Seniors healthier when medical care is coordinated

(Reuters Health) – As America’s population ages, experts are exploring how best to keep older people with multiple chronic illnesses healthy. A new study suggests that coordination between physicians may be key.

FILE PHOTO: An elderly woman sorts her daily medical prescriptions at her independent living apartment in Silver Spring, Maryland April 11, 2012. REUTERS/Gary Cameron/File Photo

In a reanalysis of 25 earlier studies including 12,579 patients, researchers found that coordination of care for older adults with multiple medical conditions resulted in improved health. Patients in the study had combinations of disorders such as heart failure and obstructive lung disease, arthritis and depression, diabetes and depression, or diabetes and cardiovascular disease.

Currently more than 62 percent of older Americans have multiple chronic conditions, the researchers noted in CMAJ. And many of those seniors receive care from a variety of specialists who don’t communicate with one another.

“To address the challenges faced by our rapidly aging population, we need to focus on a more patient-oriented and holistic strategy that targets management of patients with common disease combinations, such as diabetes and depression, rather than treating one disease at a time,” said study leader Monika Kastner, a health services researcher at the University of Toronto, Canada, and research chair at North York General Hospital.

Care coordination, Kastner explained in an email, can be defined as efforts by health care professionals to facilitate and coordinate appropriate, timely and efficient delivery of health care services for a patient.

The average age in the studies was 67. One area where coordination made a big difference was in patients who had a chronic physical condition along with depression. For example, patients with both depression and diabetes had improvements in both depressive symptoms and blood sugar levels when they got coordinated care.

The new article “takes us in the right direction,” said Michael Wolf, associate vice chair of research in the department of medicine at Northwestern University’s Feinberg School of Medicine in Chicago.

Wolf has personal experience with a problem that’s common when care is fragmented: the possibility that doctors will provide a patient with overlapping medications.

“My sister at one point was on 24 medications,” he said in a phone interview. “It wasn’t till she was hospitalized that a surgeon pointed out that she was taking multiple medications to treat the same thing. They had been prescribed by different people. When she left the hospital, the number had been reduced to six or seven.”

Presently, however, there is no template to show health care providers how to accomplish coordinated care with the system set up the way it is, Wolf pointed out.

There are a number of reasons why patients rarely get coordinated care, said Dr. Alicia Arbaje, director of translational care research in the division of geriatric medicine and gerontology at Johns Hopkins University in Baltimore, Maryland.

Top on the list is the way practitioners are reimbursed, Arbaje said by phone. And beyond that, “we haven’t caught up in our training of physicians to learn how to work with other providers or even as a team,” she added. “Also, we don’t have a culture of accountability. In the culture we have, once a patient is out of the hospital, that patient is now someone else’s responsibility. And the same is true outside the hospital.”

Patients often assume that their doctors are all on the same page, Arbaje said. “I think some levers could get moved if there was some outrage from the public,” she added. “People asking why isn’t care done this way.”

SOURCE: bit.ly/2ogyMb6 and bit.ly/2odAjP9 CMAJ, online August 27, 2018.

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U.S. FDA proposes restricting compounding of three drug substances

(Reuters) – The U.S. Food and Drug Administration on Monday proposed excluding three substances from a list of ingredients that could be used to manufacture compounded medications in bulk for use by hospitals and doctors’ offices.

FILE PHOTO: A view shows the U.S. Food and Drug Administration (FDA) headquarters in Silver Spring, Maryland August 14, 2012. REUTERS/Jason ReedREUTERS/File Photo

The action was the first time the regulator has moved to exclude any substance from a list of ingredients that may be used to produce in bulk compounded medications that do not need to go through the agency’s safety approval process.

Those substances included vasopressin, the active ingredient in Endo International Plc’s blood pressure drug Vasostrict, which has been the subject of a lawsuit by the company targeting how the FDA regulates drug compounding. Shares of Endo jumped 5 percent.

The other two substances are bumetanide and nicardipine hydrochloride, which the regulator said are also ingredients of one or more FDA-approved drug products.

On Aug. 13, Buffalo, New-York-based pharmaceutical company Athenex Inc said it had begun selling a compounded formulation of vasopressin that could compete with Vasostrict. Its stock price fell 1.43 percent to $14.45 on the news of the FDA’s proposal.

Endo, which reported $399.9 million in Vasostrict sales in 2017, said it was “extremely pleased” with the FDA’s proposal. Its stock price mid-Monday was $16.33, up 5.08 percent.

Athenex did not respond to requests for comment.

Compounded medications are custom-made medications that traditionally were formulated by pharmacies for specific patients.

By 2012, the practice had mushroomed, with some pharmacies selling thousands of doses of regularly used mixtures for physicians to keep for future use.

That year, there was a fungal meningitis outbreak caused by tainted steroids made by a compounding pharmacy. That prompted Congress in 2013 to pass a law aimed at bringing more compounding pharmacies, traditionally overseen by states, under FDA oversight.

The law, the Drug Quality and Security Act, created a category of “outsourcing facilities” that could register with the FDA and sell products in bulk while following federal manufacturing standards.

The FDA was also required to determine that bulk compounding using a drug substance was necessary to satisfy an unmet “clinical need” and include those substances on a list.

Under an interim policy, it allowed use of substances with no major safety issues, that compounders could nominate for eventual inclusion on the list.

Endo sued in October, claiming the FDA was authorizing the compounding of hundreds of drugs without proper evaluation, including “essentially a copy” of Vasostrict by another company.

Reporting by Nate Raymond in Boston; Editing by David Gregorio

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McCain’s Complicated Health Care Legacy: He Hated the ACA. He Also Saved It.

There are many lawmakers who made their names in health care, seeking to usher through historic changes to a broken system.

John McCain was not one of them.

And yet, the six-term senator from Arizona and decorated military veteran leaves behind his own health care legacy, seemingly driven less by his interest in health care policy than his disdain for bullies trampling the “little guy.”

He was not always successful. While McCain was instrumental in the passage of the Americans with Disabilities Act in 1990, most of the health initiatives he undertook failed after running afoul of traditional Republican priorities. His prescriptions often involved more government regulation and increased taxes.

In 2008, as the Republican nominee for president, he ran on a health care platform that dumbfounded many in his party who worried it would raise taxes on top of overhauling the U.S. tradition of workplace insurance.

Many will remember McCain as the incidental savior of the Affordable Care Act, whose late-night thumbs-down vote halted his party’s most promising effort to overturn a major Democratic achievement — the signature achievement, in fact, of the Democrat who beat him to become president. It was a vote that earned him regular — and biting — admonishments from President Donald Trump.

McCain died Saturday, following a battle with brain cancer. He was 81. Coincidentally, his Senate colleague and good friend Ted Kennedy died on the same date, Aug. 25, nine years ago, succumbing to the same type of rare brain tumor.

Whether indulging in conspiracy theories or wishful thinking, some have attributed McCain’s vote on the ACA in July 2017 to a change of heart shortly after his terminal cancer diagnosis.

But McCain spent much of his 35 years in Congress fighting a never-ending supply of goliaths, among them health insurance companies, the tobacco industry and, in his estimation, the Affordable Care Act, a law that extended insurance coverage to millions of Americans but did not solve the system’s ballooning costs.

His prey were the sort of boogeymen that made for compelling campaign ads in a career stacked with campaigns. But McCain was “always for the little guy,” said Douglas Holtz-Eakin, the chief domestic policy adviser on McCain’s 2008 presidential campaign.

“John’s idea of empathy is saying to you, ‘I’ll punch the bully for you,’” he said in an interview before McCain’s death.

McCain’s distaste for President Barack Obama’s health care law was no secret. While he agreed that the health care system was broken, he did not think more government involvement would fix it. Like most Republicans, he campaigned in his last Senate race on a promise to repeal and replace the law with something better.

After Republicans spent months bickering amongst themselves about what was better, McCain was disappointed in the option presented to senators hours before their vote: hobble the ACA and trust that a handful of lawmakers would be able to craft an alternative behind closed doors, despite failing to accomplish that very thing after years of trying.

What bothered McCain more, though, was his party’s strategy to pass their so-called skinny repeal measure, skipping committee consideration and delivering it straight to the floor. They also rejected any input from the opposing party, a tactic for which he had slammed Democrats when the ACA passed in 2010 without a single GOP vote. He lamented that Republican leaders had cast aside compromise-nurturing Senate procedures in pursuit of political victory.

In his 2018 memoirs, “The Restless Wave,” McCain said even Obama called to express gratitude for McCain’s vote against the Republican repeal bill.

“I was thanked for my vote by Democratic friends more profusely than I should have been for helping save Obamacare,” McCain wrote. “That had not been my goal.”

Better known for his work on campaign finance reform and the military, McCain did have a hand in one landmark health bill — the Americans with Disabilities Act of 1990, the country’s first comprehensive civil rights law that addressed the needs of those with disabilities. An early co-sponsor of the legislation, he championed the rights of the disabled, speaking of the service members and civilians he met in his travels who had become disabled during military conflict.

McCain himself had limited use of his arms due to injuries inflicted while he was a prisoner of war in Vietnam, though he was quicker to talk about the troubles of others than his own when advocating policy.

Yet two of his biggest bills on health care ended in defeat.

In 1998, McCain introduced a sweeping bill that would regulate the tobacco industry and increase taxes on cigarettes, hoping to discourage teenagers from smoking and raise money for research and related health care costs. It faltered under opposition from his fellow Republicans.

McCain also joined an effort with two Democratic senators, Kennedy of Massachusetts and John Edwards of North Carolina, to pass a patients’ bill of rights in 2001. He resisted at first, concerned in particular about the right it gave patients to sue health care companies, said Sonya Elling, who served as a health care aide in McCain’s office for about a decade. But he came around.

“It was the human, the personal aspect of it, basically,” said Elling, now senior director of federal affairs at Eli Lilly. “It was providing him some of the real stories about how people were being hurt and some of the barriers that existed for people in the current system.”

The legislation would have granted patients with private insurance the right to emergency and specialist care in addition to the right to seek redress for being wrongly denied care. But President George W. Bush threatened to veto the measure, claiming it would fuel frivolous lawsuits. The bill failed.

McCain’s health care efforts bolstered his reputation as a lawmaker willing to work across the aisle. Sen. Chuck Schumer of New York, now the Senate’s Democratic leader, sought his help on legislation in 2001 to expand access to generic drugs. In 2015, McCain led a bipartisan coalition to pass a law that would strengthen mental health and suicide prevention programs for veterans, among other veterans’ care measures he undertook.

It was McCain’s relationship with Kennedy that stood out, inspiring eerie comparisons when McCain was diagnosed last year with glioblastoma — a form of brain cancer — shortly before his vote saved the Affordable Care Act.

That same aggressive brain cancer killed Kennedy in 2009, months before the passage of the law that helped realize his work to secure better access for Americans to health care.

“I had strenuously opposed it, but I was very sorry that Ted had not lived to see his long crusade come to a successful end,” McCain wrote in his 2018 book.

While some of his biggest health care measures failed, the experiences helped burnish McCain’s résumé for his 2000 and 2008 presidential campaigns.

In 2007, trailing other favored Republicans, such as former New York City mayor Rudy Giuliani in early polling and fundraising, McCain asked his advisers to craft a health care proposal, said Holtz-Eakin. It was an unusual move for a Republican presidential primary.

The result was a remarkable plan that would eliminate the tax break employers get for providing health benefits to workers, known as the employer exclusion, and replace it with refundable tax credits to help people — not just those working in firms that supplied coverage — buy insurance individually. He argued employer-provided plans were driving up costs, as well as keeping salaries lower.

The plan was controversial, triggering “a total freakout” when McCain gained more prominence and scrutiny, Holtz-Eakin said. But McCain stood by it.

“He might not have been a health guy, but he knew how important that was,” he said. “And he was relentless about getting it done.”

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Bayer, J&J’s heart drug Xarelto fails trial to widen use

FRANKFURT (Reuters) – Bayer and Johnson & Johnson’s campaign to widen the market for its heart drug Xarelto hit a snag on Sunday when a study for a potential new patient subgroup failed to show a statistically reliant benefit.

The blockbuster clot prevention drug could not be shown to reduce the rate of dangerous blood clots in a certain group of high-risk patients after discharge from hospital, the New England Journal of Medicine reported.

Participants in the so-called Mariner study had previously been admitted to hospital for a range of conditions that are associated with a higher risk of venous thromboembolism, such as heart failure, acute respiratory disease, ischemic stroke or infections.

Bayer reported 3.3 billion euros ($3.77 billion) in Xarelto revenues last year, mainly from stroke prevention in the elderly, and expects annual sales to rise above 5 billion euros.

A Bayer spokesman said that the latest results, also presented at the European Society of Cardiology congress in Munich, did not change its peak sales estimate or have any implications for other conditions that Xarelto is approved for.

It is a reversal of fortunes for Bayer, which in July won approval for additional Xarelto use in the potentially lucrative market for atherosclerosis patients.

Bayer has the marketing rights for the drug outside the United States while partner J&J sells Xarelto in the U.S., with Bayer being eligible for royalties on U.S. sales of 20-30 percent.

Reporting by Ludwig Burger; Editing by Kirsten Donovan

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Cargill recalls 25,000 lbs of possibly contaminated beef

(Reuters) – A Cargill Meat Solutions plant in Colorado is recalling more than 25,000 pounds (11,300 kg) of ground beef that could be contaminated with E. Coli, the U.S. Department of Agriculture said.

The meat carries an “EST. 86R” label inside the USDA mark of inspection and a use-by date of Sept. 5, the USDA’s Food Safety and Inspection Service said this week in a statement. It was shipped from Cargill’s facility in Fort Morgan, Colorado, to warehouses in California and Colorado, FSIS said.

E. Coli bacteria can cause dehydration, bloody diarrhea and abdominal cramps, and in some rare cases it can develop into a life-threatening type of kidney failure.

FSIS said the problem was discovered on Aug. 22 when the company inspected its records and found the beef might have been associated with a product presumed positive for E. Coli.

The company then notified FSIS, the inspection service said, adding in its statement that there have been no confirmed reports of adverse reactions due to these products being eaten.

Cargill Meat Solutions is a Wichita, Kansas-based division of Cargill Inc [CARG.UL].

Reporting by Maria Caspani; Editing by Marguerita Choy

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Play predicts chilling future for Britain’s prized health service

EDINBURGH (Reuters) – A desperate mechanic driven to operate on his sick wife is the subject of a disturbing play which looks at the future of Britain’s prized public health service, shown at the Edinburgh Fringe.

FILE PHOTO: Demonstrators hold placards during a march in support of the National Health Service, in central London, Britain, June 30, 2018. REUTERS/Simon Dawson

“After the Cuts” is the dystopian story of Jim, a retired mechanic, and his wife Agnes who cannot afford medical treatment when she is diagnosed with cancer. Years into the future, healthcare in Britain is no longer free.

The performance coincides with the celebration of the seventieth anniversary of Britain’s National Health Service (NHS) and its “cradle to grave” care. The anniversary has provoked public reflection on its integrity as tight government budgets put pressure on services. 

Cost restraints amid the growing demands of an aging population have compounded anxiety over the consequences of Britain’s exit from the European Union next year, and the potential impact on the supply of medicines and staff.

The subject is close to the public’s heart, director Beth Morton told Reuters at the world’s biggest arts and culture festival in Edinburgh.

“The audiences react so differently (…) some laugh a lot, in serious places too, perhaps because of discomfort. People cry, because they feel the human connection,” she said.

“The message is not to take the NHS for granted.”

Accompanied by dim lighting and a soundtrack that is by turns mournful and menacing, the setting in a small performing space creates a charged atmosphere.

The drama culminates a scene where Jim operates on his wife to a backdrop of metallic, violent sound effects.

Despite the grim topic, the play is also peppered with bittersweet jokes: the couple laugh over the costs of a hospital trip where they are billed for electricity, water and toilet trips and Agnes is continually compared to the broken vacuum cleaner, which Jim haphazardly mends.

A recent poll found the NHS is a principle concern of British voters, with 77 percent of the public backing an increase in public spending on healthcare.

The show will tour Britain in spring 2019.    

Reporting by Grace van der Wielen; Editing by Elisabeth O’Leary and Ros Russell

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African swine fever hits Romania’s biggest pig farm

BUCHAREST (Reuters) – Romania has confirmed an outbreak of deadly African swine fever at the country’s largest pig breeding farm and all 140,000 animals will be culled, the national food safety authority ANSVSA’s office in the affected region said on Saturday.

The farm complex, which consists of three adjoining properties and is located in the southern county of Braila, is owned by Romanian company TEBU Consult.

“On Friday morning I sent samples to the national reference lab and tests confirmed the existence of the virus. From Monday, all pigs at the farms, or 140,000, will be culled,” DSV Braila director Gicu Dragan told state news agency Agerpres.

Dragan said the farms have used water from the nearby river Danube. The official said he had heard reports that some smallholders had been dumping the corpses of infected pigs into the Danube, suggesting the highly contagious virus might have been spread by river water.

“We’ve been focusing on mainland and the virus might have emerged from the waters,” he said.

Romania has reported hundreds of outbreaks of the disease among pigs kept in backyards and smallholdings as well as several large private farms located especially in the south of the country. About 100,000 pigs have been culled so far.

African swine fever affects pigs and wild boar and has spread in Eastern Europe in recent years. It does not affect humans.

Hungary, Russia, Poland, Ukraine and Romania are among the countries affected, alarming governments and pig farmers due the pace at which it has spread.

Reporting by Radu Marinas; Editing by Helen Popper

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Eyes Could Be Window to Predicting Alzheimer’s

News Picture: Eyes Could Be Window to Predicting Alzheimer's

Latest Alzheimer’s News

THURSDAY, Aug. 23, 2018 (HealthDay News) — An eye exam might spot people with Alzheimer’s disease before they show any symptoms, researchers report.

“All of us have a small area devoid of blood vessels in the center of our retinas that is responsible for our most precise vision. We found that this zone lacking blood vessels was significantly enlarged in people with pre-clinical Alzheimer’s disease,” explained co-principal investigator Dr. Rajendra Apte. He is a professor of ophthalmology and visual sciences at Washington University School of Medicine in St. Louis.

Previous studies have found that the eyes of people who had died from Alzheimer’s showed signs of thinning in the center of the retina and deterioration of the optic nerve.

In this new study, Apte’s team used a noninvasive technique called optical coherence tomography angiography to examine the thickness of the retinas and fibers in the optic nerves of 30 people, average age mid-70s, who had no symptoms of Alzheimer’s.

A form of the test is available at many eye doctors in the United States.

After the eye tests, PET scans and cerebrospinal fluid analyses revealed that about half of the study participants had elevated levels of the Alzheimer’s-related proteins amyloid or tau. So, even though they didn’t have any Alzheimer’s symptoms, these people were likely to develop the disease.

“In the patients with elevated levels of amyloid or tau, we detected significant thinning in the center of the retina,” Apte said in a university news release.

According to study first author Dr. Bliss O’Bryhim, “This technique has great potential to become a screening tool that helps decide who should undergo more expensive and invasive testing for Alzheimer’s disease prior to the appearance of clinical symptoms.” O’Bryhim is a resident physician in the department of ophthalmology and visual sciences.

“Our hope is to use this technique to understand who is accumulating abnormal proteins in the brain that may lead them to develop Alzheimer’s,” she added.

It’s believed that Alzheimer’s-related plaques can accumulate in the brain two decades before symptoms appear, so scientists are trying to find ways to detect the disease earlier.

Currently, PET scans and lumbar punctures are used to help diagnose Alzheimer’s, but these methods are invasive and expensive.

Further research is needed, but this eye test could one day make it possible to screen people in their 40s or 50s for early signs of Alzheimer’s, and begin treatment to delay further progression of the disease, the study authors suggested.

The study was published Aug. 23 in the journal JAMA Ophthalmology.

— Robert Preidt

MedicalNews
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SOURCE: Washington University School of Medicine, news release, Aug. 23, 2018


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Readers And Tweeters Revisit Surgery Centers, Think Twice About Single-Payer

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.


A Duty To Report On Surgery Centers

Your article regarding unreported bad outcomes from outpatient surgery centers (“Lax Oversight Leaves Surgery Center Regulators And Patients In The Dark,” Aug. 9) had been a concern of mine for some time. I am a retired radiologist and have personally seen bad outcomes and wondered if they are a public safety issue and go unreported. Accredited hospitals must keep track of outcomes, but the outpatient surgery centers are variable. Good investigative journalism as yours provides a valuable service to the public and will save lives.

— James LaManna, Gillette, Wyo.

On Twitter, a spine surgeon pointed out what he sees as holes in the story. Dr. Paul Kraemer, a specialist at North Meridian Surgery Center in Carmel, Ind., argued that the story was based on the false assumption that hospitals have better trained staff than do surgery centers. Rather than set up the dichotomy of surgery center vs. hospital, he told KHN, the article should have differentiated between generalist and specialty centers — that is, those performing spine procedures occasionally vs. every day. At specialty centers, the nurses in the recovery room can spot a problem — especially an airway problem — and alert a surgeon or anesthetist to intervene, he said. They see what is normal and recognize early warning signs of trouble, whether the procedure is simple or complex.

1. No mention of millions who have had surgery safely to provide perspective.

2. No mention that same complication can happen in hospital (seen it)

3. No mention of conflicts inherent in hospital news promoting and funding story

4. No mention of steps taken to prevent tragedy

— Paul Kraemer MD (@PK_Spine) August 1, 2018

— Dr. Paul Kraemer, Carmel, Ind.

Dr. Ronald Hirsch of Illinois told KHN he has been trying for a year to get insight from the Centers for Medicare & Medicaid Services on its fast-track approval of increasingly complex procedures — while oversight lags.

And yet, @CMSGov allows @Humana to authorize “Inpatient Only” surgeries to be done at surgery centers on Medicare Advantage beneficiaries. Hip fracture repair? Open cholecystectomy? Carotid artery stenting? https://t.co/0BZ0JSDlwf

— Ronald Hirsch, MD (@signaturedoc) August 10, 2018

— Dr. Ronald Hirsch, Elgin, Ill.

Glenn Krauss of Vermont explained why he avoids surgery centers at all costs.

— Glenn Krauss, Burlington, Vt.


Filling A Gnawing Need On Campus

“Insuring Your Health” columnist Michelle Andrews did her homework on solutions for a rampant problem: food insecurity among college students (“For Many College Students, Hunger Can ‘Make It Hard To Focus In Class,” July 31). Readers such as J.K. Devine of Gainesville, Ga., joined a chorus of those commending universities for coming to the aid of hungry scholars.

Enjoyed reading your story about college students going hungry. The University of North Georgia is one of those universities that has started food pantries on 3 of its 5 campuses to help students, faculty and staff who need it.

— J.K. Devine (@JKDevine1) July 31, 2018

— J.K. Devine, Gainesville, Ga.

A Californian shared her firsthand experience with hunger as a college freshman.

I remember freshmen year going to bed hungry every night, wishing I was home so I could at least have cereal. I did have a dinning hall pass, but social anxiety and peak dinner times don’t mix.

— Korahline (@Krhddg) August 1, 2018

— Paola Viveros, Oxnard, Calif.

Doctors for America, a coalition of 18,000 physicians and medical students whose goal is to improve access to health care, also rallies to fight hunger, especially among medical students who are at risk of being saddled with tuition debt.

While the US is the wealthiest country, up to a half of all college students suffer from food insecurity. We must not allow future medical students to suffer from such a gap. All while the US is declining their contribution to student financial aid https://t.co/rHgWlrMpKm

— Doctors for America (@Drsforamerica) August 3, 2018

Zachary LeClaire of California has adopted the philosophy that he would rather go hungry than let his college bills add up. On Twitter, he mused: Are parents doing enough to tend to the financial needs of their “dependents”?

One of the main problems with this is many college students are under the age of 24 and are considered “dependent students” regardless of whether or not they’re parents actually give them any money. Also I’d rather eat 1 meal a day than be in debt for the rest of my life

— A useless philosopher (@GenYDiogenes) July 31, 2018

— Zachary LeClaire, Huntington Beach, Calif.

Although nutrition needs are being addressed where she lives in Washington state, Erin Davis looked at the big picture.

https://t.co/nniqYTfIsN

Proud and thankful that my institution has a food bank for students. Food insecurity among community college students is a pervasive problem that also needs larger, systemic solutions.

— Erin Davis (@FreckleErin) August 1, 2018

— Erin Davis, Spokane, Wash.


Second Thoughts On Single-Payer

In almost 100 percent of the discussions on health coverage plans, it is assumed that providers will both exist and will work for whatever the plan will pay them (“Once Its Greatest Foes, Some Doctors Are Now Embracing Single-Payer,” Aug. 7). Most people, when they hear “single-payer,” expect that everything will be covered with minimal copay and deductible. They are wrong, but no one will admit it upfront.

The alleged coverage crisis — wherein medical insurance was conflated with service availability, resulting in Obamacare — was caused by the government. Both Medicaid and Medicare health benefits were originally designed to provide basic health services while paying providers little more than direct costs, allowing private pay and commercial insurance payments to cover overhead and profit. Medicaid and Medicare were not expected to be a significant percentage of any provider’s practice. Over time, the good-hearted liberals kept expanding the scope of benefits with marginal improvements in reimbursement calculations and certainly without consideration of “unintended consequences,” especially the predictable ones pertaining to demand and cost.

Experience shows that A) any national single-payer system will be run at least as well as the VA and the Indian Health Services and B) our Fearless Leaders will exempt themselves from the system.

— Ed Connelly, Shaftsbury, Vt.

On Twitter, Ryan Quattro of Michigan wondered how an overhaul in health care policy might play against the backdrop of precarious foreign, defense and other domestic policies.

We need to have a conversation on what single-payer means for US role in the world.

End of role in NATO and seriously reduced military means reduced influence in world. Then there is the issue of infrastructure. $2.5 trillion. America is a hot mess.

— Ryan Quattro (@forzaquattro77) August 2, 2018

— Ryan Quattro, Ann Arbor, Mich.

A reader in Iowa warned that the flip side of single-payer means doctors would earn far less than they traditionally do, and that American innovation would be sacrificed.

Wait until these new physicians have to pay back their student loans on single payer compensation…good luck…oh, say goodbye to innovation, too. #Shame
Once Its Greatest Foes, Doctors Are Embracing Single-Payer https://t.co/MSpDmvkv2k via @khnews

— Sean Yolish (@SeanYolish) August 8, 2018

— Sean Yolish, West Des Moines, Iowa

Power to the younger generation, was the message from an Idaho tweeter.

The youngin’s are gonna change our country for the better. I believe that. Enough is enough.

— IndiraShanti (@IndiraShanti) August 2, 2018

— Tina Neidig, Boise, Idaho

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Tuition-Free Med School Touches Off Multimillion-Dollar Debate

New York University’s School of Medicine is learning that no good deed goes unpunished.

The highly ranked medical school announced with much fanfare Aug. 16 that it is raising $600 million from private donors to eliminate tuition for all its students — even providing refunds to those currently enrolled. Before the announcement, annual tuition was $55,018.

NYU leaders said the move will help address the increasing problem of student debt among young doctors, which many educators argue pushes students to enter higher-paying specialties instead of primary care, or deters them from becoming doctors in the first place.

“A population as diverse as ours is best served by doctors from all walks of life, we believe, and aspiring physicians and surgeons should not be prevented from pursuing a career in medicine because of the prospect of overwhelming financial debt,” Dr. Robert Grossman, the dean of the medical school and CEO of NYU Langone Health, said in a statement. NYU declined a request to elaborate further on its plans.

The announcement generated headlines and cheers from students. But not everyone thinks that making medical school tuition-free for all students, including those who can afford it, is the best way to approach the complicated issue of student debt.

“As I start rank ordering the various charities I want to give to, the people who can pay for medical school in cash aren’t at the top of my list,” said Craig Garthwaite, a health economist at Northwestern University’s Kellogg School of Management.

“If you had to find some cause to put tons of money behind, this strikes me as an odd one,” said Dr. Aaron Carroll, a pediatrician and researcher at Indiana University.

Still, medical education debt is a big issue in health care. According to the Association of American Medical Colleges, which represents U.S. medical schools and academic health centers, 75 percent of graduating physicians had student loan debt as they launched their careers, with a median tally of $192,000 in 2017. Nearly half owed more than $200,000.

But it is less clear how much of an impact that debt has on students’ choice of medical specialty. The AAMC’s data suggests debt does not play as big a role in specialty selection as some analysts claim.

If debt were a huge factor, one would expect that doctors who owed the most would choose the highest-paying specialties. But that’s not the case.

“Debt doesn’t vary much across the specialties,” said Julie Fresne, AAMC’s director of student financial services and debt management.

Garthwaite agrees. He said surveys in which young doctors claim debt as a reason for choosing a more lucrative specialty should be viewed with suspicion. “No one [who chooses a higher-paying job] says they did it because they want two Teslas,” he said. “They say they have all this debt.”

Carroll questioned how much difference even $200,000 in student debt makes to people who, at the lowest end of the medical spectrum, still stand to make six figures a year. “Doctors in general do just fine,” he said. “The idea we should pity physicians or worry about them strikes me as odd.”

Choice of specialty is also influenced by more than money. Some specialties may bring less demanding lifestyles than primary care or more prestige. Carroll said his surgeon father was not impressed when he opted for pediatrics, calling it a “garbageman” specialty.

There is also an array of government programs that help students afford medical school or forgive their loans, although usually in exchange for agreeing to serve for several years either in the military or in a medically underserved location. The federal National Health Service Corps, for example, provides scholarships and loan repayments to medical professionals who agree to work in mostly rural or inner-city areas with a shortage of medical professionals. And the Department of Education oversees the Public Service Loan Forgiveness program, which cancels outstanding loan balances after 10 years for those who work for nonprofit employers.

Medical schools themselves are addressing the student debt problem. Many — including NYU — have created programs that let students finish medical school in three years rather than four, which reduces the cost by 25 percent. And the Cleveland Clinic, together with Case Western Reserve University, has a tuition-free medical school aimed at training future medical researchers that takes five years but grants graduates who hold both a doctor of medicine title and a special research credential or master’s degree.

This latest move by NYU, however, is part of a continuing race among top-tier medical schools to attract the best students — and possibly improve their national rankings.

In 2014, UCLA announced it would provide merit-based scholarships covering the entire cost of medical education (including not just tuition, like NYU, but also living expenses) to 20 percent of its students. Columbia University announced a similar plan earlier this year, although unlike NYU and UCLA, Columbia’s program is based on students’ financial need.

The programs are funded, in whole or in part, by large donors whose names brand each medical school — entertainment mogul David Geffen at UCLA, former Merck CEO P. Roy Vagelos at Columbia, and Home Depot co-founder Kenneth Langone at NYU.

Economist Garthwaite said it is all well and good if top medical schools want to compete for top students by offering discounts. But if their goal is to encourage more students to enter primary care or to steer more people from lower-income families into medicine, giving free tuition to all “is not the most target-efficient way to reach that goal.”

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