A Public Option Must Be Included to Make a Workable HealthCare Reform Bill

A recent journal article and a recent editorial provide good arguments for including a public option in the health care reform. The logic is clear but will Congress and the administration support it or succumb to the lobbying of the health insurance industry and its invested (and well rewarded) defenders? The New York Times editorial “The Public Plan, Continued” (10/17,/2009) states that,

[…] we strongly support inclusion of a public option — the bigger and stronger the better. That is the best way to give consumers more choices, inject more competition into insurance markets, hold down the cost of insurance policies, and save money for the federal budget. Here are some of the basic issues to consider, and the current legislative state of play:

WHO COULD ENROLL? While critics rail against a government takeover of health care, the reality is that the vast majority of Americans — those who have access to health insurance offered by large employers — would not be eligible to enroll in a public plan. […]

DOES IT MAKE INSURANCE MORE AFFORDABLE? Most experts agree that a public plan should be able to provide insurance at a lower cost because it would have no need to earn a profit and could either demand or bargain for lower prices from health care providers. That should spur private insurers, eager to attract millions of new customers on the exchanges, to find ways to hold down their premiums as well, at least on the exchanges. […]

WHAT’S THE STRONGEST PUBLIC PLAN? That is apt to emerge from the House, where the Democrats need only a majority to pass legislation and are constrained only by the need to satisfy conservatives in their own party. […]

A PUBLIC PLAN FOR EVERYBODY? Too often insurance markets are dominated by one or two big companies. We believe that, after a break-in period, the insurance exchanges, with a public option, should be opened to virtually everyone covered by large employer-based plans. That would give the vast majority of Americans a bigger choice of insurance options than they now have at most workplaces — and a greater stake in pushing Congress to approve a strong public plan.

In his piece “Poor Substitutes — Why Cooperatives and Triggers Can’t Achieve the Goals of a Public Option” (The New England Journal of Medicine, 09/23/2009), Jacob S. Hacker writes that,

According to a recent survey, a majority of U.S. physicians support health care reform that includes a new national public health insurance plan, which would compete with private plans. Polls have shown that a substantial majority of Americans support the public option as well.

[…] Senate Finance Committee chairman Max Baucus (D-MT) recently unveiled his draft bill […], which contains no competing public plan. Instead, it substitutes the largely untested idea of providing federal loans and start-up funds to encourage the creation of decentralized, member-run health care “cooperatives.” Another prominent senator on the Finance Committee, Olympia Snowe (R-ME), has indicated that she would support a public plan only in the event that private health plans failed to offer affordable coverage in a particular region, “triggering” the creation of a public option. President Barack Obama — while reiterating his support for a public plan — has said that he could support both these alternatives if they could create accountability and competition for private insurance.

Could they? Both proposals lack adequate specificity to make the answer clear […]. But analysis of existing outlines of both ideas and similar initiatives in prior legislation suggest that they could not.

The “public option” is meant to bring greater competition, choice, accountability, and cost restraint to U.S. health insurance. It would do so by offering the choice of a new national, public, nonprofit insurance plan modeled after Medicare to those who lack employer-sponsored coverage or work for very small firms that decide to buy coverage through a proposed national insurance “exchange.” This plan would be subject to the same rules as private health plans and would be wholly self-financing, with revenues derived entirely from premiums, employer contributions, and the same government subsidy payments for lower-income Americans that would be available to private plans. […]

As envisioned, cooperatives almost certainly could not achieve the key aims of the public plan. Although they might offer a backup option in some regions, they would have little chance of offering the broad choice of providers and portable, standardized, nation-spanning coverage that a national public plan offers. Moreover, as is the case with any private health plan entering a local market, decentralized cooperatives would find it difficult to get off the ground and expand, much less attain the reach or authority required to drive widespread delivery and payment reforms or compete strongly with private insurers. The history of consumer health cooperatives supports this pessimism.[…]

Any new federally authorized health plan must be able to counterbalance the leverage of dominant insurers and providers, in part by constructing its own competitive provider networks. Otherwise, it will have neither the market share nor the bargaining power necessary to become established and serve as a check on those entities. Alas, cooperatives have no real prospect of garnering the requisite market power. The Congressional Budget Office, which has said that the competing public plan could achieve substantial savings if it paid rates linked to Medicare’s payment schedule, has concluded that cooperatives would have “very little effect” on health care spending.^[…]

In short, neither the cooperative nor the trigger represents an acceptable substitute for the immediate creation of a national public plan. Rather than developing fig leaves to provide political cover, congressional leaders and the President should push for a national public plan that competes on a level playing field with private insurance to provide coverage to people who are uninsured and workers in the smallest firms. Such competition is the key to creating greater choice and accountability in increasingly consolidated insurance markets.

Is the High Cost of New Cancer Drugs in the U.S. Justified?

Nick Mulcahy’s Medscape Medical News piece “Time to Consider Cost in Evaluating Cancer Drugs in United States?” (7/14/2009) offers an interesting discussion on the increasing high cost of new cancer medicines. Most government, academic, and industry experts interviewed in this piece felt that this “spiraling” cost  “is not sustainable.” Mulcahy explains that,

Oncology drugs are now the best-selling class of drug, having surpassed lipid regulators. Last year, oncologic drugs had annual sales in the United States of $19.2 billion, according to figures from IMS Health (Plymouth Meeting, Pennsylvania). Sales have increased more than 4-fold in the past 10 years, from less than $5 billion in 1998 to the current level. Newer anticancer agents are particularly expensive. Most of the cancer agents (> 90%) approved by the Food and Drug Administration (FDA) in the past 4 years cost more than $20,000 for a 12-week course of therapy, writes Tito Fojo, MD, the lead author of a new essay about the cost of cancer drugs published online June 29 in the Journal of the National Cancer Institute. Such big price tags have produced sticker shock among clinicians and at least 1 industry executive. […]

“There is a shocking disparity between value and price, and it’s not sustainable,” said Roy Vagelos, MD, at the 2008 annual meeting of the International Society for Medical Publication Professionals, according to cnbc.com. Dr. Vagelos is a former chief executive at Merck and the current chair of 2 biotech companies, Regeneron and Theravance. […]

In the essay, Dr. Fojo, who eventually enlisted bioethicist Christine Grady, PhD, from the National Institutes of Health, in Bethesda, Maryland, as a coauthor, reviews the “marginal benefits” that a number of high-priced agents produce in terms of survival. He highlights cetuximab for NSCLC, which costs $80,000 for an 18-week course but provides only the above-mentioned 1.2 months of additional survival.

Dr. Fojo cites multiple examples of cancer drugs with high costs and marginal benefits, including bevacizumab (Avastin, Genentech) for metastatic breast cancer (provides progression-free survival improvement but no increase in overall survival; estimated total cost of therapy, $90,816). Nevertheless, a health economist who agrees that these cancer drug prices are not sustainable says, “There is too much blame on pharmaceuticals for rising healthcare costs in general.” Attention should also be paid to the overall cost of cancer care, suggested Shelby Reed, PhD, from Duke Clinical Research Institute, in Durham, North Carolina. […]

In their essay, Drs. Fojo and Grady make a number of proposals for cancer drug–expenditure reduction and improvement in treatment decision-making. The purpose of the proposals is to get oncologists to discuss change. […] The [lead]  proposal: a UK-style spending threshold for cancer drugs in the United States. […] In their proposal, Drs. Fojo and Grady propose that an American threshold for anticancer drugs be set at $129,000, which is the cost of a QALY in patients treated with renal dialysis. Dr. Fojo said that dialysis was an appropriate comparator. The threshold would apply to federal reimbursement of cancer drugs such as that from Medicare. […]

In interviews with experts, Medscape Oncology found support for the idea of a UK-style spending threshold for cancer drugs but little belief in the political possibility of its enactment. […]

Ultimately, the United States may not have the appropriate kind of healthcare system to implement a cost-effectiveness type of approach to evaluating drugs, including cancer drugs, said another expert.

“These approaches tend to be more common in ‘single-payer’ systems, like those with a public healthcare system or nationally coordinated health insurance,” said Michael Drummond, PhD, from University of York, in the United Kingdom, and the former president of the International Society of Pharmacoeconomics and Outcomes Research. Currently, “about 25 to 30 countries” employ cost-effectiveness analysis in their review of drugs, he told Medscape Oncology. […]

The high cost of drugs is part of the equation that threatens quality of cancer care in many areas of the country, says COA president Patrick Cobb,MD, who is also a partner in Hematology-Oncology Centers of the Northern Rockies, in Billings, Montana.

“The increasing cost of drugs, declining Medicare reimbursement, and current financial crisis have created a ‘perfect storm’ that jeopardizes community cancer clinics, where most Americans with cancer are treated,” he said in a press statement. Dr. Saltz sees a change coming in cancer drug prices. “There is not enough money to pay for what we are doing. However, I don’t think the price drop will be a well-thought-out event,” he said, adding that the drop may come only if the cancer care system nears a “total collapse.”

Reasons for Breast Reduction Surgery

I know a few women who had breast reduction surgery to ease the discomfort of being overly endowed. I read with interest physician Jennifer Walden’s Medscape Blog “The Case of Tennis Star Simona Halep: Why Do Women Seek Breast Reduction Surgery?: Medscape Connect”  (posted 6/12/2009). I think that this is useful information for other women who might be considering it and for the people (probably, mostly of the male persuasion) who might think that it’s a crime against nature. Walden said,

London press release on May 29th went like this: “Junior French Open champ Simona Halep is set to undergo a surgery to reduce her 34DD boobs. The 17-year-old feels they are a disadvantage and has vowed to have a reduction later this year. “The breasts make me uncomfortable when I play,” the Sun quoted her as saying.”It”s the weight that troubles me – my ability to react quickly,” she added. However, fans of the Romanian tennis player didn’t seem too happy with her decision. They flocked to sign an online petition: Save Simona Halep Boobs. One stormed: “It will be a crime against nature.”

Simona Halep, as you may or may not know, is from Romania and is a budding Junior tennis player. She is ranked #258 in the world. She won the Junior French Open tennis tournament in 2008, and although not yet fully developed as a professional, she reached the second round of the qualifiers for the Senior French Open in 2009. In May 2009 she received widespread media attention all over the world for expressing her desire to go through breast reduction surgery in order to perform better on the tennis court. I found it surprising to read on blogs and sports pages online how much fans and readers did not understand the purpose and benefit of breast reduction surgery. Comments ranged from disgust to outrage to frank misunderstanding of what the indications and outcomes are for breast reduction surgery.

Constant back and neck pain, gouges in your shoulders from bra straps, difficulty with clothing fit, and deteriorating posture and an inability to participate in certain activities rank among the common complaints of women with large breasts. Breast reduction surgery (reduction mammaplasty) may help relieve these symptoms. As technology advances, more women are seeking consultations from plastic surgeons to discuss options for adjusting their breast sizes to a healthier and more comfortable level. According to the American Society of Plastic Surgeons, more than 104,000 breast reduction surgeries were performed in 2006. Breast reduction is often considered a medically necessary treatment due to its interference with the activities of daily life and physical symptoms, so third party payors and referrals from primary care physicians are often involved. […]

Women can have breast reduction surgery at any age, but it’s generally advisable to wait until you’re at least age 17 or 18, by which time your breasts are likely to be fully developed. However, sometimes surgery is performed in teens who suffer significant emotional and psychological effects of having too-large breasts (called juvenile breast hypertrophy).  Patients are often advised that if they want children and wish to breastfeed, they may consider postponing breast reduction surgery until afterwards. Changes to breast tissue during pregnancy could alter your surgical results. Also, after the surgery, breast-feeding may be difficult. […]

According to MayoClinic.com “Breast Reduction Surgery: Decrease Breast Size, Ease Discomfort” indications for breast reduction surgery include:

• Chronic back, neck, and shoulder pain
• Poor posture
• Skin rash under the breasts
• Deep grooves in the shoulders from bra strap pressure
• Restricted levels of activity
• Low self-esteem
• Difficulty wearing or fitting into certain bras and clothing

Politicians Need to Stop Quavering to the NRA: Support S. 843 and Close the Gun Show Loophole

In “Gun (In)Sanity”  (Editor’s Cut The Nation 6/2/2009) Katrina Vanden Heuvel makes a lot of sense in her call to arms to support and pass the Gun Show Background Check Act (S. 843). Here are some long excerpts from her piece.

Despite a Democratic Congress and President, it’s been a bad time for common sense measures to curb gun violence. Earlier this year, a voting rights bill for the citizens of the District of Columbia was stalled by a Senate amendment that would strip the city of its right to regulate guns. And last month, the credit card reform bill was hijacked in the Senate and amended so that concealed guns are now permitted in our national parks. Here’s hoping the majority of Americans who support sane gun control begin to turn the tide.

Bills have now been introduced in both the House and Senate to at long last close the absurd and dangerous gun show loophole which permits the sale of guns without any criminal background check. Background checks are required for any gun purchase at federally licensed dealers. The result? 1.6 million felons and other prohibited purchasers have been stopped from buying guns. But those same people can go to a gun show in more than 30 states and buy a weapon — no questions asked. It doesn’t matter, for example, if Maryland requires a background check when the same individual can cross into Virginia and buy an assault weapon without a hitch. That’s why 4 out of 10 guns are sold by unlicensed sellers without background checks.

The Columbine killings were committed using two shotguns, an assault rifle, and a TEC-9 assault pistol — all four weapons were purchased from gun shows. The person who bought three of the weapons later said she wouldn’t have done so if a background check had been required. Recently, the brother of a Virginia Tech victim was followed by ABC News into a gun show where he was able to purchase ten guns in under an hour — again, no questions asked.

Senator Frank Lautenberg’s Gun Show Background Check Act [S. 843] would require background checks at any event where 50 or more firearms are offered for sale. It wouldn’t stop a grandfather from giving his prized handgun to his grandson, as the cynical NRA would have America believe. Nor does it take on the 2nd Amendment. Despite the NRA’s whipping gun owners into a buying frenzy over the notion that President Obama and the Democrats are coming after their guns — a hysteria that has led to a surge of sales at gun shows nationwide — this legislation does no such thing. It simply insists — in the interest of public safety — that you clear a criminal background check before buying a gun.

“There is no rational reason to oppose closing the loophole,” Senator Lautenberg said when he introduced the bill with 14 cosponsors last month just days after the 10th and 2nd anniversaries of the shootings at Columbine and Virginia Tech, respectively. “The reason it’s still not closed is simple: the continuing power of the special interest gun lobby in Washington.”

[…] The White House has clearly made a political decision at this time not to push for closing the gun show loophole or the assault weapons ban — both of which it clearly supports and would gladly sign into law.

So it’s time for rational, concerned citizens to take matters into their own hands. Polls show over 85 percent of the public wants the gun show loophole closed now. That’s a lot of voters. Speak out — let your Senators and Representatives know where you stand. Threaten to stop any contributions to representatives who won’t listen.  […] Don’t let the NRA’s lies and fulmination hold sway over this life-saving measure.

Arguing for a Publicly-Funded, Non-Profit Health Insurance Plan Option

The 5/28/2009 issue of The New England Journal of Medicine contains three Perspectives on the health care reform issue. In “Healthy Competition — The Why and How of “Public-Plan Choice” Jacob S. Hacker, Ph.D., (Professor of Political Science at UC Berkeley and author of Health Care for America) makes a solid argument for including a publicly funded insurance option in U.S. health care reform. Here are some excerpts from this article

[…] The aim of public-plan choice is healthy competition that will ensure Americans are better cared for and more secure. Such competition does not require an endless array of choices but rather a reasonable number of meaningfully different choices. Indeed, the key reason for public-plan choice is that public health insurance offers a set of valued features that private plans are generally unable or unwilling to provide: stability, wide pooling of risks, transparency, affordable premiums, broad provider access, and the capacity to collect and use patient information on a large scale to improve care. Public health insurance emphasizes the broad sharing of risk, ensuring coverage that is affordable and of high quality for the small portion of the population that accounts for most health care spending. On the other hand, private plans are generally more flexible and more capable of building integrated provider networks, and they have at times moved into new areas of care management in advance of the public sector. […]

Healthy competition is about accountability. If public and private plans are competing on fair and equal terms, allowing enrollees to choose between the two will place a crucial check on each. If the public plan becomes too rigid, more Americans will opt for private plans. If private plans engage in practices that obstruct access to needed care and undermine health security, then the public plan will offer a release valve. New rules for private insurance could go some way toward encouraging private plans to focus on providing value. But without a public plan as a benchmark, backup, and check on private plans, key problems in the insurance market will remain.

Perhaps the most pressing of these problems is skyrocketing costs. Public health insurance has much lower administrative expenses than private plans, it obtains larger volume discounts because of its broad reach, and it does not have to earn a profit, as many private plans do. Furthermore, experience with Medicare suggests that public insurance is better equipped to control spending over time while maintaining broad access to care.[…] Nearly all other advanced industrial democracies rely much more on public health insurance than the United States does, and all have lower health care costs per person, have seen their costs rise more slowly, and yet have maintained better overall health outcomes and much stronger health security for all their citizens. […]

To be sure, there are reasonable concerns about how the bargaining power of a new public plan will be used — concerns reflected in current proposals for alternative models that would fulfill some of the goals of a Medicare-like public plan but would have limited ability to secure lower rates and might be run by state governments[…] or even private insurers under public contract. Yet a watered-down public plan would be a grave mistake. Instead, the public plan should include safeguards designed to ensure that providers are fairly represented, that initial rates are reasonable, and that bargaining for lower prices does not negatively affect patients’ access to care or shift costs onto private insurers.

Rather than a weak alternative, a new public plan should be Medicare-like — national, governmental, and built on Medicare’s basic infrastructure. But it should not be Medicare. It needs to have a broader set of benefits. It must have a separate risk pool. It should improve on the way in which Medicare pays providers, particularly physicians. And, most important, it must compete on a level playing field with private insurance plans. This means, above all, that its administration should be separate from the agency that runs the new health insurance pool that contracts with and regulates private insurers. […] Creating a level playing field requires attention to the three R’s of workable public–private competition: rules that are the same for all plans, risk adjustment, and regional pricing. […]

For other views on health care reform go to “Public Health Care and Health Insurance Reform — Varied Preferences, Varied Options” and “The Proposed Government Health Insurance Company — No Substitute for Real Reform” both published in the same issue of the NEJM.

Good News: Supreme Court Strips Gun-Ownership Rights From Those Convicted of Domestic Violence

Here is some good news for those of us who support gun-control laws in the interest of protecting public safety.  In the Los Angeles Times “Supreme Court Upholds Gun-Control Law” (2/25/2009) David G. Savage reported,

The Supreme Court upheld the broad reach of a federal gun-control law Tuesday and said that no one who has a conviction for any crime of domestic violence may own a firearm. The 7-2 decision strips gun rights from tens of thousands of people who were convicted or had pleaded guilty to an assault against a spouse, a live-in partner, a child or a parent. These crimes include not just felonies, but misdemeanors.

“Firearms and domestic strife are a potentially deadly combination nationwide,” Justice Ruth Bader Ginsburg said.

Gun-control advocates and law enforcement officials praised the ruling. On average, more than three people are killed each day by domestic partners, according to the Brady Center to Prevent Gun Violence. About 14% of police officers who are killed in the line of duty die in response to a domestic violence call, the group said.

Since 1996, federal authorities have turned down more than 175,000 prospective gun buyers because of domestic violence charges, according to the Brady Center. Most of them could have had their rights restored had the court ruled the other way. Tuesday’s ruling did not involve the 2nd Amendment and its right “to keep and bear arms.” Last year, the high court ruled that law-abiding citizens had a constitutional right to have a gun at home for self-defense, but it said felons could be denied gun rights.

In 1968, Congress made it illegal for felons to own a gun in the United States. Lawmakers in 1996 extended this ban to include those convicted of “a misdemeanor crime of domestic violence.”

Until Tuesday, however, it had been unclear who is covered by this provision. Only about half the states have laws that make domestic violence a crime. Across the nation, prosecutors often charge offenders with an assault or battery. Two years ago, the U.S. 4th Circuit Court of Appeals ruled that the federal gun ban did not extend to state charges involving assault or battery. Randy Hayes, a West Virginia man, had challenged the federal law after he was convicted of illegal gun possession. He was found with three guns in his house in 2004. Ten years earlier, he had pleaded guilty to misdemeanor battery against his then-wife. Ruling for Hayes, the appeals court said this “generic battery” conviction did not count as a “misdemeanor crime of domestic violence,” and it freed him from the federal charges.

The Supreme Court overturned that ruling Tuesday in United States vs. Hayes and restored the broad view of the federal law. Ginsburg’s opinion said the ban on gun ownership extends to any person who has been convicted of any crime involving “physical force or the threatened use of a deadly weapon,” so long as there was a “domestic relationship” between the perpetrator and the victim. Congress sought to keep “firearms out of the hands of domestic abusers,” she said, but the law would be a “dead letter” in much of the nation if it were read as narrowly as Hayes sought.

Only Chief Justice John G. Roberts Jr. and Justice Antonin Scalia dissented. They focused on the precise words of the law and said it should be applied narrowly. […]

Solid Studies Show that Selenium and Vitamins C and E Supplements Do Not Prevent Cancer

Two large well-designed studies published in the 1/7/2009 issue of the Journal of the American Medical Association (JAMA) showed that regularly taking selenium and vitamins C and/or  E supplements did not help prevent cancer. As reported by Liz Szabo in USA Today, these and other studies demonstrate that  “Vitamins Get ‘F’ in Cancer Prevention.” As an added bonus, the article has a nice table that summarizes findings from recent studies testing the value of vitamins in preventing certain cancers and heart disease. Szabo writes,

A flotilla of recent studies — including two papers published today — has sunk the notion that individual vitamin supplements prevent cancer. With so many earlier studies suggesting that people can eat their way to longer lives, experts acknowledge that their latest findings may leave people confused and even frustrated.

“A lot of people are looking at this and asking, ‘What happened?’ ” says Lori Minasian, whose study in today’s Journal of the American Medical Association found that taking vitamin E or selenium does not ward off cancer. But researchers also say that diet is one of the most difficult areas to study. Unlike lab rats, after all, no one eats one thing all the time.

“Cancer is complex and the interaction of nutrients is complex, so put the two together and you’ve got a lot of really tough scientific questions to answer,” says the American Cancer Society’s Colleen Doyle.

Researchers have noted for years that populations with healthy diets — lots of vegetables, little junk food — are less likely than others to get cancer, says Peter Gann of the University of Illinois-Chicago, who wrote an editorial accompanying the new papers. It’s been much more challenging to tease out the specific foods — or even compounds — that keep cells from turning malignant, Gann says. Is it the fish oil? The soy? The lack of red meat? Experts also note that the specific dose of a vitamin may be critical.

People who get too little of a nutrient may be at greater risk of cancer, but so may those who get too much, Minasian says. Given the popularity of vitamins and other supplements, she says it’s important for researchers to find the right combination. Other experts, such as Gann, say that it may be time for researchers to abandon the idea of using individual vitamins to prevent cancer.

Instead, he says, health-conscious consumers should focus on getting their vitamins from plant foods, such as vegetables and whole grains, which contain precise mixtures of hundreds or even thousands of compounds. Many of these compounds may work better in the combinations selected by nature. Doyle says there are still lots of proven ways, in addition to a plant-based diet, to reduce the risk of cancer: Exercise, maintain a healthy weight and avoid tobacco. Screenings for colon cancer, cervical cancer and breast cancer also have been shown to save lives. […]

Szabo has also written a very helpful “Q&A: Which Studies Are Worth Attention?” which explains to consumers how to evaluate research on diet. Here are a couple of excerpts from this Q&A, which I think should be required reading for people considering the use of dietary supplements for cancer prevention.

Q. Why do the new studies contradict the findings of earlier research?

A. Many of those earlier studies were preliminary. That means they usually can’t prove cause and effect, Gaziano says. Scientists are familiar with these limitations. “Conflicting results are part and parcel of the scientific process,” Gaziano says. “It’s why we’re often reluctant to make a clinical recommendation based on a single result.” But consumers — who pay much closer attention to diet news than to other areas of medicine — can easily get confused if they mistake these early findings for solid results, says Peter Gann of the University of Illinois at Chicago, who wrote an editorial accompanying Gaziano’s studies in The Journal of the American Medical Association.

Q. So which studies should we pay attention to?

A. The strongest studies are called randomized clinical trials. These are the best experiments for proving that one thing causes another, Gaziano says. In these tests, researchers randomly assign one group of people to do one thing, such as take a vitamin, but assign a comparison group to do something else, such as take a placebo pill, he says. In a “double-blind trial” — the most rigorous kind — neither patients nor their immediate doctors know which pills they’re taking. Only the researchers running the trial know who’s in which group. An outside panel oversees the study to make sure that patients aren’t harmed and may stop the study early if problems surface.

Q. What’s the best way to research a health study?

A. Because all drugs — including vitamins and herbs — have side effects, it’s worth taking the time to do some research putting them in your body, Gaziano says. Gaziano suggests that consumers read news stories carefully to assess how doctors got their results. If a story isn’t clear, patients should consider looking up the original article in a medical journal or asking their doctors. Patients can also consult the websites of major medical organizations, such as the American Cancer Society,the Centers for Disease Control and Prevention or the National Cancer Institute. These groups sift through scientific evidence when making recommendations about diet, screening tests and other health issues.

Among 8 Industrialized Countries Chronically Ill Patients in the U.S. have the Most Negative Health Care Experience

A study “In Chronic Condition: Experiences of Patients With Complex Health Care Needs, in Eight Countries, 2008,” supported by the Commonwealth Fund and published in the November 13 issue of the journal Health Affairs, concluded  that “Chronically ill U.S. patients have the most negative access, coordination, and safety experiences” compared with similar patients in Australia, Canada, France, Germany, the Netherlands, New Zealand, and the United Kingdom. The study authors, Cathy Schoen and her colleagues, surveyed 7,500 patients who had one or more of the following chronic conditions: hypertension, heart disease, diabetes, arthritis, lung problems, cancer, or depression.

As pointed out in the November 17, 2008 The New York Times editorial, “The Wrong Place to Be Chronically Ill” this study,

[…] is the latest telling evidence that the dysfunctional American health care system badly needs reform. The results of the study […] belie the notion held by many American politicians that health care in this country is the best in the world. That may be true at a handful of pre-eminent medical centers, but it is hardly true for the care provided to a huge portion of the population. […]

The care they received in this country — or more often did not receive — ought to be a cause for shame. More than half of the American patients went without care because of high out-of-pocket costs. They did not visit a doctor when sick, skipped a recommended test or treatment or failed to fill a prescription. The uninsured suffered most, but even 43 percent of those who had insurance all year skipped care because of costs.

Americans also were most likely to report wasting time because their care was so poorly organized. About a third reported that medical records and test results were not available when needed or that tests were duplicated unnecessarily. A third experienced a medical error, such as being given the wrong medication or test results. Some 40 percent found it very difficult to get after-hours care without going to an emergency room. The United States did comparatively well in some areas, such as providing relatively prompt access to specialists and clear instructions to patients leaving the hospital. But the nation’s overall performance was abysmal.

By contrast, Dutch patients reported far more favorable experiences with their health care system, largely because the Netherlands provides universal coverage (through individual mandates and private health insurance), a strong primary care system and widespread use of electronic medical records. It should be possible to achieve the same level of performance here.

To pinpoint specific areas of improvement for the U.S. health care system, here are some highlights from the study discussion section:

The survey findings of significant variations in care experiences regarding access, safety, and coordination/efficiency indicate that countries’ policies and care systems make a difference for patients coping with complex, chronic conditions. U.S. patients appear at particularly high risk as a result of coverage gaps and poorly organized care. Chronically ill patients in countries with strong primary care infrastructures tend to fare better. Yet deficits in transitional care when patients leave the hospital, inadequate coordination for patients seen by multiple clinicians, and weak efforts to engage or support patients to manage their conditions exist in all countries.

Countries’ policies make a difference. Repeating patterns observed in earlier surveys, the United States continues to stand out for more negative patient experiences, ranking last or low for access, care coordination/efficiency, and patient-reported safety concerns. The percentage of chronically ill U.S. adults who reported access problems, errors, delays, duplication, and other symptoms of poorly organized care was two to three times the level reported in the lowest-rate countries in the survey (a 20-30 percentage point spread). Along with Canadians, U.S. patients were also the most likely to indicate a primary care system under stress–lack of rapid access, difficulty getting care after hours, and high ER use.

The United States did comparatively well on measures of transitional care during hospital discharge, and responses were more positive on some items related to patient-centered care (for example, setting goals and priorities). Yet U.S. patients often cannot afford to follow recommended care. Recent studies indicate that the trend toward higher cost sharing for insured patients appears to be undermining access and adherence to recommended care.¹³ In effect, insurance designs may be undermining efforts to hold physicians accountable for achieving outcome targets or evidence-based guidelines. Lack of affordable access, waits for primary care, and inadequate coordination put chronically ill U.S. patients–especially those with multiple chronic conditions–at high risk of poor health outcomes. Notably, despite spending much more, the United States has been falling behind all of the other surveyed countries in reducing premature deaths from conditions amenable to health care.¹⁴

Study Shows That Nonviolent Resistance Works Better Than Armed Insurgency

This is a slightly old, but still highly relevant piece. In the October 30, 2008 issue of The Progressive, Amitabh Pal’s article, “Nonviolence Is The Right Choice—It Works” reports the results of a study “Why Civil Resistance Works-The Strategic Logic of Nonviolent Conflict” that was published in the journal International Security. As Pal explains,

Nonviolent resistance is not only the morally superior choice. It is also twice as effective as the violent variety. That’s the startling and reassuring discovery by Maria Stephan and Erica Chenoweth, who analyzed an astonishing 323 resistance campaigns from 1900 to 2006.

“Our findings show that major nonviolent campaigns have achieved success 53 percent of the time, compared with 26 percent for violent resistance campaigns,” the authors note in the journal International Security. [….] The result is not that surprising, once you listen to the researchers’ reasoning.

“First, a campaign’s commitment to nonviolent methods enhances its domestic and international legitimacy and encourages more broad-based participation in the resistance, which translates into increased pressure being brought to bear on the target,” they state. “Second, whereas governments easily justify violent counterattacks against armed insurgents, regime violence against nonviolent movements is more likely to backfire against the regime.”

In an interesting aside that has relevance for our times, the authors also write that, “Our study does not explicitly compare terrorism to nonviolent resistance, but our argument sheds light on why terrorism has been so unsuccessful.”

To their credit, the authors don’t gloss over nonviolent campaigns that haven’t been successes. They give a clear-eyed assessment of the failure so far of the nonviolent movement in Burma, one of the three detailed case studies in the piece, along with East Timor and the Philippines.

Too bad for all of us that this article is probably not going to sway toward more peaceful endeavors most of the people feeding the various violent insurgencies around the world.

Prevention Study Results Show No Benefit From Vitamin E and Selenium in Prostate Cancer

Early results from a large study show that selenium and vitamin E supplements do not help prevent prostate cancer and may actually cause some harm. Results from this study were discussed in the Medscape Medical News October 29, 2008 article, “Vitamin E and Selenium in Prostate Cancer” by Nick Mulcahy. For more information on the status of this clinical trial go to “Selenium and Vitamin E cancer Prevention Trial (SELECT)” Questions and Answers Web page at the National Cancer Institute http://www.cancer.gov Website.

Mulcahy reported,

The SELECT (Selenium and Vitamin E Cancer Prevention Trial) prostate cancer prevention study is instructing its 35,000-plus participants to stop taking the 2 nutritional supplements because of an apparent lack of benefit and a possibility of harm.

“The Data and Safety Monitoring Committee made the decision to stop use of the supplements, not to stop the trial. We will follow participants for 3 more years to determine if there is any benefit or any harm,” said Larry Baker, MD, chairman of the Southwest Oncology Group, which coordinated the trial, and professor of medicine at University of Michigan Medical School in Ann Arbor.

The Data and Safety Monitoring Committee said that “the data could not exclude a small chance that the study supplements might have effects later in the men’s lives.” However, the antioxidants selenium and vitamin E, taken alone or together for an average of 5 years, did not prevent prostate cancer, according to the committee.

[…] The data from SELECT also show 2 trends that were of concern but not statistically significant: in men taking only vitamin E, there were slightly more cases of prostate cancer; and, in men taking only selenium, there were slightly more cases of diabetes. Neither of these findings means an increased risk from the supplements, and they could be due to chance, according to the National Cancer Institute (NCI), which funded the trial.

The Data and Safety Monitoring Committee also determined that it was unlikely that selenium and vitamin E supplementation would ever produce a 25% reduction in prostate cancer, which was the study’s goal. Dr. Baker said that the results to date speak for themselves, and that SELECT is a much larger trial than previous trials that suggested benefit. “This is the definitive study and anyone who argues that is ignoring the facts.”

SELECT Details

Participants were randomized to 1 of 4 groups (2 capsules a day): selenium (200 μg) and vitamin E (400 mg); selenium and placebo; vitamin E and placebo; or 2 placebos. The 35,000-plus participants consisted of African-American men who were 50 years or older, and men of other races and ethnicities who were 55 years or older. The eligibility age was lower for African Americans because of the earlier average onset of the disease.

Selenium is a nonmetallic trace element found especially in plant foods, such as rice, wheat, seafood, meat, and Brazil nuts. Selenium is an antioxidant that may help control the cell damage that can lead to cancer, according to the NCI. Vitamin E is found in a wide range of foods, especially vegetables, vegetable oils, nuts, and egg yolks. Like selenium, vitamin E is an antioxidant.