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Judge Upholds Policy Barring Unimmunized Students from School during Outbreaks

June 25, 2014

Brian L. Grant MD

vaccines-child-needs-400x400MCNTalk has been following the vaccination refusal controversy for some time. As noted in this recent Times article, a NY court has affirmed the right to deny access to schools by unvaccinated children when another student is ill with a vaccine-preventable disease.

These particular cases are interesting because they illustrate a clash in values between sincerely held beliefs, religious or otherwise, and the public good. It leaves unanswered or at least unresolved the question of whether beliefs may trump good science. Also un-addressed is the practice in place whereby one can invoke religion where convenient, though scriptures are silent on vaccines and many other practices that individuals may choose to invoke religion to justify or excuse behaviors and choices.

Vaccines are a medical miracle that have virtually eliminated smallpox, diphtheria, measles, pertussis, and polio, maladies that have killed and maimed untold millions in the world and which can easily re-emerge when there is a sufficient number of unvaccinated to allow for transmission from person to person, versus current herd immunity that keeps the diseases in check.

Beyond the bad science claiming dangers of vaccinations are the polarizing effect of well-meaning parents and others who have come to believe these claims, clashing with other parents and authorities who do not want to support policies that in turn support the unvaccinated exposing their children and others to preventable risk.

The comments by readers, available along with the article, contain many compelling arguments worth considering on the topic.

How Health Plans Refusing Coverage Can Be of Benefit

June 23, 2014

by Brian L. Grant, MD

piggypill_art_200_20080229084133As noted in this New York Times article, more health plans are refusing to cover certain drugs unless the companies charge less for them.

Imagine a world in which food, housing, clothing, cars or other items we consume increased in price by 14% or more per year? What keeps this from happening in general is the pressure of the free market, responding to the pain that we feel every time we pull out our wallet to pay for something – motivating us to shop smartly, consider alternatives, and sometimes make a choice that is not what we would select if money were no object. How many of us work in companies where we can raise our prices by double digits annually, or see our pay increase by similar amounts year over year?

Not so in the world of specialty pharmaceuticals. We have been shielded from price by the impact of insurance payments and convinced that nothing but “the best” is good enough for us patients and that the insurance company writing the check (after our employers or government pay for the insurance), has no business exercising its economic power and “interfere” in what doctor thinks is best.

Nonsense! So long as we have abrogated payment to a third party, these third parties, be they government or commercial, have an obligation to introduce competition and create some pain and perhaps friction in the system. The days of patients paying for their own care are not likely to return. Kudos to the creative efforts to weigh cost and benefits, create formularies, and hopefully drive down some of the egregious pricing that appears to be in play.

Some drug companies choose to do end runs around co-pay requirements by giving rebates to patients, while still getting the big dollars from the carriers for the higher priced drugs. The move to escalate the fight by deleting certain drugs from formularies, forcing patients to pay the entire cost if they or their doctor refuse the alternatives, is a rational and needed escalation.

Boeing’s Flight Plan for a New Era of Health Care

June 20, 2014

boeing flight planIn the fall, 30,000 Puget Sound-area Boeing employees and retirees will be able to choose between two accountable care organizations (ACOs) for their personal and family health plan, a coverage option Boeing is calling the “Preferred Partnership.”

There were more than 600 ACOs nationwide at the start of the year, and they are being touted as a key strategy for curbing U.S. health-care costs.

The fundamental idea is that doctors and hospitals are rewarded for keeping and making patients healthy, rather than a “fee for service” approach where they earn more for prescribing lots of tests or scheduling appointments regardless of how a patient fares.

The contracts also include quality goals that matter to patients, such as the ability to schedule appointments in a timely manner and maintaining patient safety and satisfaction.

There are additional benchmarks tied to costs, including reducing readmissions to hospitals after treatments and effectively managing chronic conditions such as diabetes and heart disease.

Dr. Elliott Fisher, director of the Dartmouth Institute for Health Policy and Clinical Practice in New Hampshire, is hopeful the ACOs can help heal an inefficient health-care system. “There is so much waste,” Fisher said. “ACO arrangements are intermediate steps toward more fundamental reforms.”

Read more

Veterans Administration Wait Lists — What Can We Learn from This?

June 17, 2014
Image courtesy of the

Image courtesy of the

Brian L. Grant MD

This editorial from the Seattle Times by Roger Stark raises a number of issues worth discussing. The recent controversy about the VA has been long in the making. It is about culture and corruption. But it also allows us an opportunity to look more closely at the fundamentals of the VA, ask tough questions and perhaps make some basic changes.

There is a lack of understanding about the VA and people tend to mix up and confuse issues. And the reverential manner with which it is spoken by most elected officials makes it difficult to have meaningful conversations.

My time in the VA is quite dated, going back to several rotations as a resident physician in the 70’s and 80’s. Back then I was struck by a number of observations:

  • Most admissions and patients were there for conditions that had nothing to do with military service. And a number of them were receiving permanent pensions because their conditions were identified in the course of service. Chronic Schizophrenia comes to mind. We now know that this is a biologic condition, not environmental, coincidentally becoming symptomatic in late adolescence and early adulthood when individuals may be in military service. If one lasted long enough in service, an early discharge and a lifetime of benefits would result, though the disease would have developed irrespective of service. Other medical admissions were often older Veterans with the usual maladies of age and lifestyle that one encounters in any hospital, such as heart and lung diseases, often flowing from lifestyle issues like tobacco use and diet.
  •  These hospitals were large institutions, often in the same vicinity as other facilities and clinics that offer excellent care options.
  • The staff were of high quality and some, like the Seattle VA, were teaching institutions affiliated with an excellent medical school, and helped train medical students and residents. They cared about their patients.

Setting aside the current controversy, we should ask several questions about the VA and where it should fit in the US Healthcare system:

  • What is the social contract between the VA and Veterans? Who should it serve and why? What is the distinction between those injured in the course of duty and those not? Should those who have served but have no injuries from their service be entitled to free health care via the VA system?
  • Does the current VA disability system work and when should an injury translate into economic benefits vs. treatment for the condition?
  •  What are the moral hazard and political implications of tying an injury to compensation? How does compensation muddy diagnoses like PTSD and traumatic brain injury?
  •  Assuming care is owed or committed, is a free-standing government run system the best way to accomplish this? What are the alternatives?

Readers of this blog know that the current healthcare system is not defended in terms of its economics. It is expensive and costs inflate far in excess of other countries with quality systems or the overall US economy. And there are inherent problems in a system where doing and procedures are rewarded while prevention and thinking is not. Furthermore the system is one where the patient is generally ignorant and disengaged on costs and treatment options and believes or acts as if the details and cost of care is an entitlement owed to them by their employer or government. This trend may be changing as cost sharing via copays and deductibles is growing under many policies. Most of us spend more time shopping for a TV set than a medical procedure or hospitalization that will cost 20-50 times as much or more, because with the TV and other personal expenditures, our interests lie in getting the best value for price.

Once we decide which Veterans to serve, could this not be better accomplished without a massive VA treatment bureaucracy? We have perfectly workable if imperfect government payment schemes including Medicare that can easily be ported to the VA and allow eligible Veterans to receive care from the facilities of their choice in the community.

Centers of excellence providing care for conditions unique to combat could be formed in partnership with high quality medical schools and research institutions for conditions such as amputations and combat-related PTSD.

Current VA resources and staff could be re-deployed into the private sector, where shortages exist presently and where demand would increase with Veterans entering the same system.

Is the current system inherently flawed and rather than focusing on current corruption, are bigger questions needing to be asked and answered?

Are Doctor Ratings Misleading?

June 13, 2014

Cartoon teacher manager check evaluation form reportHave you ever read their on-line ratings before you’ve gone to see a new physician? It seems like a logical thing to do — after all, you’re trusting a stranger to make decisions about your health that are quiet likely to be life-affecting. That is, after all, why you are going to see them in the first place. 

Yet just how useful or accurate are on-line ratings? This Atlantic Monthly article explores the question, pointing out some obvious dilemmas: reviewers are often influenced by secondary considerations such as easy access to parking or their waiting room experience, and there’s no guarantee that the reviewer was even seen by the physician being reviewed.

To top it all off, there is evidence that satisfied patients are not the best cared for or healthiest. A March 2012 study in the Archives of Internal Medicine showed that patients with the highest satisfaction scores were more likely to be taking prescription medications, visit doctors’ offices, and enter the hospital. They were also likelier to be in poor health and die in the ensuing years. Read more…

30% of the world’s population is overweight

June 10, 2014

global obesityAlmost a third of the world population is now overweight or obese – about 2 billion people worldwide. No country has been able to curb obesity rates in the last three decades, according to a new global analysis released in May, led by Christopher Murray of the Institute for Health Metrics and Evaluation at the University of Washington. He and colleagues reviewed more than 1,700 studies covering 188 countries from 1980 to 2013.

“Our children are getting fatter,” Dr. Margaret Chan, the World Health Organization’s director-general, said bluntly during a speech at the agency’s annual meeting in Geneva. “Parts of the world are quite literally eating themselves to death.”

Read more…

How a tattoo can help reconstruct a life

June 5, 2014

Would you travel around the world for a tattoo? More than 5,000 women have, to visit Little Vinnie’s in Finksburg, Maryland, where proprietor Vinnie Myers specializes in 3-dimensional nipple tattoos, an important final step in breast reconstruction after cancer surgery.

After a woman undergoes a mastectomy and breast reconstruction, the darker, sensitive skin of the nipple and areola is usually removed entirely. Surgical reconstruction is possible, but obtaining a tattoo allows women to forego further surgery and the resultant scar. Mr. Myers has been providing such tattoos since 2001, introducing a new specialization that has helped thousands of women worldwide. Read more…and watch the video.


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