shown that many patients have expectations of receiving particular tests when visiting physicians.
It is possible that physicians are ordering these tests defensively, to guard against potential lawsuits.
Physicians may not be aware of USPSTF recommendations.
There may be a financial incentive to ordering these tests, especially if a physician’s office includes a laboratory.

Abput onxce a decade we see research that repats the information that a good hostry adn physical exam are far more use than batteris of tests. I wonder how much is the result ofthe seond observation. Our legislators, mostly lawyers, seem uninterEsted in changing the current state of affiARS..

Posted by at 10:17 AM | Permalink | Comments (0)

An interesting editorial from today's BMJ questions the value of choice in medical care. Multiple choices may not be the equivalent of better, for instance;
"In a recent bestselling business book, psychologist Barry Schwartz argues that the amount of choice on offer in life exceeds our ability to effectively exercise that choice, or even to enjoy it. The debilitating effects of choice overload may be bewilderment and high levels of anxiety and stress. When a brush with illness in the United States caused health economist Rhiannon Tudor Edwards to question the value of choice in health care, she concluded that having less choice in health care is a price well worth paying for universal coverage. The UK Public Administration Select Committee wisely advises caution, calling on the government to be more realistic about the role and limitations of choice. The paradox of choice is that more can sometimes mean less. "

Posted by at 10:26 AM | Permalink | Comments (0)

This note from Dr. Garg should make all of us think about the best way to vaccinate the public. It is poor public relations and probably poor economics if patients cannot obtain timely flu vaccine from their primary care physician. Dr Garg writes:
"Unfortunately the doctors offices lose out - they get the vaccines last after all the big conglomerates, warehouses, drug stores and grocery stores get it. And furthermore, as we doctors receive our supply, finally in mid-November or late november, a lot of missed opportunities for vaccination pass by. I did receive my doses of flu vaccine I ordered finally this week which should be enough at least for my highest risk patients. However, this past month I had a LOT of lost opportunities for immunization, because some of the oldest and sickest patients who see me on a regular basis were in the office and wanted to get flu vaccine. They were surprised to hear that the vaccine didn't get delivered to their doctor, but the local grocery stores had it."
What should the CDC/CMS role be in ensuring availability of flu vaccine to primary care doctors? Surely the doctor's office should receive vaccine beforr the corner grocery stores.

Posted by at 12:16 PM | Permalink | Comments (4)

From the Economist today is a wonderful story of how immunization may improve the economic outlook of poor countries.
Dr Bloom and Dr Canning (from the HSPH) believed that previous attempts to quantify the non-medical benefits of vaccination had been too narrow. These had looked at such data as the cost of a programme per life saved, but had failed to take account of recent work on the effects of health on incomes. For their study, they and Mr Weston identified how vaccination, in particular, might increase wealth.

Posted by at 4:48 PM | Permalink | Comments (0)

This week the BMJ reports that the U.S. is not the only country involved in the quagmire of evaluating complementary medical therapies (CAM). Citizens in both the US and the UK are voting for CAM with their feet, based on anecdotes and uncertain evidence. The BMJ author notes that the popularity of CAM should not be confused with its value. Payment by reimbursement agents should be based on effectiveness, not politics or popularity.

Posted by at 7:13 PM | Permalink | Comments (0)

From today's Telegraph we find The following account of poor care in the U.K.
Thousands of patients are being denied the best treatment by the NHS because a third of hospital trusts say they have too little money to follow best practice, the Government's spending watchdog said yesterday.
Only 25 per cent of the trusts surveyed could verify that they were implementing Nice appraisals of drugs and treatments within three months. A third said they had been unable to fund guidance issued by Nice in 2002-03.

Is this really much different from the Medicare programs and many insurance companies which pay for 'hands on' care but not for advice and consultation, which is often more effective than pills, for chronc diseases?

Posted by at 11:33 AM | Permalink | Comments (0)

And sone want to emulate the NHS!
From today's Telegraph
An NHS trust is stopping all non-urgent surgery at a hospital and closing the waiting list at another in an attempt to reduce its forecast deficit of £68 million.

The 92 planned operating sessions across the trust are being cut to 50 and overall treatment at the hospitals will fall by 25 per cent.

Posted by at 10:49 PM | Permalink | Comments (0)

From the Kasier Familiy Foundation Reproductive Health Report.
The U.S. is the only nation that is a "major economic power" with a total fertility rate high enough to maintain its work force and economic prosperity as the population ages, according to a Population Reference Bureau report released on Tuesday, the Wall Street Journal reports. Most other wealthy nations' total fertility rates are declining as the population of older, nonworking citizens expands.

Posted by at 11:01 AM | Permalink | Comments (1)

In an August 22 report from the WHO the goals (or Millenium Report. similar to Healthy People) states that "Despite gains in reducing poverty worldwide, the data presented in the new WHO report indicate that if trends established in the 1990s continue, the majority of developing countries will not achieve the health MDGs. This in turn will affect progress towards other goals. With less than ten years to the target date of 2015, none of the poorest regions of the developing world are on track to meet the child mortality target. For maternal mortality, declines have been limited to countries which already have lower mortality levels. The goal of reversing the spread of HIV/AIDS and reversing the incidence of malaria and other communicable diseases remains a huge challenge in sub-Saharan Africa. The safe water target may be achieved globally, but not in sub-Saharan Africa.

"Providing universal access to broad-based health services could save several million children's lives each year,” said Dr LEE. “That would reverse the downward trends and bring us two-thirds of the way to meeting the child mortality goal, and 70% to 80% towards meeting the maternal mortality goal.” “We have the treatments; the technology is known and affordable,” Dr LEE said. “The problem in many countries is getting the staff, medicines, vaccines and information to those who need them on time and in sufficient quantities. In too many countries, the health systems to do that either do not exist or are on the point of collapse.”
Health and the Millennium Development Goals also identifies future health challenges in the developing world. If health is to have its full impact on reducing poverty, there is a need to address:

the growing burden of noncommunicable disease in the developing world, which is leading to a “double burden” of ill-health;
the “nutrition transition” in which people in developing countries begin to adopt unhealthy eating habits common in richer countries and suffer the health consequence;
the need for universal access to reproductive and sexual health services as agreed at the Cairo International Conference on Population and Development; and
the impact of globalization on the spread of disease and migration of health staff.

Posted by at 11:09 AM | Permalink | Comments (0)

From the Daily Telegraph August 15,2005

With 2,000 newly qualified medics in Britain unable to find a position, life on the dole beckons even after six years of training - which is why a growing number are moving to Australia. We should be so lucky. If we were to move to a planned health and medical system we might have 100,000 redundant physicians and have affordable accessible health services! Now, if we could do the same for lawyers.

Posted by at 10:42 AM | Permalink | Comments (0)

The Commission on Health Care for the UK puts out annual reports on health status. There is no comparable body in the US. The closest reports are those from the Kaiser Family Foundation and the Institute of Medicine.
This year, the report reviews the state of healthcare from the point of view of the people who use healthcare services. This mainly refers to patients, but also includes carers and others who use services.
Are people able to gain access to the healthcare services that they need? Are the services safe, effective and sensitive to their needs?
How well do providers inform and involve people in the development and improvement of their services?
Are people getting a fair deal from healthcare services and the lessons that we can all learn from their experiences?

Posted by at 11:28 AM | Permalink | Comments (0)

Fromthe BMJ Round Up of news - July 22, 2005:
US health system doesn't give value for money, report says
New York Janice Hopkins Tanne

More is spent per person on health care in the United States than in any of the other 29 industrialised countries in the Organization for Economic Cooperation and Development (OECD). The reason is higher prices in the United States, not malpractice litigation and defensive medicine, says an annual study published in Health Affairs (2005;24:903-14).
That study covered 12 000 patients treated in US and Canadian hospitals (Archives of Internal Medicine 2005;165:1506-13).

The study also refutes the argument that high spending in the US means that healthcare capacity is high. It says that many other OECD countries have a higher number of doctors, nurses and hospital beds per population and their spending is much lower than that in the US.

Posted by at 11:51 AM | Permalink | Comments (1)

The weeks BMJ has an wonderful editorial about health status after the break-up of the Soviet Union. It is worth reading. I don't want to give away the punch line. I hope someone will comment on this piece

Posted by at 11:42 AM | Permalink | Comments (0)

A new analysis of birth records from the Center for Immigration Studies shows that immigrants (legal & illegal) accounted for a larger share of births in 2002 than in 1910, during the peak of the last great wave of immigration. The children born to immigrants are arguably the most important long-term legacy of immigration and are a key measure of its magnitude. The new report provides detailed information on births to immigrants for every state and many counties, including estimates for births to illegal aliens.
In 2002, 23 percent of all births in the United States were to immigrant mothers (legal or illegal), compared to 15 percent in 1990, 9 percent in 1980 and 6 percent in 1970.
Even at the peak of the last great wave of immigration in 1910, the share of births to immigrant mothers did not reach the level of today. And after 1910 immigration was reduced, whereas current immigration continues at record levels, thus births to immigrants will continue to increase.
Our best estimate is that 383,000, or 42 percent, of births to immigrants are to illegal alien mothers. Thus births to illegals now account for nearly 1 out of every 10 births in the United States.

Posted by at 4:55 PM | Permalink | Comments (3)

Press Release from "Health Affairs"
Bethesda, MD — The obesity epidemic is adding billions of dollars to the U.S. health care tab by increasing the prevalence of treated disease: Between 1987 and 2002, the share of private health spending attributable to obesity soared more than tenfold, from $3.6 billion to $36.5 billion, according to a study published today in the online version of the journal Health Affairs. In 2002, spending on medical care related to obesity accounted for 11.6 percent of all private health care spending, compared with 2 percent in 1987.
Current approaches to controlling health care costs are not working because they ignore the true drivers of those costs. Increases in the number of people getting treatment for serious health problems like diabetes, heart disease, high cholesterol, and mental disorders are directly linked to population increases in obesity. If insurers and employers are serious about reining in health care spending, then obesity prevention should be at the top of their agenda. Read the article
One more reason to try and changed behavioirs by holding individuals responsible for their own outcomes. Should we pay for others' bad behavior?

Posted by at 12:59 PM | Permalink | Comments (0)