Monday, January 12, 2009

News Clipping Archives

Maryland / Regional

Some Md. residents, thinking stomach flu, actually hit with norovirus (Baltimore Sun)

Vaccinations are for adults as much as for kids (Baltimore Sun)

National / International

F.D.A. Is Lax on Oversight During Trials, Inquiry Finds (New York Times)

Teen pregnancy rate highest in Mississippi (Baltimore Sun)

Cellphones' Growth Does a Number on Health Research (Washington Post)

Opinion

The Annapolis agenda (Baltimore Sun Editorial)

Legislating elder care (Frederick News-Post Commentary)

Obama's Health-Care Headache (Washington Post Commentary)

Cover the Children (Washington Post Commentary)

'Concierge' health care adds to peace of mind (Baltimore Sun Letter to the Editor)

 

 

Some Md. residents, thinking stomach flu, actually hit with norovirus

Days of misery probably not caused by stomach flu

 

By Frank D. Roylance

Baltimore Sun

Monday, January 12, 2009

 

It can begin with explosive suddenness, what a St. Joseph Medical Center infection control specialist called "an aggressive evacuation of fluids from the body," followed by days of weakness and malaise.

 

It's the norovirus, a gastrointestinal infection often mistakenly called the stomach flu. A common affliction in winter, it has hit Marylanders especially hard in recent weeks, according to public health officials.

 

Last month, St. Joseph hospital was seeing an average of 10 patients a day in the emergency room, "and maybe two to four were admitted with severe dehydration," said Leigh Chapman, manager of infection control there.

 

"Sometimes families would come in; it would attack the whole family," she said.

 

And the season may not have peaked yet, according to the state Health Department. "We can't ever know when the peak of the season is until the season is over," said Alvina Chu, chief of the department's division of outbreak investigations.

 

The norovirus is the same type that sometimes infects cruise ship passengers, causing severe gastroenteritis to sweep through the onboard community.

 

Severe symptoms can appear just 12 to 48 hours after exposure and may last 24 to 48 hours. They include diarrhea and vomiting, stomach pain, low-grade fever, headache, muscle aches, chills and exhaustion.

 

The Health Department estimates the severity of the norovirus season by counting "outbreaks" (three or more closely related cases within a week, typically in institutions such as hospitals, schools or nursing homes). It investigated 32 Maryland outbreaks during the middle three weeks of December, compared with just three during the same period in 2007. Chu said that's probably because this year's norovirus season began earlier than usual.

 

The greatest danger from the illness is dehydration, especially among the very young or the elderly who have other medical problems, such as diabetes. Severe fluid loss can require treatment in a hospital.

 

"That can make patients feel so weak. ... It knocks you out," said Chapman, who also fell ill with the virus. She compared its acute effects with those of food poisoning.

 

The best way to prevent a norovirus infection is careful hand hygiene, health officials agree.

 

"It's just so important," especially after being in public or using communal phones or keyboards, Chapman said. "You want a balance of washing your hands, whether it's with soap and water or alcohol-based sanitizers; and respiratory etiquette. Do not cough or sneeze into your hand; cough into your arm or sleeve."

 

Copyright © 2009, The Baltimore Sun

 

 

 

Vaccinations are for adults as much as for kids

Vaccinations are not just for kids; grown-ups need them, too

 

By Stephanie Desmon

Baltimore Sun

Monday, January 12, 2009

 

Vaccines, it turns out, aren't just for children.

 

Long the purview of the pediatrician's office, immunizations are often forgotten about once patients turn 18. But the Centers for Disease Control and Prevention, as well as leading doctors' organizations, recommend that adults continue to receive certain routine shots throughout their lives to keep up immunity against infectious diseases, from tetanus and whooping cough to pneumonia and shingles.

 

"A lot of adults think it's the thing you get as a kid and once you're an adult you don't need them," said Dr. Vincenza Snow, director of clinical programs and quality of care for the American College of Physicians in Philadelphia.

 

But adults do need vaccines - and their busy doctors don't always have the time to make sure their immunizations are up to date.

 

"All doctors want to do the right thing, but sometimes the real-life visit gets in the way," Snow said. "If they're in for chest pains during flu season, these things tend to get forgotten, or we say [we'll] get the flu shot on the next visit, but the next visit doesn't happen."

 

The flu shot is the vaccine we hear about most, because influenza kills thousands each year and puts tens of thousands in the hospital. People older than 50 and those with chronic health problems should get flu shots. Primary-care doctors often administer them at their offices, while workplaces and grocery store chains also offer clinics to get as many adults vaccinated as possible.

 

And even then, only about 70 percent of Americans older than 65 get their yearly flu shots.

 

"People are not receiving the vaccines they should," said Dr. Gina Mootrey, associate director for adult immunizations at the CDC.

 

A number of surveys have been done, she said, asking adults whether or not they get vaccinated and, if not, why not. While some parents have worried about the safety of vaccination for their children, safety does not appear to be a major concern when it comes to their own shots.

 

"The most common reason is they did not know they needed the vaccine," she said.

 

Vaccines are considered one of the greatest public health advances of the 20th century, leading to the near eradication of many diseases in the United States and saving countless lives. In many ways, vaccines are a victim of their own success. Those who weren't around when diphtheria and tetanus were serious health threats in the U.S. may question the need for vaccination against those diseases or forget about them entirely.

 

"There are risks associated with giving vaccines and they're usually very minimal," said Dr. Robin Motter, a family physician in Hunt Valley. "The risk you encounter if you don't get a vaccine can be life-threatening."

 

Some childhood vaccines give lifelong immunity, but the effects of others wane over time. To that end, the CDC recommends that every 10 years, adults get a booster shot containing a vaccine against tetanus, diphtheria and pertussis (Tdap) - and not just when they step on a nail.

 

But that's typically when most adults think about booster shots. A 2002 survey showed that in the previous 10 years, only 57 percent of adults ages 18-49 had received the booster. Only 44 percent of those older than 65 were vaccinated over the same period, Mootrey said.

 

"People don't like shots," she said.

 

Some vaccines recommended by the CDC are newly licensed and have not had time to completely take hold. The vaccine against the Human Papillomavirus (HPV), for example, is recommended for women through the age of 26. Girls tend to get their first of three doses of the Gardisil vaccine when they are 11 or 12, before their first sexual encounter, to protect them from contracting the virus, which can lead to cervical cancer later in life.

 

It is controversial in some circles - despite the proven safety and effectiveness of the vaccine. Some parents are uneasy having their pre-adolescent daughters vaccinated against a disease that is clearly related to sexual activity, especially when they still consider them little girls, said Dr. William Schaffner, chairman of the department of preventive medicine at Vanderbilt University School of Medicine in Nashville, Tenn.

 

But young adults who haven't been immunized really ought to be, he said.

 

Another one that hasn't caught on is the zoster vaccine, which immunizes against shingles. The shingles vaccine is relatively new and is recommended for people 60 and older. Schaffner, who with his wife was part of the clinical trial testing the shingles vaccine several years ago, said only 2 percent to 8 percent of senior citizens have been vaccinated.

 

"A lot of people don't know it's available," said Schaffner, who is also president-elect of the National Foundation for Infectious Diseases. "Doctors are not integrating it into their practices."

 

There's been a shortage of shingles vaccine this year because it uses the same basic material as the shot for chickenpox, and some states have started recommending a second dose of chickenpox vaccine for children who have received one dose. The shortage is expected to ease shortly, however, Mootrey said.

 

At the same time, Schaffner said some doctors don't push vaccination because some insurers don't cover it.

 

Many of the diseases for which there are vaccinations are no longer fatal. But being immunized protects others - including babies too young for certain shots and for whom such diseases would be extremely dangerous - from getting sick.

 

"We protect more than just ourselves," Snow said. "We're protecting our entire community."

 

Motter, who is chair of family medicine at Greater Baltimore Medical Center in Towson, generally discusses immunization with her patients when they come in for an annual physical. She also thinks about vaccines in general during flu season.

 

"When I'm talking about their flu shot, I look down their chart to see if they're up-to-date on everything else," she said.

 

Sometimes, patients are the ones who ask about immunizations, especially if they are planning to travel internationally. But mostly it's up to her to initiate the conversation.

 

Senior medical secretary Yvette Gouchenour has worked in health care for years, the past 14 in the medical office where Motter works. She knows that it is standard procedure to encourage proper vaccination. She knows that the CDC recommends people in her field receive the three-dose hepatitis B vaccine. Still, it wasn't until last week that Motter gave Gouchenour her final hepatitis B shot. Gouchenour blamed convenience for the many-year delay.

 

"You want to limit your risk to any disease," she said. "In health care, you have that risk every day."

 

Copyright © 2009, The Baltimore Sun

 

 

 

F.D.A. Is Lax on Oversight During Trials, Inquiry Finds

 

By Gardiner Harris

New York Times

Monday, January 12, 2009

 

The Food and Drug Administration does almost nothing to police the financial conflicts of doctors who conduct clinical trials of drugs and medical devices in human subjects, government investigators are reporting.

 

Moreover, the investigators say, agency officials told them that trying to protect patients from such conflicts was not worth the effort.

 

In 42 percent of clinical trials, the agency did not receive forms disclosing doctors’ financial conflicts and did nothing about the problem, according to the investigation, which was conducted by the inspector general of the Department of Health and Human Services and whose results were scheduled to be made public Monday.

 

In 31 percent of the trials in which the agency did receive the required forms, agency reviewers did not document that they looked at the information. And in 20 percent of the cases in which doctors revealed significant financial conflicts, neither the F.D.A. nor the sponsoring companies took any action to deal with the conflicts, the investigators found.

 

Karen Riley, a spokeswoman for the F.D.A, said the agency opposed reviewing doctors’ financial conflicts before trials because they represented just one possible source of bias.

 

A similar investigation by the inspector general last year found that the National Institutes of Health did almost nothing to police the financial conflicts of university professors who received federal money. And like their colleagues at the F.D.A., officials at the health institutes said they did not want to start doing so, that investigation found.

 

The inquiries feed a growing debate about how money that doctors routinely collect from drug and device makers may hurt patients and skew studies.

 

In 1999, the agency required drug and device companies to disclose the financial conflicts of doctors overseeing patient care in clinical trials. The rules require companies to collect this information before the start of any trial and to consult with the F.D.A. to resolve serious conflicts.

 

But the inspector general found that the agency had done almost nothing to enforce these rules or even to use the information generated.

 

Fewer than 1 percent of the doctors who helped oversee clinical trials registered with the agency and who filed the required financial disclosure forms reported that they had a significant conflict of interest. By contrast, studies have found that one-fifth to one-third of all doctors have such conflicts.

 

“This represents 206 of the 29,691 clinical investigators listed in financial interest forms,” the report says. “Of these 206 clinical investigators, almost all disclosed only one financial interest.”

 

Since the F.D.A. does not have a complete list of all clinical investigators, the agency has no way of knowing whether every doctor who is required to file a form actually did so.

 

The rules allow drug and device makers to avoid reporting doctors’ financial conflicts if the companies certify that they tried diligently to get the information but could not. Companies cited this exemption in 28 percent of drug and device applications, the inspector general found. But in an additional 23 percent of applications, companies filed neither an exemption nor the appropriate disclosure forms.

 

The inspector general recommended that the F.D.A. do a better job of making sure that companies follow the rules regarding financial disclosures, that agency reviewers actually read these disclosures, and that all of this is done before trials take place so patients are protected.

 

But the report said the agency replied that collecting and checking this information before the trials was not worth the effort for either the companies or the agency, even though the agency’s own rules required it.

 

Copyright 2009 The New York Times Company

 

 

 

Teen pregnancy rate highest in Mississippi

 

Baltimore Sun

Monday, January 12, 2009

 

Mississippi now has the nation's highest teen pregnancy rate, displacing Texas and New Mexico for that lamentable title, according to a new federal report released last week.

 

Mississippi's rate was more than 60 percent higher than the national average in 2006, the U.S. Centers for Disease Control and Prevention said. The teen pregnancy rate in Texas and New Mexico was more than 50 percent higher.

 

The three states have large proportions of black and Hispanic teenagers - groups that traditionally have higher birth rates, experts said.

 

The lowest teen birth rates continue to be in New England, where three states have teen birth rates at just half the national average.

 

It's not clear why Mississippi surged into first place. The state's one-year increase of nearly 1,000 teen births could be a statistical blip, said Ron Cossman, a Mississippi State University researcher who focuses on children's health statistics.

 

More than a year ago, a preliminary report on the 2006 data revealed that the U.S. teen birth rate had risen for the first time in about 15 years. But the new numbers provide the first state-by-state information on the increase. The new report is based on a review of all the birth certificates in 2006. Significant increases in teen birth rates were noted in 26 states.

 

"It's pretty much across the board" nationally, said Brady Hamilton, a CDC statistician who worked on the report.

 

About 435,000 of the nation's 4.3 million births in 2006 were to mothers ages 15 through 19. That was about 21,000 more teen births than in 2005.

 

Associated Press

 

Copyright © 2009, The Baltimore Sun

 

 

 

Cellphones' Growth Does a Number on Health Research

 

By David Brown

Washington Post

Monday, January 12, 2009; A04

 

In our information-crazy, never-out-of-touch world, it's becoming harder and harder to find out who we are and what we do.

 

That's the ironic truth facing epidemiologists around the country.

 

The popularity of cellular telephones, an increasingly mobile population, rising expenses, flat budgets and new insights into ways people can answer a question differently depending on how it's asked -- all are conspiring to make health surveys more difficult.

 

In public health, pretty much everything depends on good data. Researchers and policymakers can't identify a problem, figure out whether it's serious and devise a strategy to fight it without first being able to count it. "If you can't measure something, you won't be able to change it" is an oft-heard aphorism.

 

How big a problem is obesity? Are restrictions on smoking changing people's habits? Is autism more prevalent than it was a decade ago? Is the recession affecting people's access to health insurance?

 

All are questions of national importance -- and none can be answered without unbiased surveys of a representative sample of the population.

 

Cellular telephones are perhaps the biggest threat to survey data that epidemiologists have confronted in years.

 

The National Center for Health Statistics reported that in the first half of last year, 16 percent of American adults lived in households that have only cellphones. This was up from 7 percent three years earlier, and rising rapidly.

 

The federal government's main tool for measuring the health habits of Americans, the Behavioral Risk Factor Surveillance System (BRFSS), uses the telephone to interview a nationwide sample of adults (470,000 this year). Historically, interviewers called only conventional telephones, as all but the 2 to 3 percent of households with no phones at all could be reached through them. But that's not remotely true anymore.

 

Surveyors, however, cannot just extrapolate from the land-line respondents. That's because studies have shown that people who have only cellphones are different from people who don't have them or use them only occasionally.

 

Young people, men and Hispanics are all more likely than the "average" American to have cellphones only. But those demographic factors don't explain everything. Even after they are taken into account by statistical means, cellphone-only users are different.

 

The BRFSS surveyors this year will include cellphone numbers in every state, with a goal of having 10 percent of the interviews done that way. But it's easier said than done.

 

Federal law requires that calls to cellphones be hand-dialed; it is illegal to use automatic dialers, which are standard tools for survey and polling firms. Furthermore, a huge fraction of "owners" of cellphone numbers are children ineligible for the health surveys. Once reached, some cellphone users are reluctant to talk at length because they have to pay for incoming calls.

 

Consequently, it takes roughly nine calls to working cellphone numbers to get one completed survey, compared with five calls to working land-line numbers, said Scott Keeter, a polling expert at the Pew Research Center for the People and the Press, an independent opinion research group. Further, an interview conducted with someone who uses a cellphone costs 2 1/2 times as much as an interview with someone on a conventional phone. In addition to higher labor costs, most surveys now reimburse cellphone users for their minutes, either in cash or through credits to online merchants such as Amazon.com.

 

People's willingness to answer questions has also been affected by the barrage of phone calls, many unsolicited, they get every day. The response rate in public opinion polls has fallen from about 60 percent two decades ago to 25 percent now, according to Keeter.

 

Government-sponsored health surveys have fared better. The "cooperation rate" for the BRFSS in 2007 was 72 percent, the same as in 1994. The smaller, in-person National Health Interview Survey had a response rate of 87 percent in 2006. A decade earlier, it was 92 percent.

 

But the problem goes beyond changing technology and responsiveness. It turns out that people answer the same question differently depending on how you reach them -- a "mode effect."

 

For example, when a group of people with the same age, race and education are called on a conventional phone, 25 percent say they smoke, but on a cellphone 31 percent say they do. On a land line, 38 percent say they have been tested for HIV, while on a cellphone 54 percent say they have.

 

The reason for this is unclear. Ali H. Mokdad, an epidemiologist who until recently was at the federal Centers for Disease Control and Prevention and ran the BRFSS, speculates it may have something to do with the fact that people on land lines are usually at home, where they have a role and image to maintain even if they are answering in privacy.

 

"They are less likely to say something bad about their own behavior. It's like 'This is my house,' " he said.

 

A study published three years ago showed that when women were interviewed by phone, rather than in person, they tended to underreport their weight, and both men and women (but men more) tended to overreport their height. Both estimates were exaggerated -- women's weight lower and men's height higher -- compared with surveys in which height and weight were measured.

 

The study showed the importance of using measurements to determine the national prevalence of obesity, as interview data alone substantially underestimate it.

 

The internal architecture of a survey can also affect the results.

 

Where a question falls in a series of them can increase the likelihood of a certain answer, a phenomenon known as "differential item functioning." The ethnicity of the respondent may also make a difference. According to a study published in 2006, Hispanics are more likely to give answers at the extremes of numerical scales "because of a cultural value that associates extreme responses with sincerity."

 

In all, what seems like a fairly simple and straightforward task is in truth hard and messy.

 

"It's a bit like making sausage," said Christopher J.L. Murray, a physician and epidemiologist who heads the Institute for Health Metrics and Evaluation at the University of Washington.

 

"As soon as you start to explore how surveys are made," he said, "you begin to see how difficult it is to get consistent information at the population level over time."

 

© 2009 The Washington Post Company

 

 

 

The Annapolis agenda

Our view: The General Assembly reconvenes this week to confront budget challenges but should not lose sight of a host of other pressing concerns that require action

 

Baltimore Sun Editorial

Monday, January 12, 2009

 

Maryland lawmakers return for their annual 90-day legislative session in Annapolis this Wednesday with some trepidation. The anxiety-prone need only wait one week for the genuine discomfort to begin. That's when Gov. Martin O'Malley must submit his budget for the next fiscal year, and it's shaping up to be a headache and a half.

 

With the recession having already forced difficult cuts in recent months, the outlook for the immediate future is truly grim. Interest groups are no longer jamming State House hallways in search of new programs but with a goal of merely avoiding a major budget reduction. Mr. O'Malley is almost certain to propose a no-growth budget. That sounds misleadingly simple to achieve - no employee raises, no new initiatives, no expansion of government. But costs can't be frozen so easily, particularly in entitlement programs that must expand with inflation and need. And with the easy budget cuts made, government will have to do less with less.

 

The challenge then is not merely to spread the pain evenly across state agencies but to recognize and preserve what should be government's highest priorities. At the top of that list should be K-12 public education. But not far behind are programs that soften the economic hardship felt by the poor, the sick and the newly unemployed.

 

The fiscal storm has arrived with such fury that the governor is going to have to dip into the state's reserve fund and tap some of the hundreds of millions of dollars set aside for so-called rainy days. Future revenues from slot machines can restore the account soon enough.

 

President-elect Barack Obama's stimulus package should provide some relief as well. Certainly, if the federal government chooses to pick up a higher percentage of the shared costs of Medicaid, for instance, that's less to cut. But such help is far from certain, and it would be best not to count on it yet. Nevertheless, a fiscal 2010 budget cannot be the only bill to pass this session.

 

Here, in brief, is some of what legislators should be able to accomplish in the next three months:

 

Death penalty. With the governor's task force's findings in hand, Maryland must repeal capital punishment. The evidence is all too clear: The inequities and opportunities for error are too great while a sentence of life without parole is a workable, more humane alternative.

 

Higher education. Recent caps on in-state tuition have made state universities more competitive, but the state needs a long-term strategy not only for the University System of Maryland but also for too-often-overlooked community colleges. At minimum, the expiring fund (financed by a portion of corporate taxes) that has helped keep tuition low should be renewed.

 

Smart Growth. It's time to put teeth in the law and impose statewide standards that limit sprawl and encourage urban redevelopment. State law ought to be made clear: County comprehensive plans should matter despite the unfortunate precedent set by last year's court ruling favoring the planned Terrapin Run mega-development in Western Maryland.

 

Domestic violence. Lawmakers should keep guns out of the hands of abusive spouses by strengthening protective orders. In cases of permanent protective orders, removing guns from a home ought to be mandatory; with temporary orders, it should be up to a judge to decide.

 

Public safety. Information on juvenile offenders should be more readily shared by government agencies. Some limits need to be placed on good-time credit for prisoners so that it is no longer a nearly automatic benefit.

 

Business. The tax credit program that aids developers who are renovating historic buildings should not be allowed to expire or city participation capped - as it's been vital to Baltimore's renaissance. Meanwhile, lawmakers should refrain from raising business-related taxes.

 

Drunken driving. Taking a cue from a statewide task force, legislators should approve measures to suspend for six months the driver's licenses of those under age 21 convicted of alcohol possession and make it a criminal offense for an adult to provide alcohol to minors.

 

Copyright © 2009, The Baltimore Sun

 

 

 

Legislating elder care

 

By Katherine Heerbrandt

Frederick News-Post Commentary

Monday, January 12, 2009

 

Two state lawmakers are looking into complaints about a local nursing home that may result in new oversight legislation this year. Delegates Sue Hecht and Galen Clagett received complaints about Northampton Manor from concerned family members.

 

"By the time someone complains to a politician about a nursing home, they've usually run through their course of options, and we find that the complaints are solid," Clagett said. Many family members are hesitant to speak up, Clagett said, for fear of retribution or making matters worse for their loved one.

 

Hecht and a representative from Clagett's office, Carol Krimm, attended a family council meeting at Northampton on Dec. 20, along with Wendy Kronmiller, director of the Department of Health and Mental Hygiene's Office of Health Care Quality. Kronmiller brought two staffers, a nurse surveyor and another staff member responsible for nursing facilities in western Maryland. Kronmiller's office monitors quality of care in Maryland's 8,000 health care and community residential programs.

 

"They listened patiently to all the complaints and were very compassionate in their response," Krimm said. "They assured the families there would be follow-up with the facility and commented on the high number of family members at the meeting."

 

Families were urged to bring complaints to management at the next family council meeting on Jan. 17. In the meantime, state inspectors have been visiting the home. At the Dec. 20 meeting, Delegate Hecht took plenty of notes. She says she plans a return visit. "We heard of some awful things happening," she said.

 

Quality of care at nursing homes has been a serious concern for Hecht, who wrote Vera's Law, which passed in 2003. Named after her mother who experienced verbal abuse as a resident in a nursing home, the law establishes guidelines for the use of surveillance cameras in patients' rooms.

 

Hecht wants to take that a step further and make cameras mandatory in all public spaces in the nursing facilities. The cameras protect both residents and the nursing home staff from false or exaggerated charges, Hecht said. She knows of a home in Washington County that employs cameras in public spaces with good results, she said.

 

Clagett said he doesn't disagree cameras can be useful, but believes their use just treats the symptoms, not the real issue of comprehensive health care reform. It's up to lawmakers to ensure that oversight regulations in place are enforced, he said. Days before Hecht and company visited Northampton, the Centers for Medicare and Medicaid Services released its ratings of nursing homes, as mentioned in this space recently. Northampton was one of two Frederick County facilities, including College View, to receive one of five stars for a "much below average" ranking.

 

To view, visit medicare.gov/ nhcompare/home.asp. The ratings are just one tool for evaluating a nursing home, and even nursing homes with just one star meet the minimum requirements of Medicare, according to the website. More thorough inspection reports outlining documented deficiencies are available to the public at each nursing home.

 

Nursing homes are the second most heavily regulated industry after nuclear power, and ample information is available on violations committed by each facility, including a National Watch List that identifies homes cited for actions that resulted in actual harm to residents, or put residents in immediate jeopardy. Despite its low rating, Northampton is not on the National Watch List, but College View Center is.

 

Copyright 1997-09 Randall Family, LLC

 

 

 

Obama's Health-Care Headache

 

By Robert J. Samuelson

Washington Post Commentary

Monday, January 12, 2009; A13

 

Barack Obama talked somberly last week about getting the federal budget under control once the present economic crisis has passed. To do that, he'll have to confront the rapid growth of health spending, which in 2007 was already a quarter of total federal spending of $2.7 trillion. If Obama is serious, he should read a fascinating study from the McKinsey Global Institute, the research arm of the famed consulting company.

 

American health care has gone haywire. It provides much splendid care but has glaring deficiencies. It is so costly that 15 percent of the population lacks health insurance. Runaway spending is also crowding out other government programs and, through bloated insurance premiums, squeezing workers' take-home pay. What McKinsey provides is a plausible estimate of the overspending: one-third. In 2006, U.S. health spending totaled $2.1 trillion. Of that, McKinsey figures that $650 billion exceeded the norms of other rich nations.

 

For the extra money, we receive no indisputably large benefit in national well-being. On some health measures (breast cancer survival rates), we do better than many countries; on some others (life expectancy), we do worse. We are constantly searching for villains to explain this unsatisfactory situation. The McKinsey study debunks some popular candidates.

 

One is that our mixed private-public insurance system drives up costs through high administrative overhead. Claims forms create a paperwork morass; marketing expenses add to the burden. True, U.S. overhead costs are more than double the level in other countries. But the effect is modest, because all administrative costs (including government programs such as Medicare) account for only 7 percent of total health costs.

 

The same is true of another common scapegoat: the alleged overuse of emergency room care. In 2006, all emergency room care cost $75 billion, about 3.5 percent of total health spending. That's too small to explain overall trends.

 

What really drives health spending, the study finds, is that Americans receive more costly medical services than do other peoples, and they pay more for them. On a population-adjusted basis, the number of CT scans in 2005 was 72 percent higher in the United States than in Germany; U.S. reimbursement rates were four times higher. Knee replacements were 90 percent more frequent than the average in other wealthy countries. In 2005, there were 750,000 knee and hip replacements, up 70 percent in five years, reports the journal Health Affairs.

 

We have a health-care system that reflects our national values. It's highly individualistic, entrepreneurial and suspicious of centralized supervision. In practice, Medicare and private insurers impose few effective controls on doctors' and patients' choices. That's the way most Americans want it. Patients understandably desire the most advanced surgeries, diagnostic tests and drugs. Doctors want the freedom to prescribe.

 

Open-ended insurance reimbursement encourages expensive medicine by making it easier to recover the costs of clinical advances. Economist Amy Finkelstein of MIT has estimated that roughly half the real increase in per capita health spending from 1950 to 1990 reflected the spread of comprehensive health insurance. In 2006, consumers' out-of-pocket spending represented 13 percent of total health spending, down from about half in 1960. Unfortunately, this semi-automatic system may now frustrate other national goals by displacing other spending and spawning ineffective or unneeded care.

 

On paper, there are various ways to control health spending: stricter regulation of prices and the availability of care; "market mechanisms" to push consumers toward more efficient or skimpier care. All have foundered, because they cannot be used aggressively. The reason is politics. There is no major constituency for controlling spending. Because most patients don't pay medical bills directly, they have little interest in using less care or shopping for lower-priced services. Providers (doctors, hospitals, drug companies) have no interest in limiting care. What others call "health costs" are their incomes -- wages, salaries, profits.

 

Unless we rectify this political imbalance, efforts to control health spending may fail. We need mass constituencies that favor cost control. But our consistent policy has been to conceal the burden of health spending by burying it in untaxed corporate fringe benefits or government budgets.

 

We could change this. We could charge the elderly more for Medicare. We could tax employer-provided health insurance as ordinary income. We could create a dedicated federal tax to cover government health costs -- if health spending increased more than revenue, the tax would automatically rise. People would quickly feel the costs of our present system. Of course, that would be unpopular, because it would compel Americans to face a discomforting issue -- how important is health care compared with other priorities?

 

Will Obama be so bold? In the campaign, he proposed more, not less, health spending. It's easier to embrace the rhetoric of change than change itself.

 

© 2009 The Washington Post Company

 

 

 

Cover the Children

 

By E. J. Dionne Jr.

Washington Post Commentary

Monday, January 12, 2009; A13

 

When Bill Clinton's health-care proposal was foundering in the summer of 1994, a group of senators suggested that the administration put off trying to get universal coverage and insist instead on insuring all children. The idea was to make, at least, a down payment on reform.

 

The White House said no and pressed on with its doomed effort to get a bigger bill. The Republicans won control of Congress in the fall. It wasn't until 1997, thanks to the unlikely duo of Sens. Ted Kennedy and Orrin Hatch, that a children's health-care program was finally passed.

 

One of the clearest signals President-elect Barack Obama has sent is his determination to learn from the Clinton years, particularly from the former president's failures on health care.

 

When Tom Daschle, Obama's pick to be secretary of health and human services, returned to the Senate last week for his first round of confirmation hearings, he offered a long list of criticisms that others had directed at the original health-care reform effort. This time, he said, would be different.

 

And this week, the House of Representatives is determined to prove Daschle right. It is scheduled to take up an extension of the State Children's Health Insurance Program (SCHIP), as the Kennedy-Hatch initiative is called, so that 10 million kids can get insurance. Getting more children covered before Congress starts wrangling over the larger health-care bill is good politics and the right thing to do. Congress needs to act anyway, because the program expires March 31. It might as well act fast, and act generously.

 

The SCHIP bill is unfinished business from the Bush years, and Democrats have no better way to show, and show quickly, how different their approach to government will be from the style and priorities that prevailed during the outgoing president's term.

 

President Bush twice vetoed an extension of SCHIP. He opposed the additional $35 billion the Democrats wanted to spend to cover more children and also disliked the tobacco tax they proposed using to pay for it. There are many big things people hold against Bush, but this one has always stuck in my craw. If "compassionate conservatism" -- remember that phrase? -- means anything, surely it should mean helping more children go to the doctor when they need to.

 

Some advocates of universal coverage have argued that an expansion of SCHIP should be delayed so that the issue of covering children can be taken up as part of a larger health proposal. The worry is that passing the most popular part of reform now (is there a more sympathetic group to cover?) would make it easier to delay the broader effort.

 

These are good-faith concerns, but Congress would be right to ignore them. The economic downturn has made the expansion of SCHIP all the more urgent.

 

It's not just that sharp increases in unemployment add to the ranks of the uninsured. State governments are hurting, too, and they are responding to revenue shortfalls by shrinking health-care programs.

 

According to Families USA, a group that pushes for fundamental health-care reform, states have enacted budget cuts that will leave some 275,000 people without health coverage, including 260,000 children in California. By the end of this year, if further proposed cuts go through, the number losing health coverage nationwide could rise to more than 1 million, almost half of them children. Other states have reduced benefits to those they still insure.

 

All this makes more compelling the case for putting fiscal relief to the states in a stimulus bill. It also makes clear that universal health insurance coverage should be an urgent priority. But getting the children's program done in the meantime could create momentum and reduce the size of the problem that needs to be solved in a comprehensive bill -- 10 million kids now, the rest later.

 

Senate Majority Leader Harry Reid has not made any commitments as to when he would take up children's health care, though he has listed it as a priority. It would do the new president and members of the Democrats' expanded congressional majority no harm to move expeditiously on a proposal that is simultaneously bipartisan -- SCHIP has always enjoyed significant Republican support -- and embodies Obama's oft-stated commitment to "programs that work." This one surely does.

 

How often did Obama promise to "turn the page," implying that his presidency would be very different from George W. Bush's while also taking lessons from Bill Clinton's shortcomings? Winning a quick health-care victory for children would prove that he's determined to do both.

 

© 2009 The Washington Post Company

 

 

 

'Concierge' health care adds to peace of mind

 

Baltimore Sun Letter to the Editor

Monday, January 12, 2009

 

As a patient in a retainer-fee medical practice, I would like to say that I am completely satisfied with the quality of care I receive ("In defense of so-called concierge medicine," Dec. 29).

 

I am a senior on a modest income, but I consider my health a priority and am willing to pay a fee for personalized care from a doctor who knows me well.

 

And there is much peace of mind in knowing that I can call at any time and quickly get the professional advice I need.

 

Ruth M. Pyle, White Hall

 

Copyright © 2009, The Baltimore Sun