Category: Policy and politics

Farewell to Fatso?

published date
February 16th, 2007 by

Two recent Boston Globe headlines on Tufts Health Plan may be related

The layoff is to reduce administrative costs as Tufts tries hard to compete with Blue Cross, Harvard Pilgrim and Fallon. The restriction on obesity surgery is a cost reduction exercise, too. The Globe article and other commentators have focused on the effect on individual patients…

Doctors condemned the new policy, which takes effect March 6, saying Tufts is ignoring a growing body of clinical evidence that shows that such operations help those who have exhausted other methods to lose weight. Delaying surgery worsens conditions such as diabetes and heart disease that are often complications of pronounced weight gain, they said.

“This is Draconian,” said Dr. Philip Schauer , president of the American Society for Bariatric Surgery and director of bariatric surgery at the Cleveland Clinic. “This flies in the face of the medical evidence. These policies sentence a patient to a life of dealing with obesity without the possibility of parole.”

…but it seems plausible to me that Tufts is looking for ways to dump obese patients out of its plans and onto its competitors. Beyond the considerable money saved from not covering bariatric surgery, Tufts may benefit from a healthier, lower cost patient mix. Not only will obese people quit Tufts, but some non-obese people may actually select Tufts for taking a hard line against members they think may be driving up their own insurance costs.

Then again, it’s certainly possible that Tufts is doing what it says it is: making a decision that saves costs and improves patients’ health.

The sad case of Rebecca Riley

published date
February 15th, 2007 by

The tragic death of 4-year old Rebecca Riley, who died after an overdose of psychiatric medications, has sparked a lot of discussion and finger pointing. An article in today’s Boston Globe (Bipolar labels for children stir concern) suggests that part of the problem is the overuse of bipolar disorder as a diagnosis.

Riley… was exceptionally young when she was diagnosed, just 2 1/2. But among somewhat older children, the bipolar label has proliferated to the point that some psychiatrists now suspect the diagnosis may be sometimes misused, placing some children at unnecessary risk from the serious medications that usually follow.

I asked Mickey Segal, MD, PhD, CEO of decision support company SimulConsult, for his thoughts. Here’s what he said:

The case is odd because the parents are charged with murder using prescribed drugs, yet the doctor is being investigated by the Board of Registration in Medicine for prescribing the drugs. What scenario is being suggested?

The article also suggests that diagnosis of bipolar disorder is colored by reimbursements:

[Dr. Jennifer Harris , a clinical instructor at Harvard University and supervisor at Cambridge Health Alliance] and others point out that a diagnosis of bipolar disorder is considered more serious than attention deficit hyperactivity disorder or post traumatic stress disorder. A child diagnosed as bipolar thus tends to have much easier access to a range of help, from a spot in a therapeutic school to insurance coverage for hospitalization.

But it is a serious matter to suggest that “up-coding” influences treatment decisions.
Part of the problem is that there is no way to make a definitive diagnosis of either bipolar disorder or attention deficit disorder, since we don’t have genes for either disease yet. Since drugs for both disorders have dangers, we need a deeper understanding of these diseases, hopefully resulting in therapies that are more benign or more effective. Until then, doctors and patients will try different things and there will be some tragedies.

I guess she’s needed at home

published date
February 14th, 2007 by

A decidedly mixed message from the Chinese authorities (from Kaiser Daily HIV/AIDS report).

The Chinese government on Monday praised HIV/AIDS advocate and retired physician Gao Yaojie after placing her under house arrest last week to prevent her from visiting the U.S. to accept an award from the group Vital Voices Global Partnership… According to Gao’s friend and Beijing-based AIDS advocate Hu Jia, Chinese authorities from the eastern province Henan told Gao not to attend the Vital Voices awards ceremony. When Gao refused, she was put under house arrest to prevent her from traveling to Beijing to apply for a U.S. visa…Gao in the 1990s alerted people in Henan of HIV cases that occurred through tainted blood transfusions. Gao also distributed material warning people of HIV and the risks of donating blood. In addition, Gao has distributed medicine to HIV-positive people, provided cared for AIDS orphans and hosted people living with HIV/AIDS in her home. She also has written a book about the HIV/AIDS epidemic in China. Chinese authorities in 2001 and 2003 prevented Gao from traveling abroad to accept awards for her work (Kaiser Daily HIV/AIDS Report, 2/6). According to the AP/ Herald Tribune, Communist Party deputy secretary for Henan Chen Quanguo visited Gao in her home and praised her “long-standing contributions” to the province’s “education, health and AIDS prevention work.”

I guess she’s lucky not to live in Libya.

What you don’t know can’t hurt you

published date
February 8th, 2007 by

As a doctor friend said, “If someone thinks they’re completely healthy it just means they haven’t had a full workup.” What I think he meant is that if you go looking with the latest tools and diagnostics you’ll find something, even if it’s not really there.

That sentiment was reinforced for me today by an AuntMinnie article on overdiagnosis of lung cancer.

Overdiagnosis is common in computed tomography (CT) lung cancer screening, according to a report in the February issue of Radiology.

“Screening high-risk patients with chest CT may result in lung cancer overdiagnosis, especially in women,” Dr. Rebecca M. Lindell from the Mayo Clinic, Rochester, MN, told Reuters Health…

“Overdiagnosis, especially in women, may be a substantial concern in lung cancer screening,” the authors conclude.

At a minimum, such overdiagnosis exacts a high emotional toll on patients and their families. It can be physically and financially damaging, too when unpleasant and sometimes dangerous treatments ensue for those who don’t need it.

You know the rule!

published date
February 8th, 2007 by

I wouldn’t recommend this day care provider, described in today’s Wall Street Journal:

Jennifer Morrison, Columbus, Ohio, was called away from work one day by her child-care teacher asking her to pick up her 2-year-old daughter because she was running a slight fever. When Ms. Morrison arrived, she saw that her daughter had no other symptoms and felt fine; she was overheated from playing outside. But the teacher told her, “You know the rule,” and insisted she take her home for 24 hours.

A lot of schools and day care centers have mindless policies (for example on lice). Try to avoid those places!

The Journal did highlight some sensible guidelines from the American Academy of Pediatrics on when to keep your kid home:

  • If too sick to participate in school activities comfortably
  • If needs more care than the staff can provide
  • If contagious

As the article points out, it can sometimes be hard to figure out what to do. But the 24 hour rule as described above is pure idiocy.