By ROBERT REICH

One of my regrets in life is losing the chance to debate Mitt Romney and whip his ass.

It was the fall of 2002. Mitt had thundered into Massachusetts with enough money to grab the Republican nomination for governor. Meanwhile, I was doing my best to secure the Democratic nomination. One week before the Democratic primary I was tied in the polls with the state treasurer, according to the Boston Herald, well ahead of four other candidates. But my campaign ran out of cash. Despite pleas from my campaign manager, I didn’t want to put a second mortgage on the family home. The rest is history: The state treasurer got the nomination, I never got to debate Mitt, and Mitt won the election.

With Trump, Gingrich, Bachmann, and possibly Palin now in the race for the Republican presidential nomination, “GOP” is starting to mean Goofy, Outrageous, and Peculiar. Mitt would pose the most serious challenge to a second Obama term.

I say this not because Mitt’s mind is the sharpest of the likely contenders (Gingrich is far more nimble intellectually). Nor because his record of public service is particularly impressive (Tim Pawlenty took his governorship seriously while Mitt as governor seemed more intent on burnishing his Republican credentials outside Massachusetts). Nor because Mitt is the most experienced at running a business (Donald Trump has managed a giant company while Mitt made his money buying and selling companies.) Nor, finally, because he’s especially charismatic or entertaining (Sarah Palin can work up audiences and Mike Huckabee is genuinely funny and folksy, while Mitt delivers a speech so laboriously he seems to be driving a large truck).

Mitt Romney’s great strength is he looks, sounds, and acts presidential.

Policy wonks like me want to believe the public pays most attention to candidates’ platforms and policy positions. Again and again we’re proven wrong. Unless a candidate is way out of the mainstream (Barry Goldwater and George McGovern come to mind), the public tends to vote for the person who makes them feel safest at a visceral level, who reassures them he’ll take best care of the country â€" not because of what he says but because of how he says it.

In this regard, looks matter. Taller candidates almost always win over shorter ones (meaning even if I’d whipped him in a debate, Romney would probably still have won the governorship). Good-looking ones with great smiles garner more votes than those who scowl or perspire (Kennedy versus Nixon), thin ones are elected over fat ones (William Howard Taft to the contrary notwithstanding), and the bald need not apply (would Eisenhower have made it if Stevenson had been blessed with a thick shock?).

Voices also matter. Deeper registers signal gravitas; higher and more nasal emanations don’t command nearly as much respect (think of Reagan versus Carter, or Obama versus McCain).

And behavior matters. Voters prefer candidates who appear even-tempered and comfortable with themselves (this was Obama’s strongest advantage over John McCain in 2008). They also favor the candidate who projects the most confidence and optimism (think FDR, Reagan, and Bill Clinton).

Romney has it all. Plus a strong jaw, gleaming white teeth, and perfect posture. No other Republican hopeful comes close.

What does Mitt stand for? It’s a mystery â€" other than a smaller government is good and the Obama administration is bad. Of all the Republican hopefuls, Romney has most assiduously avoided taking positions. He’s written two books but I challenge anyone to find a clear policy in either. Both books are so hedged, conditioned, boring and bland that once you put them down you can’t pick them up.

Mitt is reputed to say whatever an audience wants to hear, but that’s not quite right. In reality he says nothing, but does it in such way audiences believe they’ve heard what they want to hear. He is the chameleon candidate. To call Mitt Romney an empty suit is an insult to suits.

Yet Romney is gaining ground over Obama. According to the most recent Marist poll, in a hypothetical presidential matchup Obama now holds a one percent point lead over Romney,  46 to 45. In January, Obama led Romney by 13 points.

Why is Mitt doing so well? Partly because Obama’s positions are by now well known, while voters can project anything they want on to Mitt. It’s also because much of the public continues to worry about the economy, jobs, and the price of gas at the pump, and they inevitably blame the President.

But I suspect something else is at work here, too. To many voters, President Obama sounds and acts presidential but he doesn’t look it. Mitt Romney is the perfect candidate for people uncomfortable that their president is black. Mitt is their great white hope.

Robert Reich served as the 22nd United States Secretary of labor under President William Jefferson Clinton from 1992 to 1997. He shares many of his thoughts and columns at Robert Reich.org, where this post first appeared.

Filed Under: THCB

Tagged: GOP, Mitt Romney, Political candidates, Robert Reich May 10, 2011

There are more than 100 different viruses which can cause common cold. But the most commonly involved virus is rhinovirus, which cause up to half (50%) of all common cold infections. Other commonly involved viruses include corona viruses (which is a type of picorna virus and causing 10-15% of common cold infections), influenza viruses (causing 5-10% common cold infections), para-influenza viruses, human respiratory syncytial viruses, adenoviruses, enteroviruses etc. Among adults majority of common cold infections are due to corona viruses with 99 known serotypes and probably larger numbers of unknown serotypes.

All humans (non healthy as well as healthy persons) are susceptible to common cold infections, and preschool children are particularly more prone to get infected by common cold viruses. Immunity against one type of virus does not help in preventing infection by another type of common cold causing virus and a person may have common cold several times a year.

Common cold is common in particular season or time of the year. Common cold is more common during time of fall and winter season due to several reasons. During winter people tend to remain closer to each other in compare to summer or other seasons, which makes it easier to transmit the virus from one person to another. In the tropical regions where winter season is mild or absent, common cold is more frequently seen during rainy season, may be due to getting wet in rain more frequently.

Children are more prone to common cold in compare to adults and aged persons, as children have not developed immunity against most common viruses responsible for cold. As children grow older the frequency of attacks of common cold reduce. Children also tend to have frequent cold de to close mixing with peer age group.

Related posts:

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Symptoms of Common Cold

How to Prevent Cold Sores?

How common is Rotavirus Infection?

What are the Complications & Treatment of Cold Sores?

Cold Sore: Things You Need to Know

Symptoms of Cold Sores

Some common Questions about Shingles or Herpes Zoster

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Jodie Morris/Kaiser Health News

Under federal law, health insurers must spend at least 80 percent of premium revenues on medical services or quality improvement.

Consumers in nine states owed an expected $95 million in rebates from their health insurers might not see those rebates after all.

Those states' regulators are asking the Obama Administration to ease up on rules that say insurers must spend at least 80 percent of their premium revenue on medical care or quality improvements.

The regulators say some insurers are unable to quickly make the changes needed to hit that spending target â€" and would have to pay rebates to consumers. They say that, without relief, insurers would flee their markets, leaving some policyholders unable to qualify or afford other coverage.

Not so, say consumer advocates, who say most insurers should be able to meet the spending rule.

 

"The end impact will be to deny consumers the millions in rebates they expect to get on this year's premiums," says Carmen Balber, Washington director of the advocacy group Consumer Watchdog.

Under the federal health law, insurers must spend at least 80 percent of premium revenues on medical costs or quality improvements; the remainder can go toward administrative costs, broker commissions and profits. Many health plans, but not all, already meet that target.

The spending requirement, called the "medical loss ratio," applies to all health plans, except those offered by companies that are self-insured, where an insurance company just does the paperwork, and the employer decides what the benefits include.

The waivers sought by the states would affect only individual policies bought by people who don't get coverage through their jobs. Nationwide, more than 18 million Americans purchase their own policies.

Up to 9 million Americans with individual policies and in group plans could be eligible for rebates, according to government estimates.

In the states asking for an adjustment, potential rebates total more than $95 million for policies in effect this year.

The Department of Health and Human Services is expected to rule soon on requests from New Hampshire and Nevada to ease the rule. Other states that have applied are Florida, Kentucky, Louisiana, North Dakota, Georgia, Kansas and Iowa. Maine has already been granted an adjustment, with insurers there being allowed to spend only 65 percent of revenue on medical care during each of the next three years.

In deciding whether to lower the target in some states, the administration will weigh how many insurers might leave a market, how many people would be affected and whether policyholders have other options, such as special insurance pools for people with health problems, says Steven Larsen, deputy administrator of the Center for Consumer and Insurance Oversight at HHS.

He says deciding on the states' requests is a balancing act: While insurers should be pushed to spend more on medical care, it "might not be in consumers' best interest" to drive them out of the marketplace.

Because of that, some analysts predict that the administration will grant most of the states' requests.

"The last thing the Obama administration wants is the Des Moines Register writing about 500 people who lost their health insurance in Iowa because of the Obama health plan," says Robert Laszewski, a consultant to the health care industry and a former insurance executive.

By Marco Smit

At Health 2.0 Advisors we not only scan and analyze the healthcare innovation landscape incessantly, we also share our thoughts and insights with clients and at conferences at times. On that note, on May 13 at 10am I will be moderating a panel on cloud-computing in healthcare at Tiecon 2011. It is the first panel right after the ‘interesting’ Steve Case speaks â€" Marissa Meyer from Google closes on Saturday evening.

Cloud-computing is one of the topics that Health 2.0 Advisors will start sharing more perspective on in public this year, in addition to unplatforms/mobile, analytics, and care delivery innovation. What these topics all have in common is that they are forces rapidly changing the healthcare landscape (competitive landscape, business models, patient-provider dynamics, other) and companies are grappling where they all fit in with their strategies and business realities.

This Tiecon 2011 panel is a good reflection of that: cloud-based EMR-systems where a novelty 18 months ago, but the number of companies offering them (stand-alone or embedded in e.g. a practice management suite), has exploded since. But cloud-computing goes far beyond EMRs of course. That is why the panel will cover a range of experiences, struggles, and expectations for the future of the cloud from large (IBM, Kaiser Pemanente) and small â€" but rapidly growing (Practice Fusion, CareCloud) â€" companies that have cloud-computing in their DNA.

Marco Smit is President of Health 2.0 Advisors, the market intelligence arm of the Health 2.0 family.

Filed Under: Health 2.0, THCB

Tagged: Health 2.0 May 9, 2011

Common cold is an infectious disease of upper respiratory tract (mainly nose and throat), caused by virus. Common cold is the most common infectious disease affecting humans. It is estimated that adults on an average contact common cold two to four times a year and children on an average contact common cold 6-12 times a year. Most common causative viruses are rhinoviruses and corona viruses, although there are more than 100 different viruses which can cause common cold and cause great variation of symptoms of common cold. Common cold is usually a harmless disease, although it may trouble you greatly. It is not uncommon among healthy individuals also and a healthy person may have a few attacks of common cold each year. The symptoms of common cold generally last for a week to 10 days and resolve spontaneously. If symptoms do not resolve within a week, you should consult your doctor. Sometimes symptoms may last as long as three weeks.

Common symptoms of common cold are fever, sore throat, runny nose, cough etc. Watery eyes, frequent sneezing and nasal congestions may also occur in common cold. All the symptoms mentioned here may or may not be present in one individual.

What are the synonyms of common cold?

The synonyms of common cold include acute coryza, flu, cold, nasopharyngitis, acute viral rhinopharyngitis etc.

Common cold, influenza and other types of upper respiratory tract infections (RTI) are collectively called influenza like illnesses.

There is a common phrase about common cold, that “if you get treated for common cold by visiting a doctor, your common cold will be cured in a week and if you do not receive any treatment for common cold, you will be cured in seven days”. This phrase explains about common cold better than any explanation, as far as treatment requirement for common cold is concerned.

Common cold generally needs no treatment or if treated, it should be symptomatic treatment.

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How to Prepare Yourself for Cold Sores, for Appointment with Doctor

Symptoms of Cold Sores

Some Common Questions about Nutrition Intake

Cold Sore: Things You Need to Know

Is there any Home Remedy Available for Cold Sores?

How to Prevent Cold Sores?

What are the Complications & Treatment of Cold Sores?

The Global Burden of Diarrhea

Treatment of Ringworm

Acute Diarrhea

Enlarge iStockphoto.com

Big Sky and relatively big enrollment in high-risk pools.

iStockphoto.com

Big Sky and relatively big enrollment in high-risk pools.

Though it's nearly 2,000 miles from Washington, Montana plays an oversized role in the health care debate. Its senior senator, Max Baucus, was one of the biggest players in crafting the sweeping federal health law.

And now Montana leads the country in the proportion of people who have signed up for the health law's insurance program for those with pre-existing conditions.

Still, the absolute number is quite low. Montana has signed up just 198 people.

 

In fact, as of the end of March, 18,313 people nationwide had signed up for the Pre-Existing Condition Insurance Plan â€" up from 12,437 on Feb. 1, according to data released today.

The numbers remain far below initial estimates for the high-risk pools established in the 2010 health law. Two reasons: high premiums and consumers' lack of awareness about the program.

The plans, which are run either by individual states or by the federal government if the states opted not to participate, became available to most people last September. They are intended to serve as a bridge until the insurance market reforms are implemented in 2014, when insurers will no longer be able to deny coverage or charge higher rates for people with pre-existing conditions.

The Congressional Budget Office had estimated that as many as 4 million uninsured Americans would be eligible for the program and that 200,000 would be enrolled by 2013. And the Chief Actuary of Medicare and Medicaid estimated that 375,000 people would enroll in these high risk pools by the end of 2010.

Citing the low enrollment, some Republicans including Rep. Fred Upton (R-MI), have criticized the administration's handling of the program.

The cost of the plan, and the fact that many people still don't know about it, may be keeping enrollment down.

But administration officials point to the trend and are optimistic.

"We're encouraged by the jump in enrollment and we're excited to build and expand on our recent outreach efforts to reach even more people," said Richard Popper, director of insurance programs at the federal Center for Consumer Information & Insurance Oversight.

Enrollment varies widely by state. Pennsylvania has the highest enrollment with 2,684 people while North Dakota has enrolled just six people.

The U.S. Department of Health and Human Services lowered premiums in the plans it runs by about 20 percent this year and asked the states running their own programs to consider lowering their rates as well. Despite the slow start, Obama administration officials have said they are pleased with the program.

Most states require applicants to show proof that they've been rejected for coverage by a private insurer within the past six months or been denied coverage for certain benefits. At least a dozen states, including Pennsylvania, give applicants the option to provide a doctor's note as proof they have a pre-existing condition such as cancer or rheumatoid arthritis.

HHS has hired a private contractor to administer the programs it runs in states but generally they have enrolled fewer people than states running their own program.

Michael Keough, executive director of Inclusive Health, which runs the plan in North Carolina, credits increased awareness and lower premiums for the enrollment increase.

His plan cut rates by 10 percent across the board in January and rates fell as much as 30 percent for people between ages 55 and 64. The average premium for a 50-year-old in the plan is $285 with a $3,500 deductible.

More than 1,500 people have signed up for the program in North Carolina as of April, doubling enrollment since February.

"The trend line is increasing and that is what you want and the program is starting to have the desired impact," Keough said. "The plans still have the shadow of the original expectations to live with however accurate or not."

By CHRISTOPHER J. ASAKIEWICZ

Personal data privacy once again has taken front stage in Sorrel v. IMS Health, Inc.[1] Vermont passed the Vermont Confidentiality of Prescription Information Law that allows doctors which prescribe drugs to patients, to decide whether pharmacies can sell their prescription drug prescription records.[2] IMS Health as well as other health information companies contested the law, arguing that the law poses a restriction on commercial speech as access to such information helps pharmaceutical companies market their drugs effectively to doctors. The Supreme Court is now tasked with determining the constitutionality of the restriction on access to prescription information with regards to our First Amendment. [3]

However, this post is focused on the secondary effects asserted in amici curiae briefs supporting the petitioners of allowing companies to purchase such information, specifically the concern of data privacy and patient re-identification. [4] Under the Health Information Portability and Accountability Act (HIPAA), personal health information is de-identified by your local pharmacy prior to such information being shared with any third party. By de-identifying the data, your personal data cannot, it is believed, be linked or traced back to you. De-identifying your health information is a way for covered entities to share your information without your consent or authorization and in accordance with the law. The information once shared is completely anonymized. After the transfer to a third party, like IMS Health, your information is solely data of zeros and ones that translate to dates of dispensing and drug names. No longer does your prescription record list your name or month or day of birth. [5]

Briefs in the case assert that data mining firms could, hypothetically, create profiles based on these de-identified prescription records. Such prescription profiles would constitute certain patient’s prescription habits, including an individual’s medication types, pharmacies visited and dates dispensed. The briefs argue that linking and mining further public information to these drug profiles could result in patient re-identification.

IMS Health, Inc., of course, asserts that it has no knowledge of any patient re-identification and it protects such records with all the security privacy measures set forth under HIPAA and as strengthened by Health Information Technology for Economic and Clinical Health Act (HITECH). So what is the issue, I ask?

A pharmaceutical company does not need nor want to know who you are. Aggregate data is more beneficial to a marketing company, rather than just one record with your name on it. What benefit would a company get from a record that says, John Doe, DOB: 01-Jan-1984? The company could send you a mailer, but under the current regulations, you can opt out of the marketing material and it stops there. However, what helps a pharmaceutical company is aggregate datasets that say Dr. Jane Doe, MD writes 100 scripts for Lipitor ® a month. No one cares if the patients are unidentifiable, and most likely, the pharmaceutical company wants to keep it that way. Not only will the de-identified data be cheaper to buy, but it also assures the third party purchasing the data that it is not aiding a HIPAA violation.

Last, it is also asserted that there is no penalty for re-identification of personal health data, but there are stark penalties under HIPAA for “a person who knowingly … (1) uses or causes to be used a unique health identifier; (2) obtains individually identifiable health information relating to an individual; or (3) discloses individually identifiable health information to another person.” [6] If the offense is committed with the intent to sell, transfer or use the individually identifiable health information for commercial advantage, the penalty could be up to $250,000 and 10 years imprisonment. [7] If claims are brought against companies, like IMS Health, the companies will surely argue they are not covered entities subject to the penalties under HIPAA; however, this does not prevent civil lawsuits against them.

What will happen if a breach occurs due to patient re-identification? Most likely, the current healthcare environment where many companies are acting under corporate integrity agreements or deferred prosecution agreements, promotes reporting, if not out of altruistic purpose at least a compliance purpose. With this said, once reported to both the Department of Health and Human Services, Office of Civil Rights, as well as, in most states, the Secretary of state, privacy and confidentiality laws require notification to be provided to the patient that has been re-identified. This patient whose privacy rights have been infringed can then bring an individual civil claim against the organization responsible for the disclosure of their health information as well as the collateral damages caused by the unauthorized disclosure. Now, what company today wants to get involved with this type of bad publicity?

In conclusion, just because the possibility exists that a patient can be re-identified with data mining practices, does not mean that our current environment will foster such. The nine Justices of the Supreme Court need to be more concerned with the First Amendment and the commercial speech implications of their ruling, rather than amici curiae briefs supporting public policy positions based on unwarranted fears of patient information disclosure.[8]

I therefore urge you to put yourself in the role of your favorite Justice and consider if you should be more concerned that a company is going to buy your prescription records and try to determine that you took amoxicillin for a sinus infection when you were five years old, or if that company would rather purchase all the information you posted on Facebook ® or other social networking sites, including all the locations you have checked in. Which do you think is more useful to market its products? It is with this mindset that you must consider if the regulation directly advances the governmental interest “in protecting the public health of Vermonters, … the privacy of prescribers and prescribing information” and is no more extensive than necessary to serve that interest. [9]

This post first appeared on Health Reform Watch, the web log of the Seton Hall University School of Law, Health Law & Policy Program.

Christopher J. Asakiewicz, JD, works for ImClone Systems Corporation, an affiliate of Eli Lilly and Company. He graduated from Seton Hall Law in 20011 with a concentration in Health Law.

Filed Under: THCB

Tagged: Christopher Asakiewicz, HIPAA, Personal data, Privacy, Sorrel v. IMS Health May 5, 2011

Diagnosis of hemolytic anemia:

Hemolytic anemia is diagnosed based on clinical findings (the symptoms of hemolytic anemia such as pale skin, breathlessness, generalized weakness etc.) and certain laboratory investigations. The first test (laboratory test) done for diagnosis of anemia (including hemolytic anemia) is hemoglobin estimation. According to World Health Organization (WHO) hemoglobin level below 130 grams per liter blood in adult male is anemia and hemoglobin level below 120 grams per liter blood in adult female is anemia. Once anemia is diagnosed the next step is to find out type of anemia (such as hemolytic anemia, iron deficiency anemia, pernicious anemia etc.). The laboratory tests done for diagnosis of hemolytic anemia include peripheral blood smear microscopy, estimation of bilirubin (mainly unconjugated bilirubin), Coombs test, estimation of lactate dehydrogenase, hemosiderin and urobilinogen estimation etc.

Peripheral blood smears microscopy:

This is an important investigation in diagnosis of hemolytic anemia. The red blood cell morphology may show abnormality such as the red blood cells become smaller and rounder (spherocytes). There may be fragments of red cells in the peripheral blood smear. The reticulocytes (the precursors of red blood cells) may be higher in number.

Bilirubin level will be elevated (normally 0.1 to 0.8 mg per 100 ml blood), which may cause jaundice. Coombs test (direct Coombs test), if positive indicates hemolysis (breakdown of red cells) due to immune response. Increased hemosiderin level in urine indicates intravascular hemolysis.

Treatment of Hemolytic anemia:

The definitive treatment of hemolytic anemia depends on the cause of the anemia. Symptomatic treatment of hemolytic anemia (as well as all other types of anemia) includes blood transfusion (packed red cell transfusion or whole blood transfusion), especially if anemia is marked.

If extravsacular hemolysis is predominant, removal of spleen (splenectomy) may cause improvement of hemolytic anemia, as most red cells are red cells are removed from circulation by spleen. If hemolytic anemia is due to immune related cause treatment with steroids may be helpful.

Related posts:

Know about Hemolytic Anemia

Pathophysiology of Hemolytic Anemia

What are the Causes of Hemolytic Anemia?

Treatment of Iron Deficiency Anemia

What are the Symptoms of Iron Deficiency Anemia?

What are the causes of Iron Deficiency Anemia?

What are the Complications of Iron Deficiency Anemia?

Who are at Risk of Iron deficiency Anemia?

Prevention of Iron Deficiency Anemia

How Amenorrhea is diagnosed?

Enlarge iStockphoto.com

Big Sky and relatively big enrollment in high-risk pools.

iStockphoto.com

Big Sky and relatively big enrollment in high-risk pools.

Though it's nearly 2,000 miles from Washington, Montana plays an oversized role in the health care debate. Its senior senator, Max Baucus, was one of the biggest players in crafting in the health law.

And now Montana leads the country in the proportion of people who have signed up for the health law's insurance program for those with pre-existing conditions.

But the absolute number is quite low. Montana has signed up just 198 people.

 

In fact, as of the end of March, 18,313 people nationwide had signed up for the Pre-Existing Condition Insurance Plan â€" up from 12,437 on Feb. 1, according to data released today.

The numbers remain far below initial estimates for the high-risk pools established in the 2010 health law. Two reasons: high premiums and consumers' lack of awareness about the program.

The plans, which are run either by individual states or by the federal government if the states opted not to participate, became available to most people last September. They are intended to serve as a bridge until the insurance market reforms are implemented in 2014, when insurers will no longer be able to deny coverage or charge higher rates for people with pre-existing conditions.

The Congressional Budget Office had estimated that as many as 4 million uninsured Americans would be eligible for the program and that 200,000 would be enrolled by 2013. And the Chief Actuary of Medicare and Medicaid estimated that 375,000 people would enroll in these high risk pools by the end of 2010.

Citing the low enrollment, some Republicans including Rep. Fred Upton (R-MI), have criticized the administration's handling of the program.

The cost of the plan, and the fact that many people still don't know about it, may be keeping enrollment down.

But administration officials point to the trend and are optimistic.

"We're encouraged by the jump in enrollment and we're excited to build and expand on our recent outreach efforts to reach even more people," said Richard Popper, director of insurance programs at the federal Center for Consumer Information & Insurance Oversight.

Enrollment varies widely by state. Pennsylvania has the highest enrollment with 2,684 people while North Dakota has enrolled just six people.

The U.S. Department of Health and Human Services lowered premiums in the plans it runs by about 20 percent this year and asked the states running their own programs to consider lowering their rates as well. Despite the slow start, Obama administration officials have said they are pleased with the program.

Most states require applicants to show proof that they've been rejected for coverage by a private insurer within the past six months or been denied coverage for certain benefits. At least a dozen states, including Pennsylvania, give applicants the option to provide a doctor's note as proof they have a pre-existing condition such as cancer or rheumatoid arthritis.

HHS has hired a private contractor to administer the programs it runs in states but generally they have enrolled fewer people than states running their own program.

Michael Keough, executive director of Inclusive Health, which runs the plan in North Carolina, credits increased awareness and lower premiums for the enrollment increase.

His plan cut rates by 10 percent across the board in January and rates fell as much as 30 percent for people between ages 55 and 64. The average premium for a 50-year-old in the plan is $285 with a $3,500 deductible.

More than 1,500 people have signed up for the program in North Carolina as of April, doubling enrollment since February.

"The trend line is increasing and that is what you want and the program is starting to have the desired impact," Keough said. "The plans still have the shadow of the original expectations to live with however accurate or not."

By AMY ROMANO

I’ve been writing about safe and effective maternity care for years and direct a coordinated national effort to transform maternity care, but this is a post where the political gets personal.

Last weekend, I attended the birthday party for the sweetest one year old. There were all of the typical rituals â€" hands and face covered in cake frosting, a pile of toys and new clothes, and a tuckered out babe falling asleep as the party wound down. But this birthday was bittersweet, because it also marks the anniversary of a crisis that very nearly cost the life of this child’s mother, my friend.

Nine days after giving birth, rather than gazing with equal parts sheer love and sheer exhaustion at her baby, my friend â€" we’ll call her  Near Miss Mom â€" was unconscious in an ICU on a ventilator, recovering from the emergency hysterectomy and blood transfusion that had saved her life.

I’d say Near Miss Mom had become a “statistic” but we keep no statistics on near miss maternal events, even though multiple agencies and organizations have sounded alarm bells about the rising rate of maternal mortality and have cautioned that for every maternal death, there are many more near misses. Legislation just introduced in the House by Representative Conyers would, among other provisions, establish steps toward a standard definition and routine counting and reporting of maternal near misses.

Because if we’re not counting near misses, we’re not systematically learning what our health care system could be doing to avert them, and for that matter the deaths that do occur. A  just-released report from a state-wide, multi-year investigation of maternal deaths in California found that 38% were likely to be preventable. Let’s take Near Miss Mom’s case, which almost certainly could have been averted far before she was so close to death.

Near Miss Mom almost died:

• Because her postpartum discharge teaching didn’t include anything about how to recognize and get help for postpartum hemorrhage â€" even though she had three major risk factors for hemorrhage

• Because the hospital had no protocol to systematically deal with late postpartum hemorrhage â€" even though the largest maternal quality collaborative in the country has a freely available toolkit for that

• Because no one was measuring her blood loss while she sat in the ER on two different occasions for hours at a time â€" even though she was sitting in a pool of blood so deep it was pouring over the tops of her thighs and the sheets had to be changed more than once

• Because she had to “wait in line” for the MRI and then wait some more for someone to interpret it â€" even though there are less sophisticated but equally effective methods to rule in or out the rare defect they were concerned about.

• Because no one in the ER communicated the severity of her condition to the obstetrician who was “overseeing” her care â€" even though the OB was in house and could have visited her herself. When she finally reached Near Miss Mom’s bedside, it didn’t take her long to call a Code Red and assemble the team for the emergency hysterectomy.

Patient safety advocates and experts will see some familiar themes in this list â€" lack of standards and accountability, poor communication, system failures â€" and although  maternity care is the most common reason for hospitalization, how often do we think of hospital safety as it pertains to maternal health? My best guess is that the disconnect arises from the fact that childbearing women are usually healthy and therefore (physically at least) resilient. Unlike patients who enter the hospital sick or injured, it can take many errors and system failures to actually kill a mother. Yet this means the problems can get so immense and intractable before we see the accumulation of harm. That adds up to a lot of women coping with preventable injury, illness, and emotional trauma at the same time that they should be experiencing the joys and taking on the challenges of new motherhood.

I recently asked Near Miss Mom recently what it felt like to be bleeding to death. Her response wasn’t what I expected, but knowing what I know of the fractured and fragmented system, it’s not surprising.

“Honestly, I don’t know. I was so overwhelmed with the lack of care in the ER and by my OB practice that I wasn’t really thinking about bleeding to death. But why would I? No one thinks about that as a possibility. I mean, I assume no one does. Why would we when we have an expectation of proper care? It wasn’t until I was admitted and in my room, and the OB was asking why the blood was taking so long that I realized I was potentially screwed. My first thoughts were my daughter and husband and would I be there for them. Right after that I went into shock so not much time to truly think about actually dying. I mean, dying? Really? I knew I was bleeding all day but I never thought they would let me reach the point of near death.”

Since the moment Near Miss Mom began her recovery, her most fervent hope has been to help make sure this doesn’t happen to any one else ever again. Unfortunately, when we met with her OB team after the fact, they declined her offer to be involved in quality improvement efforts because those matters are confidential. They also told her that she would need to meet separately with the ER team because they run their own quality improvement programs and the OB Department can’t influence what the ER does (if that’s not silo thinking, I don’t know what is). Then they asked if either of the companions she brought with her for support and advocacy were lawyers and, just for good measure, billed her insurance company for the time spent meeting.

Near Miss Mom has been trying for a year to use her story to spark desperately needed improvements in maternity care, but has encountered road blocks at every turn. Even writing down her story has been too much at times, as she deals with still incomplete medical records, post traumatic distress triggers, and the time and energy constraints all new mothers face.

But she is ready to make change and as her first public acts of activism, Near Miss Mom will join a delegation to get lawmakers to sponsor the Maternal Health Accountability Act and she will use her story to ask others to donate blood in the month of May to honor Mother’s Day. Near Miss Mom writes,

“Without the people who donated blood, I would not be here. It wasn’t only the surgery that saved my life. It was the blood. Eleven strangers saved my life. And saved my baby’s mother.”

I will be at Near Miss Mom’s side for both of these courageous acts of activism. We hope others will do the same in their own communities. Will you join us?

Amy Romano, MSN, CNM, is the Project Director of the HYPERLINK “http://transform.childbirthconnection.org” Transforming Maternity Care Partnership, a multi-stakeholder collaborative effort to achieve a high-quality, high-value maternity care system, coordinated by Childbirth Connection.

Filed Under: THCB

May 3, 2011

Enlarge iStockphoto.com

How much salt is too much?

iStockphoto.com

How much salt is too much?

Might be time to dust off Woody Allen's Sleeper, the 1973 movie that, among other zany things, told us all the foods that we thought were bad for us (think steak and hot fudge) were found by future generations to be good.

A provocative study in the latest issue of JAMA suggests that moderate salt intake might be no problem and that for many people diets very low in salt could be a recipe for trouble.

European researchers studying nearly 4,000 people as they aged found increases in systolic blood pressure were associated with increases in salt measured in the urine. (Sorry, that's how the researchers could accurately quantify how much salt people had in their systems.)

 

Changes in diastolic blood pressure (the bottom number in blood pressure readings) didn't show a relationship with salt.

And, perhaps most interesting of all, the increases in salt and diastolic pressure were not associated with an increase in deaths from cardiovascular disease, such as heart attacks and strokes. Indeed, people with less salt in their urine were more likely to die from cardiovascular causes.

Surprising, right? Previous research has predicted, for instance, that lowering salt intake just a little â€" a half-teaspoon a day â€" would save the lives of at least 44,000 Americans a year.

Well, it wasn't surprising to Dr. Jan A. Staessen, a hypertension researcher at the University of Leuven, who is the senior author on the paper. He told the news@JAMA blog:

We started this research more than 25 years ago, and in all our studies, it was almost impossible to find an association between blood pressure and 24-hour sodium excretion. We were a bit surprised to see an inverse relationship between sodium intake and cardiovascular death.

He acknowledges that limitations of the study don't make it easy to explain exactly what's going only. Staessen theorized that cutting way back on salt can "activate some of the systems that conserve sodium and they are known to have a negative influence on cardiovascular outcomes." In any case, he said, the findings should give pause to people making population-wide recommendations to cut salt intake.

The Centers for Disease Control and Prevention, one of the big proponents of lower salt consumption, isn't so sure about that. In an interview with the New York Times, CDC's Dr. Peter Briss faulted the study, saying it was small, included relatively young subjects and had relatively few cardiovascular deaths.

Among the people in the the study, there were 84 deaths due to cardiovascular disease. The majority of those â€" 54 â€" occurred in the third of people who happened to have the lowest salt consumption.

The limitations, Briss said, make it hard to draw conclusions that would overturn the previous work that has link increased salt intake and bad health outcomes. "At the moment, this study might need to be taken with a grain of salt," Briss told the Times.

The European researchers had no financial conflicts of interest to report. They received funding from a bunch of governments.

By GLENN LAFFEL, MD

Amazon Web Services (AWS), “the cloud” for many, experienced a serious interruption in service beginning on April 21st. The problem lingered for at least 6 days. Many websites that relied on Amazon services went down or saw their performance degraded during the event.

The AWS failure disproportionately affected startups like Foursquare, Quora and Reddit, companies that are “focused on moving fast in pursuit of growth, and less apt to pay for extensive backup and recovery services.”

One of the affected companies was a health care startup. What follows is a transcription (including typos) of an AWS Discussion Forum that this company initiated 24 hours after the outage began. The company’s contributions are in italics.

Life of our patients is at stakeâ€"I am desperately asking you to contact

Sorry I could not get through in any other way. We are a monitoring company and are monitoring hundreds of cardiac patients at home. We are unable to see their ECG signals since 21st of April. Can you please contact us? Or please let me know how can I contact you more ditectly. Thank you.

Oh this is not good. Man mission critical systems should never be run in the cloud. Just because AWS is HIPPA certified doesn’t mean it won’t go down for 48+ hours in a row.

(+30 minutes since comment thread began) Well, it is supposed to be reliable…
Anyway, I am begging anyone from Amazon team to contact us directly. Thank you
â€"
Go to your backups? Or make a big deal out of it on the forums maybe someone will take a look. In any case anecdotal empirical evidence has shown don’t bother with premium support its a freaking joke.
â€"
Thanks for the comments, but we are really desparate. Amazon team â€" please contact us
â€"
(+10 hours since comment thread began) Not restored. Not heard from Amazon. People out there â€" please take a look at our volumes! This not just some social network website issue, but a serious threat to peoples lives!
â€"
Your only option at this point is Premium support. However, they’re just going to tell you to wait. Sorry.
â€"
(+ 13 hours) There is some progress. 2 servers are operational and one still not working. Unfortunately, the one on which we have the most patients
â€"
Aren’t you braking some compliance laws by not having a highly-available environment?
â€"
You put a life critical system on virtual hosted servers? What the hell is wrong with you
â€"
Not sure whether you’re plain incompetent or irresponsible. Anyway, you should be ashamed and prepare yourself with lots of money to pay for the lawyers. Would it be so difficult to have a contingency plan? another provider? or even another availability zone? Are you so fsklong dumb as to think that nothing could ever happen to a data center.
â€"
(+ 15 hours) This is a home based system, not an intra hospital system. So the promised 99.95% uptime is fine. But this situation showed that the promised 99.95% = fiction… BTW. All three servers are working â€" hopefuly the situation will remain stable
â€"
While I’m not going to suggest Amazon shouldn’t be ashamed of themselves.. I have to admit this is a pretty sickening tale. If I were running a system that could potentially lead to loss of human life. You’d better believe hot-spare data center would be in my mind.
â€"
Your CTO will be a serious liability, and your board is going to crush your C*O staff very soon, if they’re awake. If you haven’t notified doctors and patients already, your liabilities just got worse. If you can’t roll over your IP routing, then you should not be in business. This should be going to a different server and duplicated by your own policies to ensure compliance with ALL regulatory requirements. You’re failing and you probably don’t even know how bad your company is failing. If I were you, I’d beg John Halamka to guide you out of this mess.
â€"
“This not just some social network website issue, but a serious threat to peoples lives!” Which begs the question, why did you leave yourself â€" and your patients â€" open to this risk in the first place? I hope for your patients’ sake that you begin taking more seriously your IT planning. Since you apparently don’t have a fail-over â€" and are waiting for Amazon anyway â€" you might want to think about solving the weakness you built into your own system, i.e., start working on an alternative method of getting what you need. And if you can’t find a way to do that even now, I submit that you should never have launched your service at all.
â€"
Not even your servers are redundant? One of your servers is offline, and there’s not a hot swapable replacement? for a life-critical system? Man, pray God nothing happens, because on contrary, the responsibles for this design are surely going to serve sometime on a nearby prison.
â€"
If you were smart, you would have a distaster recovery plan for just this kind of thing. Judging from your lack of said preparations, you lot figured the cloud never goes down, and got greedy by not wanting to spend money on hot standby machines on a different infrastructure. Good going. Hope none of your cardiac patients croak because you’re going to get sued into next week…
â€"
(+15 hours) As I wrote, this is not a life saving system.Which does not mean that patient’s life cannot be saved using it.That is all I have to say. Good luck to others
â€"
Dude/Dudet. You put that patients lives are at stake in your title … Don’t try to back track. Just admit it was stupid and move on.
â€"
Ah, so the title of this thread was a ruse? Either it isn’t so critical after all, and shame on you for trying to make it seem like it was, or else it is critical, and now you’re lying about it in order to not be shamed by others. Either way, shame on you.
â€"
A perfect case study of what NOT TO DO. Why gamble when people’s LIVES are at stake!?
â€"
We all do mistakes, but the important thing is learn from them. I’ll also have to review and change my policies. As for Amazon, it is a total shame that didn’t give ANY kind of assistance not even to this request. Regards
â€"
Agreed. Sounds like he’s a startup. Failing over to other data centers is extremely expensive to set up and operate. Particularly if his data is write-heavy. No reason for everyone to go all self-righteous on him. In the end, the market will decide. if his patients die, he’ll be fired and/or his company will go out of business. Others will learn, the marketplace will move on.
â€"
This is a Hoax. There are NO Patients in Danger. This was pure Hype from a Sick Person. Don’t fall for this BS. Use your Common Sense. Nobody in charge would allow this FruitCake to load any sort of critical monitoring systems up. You have been had. I respect your very real emotions, and your helpful and constructive responses to this fool, but he made all of this up, to get a Rise out of you. Next time, be more logical and think, before you answer crap like this.

Pizaazz Note: The long-term impact of the AWS outage on cloud computing is uncertain. It may be negligible. IDC estimates that corporate cloud computing will grow by more than 25% per year to $55.5 billion by 2014.

Glenn Laffel, MD, PhD, is a successful entrepreneur in health information technology. He blogs at Pizaazz.

Filed Under: THCB

Tagged: Amazon, Cloud Computing, Cloud-based EHR, Glenn Laffel May 2, 2011

Enlarge Frederick M. Brown/Getty Images

California anesthesiologist Michael Port fills a syringe with the anesthetic propofol in 2009.

Frederick M. Brown/Getty Images

California anesthesiologist Michael Port fills a syringe with the anesthetic propofol in 2009.

Modern medicines can be lifesavers. But they don't do much good if patients can't get them.

And, these days, drug shortages are a real problem. Turns out that a record number of medicines â€" to treat conditions ranging from cancer to life-threatening infections â€" are in short supply, the Washington Post reports.

There were shortages of 211 drugs last year, three times the number in 2006.

One of the worst problems is with cytarabine, a medicine for various forms of leukemia and lymphoma.

 

Shortages of the antibiotic amikacin and acyclovir, an antiviral, have "contributed to patient deaths from infections that were only sensitive" to those drugs, according to a 2010 survey of more than 1,800 health professionals conducted by the nonprofit Institute for Safe Medication Practices. Some drugs used in surgery, such as the anesthetic propofol, have also been hard to find.

The ISMP survey found doctors, nurses and pharmacists "feel unsupported by the Food and Drug Administration" in dealing with the shortages and are "perplexed regarding why the U.S. is experiencing drug shortages of epic proportion that are often associated with third-world countries."

What's causing the shortages? The FDA, which tracks the growing problem with medically necessary drugs, says some of the most important factors are manufacturing difficulties. There are raw material shortages in some cases. Reduced factory capacity due to industry consolidation is another issue. And some companies have dropped older drugs, leaving manufacturing in the hands of fewer companies.

"The types of products we're seeing shortages of are really concerning," FDA's Valerie Jensen, told the Post. "This is affecting oncology drugs, critical-care drugs, emergency medicine drugs. We're doing everything we can under our current authority to try to deal with this situation."

This report of recent activity in Massachusetts may be of special interest to my out-of-state readers. The insurance exchange set up by the Legislature when the MA health care access bill was passed has gotten very good grades. The folks there have had many things to balance, and they have done it thoughtfully. This report was posted on April 22 by Glen Shor, the current Executive Director. He succeeded Jon Kingsdale last April.

April showered us with reasons to be optimistic about the state of health care reform in Massachusetts.

Faced with projected 11% membership growth in the Commonwealth Care program next year as people lose unemployment benefits â€" and no additional resources to cover that growth â€" we encouraged our Medicaid managed care organizations to deliver high-quality, cost-effective coverage for less. They came through for the taxpayers with savings of $80 million, meaning that our members will not have to face the prospect of benefit reductions or unaffordable co-payments.

There was also good news for small business owners looking for an easy way to find affordable health insurance for their employees. Starting in July, we are eliminating all up-front fees for purchasing coverage through the Health Connector and will be launching a wellness program and premium discounts for qualifying small businesses. Within a few months, we will also be expanding the choice of health insurance carriers available to small businesses through our easy-to-use, online shopping experience â€" and even adding an additional carrier for individual purchasers. Our unsubsidized Commonwealth Choice program has doubled in membership over the past year-and-a-half, and these upgrades should make it an even more appealing tool for comparing options and choosing coverage that best suits one’s needs.

And, of course, the fifth anniversary of Massachusetts health care reform was officially marked by Governor Patrick and others at the Dorchester House this month. While we are proud of the fact that 98.1 percent of our residents and 99.8 percent of our children have coverage, the event poignantly showcased that reform isn’t just about numbers. It’s about helping people. We’re succeeding on both fronts.

On the national scene, the Massachusetts experience continues to be closely examined as other states begin to develop their health insurance Exchanges. Partnering with MassHealth and the University of Massachusetts Medical School, we were successful in obtaining a $35.6 million three-year federal grant that will not only help us share our technological knowledge and practices with other New England states but also improve our web-based shopping experience for Massachusetts consumers and small businesses.

Video: A Crash Course In Beating The Cubicle Trap

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A crash course in beating the cubical trap. Breaking up a day of inactivity with movement, even if just for a few minutes, can make a difference.

On this week's podcast we're getting physical, with lots of stories about the dangers of a sedentary life. Whether you are suffering from knee pain like our colleague Richard Knox, or just feel weary after a day sitting at your desk, the solution might be to get moving.

We'll hear a story of some folks who have taken this advice to heart; they've installed "treadmill desks" at work.

Plus, we'll discuss child nutrition. Schools in L.A. are getting rid of flavored milk, thanks to the efforts of celebrity chef Jamie Oliver, and soon, many schools might find it easier to get produce from their neighbors to put into their school lunches. Meanwhile, the Obama administration wants to curb marketing of sugary foods to children â€" but the response by some to the guidelines hasn't been all that sweet.

You can find the podcast at the bottom of the page under the podcast heading. To subscribe to the Your Health podcast, click here.

By JULIE APPLEBY

Fed up with the unpredictable cost of health insurance for his small business, Mike Sarafolean last year made a dramatic change: Instead of picking a plan to offer workers, he now sends them to a “private exchange” or marketplace where they compare and choose their own insurance. And the amount his company pays toward coverage is capped.

Mike Sarafolean, CEO of Orion Corporation of Minnesota, last year joined a growing number of employers embracing a dramatic change in the way they offer health benefits (Photo by Andy King).

The move puts his St. Paul, Minn.-based company on the leading edge of a nascent trend that could shape how more employers offer and pay for their health benefits in the coming years. It is part of an ongoing evolution in job-based health benefits that is gradually shifting cost and responsibility to workers.

The private exchanges, mainly run by former insurance executives and employee benefit consulting firms, operate in more than 20 states.

While representing only a tiny fraction of workplaces, the movement may be about to grow: One of the nation’s largest employer-benefits consulting firms â€" Aon Hewitt â€" said Wednesday it will launch of an exchange aimed at large companies. It hopes to have at least 100,000 workers enrolled by early next year.

Proponents say the effort shields employers from unpredictable premium hikes because they will choose how much to increase their contribution each year and those amounts may be less than premiums actually increase. If that happens, workers would make up the difference.

Tempering such increases, proponents say, would be competition among insurers because workers would have a wider choice of plans, rather than just the one or two currently offered by many employers.

“We’re trying to create a retail marketplace that is competitive,” says Ken Sperling, who is overseeing the Aon Hewitt effort. Employees would get be able to choose among several carriers. “Insurers would have to compete for their business.”

The exchanges, which have some similarities to state-based programs mandated by the federal health overhaul law, also save employers money partly because workers, when given a variety of choices, are likely to choose less generous benefit plans, which will carry lower premiums, say proponents.

“Most companies are over-insuring their employees right now. We want to right-size that,” says Curtiss Butler, chief marketing officer at Liazon, which also operates a private exchange.

Others, including Carmen Balber of the advocacy group Consumer Watchdog, caution that private exchanges potentially could be used by insurers to “cherry pick” employers with younger and healthier workforces. Balber also said private exchanges potentially could steer workers toward policies that have low premiums, but also high annual deductibles and other charges. Such policies are more profitable for insurers, but can leave unprepared consumers on the hook for thousands in medical costs each year.

Private exchanges “absolve the employer from having any responsibility for providing benefits or getting a good deal for consumers,” says Balber.

Frustrated By Double-Digit Premium Hikes

Sarafolean, CEO of Orion Corp. of Minnesota, which provides services for people with disabilities, doesn’t see it that way.

Before he made the switch, Sarafolean said he had a limited number of insurance choices to offer his 70 workers: “I had to buy a plan that would make sense and fit for most people. Now they make choices that fit for them.”

For the past few years, his company faced “double-digit premium increases every renewal.” To slow those increases, Sarafolean said he had switched to a policy with large annual deductibles: payments of $4,500 by individuals or $9,000 by families before insurance began paying most medical costs. His employees also paid about $90 a month toward their premium.

A little more than a year ago, Orion received a 40 percent renewal increase, prompting him to move to Minneapolis-based Bloom Health, which set up private exchanges in Michigan, Minneapolis and Indiana.

Now, his company makes contributions ranging $125 a month for younger workers to $350 for older ones to special health reimbursement accounts, which workers then use to buy an insurance policy.

By making the change to a flat contribution and a private exchange, the company is saving 10 percent over its previous year’s cost of insurance, he says. Many of his workers also spend less, he says.

Gabrielle Smith, an employee of Orion Corporation of Minnesota, changed her benefit plan with the small company (Photo by Andy King).

He’s not sure what he will choose in 2014, when the state-based insurance exchanges are set to open as part of the health care law approved by Congress last year. Initially, those exchanges are aimed at individuals and small companies that are shopping for insurance. States can decide later in the decade whether to open them to large businesses.

Sperling, who is overseeing Aon Hewitt’s private exchange, compares the flat-payment change to one that gained speed in the early 1990s: Employers abandoning pensions in favor of offering workers 401(k) plans for retirement savings.

But just as 401(k) plans transferred the risk of market downturns to workers, the flat-payment model would shift risk to workers if rapidly rising health costs outpace increases in employer contributions.

“From a consumer point of view, it makes me nervous because as premiums go up, it’s simply a mechanism to cost-shift,” says Sabrina Corlette, research professor at the Health Policy Institute at Georgetown University in Washington D.C. “That said, if it allows a small employer to continue to offer insurance … it’s not a terrible compromise.”

The model has been compared to House Budget Committee Chairman Paul Ryan’s proposal to cap government payments for future Medicare enrollees, giving them a set amount to buy coverage from private insurers. Under Ryan’s plan, the government contribution would grow with general inflation, which is less than medical inflation, saving taxpayer dollars, but substantially increasing beneficiaries’ costs, according to the Congressional Budget Office.

Sperling says he expects most employers will annually set increases in their health insurance contributions to an amount approximating wage increases â€" about 2 to 3 percent annually â€" which are generally well below medical inflation. But he says the competition created by the exchanges will help slow medical premium growth.

Rejection For Health Conditions

Unlike most of the private exchanges, the Bloom Health model, which serves about 25,000 people, sends workers to buy their own policies on the so-called individual market, rather than through a group health policy.

However, insurers selling individual policies in most states can reject applicants with medical problems, a practice that will end in 2014 under rules in the health care law.

Bloom CEO Abir Sen says his company offers its services only in states where rejected applicants can qualify for special state-run, high-risk insurance programs, which generally cost at least 25 percent more.

Gabrielle Smith, a 16-year employee of Orion who has an auto-immune disease, worried that under Bloom she would be unable to get insurance “or it would be so in excess of what I could afford.”

Smith, 48, did get coverage â€" through Minnesota’s high-risk pool â€" and found that she still was able to lower her deductible by $1,500 a year compared with the former $4,500 deductible plan offered at Orion. She now pays $45 a month for her premium.

“I haven’t heard anyone who is unhappy with the current insurance because it was all individualized,” says Smith. “Some of the younger employees with no medical conditions (found low-cost plans that) don’t require any money out of their paychecks.”

Other private exchanges, including Buffalo-N.Y.-based Liazon, which serves about 25,000 employees in 23 states, and the new Aon Hewitt model send workers to group policies, which cannot reject applicants with health problems. The exchanges vary in other ways, too: While Bloom and Aon Hewitt offer a variety of insurers, for example, Liazon contracts primarily with one main health insurer in each region.

Aon Hewitt’s model would offer only five different types of policies, ranging from high-deductible “bronze” and “silver” level plans to a high-end “platinum” plan with a broad network of doctors and hospitals and minimal consumer spending on deductibles or co-payments.

All the exchanges plan to collect revenue by charging employers a monthly fee, receiving commissions from insurers, or both.

It’s unclear how the advent of state-based exchanges will affect programs such as Bloom, Liazon and Aon Hewitt, or whether there will still be a demand for their services by small businesses.

“As of 2014, why will the private exchanges be needed?” asks Paul Fronstin of the Employee Benefit Research Institute, a nonprofit research group based in Washington.

On their websites, the private exchanges say what sets them apart from future state exchanges will be their level of customer service. By opening now, private exchanges also could be in a position to bid for contracts to run state exchanges, a move Sperling says Aon Hewitt would consider.

But Balber at Consumer Watchdog counters that the state exchanges may be better for consumers than private ones because states can choose to actively monitor the quality and cost of the insurers allowed to participate. In theory, private exchanges could do the same, but Balber is skeptical.

“To presume a private exchange is going to examine trends in premium increases and pressure insurers to lower prices is unlikely,” she says.

Benefit experts say there is growing interest in the move to a flat payment model, dubbed “defined contribution.” A March survey of very large employers by the HR Policy Association found that 36 percent are considering capping contributions for workers’ insurance over the next 10 years.

Some firms already set a cap on contributions for retirees, Fronstin says. But he predicts that most employers will take a wait-and-see approach before changing their health coverage for current employees.

Aon Hewitt’s Sperling says as the health system overhaul takes effect, most employers will continue to offer coverage to workers: “They’re either going to stay in the game and be more requiring of their employees (around healthy behavior) or will look for a realistic exit strategy, which could be a corporate exchange.”

This story first appeared on Kaiser Health News in collaboration with USA Today.

July Appleby is a staff writer for Kaiser Health News.

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Filed Under: THCB

Tagged: Employers, Julie Appleby, Private exchanges Apr 29, 2011

Sometimes an older and cheaper drug beats the shiny, newer competition by being just as effective for a fraction of the cost. But it takes a lot of time and money to prove it.

A government-sponsored study released yesterday compared Lucentis, a drug approved to treat a common form of blindness in the elderly called macular degeneration, to Avastin, a cancer drug eye doctors have been using to treat the eye disease for years.

National Eye Institute

Wet form macular degeneration occurs when abnormal blood vessels behind the retina start to grow under the macula.

It found that patients who got Avastin could read an average of 8 more letters on an eye chart after a year - while Lucentis patients were able to read 8.5 more letters after a year of treatment.

 

"Health care providers and payers worldwide will now have to justify the cost of using ranibizumab [Lucentis,]" said an editorial accompanying the study in the New England Journal of Medicine.

As we reported before, getting the trial going took years and was pretty complicated, since drug companies are loathe to pay for these kinds of head-to-head studies. It highlights the challenges the government faces in doing comparative effectiveness research.

But since Avastin costs about $50 a pop, while Lucentis costs $2,000, results like this suggest Medicare could save a bundle if people choose the cheaper option.

About 1.75 million people in the U.S. have macular degeneration, but before you get too excited, the drug is used to treat those with the wet form of the disease â€" only about 15 percent of that population.

Genentech, which makes both drugs, told the New York Times on Thursday that it still believes that Lucentis is safer and better. It's better at drying the fluid in the eye that is believed to cause the vision loss, and the trial showed it was associated with slightly fewer serious complications.

However, the authors of the study said there weren't enough patients in the trial to draw conclusions about safety.

By DAVIS LIU, MD

The New York Times recently published an article titled the Family Can’t Give Away Solo Practice wistfully noting that doctors like Dr. Ronald Sroka and “doctors like him are increasingly being replaced by teams of rotating doctors and nurses who do not know their patients nearly as well. A centuries-old intimacy between doctor and patient is being lost, and patients who visit the doctor are often kept guessing about who will appear in the white coat…larger practices tend to be less intimate”

As a practicing family doctor of Gen X, I applaud Dr. Sroka for his many years of dedication and service.  How he can keep 4000 patients completely clear and straight in a paper-based medical system is frankly amazing.  Of course, there was a price.  His life was focused solely around medicine which was the norm of his generation.  Just because the current cohort of doctors wish to define themselves as more than their medical degree does not mean the care they provide is necessarily less personal or intimate or that the larger practices they join need to be as well.

The New York Times article and many patients typically confuse high quality care with bedside manner.  Not surprising.  In the November 2005 survey by the Employee Benefits Research Institute, 85 percent or more of the public felt that the following characteristics were important in judging the quality of care received:

The skill, experience, and training of your doctors
Your provider’s communication skills and willingness to listen and explain thoroughly
The degree of control you have in decisions made regarding your health care
The timeliness of getting care and treatments
The ease of getting care and treatments

The first three items relate to the ability of a doctor to translate knowledge, training, and expertise into the ability to listen, communicate, and partner with a patient.  This is bedside manner.  The last two items relate to whether a patient can be seen quickly and easily when care is needed.

But beyond bedside manner and ease of getting care, both which are very important, does the public care about getting the right care or just assume that it is a given?  My suspicion is that they assume all medical care provided by doctors is the same, yet research demonstrates the contrary.  One study found that 75 percent of primary care doctors provided the wrong type of colon cancer screening. Those most likely to do the wrong test after a positive stool screening test?  Those who graduated from medical school before 1978, who were not board-certified, and who were in solo practice.

Personal relationships between doctors and patients are important, but that should not be the only criteria regarding high quality care.

I love primary care.  I’ve worked at Kaiser Permanente (KP) in Northern California since 2000, a “larger practice”.  The number of patients a full-time doctor cares for is about half of the 4000 patients of Dr. Sroka’s.  Doctors have access to a comprehensive electronic medical record that provides real-time information about a patient’s lab work, imaging studies, and medications 24/7.  Primary care doctors and specialists can collaborate working off a common database and eliminating the uncertainty that exists in a paper based medical system and when doctors work in isolated solo practices.  Our primary care doctors are supported with a call center which is open all year round day and night to provide patients advice on symptoms and advice on when problems can be safely cared at home, when a doctor’s appointment is needed, or when medical care is more emergent.

In other words, doctors can be doctors.

Let’s not assume or confuse the rising trend of large group practices or the implementation of more electronic medical records and technology in doctors’ offices as automatically dooming doctor-patient relationships to becoming more impersonal.  The rise of social media like Twitter and Facebook have increasingly made society more connected than ever.

If Americans and doctors want solo practices, then they will demand them.  Certainly there are successful solo practice models like the Ideal Medical Practice, which also supported by information technology, that can provide patients with a doctor who is a sole proprietor.  To say all primary care doctors should join large group practices should be absurd because doctors like patients are individuals and one type of practice does not fit all.

Yet, the fundamental problem with this New York Times piece is the implication that solo practices provide doctor-patient relationships that are more intimate and where patients have a level of trust and confidence in doctors that perhaps exceeds that of thoughtfully designed larger practices.  It offers no evidence if the quality of care delivered is as good.  Let’s not use a practice model which was prevalent in the 1960s and assume its passing is a bad thing.  It may not be up to the challenges of the 21st century.

Davis Liu, MD, is a practicing board-certified family physician and author of the book, “Stay Healthy, Live Longer, Spend Wisely â€" Making Intelligent Choices in America’s Healthcare System.” Follow him at his blog, Saving Money and Surviving the Healthcare Crisis or on Twitter, davisliumd.

Filed Under: THCB

Tagged: Davis Liu, Family doctors, Physicians, primary care Apr 26, 2011

Ringworm is a clinical condition due to infection by fungus in the skin. The same fungus can infect pets such as cats, sheep, cattle etc. too. Ringworm is known as dermatophytosis in medical term. Although it is called ringworm, it is not caused by any worm or parasite, but by fungi of different species. It is called ringworm, because the skin lesion the fungal infection produce is commonly of ring shape, but not always.

It is estimated that, presently as many as 20% of world population may be infected by different species of dermatophytes (the causative agent of ringworm), making it probably the commonest disease, although not many have symptoms serious enough to seek medical attention. Some individuals are prone to ringworm infection, such as wrestlers and athletes. Wrestlers may even be disqualified if found to have ringworm (may be for the fear that he may cause ringworm infection to other wrestlers during wrestling).

The dermatophytes, which cause ringworm, feed on the keratin layer of the skin. Keratin is the protenaceous material found in the outermost layer of skin (epidermis, which is usually a layer of dead skin cells), as well as in the hairs and nails (finger nails and toe nails). The dermatophytes survive and thrive on the skin, especially if skin is moist and warm. Dermatophytes also thrive well in the hair (may be outside of the shaft or inside the hair shaft).

What are the different types of ringworms?

There are several types of ringworms seen in humans, depending on the location mainly.

• Tinea pedis, also commonly known as athlete’s foot, occurs in the feet.
• Tinea capitis occurs in scalp.
• Tinea cruris, also known as “jock itch” occurs in groin.
• Tinea unguium occurs in fingernails and toenails.
• Tinea corporis occurs in upper limbs, lower limbs and body/trunk.
• Tinea manuum occurs in palms.
• Tinea faciei occurs in face.
• Tinea barbae occurs in facial hair, which should be differentiated from “sycosis barbae” which is a bacterial infection commonly due to injury to facial skin while shaving.

There are also other clinically similar conditions, but not true ringworm as they are not caused by dermatophytes, such as Tinea versicolor (caused by Malassezia furfur) and Tinea nigra.

Treatment of ringworm:

There are several highly effective antifungal antibiotics (topical as well as systemic) available for treatment of ringworm.

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Causes and Risk Factors of Nail Fungus Infection

What is Athlete’s Foot?

How top Prevent Nail Fungus Infection?

Diagnosis & Home Remedy of Nail Fungus Infection

Treatment of Nail Fungus Infection

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Fungal Infection of Toenails & its Treatment

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Faith-based groups that share health-care expenses struggle with the question of how much of the burden to share.

Stan Rohrer/iStockphoto.com

Faith-based groups that share health-care expenses struggle with the question of how much of the burden to share.

The Bible says that Christians should share each other's burdens, and for some, that means sharing the burden of medical bills. They join together in health care sharing ministries, usually paying monthly "shares" of a few hundred dollars or more to cover other members' health care expenses. They then get their own expenses covered in turn. The ministries divvy up the money to cover that month's "needs," as they're called.

Under the health care overhaul, health care sharing ministries can continue to operate, and their members won't be subject to the penalty that will be levied on individuals starting in 2014 if they don't have health insurance.

Even though the ministries aren't providing health insurance, they wrestle with some of the same issues that insurers do: What to do about would-be members who have possibly pricey pre-existing medical conditions? Just how far should burden-sharing go?

 

The answer: It depends. Medical sharing ministries â€" which have about 120,000 members nationwide â€" each have rules that limit coverage of new members' pre-existing conditions to some extent. Christian Healthcare Ministries, for example, will cover up to $15,000 in needs for a pre-existing medical condition during the first year after a new member joins, says the Rev. Howard Russell, the ministry's executive director.

At Samaritan Ministries, the policy is more restrictive: It doesn't share expenses for medical conditions that a member has upon joining, says James Lansberry, executive vice president at Samaritan. (Once a member goes for 12 months without being treated for a particular condition, however, the ministry no longer considers it pre-existing and will share those expenses.)

Although the health law requires insurers to cover everyone without regard to pre-existing medical conditions starting in 2014, those provisions don't apply to health care sharing ministries, says Kansas Insurance Commissioner Sandy Praeger, who is also chair of the health insurance and managed care committee of the National Association of Insurance Commissioners. "As long as they are not regulated as insurance entities, those new rules will not apply," she says.

Noting that nearly half of the ministry's 56,000 members have incomes of 200 percent or less of the federal poverty level ($44,700 for a family of four in 2011), Lansberry says, "If we shared all needs whenever they occurred, our shares would be too high."

In addition to affordability concerns, there's another reason to restrict coverage of pre-existing conditions for new members, Lansberry says: "Human nature being what it is, people will wait to join until they're sick."