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by: Mathew Casper


Marketplace > University of Kentucky > Health and Public Affairs > CPH 758 > SP TOP HLTH SERVICE MGMT POLCY GOVERNCE
Mathew Casper
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Date Created: 10/23/15
Readings for Health Economics CPH 758 Spring 2009 Scott Hankins For each of the articles you should be able to o Summarize in 1 paragraph 0 Explain how it relates to the class lectures 0 Explain Why I choose to include it Health Spending Exceeded Record 2 Trillion in 2006 By ROBERT PEAR 8 January 2008 The New York Times WASHINGTON National health spending soared above 2 trillion for the first time in 2006 and has nearly doubled in the last decade amounting to an average of 7000 a person the government reported on Monday With the advent of a prescription drug benefit in 2006 Medicare spending grew at its fastest pace since 1981 the report said Private health insurance spending grew at the slowest rate since 1997 and spending on Medicaid which covers low income people declined for the first time since creation of the program in 1965 Over all the report said health spending increased 67 percent in 2006 slightly faster than in 2005 and now accounts for 16 percent of the total output of good and services a slightly larger share than in 2005 Introducing the Medicare drug benefit for older Americans and people with disabilities caused changes that rippled through the entire health care sector Health spending by businesses grew 57 percent in 2006 to 4968 billion the slowest rate of increase since 1997 Aaron C Catlin an economist at the Health and Human Services Department said the quotdeceleration in employer payments for private health insurancequot resulted in part from the fact that Medicare now subsidized drug costs for many retirees Employers lobbied for such subsidies when Congress created the benefit Retail spending on prescription drugs shot up 85 percent in 2006 to 2167 billion in part because more prescriptions were filled by Medicare beneficiaries especially those lacking drug coverage in the past The increase was much greater than the 58 percent increase in 2005 but well below the average increase of 134 percent a year from 1995 to 2004 Other factors that drove up drug spending included the use of existing drugs for new purposes and the increased use of high cost biotechnology products the report said National health spending first exceeded 1 trillion in 1995 Since then even when adjusted for in ation health spending has grown at a rapid clip increasing 64 percent in 11 years The data published in the journal Health Affairs showed that spending on hospitals doctors and nursing homes grew more slowly in 2006 than in 2005 But administrative costs increased more than twice as fast One reason is that private insurance companies have a larger role in Medicare and they typically have higher administrative costs than the traditional fee for service Medicare program federal health economists said Medicare spending increased 187 percent in 2006 to 4013 billion while spending on Medicaid which is jointly financed by the federal government and the states declined 1 percent to 3106 billion The new drug benefit contributed to an overall increase in drug spending and a profound shift in who pays Public programs accounted for 34 percent of retail drug spending in 2006 up from 28 percent in 2005 Medicare39s share of drug spending surged to 18 percent in 2006 from 2 percent in the previous year while Medicaid39s share fell to 9 percent from 19 percent Mr Catlin the economist said most of the decline in Medicaid spending had occurred because drug costs for six million people shifted to Medicare from Medicaid The decline also re ects the fact that some states restricted eligibility for Medicaid and froze or reduced payments to health care providers Enrollment in Medicaid grew two tenths of 1 percent in 2006 the smallest increase since 1998 the report said Private insurers which manage the drug benefit for Medicare negotiate discounts with pharmaceutical companies The discounts were generally smaller than those provided under Medicaid the report said The growth of drug spending in 2006 would have been even higher but for the increased use of generic drugs and the emergence of drug discount programs at big retailers like Wal Mart the report said In 2006 the figures show 63 percent of prescriptions were filled with generics an increase from 56 percent in 2005 Analyzing trends over the last two decades federal researchers found that government programs were paying a larger share of health costs while households were paying a smaller share and private businesses were paying about the same proportion 25 percent Despite the attention paid to pharmaceuticals retail drug spending accounts for just over 10 percent of all health spending Spending for doctors39 services grew 59 percent in 2006 to 4476 billion This was the slowest rate of growth since 1999 and re ected constraints imposed by Medicare and private insurers Spending on nursing homes also grew at the slowest pace since 1999 rising 35 percent to 1249 billion The Man Problem Science Confronts Vexing Issue Of Men39s Shorter Life Spans WSJ April 24 2007 By TARA PARKERPOPE When it comes to health one of the biggest risks a man faces in his lifetime is being a man At every stage of life from infancy to the teen years to middle age a man is at far higher risk for getting sick and dying than a woman The average life expectancy of a ma 75 years is more than five years shorter than that of a woman The reasons for the troubled state of men39s health are complex Biology such as the different ways men and women react to stress likely plays a role And men taught since boyhood to be stoic in the face of pain often are their own worst enemy avoiding doctors and engaging in risky behaviors such as reckless driving that threaten health Men39s health issues also get less public attention and funding at a time when women39s health concerns such as breast cancer are in the national spotlight There39s now a growing effort by doctors and health researchers to bring more resources to improving men39s health Medical schools such as Johns Hopkins and Columbia University have created departments devoted to gender specific medicine Health groups are calling on Congress to create an Office of Men39s Health similar to the current Office of Women39s Health established in 1990 Men on their own can take a few simple steps to boost their health Doctors say that by focusing on a few key areas blood pressure cholesterol waist size and sexual function a man can make dramatic improvements in his overall health One recent study in the medical journal I AMA found that preventing weight gain and alcohol abuse in midlife were two major factors in determining whether a man lived and stayed healthy until the age of 85 quotMen need to know that they are vulnerable but that they can change thingsquot says Harvey B Simon an internal medicine specialist and editor of the Harvard Men39s Health Watch newsletter Part of the problem is that for most of the past 30 years issues of women39s health have been the focus of government research and private advocacy in an effort to atone for years of neglect of women by the health care system In 1985 a seminal report from the US Public Health Service Task Force concluded that because women historically haven39t been included in medical research women often didn39t receive quality information or health care To make amends the government in 1990 created the Office of Women39s Health and launched the 750 million Women39s Health Initiative which was devoted to studying major women39s health issues including menopause hormones calcium and dietary in uences on breast cancer Unintended Consequences Now some experts question whether the intense focus on women has had the unintended result of allowing men39s health issues to slide For instance Congress directed 778 million to breast and ovarian cancer research from 2002 to 2006 85 more than the 420 million it set aside for prostate cancer research during the same period according to data from the Congressionally Directed Medical Research Programs office Nobody thinks breast cancer should get less attention but there is growing concern that the big killers of men heart disease prostate cancer injuries and suicide aren39t getting equal billing Even though men historically were over represented in research science still has not answered many questions about men39s health says New York physician Marianne J Legato who was recently appointed adjunct professor at Johns Hopkins for gender specific medicine For instance why do men typically have more abdominal fat considered to be the most unhealthy type of body fat Why do men have naturally lower HDL or quotgoodquot cholesterol than women Why are men more vulnerable to heart disease at a younger age Why are boy babies more likely to have health problems than girls On average men at any age are 40 more likely to die than women A 20 year old man for instance is three times as likely to die in an accident as a woman A 60 year old man is 39 more likely to die of diabetes And when diseases such as diabetes heart disease or hypertension are diagnosed in men they tend to be at a far later stage in the disease process after extensive damage has already been done One of the biggest obstacles to improving care for men may be men themselves Boys and girls receive similar levels of pediatric care likely because their mothers are in charge of it But after males reach adulthood their participation in health care plummets A Centers for Disease Control and Prevention study found that even when visits for pregnancy are excluded women are twice as likely as men to schedule regular annual exams and use preventive services Another survey found that three times as many men as women hadn39t seen a doctor in the past year And one out of four men says he quotwaits as long as possiblequot before seeking help for a health problem according to Harvard Men39s Health Watch One problem is that while obstetrics and gynecology are dedicated to women39s health there39s no specialty dedicated to men In surveys about 90 of women report having a personal physician while only two thirds of men do quotWhen women go to the gynecologist they don39t just get gynecological problems diagnosed the doctor checks her for diabetes blood pressure depressionquot says Jean Bonhomme a preventive medicine doctor in Atlanta and board member of the Men39s Health Network a nonprofit advocacy group quotBut we don39t have anything analogous to that for men We need to use the opportunities we have to bring men back into the health care systemquot One such opportunity may be the success of erectile dysfunction drugs like Pfizer39s Viagra Studies show that erection problems are one of the earliest warning signs of heart disease because the same unhealthy buildup that damages the arteries to the heart also damages the arteries to the penis Last year the Archives of Internal Medicine reported on a study of nearly 4000 Canadian men that showed men with erectile dysfunction were nearly 50 more likely to be diagnosed with diabetes or metabolic syndrome a collection of health risks that are associated with heart disease The link between erectile health and heart health has triggered a new push in the medical community to use the quotViagra visitquot the time when a man asks his doctor for an erectile dysfunction drug as a way to screen men for heart disease Teaching a man that erectile function is linked to cardiovascular health diabetes and weight gain can help motivate him to make healthy lifestyle changes quotSexual health is the portal to men39s healthquot says Ridwan Shabsigh associate professor of urology at Columbia University in New York Two major health issues for men stress and depression exact a serious physical toll on men but are currently ignored by many doctors who treat men New research shows there may be major differences in the male stress reaction compared with the female stress response The typical stress response is called quotfight or ightquot a physical reaction to danger that helps the body rapidly mobilize energy delivering glucose to muscles and boosting the heart rate and blood pressure While the stress response protects us in the face of danger such as fighting a war or eeing a burning house it causes damage if stress is chronic as is often the case with job deadlines and financial worries Stress and Evolution In recent years evidence has been mounting that women may be evolutionarily better equipped to cope with modern stress She can still fight or ee if necessary but in times of stress a woman39s body also releases oxytocin which is known as a bonding hormone This has been dubbed the quottend and befriendquot stress response and may help explain why women are more likely to seek counseling and confide in friends and family during stressful times A unique female stress response makes evolutionary sense Imagine an ancient village being invaded by marauders The men have to gear up to fight but the best strategy for a woman may have been to gather children close comfort them and surround herself with other women to help during the crisis Though still only a theory this coping mechanism may help explain at least part of the reason why women overall are more healthy than men And in the case of depression twice as many women as men are diagnosed fueling the belief that depression is a woman39s health issue But many mental health researchers believe that the medical community is culturally biased to find depression in women and ignore it in men For instance one key question to diagnosing depression is to ask whether a patient has crying spells quotWe miss a lot of depression in men because we look for emotional expressions that men have been taught not to showquot notes Dr Bonhomme quotThe first thing you learn as a young man is that men aren39t supposed to cry When women are depressed they may show sadness but a guy may go to a bar and line up a whole bunch of drinksquot But missing depression in men has proved to be deadly Suicide rates are four times higher for men than women according to the CDC and between the ages of 15 and 34 it39s the second leading cause of death among men It remains among the top five until the age of 54 Doctors say men have the most power to improve the state of their health with just a few simple steps First be aware of your blood pressure and cholesterol numbers and take active steps to lower both if they reach an unhealthy range quotJust focusing on those two single things can make a huge difference in longevityquot says Peter A Gross chief medical officer at Hackensack University Medical Center in New Jersey quotMen may think they39re more indestructible than women when in fact we may be genetically inferior to womenquot Next men need to be aware of their waist circumference Abdominal fat has long been a risk factor for heart disease A waist size above 40 inches for men 35 inches for women puts you in a danger zone Don39t rely on your pant size and instead take out a tape measure quotMen say their pant size hasn39t changed in years but they have this strategy of just lowering their beltquot notes Harvard39s Dr Simon quot1 think it39s another area of real ignorance among u men A recent J AMA study showed that preventing weight gain in men during midlife was also a major factor in predicting his longevity The same study showed that men with excessive alcohol consumption defined as three or more drinks a day were more likely to die before age 85 or be unhealthy during their elderly years Men don39t have to give up alcohol altogether other studies show that one to two alcoholic beverages a day boosts a man39s heart health A Legacy of Health Fathers of young boys have the most to gain by taking charge of their health Studies show boys tend to mimic the behavior of their dads while girls tend to copy their mothers so a dad who takes care of himself and makes regular doctor visits can have a big impact on his son39s health as well And parents of both sexes can work to dissuade the risk taking behavior in boys and teens that puts young men at such high risk for accidental death Teaching boys that it39s OK to cry and that they don39t have to be stoic when hurt can go a long way toward protecting them as they age notes Dr Bonhomme quotYou don39t have to retrain a whole society but for the ones that are coming up now we can take a different tact and raise them to be more health consciousquot says Dr Bonhomme quotWhen a boy is 8 years old and skins his knee he39s taught that if something hurts don39t pay it any mind because it will go away That works when you39re young but it doesn39t work in middle u age URL for this article httponlinewsjcomarticleSB117735809444879393html A Surprising Secret to a Long Life Stay in School By GINA KOLATA The New York Times January 3 2007 James Smith a health economist at the RAND Corporation has heard a variety of hypotheses about what it takes to live a long life 7 money lack of stress a loving family lots of friends But he has been a skeptic Yes he says it is clear that on average some groups in every society live longer than others The rich live longer than the poor whites live longer than blacks in the United States Longevity in general is not evenly distributed in the population But what he asks is cause and what is effect And how can they be disentangled He is venturing of course into one of the prevailing mysteries of aging the persistent differences seen in the life spans of large groups In every country there is an average life span for the nation as a whole and there are average life spans for different subsets based on race geography education and even churchgoing But the questions for researchers like Dr Smith are why And what really matters The answers he and others say have been a surprise The one social factor that researchers agree is consistently linked to longer lives in every country where it has been studied is education It is more important than race it obliterates any effects of income Year after year in study after study says Ricth Hodes director of the National Institute on Aging education keeps coming up And health economists say those factors that are popularly believed to be crucial 7 money and health insurance for example pale in comparison Dr Smith explains Giving people more Social Security income or less for that matter will not really affect people s health It is a good thing to do for other reasons but not for health Health insurance too he says is vastly overrated in the policy debate Instead Dr Smith and others say what may make the biggest difference is keeping young people in school A few extra years of school is associated with extra years of life and vastly improved health decades later in old age It is not the only factor of course There is smoking which sharply curtails life span There is a connection between having a network of friends and family and living a long and healthy life And there is evidence that people with more powerful jobs and presumably with more control over their work lives are healthier and longer lived But there is little dispute about the primacy of education If you were to ask me what affects health and longevity says Michael Grossman a health economist at the City University of New York I would put education at the top of my list Graduate Student Finds Answer The first rigorous effort to decide whether education really changes people so they live longer began in a most inauspicious way It was 1999 and a Columbia University graduate student Adriana Lleras Muney was casting about for a topic for her doctoral dissertation in economics She found an idea in a paper published in 1969 Three economists noted the correlation between education and health and gave some advice If you want to improve health you will get more return by investing in education than by investing in medical care It had been an in ammatory statement Dr Lleras Muney says And for good reason It could only be true if education in and of itself caused good health But there were at least two other possibilities Maybe sick children did not go to school or dropped out early because they were ill Or maybe education was a proxy for wealth and it was wealth that led to health It could be that richer parents who gave their children everything including better nutrition better medical care and a better education had children who by virtue of being wealthy lived longer How she asked herself could she sort out causes and effects It was the chicken and egg problem that plagues such research The answer came one day when Dr Lleras Muney was reading another economics paper It indicated that about 100 years ago different states started passing laws forcing children to go to school for longer periods She knew what to do The idea was when a state changed compulsory schooling from say six years to seven years would the people who were forced to go to school for six years live as long as the people the next year who had to go for seven years Dr Lleras Muney asked All she would have to do was to go back and find the laws in the different states and then use data from the census to find out how long people lived before and after the law in each state was changed I was very excited for about three seconds she says Then she realized how onerous it could be to comb through the state archives But when her analysis was finished Dr Lleras Muney says I was surprised I was really surprised It turned out that life expectancy at age 35 was extended by as much as one and a half years simply by going to school for one extra year Her prize winning paper appeared in Review of Economic Studies And she ended up with a job as an assistant professor at Princeton Now others papers have appeared examining the 9 effects of changed laws on compulsory education in Sweden Denmark England and Wales In every country compelling children to spend a longer time in school led to better health You might think that forcing someone to go to school who does not want to be there may not be the same thing as going to school because you want to Dr Lleras Muney said That did not seem to be the case Not everyone was convinced Victor Fuchs a health economist at Stanford points out that it is not clear how or why education would lead to a longer life And he said there are other mysteries For example women increased their years of schooling more than men have in recent decades But men are catching up with women in their life spans And it might be expected that after a certain point more years of school would not add to a person s life span That however is not what the data shows The education effect never wanes But most researchers say they are swayed by Dr Lleras Muney s work and the studies in other countries That though leaves the question of why the education effect occurs Dr Lleras Muney and others point to one plausible explanation 7 as a group less educated people are less able to plan for the future and to delay gratification If true that may for example explain the differences in smoking rates between more educated people and less educated ones Smokers are at least twice as likely to die at any age as people who never smoked says Samuel Preston a demographer at the University of Pennsylvania And not only are poorly educated people more likely to smoke but he says everybody knows that smoking can be deadly and that includes the poorly educated But education Dr Smith at RAND finds may somehow teach people to delay gratification For example he reported that in one large federal study of middle aged people those with less education were less able to think ahead Most of adherence is unpleasant Dr Smith says You have to be willing to do something that is not pleasant now and you have to stay with it and think about the future He deplores the dictums to live in the moment or to live for today That advice Dr Smith says is the worst thing for your healt An Observation on the Street In the late 1970 s Lisa Berkman now a professor of public policy at the Harvard School of Public Health took a part time job at a San Francisco health care center It drew people from Chinatown and the city s Italian neighborhood North Beach as well as from the Tenderloin district a poor area where homeless people lived on the streets and mentally ill people roamed And she noticed something striking In Chinatown and North Beach there were these tightly bound social networks Dr Berkman recalls You saw old people with young people In the Tenderloin people were just sort of dumped People were really isolated and did not have ways of figuring out how to make things work A few years later she was haunted by that observation She had entered graduate school and was studying Seventh day Adventists when she began to wonder whether the standard explanation for their longer lives 7 a healthy vegetarian diet 7 was enough They were at decreased risk from many many diseases even ones where diet was not implicated Dr Berkman says And she adds it seemed they simply had a slower rate of aging Seventh day Adventists like the people in Chinatown and North Beach had incredibly cohesive social networks Dr Berkman notes Could that be the clue Thirty years later studies have borne out her hunch The risks of being socially isolated are phenomena Dr Berkman says associated with twofold to fivefold increases in mortality rates And the correlations emerged in study after study and in country after country Yet Dr Berkman adds there was that perennial question Did social isolation shorten lives or were people isolated because they were sick and frail and at great risk of death She knows that sometimes ill health leads to social isolation But Dr Berkman says the more she investigated the more evidence she found that social isolation might also lead to poor health and a shorter life by for example increasing stress and making it harder to get assistance when ill But researchers also warn that their findings that education and to a lesser degree social networks may directly affect health do not necessarily mean that other hypotheses would also hold up The cautionary tale health economists say is the story of the link between health and wealth Over and over again studies show that health is linked to wealth It even matters where a person lives For example in a new analysis of Medicare beneficiaries Stephanie Raymond and Kristen Bronner of Dartmouth College find that the lowest death rates are in the wealthiest places So in San Francisco with a per capita income of 57496 just 416 percent of Medicare beneficiaries die each year But in Tuscaloosa Ala whose per capita income is 24257 the annual death rate was 597 percent Race was not a large factor If you control for where people live the disparities between black and white mortality rates become much smaller said Jonathan Skinner a Dartmouth health economist ll An obvious explanation is that wealth buys health And it seems plausible Poorer people at least in the United States are less likely to have health insurance or access to medications But Dr Fuchs says then why don t differences between rich and poor shrink in countries where everyone has health care All you have to do is look at the experience of countries like England that have had health insurance for more than 40 years he says There is no diminution in the class differentials It s been the same in Sweden It s true everywhere In fact Dr Smith says the wealth health connection at least among adults goes in the wrong direction It is not that lower incomes lead to poor health so much as that poor health leads to lower incomes he found A Skewing 0f the Numbers Sick people tend to have modest out of pocket medical expenses but often are unable to work or unable to work full time The result can be a drastic and precipitous and long lasting drop in income As the ranks of middle and upper income populations become depleted of people who are ill there is a skewing of the data so healthy people are disproportionately richer That effect emerged when Dr Smith analyzed data from the National Institute on Aging s National Health and Retirement Survey a national sample of 7600 American households with at least one person aged 51 to 61 If someone developed cancer heart disease or lung disease 7 which will affect about a fifth of people aged 51 to 61 over the next eight years 7 the household s income declined by an average of more than 37000 And its assets 7 its wealth 7 fell by 49000 over the ensuing eight years even though out of pocket medical expenses were just 4000 Dr Smith also asked whether getting richer made people healthier an effect that could translate into a longer life It does not he concluded after studying the large increases in income during the stock market surge of the 1990s I find almost no role of financial anything in the onset of disease Dr Smith says That s an almost throw you out of the room thing he confesses but the data he and other economists insist is consistent Income says Dr Preston is so heavily in uenced by health itself Much More Than Genes and Luck As director of the National Institute on Aging Dr Hodes often speaks to policy makers giving briefings on the latest scientific findings But he and others say all too often there is a disconnect W There are some important findings Health and nutrition early in life even prenatally can affect health in middle and old age and can affect how long people live For the most part genes have little effect on life spans Controlling heart disease risk factors like smoking cholesterol blood pressure and diabetes pays off in a more vigorous old age and a longer life And it seems increasingly likely that education plays a major role in health and life spans And then there is the question of what to do It might seem logical to act now pouring money into education or child health for example But scientists often say they would like good evidence beforehand that a program that sounds like it would make a difference like keeping students in school longer really works And if the goal is longer and healthier lives is that the most cost effective way to spend public money There are just so many questions remaining says Richard Suzman a program director at the National Institute on Aging Even studies showing that for many people the die may be cast early in life do not reveal how best to make changes We have only a vague idea of when and where early experience links to old age or when and where to intervene Dr Suzman says When it comes to changing things says Dr Skinner the Dartmouth economist we are in uncharted territory The New York Times July 30 2006 So Big and Healthy Grandpa Wouldn t Even Know You By GINA KOLATA Valentin Keller enlisted in an all German unit of the Union Army in Hamilton Ohio in 1862 He was 26 a small slender man 5 feet 4 inches tall who had just become a naturalized citizen He listed his occupation as tailor A year later Keller was honorably discharged sick and broken He had a lung ailment and was so crippled from arthritis in his hips that he could barely walk His pension record tells of his suffering His rheumatism is so that he is unable to walk without the aid of crutches and then only with great pain it says His lungs and his joints never got better and Keller never worked again He died at age 41 of dropsy which probably meant that he had congestive heart failure a condition not associated with his time in the Army His 39 year old wife Otilia died a month before him of what her death certificate said was exhaustion People of Valentin Keller s era like those before and after them expected to develop chronic diseases by their 40 s or 50 s Keller s descendants had lung problems they had heart problems they had liver problems They died in their 50 s or 60 s Now though life has changed The family s baby boomers are reaching middle age and beyond and are doing fine I feel good says Keller s great great great grandson Craig Keller At 45 Mr Keller says he has no health problems nor does his 45 year old wife Sandy The Keller family illustrates what may prove to be one of the most striking shifts in human existence 7 a change from small relatively weak and sickly people to humans who are so big and robust that their ancestors seem almost unrecognizable New research from around the world has begun to reveal a picture of humans today that is so different from what it was in the past that scientists say they are startled Over the past 100 years says one researcher Robert W Fogel of the University of Chicago humans in the industrialized world have undergone a form of evolution that is unique not only to humankind but unique among the 7000 or so generations of humans who have ever inhabited the eart The difference does not involve changes in genes as far as is known but changes in the human form It shows up in several ways from those that are well known and almost taken for granted like greater heights and longer lives to ones that are emerging only from comparisons of health records The biggest surprise emerging from the new studies is that many chronic ailments like heart disease lung disease and arthritis are occurring an average of 10 to 25 years later than they used to There is also less disability among older people today according to a federal study H that directly measures it And that is not just because medical treatments like cataract surgery keep people functioning Human bodies are simply not breaking down the way they did before Even the human mind seems improved The average IQ has been increasing for decades and at least one study found that a person s chances of having dementia in old age appeared to have fallen in recent years The proposed reasons are as unexpected as the changes themselves Improved medical care is only part of the explanation studies suggest that the effects seem to have been set in motion by events early in life even in the womb that show up in middle and old age What happens before the age of 2 has a permanent lasting effect on your health and that includes aging said Dr David J P Barker a professor of medicine at Oregon Health and Science University in Portland and a professor of epidemiology at the University of Southampton in England Each event can touch off others Less cardiovascular disease for example can mean less dementia in old age The reason is that cardiovascular disease can precipitate mini strokes which can cause dementia Cardiovascular disease is also a suspected risk factor for Alzheimer s disease The effects are not just in the United States Large and careful studies from Finland Britain France Sweden and the Netherlands all confirm that the same things have happened there they are also beginning to show up in the underdeveloped world Of course there were people in previous generations who lived long and healthy lives and there are people today whose lives are cut short by disease or who suffer for years with chronic ailments But on average the changes researchers say are huge Even more obvious differences surprise scientists by the extent of the change In 1900 13 percent of people who were 65 could expect to see 85 Now nearly half of 65 year olds can expect to live that long People even look different today American men for example are nearly three inches taller than they were 100 years ago and about 50 pounds heavier We ve been transformed Dr Fogel said What next scientists ask Today s middle aged people are the first generation to grow up with childhood vaccines and with antibiotics Early life for them was much better than it was for their parents whose early life in turn was much better than it was for their parents And if good health and nutrition early in life are major factors in determining health in middle and old age that bodes well for middle aged people today Investigators predict that they may live longer and with less pain and misery than any previous generation Will old age for today s baby boomers be anything like the old age we think we know Dr Barker asked The answer is no Trying to Change a Pattern Craig Keller does not know what to expect of his old age But he is optimistic by nature and he knows he has already lived past the life span of his beleaguered ancestor Valentin He is 5 foot 9 200 pounds and exuberantly healthy He grew up in Hamilton the same Ohio town where Valentin lived worshiped and was buried And he still lives there working as a court bailiff married to Sandy whom he met when they were in second grade Now married 25 years the Kellers have two grown daughters a lively black dog and no complaints Craig and Sandy Keller had all the advantages of middle class Americans of their age childhood vaccines plenty of food antibiotics when they fell ill Now wanting to stay healthy they walk in the evenings try to eat well and rely on their strong faith which they say makes a big difference to their health And they enjoy life Mr Keller pulls his wife s tan Chevy Malibu into the driveway of his small immaculate house on a sidewalk lined street It is the same house that he grew up in he and Mrs Keller bought it from Mr Keller s parents 22 years ago While Mrs Keller brings out a snack of a homemade cheese ball crackers sandwiches fruit salad and brownies Mr Keller settles in to marvel at the contrast between his comfortable life and the lives of his ancestors For him the idea of falling ill in his late 20 s and never working again is unimaginable He knows though that he is nearing the age when many of his ancestors died His father Carl D Keller a lifelong smoker developed prostate cancer then emphysema and then lung cancer which killed him at age 65 His father s father Carl W Keller also a smoker died of cancer of the esophagus just after he turned 69 His grandfather on his mother s side died of cirrhosis of the liver at 55 his grandmother died at 56 of breast cancer They never got out of their 50 s and 60 s Mr Keller said So that s kind of in the back of your mind He worries about his lungs given his family history He had pneumonia once and has had bronchitis But Mr Keller reasons he is so physically different from his ancestors 7 he has never smoked and is so much healthier so much better fed 7 that he really thinks he will break the spell And if exercise is good for health the Kellers certainly have exercised Mr Keller displays a bookcase in their basement crammed with athletic trophies Mrs Keller s are from baton twirling Mr Keller s are from baseball basketball softball and soccer Their daughters 19 year old Rachel and 22 year old Kristy got theirs cheerleading Mrs Keller said that when she was her daughters age I didn t think about my health very much But later in my 30 s and toward my 40 s she said I started to think about it You try to eat right you try to exercise And you do see your parents with illnesses And you wonder about yourself My mom had a quadruple bypass when she was 75 and she had to have a pacemaker after that She s now in her 80 s but you do wonder Was it genetic destiny or health habits that caused her mother s heart disease Mrs Keller asks herself Her mother smoked for more than a decade finally quitting with great difficulty before Mrs Keller was born She said the Lord helped her Mrs Keller said Mrs Keller has never smoked Concerned about heart disease she had her cholesterol level tested a few years ago and now takes medication to lower it She walks at lunch with the women in her office and after dinner with her husband Her daughter Rachel petite and quiet with a quick smile is already thinking about her family s medical history She worries about heart disease worries about lung disease She has already had her cholesterol level measured 7 it was normal And she is shocked when people her age start smoking In high school none of my friends smoked she said They came back from their first year in college and all of them did It s hard to think about getting old when you re young Rachel added But when you see your family members 7 my grandpa died of lung cancer my grandparents on both sides had cancer So it s on my mind a lot of times But still the future is so distant it is almost unfathomable to her I wonder what we re going to be like when we re old she mused Lives Plagued by Illness Scientists used to say that the reason people are living so long these days is that medicine is keeping them alive though debilitated But studies like one Dr Fogel directs of Union Army veterans have led many to rethink that notion The study involves a random sample of about 50000 Union Army veterans Dr Fogel compared those men the first generation to reach age 65 in the 20th century with people born more recently The researchers focused on common diseases that are diagnosed in pretty much the same way now as they were in the last century So they looked at ailments like arthritis back pain and various kinds of heart disease that can be detected by listening to the heart The first surprise was just how sick people were and for how long Instead of inferring health from causes of death on death certificates Dr Fogel and his colleagues looked at health throughout life They used the daily military history of each regiment in which each veteran served which showed who was sick and for how long census V manuscripts public health records pension records doctors certificates showing the results of periodic examinations of the pensioners and death certificates They discovered that almost everyone of the Civil War generation was plagued by life sapping illnesses suffering for decades And these were not some unusual subset of American men 7 65 percent of the male population ages 18 to 25 signed up to serve in the Union Army They presumably thought they were fit enough to serve Dr Fogel said Even teenagers were ill Eighty percent of the male population ages 16 to 19 tried to sign up for the Union Army in 1861 but one out of six was rejected because he was deemed disabled And the Union Army was not very picky Incontinence of urine alone is not grounds for dismissal said Dora Costa an MIT economist who works with Dr Fogel quoting from the regulations A man who was blind in his right eye was disqualified from serving because that was his musket eye But Dr Costa said blindness in the left eye was OK After the war ended as the veterans entered middle age they were rarely spared chronic ailments In the pension records there were descriptions of hernias as big as grapefruits Dr Costa said They were held in by a truss These guys were continuing to work although they clearly were in a lot of pain They just had to cope Eighty percent had heart disease by the time they were 60 compared with less than 50 percent today By ages 65 to 74 55 percent of the Union Army veterans had back problems The comparable figure today is 35 percent The steadily improving health of recent generations shows up in population after population and country after country But these findings raise a fundamental question Dr Costa said The question is OK there are these differences and yes they are big But why she said That s the million dollar question said David M Cutler a health economist at Harvard Maybe it s the trillion dollar question And there is not a received answer that everybody agrees with Outgrowing the Past Don Hotchkiss a civil engineer in Las Vegas and a descendant of Civil War veterans is an avid Civil War re enactor Early on he and his brother tried to sleep in an exact replica of one of the old tents It was too small Mr Hotchkiss said He is six feet tall and stocky His brother a police officer in Phoenix is thinner but 6 foot 2 The tents were made for men who were average size then In the past 145 years we ve ballooned up Mr Hotchkiss said At a recent meeting of a Las Vegas chapter of the Sons of Confederate Veterans eight burly men crowded into a library meeting room All had experienced the equivalent of the Civil War tent problem At the re enactments all the directors all the costume directors say the re enactors are just too darn big said George McClendon a hefty 67 year old retired airline pilot Mr McClendon is right Men living in the Civil War era had an average height of 5 foot 7 and weighed an average of 147 pounds That translates into a body mass index of 23 well within the range deemed normal Today men average 5 foot 912 and weigh an average of 191 pounds giving them an average body mass index of 282 overweight and edging toward obesity Those changes along with the great improvements in general health and life expectancy in recent years intrigued Dr Costa Common chronic diseases 7 respiratory problems valvular heart disease arteriosclerosis and joint and back problems 7 have been declining by about 07 percent a year since the turn of the 20th century And when they do occur they emerge at older ages and are less severe The reasons she and others are finding seem to have a lot to do with conditions early in life Poor nutrition in early years is associated with short stature and lifelong ill health and until recently food was expensive in the United States and Europe Dr Fogel and Dr Costa looked at data on height and body mass index among Union Army veterans who were 65 and older in 1910 and veterans of World War II who were that age in the 1980 s Their data relating size to health led them to a prediction the World War II veterans should have had 35 percent less chronic disease than the Union Army veterans That they said is exactly what happened They also found that diseases early in life left people predisposed to chronic illnesses when they grew older Suppose you were a survivor of typhoid or tuberculosis Dr Fogel said What would that do to aging It turned out he said that the number of chronic illnesses at age 50 was much higher in that group Something is being undermined he said Even the cancer rates were higher Ye gods We never would have suspected that Men who had respiratory infections or measles tended to develop chronic lung disease decades later Malaria often led to arthritis Men who survived rheumatic fever later developed diseased heart valves And stressful occupations added to the burden on the body People would work until they died or were so disabled that they could not continue Dr Fogel said In 1890 nearly everyone died on the job and if they lived long enough not to die on the job the average age of retirement was 85 he said Now the average age is 62 A century ago most people were farmers laborers or artisans who were exposed constantly to dust and fumes Dr Costa said I think there is just this long term scarring Searching for Answers Dr Barker of Oregon Health and Science University is intrigued by the puzzle of who gets what illness and when Why do some people get heart disease and strokes and others don t he said It s very clear that current ideas about adult lifestyles go only a small way toward explaining this You can say that it s genes if you want to cease thinking about it Or you can say When do people become vulnerable during development Once you have that thought it opens up a whole new world It is a world that obsesses Dr Barker Animal studies and data that he and others have been gathering have convinced him that health in middle age can be determined in fetal life and in the first two years after birth His work has been controversial Some say that other factors like poverty may really be responsible But Dr Barker has also won over many scientists In one study he examined health records of 8760 people born in Helsinki from 1933 to 1944 Those whose birth weight was below about six and a half pounds and who were thin for the first two years of life with a body mass index of 17 or less had more heart disease as adults Another study of 15000 Swedish men and women born from 1915 to 1929 found the same thing So did a study of babies born to women who were pregnant during the Dutch famine known as the Hunger Winter in World War 11 That famine lasted from November 1944 until May 1945 Women were eating as little as 400 to 800 calories a day and a sixth of their babies died before birth or shortly afterward But those who survived seemed fine says Tessa J Roseboom an epidemiologist at the University of Amsterdam who studied 2254 people born at one Dutch hospital before during and after the famine Even their birth weights were normal But now those babies are reaching late middle age and they are starting to get chronic diseases at a much higher rate than normal Dr Roseboom is finding Their heart disease rate is almost triple that of people born before or after the famine They have more diabetes They have more kidney disease That is no surprise Dr Barker says Much of the body is complete before birth he explains so a baby born to a pregnant woman who is starved or ill may start life with a predisposition to diseases that do not emerge until middle age The middle aged people born during the famine also say they just do not feel well Twice as many rated their health as poor 10 percent compared with 5 percent of those born before or after the famine 20 We asked them whether they felt healthy Dr Roseboom said The answer to that tends to be highly predictive of future mortality But not everyone was convinced by what has come to be known as the Barker hypothesis the idea that events very early in life affect health and well being in middle and old age One who looked askance was Douglas V Almond an economist at Columbia University Dr Almond had a problem with the studies They were not of randomly selected populations he said making it hard to know if other factors had contributed to the health effects He wanted to see a rigorous test 7 a sickness or a deprivation that affected everyone rich and poor educated and not and then went away Then he realized there had been such an event the 1918 u The u pandemic arrived in the United States in October 1918 and was gone by January 1919 af icting a third of the pregnant women in the United States What happened to their children Dr Almond asked He compared two populations those whose mothers were pregnant during the u epidemic and those whose mothers were pregnant shortly before or shortly after the epidemic To his astonishment Dr Almond found that the children of women who were pregnant during the in uenza epidemic had more illness especially diabetes for which the incidence was 20 percent higher by age 61 They also got less education 7 they were 15 percent less likely to graduate from high school The men s incomes were 5 percent to 7 percent lower and the families were more likely to receive welfare The effects Dr Almond said occurred in whites and nonwhites in rich and poor in men and women He convinced himself he said that there was something to the Barker hypothesis Craig Keller hopes it is true He looks back at the hard life of his ancestors even those of his great grandfather and his grandfather working as painters exposed to fumes And of course there was poor Valentin Keller his Civil War ancestor his health ruined by the time he was Today Mr Keller says he is big and healthy almost despite himself He would like to think it is because he tries to live well but he is not so sure especially when he hears about what Dr Barker and Dr Fogel and the others have found Maybe it was his good fortune to have been born to a healthy mother and to be well fed and vaccinated I don t know if we have as much control as we think we do he said 21 The New York Times August 31 2006 Live Long Die Young Answer Isn t Just in Genes By GINA KOLATA Josephine Tesauro never thought she would live so long At 92 she is straight backed firm jawed and vibrantly healthy living alone in an immaculate brick ranch house high on a hill near McKeesport a Pittsburgh suburb She works part time in a hospital gift shop and drives her 1995 white Oldsmobile Cutlass Ciera to meetings of her four bridge groups to church and to the grocery store She has outlived her husband who died nine years ago when he was 84 She has outlived her friends and she has outlived three of her six brothers Mrs Tesauro does however have a living sister an identical twin But she and her twin are not so identical anymore Her sister is incontinent she has had a hip replacement and she has a degenerative disorder that destroyed most of her vision She also has dementia She just does not comprehend Mrs Tesauro says Even researchers who study aging are fascinated by such stories How could it be that two people with the same genes growing up in the same family living all their lives in the same place could age so differently The scientific view of what determines a life span or how a person ages has swung back and forth First a couple of decades ago the emphasis was on environment eating right exercising getting good medical care Then the view switched to genes the idea that you either inherit the right combination of genes that will let you eat fatty steaks and smoke cigars and live to be 100 or you do not And the notion has stuck so that these days many people point to an ancestor or two who lived a long life and assume they have a genetic gift for longevity But recent studies find that genes may not be so important in determining how long someone will live and whether a person will get some diseases 7 except perhaps in some exceptionally long lived families That means it is generally impossible to predict how long a person will live based on how long the person s relatives lived Life spans says James W Vaupel who directs the Laboratory of Survival and Longevity at the Max Planck Institute for Demographic Research in Rostock Germany are nothing like a trait like height which is strongly inherited How tall your parents are compared to the average height explains 80 to 90 percent of how tall you are compared to the average person Dr Vaupel said But only 3 percent of how long you live compared to the average person can be explained by how long your parents lived You really learn very little about your own life span from your parents life spans Dr Vaupel said That s what the evidence shows Even twins identical twins die at different times On average he said more than 10 years apart The likely reason is that life span is determined by such a complex mix of events that there is no accurate predicting for individuals The factors include genetic predispositions disease TY nutrition a woman s health during pregnancy subtle injuries and accidents and simply chance events like a randomly occurring mutation in a gene of a cell that ultimately leads to cancer The result is that old people can appear to be struck down for many reasons or for what looks like almost no reason at all just chance Some may be more vulnerable than others and over all it is clear that the most fragile are likely to die first But there are still those among the fragile who somehow live on and on And there are seemingly healthy people who die suddenly Some diseases like early onset Alzheimer s and early onset heart disease are more linked to family histories than others like most cancers and Parkinson s disease But predisposition is not a guarantee that an individual will develop the disease Most in fact do not get the disease they are predisposed to And even getting the disease does not mean a person will die of it There are of course some valid generalizations On average for example obese men who smoke will die sooner than women who are thin and active and never get near a cigarette But for individuals there is no telling who will get what when or who will succumb quickly and who will linger We are pretty good at predicting on a group level said Dr Kaare Christensen a professor of epidemiology at the University of Southern Denmark But we are really bad on the individual level Looking to Twins James Lyons used to think his life would be short Mr Lyons a retired executive with the Boy Scouts of America thought of his father who died at 55 He had one heart attack It was six hours from onset to death and that was it Then there were his first cousins on his father s side One died at 57 and another at 50 He was in a barber chair and had a heart attack Mr Lyons said of the 50 year old He died on the spot He was a big strapping guy 6 4 healthy and energetic Then boom One day he was there and the next day he was gone I approached my 50 s with trepidation said Mr Lyons who lives in Lansing Mich But his 50 s came and went and now he is 75 He is still healthy and he has lived longer than most of his ancestors He is baf ed as to why It seems like common sense Family members tend to look alike And many characteristics are strongly inherited 7 height weight a tendency to develop early onset heart disease or to get diabetes Even personalities run in families Life span would seem to fit with the rest But scientists have been trying for decades to find out if there really is a strong genetic link to life spans and if so to what extent TY They turned to studies of families and of parents and children but data analysis has been difficult and any definitive answer elusive If a family s members tend to live to ripe old ages is that because they share some genes or because they share an environment Is it good socioeconomic status good health or good genes Dr Christensen asked How can you disentangle it His solution a classic one in science was to study twins The idea was to compare identical twins who share all their genes with fraternal twins who share some of them To do this Dr Christensen and his colleagues took advantage of detailed registries that included all the twins in Denmark Finland and Switzerland born from 1870 to 1910 That study followed the twins until 2004 to 2005 when nearly all had died Now Dr Christensen and his colleagues have analyzed the data They restricted themselves to twins of the same sex which obviated the problem that women tend to live longer than men That left them with 10251 pairs of same sex twins identical or fraternal And that was enough for meaningful analyses even at the highest ages We were able to disentangle the genetic component Dr Christensen said But the genetic in uence was much smaller than most people even most scientists had assumed The researchers reported their findings in a recent paper published in Human Genetics Identical twins were slightly closer in age when they died than were fraternal twins But Dr Christensen said even with identical twins the vast majority die years apart The investigators also asked when the genetic factor kicked in One hypothesis favored by Dr Christensen was that the strongest genetic effect was on deaths early in life He thought that deaths at young ages would re ect things like inherited predispositions to premature heart disease or to fatal cancers But there was almost no genetic in uence on age of death before 60 suggesting that early death has a large random component 7 an auto accident a fall In fact the studies of twins found almost no genetic in uence on age of death even at older ages except among people who live to be very old the late 80 s the 90 s or even 100 The average age at which people are dying today in the United States is 685 for men and 761 for women according to Arialdi M Minio of the National Center for Health Statistics This statistic differs from life expectancy which estimates how long people born today are expected to live Finding Randomness Even though there may be a tendency in some rare families to live extraordinarily long the genetic in uence that emerged from the studies of twins was significantly less than much of the public and many scientists think it is A woman whose sister lived to be 100 has a 4 percent chance of living that long Dr Christensen says That is better than the 1 percent chance for women in general but still not very great because the absolute numbers 1 out of 100 or 4 out of 100 are still so small For H men the odds are much lower A man whose sister lived to be 100 has just a 04 percent chance of living that long In comparison men in general have a 01 percent chance of reaching 100 Those data fit well with animal studies says Caleb Finch a researcher on aging at the University of Southern California Genetically identical animals 7 from worms to ies to mice 7 living in the same environments die at different times The reason is not known Dr Finch said It s random he said Since we can t find any regular pattern that s the hand wave explanation 7 randomness And random can mean more than one thing There are two phases of randomness Dr Finch said There s the randomness of life experiences The unlucky ones who get an infection get hit on the head or get mutations that turn a cell into cancer And there are random events in development Random cell growth and division and random differences in which genes get turned on and how active they are during development can cause identical twins to have different numbers of cells in their kidneys and even different patterns of folds in their brains Dr Finch pointed out And random differences in development early in life can set the stage for deterioration decades later But seemingly random events can still come as a shock That s how Annmarie Bald felt when her identical twin Catherine Polk died in her sleep of a heart attack It happened seven years ago when Ms Polk was 43 To this day Ms Bald of Forked River NJ lives in fear that the same thing will happen to her She nervously sees her doctor every year for a checkup and every year her doctor tells her the same thing her heart is fine The question in my mind every day is How did I end up still here and she s gone Ms Bald said It s not something you ever get over Yet even diseases commonly thought to be strongly inherited like many cancers are not researchers found In a paper in The New England Journal of Medicine in 2000 Dr Paul Lichtenstein of the Karolinska Institute in Stockholm and his colleagues analyzed cancer rates in 44788 pairs of Nordic twins They found that only a few cancers 7 breast prostate and colorectal 7 had a noticeable genetic component And it was not much If one identical twin got one of those cancers the chance that the other twin would get it was generally less than 15 percent about five times the risk for the average person but not a very big risk over all Looked at one way the data say that genes can determine cancer risk But viewed another way the data say that the risk for an identical twin of a cancer patient is not even close to 100 percent as it would be if genes completely determined who would get the disease Dr Robert Hoover of the National Cancer Institute wrote in an accompanying editorial There is a low absolute probability that a cancer will develop in a person whose identical m twin 7 a person with an identical genome and many similar exposures 7 has the same type of cancer This should also be instructive to some scientists and others interested in individual risk assessment who believe that with enough information it will be possible to predict accurately who will contract a disease and who will not Alzheimer s disease also has a genetic component but genes are far from the only factor in determining who gets the disease said Margaret Gatz of the University of Southern California and Nancy Pedersen of the Karolinska Institute Dr Gatz and Dr Pedersen analyzed data from a study of identical and fraternal Swedish twins 65 and older If one of a pair of identical twins developed Alzheimer s disease the other had a 60 percent chance of getting it If one of a pair of fraternal twins who are related like other brothers and sisters got Alzheimer s the other had a 30 percent chance of getting it But Dr Pedersen noted Alzheimer s is so common in the elderly that it occurs in 35 percent of people age 80 and older If genes determine who gets Alzheimer s at older ages Dr Pedersen says those genes must be very common have small effects and probably interact with the environment As for other chronic diseases of the elderly Parkinson s has no detectable heritable component studies repeatedly find Heart disease appears to be indiscriminate striking almost everyone eventually says Dr Anne Newman of the University of Pittsburgh who has studied it systematically in a large group of elderly people But the general picture is consistent in study after study A strong family history of even a genetically linked disease does not guarantee a person will get it and having no family history does not mean a person is protected Instead chronic diseases strike almost at random among the elderly making it perhaps not so surprising that life spans themselves have such a weak genetic link Matt McGue a psychology professor at the University of Minnesota who studies twins contrasts life spans with personality which he says is about 50 percent heritable or attention deficit hyperactivity disorder which is 70 to 80 percent heritable or body weight which is 70 percent heritable I ve been in this business for a long while and life span is probably one of the most weakly heritable traits I ve ever studied Dr McGue said Seeking Rare Families At the National Institute on Aging the question still hovers Is it possible to find genetic determinants of exceptional health and longevity If you could identify factors for exceptionally good health that might allow people to avoid disease said Evan Hadley director of the institute s geriatrics and clinical gerontology program There are two methods to do this Dr Hadley said One is to look at how the genes of centenarians differ from those of the rest of the population But he said that requires that if longevity genes exist they are common among centenarians And so far such studies have not yielded much that has held up 7 with one well accepted exception a gene for a cholesterol carrying protein that affects risk for heart disease as well as Alzheimer s disease Those who have that gene have double the chances of living to 100 But that chance is not much anyway Only about 2 percent of people born in 1910 could expect to reach 100 The second approach is to look for rare genes in unusually long lived families If there is something in a family it may be in only one or a few families Dr Hadley said But it may have a big effect So the National Institute on Aging is starting a research project with investigators at three United States medical centers and at Dr Christensen s center in Denmark The plan is to find exceptional families those in which there is a cluster of very old closely related members 7 two sisters in their 90 s for example 7 whose children who would typically be in their 70 s and grandchildren can be studied too Today many families have a few members living to advanced ages but very few families have many of them And in large families just by chance someone may live past 90 but it is unlikely that most of the brothers and sisters will get there For these families there does not appear to be a genetic component to life spans For now the study is in a pilot phase testing a scoring system to define the families who seem to fit the criteria If you are really really old in a family that gets you more points Dr Hadley said You get more points for being 97 than for being 92 But we also are looking at the whole family structure If there are just two siblings in a family and both live to 98 that s very exceptional But suppose there are eight kids and they all made it to 87 That s pretty unusual too If the researchers find genes in the oldest family members that seem to be associated with protection from a disease like heart disease and with a long life they will follow the younger members of the family children in their 60 s and 70 s asking if the same genes seem to protect them as they age Some wonder if the project can succeed said Dr Newman who is directing one study center at the University of Pittsburgh The big debate is is it possible for there to be a few genes that are protective or is it going to be so complicated that we won t be able to figure out the genetic factors Is it going to be that some people are just lucky She is optimistic reasoning that since some families tend to have early onset of certain diseases others probably have a genetic predisposition to get diseases like heart disease cancer and Alzheimer s so late that most members do not get them at all and live very long and healthy lives This would be the ip side of early onset she says 27 Mrs Tesauro is in the pilot study She had always been healthy and active a self described tomboy growing up who played tennis until she was 85 I just can t sit still she said She was a woman who knew her mind so eager to go to college that she defied her father who thought it was a waste of money and worked her way through She ended up with a master s degree in education and a career as a high school teacher Her twin was different She was the frilly type Mrs Tesauro said and was not much of a student She failed a grade in high school and barely graduated Both Mrs Tesauro and her sister married and had children Mrs Tesauro was born first and it is a common belief even among scientists that the twin born first is stronger and lives longer But when he looked at the Scandinavian data Dr Christensen said he found that birth order made no difference in health or longevity The day before visiting Mrs Tesauro for the first time the Pittsburgh investigators tried to call her just to be sure she was still alive and still healthy enough to be interviewed When they could not reach her they began to worry But all was well Mrs Tesauro answered the phone the next morning and explained why they had had such trouble She was out running errands 28 Old but Not Frail A Matter of Heart and Head The New York Times October 5 2006 By GINA KOLATA Mary Wittenberg the 44 year old president of New York Road Runners is a fast strong and experienced runner But she races best she says when she runs just behind Witold Bialokur He can run 10 kilometers or 62 miles in less than 44 minutes and he is so smooth and controlled He s like a metronome with his pacing Ms Wittenberg says I am often struggling to keep up with him and it s a good day when I do While Mr Bialokur s performance would be the envy of most young men he is not young Mr Bialokur is 71 It is one of the persistent mysteries of aging researchers say Why would one person like Mr Bialokur remain so hale and hearty while another who had seemed just as healthy start to weaken and slow down sometimes as early as his 70 s That says Tamara Harris who is chief of the geriatric epidemiology section at the National Institute on Aging is a central issue that is only now being systematically addressed The question is why some age well and others do not often heading along a path that ends up in a medical condition known as frailty Frailty Dr Harris explains involves exhaustion weakness weight loss and a loss of muscle mass and strength It is she says a grim prognosis whose causes were little understood It means that some people spend a long time in a period of their life where they have lost function Dr Harris says People find that very distressing and there is a tremendous health care cost Now though scientists are surprised to find that in many cases a single factor 7 undetected cardiovascular disease 7 is often a major reason people become frail They may not have classic symptoms like a heart attack or chest pains or a stroke But cardiovascular disease may have partly blocked blood vessels in the brain the legs the kidneys or the heart Those obstructions in turn can result in exhaustion or mental confusion or weakness or a slow walking pace Investigators say that there is a ray of hope in the finding 7 if cardiovascular disease is central to many of the symptoms of old age it should be possible to slow or delay or even prevent many of these changes by treating the medical condition A second finding is just as surprising to skeptical scientists because it seemed to many like a wrongheaded cliche 7 you re only as old as you think you are Rigorous studies are now showing that seeing or hearing gloomy nostrums about what it is like to be old can make people walk more slowly hear and remember less well and even affect their cardiovascular systems Positive images of aging have the opposite effects The constant message that old T l people are expected to be slow and weak and forgetful is not a reason for the full blown frailty syndrome But it may help push people along that path Still it is a view that can lead to blaming the victim and some scientists at first resisted it Now though more and more say they have been won over by an accumulating body of evidence I am changing my initially skeptical view says Richard Suzman who is director of the office of behavioral and social research programs at the National Institute on Aging There is growing evidence that these subjective experiences might be more important than we thought The Walking Test Eleanor Simonsick s initiation into the unrecognized debilitations of aging came with a research study she helped setup The question was whether older people who are relatively vigorous are also longer lived As an epidemiologist at the National Institute on Aging she thought it was time to ask that in a rigorous way So she and her colleagues recruited 3075 apparently healthy people in their 70 s who said they could walk a quarter of a mile with no trouble and climb a ight of stairs Each was asked to walk up and down a corridor 10 times for a distance of a quarter mile maintaining their pace and not stopping to rest A quarter of them could not do it And it was not just a matter of age The average age of those who could do it was 73 So was the average age of those who could not Dr Harris explained I believe most people can amble But we were asking them to walk as quickly as they could without stopping That s what people couldn t do Some walked so slowly with tiny steps and labored cadences that the researchers told them that they could stop because it was clear that they could never finish Others Dr Simonsick added just said I m done I m sitting down It s very sad she added It s not like we put them on a treadmill and cranked it up You get the sense that they are simply deconditioned The problem became worse In the first two years a third of the group that could walk the quarter mile said they were beginning to have difficulty Dr Harris said We thought Oh this is impossible But it was real The researchers published their data in the May 3 issue of The Journal of the American Medical Association finding that being unable to walk a quarter mile within five minutes portended troubles For each minute beyond five the risk of dying in the next four years increased by a third the risk of having a heart attack increased by 20 percent and the risk of having a disability increased by half Those who took more than six minutes for the quarter mile walk had the same risk of dying or having a heart attack as those who could not walk the distance at all and the effect was independent of age That led to the next question Could teaching people to walk farther and faster prevent their growing so weak they could hardly walk Dr Jack Guralnik acting chief of the laboratory of epidemiology demography and biometry at the National Institute on Aging hopes it can A new pilot study that he helped direct found that with training people could walk faster improve their balance and more easily rise from a chair Now he wants to expand that study to explore whether such training helps people retain their ability to walk and improves their health Richard J Hodes director of the National Institute on Aging is intrigued It would be an extremely expensive study Dr Hodes said adding that its costs have not been added up But he said if training could keep just 10 percent to 20 percent more people mobile I m sure billions would be saved Staving Off Frailty Dorothy Bower 78 used to take walks around the grounds of her assisted living residence in Wilkinsburg Pa near Pittsburgh But no more In the past six months Ms Bower says she has lost her energy I make it down the hall and to the dining room she says I have the feeling that if I worked at it I would get better but it s hard to get the motivation to try harder It is enough of an effort as far as I m concerned to get to the door of our room Mrs Bower says That takes me about five minutes Mrs Bower s problem is frailty doctors say It is increasingly common as people age and its symptoms 7 losing muscle mass and strength feeling depleted walking slowly losing weight and doing less and less in a day 7 go together says Dr Linda Fried a geriatrician and epidemiologist at Johns Hopkins who defined and characterized the syndrome They are all connected and form a vicious cycle she says Gerontologists say the full frailty syndrome is uncommon until people reach their 80 s but its likelihood increases rapidly from then on For example the Cardiovascular Health Study a national study of more than 5000 participants 65 and older found that 95 percent of those 75 to 79 were frail Among those 80 to 84 about 16 percent were frail and nearly a quarter of those 85 to 89 had the frailty syndrome I would say all 100 year old people are frail said Dr Anne Newman a professor of epidemiology and medicine at the University of Pittsburgh Most 90 year olds are frail And some 80 year olds are frail Dr Newman and her colleagues wondered what could be causing frailty in some but not others They thought of undetected cardiovascular disease The idea was that blood ow to the heart or muscle or brain could be impeded even if a person had had no overt signs of cardiovascular disease It was a new way to think about cardiovascular disease and a new way to think about aging Dr Newman said With frailty she said the slowing of gait the loss of muscle strength we had chalked up to being totally nonpreventable When Dr Newman and her colleagues examined participants in the Cardiovascular Health Study they saw evidence that their hunch seemed right Participants with obvious disease who had congestive heart failure or a heart attack or stroke for example 7 were likely to be frail But those with no symptoms but partly blocked blood vessels seen on scans and other tests were nearly three times as likely to be frail as healthier people And they became disabled 7 unable to care for themselves 7 about five years earlier than people without cardiovascular disease at the start of the study The researchers emphasize that cardiovascular disease is unlikely to be the sole cause of frailty Severe arthritis or osteoporosis for example could make people slow down and set the cycle in motion Strokes heart attacks cancer or any number of illnesses could bring on the frailty syndrome But in explaining frailty among seemingly healthy people the findings on cardiovascular disease made sense With a lot of people slow walking is due to poor blood ow in the legs Dr Newman says Then their muscles atrophy And reduced blood ow to the brain she says can make people feel sluggish and depleted and unable to move quickly Cardiovascular disease may be why Mrs Bower became frail For 60 years she says she has had diabetes a disease that damages blood vessels So even though she has not had a heart attack or a stroke blood ow to her muscles heart and brain may be impeded researchers say If they are right about frailty Dr Newman and others say then the condition may be prevented or delayed by not smoking and keeping cholesterol and blood pressure levels low and by staying active But the researchers add their finding may be good news for today s middle age people who had the advantage of drugs to control their blood pressure and cholesterol levels before serious damage to blood vessels set in And many are more active than their parents were when they were middle age Dr Newman for one is optimistic I think there will be less frailty and I think it will be delayed she says Overcoming Stereotypes At 79 Dr Robert Butler still works 60 hours a week He is president and chief executive of the International Longevity Center a research and education foundation in New York and a W professor of geriatrics at the Mount Sinai School of Medicine He says he expects nothing less of himself attributing his vigor in part to his luck in having excellent health and in part to something more subtle He never bought into the pervasive stereotypes of old age Dr Butler noticed the problem when he was a medical student He recalls the private names doctors had for the elderly like crock and old biddy In the decades since he says attitudes among doctors and the general public have not really changed And he adds the stereotypes have an effect My experience with older people is that they certainly do get cowed by this he said But how much and to what extent people get cowed surprised even researchers It is hard to avoid seeing or hearing demeaning depictions of the elderly There are greeting cards that make old people the butt of jokes There are phrases like senior moment to describe a memory lapse Then there are the ways older people are treated For example researchers find that people use elderspeak speaking louder and using simpler words and sentences when talking to old people Still when Becca Levy a psychologist at Yale University began her work on stereotypes effects on the elderly she was not sure that she would find anything of note She had examined the area with a study finding that older people in two cultures with a positive view of aging China and the deaf Americans fared better on memory tests than older people in the general American population Such studies are tricky though because there can be hundreds of differences between cultural groups and something else could be responsible for the memory differences So Dr Levy and her colleagues decided try a method that was used to study the effects of stereotypes about race and gender The idea is to ash provocative words too quickly for people to be aware they read them In her first study Dr Levy tested the memories of 90 healthy older people Then she ashed positive words about aging like guidance wise alert sage and learned and tested them again Their memories were better and they even walked faster 5 lt4 5 lt4 5 lt4 Next she ashed negative words like dementia decline senile confused and decrepit This time her subjects memories were worse and their walking paces slowed Thomas Hess a psychology professor at North Carolina State University came to a similar conclusion about the effects of stereotypes of aging In his studies older people did significantly worse on memory tests if they were first told something that would bring to mind aging stereotypes It could be as simple as saying the study was on how aging affects learning and memory They did better on memory tests if Dr Hess first told them something positive like saying that there was not much of a decline in memory with age But Dr Levy wondered were there long term effects of believing the stereotypes of aging She found a study that could provide answers the Ohio Longitudinal Study of Aging and Retirement The two decade long study included 1157 people nearly every resident of YY Oxford Ohio who was 50 or older and was not suffering from dementia And it had questions about beliefs about aging It turned out that people who had more positive views about aging were healthier over time They lived an average of 76 years longer than those of a similar age who did not hold such views and even had less hearing loss when their hearing was tested three years after the study began The result persisted when the investigators took in account the participants health at the start of the study as well as their age gender and socioeconomic status Some like Dr Suzman were swayed but Dr Hodes urges caution As provocative as the data may be he notes the studies cannot tell for sure what is cause and what is effect It may be that people who had negative attitudes about aging somehow knew that they were not really well Dr Hodes confesses that in this case indirect studies may be the best that can be done To obtain direct evidence would require randomly assigning some participants to keep hearing negative comments about themselves as they age and others to hear positive things How ethical would that be he asks If it is true that perceptions of aging affect memory behavior and health 7 and many researchers are betting that they do 7 that may bode well for today s middle age people Dr Levy says They may not be quite so willing to declare themselves old when they reach their 60 s and beyond and they may be less likely to believe the stereotypes of old age Still Dr Levy and others say it can be difficult to resist the pervasive stereotypes of aging Many people may accept them without realizing it Then they become a self fulfilling prophecy Dr Levy said But not for people like Dr Butler or Mr Bialokur who managed to escape that trap Others too say they have thrived simply by ignoring the stereotypes Anita Vazzano who turned 75 on Aug 9 says she just does not give old age much of a thought A widow who lives alone she still works taking a bus each day from her home in Bensonhurst Brooklyn to her office in Manhattan She knows many people become weak and frail when they grow old but that is not her she says It has to happen someday but that day is so far off Mrs Vazzano says She knows the stereotypes She has seen the offensive greeting cards And she hates them If I was old she says then catches herself and laughs In her view she adds old age is not going to happen for a long time 34 Diet and Fat A Severe Case of Mistaken Consensus The New York Times October 9 2007 By JOHN TIERNEY In 1988 the surgeon general C Everett Koop proclaimed ice cream to a be public health menace right up there with cigarettes Alluding to his office s famous 1964 report on the perils of smoking Dr Koop announced that the American diet was a problem of comparable magnitude chie y because of the high fat foods that were causing coronary heart disease and other deadly ailments He introduced his report with these words The depth of the science base underlying its findings is even more impressive than that for tobacco and health in 1964 That was a ludicrous statement as Gary Taubes demonstrates in his new book meticulously debunking diet myths Good Calories Bad Calories Knopf 2007 The notion that fatty foods shorten your life began as a hypothesis based on dubious assumptions and data when scientists tried to confirm it they failed repeatedly The evidence against H39aagen Dazs was nothing like the evidence against Marlboros It may seem bizarre that a surgeon general could go so wrong After all wasn t it his job to express the scientific consensus But that was the problem Dr Koop was expressing the consensus He like the architects of the federal food pyramid telling Americans what to eat went wrong by listening to everyone else He was caught in what social scientists call a cascade We like to think that people improve their judgment by putting their minds together and sometimes they do The studio audience at Who Wants to Be a Millionaire usually votes for the right answer But suppose instead of the audience members voting silently in unison they voted out loud one after another And suppose the first person gets it wrong If the second person isn t sure of the answer he s liable to go along with the first person s guess By then even if the third person suspects another answer is right she s more liable to go along just because she assumes the first two together know more than she does Thus begins an informational cascade as one person after another assumes that the rest can t all be wrong Because of this effect groups are surprisingly prone to reach mistaken conclusions even when most of the people started out knowing better according to the economists Sushil Bikhchandani David Hirshleifer and lvo Welch If say 60 percent of a group s members have been given information pointing them to the right answer while the rest have information pointing to the wrong answer there is still about a one in three chance that the group will cascade to a mistaken consensus Cascades are especially common in medicine as doctors take their cues from others leading them to overdiagnose some faddish ailments called bandwagon diseases and overprescribe certain treatments like the tonsillectomies once popular for children Unable to keep up with m the volume of research doctors look for guidance from an expert 7 or at least someone who sounds confident In the case of fatty foods that confident voice belonged to Ancel Keys a prominent diet researcher a half century ago the K rations in World War II were said to be named after him He became convinced in the 1950s that Americans were suffering from a new epidemic of heart disease because they were eating more fat than their ancestors There were two glaring problems with this theory as Mr Taubes a correspondent for Science magazine explains in his book First it wasn t clear that traditional diets were especially lean Nineteenth century Americans consumed huge amounts of meat the percentage of fat in the diet of ancient hunter gatherers according to the best estimate today was as high or higher than the ratio in the modern Western diet Second there wasn t really a new epidemic of heart disease Yes more cases were being reported but not because people were in worse health It was mainly because they were living longer and were more likely to see a doctor who diagnosed the symptoms To bolster his theory Dr Keys in 1953 compared diets and heart disease rates in the United States Japan and four other countries Sure enough more fat correlated with more disease America topped the list But critics at the time noted that if Dr Keys had analyzed all 22 countries for which data were available he would not have found a correlation And as Mr Taubes notes no one would have puzzled over the so called French Paradox of foie gras connoisseurs with healthy hearts The evidence that dietary fat correlates with heart disease does not stand up to critical examination the American Heart Association concluded in 1957 But three years later the association changed position 7 not because of new data Mr Taubes writes but because Dr Keys and an ally were on the committee issuing the new report It asserted that the best scientific evidence of the time warranted a lower fat diet for people at high risk of heart disease The association s report was big news and put Dr Keys who died in 2004 on the cover of Time magazine The magazine devoted four pages to the topic 7 and just one paragraph noting that Dr Keys s diet advice was still questioned by some researchers That set the tone for decades of news media coverage Journalists and their audiences were looking for clear guidance not scientific ambiguity After the fat is bad theory became popular wisdom the cascade accelerated in the 1970s when a committee led by Senator George McGovern issued a report advising Americans to lower their risk of heart disease by eating less fat McGovern s staff were virtually unaware of the existence of any scientific controversy Mr Taubes writes and the committee s report was written by a nonscientist relying almost exclusively on a single Harvard nutritionist Mark Hegsted That report impressed another nonscientist Carol Tucker Foreman an assistant agriculture secretary who hired Dr Hegsted to draw up a set of national dietary guidelines The Department of Agriculture s advice against eating too much fat was issued in 1980 and would later be incorporated in its food pyramid Meanwhile there still wasn t good evidence to warrant recommending a low fat diet for all Americans as the National Academy of Sciences noted in a report shortly after the USDA guidelines were issued But the report s authors were promptly excoriated on Capitol Hill and in the news media for denying a danger that had already been proclaimed by the American Heart Association the McGovern committee and the USDA The scientists despite their impressive credentials were accused of bias because some of them had done research financed by the food industry And so the informational cascade morphed into what the economist Timur Kuran calls a reputational cascade in which it becomes a career risk for dissidents to question the popular wisdom With skeptical scientists ostracized the public debate and research agenda became dominated by the fat is bad school Later the National Institutes of Health would hold a consensus conference that concluded there was no doubt that low fat diets will afford significant protection against coronary heart disease for every American over the age of 2 The American Cancer Society and the surgeon general recommended a low fat diet to prevent cancer But when the theories were tested in clinical trials the evidence kept turning up negative As Mr Taubes notes the most rigorous meta analysis of the clinical trials of low fat diets published in 2001 by the Cochrane Collaboration concluded that they had no significant effect on mortality Mr Taubes argues that the low fat recommendations besides being unjustified may well have harmed Americans by encouraging them to switch to carbohydrates which he believes cause obesity and disease He acknowledges that that hypothesis is unproved and that the low carb diet fad could turn out to be another mistaken cascade The problem he says is that the low carb hypothesis hasn t been seriously studied because it couldn t be reconciled with the low fat dogma Mr Taubes told me he especially admired the iconoclasm of Dr Edward H Ahrens Jr a lipids researcher who spoke out against the McGovern committee s report Mr McGovern subsequently asked him at a hearing to reconcile his skepticism with a survey showing that the low fat recommendations were endorsed by 92 percent of the world s leading doctors Senator McGovern I recognize the disadvantage of being in the minority Dr Ahrens replied Then he pointed out that most of the doctors in the survey were relying on secondhand knowledge because they didn t work in this field themselves This is a matter he continued of such enormous social economic and medical importance that it must be evaluated with our eyes completely open Thus I would hate to see this issue settled by anything that smacks of a Gallup poll Or a cascade Medical Mystery One Doctor39s Lonely Quest To Heal Brain By Thomas M Burton 26 September 2007 The Wall Street Journal ATLANTA As a young researcher in the 19603 Donald G Stein drilled through the skulls of anesthetized rats and vacuumed out sections of their brains to see the effect on their behavior But he quickly became fascinated by something outside the scope of the research Why did some female rats promptly recover from their injuries while males remained impaired His supervisors told him the difference was inconsequential and urged him to move on to more important topics But over his 40 year career as a brain researcher and university administrator he never let go of the question Decades of research often conducted in his spare time and with piecemeal funding led him to a surprising hypothesis that progesterone a natural female hormone that protects fetuses in the womb may actually protect and heal injured brains His work slowly helped overturn medical orthodoxy that states that brain tissue once injured stays that way Now he and colleagues plan a large scale human trial over the next several years While the outcome is far from assured the effort could produce a new treatment for the estimated 10 million people world wide who suffer traumatic brain injuries each year Dr Stein39s journey shows just how difficult it is to challenge the medical establishment which often begrudges ideas outside the mainstream It also underscores how difficult it is for a lone researcher to persevere without drug company or other major financial support For many years Dr Stein held administrative jobs and had to moonlight to continue his research Drug companies tend to focus more on blockbuster drugs they design than on naturally occurring ones with minimal profit potential quotThis is probably the most promising breakthrough in improving outcomes for traumatic brain injury says Gregory O39Shanick national medical director of the Brain Injury Association of America which advocates for families of people disabled from brain injury He first heard Dr Stein present his findings at an international medical meeting in 1992 quotIt39s absolutely astonishing that it39s taken this long he says Dr Stein an energetic and wise cracking 68 year old researcher at Emory University was the only member of his family to take up a career in science quotIf you grow up in a tenement in the Bronx Dr Stein says quotthe last thing you want is to work with rats As an undergraduate at Michigan State University in the early 19603 he helped pay some of his school costs by working in a state mental hospital and the psychiatric ward of a veterans39 hospital He grew appalled by the ineffective treatments of the day such as blasting hopelessly psychotic patients with water from a high pressure hose to shock them out of their condition and wrapping them in wet bedsheets Some of these patients had been given lobotomies an VA operation that mimics a form of brain injury The therapies quotseemed medieval to me and I was convinced there had to be a better wayquot he says A few years later as a doctoral candidate at the University of Oregon in 1964 he stumbled onto what would turn out to be his life39s work His job was to surgically injure rats39 brains to help determine which parts control memory and consciousness But he was struck by an anomaly Why was it that about 30 of the injured rats didn39t act impaired at all Medicine39s prevailing view held that injured brain tissue would never heal so his professors found his data of little interest quotI was told 39Don39t waste your time on that Stick to your topicquot39 They explained the differences as quotnatural variationquot he said But he was skeptical Dr Stein took the question with him later that year to the Massachusetts Institute of Technology where he embarked on a prestigious postdoctoral fellowship His supervisor Steven Chorover and others at MIT urged him to stick with the memory work quotThe work he wanted to pursue was not something we were working onquot recalls Dr Chorover Dr Stein still wanted to figure out why those brain injured rats seemed to recover But he says he concluded that he wouldn39t win tenure if he pursued the question In 1966 with a wife and young child to support he left MIT to take a job as a psychology professor and director of the brain research lab at Clark University in Worcester Mass His growing interest in the possibility of recovery from brain injury put him in a tiny minority Most neurologists at the time still agreed with Nobel laureate Santiago Ramon y Cajal who wrote in 1913 quotIn the adult brain nervous pathways are fixed and immutable Everything may die nothing may be regeneratedquot Starting in the late 1960s Dr Stein began publishing research that suggested the Nobel winner was wrong His lab began methodically studying precisely why some rats stayed smart despite injury The researchers would place rats in a large vat of water The rats had to swim to reach a safe platform in a test called a quotwater mazequot Then the scientists surgically damaged the animals39 brains to study what happened after injury Would they still be able to maneuver through the maze The rats that recovered quickly were all female although not all of the females recovered Dr Stein considered whether the explanation might be something complex like molecular or genetic differences between males and females But investigating that would take much more time and money than seeing if a female hormone might yield some clues First his team evaluated estrogen but didn39t find a major correlation Then they tried progesterone a female hormone that helps protect fetuses from injury during pregnancy In these early experiments Dr Stein tested female rats to see if they would recover better or worse at different times during their hormonal cycles that resemble human menstruation Progesterone levels rise and fall during these cycles and these early studies did indeed show that female rats that were high in progesterone recovered faster 39 Dr Stein thought he had a big part of the answer to the question that had been vexing him for years The medical establishment however largely shrugged off the results A naturally occurring hormone like progesterone some forms of which have been available generically for infertility is of little interest to drug makers That39s because the substance probably can39t gain secure patent protection That shut off a major avenue of potential funding for his research quotBig pharma likes more of an airtight protectionquot says Todd Scherer director of the Office of Technology Transfer at Emory Dr Stein39s current academic home Caroline Loew senior vice president for science and regulatory affairs at Pharmaceutical Research and Manufacturers of America the main drug industry trade group says drug companies need patent protection for their research investments But she suggested the situation could benefit from a government action along the lines of the federal Orphan Drug Act which increased financial incentives for companies researching rare diseases A similar idea quotmay apply to this casequot she says Dr Stein was turned down for half a dozen or more grants from the National Institutes of Health during the 1970s and 1980s Zaven S Khachaturian a leading scientist and former NIH official says his ideas were quotreally creative but the NIH system never gave them the good scores they deservedquot At one point he says quotI just told Don Stein that sometimes it doesn39t pay to keep hitting your head against the wallquot Dr Khachaturian says Dr Stein recalls feeling quotshakenquot by the denials while at the same time growing more determined to prove his case He kept up a steady drumbeat of research published in a wide range of journals such as Science Brain Research Experimental Neurology and others During his time at Clark Dr Stein was given to jeans long hair and shooting his mouth off in faculty meetings or challenging guest speakers even eminent ones quotEyebrows would go up whenever Don39s hand would go upquot recalls Julio Ramirez a former student now a professor of neuroscience at Davidson College But Dr Stein also was developing into a powerful speaker himself One speech in Copenhagen in the late 1980s ended up offering a lifeline for his research Diane Bistany then a senior officer at reinsurance company General Re Corp heard the talk and was impressed Dr Stein spoke for 40 minutes without notes pacing the stage as he made an impassioned argument for the notion that progesterone could be crucial to recovery for thousands of people with traumatic brain injury There are five million patients in the US alone disabled from brain injury quotNot only was it his knowledge but he had a passion for his research and conveyed that this research was going to get somewhere and mean somethingquot Ms Bistany says Gen Re soon contributed grants of 50000 a year for eight years keeping his research going Around the same time Dr Stein grew frustrated at Clark which was emphasizing clinical psychology and less so the research he preferred He applied for various positions at other f universities but his ideas while intriguing enough to win him speaking invitations still seemed too far out of the mainstream to win him a pure research job Finally in 1988 he landed an administrative position as dean of the graduate school and associate provost for research at Rutgers University in Newark NJ He would work as dean until about 4 pm then return to the lab for several hours of work in the evening along with his research team Their work progressed step by step First did progesterone lower swelling in the brain If so did it matter if the animals were females What did estrogen do if anything When did the progesterone have to be given At what dose Did progesterone affect animals39 memories He found that female rats with much higher pregnancy level amounts of progesterone did far better than other rats in following mazes Even male rats also recovered far better from injury when given the hormone performing just as well as the highest performing females The stuff worked when given up to 24 hours after injury Then in one crucial experiment in 1991 his team tested the amount of cerebral edema or brain swelling in brain injured rats with high progesterone levels versus others with none Edema is important because of its role in causing brain damage to proliferate Robin L Roof then a postdoctoral fellow in Dr Stein39s lab was waiting for the results while vacationing in a Michigan cottage When a colleague left a message that there was quotno differencequot she thought the experiment had failed But it turned out the colleague meant that progesterone protected injured rats did just as well as rats with no injury at all Immediately says Dr Roof now a researcher at Pfizer Inc she realized quotthis was career changing researc quot Still why would a hormone that rises and falls with menstrual cycles and enables fertility protect the brain Unlike estrogen progesterone doesn39t produce visible female sex characteristics It is present in men at low levels It rises sharply during pregnancy and helps protect the fetus Through multiple studies Dr Stein and colleagues concluded that it protects the brain in similar fashion In 1995 Dr Stein joined Emory as dean of the graduate school and vice provost University administrators neglected to provide him lab space thinking his brain injury research was little more than a hobby So for six years his team worked in a moldy double wide trailer between a parking lot and an industrial size trash bin To complete the picture they installed plastic amingos in front But meanwhile NIH began to back his progesterone research and the Centers for Disease Control and Prevention also began giving him grants His studies continued to show positive findings with progesterone and scientists elsewhere began to confirm them Often such confirming studies get done because other scientists start out skeptical Dr Robert Vink chairman of neurosurgical research at the University of Adelaide in Australia was among the skeptics but he grew intrigued by Dr Stein39s work Dr Vink has confirmed that progesterone is beneficial in brain injured animals in numerous ways such as H lowering brain swelling and cell death and improving animals39 cognitive abilities He says Dr Stein is quotpersevering He39s got data 10 or 12 years now showing that progesterone in animals is neuroprotective There39s no doubt about itquot Still others remain on the fence David A Hovda a prominent University of California Los Angeles neurosurgery professor says he is still unconvinced that progesterone will prove to be an effective human treatment But he says he admires Dr Stein39s work quotDon Stein has a history of stirring the potquot he says In the past decade Dr Stein says he and his team have repeatedly run into walls when trying to discern the cellular and molecular mechanism through which progesterone works But at other times they did have success on this quotcellular pathwayquot research and now are finding that there are at least three or four such mechanisms By 2000 the findings of Dr Stein and other brain scientists were swaying the textbooks One leading neurology tome quotPrinciples of Neurosciencequot said in its 2000 edition that functions such as thought language and memory quotare all made possible by the serial and parallel interlinkages of several brain regions each with specific functions As a result damage to a single area need not result in the loss of an entire faculty as many earlier neurologists predictedquot Still as a practical matter this was just nifty rat science Dr Stein39s hypotheses wouldn39t really matter until they were borne out in humans After hearing Dr Stein lecture a decade ago Arthur Kellermann then Emory39s chief of emergency medicine resolved to get human studies going He introduced Dr Stein to David Wright a young Emory emergency doctor with research ambitions Drs Wright and Kellermann wrote an NIH grant application in 1999 for the first phase of human study Two years later the federal agency approved a grant of 22 million for the first stage of human research Over the next three years the study focused on 100 head injured patients who had been brought into the emergency room at Grady Memorial Hospital in downtown Atlanta Some patients received standard treatment to control bleeding and fevers along with state of the art head injury treatment Others were also given intravenous progesterone at triple the highest natural levels at the end of pregnancy One Saturday morning in 2005 Dr Stein was driving north of Atlanta on a shopping trip with his wife when a stern sounding Dr Kellermann called him Dr Kellermann said he had just learned the study39s findings adding quotPull over to the side of the roadquot Dr Stein froze fearing that decades of research with animals would prove useless that progesterone might have turned out to raise the death rate in humans for some unforeseen reason His heart was thumping as Dr Kellermann told him the results Patients on progesterone had a death rate of just 13 from their head injuries less than half the 30 death rate of those on standard treatment And progesterone showed no negative side effects The 100 subject study V Y was too small to prove that progesterone caused the lowered death rate but the findings were consistent with animal research Don Stein was so elated that he had to ask his wife to take over the driving In the respected journal quotAnnals of Emergency Medicinequot this past April Dr Stein and his researchers summarized the study quotModerate traumatic brain injury survivors who received progesterone were more likely to have a moderate to good outcome than those randomized to placeboquot The story is still far from over Before progesterone can be approved as a treatment Dr Stein39s findings must be proved in a larger study of humans But as he and his team have persisted in research he has himself become the mainstream of neuroscience His animal research now has been replicated in dozens of studies at numerous research institutions Dr Stein and his Emory team have applied for NIH funds to do a 1000 patient study which will give the definitive word The NIH already has given an initial 229000 grant to plan the study but Emory hasn39t yet officially applied for the full grant Such a trial could take five years or more Meanwhile Emory39s technology transfer office is quotoptimisticquot about developing and marketing progesterone as a treatment for brain injury says Dr Scherer director of that office For Dr Stein the results of the clinical study in emergency head trauma patients were further reason for enthusiasm quota tremendous culminationquot as he puts it quotMost bench scientists work for years to discover a truth about naturequot he says quotVery few of us ever get to have a major impact on people39s lives How can you not be excitedquot 43 Hacking Your Body39s Bacteria for Better Health Brandon Keim 042607 WIRED magazine Modern humans are bacteria killing machines We assassinate microbes with hand soap mouthwash and bathroom cleaners It feels clean and right But some scientists say we39re overdoing it All this killing may actually cause diseases like eczema irritable bowel syndrome and even diabetes The answer they say is counterintuitive Feed patients bacteria quotProbiotics pills containing bacteria have resulted in complete elimination of eczema in 80 percent of the people we39ve treatedquot says Dr Joseph E Pizzorno Jr a practicing physician and former member of the White House Commission on Complementary and Alternative Medicine Policy Pizzorno says he39s used probiotics to treat irritable bowel disease acne and even premenstrual syndrome quotIt39s unusual for me to see a patient with a chronic disease that doesn39t respond to probioticsquot Clinical trial data on probiotics is incomplete but there are many indications that hacking the body39s bacteria is beneficial In sheer numbers bacterial cells in the body outnumber our own by a factor of 10 with 50 trillion bacteria living in the digestive system alone where they39ve remained largely unstudied until the last decade As scientists learn more about them they39re beginning to chart the complex symbiosis between the tiny bugs and our health quotThe microbes that live in the human body are quite ancientquot says NYU Medical Center microbiologist Dr Martin Blaser a pioneer in gut microbe research quotThey39ve been selected through evolution because they help usquot And it now appears that our daily antibacterial regimens are disrupting a balance that once protected humans from health problems especially allergies and malfunctioning immune responses quotAfter the Second World War when our lifestyles changed dramatically allergies increased Autoimmune diseases like diabetes and in ammatory bowel disease are increasingquot says Kaarina Kukkonen a University of Helsinki allergy expert quotThe theory behind what causes the diseases is the same Lacking bacterial stimulation in our environments may cause this increase I think this is the tip of the icebergquot In a recent study Kukkonen and her colleagues gave a probiotic containing four strains of gut bacteria to 461 infants labeled as high risk for developing allergic disorders After two years the children were 25 percent less likely than those given a placebo to develop eczema a type of allergic skin in ammation The study was published in the January issue of Journal of Allergy and Clinical Immunology Microbial exposures early in life scientists believe cause mild in ammation that calibrates the body39s responses to other pathogens and contaminants later in life Without exposure as infants researchers say people can end up with unbalanced immune systems quotMany of the most difficult problems in medicine today are chronic in ammatory diseasesquot says Blaser quotThese include rheumatoid arthritis lupus atherosclerosis eczema and multiple sclerosis One possibility is that they39re autoimmune or genetic diseases The other possibility is that they are physiological responses to changes in microbiotaquot Blaser39s specialty is Helicobacter pylori a strain once common in every human stomach but now rare in the West Its disappearance may have benefits H pylori related in ammation is associated with peptic ulcers and some stomach cancers However H pylori also reduces acid re ux which in turn is associated with asthma and esophageal cancers H pylori39s decline says Blaser correlates with a rapid rise in those af ictions H pylori deficiency may also contribute to obesity he says because the bacteria help regulate production of two hormones ghrelin and leptin that affect metabolism and appetite Low levels of Bacteroidetes have also been linked to obesity Studies indicate that bacterial imbalances are associated with irritable bowel syndrome post surgical infections and type 1 diabetes The health food movement has moved ahead with probiotics without regard for clinical trial results Women commonly use supplements like acidophilus to treat yeast infections Other probiotics are making their way into products such as Kashi Vive cereal quotto help you care for your digestive systemquot and Dannon39s Activia yogurt which in its first year boasted more than 100 million in sales But scientists say over the counter probiotics are of inconsistent quality Pizzorno for example buys his probiotics from companies that sell directly to doctors Consumer probiotics don39t always contain medically recognized bacterial strains he said and often the bacteria they contain are dead quotMost of the companies don39t have any research ongoing at allquot says Stig Bengmark a University of London hepatologist quotThey buy cheap bacteria from yogurt companies and say it39s good but it39s never provenquot To more precisely hack the gut bacteria Blaser calls for a Gut Genome Project modeled after the Human Genome Project It39s a daunting task The human genome mapped to great fanfare but still dimly understood contains a tenth of the genes believed to be in our gut bacteria But though difficult such research could prove vital quotThe world is very aware of the concept of global warming which is a macro ecological changequot Blaser says quotI postulate that there are similar micro ecological changes going on inside usquot Study Suggests Some Cancers May Go Away The New York Times November 25 2008 By GINA KOLATA Cancer researchers have known for years that it was possible in rare cases for some cancers to go away on their own There were occasional instances of melanomas and kidney cancers that just vanished And neuroblastoma a very rare childhood tumor can go away without treatment But these were mostly seen as oddities 7 an unusual pediatric cancer that might not bear on common cancers of adults a smattering of case reports of spontaneous cures And since almost every cancer that is detected is treated it seemed impossible even to ask what would happen if cancers were left alone Now though researchers say they have found a situation in Norway that has let them ask that question about breast cancer And their new study to be published Tuesday in The Archives of Internal Medicine suggests that even invasive cancers may sometimes go away without treatment and in larger numbers than anyone ever believed At the moment the finding has no practical applications because no one knows whether a detected cancer will disappear or continue to spread or kill And some experts remain unconvinced Their simplification of a complicated issue is both overreaching and alarming said Robert A Smith director of breast cancer screening at the American Cancer Society But others including Robert M Kaplan the chairman of the department of health services at the School of Public Health at the University of California Los Angeles are persuaded by the analysis The implications are potentially enormous Dr Kaplan said If the results are replicated he said it could eventually be possible for some women to opt for so called watchful waiting monitoring a tumor in their breast to see whether it grows People have never thought that way about breast cancer he added Dr Kaplan and his colleague Dr Franz Porzsolt an oncologist at the University of Ulm said in an editorial that accompanied the study If the spontaneous remission hypothesis is credible it should cause a major re evaluation in the approach to breast cancer research and treatment The study was conducted by Dr H Gilbert Welch a researcher at the VA Outcomes Group in White River Junction Vt and Dartmouth Medical School Dr Per Henrik Zahl of the Norwegian Institute of Public Health and Dr Jan Maehlen of Ulleval University Hospital in Oslo It compared two groups of women ages 50 to 64 in two consecutive six year periods 46 One group of 109784 women was followed from 1992 to 1997 Mammography screening in Norway was initiated in 1996 In 1996 and 1997 all were offered mammograms and nearly every woman accepted The second group of 119472 women was followed from 1996 to 2001 All were offered regular mammograms and nearly all accepted It might be expected that the two groups would have roughly the same number of breast cancers either detected at the end or found along the way Instead the researchers report the women who had regular routine screenings had 22 percent more cancers For every 100000 women who were screened regularly 1909 were diagnosed with invasive breast cancer over six years compared with 1564 women who did not have regular screening There are other explanations but researchers say that they are less likely than the conclusion that the tumors disappeared The most likely explanation Dr Welch said is that there are some women who had cancer at one point and who later don t have that cancer The finding does not mean that mammograms caused breast cancer Nor does it bear on whether women should continue to have mammograms since so little is known about the progress of most cancers Mammograms save lives Dr Smith said Even though they can have a downside 7 most notably the risk that a woman might have a biopsy to check on an abnormality that turns out not to be cancer 7 the balance of benefits and harms is still considerably in favor of screening for breast cancer he said But Dr Suzanne W Fletcher an emerita professor of ambulatory care and prevention at Harvard Medical School said that it was also important for women and doctors to understand the entire picture of cancer screening The new finding she said was part of the picture The issue is the unintended consequences that can come with our screening Dr Fletcher said meaning biopsies for lumps that were not cancers or it now appears sometimes treating a cancer that might not have needed treatment In general we tend to underplay them Dr Welch said the cancers in question had broken through the milk ducts where most breast cancers begin and invaded the breast Such cancers are not microscopic often are palpable and are bigger and look more ominous than those confined to milk ducts so called ductal carcinoma in situ or DCIS Dr Welch said Doctors surgically remove invasive cancers and depending on the circumstances may also treat women with radiation chemotherapy or both The study s design was not perfect but researchers say the ideal study is not feasible It would entail screening women randomly assigning them to have their screen detected cancers treated or not and following them to see how many untreated cancers went away on their own But they said they were astonished by the results 47 I think everybody is surprised by this finding Dr Kaplan said He and Dr Porzsolt spent a weekend reading and re reading the paper Our initial reaction was This is pretty weird Dr Kaplan said But the more we looked at it the more we were persuaded Dr Barnett Kramer director of the Office of Disease Prevention at the National Institutes of Health had a similar reaction People who are familiar with the broad range of behaviors of a variety of cancers know spontaneous regression is possible he said But what is shocking is that it can occur so frequently Although the researchers cannot completely rule out other explanations Dr Kramer said they do a good job of showing they are not highly likely A leading alternative explanation for the results is that the women having regular scans used hormone therapy for menopause and the other women did not But the researchers calculated that hormone use could account for no more than 3 percent of the effect Maybe mammography was more sensitive in the second six year period able to pick up more tumors But the authors report mammography s sensitivity did not appear to have changed Or perhaps the screened women had a higher cancer risk to begin with But the investigators say the groups were remarkably similar in their risk factors Dr Smith however said the study was awed and the interpretation incorrect Among other things he said one round of screening in the first group of women would never find all the cancers that regular screening had found in the second group The reason he said is that mammography is not perfect and cancers that are missed on one round of screening will be detected on another But Dr Welch said that he and his colleagues considered that possibility too And he said their analysis found subsequent mammograms could not make up the difference Dr Kaplan is already thinking of how to replicate the result One possibility he said is to do the same sort of study in Mexico where mammography screening is now being introduced Donald A Berry chairman of the department of biostatistics at M D Anderson Cancer Center in Houston said the study increased his worries about screenings that find cancers earlier and earlier Unless there is some understanding of the natural history of the cancers that are found 7 which are dangerous and which are not 7 the result can easily be more treatment of cancers that would not cause harm if left untreated he said There may be some benefit to very early detection but the costs will be huge 7 and I don t mean monetary costs Dr Berry said It s possible that we all have cells that are cancerous and that grow a bit before being dumped by the body Hell bent for leather early detection research will lead to finding some of them What will be the consequence Prophylactic removal of organs in the masses It s really scary awnv w p rmn nF39rn w me sad 1 m w whole hfe runs before the eyes What I could say It s not a real cancer 1 Mn go away don t worry about 1L she added quotThat s such a dxfferent message magma how you would feel unchecked Some Cancers Migm Regress A swear smdy m Dream cancerw Narwav mmd sxgmhcanlnumbar com I comm group mgmed m wen s reene sway wlhauursalmenl comma mun 5mquot hav ow dexacladwm mare A rrequavtscraanmg 55 an uszs nr mum anus mm m we 099 men comm amup um xmengd mm me em my am no u c was gem WW cu em Madam mm m M Who Gets Health Care Rationing in an Age of Rising Costs First in a Series Life Support The Big Secret In Health Care Rationing Is Here By Geeta Anand 12 September 2003 The Wall Street Journal PHILADELPHIA A former machine operator and part time minister Angel Montanez Diaz 69 years old has spent 140 days in intensive care at Northeastern Hospital so far this year Suffering from dementia he needs a ventilator to breathe and a stomach tube to eat The hospital needs his bed His stay has already cost about 280000 nearly half of which will end up as a loss for the hospital Who39s going to decide what happens to Mr Montanez Diaz In England Canada and some other countries a government health care bureaucracy would supply some guidelines In the US the answer lies in the hands of people such as Lorraine Micheletti The nurse manager in intensive care Ms Micheletti makes daily battlefield decisions that in uence whose lives should be prolonged and who should leave the ICU With her hospital facing a cost crunch she39s under pressure to get patients out of the glass walled unit quickly While she can39t deny or withdraw care she uses not so subtle means to decrease patient stays She cajoles doctors to move their patients along She pushes the hospital39s pharmacy committee to relax guidelines that require patients on certain drugs to stay in the ICU She prods families to let some very ill patients die with less medical intervention Without any official rules she uses only her judgment from 27 years of experience quotYou get a feel for itquot says Ms Micheletti 50 who mixes straightforward talk and a ribald sense of humor to get her way quotNine out of 10 times I39m right Every now and then I39m proven wrong There are always a few cases that are miraclesquot The word for what Ms Micheletti does every day at this 173 bed hospital is one of the big secrets of American health care Rationing Although the US spends far more per person on health care than any other country and it spends ever more each year there aren39t enough doctors drugs and dollars to do everything for everybody So who gets the care And who makes these momentous life or death decisions There is no formal rationing system in the US with its complex mix of private insurance and Medicare and Medicaid coverage plus 41 million uninsured people who pay for their own care or get treated as charity cases But in fact health care rationing occurs every day in the US in thousands of big and small decisions made mostly out of sight of patients according to rules that often aren39t consistently applied The people who make these decisions are harried doctors Medicaid functionaries hospital administrators insurance workers and nurses These are the gatekeepers of the American health care system the ones forced to say quotnoquot to certain demands for treatment 50 Many American patients enjoy more exibility than they would in a government controlled system and get better care But the US free for all creates special burdens of its own Northeastern must give enormous decision making power to doctors nurses and caseworkers to weigh patient needs against what insurers will cover a quotdamn near impossible taskquot says Robert Perry Northeastern39s chief executive officer quotAll you should be asking them to do is take care of sick people as quickly as possiblequot Instead hospital workers are forced to make rationing decisions on a case by case basis he says quotHealth care is all backwards in this country The biggest decisions are all made in the worst conditionsquot Four years ago Northeastern which serves mostly lower income residents was losing money and in danger of closing To stay in business administrators told the hospital staff that among other things they must get patients out faster Since then the average patient stay has been reduced from 49 days to 46 days This year the hospital39s goal is to bring the number down to 42 That puts a huge responsibility in the hands of Ms Micheletti and her 26 nurses She works closely with a private practice doctor whom the hospital pays to oversee ICU patients quotYou could say I39m rationing carequot she says She firmly believes that her decisions aren39t simply about money In deciding how to dispense care in times of scarce resources her quotfirst question has to be What quality of life does he have Is he going to live 10 years with a good quality of life quot This spring she considered the case of John Ems a 79 year old former refrigerator repair specialist In April he was admitted to Northeastern with anemia and gastrointestinal bleeding After three weeks in the hospital Mr Ems went into cardiac respiratory failure Nurses and doctors rushed to shock his heart back to life They revived him but one of his lungs collapsed Patients in this condition can die quickly or linger in intensive care for a long time The next day Ms Micheletti talked to the nurse who was directly caring for Mr Ems looked at his chart and within minutes she says determined his likely fate She saw that he had a history of emphysema and heart trouble Considering the fact that he wasn39t able to breathe without a ventilator and that his lung had collapsed she concluded Mr Ems was going to die Her goal she says became to prepare the family to let go of him She urged Mr Ems39s nurse to talk to his family about not resuscitating him or withdrawing care quotYou should start having that conversationquot she said That same day Ms Micheletti talked to the family herself She motioned to Mr Ems39s son Tom a tall man with tattoos covering both arms to join her outside the room where his father lay propped up on three pillows asleep Inside the sick man39s 14 year old grandson continued to stroke his arm and call out softly quotPoppy Poppyquot Putting an arm around Tom Ems39s shoulders Ms Micheletti asked if he had thought about the kind of medical attention his father should receive She told him it was unlikely his father would ever come off a ventilator which meant he would probably need to go to a nursing home if he lived quotYou have to think about what39s humanequot she said m Ms Micheletti told Mr Ems he should consider a few alternatives Doctors could gradually withdraw medical care and make his father comfortable on a morphine drip until he died Or they could leave everything in place but not resuscitate him if his heart stopped A laid off trucker who delivers pizza for a living Mr Ems grew tearful He told Ms Micheletti his father a warm patient person had lived with him his whole life and was the primary caretaker for the grandson at his bedside A few days later John Ems39s blood pressure plummeted Nurses asked for permission to stop his blood pressure medication and not to resuscitate him if his heart stopped beating Tom Ems says he agreed because doctors told him his father was likely brain dead Without the medicine Mr Ems39s heart stopped beating A few minutes later he was dead Sometimes rationing causes Ms Micheletti to take on her own hospital She encountered resistance from administrators earlier this year when trying to move 26 year old Leslie DeJesus out of the ICU to a regular hospital bed Ms DeJesus a part time security guard was the fourth patient with the same blood disorder who remained in intensive care for days because hospital guidelines required patients to be closely monitored while receiving a calcium drip that accompanies the treatment In rare cases calcium can cause heart problems But some hospitals have changed their protocols to allow such patients to be monitored less closely believing the risk is small Ms DeJesus remained in intensive care for 27 days much to Ms Micheletti39s chagrin Repeatedly she tried to persuade the patient39s oncologist and her own boss to sign off on moving Ms DeJesus to a regular hospital bed quotShe39s healthier than I am Ms Micheletti told her boss She called the patient a quotwalkie talkie hospital shorthand for a person who is mobile and alert Only when Ms DeJesus39 lab tests came back clear and the admissions nurse had two patients waiting for her bed did Ms Micheletti prevail upon the doctors to sign her out Ms DeJesus unaware of the behind the scenes pressure to get her out was eager to get home to her two young children She smiled and waved to the nurses as her bed was wheeled down the hall seven quotGet Well Soon balloons trailing behind her The cost of her stay was 106000 but the insurance company39s negotiated rate for that illness is only 10000 quotWe took a bath on that one says Ray Lefton Northeastern39s chief financial officer With prodding from Ms Micheletti who is on the hospital committee that writes guidelines for using intravenous medicines the protocol for that treatment was changed this summer The new guidelines still awaiting final approval allow patients to be monitored outside of the ICU The emphasis on moving patients along is a big change from the past when cost cutting pressures weren39t so great and nurses quotnever thought about insurance Ms Micheletti says 65quot quotYou just did what needed to be done You dared not ask the question of when the patient would be releasedquot Born in the Philippines Ms Micheletti came to the US in 1977 and has worked at seven different hospitals rising from staff nurse to nurse manager mostly in intensive care units Her current post pays 76500 a year and provides regular hours allowing her to spend time with her husband Arnold a computer programmer and their two daughters ages 6 and 11 She derives a lot of satisfaction she says out of training her nurses The hospital has little money for educational programs so she puts them on herself luring staff to the unpaid sessions with everything from pizza lunches to picture frames and other gifts donated by drug company sales reps Since Northeastern one of five hospitals operated by Temple University Health System a nonprofit group in Philadelphia put in place its turnaround plan three years ago its fortunes have improved In 2002 it posted a profit of 26 million on an operating budget of 85 million For meeting financial goals and improving patient satisfaction each hospital employee got a 300 bonus Managers including Ms Micheletti got a 2000 bonus Despite the financial incentives Ms Micheletti sometimes finds herself fighting to keep a patient in the ICU Sam Buoncristiano a 55 year old junkyard owner came to her unit in May after suffering a heart attack He needed special tests to determine if his arteries were blocked Northeastern doesn39t perform these tests but offered to arrange for him to be transferred to another hospital Mr Buoncristiano wanted to go home first Ms Micheletti was convinced his arteries were dangerously clogged because he continued to have chest pain She went into his room and pressed him to stay in Northeastern39s ICU Mr Buoncristiano said he would think it over Then she hovered by the door waiting to speak to the doctor attending him quotDoctor don39t let him go homequot she said accosting the physician outside the room where Mr Buoncristiano lay restless his eyes moving from the overhead television to the door quotIf he goes home he39s going to diequot she said The doctor nodded picked up Mr Buoncristiano39s medical chart and went in the room He came out a few minutes later and told Ms Micheletti the patient had agreed to stay Mr Buoncristiano went on to another hospital where doctors found he had a blocked artery and inserted a device called a stent to prop open the passageway He is now back at work and credits Ms Micheletti for quottreating me real goodquot While Ms Micheletti has worked hard to decrease the average patient stay this year one person can throw off her numbers quotYou can eat up all of your profits if one or two patientsquot linger in the ICU she says or Angel Montanez Diaz was living with his wife and working at a corrugated box company when his dementia set in during the early 1990s He and his brother Moises had immigrated to the US in the late 1950s leaving behind the family sugar cane farm in Puerto Rico Outside of work his brother says Angel39s passions were always religion and baseball especially the Yankees He led services several days a week and taught Sunday school at the First Christian Missionary Church which serves Philadelphia39s Hispanic population When his dementia grew severe his wife and two adult children had trouble taking care of him His brother offered to take over A retired charter pilot Moises Montanez Diaz says he was home anyway taking care of his grown son who is wheelchair bound Moises took care of Angel at his home in North Philadelphia for several years In May 2002 Angel choked on some food and went to the emergency room at Northeastern He developed complications After two months in the hospital he was sent to a rehabilitation center and later to a nursing home On Valentine39s Day this year Angel Montanez Diaz showed up at Northeastern ICU with intestinal bleeding and pneumonia As soon as he seemed stable Ms Micheletti pushed to move him back to the nursing home Because he had been on a ventilator for months and had a chronic lung infection among other things she decided he would never be well enough to go home Yet he might live for many more months in intensive care at a huge cost to the hospital Moises now Angel39s legal guardian didn39t want him returned to the nursing home because he thought the care was inadequate Thinking that Angel needed more time in the ICU Moises wasn39t motivated to quickly find another nursing home Angel is insured by a Medicare HMO In order to get him out hospital officials started calling around trying to find a nursing home to accept him It was a big problem quotEither they won39t accept him or they don39t take his health insurance or they don39t have a bedquot says Ms Micheletti quotHe39s really here because he39s got no place else to goquot Nursing homes also ration care They have little incentive to take very sick patients because in many cases they receive a fixed reimbursement rate from insurance which doesn39t cover the full cost of the care As a result nursing homes often try to limit the number of severely ill patients they take to make sure they can cover costs The hospital eventually found a nursing home to accept Mr Montanez Diaz but he was shuttled back to the hospital several times with fevers and infections Once Northeastern sent him out to the nursing home only to see him returned the very same day When he kept coming back to the ICU Ms Micheletti began prodding Moises to stop keeping him alive Mr Montanez Diaz was in chronic pain mentally incompetent and unable to breathe or eat quotThat39s not Angel in therequot she told the brother quotThat39s just a shell of himquot Moises began to cry 54 quotWhat do you do with this patientquot an exasperated Ms Micheletti said later quotWe can39t send him home because he needs too much care He comes down with pneumonia very quick His skin breaks down because it39s very fragile And yet his brother is not ready to let him diequot Moises says Angel 10 years his senior raised him after their parents died and he wants to repay that kindness by caring for him now Moises comes to his brother39s bedside every day exercising his frail stiff arms and legs and shaving his face His goal isn39t to restore Angel39s mental capacity which he thinks is unrealistic but to get him off the ventilator so he can take him home At his home Moises has kept his brother39s bedroom the same as when he first went into the hospital A worn black Bible sits on a small table by his bed Angel39s clothes still hang in the closet Pressure on Moises is increasing In addition to Ms Micheletti two hospital doctors and a nursing home have also urged him to sign a form saying his brother should not be resuscitated quotThey39ve become like Jack Kevorkianquot he says quotThey want to put my brother out of his miseryquot On July 29 Moises arrived at the hospital at 10 am to find his brother gone He had been sent to another nursing home When he stopped by her windowless office that day Ms Micheletti hoped Moises would thank her and the staff for caring for his brother for so long Instead she says he came up to her smiled and said quotSo you finally got rid of himquot She lost her temper she says and responded quotYes we got rid of himquot Later she said she also understood Moises39s devotion to keeping his brother alive particularly when she watched the two men interact The sick man doesn39t respond to commands from anyone she says but when his brother speaks to him in Spanish quotthere39s this look in his eyes this icker of recognition He knows his brother is somewhere in there and he can still get to him 39 55 Who Gets Health Care Rationing in an Age of Rising Costs Second in a Series Health Club Behind Medicare39s Decisions An Invisible Web of Gatekeepers By Laurie McGinley 16 September 2003 The Wall Street Journal TUCSON Ariz One evening in 1986 while Chris Erringer was sitting in his Toyota Land Cruiser a stranger approached him and shot him under the right eye Mr Erringer jumped out of the truck lunged at his assailant and collapsed The gunman shot him in the back stole his money and ed Mr Erringer says When he came to quotnothing workedquot The attack left Mr Erringer a quadriplegic with painfully knotted back and neck muscles His only relief shots of a mild anesthetic which his doctors administered twice a month Mr Erringer who was left unable to work and lived on Social Security disability benefits depended on Medicare to pay for the treatments Then in September 1999 came a letter that would change his life again Medicare would no longer cover the injections quotIt didn39t really explain whyquot he says quotIt just said noquot Mr Erringer continued to get the trigger point injections as they39re known but only once a month or sometimes less He cut down on the shots in case Medicare rejected his doctors39 appeal and he ended up getting stuck with the whole bill Because of the pain he mostly sat in his wheelchair quotlike a rag dollquot says Larry Shepherd a friend and Mr Erringer39s legal guardian Mr Erringer39s headaches and depression worsened The rare dinner or movie out became even rarer quotI kept wonderingquot says Mr Erringer now 44 years old and gray haired quotWhy did Medicare do this out of the bluequot Finding the answer took Mr Erringer more than a year of frustrating arguments and appeals a legal crusade that turned into a class action suit against Medicare39s bosses The decision makers it turned out weren39t in the massive Baltimore headquarters of the federal Centers for Medicare and Medicaid Services which runs the Medicare program for nearly 40 million elderly and disabled Americans The real authority lay in the hands of a North Dakota insurance company one of the hidden gatekeepers of American medicine who ration health care About two dozen of these government contracted insurers handle the claims for doctor visits and hospital outpatient procedures submitted to the 250 billion a year federal program The Medicare agency commonly known as quotCMSquot sets national policies on coverage for some items including expensive new technical advances But the agency gives the insurers whose territories cover multiple states or even whole regions broad authority to fill in the blanks laying down local rules on what Medicare will cover and what it won39t The result Decisions on everything from trigger point injections to psychiatric services to the use of ultrasound and CT scans are in the hands of the insurers and their little known medical directors as Those decisions can vary widely from region to region creating a patchwork of rules that sometimes angers doctors and patients In the late 1990s dermatologists howled as medical directors in Florida and elsewhere restricted the treatment of certain skin lesions that can be precursors to skin cancer In 2001 CMS issued a national ruling lifting the restrictions In a recent report the General Accounting Office Congress39s watchdog agency found that in the past few years there was widespread variation in coverage for a new treatment called bilateral deep brain stimulation for debilitating tremors caused by Parkinson39s disease For example insurers covered the treatment for certain patients treated in Kansas but not in Florida The inconsistencies ended in April when CMS responding to the request of a Texas patient approved the treatment nationally Meanwhile when meetings are called to consider these local policies they39re attended mostly by doctors and manufacturers pushing for approval of services and devices A Medicare spokesman notes that insurers announce the meetings on the Internet and elsewhere but quotthe general public doesn39t show up for these thingsquot Mr Erringer39s fight for answers offers a window into how these insurers regulate and sometimes restrict medical care often with policy rulings that most patients and many doctors weren39t aware of until a claim is denied quotIt39s rationing It39s a way to limit thingsquot says Grant Bagley a former top Medicare coverage official who now represents manufacturers providers and beneficiaries as a partner at the Arnold amp Porter law firm in Washington Tom Scully the administrator of CMS sharply disputes that notion as does the insurer that cut back on coverage for Mr Erringer The medical directors Mr Scully says quothave no economic incentive to deny coverage for anything They are trying to do the right thingquot Indeed the issue here isn39t quotgreedyquot insurers limiting health care to pocket extra profit The insurers are paid by the number of claims they process regardless of whether the claims are accepted or rejected and Medicare covers about 99 of the procedures and items submitted for claims according to the GAO report While the insurers write the reimbursement checks for Medicare patients the money comes from a government funded bank account Last year Medicare paid the insurers 108 billion to handle 970 million claims from doctors hospitals and other health care providers The local policies are one of the few brakes in a program that costs more every year and will cost even more when the baby boom generation retires especially if Congress adds prescription drug coverage Without local rules on coverage says Mr Scully quotspending would be higher because nobody would ever say no and it would be ludicrousquot He argues moreover that the local policies provide needed exibility for regional variations in medical practice and that the decision making process is quotfaster less politicized and less controversialquot than on the national level especially for new technology At the same time he39s encouraging medical directors across the country to work together more to make their policies more consistent av Back in September 1986 Mr Erringer then 27 was estranged from his adoptive parents and trying to figure out what to do with his life He had been laid off from a job moving mobile homes and was pursuing passions for music hiking and motorcycles When he was attacked he was four wheeling in a dried up riverbed in northern Tucson He was rescued by hikers and spent more than five months in the hospital leaving with a grim trophy a bullet that severed his spinal cord The surgeon carved Mr Erringer39s initials on the bottom The bullet that went in under his eye fragmented one piece got infected and was removed but others including one in his ear canal remain quotIf I stick a Q tip in my ear I have to be carefulquot not to bump it he says Mr Erringer faces a lifetime of limits and loneliness He is plagued by bladder infections has no use of his legs and only very limited use of his arms which are too weak to move his wheelchair backward through the carpets in his house quotThis brown carpeting is like quicksandquot he says He passes time listening to ZZ Top Mozart and Michelle Branch and playing Tomb Raider video games using partially numb hands that he says quotare like two dog pawsquot Like many people who are paralyzed Mr Erringer has intractable chronic pain called myofascial or quotreferredquot pain It starts in the right shoulder where there are weak muscles between the active and inactive muscle areas but can radiate to different parts of the body quotIt can be both shoulders and neckquot he says quotI39m just a rack of pain sometimes When I39m moving it hurts all the timequot Mr Erringer depended and still does on Mr Shepherd who became his legal guardian in the early 1970s when Mr Erringer was around 13 Mr Shepherd now 65 took in Mr Erringer after a bitter argument between the boy and his adoptive father the culmination of a long con ict between the two Mr Shepherd was a family friend He had bought some property from the adoptive father and for a short time the two were in business together After Mr Erringer was shot and other arrangements to care for him fell through Mr Shepherd stopped working and took care of him full time Mr Shepherd gets a low hourly wage from the state to care for Mr Erringer For Mr Erringer39s muscle spasms starting at quottrigger pointsquot in his neck and back doctors prescribed physical therapy epidural injections and running electrical current through the muscles quotIt didn39t help except for the cheap thrill of getting shockedquot Mr Erringer says The only thing that worked was injections of the anesthetic Marcaine made by AstraZeneca PLC and occasional steroids which he no longer gets Every two or three weeks doctors would inject the anesthetic often in several different shots directly into his tightly knotted muscles Relief lasted about 10 days His doctors saw few alternatives quotAggressive pain management improves Chris39s ability to care for himself and to maintain some quality of lifequot says Charles Blake a specialist in rehabilitation medicine quotIn spite of all this he39s a nice personquot Then in September 1999 came the letter from Noridian Administrative Services an insurer in Fargo ND that handles Medicare claims in Arizona Noridian handles more than 56 million claims a year from 11 states 58 Mr Erringer39s four injections from August 1999 which totaled 15725 had been denied quotThe information we have in your case does not support the need for this many visits or treatmentsquot the letter said without further explanation Mr Erringer felt panicky and confused quotI wasn39t fakingquot he says quotWho would want needles stuck two inches deep in knotted up muscles unless they needed itquot Noridian subsequently refused to pay for the trigger point injections totalling almost 1100 that Mr Erringer got from August 1999 through early February 2000 He and his doctors appealed Dr Blake submitted office notes showing concern about Mr Erringer39s discomfort Noridian personnel in Fargo ND who weren39t involved in the initial denial turned down the first two appeals Traci Arzt the Noridian hearing officer who denied the second appeal wrote in her decision that Mr Erringer39s file didn39t show the medical necessity of more than 12 shots a year quotThere was no indication that you were showing improvement from these injectionsquot she wrote Mr Erringer who lives on Social Security disability benefits of about 660 a month was furious The medical necessity of the shots had never been called into question before and nobody had ever asked if he were quotshowing improvementquot He says he finds the whole idea of improvement ludicrous given his condition quotIt shows they didn39t know anything about mequot he says He contacted Sally Hart of the Arizona Center for Disability Law and Center for Medicare Advocacy in Tucson Ms Hart who had helped Mr Erringer on a separate medical bureaucracy issue studied the rejection letters and found a valuable clue The denials were based on a new quotlocal medical review policyquot one of the most contentious features of the Medicare system CMS has issued hundreds of rules since its creation in 1965 on everything from liver transplants to cardiac pacemakers specifying what the government will pay for and for which patients Beyond those guidelines Medicare gives its regional gatekeepers broad leeway to establish their own standards known as local medical review policies or LMRPs The guiding criterion in establishing these policies that procedures be quotreasonable and necessaryquot Medicare gave private insurers a prominent role in the program to assuage the American Medical Association39s fears that Medicare was the first step toward nationalized health care For years the insurers raised few questions about the claims submitted But over the past decade Medicare officials in an effort to reduce billions of dollars in fraudulent and improper payments have encouraged insurers to be more aggressive in setting policies in making sure doctors bill the program correctly The result The insurers have created more than 9000 local medical review policies CMS in recent years has pushed the insurers to set more uniform policies solicit more physician and public response before enacting them and then post the rules on the Internet so it39s easier for people to find them 59 Ms Hart was familiar with local medical review policies from her work as a patient advocate She got a copy of Noridian39s policy on trigger point injections and appealed to the Social Security Administration whose administrative law judges handle Medicare appeals if a patient wants to go beyond the insurance company decision Unlike the insurers39 employees Social Security judges aren39t bound by local medical review policies Usually in consultation with a medical adviser these judges determine whether a service is reasonable and necessary Six months later at an August 2001 hearing in Tucson administrative law judge James Lawwill sided with Mr Erringer and ordered Noridian to pay the bill for the past claims All other methods of treatment he later wrote in his decision on the case quothave been unsuccessful in controlling his intractable painquot While pursuing the administrative appeals Ms Hart Mr Erringer39s lawyer brought a class action suit against the government in federal district court in Tucson The suit filed jointly with lawyers at the Center for Medicare Advocacy in Willimantic Conn was intended to force Medicare to notify beneficiaries when claims are denied due to a local policy change so they can appeal more effectively Medicare agreed last fall to make the change nationwide as part of a settlement and also told its contractors to inform patients how to get copies of the LMRPs at issue But Mr Erringer lost another part of his case The suit also sought to require the government to publicly define quotreasonable and necessaryquot and other criteria used by contracted insurers in setting local coverage policies The judge ruled that Medicare wasn39t required to do so because such criteria are interpretive and thus exempt from federal rule making requirements Medicare has tried in the past to define quotreasonable and necessaryquot but the effort has been derailed by criticism from one side or the other Ms Hart and Mr Erringer are appealing the decision Still there was one question Mr Erringer couldn39t answer Why did Noridian change its policy in the first place Insurers may adopt local medical policies if they see a problem that suggests overuse of a specific service or a quotsignificant riskquot to the Medicare trust funds That39s what happened with the trigger point injections says William Mangold a Noridian medical director in Phoenix In the fall of 1998 TransAmerica Occidental Life Insurance Co which analyzed claims trends for Noridian brought Dr Mangold and his five fellow medical directors a problem In analyzing claims to look for trends in demand TransAmerica noticed a substantial increase in trigger point injections Medicare medical directors around the US had noticed similar trends So TransAmerica suggested restricting coverage to one injection a month in most cases The policy added that patients with chronic pain might need more shots even weekly if there were strong evidence of medical need Dr Mangold and the other Noridian medical directors adopted the injection policy effective July 1 1999 after running it by their physician advisory committees The change was published in a newsletter sent to doctors who participate in Medicare Mr Erringer39s doctors say they didn39t see the announcement because they39re inundated with information from various sources and don39t have a chance to read it all Dr Mangold an avid biker and former marathon runner who spent most of his career as a family physician and then plastic surgeon says his goal is to make sure patients get what they need while ensuring Medicare doesn39t pay for inappropriate treatments He resisted friends who urged him to apply for a Medicare medical director job when it became available in 1997 quotAre you kidding I hate Medicarequot the 60 year old doctor recalls telling his friends To him it was quota large organization it was tough to find a person to discuss things withquot That39s why you should do it they responded So he agreed in an effort to quotput a human face on Medicarequot Dr Mangold the former president of the Arizona Medical Association says he first heard of Chris Erringer when details of the proposed class action settlement in the case were posted last November on the CMS Web site He39s chagrined that the dispute went so far quotThe doctors when denied should have called me and said This guy really needs this39 quot he says today He says that he has authority within boundaries to decide whether a service should be covered and that doctors call each week Dr Blake and his staff say they never heard of such an approach quotNoridian tells us to appeal everything to headquarters in Fargo and that39s what we didquot says Barbara Ellis Dr Blake39s office manager adding that documentation was provided to show Mr Erringer39s chronic pain problem A Noridian spokesman says medical directors aren39t the front line in appeals Still Dr Mangold says he isn39t sure if he would have approved the shots had Mr Erringer39s doctors contacted him Such frequent shots are quotcontroversialquot even for someone with Mr Erringer39s condition he says Based on factors including his own experience and discussions with pain specialists quotit doesn39t sound like a good way to treat pain over the long termquot James Rathmell professor of anesthesiology at the University of Vermont College of Medicine and a specialist in pain treatments says there39s little consensus in the medical community about how many injections are appropriate Indeed a number of other Medicare insurers limit the frequency of the shots Dr Rathmell who doesn39t know Mr Erringer says that in his case injections every two to three weeks quotsounds reasonable and doesn39t seem excessivequot For now Mr Erringer continues to get shots just once a month and endure the pain when the effects wear off Noridian covers the injections but he39s reluctant to try for more shots afraid it would ignite another battle Indeed Noridian39s newest policy adopted in August 2002 is tougher than the previous one citing a new study it generally limits patients to injections every other month although it says more are permitted with proof of medical need Even if Noridian approved as many shots as Mr Erringer thinks he needs he doesn39t know if he could afford the 1150 in copayments for each visit He39ll have a little more money now that his friend Mr Shepherd is going on Social Security but that raises a whole other set of concerns quotWe aren39t getting any youngerquot he says And without Mr Shepherd quotI see 20 to 30 years of sitting in a nursing homequot Who Gets Health Care Rationing in an Age of Rising Costs Third in a Series Message in a Bottle To Sell Pricey Drug Lilly Fuels a Debate Over Rationing By Antonio Regalado 18 September 2003 The Wall Street Journal In the war over how health care should be allocated in the US one of the big new battlegrounds is an expensive drug called Xigris A committee of doctors and academics was convened this year to study quotethics and rationingquot in intensive care units after debate erupted over who should get Xigris The drug used to treat severe sepsis a deadly syndrome associated with severe infections costs 6800 per treatment Some doctors and patients concerned about reluctance to prescribe the drug are questioning whether patients are dying because of tight fisted hospital policies quotIt39s amazing This is a new lifesaving technology that worksquot says Jay Steingrub director of Baystate Medical Center39s medical intensive care unit in Springfield Mass who has begun speaking out on the issue quotYet it39s been rationed without the American public being aware of itquot Behind the scenes an unconventional campaign by Xigris39s maker Eli Lilly amp Co is fueling the debate With Xigris39s sales far below expectations Lilly is stoking a controversy over who should get expensive treatments in times of limited resources It gave a 18 million grant for the study of health care rationing practices It successfully lobbied for a special reimbursement of half the drug39s cost for Medicare patients It hired public relations firms that helped the drug maker shape a rationing debate strategy And it has rallied patients and doctors who believe in the drug Dr Steingrub for instance occasionally travels and speaks on behalf of Lilly and is paid per diem consulting fees by the company He says he began speaking out about rationing after becoming concerned that patients weren39t being informed of their options quotI talk about the academic aspectsquot of the drug39s use he says quotI don39t push the productquot Lilly39s campaign for Xigris re ects the unique way in which health care is rationed in America In other countries for better or worse government bureaucracies set guidelines for what drugs cost and who gets them But in the US these decisions are made every day by a vast array of gatekeepers from doctors to government employees to insurance officials And all of these people are targets for a big company that wants to in uence the process Xigris was approved in late 2001 to treat severe sepsis which kills about 250000 people a year Lilly had counted on Xigris the first new treatment for sepsis in years to be a blockbuster and some analysts were predicting sales would reach 1 billion a year Lilly launched a giant marketing blitz doctors arriving at one conference found Xigris39s name emblazoned on the key cards to their hotel rooms But rising costs have forced hospitals and doctors to make hard decisions Many expensive treatments and procedures are being scrutinized with medical benefits closely weighed 7quot against cost Xigris hasn39t fared well in those calculations According to Lilly an estimated 750000 suffer from severe sepsis each year Sales figures suggest doctors wrote fewer than 15000 prescriptions for Xigris in 2002 Total sales were only 100 million Lilly marketing executives declined to be interviewed for this article In a prepared statement Lilly said it believes its drug is quotunderutilizedquot because doctors don39t always recognize severe sepsis and because of inadequate reimbursement from insurers and the government Lilly says its goal is quotto make sure that all patients who meet the eligibility criteria for the use of Xigris receive the treatmentquot The company says it won39t lower the price of the drug Xigris39s price is based on the benefit it gives patients as well as the high cost of discovering and manufacturing the drug Lilly says A recent survey published by the Society of Critical Care Medicine a professional group found intensive care doctors said they were withholding treatments because of cost even though they believed it was unethical to do so According to the 620 doctors who answered the survey Xigris was the most widely rationed drug 27 said they had withheld Xigris and 43 said they might The survey wasn39t funded by Lilly but it was conducted by a doctor who consults with Lilly Some experts say the drug isn39t widely used because doctors simply aren39t convinced it works In a clinical trial of 1690 patients 25 of Xigris patients died compared with 31 of those on standard treatment Standard treatment involves putting patients on antibiotics and medicines to increase blood pressure which typically cost less than 50 a day Last year a group of scientists published a critical assessment of Xigris in the New England Journal of Medicine arguing that another study was needed in order to quotjustify the use of the drugquot Lilly rebutted the published criticisms as quotwithout meritquot and says denying Xigris to desperately ill patients is quotunethicalquot The company39s clinical trial showed Xigris saves about 1 in 16 people who would otherwise die of sepsis if given only standard treatment The rate is 1 in 8 among severe cases Lilly says In March 2002 Sandra Tiffany was in a coma suffering from sepsis When the doctor treating her Daniel Dea of Providence Saint Joseph Medical Center in Burbank Calif prescribed Xigris a hospital pharmacist came to the intensive care unit to double check the diagnosis Ms Tiffany a state senator from Nevada got the new drug and lived Dr Dea has used Xigris about 15 times since He39s had to explain his decision each time he says to the hospital pharmacy and other doctors In some cases he39s agreed not to use it quotWe have been under pres sure from the pharmacy and hospital to almost ration itquot he says Teresa Lee Yu pharmacist at Saint Joseph says that for every Xigris use there is quota significant lossquot of 3000 or more for the hospital quotIt would be a budget buster if it was not used appropriately or used indiscriminatelyquot she says Xigris is quotan expensive drug with side effectsquot says Myron Berdischewsky chief medical officer at the nonprofit Catholic hospital 63 While doctors have the ultimate say in which drugs are used he says quottoday cost is part of the equation It39s not so much rationing drugs but using them rationallyquot Shortly after treating Sen Tiffany Dr Dea says he received a phone call from Perry Communications Group Inc a public relations firm in Sacramento Calif which was seeking Xigris success stories on behalf of Lilly Sen Tiffany 54 has since worked closely with the agency giving TV interviews to describe her near death experience She39s been given a quotsecond chance to livequot she says and her aim is to quotlift awarenessquot of the Xigris treatment Dr Dea says he has begun work on a new study of Xigris funded by Lilly and has become a member of Lilly39s speakers bureau He gets a fee from Lilly but Dr Dea says it doesn39t in uence his use of the drug Lilly pays doctors speaking fees of 1000 or more depending on their seniority and expertise Rationing isn39t part of the talking points and slides Lilly gives to its lecturers who focus on sepsis and the drug39s application But the issue often comes up At one educational roundtable he attended doctors were asked which issue most affected their use of Xigris quotEveryone said the costquot Dr Dea says Xigris39s slow sales are a sore disappointment after Lilly invested nearly two decades and the company says quothundreds of millionsquot of dollars into development of the drug Sepsis is an in ammatory response that can follow infection brought on by pneumonia or major surgery But because it39s a syndrome not a single disease the condition is tricky to diagnose and difficult to develop treatments for Promising drugs tested by several companies during the 1990s failed Lilly39s drug is a version of a molecule produced by the human body that blocks in ammation and clotting The protein is complex and not easily made But in 2000 the company39s effort appeared to be rewarded Lilly said its key study showed the drug was saving lives The study was halted early and the company applied for government approval to market the drug Lilly expected Xigris to provide a much needed boost after the loss of patent protection in 2001 of its blockbuster antidepressant Prozac Xigris was also important because it was a first of a kind treatment for serious disease quotNo medicine better symbolizes our mission than Xigrisquot Sidney Taurel Lilly39s chairman president and CEO wrote in the company39s 2001 annual report calling it quotone of our industry39s genuine breakthroughsquot The Food and Drug Administration39s advisory panel split 10 10 on whether to recommend approval for Xigris with some saying another clinical trial was needed After studying Lilly39s data the FDA approved the drug in November 2001 but only for a subset of the sickest patients The study indicated Xigris worked best in patients with the most severe form of the disease The limited definition of who can get the drug has contributed to its slow sales Lilly says It has several other continuing trials of the drug hoping to win approval for other patient groups Worried about the drug39s high cost and side effects hospitals quickly began writing guidelines for its use Many adopted the criteria used in Lilly39s key trial which excluded several types of patients including those with cancer pregnant women and people over 80 By the spring of 2002 it was clear sales were falling far short of expectations Lilly shook up its external public relations putting the contract for Xigris out for bid It had been held by Edelman Worldwide a large New York firm but the winning proposal came from Belsito amp Co a small shop in Manhattan Its pitch for the Lilly contract was titled quotThe Ethics The Urgency and The Potentialquot Marybeth Belsito the ad company39s president says quotthe premise was that it was unethical not to use the drugquot Lilly put Ms Belsito in contact with Mitchell Levy head of the medical ICU at Rhode Island Hospital in Providence Dr Levy had previously conducted the survey of ICU doctors who said Xigris was the most widely rationed drug Ms Belsito proposed that Dr Levy lead a study of Xigris rationing Dr Levy insisted the study take a broad look at the rationing issue It was quotan opportunity to study something that would never otherwise get fundingquot he says Eventually Lilly agreed to provide 18 million for a comprehensive study of ICU rationing practices The 20 person group called the Values Ethics amp Rationing In Critical Care Task Force has yet to present any findings and its efforts aren39t specifically aimed at Xigris However the task force includes many leading ethicists hospital directors and ICU specialists who are in a position to in uence views on the drug Dr Levy who is also a member of the faculty at Brown University39s Medical School hopes the rationing task force will help ground physician39s decisions more firmly in medical evidence quotLilly funded the consortium because they know the data behind their drug is damn good They don39t direct the task force but they know we are going to prioritize treatments based on evidence based dataquot At their first meeting at a Scottsdale Ariz spa in January the group laid plans for a paper outlining the rationing phenomenon and a more comprehensive survey of how ICU doctors withhold treatments Dr Levy says his initial rationing survey was motivated by his concern that the drug was being used inconsistently including at the network of four nonprofit hospitals where he works Lifespan Health Systems Corp Dr Levy39s ICU was starting to use Xigris frequently but the ICU at Miriam Hospital another member of the network used it rarely leading to a noticeable difference in their pharmacy budgets Paul Yodice head of Miriam39s ICU says the difference may be because of chance given that each ICU sees different patients But he adds that Xigris is quotextraordinarily expensivequot The expenditures are hard to warrant given his doubts over whether the drug really works Dr Yodice says Lilly has had some success in its effort to clear the way for wider use of the drug Lilly won a new federal diagnostic code for severe sepsis so hospitals would begin reporting how many patients they see who have the condition and might be eligible to receive the drug The company has also encouraged state legislators to introduce legislation designed to promote the drug39s use by mandating that sepsis cases be tracked by hospitals and reported to the state government Lilly successfully petitioned the Centers for Medicare and Medicaid Services for quotnew technology status for Xigris winning a special dispensation for 50 reimbursement from the federal government up to 3400 It was the first time such approval has been given In most cases hospitals are reimbursed for the cost of treating a disease or condition rather than for a specific drug Sen Tiffany says she personally called Health amp Human Services Secretary Tommy Thompson39s office to lobby for the approval Rationing Care in the ICU In July 2002 620 Society of Critical Care Medicine members responded to a poll regarding their experiences in the last year using limited health care resources Has your hospital or institution limited the supply of a specific resource and if so what have they limited Intensive care unit beds Certain Have you rationed any of the following medications or procedures in the last 12 months MedicationTreatment Percent Source Society of Critical Care Medicine Who Gets Health Care Rationing in an Age of Rising Costs Fourth in a Series The Rules At One Hospital A Stark Solution For Allocating Care By Bernard Wysocki Jr 23 September 2003 The Wall Street Journal GALVESTON Texas Joan Richardson chief medical director at the hospital of the University of Texas Medical Branch faced an agonizing decision Should she approve a 1500 drug for a 52 year old woman with metastatic breast cancer The patient had no money no insurance and rapidly fading hope Three powerful cancer drugs had failed to help her A fourth exemestane offered a slim chance but strict rules at the hospital barred the drug from being given to patients who couldn39t pay for it Dr Richardson would have to authorize the money to come from a 25000 a month drug fund for indigents meaning some other poor person who needed a costly drug might not get it The 59 year old Dr Richardson who sports a spiky hairstyle and a west Texas twang approved just one exemestane treatment quotUnless this patient really improves this is the end of the roadquot she said The hospital says it39s too early to tell if the drug is working The rules restricting drugs at this 795 bed hospital are part of a bold experiment in allocating health care at a time of rising costs In most other US medical centers decisions about who gets scarce resources such as expensive drugs and surgical procedures are often made on an ad hoc basis with few formal guidelines for doctors and nurses on how to help their patients while hewing to budget restrictions But UTMB as this state supported hospital is known has developed a detailed playbook to help determine exactly who gets treated and who doesn39t Its rules require that patients undergo financial screening before they can be admitted and that virtually everybody pay a fee before seeing a doctor For patients who are poor or uninsured the rules restrict or proscribe the use of certain drugs and treatments Some procedures are barred outright such as hyperbaric oxygen treatments which are widely used at other hospitals to help wounds heal The system empowers certain decisionmakers such as Dr Richardson to make exceptions to the rules but usually within a specific budget Unlike most hospitals UTMB is also blunt about its need to limit some services on financial grounds quotWe are rationingquot says John Stobo UTMB39s 62 year old president and chief executive The hospital39s rationing system dubbed quotDAMPquot for quotDemand and Access Management Programquot has helped its bottom line Five years ago UTMB was headed for an 80 million budget deficit Last year it posted a modest budget surplus But the rules have hit its hometown hard UTMB a sprawling complex that includes a medical school and a nursing school is the only hospital in Galveston a port city of 55000 that has fallen on tough times Under the rationing rules UTMB has cut back on admissions of uninsured patients who are then forced to defer or forgo treatment Before DAMP was instituted in 1998 about 26 of UTMB39s patients 7V were uninsured Today that figure is 17 In the hospital39s emergency room which by federal law can39t turn away anyone who claims to need immediate care the waiting time has stretched to as long as five hours or even longer Hospital officials say they had little choice In the late 1990s uninsured patients were overwhelming the institution and many didn39t pay their bills UTMB which was established in 1891 with a mission to care for the poor was also swamped by waves of low paying patients covered by Medicare the federal program for the elderly and Medicaid the state federal program for the poor and disabled In a message to the staff posted on the hospital39s Web site in 1998 Dr Stobo warned that UTMB would have to restrict care for the indigent or become indigent itself At first Dr Stobo newly recruited from a top job at Johns Hopkins University School of Medicine in Baltimore reduced costs the traditional way He fired staff and mothballed beds When he felt he could cut no further he took a more radical step He appointed a committee of administrators doctors and midlevel staffers to codify a top to bottom system for distributing services with limits that could be consistently applied The committee which came up with the acronym DAMP set rules that start at the front door People without insurance must pay 80 before they can see a doctor unless they can prove they are indigent meaning they earn less than 2800 a month for a family of four which is 185 of the federal poverty level In that case they qualify for a discounted fee of about 30 depending on their county of residence The discount is also given to dependents and UTMB rules stipulate that children will never be turned away But otherwise anyone who shows up at UTMB without the money is sent home unless a doctor deems them sick enough to be seen immediately Under the rationing scheme the first cut is made by people such as Roslyn McCray one of 17 financial screeners who scrutinize the income and insurance of everyone seeking treatment One afternoon earlier this year Ms McCray sat in a tiny office near the entrance to the UTMB outpatient clinic and called up the computer records of John Paul Regini a 48 year old unemployed welder39s helper who sat across from her It was the second attempt by Mr Regini who is uninsured and doesn39t qualify for Medicaid to see a UTMB doctor Two months earlier he had been referred to a UTMB internal medicine specialist by a county health clinic which had diagnosed him with high blood pressure He showed up without the upfront fee The screener he saw at the time one of Ms McCray39s colleagues suggested that Mr Regini try to prove he had little or no income in order to be eligible for the discount Then she suggested a way how Get a notarized letter from his mother stating that she supported him Before he was sent home a doctor reviewed his file as UTMB rules require and concluded his situation wasn39t urgent enough for him to be seen immediately In cases where patients don39t have the upfront fee a nurse makes a quick assessment and then presents the findings to a doctor UTMB doesn39t reveal details of these doctor patient interactions citing laws protecting patient confidentiality Now Mr Regini was back with the notarized letter and 30 and it was up to Ms McCray to determine whether the document was sufficient proof that he was a dependent quotIs this still IH your phone numberquot Ms McCray asked quotNo that39s my mom s replied Mr Regini a strapping man in blue jeans She decided the letter looked legitimate and approved his appointment to see a doctor later that day Mr Regini says he was diagnosed with excess iron in his blood and is awaiting further appointments Ms McCray the 39 year old daughter of a nurse and a machinist has been a UTMB employee for 15 years and says she often shows patients how to sign up for Medicaid or for another federal state program that aids families whose incomes are above Texas39s very low Medicaid ceilings But she39s also on the lookout for people who falsely claim to be indigent quotThey come in with diamonds and wearing Saks Fifthquot she says UTMB also has strict rules for patients who have failed to pay a previous bill causing a quotbad debt agquot to pop up on the hospital computer These patients currently a staggering 64000 people or 7 of those in the hospital39s records are barred from making an appointment with a doctor unless they qualify as indigent under DAMP rules or a doctor deems their case urgent On a recent day Ms McCray reviewed the bank statements of a southeast Texas couple who had mailed them in to try to prove they were indigent and remove a bad debt ag The wife wanted to make a follow up appointment after a gastrointestinal endoscopy at her doctor39s recommendation but she owed 1300 for the procedure This time Ms McCray wasn39t persuaded The bank statements alone didn39t show that the couple39s monthly income was under 1800 DAMP39s ceiling for indigent status in their case Ms McCray mailed back a request for more financial information As a result of UTMB39s financial screening some poor sick people are deterred from seeking or getting treatment Phyllis Kinsey Scothorn 57 who underwent surgery at UTMB for a heart attack in August 2001 has troubling symptoms but can39t make an appointment at UTMB because of an unpaid bill of 869 quotI39m losing sensation in eight of my 10 fingersquot Ms Scothorn said quotI feel burning sensations in my armsquot At the time of her surgery Ms Scothorn39s then husband39s insurance covered most of her bills but she lost coverage after her divorce Earlier this year she visited a Galveston County clinic that serves the indigent where a general practitioner referred her to cardiac and neurologic specialists at UTMB but she was barred from getting those appointments she says Sitting with her new husband retired bus driver Keith Scothorn in their tiny living room in Santa Fe Texas Ms Scothorn dialed the UTMB billing office and described her illness adding that she had an application pending for Medicaid and Medicare The UTMB billing staffer told her the bad debt ag would be removed from her account if she sent in a signed letter promising payment of 50 a month quotSo that39s what your life is worth 50 a monthquot Mr Scothorn asked He said they couldn39t afford it The couple39s sole source of income is the 600 monthly pension that Mr Scothorn 66 draws from his home country of Britain He lacks US health insurance and has untreated medical problems of his own Ms Scothorn said she hasn39t gone to the UTMB emergency room because she knows she will get bills she can39t pay It39s also a matter of pride quotIt39s very hard for me to say I need financial helpquot she said A hospital spokesman says quotWe work H with patients to help them develop a payment schedule Once we and the patient have agreed on the terms we schedule additional visitsquot Before the rationing program started the UTMB pharmacy often gave away drugs to poor Texans many of whom drove hundreds of miles to get them In 1998 the pharmacy posted a loss of 12 million and a crackdown on drugs soon followed A committee established a quotgatekeeperquot list of expensive drugs requiring doctors to get approval from high level faculty members before they could be used A few drugs such as Xigris Eli Lilly amp Co39s more than 6000 medication for sepsis a deadly syndrome associated with severe infections were so tightly restricted that only Dr Richardson the chief medical director could approve their use Some commonly prescribed drugs were also put off limits such as Detrol an 85 a month long acting incontinence medication UTMB patients who can39t afford it are prescribed a shorter acting bladder control medication instead Despite the restrictions the UTMB pharmacy posted a loss of 28 million in 2001 Karen Sexton the chief operating officer proposed closing the pharmacy39s outpatient service After raising objections the pharmacy director Kim Sergeant suggested raising the amounts patients must pay and discharging some uninsured patients with a 14 day supply of drugs instead of a 30 day supply That rule was adopted and the pharmacy met Dr Sexton39s goal of narrowing its losses by 1 million last year Dr Stobo the UTMB president and chief executive brie y considered abandoning the hospital39s mission to care for the poor and focusing instead on its research strengths in tropical medicine environmental health AIDS research and other specialties But he quickly rejected that idea quotTaking care of vulnerable populations is what we39ve been doing for 110 years and we39re good at itquot Dr Stobo says quotLet39s have the intestinal fortitude to stay the coursequot In February the state of Texas facing a multibillion dollar budget deficit forced UTMB to reduce its state funded budget by 12 million over the next six months with further cuts of about 50 million likely in 2004 and beyond UTMB gets about 289 million in annual funding from the state out of an overall budget of 12 billion UTMB is upgrading its intensive care units pediatric care and other programs but with the budget cutbacks looming Dr Sexton began drawing up a list of possible programs for elimination Cochlear implants which can restore hearing to the deaf in 60 to 80 of cases but cost a total of about 78000 and are only partly reimbursed by even the most generous insurance plans were among the procedures she targeted Under existing UTMB rules only patients who paid for the implant devices themselves which cost about 20000 were allowed to receive them Dr Sexton believed doctors were being lax in enforcing DAMP rules and were giving implants to too many patients who couldn39t pay for them In March as Dr Sexton weighed whether to eliminate the program she went for a walk on the hospital grounds and struck up a conversation with a mother whose child had come to be examined for a cochlear implant quotI was crying by the time I got to the front doorquot she says Meanwhile the chairman of the otolaryngology department argued that cochlear implants offered disabled people the hope of a normal life and he promised strict adherence to DAMP rules Dr Sexton a registered nurse with a PhD focused on nursing care struggled with her decision But she believed that as long as UTMB carried an inventory of implants sympathetic staff would be tempted to keep doing procedures for nonpaying patients She halted all cochlear implants Wrestling with these issues is quotfrighteningquot she says quotWe39re talking about losing muscle not fatquot Dr Richardson the chief medical director also wrestles with the responsibilities of rationing When the new rules were established she arranged for a special fund to pay for drugs that were put off limits to poor patients To get them doctors must request waivers from Dr Richardson on paper or via e mail She also has authority to approve special quotteaching waiversquot for expensive procedures that might provide useful experience for medical students Striding to her office one recent day she pulled several waiver requests from the pocket of her white hospital coat One was for a 36 year old man on the waiting list for a heart transplant who needed a 100 a month blood thinner The patient39s government disability payments cover many of his expenses such as a device to help his heart pump but not the drug Dr Richardson a pediatrician who has spent most of her career at UTMB approved the 100 a month drug waiver Her reasoning UTMB had already expended so much money getting the patient ready for a transplant that it made no sense to stop treating him In some cases she uses cost benefit analysis Among Dr Richardson39s duties are managing patient ow and because about 100 new inpatients are admitted every day 100 must be discharged She quickly granted one doctor39s request to prescribe a 14 day supply of an antibiotic called Levaquin calculating that it was well worth its 125 tab because it would allow a woman with pneumonia to go home in a day or so and free up a hospital bed for which the hospital could charge 800 a day She made a different decision on a request for four cases of the nutritional supplement Ensure for a severely underweight patient who had recently undergone bowel surgery The cost of the supplement was several hundred dollars Shaking her head Dr Richardson said quotThe person can get Carnation Instant Breakfast for a whole lot lessquot Dr Richardson says the substitution resulted in little or no loss in nutritional value When she can she compromises Recently a patient who underwent a kidney transplant needed a 4500 medicine to stave off infection The patient39s operation was covered by Medicare but the drug called valganciclovir wasn39t quotI cut a backroom deal with the patientquot Dr Richardson says She says she agreed to cover half the price of the drug from her special fund provided the patient paid the other half quotI tried to help him but I didn39t want to break the bankquot Lately she has been forced to say no to some procedures involving illegal immigrants Before the rationing regime UTMB sometimes absorbed the cost of expensive nonemergency care for such patients quotThe issue was not Can they pay or Are they a citizen of this country quot Vl Dr Richardson says Today UTMB39s policy is to stabilize such patients but to avoid protracted treatment Not long ago a 61 year old Mexican woman arrived at the UTMB emergency room with tongue cancer Her doctor applied for a teaching waiver for surgery but Dr Richardson turned it down Her reason was that she couldn39t approve a noncitizen for a teaching case Dr Richardson says the woman was admitted to the hospital brie y but discharged with a recommendation of places to seek treatment in Mexico quotIf somebody is sick you want to treat them Dr Richardson says quotWhen you find you can no longer uphold that credo it39s tough 72 Vital Statistics The University of Texas Medical Branch at Galveston Founded 1891 Facilities 795 bed hospital complex schools of medicine nursing allied health sciences and graduate biomedical sciences correctional care Outreach Conducts clinical and educational work in 135 of 254 Texas counties Patients in 2002 850849 outpatient Visits 35099 inpatient admissions Staff 1000 full time faculty 2500 students residents and fellows 14000 employees Galveston County Population 261219 Ethnic breakdown Hispanic 18 White 73 African American 15 Median age 359 Median per capita income 42419 Population in poverty 155 U TMB patient pro le Patient breakdown by payment source in 2002 Medicaid 25 3 Medicare 228 Indigent 172 Insured commercially 168 Correctional 146 Other 3 3 Sources UTMB Texas County Information Project based on US Department of Commerce data 73 Who Gets Health Care Rationing in an Age of Rising Costs Fifth in a Series Filtering Process Longer Dialysis Offers New Hope By Peter Landers 2 October 2003 The Wall Street Journal In 2001 New York39s Rogosin Institute was about to start an unusual new program for dialysis patients It would give them a blood cleansing machine to use at home for six nights a week eight hours each night Usually patients go to a dialysis center three times a week for four hours a day The quotintensivequot treatment had shown excellent results elsewhere But because both Medicare and private insurers wouldn39t pay for it the nonprofit dialysis center could only afford to make it available to a handful of patients The center which has about 560 dialysis patients says it chooses patients for the new treatment primarily on a first come first served basis As the experience of two patients shows other factors also come into play Henry Eng a former bank manager who was getting conventional dialysis at a Rogosin clinic had earned a reputation as a diligent patient His doctor urged him to sign up quickly for the new program Mr Eng became the first to receive training and to be set up at home with a 13000 dialysis machine and a 5000 water purifier While conventional dialysis left him exhausted Mr Eng 44 years old is feeling vigorous again quotThis is the wave of the futurequot he says Jacques Charlier 58 a writer in New York was also a longtime Rogosin dialysis patient He says he kept to himself and didn39t develop a rapport with doctors and nurses there He doesn39t remember anyone telling him about the nocturnal program and ended up finding out about it last year on Rogosin39s Web site By then the waiting list was 40 people long How is it decided which patients will get the few available spaces in intensive dialysis programs each year The allocation of scarce medical resources in the US can be haphazard with unexpected factors sometimes controlling access to life changing treatments In the case of intensive dialysis the process turns not only on a patient39s health but also on such things as how informed the patient is or on their personality or even the cleanliness of their home quotThe doctors are not really selling itquot says Mr Charlier who is still hoping to get the intensive treatment quotYou have to go and get the informationquot Dialysis which cleans the blood of toxins in place of failed kidneys has long been a ashpoint in debates over health care costs and rationing The US government spends more than 15 billion a year on dialysis and other treatment for kidney failure patients Doctors estimate as many as half of the 300000 people on dialysis in the US might benefit from the six times a week treatment But only a few hundred are receiving it under limited programs paid for by dialysis centers These centers lose thousands of dollars setting up each patient although they hope they will break even over time because of lower overhead costs Rogosin says it needs to make sure patients can handle the demands of the regimen quotIt39s not our policy to go out and hustle people on thisquot says Jonathan Lorch who heads the intensive VV dialysis program quotYou don39t want people to catastrophically fail The chance for a less conscientious person to get in trouble is hugequot A big obstacle for many patients is that they don39t know about new treatments In the case of intensive dialysis doctors often don39t mention it to patients because it isn39t widely available Unless patients aggressively research the subject they39re left at the mercy of doctors and nurses who give out information about new treatments or clinical trials as they see fit In dialysis the information gap often starts with patients39 underestimating the gravity of their condition Of 100 Americans on dialysis today 23 on average will be dead a year from now a mortality rate far worse than breast cancer or colon cancer quotMost people on dialysis have no concept that their prognosis is so grimquot says Christopher Chan a kidney specialist at Toronto General Hospital Doctors who have tried the six times a week method say their patients almost universally feel more energetic A range of small studies back up the idea quotThey39re not only getting their health back they39re getting their life backquot says Toronto39s Dr Chan who has 46 patients on intensive dialysis paid for by the hospital The first attempts with six nights a week dialysis were conducted in Canada in 1994 Such treatment remains rare world wide Big for profit dialysis chains such as Nashville Tenn based Renal Care Group Inc or Fresenius Medical Care North America of Lexington Mass don39t offer the six times a week treatment because they depend on government reimbursement Medicare covers most dialysis patients but only for a maximum of three days a week as it does for Messrs Eng and Charlier Payments differ somewhat by region New York39s Rogosin for example says it gets paid 144 by Medicare for a single dialysis session Private insurers generally follow guidelines similar to the government39s Many doctors and patients feel Medicare is in effect rationing time on dialysis machines by limiting payments to three times a week Medicare39s chief clinical officer Sean Tunis says he39s waiting for proof that intensive dialysis is more effective than three day a week treatment noting that many seemingly successful new therapies ultimately fail to stand up to scrutiny No large scale studies of intensive dialysis have been conducted The National Institutes of Health is planning one soon but results aren39t expected until 2008 In the meantime quotdollars and centsquot will keep doctors from offering intensive dialysis says Robert Lockridge who co owns a dialysis center in Lynchburg Va He has dipped into profits from conventional dialysis to start a six times a week program for certain patients Dr Lockridge and others are pushing for legislation that would require Medicare to pay for more frequent treatment but bills in Congress have failed so far Ever since it was invented during World War II dialysis has forced tough decisions about who gets the treatment The world39s first hospital medical ethics committee was set up in Seattle in the 1960s specifically to consider dialysis Because only a few machines were available the committee had to ration time on them deciding which kidney failure patients would live and which would die V6 By the 1970s dialysis machines were more plentiful and a new problem emerged paying for treatment On Nov 4 1971 an activist named Shep Glazer appeared before a congressional committee hooked up to a dialysis machine quotWe live in constant terror that if these treatments are taken away from us because our money has run out death will come in a matter of weeksquot he said quotWe feel that this country is morally obligated to its citizens to provide this treatment to all who need itquot Impressed by the testimony Congress passed legislation requiring Medicare the federal program for the elderly and disabled to pay for dialysis for anyone of any age who needs it Kidney failure is the only disease to receive such special treatment Because Medicare picks up most dialysis costs private insurers typically don39t pay for the treatment for long Today dialysis is a fast growing burden on the American taxpayer Kidney failure has become more common due to the rapid spread of diabetes In 2001 the 292000 people on dialysis plus another 114000 who had received a transplanted kidney accounted for 64 of Medicare39s 242 billion budget even though they represented about 1 of Medicare39s enrollees Dr Lorch who heads Rogosin39s home dialysis program says the institute was willing to go into the red to try the treatment but not so far as to threaten the center39s viability Rogosin had a 19 million deficit in 2002 with 13 million in net assets according to IRS filings Half or more of dialysis patients aren39t good candidates for nocturnal dialysis doctors say Some patients are too weak to operate the machines while some lack the discipline to maintain the required schedule Other patients prefer to have technicians at a clinic take care of everything Still that leaves tens of thousands of eligible Americans Wealthy patients could buy a dialysis machine with their own money hire a specialized dialysis nurse to train them how to use it and pay a doctor to supervise the treatment Operating expenses and supplies would add thousands of dollars to the annual cost making the treatment prohibitive for most people Some centers such as Rubin Dialysis Center in Troy NY have a formal process to decide who gets into the home dialysis program Rubin has 25 patients in the program now Nurse Shari Meola and her staff interview patients and visit their homes sorting out those who don39t appear to have the discipline to operate the machines She also looks at the cleanliness of a home frowning on such things as cat hair which might clog up the machine Ms Meola says her lecture on the responsibilities of home dialysis is usually enough to persuade less motivated patients to drop out without the center having to officially reject them quotWe lay it out that it39s not a free ridequot she says quotThe patient has to be really motivatedquot The Rubin center gives patients the machine but asks them to pay installation costs of roughly 500 to 750 and to pay the higher water and electrical bills quotIt39s definitely cost prohibitive for some peoplequot Ms Meola says 76 The Rogosin Institute which has a contract to provide dialysis and related services to patients of New York Presbyterian Hospital says it doesn39t formally screen patients for suitability But doctors say they informally encouraged some patients to sign up because it was clear they would benefit from six times a week dialysis Rogosin says it has made efforts to make sure people know about its nocturnal dialysis program The center says it gave iers about the program to its patients and bought radio ads to get the word out when the program was launched As patients streamed in Rogosin was forced to make a waiting list that now contains more than 50 patients It stopped radio ads about the program in mid 2002 There are 14 patients in Rogosin39s nocturnal dialysis program now with two more in training Dr Lorch expects that about half of the patients on the waiting list will drop off for various reasons before beginning training those who remain may have to wait for more than a year quotThey39re not going to die in the interimquot he says quotThey39re just not going to get what we think of as the optimum treatmentquot He adds that the waiting list isn39t fixed in stone quotIf someone came to us on death39s door and needed training we39d train themquot Mr Eng the former bank manager is one of the lucky ones He lost the use of his kidneys in 1984 from a congenital disease but was able to keep working until he went on disability three years ago due to a nerve disorder By the late 1990s dialysis had weakened him so much that he could barely walk a block quotHenry was on death39s doorquot says Dr Lorch Stuart Saal a longtime Rogosin doctor had known Mr Eng for years He was impressed that Mr Eng already had experience with peritoneal dialysis another relatively rare method that requires patients to take care of themselves at home Dr Saal also knew Mr Eng was married with a stable home life Other patients he says seemed less likely to succeed because they lacked motivation or family support When Rogosin decided to start the nocturnal program Dr Saal let Mr Eng know right away quotHe39s just a very capable personquot says Dr Saal quotHe seemed to me like a guy who could do itquot Mr Eng signed up within a week and spent 3000 of his own money to knock out a wall between his bedroom and a guest room where he stores his water purifier Today Mr Eng lives up to his doctor39s hopes The white carpets at his home in Piscataway NJ are spotless He wears sanitary gloves when operating the dialysis machine and asks a visitor to put on a sanitary cap to prevent hairs from getting on the machine The results are impressive Shortly after starting the treatment Mr Eng was able to go apple picking for an afternoon the sort of activity that would have been impossible before His skin color has improved he says quotThere39s something called a uremic pallor some people call it yellowish some call it green That39s gonequot He adds that his appetite has improved and later proves it by putting away a lunch of onion soup cheese nachos and a chicken burger Mr Charlier the writer still goes to Rogosin for his three times a week treatment A published poet Mr Charlier often uses the Internet to research the historical novels he39s now working on Last year he decided to check out Rogosin39s Web site There he discovered information about the home program and thought it was perfect for him because he tries to 77 remain active quotWhen you are on regular dialysisquot he says quotyou always suffer from exhaustionquot He signed up for the waiting list In addition to being motivated patients also have to be exible if they want to get access to new treatments This May Dr Lorch invited Mr Charlier to join a clinical trial that would have given him immediate access to nocturnal dialysis But patients in the trial had to eat a fixed menu and Mr Charlier a self sufficient man who likes to cook for himself didn39t like the frozen carrots and egg substitutes on the menu And he thought the portions were too big quotThe food was terrible and the quantity was outrageousquot he says He dropped out of the trial after a day Dr Lorch was angry about that and when Mr Charlier didn39t contact Rogosin to check about his status on the regular waiting list Dr Lorch dropped him Dr Lorch says he39d reconsider if Mr Charlier tells Rogosin he39s serious about wanting to try nocturnal dialysis Mr Charlier says he plans to do that People on the waiting list who don39t stay in touch with the center may get bumped off Dr Lorch says Those who get into the program quottorture usquot he says with constant requests for information quotThat39s what we want That may sound harsh but it39s a way of us knowing who39s seriousquot 78 Patient Prognoses Five year survival rates for selected diseases and treatments Pancreatic Cancer 86 Dialysis 71 Heart Transplant 34 Breast Cancer 4 Sources US Renal Data System American Cancer Society American Heart Association Tracing a Treatment Key dates in the history of dialysis 1943 Willem Kolff invents the first dialysis machine in wartime Holland 1960 Belding Scribner of the University of Washington invents the quotScribner shunt quota device that gives access to blood vessels for repeated dialysis treatments Longterm dialysis becomes a reality 1972 Congress passes legislation making all dialysis patients eligible for Medicare regardless of age 1994 Doctors in Toronto start first experiments With nocturnal home dialysis an intensive six times a Week regimen 1996 Medicare spending on dialysis patients and others With kidney failure tops 10 billion a year 2004 The National Institutes of Health plans to begin a clinical trial comparing standard three times a Week dialysis With more intensive regimens Source WSJ research V l Who Gets Health Care Rationing in an Age of Rising Costs Sixth in a Series Life Lines Universal Care Has a Big Price Patients Wait By Elena Cherney 12 November 2003 The Wall Street Journal TORONTO Nurse Donna Riley hurried through the drab halls of St Michael39s Hospital to deliver the bad news Eduard Krause a 71 year old retired mechanic had been waiting more than six weeks for heart bypass surgery After fasting for 18 hours he was lying on a gurney ready to be rolled into the operating room Now he would have to wait a bit longer An emergency patient had been rushed into surgery bumping him from the day39s schedule quotThe lady who is having her operation is 34 years oldquot explained Ms Riley quotThey found a big tumor on her heartquot Mr Krause replied quotI can understand all that But if I go home I39m afraid I might not come backquot In Canada39s public health system which promises free equal access care to all citizens medical resources are explicitly rationed For the country as a whole that works Canada spends far less on health care yet the health outcomes of its citizens are generally as good as those in the US But the trade offs are steep Canadian hospitals are slower to adopt the latest technology meaning patients have more limited access to cutting edge medical equipment There are fewer specialists for patients to see The riskiest trade off of all is troublingly long waits Once patients see a family doctor and get a referral for specialist care it can take weeks or even months to get an appointment In some parts of the country patients waiting for admission to a hospital sometimes find themselves waiting for hours and even days on gurneys in the corridor and receiving treatment there Waiting is the giant aw in many national health care plans A study this year by the Organization for Economic Cooperation and Development found waiting times for elective surgery are a quotsignificant health policy concernquot in about half of the group39s 30 members including the United Kingdom Australia Sweden Canada Italy Denmark and Spain Waiting times weren39t a problem in the US the group said In Canada the long waits stirred a public outcry and a government inquiry when a 63 year old heart patient at St Michael39s died in 1989 after his surgery had been canceled 11 times While the inquiry concluded the death wasn39t caused by the delays it highlighted the long waiting lists and called for better management of patients in the line To tackle this crucial problem Canada is turning to Donna Riley and others like her The 51 year old nurse is one of Ontario39s quotcardiac care coordinatorsquot Her job to make sure waiting doesn39t kill patients 80 Hospitals across Canada struggling with their own waiting list woes are now trying to follow Ontario39s model The experience in Ontario the largest of Canada39s 10 provinces spotlights one of the essential problems with health care rationing and a possible solution In Canada one way hospitals restrain costs is by trying to always run at capacity It39s more efficient to run a hospital that way just as it39s more efficient to y an airplane with every seat full But running at capacity means lines always form Waits for certain nonemergency surgeries in Canada can be up to two years In parts of the country there are long lines for such things as magnetic resonance imaging or children39s mental health services Health care spending accounts for 10 of Canada39s gross domestic product while in the US it consumes about 14 Canadian patients can choose their own doctors and they never see a bill for their care Canadian physicians who are paid by the government generally earn much less than their US counterparts Despite Canada39s lower health care spending patient outcomes in a number of areas including cancer and heart disease are similar Overall life expectancy in Canada is 794 years compared with 768 years in the US the OECD says Many factors affect longevity of course Nearly one third of Americans are obese for instance compared with 15 of Canadians And since millions of Americans are uninsured many may not get access to the care they need Some US experts who have studied the Canadian system say that waiting lists are a sign that the health care system isn39t wasting money on unnecessary procedures equipment or personnel quotIf you don39t wait in a medical system there39s a problemquot says Ted Marmor a health policy expert at Yale University The question Prof Marmor says quotis whether people are waiting inappropriatelyquot In Ontario the cardiac care network works to strike this balance The network consists of 17 hospitals and 50 surgeons who share heart patient cases There are government guidelines to follow At St Michael39s six scheduled surgeries are allowed each day Ms Riley39s challenge is to juggle the elective and the urgent cases so that all six operating room slots are filled every day and no one is left waiting longer than the recommended length of time To do that she fields calls about urgent cases from community hospitals that don39t do heart surgery and need to transfer patients Using test results received by e mail or fax she fast tracks urgent cases to the attention of St Michael39s on call surgeon who decides who will be treated that day On evenings and weekends Ms Riley39s bridge games and outings to her nephew39s sporting events are often interrupted by pages from patients waiting for surgery whose pain is suddenly worse quotDonna39s the traffic cop in the middle of a busy intersectionquot says Dr William Sibbald a Toronto expert in critical care and one of the authors of the government report that led to the creation of the cardiac care network 81 Before the network was created there wasn39t much coordination between Ontario39s hospitals and doctors Surgeons managed their own list of patients and waiting times varied greatly from hospital to hospital With Ms Riley and her fellow coordinators working to distribute the patient load the mortality rate for those on the network39s waiting list has been reduced to about 039 from as high as 074 in the mid 1990s Waiting times which have been on a downward trend in recent years increased slightly in the first part of 2003 partly because the severe acute respiratory syndrome outbreak earlier this year forced the cancellation of hundreds of lab tests and elective surgeries The SARS episode showed Canada39s system lacks quotsurge capacityquot according to a report by David Naylor the dean of the University of Toronto39s medical school With hospitals already full handling a large number of patients who required isolation overwhelmed the system At least some of the early infections spread because patients shared emergency room observation areas separated only by a curtain To ensure standardized waiting times for heart patients in Ontario surgeons assign every patient a score of between one and seven depending on the severity of their symptoms The scoring system was devised by heart surgeons and cardiologists Patients are then separated into four categories emergency urgent semiurgent and elective For example a patient who is rated a 2 should wait no more than 48 hours according to network guidelines while a person rated a 35 could wait as long as 14 days A score of between 5 and 7 indicates an elective patient for whom a wait of as long as 120 days is considered safe Hospitals39 waiting times and the percentage of patients treated within the recommended time frames are posted on the network39s Web site quotUrgent people get treatment in a timely fashionquot says Dr Lee Errett chief of cardiac surgery at St Michael39s Today most urgent and semiurgent heart patients are treated within two weeks Non urgent patients wait an average of 49 days for surgery Ms Riley decided at age 12 that nursing was her calling after she helped care for a uncle dying of cancer at her family39s farm on Prince Edward Island After working as a cardiac nurse she rose to the position of head nurse on the surgical ward By the late 1980s the Ontario government tightened spending forcing hospitals to cut beds Heart patients found themselves waiting up to a year for surgery quotThere was no mechanism in placequot to triage patients or share them between surgeons or hospitals says Ms Riley quotThis always bothered u me These days Ms Riley is usually calling the hospital on her cellphone by the time she backs her Honda out of her driveway in the morning Her first call is often to the intensive care unit She needs to know how many patients are well enough to be moved to regular hospital beds quotThe ICU is the bottleneckquot she says Intensive care beds are the most expensive and scarce in the city At St Michael39s 13 ICU beds are reserved for cardiac surgery patients When St Michael39s gets hit with several 82 cardiac emergencies Ms Riley in her white gown and well worn Birkenstock sandals heads to other oors in search of the beds she needs quotDonna won39t sleep well if we cancel a cardiac surgeryquot says St Michael39s cardiac program director Ella Ferris During the day she reviews her three ring binder of elective cases penciling in notes about patients who call to complain about increased pain or scheduling concerns such as a wedding vacation or work commitment On the spring day Mr Krause was scheduled to have his long awaited bypass Ms Riley got a call about another patient a woman with a benign tumor on her heart that could cause a stroke To fit her in Ms Riley needed to cancel another patient The only one she could cancel was Mr Krause because he was rated the least urgent of the six scheduled surgeries for that day While Mr Krause had been waiting six weeks for his date in the operating room he had also waited several additional weeks before that for an angiogram and a stress test quotThey are always bookedquot he said Informed of the last minute delay Mr Krause told Ms Riley his chest pains had grown worse lately to the point where he had almost called an ambulance the night before quotThe pain is constantquot he said Mr Krause was also worrying about his ailing wife and mother in law at home His wife had broken her leg and was on crutches His 91 year old mother in law who has Alzheimer39s disease lives with the couple Mr Krause had recruited his brother and sister in law to help out while he was in the hospital A delay would force the whole family to make another set of arrangements In pushing for Mr Krause39s admission and surgery Ms Riley considered his family situation in addition to his pain He got the operation the next day quotShe39s kind of the patient advocatequot says her boss Dr Errett quotShe39s always the voice of the underdogquot Yet he says the two don39t always agree on who should be treated first quotI override her sometimesquot he says Concern for patients sometimes leads Ms Riley to an odd role reversal She finds herself hounding patients who are hesitant to schedule surgery One patient who operated a swimming pool business refused to be scheduled for his bypass quotbecause of pool season He was taking a risk by waitingquot says Ms Riley She called him every few days to check on him He had his surgery after pool season and did fine The hospitals in the cardiac care network keep a database of patient outcomes to help pinpoint those at highest risk from waiting A recent analysis of the data showed a disproportionate number of deaths were occurring in patients with a condition called aortic stenosis Because of the finding patients with the condition are now seen more quickly The system still leaves surgeons grappling with questions about how to ration finite resources On one of the busiest days in recent months an emergency patient was transferred to St Michael39s with a ruptured valve condition The survival rate for the procedure according to 83 the network39s data is just 10 to 20 Indeed the man died a few days after his six hour surgery The procedure is frustrating says Dr Errett because it claims many resources and so seldom succeeds quotI39ve met with our group and said Maybe we shouldn39t do them at all39 he says In the end the doctors decided to continue doing the procedures Some patients such as Mr Krause say that waiting isn39t too bad a price to pay for their free medical treatment Now recovered from his May surgery he takes a mile long walk before breakfast most mornings quotThe care I think was pretty excellent he says Across the Border Comparing Canadian and US health care The US spends more Health spending as a percentage of GDP Canada 97 US 139 And has more doctors No of practicing physicians per 1000 people Canada 21 US 27 Yet lives are shorter Life expectancy in years Canada 794 US 768 Note Figures are for 2001 Source OECD Health at a Glance 2003 84 Who Gets Health Care Rationing in an Age of Rising Costs Last in a series Dose of Prevention Six Prescriptions To Ease Rationing In US Health By Laura Landro 22 December 2003 The Wall Street Journal Scanning a bank of video screens Joseph Cooke zoomed in on one elderly patient lying in an intensive care unit across the street Dr Cooke gave the man a quick visual exam Then he checked the vital signs on the computer looking for any change in blood pressure heart rate or oxygen levels that might signal an impending cardiac arrest or life threatening infection From his remote command post Dr Cooke watches three units on different oors at one hospital That could help solve a massive nationwide problem With a shortage of ICU specialists patients aren39t well enough monitored leaving them vulnerable to complications that lead to longer hospital stays and force hospitals to ration beds At the New York Presbyterian Healthcare System where Dr Cooke works two new quoteICUquot stations cover six units in two different hospitals and plans call for an expansion into all 30 of its hospitals Slowly the drive to improve quality and efficiency that has swept through corporations is starting to arrive at the famously inefficient world of hospitals Across the country rising costs have forced some hospitals to effectively ration services making life and death choices about who gets care and who goes without But by boosting efficiency cutting waste and medical error and sticking to treatments that demonstrably work medical experts are finding that many harsh decisions about who gets care might not have to be made in the first place The new strategies range from installing high tech systems that replace doctors39 scribbled notes to simple practices such as making sure that patients39 beds are properly tilted so infections don39t set in The crusade to bring the quality movement to hospitals pushed in the past mainly by nonprofit groups is now starting to get a boost from Medicare and powerful employer groups Today the federal Department of Health and Human Services plans to release the first national report on the quality of health care in America which is expected to acknowledge gaps in key areas such as preventive care and chronic disease care and endorse many of the solutions quality experts propose for fixing them quotWe need to take back the money that goes into waste and harm in the system and make it an ethical imperative to free it up for the things that really add value quot says Margaret O39Kane president of the National Committee for Quality Assurance a nonprofit group that accredits about half of the nation39s managed care organizations How big could the savings be Donald M Berwick chairman of the Boston based nonprofit Institute for Healthcare Improvement estimates the US could cut 15 to 30 of its 14 trillion annual health care tab by operating more efficiently and improving quality David Wennberg director of the Center for Outcomes Research and Evaluation at Maine Medical Center says Medicare could trim 30 of its 285 billion budget by bringing the highest spending regions of the US in line with the lowest A study published by Dr Wennberg and a group of colleagues this year found that Medicare enrollees in higher spending regions A6 receive more care than those in lower spending regions but don39t have better health outcomes or satisfaction with care Adopting information technology could save 125 billion just by eliminating unnecessary paperwork according to research by the Markle Foundation Eliminating medical errors would save 376 billion says the National Academy of Science39s Institute of Medicine Reducing the overuse of just three antibiotics would have a big impact 1 billion in potential savings according to VHA Inc an alliance of 2200 nonprofit hospitals across the country including the Mayo Clinic and Cedars Sinai Some rationing is here to stay given America39s appetite for health care and an aging population that will need more of it That will require facing tough issues such as whether it is justified to pay millions of dollars to keep a few patients alive if those same dollars could keep hundreds more healthy But by redirecting money spent on unnecessary or ineffective care and improving the quality of care it39s possible to have a system of quotrationa quot rationing quotWe know that not everyone gets the health care services they need but more problematically too many people get services they do not needquot says David Dranove a professor at Northwestern University39s Kellogg School of Management and author of a recent book on rationing Hospitals are now experimenting with new ways to achieve rational rationing Here are six of the most promising ideas Wiring the Health System Many medication mistakes are caused by illegible prescriptions and decimal point errors As many as 20 of such preventable mistakes are life threatening says the Leapfrog Group a coalition of major employers trying to cut health care costs One medication mistake the group says adds more than 2000 to the cost of hospitalization That translates to 2 billion per year nationwide Using computerized order entry electronic prescribing systems that avoid handwritten errors can make a huge difference Boston39s Brigham and Women39s Hospital a pioneer in the use of such systems reduced error rates by 55 over eight months Rates of serious medication errors fell by 88 over a four year period in a subsequent study Technology can give hospitals a better handle on what39s working St Luke39s Hospital the largest hospital in the Kansas City area is investing about 4 of its operating budget in information systems compared with an average of 25 in the industry It uses an electronic data system to track 58 measures of quality such as how many patients are re admitted or have to return to the operating room Units get quotbalanced scorecardsquot to see areas where things are going well and where they need to improve Group Health Cooperative in Seattle one of the largest managed care nonprofit health plans in the country recently spent more than 40 million on a clinical information system for its 560000 members The system manages patient records delivers lab results online automatically refills prescriptions and checks for possible drug interactions quotOn the day it 86 turned on across the state of Washington 9000 pieces of paper stopped owing around the systemquot says Ted Eytan associate medical director for clinical informatics EvidenceBased Medicine As much as half of the care provided to Americans is unnecessary including procedures that don39t do any good tests that are repeated and drugs for which there is no evidence of benefit according to studies cited by a 2001 report of the National Institute of Medicine a government advisory group Meanwhile patients often don39t receive the care that evidence shows is effective Between 17 and 32 of surgeries performed on Medicare patients are unnecessary according to Dr Wennberg the outcomes researcher A survey by Rand Corp a think tank in Santa Monica Calif says patients only receive recommended care about half of the time noting a quottremendous gap between what we know works and what patients are actually gettingquot For example national data show that less than 25 of people with hypertension have it under control with recommended blood pressure medications One way to close that gap is quotevidence based medicinequot insisting that a doctor39s opinion is backed by published evidence of a treatment39s effectiveness After using its electronic records to identify people at risk for heart attacks Group Health will soon start 11000 previously untreated patients on cholesterol lowering drugs called statins It based the move on evidence of the effectiveness of statins in the Heart Protection study a five year trial of more than 20000 patients The decision quotwill cost us 700000 per year we didn39t budget forquot says Vice President Peter Adler quotbut it will improve the wellness of our patients and is likely to save us 5 million in the long runquot Another opportunity to save money is to eliminate the overuse of antibiotics which account for 15 to 20 of the average hospital drug budget Overuse has caused resistance to many antibiotics leading to more medical complications and costs A study of 11 hospitals by VHA found that three common antibiotics used in patients with kidney failure or urinary tract infections were overused or unnecessarily used based on clinical guidelines for their conditions By using lower doses or less expensive drugs the average 250 bed hospital found savings of 100000 annually which indicates more than 1 billion could be saved nationwide in all hospitals says VHA Vice President John Hitt who oversaw the study Money saved could be redirected into proven care Dr Hitt says quotIf I could take the money I was spending on excess drugs used after surgery and give everyone a beta blocker after a heart attack it would be idealquot says Dr Hitt While hospitals have been improving the rate at which they prescribe beta blocker drugs after a heart attack to prevent a second one for example as many as 30 of patients still don39t get them But more research needs to be done The budget for the federal Agency for Healthcare Research and Quality is less than 02 of total health care spending which is quotgros sly insufficientquot researchers at the Commonwealth Fund said last month The nonprofit foundation proposed a new federal agency to set national priorities for quality and develop AV standards of care much as federal highway standards helped improve auto safety The Institute of Medicine proposes a 1 billion quotinnovation fundquot to improve quality and safety Fixing Reimbursement The biggest barrier to improving care many say is a reimbursement system that doesn39t factor in quality and actually rewards waste quotNo wonder our health care system is so screwed up the best hospital in town and the worst hospital in town get paid exactly the same thing for a heart bypass or a hip replacementquot says Tom Scully who just stepped down as director of the Centers for Medicare and Medicaid Services quotThere is no other part of our economy besides health care where you have zero economic penalty for being inefficientquot Since doctors and hospitals are paid only for procedures and treatment they provide they are actually penalized if they eliminate unnecessary procedures or practice preventive care Doctors get paid to perform heart surgery and treat patients in the hospital but not to care for heart patients so that they avoid hospitalization That39s starting to change Medicare is offering incentives for doctors in pilot programs who adopt information technology and practice preventive medicine and boosting payments to hospitals that report publicly on the quality of their care A Medicare spokesman said the aim is to fix quality problems and cut costs in the long run Employer groups including the Pacific Business Group on Health and the General Electric Co led quotBridges to Excellencequot program are offering doctors incentives to provide preventive care for chronic diseases including diabetes But such efforts will have to be more widely adopted by big insurers before they make a dent The Bridges to Excellence program which includes self insured health plans run by Ford Motor Co UPS Procter amp Gamble Co and Verizon Communications Inc just doled out its first payment to doctors in a pilot program in Louisville and Cincinnati Doctors receive bonuses of 100 per patient for keeping patients39 blood pressure blood sugars and other diabetes measures under control quotWe are creating an incentive for the fundamental re engineering of processes and outcomes in physician39s officesquot says Francois de Brantes program leader for GE39s corporate health care initiatives But if the effort stays limited to self insured purchasers he says it won39t be enough to spur real change quotThe barrier we haven39t been able to overcome is getting health plans to fully participatequot Health plans have been wary about paying doctors for preventive practices because they aren39t yet sure of how that would work on a large scale or how results would be measured Some argue that doctors should be providing such care anyway Disease Management Many experts agree the best opportunity to improve care and stave off costly complications is disease management the strategy of monitoring people with chronic conditions such as AA diabetes congestive heart failure and coronary artery disease Those diseases are expected to cost 510 billion this year and soar to 107 trillion by the 2020 But many of those costs are related to preventable hospitalizations and emergency room visits For years studies have shown that getting patients into disease management programs can avoid many of those problems Disease management closely monitors a patient39s status on a regular basis A growing number of companies under contract with Medicaid or other insurers now keep tabs on patients At nonprofit Care South Carolina which serves 27000 mostly low income patients an electronic recordkeeping system monitors patients with diabetes closely and ensures that they see doctors for regular foot exams to watch for sores that might lead to amputations Chief Executive Ann Lewis says the center hospitalizes its patients less frequently than others in the state and those hospital stays are for less serious and less costly problems The average payment Medicaid has to make for their hospitalizations is 3545 compared with 10894 for diabetes patients in other programs in the state she says Better preventive care can dramatically reduce hospitalization for congestive heart failure a chronic ailment marked by progressive weakening of the heart39s pumping strength Yet standards are all over the map in the US Among Medicare patients about one third of those with the disease haven39t had the most important test to assess the function of the part of the heart that makes it pump efficiently About one third don39t have a prescription for the blood pressure medication known as an ACE inhibitor used to treat the disease Half of the patients hospitalized with congestive heart failure are readmitted within six months But numerous studies show marked improvement if patients take the right medication and are closely monitored Such care can reduce hospital costs by more than 30 and cut rehospitalizations in half studies show Florida39s Medicaid program for example contracted with a company called Lifemasters to manage thousands of residents with congestive heart failure Patients can check in by phone or Web site and nurses monitor vital signs and symptoms to identify potential problems Beneficiaries get digital scales and electronic blood pressure cuffs and even phones to call in if they need them Lifemasters gets in touch with doctors directly if a problem arises Patients in the program spent an average of 38 fewer days in the hospital and the state cut the cost of its Medicaid program by 6 in the first two years after paying the fees for the program Redesigning the ICU The sickest 1 of patients the chronically ill and those in the ICU account for 27 of all health care costs Intensive care eats up 180 billion annually much of that on care that has little effect on survival and isn39t wanted by terminally ill patients anyway studies show quotMost people when dying want the comfort and care of being surrounded by family not the torture of all sorts of tubes in every orifice you havequot says Dr Wennberg the outcomes researcher But many complications that lead to unnecessary deaths and longer stays could be prevented with ICU redesign programs including new technology such as the eICU even if they cost A39 money in the short term A few years ago at six hospitals run by Sentara Healthcare in Virginia ICU doctors were stretched quotWe didn39t have enough ICU beds we had a harder time holding on to ICU nurses and the care was just inconsistentquot says Rodney Hochman chief medical officer and CEO of Sentara39s Norfolk General Hospital Two of Sentara39s hospitals were the first to use an eICU a system designed by former intensive care specialists who launched software maker Visicu Inc These systems are operating or being installed at a total of 17 hospital groups covering about 60 ICUs By electronically monitoring more patients improving quality controls and adhering to strict guidelines about which patients should be in the unit Dr Hochman says two of his hospitals reduced ICU mortality rates adjusted by the severity of patient illness 27 and cut hospital costs for ICU patients 25 over the last two years A study to be published next month in the journal Critical Care Medicine says the eICU system has shortened the length of stays in four of the Sentara ICUs by 17 and allowed the ICU to handle 15 more cases Sentara says the 2 million it spent to buy the software and get it up and running has already paid for itself with 35 million in saved costs and new revenue By using resources efficiently Dr Hochman says the hospital may be able to avoid quothaving to decide between one patient and anotherquot Improving hospitals39 practices can make a big difference in the ICU as well VHA the nonprofit hospital alliance is sponsoring a quotTransforming the ICUquot program that has trained 20 ICU teams to follow simple guidelines that are often ignored such as correctly adjusting the tilt of the bed of a patient on a ventilator to prevent pneumonia and stopping the use of antibiotics that might cause further complications Merely improving care of patients on ventilators has saved 47 lives and 3 million in an average ICU with 1000 admissions annually VHA says VHA says in the first year of the program the collective length of stay in the ICU was reduced from nearly 25 days to 11 days which means the ICU can accept 654 more patients Together two hospitals in the program saved nearly 5000 patient days and 53 million in one year Surgical infection prevention programs being conducted with the Centers for Disease Control and Medicare have also saved millions of dollars in ICU and surgical units Getting Patients Involved The final barrier the patients Most consumers aren39t actively engaged in their care or quotprepared to make judgments about treatment alternatives based on evidencequot says Paul H Keckley executive director of Vanderbilt University39s Center for Evidence based Medicine quotWe have lulled consumers to be dependent on physiciansquot But after years of being conditioned to expect that medical care comes at little cost Americans are being asked to dig deeper into their own pocket which may make them think twice about which care has value and what is unnecessary Everyone including consumers will need to make more informed choices about which medical services are most beneficial 1 says Paul B Ginsburg president of the Center for Studying Health System Change quotIf we are to cover everyone we can39t cover everything Big Losses Estimated lives and costs that could be saved each year by delivering recommended care PROGRAM Controlling high blood pressure DEATHS 28300 HOSPITAL COSTS in millions 1243 PROGRAM Diabetes care HbAlc control DEATHS 13600 HOSPITAL COSTS in millions 1785 PROGRAM Smoking cessation DEATHS 2700 HOSPITAL COSTS in millions 977 PROGRAM Cholesterol management DEATHS 6500 HOSPITAL COSTS in millions 942 Due to heart attacks and stroke Source National Committee for Quality Assurance 91 LOCAL KNOWLEDGE by James Surowiecki The New Yorker Issue of 2005 05 30 Everyone seems to agree that the American health care system is broken yet no one can agree on how to fix it Part of the problem is that there is no American health care system Instead there are hundreds of local health care systems each with its own way of treating patients and spending money Where you live has a profound effect on how much attention your doctor gives you how many days you spend in the hospital and what drugs you are or are not prescribed For all the talk about the death of distance and the homogenization of the American landscape when it comes to health care geography is still destiny The recognition of this fact has humble roots In the nineteen seventies a doctor named John Wennberg conducted a study in his home state of Vermont and found that even in this small and relatively homogeneous corner of the country doctors in different areas adopted wildly different approaches to the treatment of tonsillitis In one town seventy per cent of children had had their tonsils removed by the time they were twelve In the town next door it was only twenty per cent Statistical uke Apparently not Over the next three decades Wennberg and other researchers documented similarly dramatic geographical variations in far more serious casesicesarean sections spinal fusions mastectomies coronary bypass surgeries No two patients or groups of patients are exactly alike so people have always been skeptical of these geographical comparisons But at this point the evidence is hard to refute A recent set of Dartmouth Medical School studies led by Wennberg looked at the way top teaching hospitals treated elderly patients who were in the last six months of their lives Patients at Mount Sinai in New York spent nearly twice as many days in the hospital as patients at the Mayo Clinic in Rochester Minnesota Patients at UCLA spent three times as many days in the intensive care unit as patients at Mass General At the high intensity hospitals patients saw doctors consulted with specialists and were given tests far more often than at low intensity ones What s more the extra attention didn t allow patients to live any longer The weeks in the hospital the batteries of tests the regular consultations they did little but drive up the cost of treatment The problem in other words isn t so much that different doctors treat patients differently It s that these differences have a major impact on the cost of health care No one is opposed to spending more if we could get better results by doing so But variations in treatment often mean that we re doing the opposite Medicare for instance pays twice as much per patient in Miami as it does in Minneapolis But again Medicare patients in Miami don t live any longer than those in Minneapolis At a time when everyone s worried about controlling health care costs we re spending tens of billions of dollars a year on care that provides little or no benefit to people And the money we shell out for unnecessary care is money we could spend a lot better somewhere else Although doctors are trained all over the country the market for medical care is not generally a national one When you need a doctor or a hospital you look for one nearby People will travel to be treated for unusual conditions or rare diseases and there seems to be less variation in the recommended treatment for these This means that insofar as doctors are competing 92 for patients they re doing so only against their local peers The same goes for collaboration Doctors have unprecedented access to enormous amounts of data on the latest findings in their fieldsiand clearly this has helped But in practice doctors like most people tend to rely on their own experiences and on those of their colleagues Once a treatment works well in a few cases and gets established as a local norm it can be hard to dislodge Patients meanwhile are unlikely to turn down extra treatment They tend to believe that more is better Habit is also reinforced by economics In medicine supply often creates its own demand If a region has many specialists patients are going to be advised to see them If a hospital has many beds patients are going to spend more time in them There are so many Medicare patients in Florida that doctors and specialists in particular have always had an incentive to practice thereiand once they re set up they ll find something to do That s why Medicare spends so much more on its patients in Miami than it does in Minneapolis There is no easy fix for this problemiat least not until we figure out how to pay doctors for the quality rather than the quantity of the care they provide We certainly don t want a national board telling doctors what they can and cannot do Geographical variations in care by the way exist in countries with nationalized health care too The hope is that eventually people will start paying attention to the data and recognize how costly these variations can be The fact that they haven t yet shows how little medicine has in common with the rest of the economy In most professions and even for that matter in the scientific community competition insures that over time good ideas are diffused through the whole system people who don t absorb and adapt fail But medicine which is in some ways quintessentially modern is in other ways a throwback a bastion of parochialism in a globalized age And there is reason to think it may remain that way for a long time As Bones McCoy on Star Trek liked to say of his twenty third century medical techniques I m not a magician Spock I m just an old country doctor Now Someone Else Has to Tell Retirees 39No39 By KRIS MAHER Wall Street Journal January 29 2007 Every week Mike Mormile receives up to 50 calls from retirees and widows who can39t pay a prescription drug bill or who missed a mailing explaining medical benefits One man said he was going to have to sell his house to keep buying his infirm wife39s medicine Mr Mormile isn39t in human resources insurance or politics He39s a member of the United Steelworkers union and one of the four people overseeing a special trust that provides certain benefits to thousands of retired steelworkers and their spouses who lost all of them when Bethlehem LTV Acme Metals and Georgetown Steel went bankrupt between 2000 and 2003 His job is to help determine when to add a new benefit or cut a program or increase premiums Sometimes he can help the caller sometimes not To please everybody he says quotwe39d be out of money in a matter of monthsquot As more companies look for ways to shed the burden of funding open ended retiree health benefits so called legacy costs and more unions try to keep some of them his experience offers a glimpse of what to expect Faced with crippling legacy costs more companies are considering the trust approach The Steelworkers and Goodyear Tire amp Rubber Co agreed last month that the company will make a one time payment for retiree health benefits into a trust The trust would be governed by a committee consisting of three members designated by the Steelworkers and four independent members jointly selected by Goodyear and the union That committee would manage the trust39s assets and maintain the benefit programs The union and the company will no longer bargain over retiree health benefits according to the union Executives at General Motors Corp and other big auto makers recently expressed interest in the Goodyear agreement because a similar deal could allow them to relinquish the massive but unfunded amount of money needed for retiree health care benefits they currently carry on their books Such agreements effectively mean quotthe employer is getting out of the retiree medical coverage businessquot says Russell Greenblatt a partner with the law firm Katten Muchin Rosenman LLP in Chicago which has worked with companies to set up similar trusts Goodyear agreed to put 1 billion into the trust and to provide for cost of living allowance and profit sharing contributions that the union estimated could amount to an additional 135 million However the trust is 200 million short of estimated future retiree medical costs quotIf they have really good investment returns they can say 39We39re going to improve the benefits39 quot says Derek Guyton a principal with Mercer Health amp Benefits in Chicago who estimates that 25 of large companies have a version of these trusts But poor returns could easily result in higher co payments for retirees or the need to trim benefits he says The Teamsters set up a union funded trust in 2001 that now covers about 15000 retirees who didn39t meet the eligibility requirements of their company39s plan To receive benefits from the 39U trust the retirees have to pay a monthly premium which the union had been able to keep at until this year Effective March 1 some premiums will increase between 3 and 10 for some retirees For a low cost plan with a 500 deductible and basic medical coverage up to 100000 average 250 monthly premiums are increasing 25 John Slatery director of the benefits department at the Teamsters says he tries to keep costs down by directing members to discounted networks and generic drugs and by getting them more involved in their health care decisions He says the trust receives and disburses about 15 million a year and has reserves of about 4 million Mr Slatery says the trust operates like a small insurance company but he outsources many administrative and other functions and has only one full time and several part time people assigned to the trust He sees further premium hikes ahead quotWe39re going to have to pass the costs on or reduce benefits or come up with more efficient ways of providing it he says The trusts that are used to pay for retiree health care benefits are created through an organization called a voluntary employees39 beneficiary association VEBAs have been around in various forms since the 1920s but have proliferated in the pastt 10 or so years due to accounting rule changes and as more companies take advantage of tax benefits on the money they contribute to VEBA trusts says Mark Wilkerson a consultant in Spokane Wash who helps state and local governments set up VEBAs There were about 12500 VEBAs in 2005 according to the Internal Revenue Service Bankruptcies in the airline and steel industries that led to the loss of retiree medical benefits for tens of thousands of workers have made VEBAs more attractive to unions Unlike pensions which are guaranteed by the federal Pension Benefit Guaranty Corp retiree health care benefits are not protected by the government The United Steelworkers trust that Mr Mormile helps run created in 2002 grew out of discussions between the leaders of the union and investor Wilbur Ross who wanted to buy the bankrupt steel makers without assuming legacy costs The union trying to save jobs for current workers but also protect its retirees suggested forming a trust fund to pay for some benefits It also agreed to manage the fund through a committee of three representatives from the union and one from the company Mr Mormile and the three other committee members meet once a quarter to discuss the state of the trust and options for adding new benefits for retirees Unlike the Goodyear plan which has a limited company contribution the steelworkers fund also receives contributions from Mittal Steel Co which bought out Mr Ross39s company based on earnings and steel shipments At first the fund had only 20 million to 30 million and couldn39t provide any benefits leaving retirees with only Medicare or any insurance they might be able to buy on their own As steel industry profits have grown the fund has received more contributions and began offering benefits in 2005 three years after the fund was established After listening to retirees the committee decided the biggest expense was prescription drugs and offered a prescription drug plan Under the plan retirees pay 10 a month which entitles m them to unlimited generic drugs With a 5 co pay and coverage of up to 6000 a year in brand name prescription drugs Last year it also decided to reimburse 41000 retirees for Medicare premiums paid in the first six months of the year Doing so has been difficult at times More than 100 retirees said last year that they missed an August deadline to sign up for the Medicare reimbursement because the mailing list provided by bankrupt steel companies was incomplete 96 Hospitals Build Deluxe Wings For New Moms By Paul Davies 8 February 2005 The Wall Street Journal EVEN AS HOSPITALS are under increasing pres sure to reduce costs they are spending heavily in an unlikely area luxurious maternity wards Amid heightened competition hospitals are betting that making a good impression on moms to be and their families during such a formative experience can build lifelong loyalty The latest boom in hospital construction is an effort to win over patients with state of the art facilities offering private suites whirlpool baths and Internet access In October Gaston Memorial Hospital in Gastonia NC opened a 120000 square foot maternity ward known as quotThe Birthplacequot that was designed by the San Francisco architectural firm responsible for the W Hotel in Mexico City The ward features a two story glass atrium with a 60 foot waterfall and a children39s library where expectant siblings can play in addition to 52 private rooms with sofa beds for tuckered out dads or partners Inova Health System in Virginia is renovating the quotMother Baby Unitquot at its Fair Oaks hospital in Fairfax Va which will have 32 private rooms with new ooring curtains and free Internet access And St Vincent Women39s Hospital in Indianapolis is in the middle of a 21 million overhaul including an upgrade of its quotFamily Care Unitquot where it now offers free massages for women in labor These efforts are all part of a broader nationwide effort to refurbish and expand outdated hospital facilities They are also in part a response to the chintz curtained delivery rooms and celebratory dinners that a few facilities particularly smaller birthing centers began offering in the 19903 Faced with growing competition from these homier options major medical centers now are making hotel like creature comforts a centerpiece of their multimillion dollar infrastructure improvements Some hospitals have long offered luxury rooms for a limited population often the super wealthy or international patients willing to pay extra for high end services That market is small and limited to top hospitals that specialize in treatments of various illnesses such as cancer But hospitals sprucing up maternity wards are expanding luxury services to the mainstream and they don39t charge individuals extra for most of the amenities The new facilities cater to demands for private rooms and baths personal services and even better food from today39s new mothers who often are older and more consumer savvy than those of generations past And as more hospitals renovate rooms say analysts patients39 expectations increase Safety and quality are important but upscale amenities sell says Harvey A Holzberg president and chief executive of Robert Wood Johnson Health System which is upgrading its hospital in New Brunswick NJ Patients tend to believe they are getting quality care he says when they see quothotel servicequot 97 Some industry experts question the wisdom of these costly frills Hospitals are fueling much of the increase in health care costs which continue to outpace in ation And hospitals have been demanding higher reimbursement rates to cover expenses including major construction projects Insurers in turn pass the increases on to employers who then charge employees higher deductibles and co payments says Dale Bradford a partner at Scheller Bradford Group a health care consulting firm in Cincinnati But hospitals say these new facilities can actually help reduce costs Many have energy conservation and design features that help them operate more efficiently than older wards they contend The investments lead to lower overhead more business better care and increased patient satisfaction At the Robert Wood Johnson University Hospital in New Jersey new amenities have helped increase business even before completion of the 20 million expansion and renovation of its maternity ward according to Mr Holzberg Births at the maternity ward reached 1985 last year compared with 1676 in 2003 and 1390 in 2002 When finished the hospital39s Center for Women and Babies will have 40 private rooms previously it had 20 rooms that could be shared by as many as three patients The new rooms have private baths sleep sofas and refrigerators And a cart offers quothigh teaquot at 3 pm each day with cookies and fruit The contrast between old and new was clear to Karen Chu who gave birth on Dec 4 to her first child Initially Ms Chu shared one of the older rooms where the beds are divided by a curtain with another mom Her roommate39s family and friends crowded into the room while Ms Chu tired from giving birth thought quotOh no how am I going to sleep with all thisquot Two hours later she was moved into a new private room at no extra charge which is the hospital39s policy whenever a room becomes available Her husband Chris was able to spend the night on a pull out bed Ms Chu said the room was quotjust like a hotelquot and the best part was the food ordered from the hospital39s new restaurant style menu She had an omelette for breakfast tilapia for lunch and chicken Marsala for dinner The price of any hospital room with niceties or without can seem high to patients though rates vary considerably by region At Gaston Memorial the standard room charge is 520 a night at Greenwich Hospital in Connecticut which offers upscale services to new moms a standard room costs 1360 Hospitals note that these are the so called hospital charges that don39t necessarily re ect what the hospitals get paid by insurers For patients with insurance the hospitals receive a negotiated fee from insurers that is much lower than the hospital39s stated room charge and the care usually is fully covered There are perks that cost patients extra At St Vincent in Indianapolis the massages are included with the room but the portrait photographer who takes pictures of the baby in a studio located on the maternity oor isn39t The optional service costs 50 to 199 depending on the photo package Patients get a disc with digital shots that can be e mailed right away to family and friends using the free Internet access being added to each room Greater efficiency in staffing is another goal of some of the upgrades At Gaston Memorial patients remain in the same room during their entire stay even when giving birth reducing nursing clerical and housekeeping services Gaston says in the four months since its new 98 maternity wing opened this and other changes have helped the hospital reduce staff time for each patient 20 The wing part of an 84 million expansion will translate into lower operating costs and reduce turnover and medical mistakes said Kathleen Besson director of women and children39s services There is more to the new ward than quotglitz and glamquot she adds For example the Jacuzzi tub and DVD players provide pain management and distraction for mothers in labor she says The Gaston center39s trees and glass atrium help reduce stress for patients and family members as well as doctors and nurses quotWe did want the place to be a destination and the first impression to be a lasting onequot Ms Besson says quotBut it also needs to be more than a fancy hote quot Modern Maternity How hospitals are catering to moms Privacy No extra charge for a room of one39s own Family support Spousal sofa bed sibling play space Cuisine Tilapia entree high tea Comfort Jacuzzi free massage Technology DVD players Web access Some hospitals that are rolling out the red carpet for expectant moms with fancier maternity wards HOSPITAL Gaston Memorial Hospital The Birthplace Gastonia NC PRICE PER NIGHT 520 Has 52 private rooms with sofa bed refrigerator whirlpool bath and DVD players Siblings can play in the children39s library HOSPITAL Greenwich Hospital Greenwich Conn PRICE PER NIGHT 1360 PERKS Tender Beginnings program includes free classes for expecting parents grandparents and siblings plus breastfeeding and prenatal yoga Serves new parents quotcelebrationquot dinner with champagne HOSPITAL Inova Hospital Mother Baby Unit Fair OaksVa PRICE PER NIGHT 400 PERKS Offers 32 private rooms hardwood oors and free Internet access HOSPITAL Robert Wood Johnson University Hospital Center for Women and Babies New Brunswick NJ PRICE PER NIGHT 1015 PERKS All private rooms with 3 pm quothigh teaquot served in the room Patients order meals from restaurant style menu HOSPITAL St Vincent Women39s Hospital Family Care Unit Indianapolis Ind PRICE PER NIGHT 787 PERKS Offers complimentary massage A baby portrait studio provides a disc with digital pictures cost ranges from 50 to 199 Prices are socalled hospital charges that may be charged to uninsured patients discounts are sometimes available For insured patients the cost is usually covered Source The hospitals H Full Price A Young Woman An Appendectomy And a 19000 By Lucette Lagnado 17 March 2003 The Wall Street Journal NEW YORK Dreams of a bright career in a big city lured Rebekah Nix here from the western plains of Texas two years ago An appendectomy sent her home But not because she was ill Ms Nix 25 years old was eeing the nearly 19200 in medical bills that had piled up on her bedroom dresser The college graduate and former magazine fact checker couldn39t fathom how two days in a hospital could cost so much until she learned that people like her who don39t have health insurance often are expected to pay far more for their medical care than large insurers health maintenance organizations or even the US government The hospital where Ms Nix was treated New York Methodist in Brooklyn typically bills HMOs about 2500 for an appendectomy with a two day stay compared with the 14000 plus doctors39 fees that Ms Nix was billed The hospital gets paid about 5000 from Medicaid the state and federal health program for the poor and about 7800 from Medicare the federal program for the elderly for the same procedure quotWhy does a single person get stuck with the whole billquot Ms Nix asks quotAn uninsured person would have a lot less money than those government agencies or insurance companiesquot Ms Nix stumbled onto a troubling fact of health care economics Most major US hospitals are required to set official quotchargesquot for their services but then agree to discount or even ignore those charges when getting paid by big institutions such as insurance companies or the government As a result almost no one but uninsured individuals ever faces the official charges In some ways hospital charges are like automobile quotlist pricesquot or hotel quotrack ratesquot posted prices that everybody knows nobody pays But in the case of hospitals the pricing disparity isn39t publicly known and falls most heavily on the vulnerable America39s 41 million people without health insurance tend to be young working class and unaware that they are being billed more than everyone else for the same services At the same time charges at virtually all hospitals have soared in recent years That39s partly due to the rising costs of new procedures and drugs Also deregulation of the hospital industry removed limits on charges in almost all states But some hospitals say they are raising charges to offset what they view as overly harsh reductions in their reimbursements by HMOs insurers and the government That would mean hospitals are effectively subsidizing their lower income from patients who are insured or have a government safety net by boosting fees paid by the uninsured quotIt is a re ection of the insanity of the systemquot says Bruce Vladeck a hospital policy expert who ran Medicare in the 1990s quotThe most vulnerable members of societyquot are being asked to quotpay cash at listquot In many areas hospitals have cranked up their charges far beyond the cost of providing treatment Before deregulation in 1997 hospital charges in New York state couldn39t be more 100 than 30 above costs They now are an average of 87 above costs says the Greater New York Hospital Association an industry trade group citing federal data In California charges have ballooned to 178 above costs By contrast in Maryland where hospital charges are still strictly regulated charges average only 28 above costs says Hal Cohen a Maryland health consultant At many hospitals the practice of cutting prices for big insurers HMOs and the government has become so routine that the discount is calculated automatically and appears on bills alongside the original charge The amount of the discount usually depends on how aggressively a particular insurer bargained with the hospital or on terms struck with a government program or how much other hospitals in the area are discounting But uninsured patients aren39t told that big institutions get these reduced rates Some hospitals then retain collection agencies to pursue the uninsured with hard nosed tactics such as suing garnisheeing wages and slapping liens on homes quotHospitals have a choice as to who will bear the costsquot says Elizabeth Warren a Harvard Law School professor who is studying the effects of health care costs on the uninsured quotThere is someone to negotiate on behalf of the insurance companies There is someone to negotiate on behalf of the state But there is no one to negotiate on behalf of people without insurancequot Hospitals say they have no choice but to give steep discounts to powerful payers even if that means uninsured patients end up being faced with higher bills Mark Mundy president and chief executive of New York Methodist says his private not for profit hospital looks to competitors in setting its charges and must offer discounts to HMOs and insurers or they won39t do business with it As for the government it pays whatever it wants quotPricing makes no sense we all know thatquot Mr Mundy says Hospitals also point out that most uninsured patients don39t pay their bills the rate of default varies across the country yet hospitals are required by law to treat all emergencies quotAnybody that shows up in my ER the first question isn39t Can they pay The question is What are we going to do39 quot to care for them Mr Mundy says quotIf I had 5000 Ms Nixes how do I handle them and keep this place alivequot Mr Mundy says many uninsured patients especially those who aren39t indigent could afford insurance and should bear at least some responsibility for their care He adds that New York Methodist unlike many hospitals doesn39t charge interest on unpaid bills Advocates for the uninsured say poor people without insurance should be charged the same low rates that Medicaid pays Instead they are asked to pay quotwhat the Emir of Kuwait paysquot says Elisabeth Benjamin a health attorney with the Legal Aid Society in New York Royalty and other wealthy foreigners ock to US hospitals where they39re among the few uninsured patients who can afford to pay full freight Ms Nix39s billing problems started on a Saturday afternoon last April when she arrived in agony at New York Methodist The previous night she had felt stabbing pains in her abdomen while celebrating her 25th birthday with friends at a Manhattan bar She had left early staggered home to Brooklyn and went to bed figuring she had food poisoning or the u When she awoke to the same unrelenting pain her boyfriend39s mother a registered nurse Ml insisted she go to the nearest hospital As she sat in a hard metal chair in the emergency room she began to worry How much is this going to cost Ms Nix had arrived in New York a little less than two years earlier fresh from graduating Phi Beta Kappa from Southwestern University in Georgetown Texas Growing up in Midland Texas she saw her hometown as a quotdesolate wastelandquot where social gatherings often revolved around high school football Her ticket out was a summer internship at Ms Magazine in Manhattan which she loved quotThis is the greatest city to be young inquot she says quotI had no intention of ever leavingquot But the internship paid just 150 a month Ms Nix helped support herself by working as a waitress while sharing a basement apartment that cost her 350 a month in rent The magazine soon hired Ms Nix as a full time fact checker with an annual salary of 30000 and health benefits But it was struggling financially and Ms Nix was laid off after the Sept 11 terrorist attacks The magazine as required by law offered to maintain her health insurance if she paid 330 a month but Ms Nix demurred She figured she couldn39t afford it on unemployment payments of 1122 a month and thought she could land another job with benefits Besides she thought she was young and had always been healthy In the months before her illness she tried offering her fact checking services as a free lancer but jobs were sporadic She was determined to be independent so she didn39t want to tell her divorced parents that she39d lost health coverage Her mother who runs a small medical supply business she founded near Midland might have been able to help Her father an independent oil consultant struggles financially By going without coverage Ms Nix became one of the estimated 39 of uninsured Americans who are between the ages of 19 and 34 according to the Kaiser Commission on Medicaid and the Uninsured in Washington In the emergency room at New York Methodist someone asked her to collect a urine sample in a paper cup She kept it at her side for six hours until at last she was admitted to the clinical area of the emergency room and asked to wait on a gurney Ms Nix remembers telling nurses and doctors that she had no money and no insurance No one seemed to mind she says Still she39d heard horror stories about how costly a hospital could be and decided to try to leave as soon as possible When she woke up on Sunday morning she was still on the emergency room gurney and the pain seemed to have subsided quotMaybe I am going to go homequot she told a doctor quotI don39t have health insurancequot According to Ms Nix the doctor responded quotIt is 1000 to come to the ER and it is another 1000 to come in againquot Ms Nix resigned herself to staying But while undergoing two CT scans she recalls telling doctors quotI don39t want any extrasquot Tests confirmed she had appendicitis Her surgeon Piotr Gorecki removed her appendix using laparoscopy a method that requires a shorter hospital stay than traditional invasive surgery The one hour surgery went smoothly Ms Nix was recovering in her room when an attending doctor ordered that she be given a nicotine patch She regularly used one to control a smoking habit but she balked at it now worried about the cost The doctor insisted she says Ms Nix left the hospital on Monday afternoon 42 hours after being admitted She had a prescription for painkillers but decided not to fill it because of the expense She also decided to skip a follow up visit that Dr Gorecki had recommended Two weeks later she received a letter from the hospital offering advice on how she could apply for Medicaid The letter also gave the first hint as to how much she would be billed quotNote hospital bill is 12973quot In mid June she learned that Medicaid had turned her down because her income was too high New York39s Medicaid rules say a single person39s income can39t exceed 352 a month unless she39s certified as disabled The hospital urged Ms Nix to appeal at a hearing before a state administrative law judge and she arranged to do so In July Ms Nix received her hospital bill It showed charges for two days at 1550 a day even though she spent the first night on the emergency room gurney It also listed operating room charges of 5340 a charge of 540 for the recovery room and a charge of 850 for the emergency room Every test administered in the emergency room was charged separately Her two CT scans together came in at 2120 One charge which showed up in a more detailed bill brought a wan smile to her face 8 for the nicotine patch Lyn Hill a spokeswoman for New York Methodist says Ms Nix was admitted at 10 pm Saturday and remained through Monday so it was appropriate to charge her for two nights regardless of where she slept The total 13110 Soon after she received 5000 in separate bills from Dr Gorecki an anesthesiologist and other doctors who had seen her at Methodist Much like hospitals some doctors also routinely accept lower payments from insurers HMOs and government programs Dr Gorecki whose charge to Ms Nix was 2500 says Medicare typically pays him only 589 for a laparoscopic appendectomy and Medicaid usually pays an even skimpier 160 The New York Health Plan Association an HMO trade group in Albany NY says Brooklyn surgeons get an average of 600 for a laparoscopic appendectomy Ms Nix39s bank account held less than 2000 She tossed some of the bills on her dresser unopened and tried not to think about the debt But often she could think of nothing else quotI knew that I was going to be in major trouble financiallyquot she says Her last hope was the Medicaid hearing which was held on a sweltering July morning at the city39s Medicaid headquarters The building was jammed with applicants standing in lines and sitting in rows of plastic chairs waiting to see case workers Judge Michael Vass sat at a desk facing Ms Nix She recalls his telling her Your case quotis bad but there are people who come in here and they have cancer and they make too much for Medicaid Unless you are over 65 or under 18 or deaf or blind you are not going to get Medicaidquot Ms Nix burst into tears She wasn39t sure what to do Her parents offered con icting advice Her mother whose work has familiarized her with the medical system told Ms Nix to get tough with the hospital and negotiate a deal to pay a few dollars a month Her father told her she should repay the debt she39d incurred whatever the hardship Without Methodist39s care he reminded her she could have died In late August a new hospital bill arrived listing the total amount due as 14182 The hospital had added an additional charge of 1072 earmarked for the Bad Debt and Charity Care Pool a state fund that compensates hospitals for caring for the uninsured Ms Nix was 103 stunned by the irony quotTack on another grand I can39t pay but use it to help someone elsequot she says The inequity in health care pricing is rooted in a policy that was designed to prevent it Rules dating back to the establishment of Medicare in the 1960s require hospitals participating in the program to set uniform charges for all procedures The idea was to prevent hospitals from charging some classes of patients such as Medicare beneficiaries more than others Hospitals were free to set charges typically kept on voluminous lists called charge masters as they wished depending on costs local competition and state regulatory limits In the early years of the program charges roughly correlated to hospitals39 costs plus a modest profit and reimbursements closely tracked charges Then in the mid 1980s Medicare started pegging most payments to standardized diagnostic codes rather than to hospitals39 charges As HMOs became more powerful in the late 1980s and early 3990s they negotiated their own rates with hospitals Ms Nix contacted the hospital and the doctors who had worked on her seeking a break Dr Gorecki the surgeon immediately slashed his fee to 1000 from 2500 a break he often gives to the uninsured Ms Nix says she has sent him two checks for 20 each The hospital was somewhat less obliging It offered to reduce her bill by 20 Ms Nix says the hospital demanded that she agree to pay within a month or two but Ms Hill the New York Methodist spokeswoman says the hospital gave Ms Nix a full year to pay Under those terms she would have faced monthly payments greater than 900 a month Ms Hill says three or four uninsured inpatients a month out of an average of about 90 uninsured inpatients treated call with concerns about their bills and they are routinely offered a 20 discount off charges before the bill is assigned to a collection agency Even so Ms Hill says uninsured patients quotalmost never payquot New York Methodist says that it racked up 50 million last year in quotbad debt and charity carequot or about 14 of its annual budget However those figures are based on the hospital39s charges not its costs Also the hospital is able to mitigate some of these losses by tapping into the New York Bad Debt and Charity Care pool In 2001 the latest year for which figures are available Methodist collected 13 million to 14 million from the pool A state health department spokesman says the pool on average reimburses hospitals for their costs at about 50 cents to 70 cents on the dollar On Oct 21 Ms Nix sent a letter to the hospital quotI understand that I am indebted to Methodist hospitalquot she wrote quotThe staff was so kind to me during my stayquot But noting that her bills for the surgery totaled nearly 19200 she wrote quotThis is more money than I will make this year almost twice as muchquot She added quotI do not wish to pay nothing for the life saving services I receivedquot but she said she couldn39t pay what Methodist wanted She had consulted bankruptcy lawyers and was considering returning to Texas The hospital didn39t respond to the letter Ms Nix soon started telling shocked friends that she was leaving On Nov 5 she stuffed everything she could into two suitcases and ew home on a ticket her mom had given her After The Wall Street Journal contacted New York Methodist about Ms Nix the hospital told her it would reduce her bill to 5000 essentially what Medicaid would have paid says Methodist39s Ms Hill The hospital also said it would give Ms Nix one year to pay provided she pay 3000 up front which she has yet to do She says she hopes to start paying the hospital back within a year In Midland she has taken over her younger brothers39 old bedroom Life is slower and she has gone to some high school football games quotI miss the glamour of the cityquot she says For the past few months she has been working part time at her mother39s medical supply firm where she earns 7 an hour for filing and filling out forms She also has been doing unpaid research for her father Her mother39s company couldn39t offer her health benefits because they were too expensive to provide Two weeks ago Ms Nix finally purchased health insurance Young and Exposed US uninsured population by age in 2001 AGES Total Uninsured 41 million Note The number of uninsured older than 65 is 08 because they are covered by Medicare Source Kaiser Commission on Medicaid and the UninsuredUrban Institute analysis 105 Behind the Bill Who Pays What Hospitals are required to list official charges for all procedures But big players such as HMOs insurance companies and the government routinely negotiate or demand big discounts Uninsured patients are almost always faced with full charges Below a sampling of charges and discounts for a relatively common procedure a diagnostic bilateral mammogram HOSPITALLOCATION UCLA Medical CenterLos Angeles OFFICIAL CHARGE 460 MEDICAID 127 MEDICARE 90 HMOs HEALTH PLANS Up to 242 POLICY ON UNINSURED Gives discounts based on individual39s ability to pay HOSPITALLOCATION Oregon Health amp Science UniversityPortland OFFICIAL CHARGE 240 MEDICAID 65 MEDICARE 59 HMOs HEALTH PLANS Average 128 POLICY ON UNINSURED Works with uninsured patients to help them find financial aid offers sliding scales payment plans HOSPITALLOCATION Jamaica HospitalQueens NY OFFICIAL CHARGE 351 MEDICAID 50 MEDICARE 96 HMOs HEALTH PLANS 40 to 78 POLICY ON UNINSURED Has sliding fee scales for uninsured HOSPITALLOCATION Johns Hopkins Hospital amp Health SystemBaltimore OFFICIAL CHARGE 261 MEDICAID 156 MEDICARE 173 HMOs HEALTH PLANS 186 POLICY ON UNINSURED State regulation of charges reduces disparity between bills to insured and uninsured HOSPITALLOCATION Grinnell Regional Medical CenterGrinnell Iowa OFFICIAL CHARGE 285 MEDICAID 73 MEDICARE 79 HMOs HEALTH PLANS 119 to 190 POLICY ON UNINSURED Works with uninsured to set a payment schedule actual payment from Medicaid Medicare andor HMOs health plans Note Charge includes hospital and physician fees Source the hospitals Faith and Credit Forgoing Insurance Mr Selby Bargains For His Health By Lucette Lagnado 24 November 2004 The Wall Street Journal TWAIN HARTE Calif Curtis Selby is one of America39s 45 million uninsured but he39s not complaining He doesn39t want health insurance Mr Selby a 55 year old cabinetmaker with a long beard small spectacles and an affable manner doesn39t believe in health insurance He has long done without it though he could afford a policy on what he makes crafting dining tables kitchen cabinets and bookcases Mr Selby abstains from health coverage because of his religious beliefs He is a member of the Old German Baptist Brethren Church a Christian denomination with similarities to the Amish The Brethren don39t believe in war Most members of his church don39t vote smoke or drink listen to the radio watch TV or surf the Internet And many don39t belong to HMOs or other health insurance plans Mr Selby says he and his fellow Brethren believe God will pull them through any crisis Brethren members have traditionally paid for their own care If a church member becomes seriously ill other Brethren will try to help with bills This has become more difficult in recent years because of rising health care costs Plagued by a series of ailments including a heart attack cancer pancreatitis and a diseased gallbladder Mr Selby has had to shell out tens of thousands of dollars In the process he has learned to shop for health care the way other Americans shop for cars He haggles over prices He asks for discounts if he pays upfront He goes to different hospitals scouting out their best offer and then pits them against each other If he still can39t get what he wants he goes to the top appealing to hospital executives quotA lot of people in a hospital don39t know what to do when someone says they want to pay cashquot Mr Selby says Mr Selby has already done what millions of Americans may soon be doing as companies shift to quotconsumer drivenquot health care plans and health savings accounts These plans typically move more health care costs to consumers which may encourage them to shop around in order to save money Advocates of these plans say they will stimulate competition among health care providers and make consumers cut back on unnecessary tests and procedures eventually lowering costs Critics counter that it39s unrealistic to expect patients to hunt for bargains quotWhen your child has been injured do you call and say Now which orthopedist will fix this collarbone the cheapest quot says Karen Davis president of the Commonwealth Fund a private foundation in New York that focuses on health care policy Mr Selby has found that shopping around for medical care isn39t easy He has experienced first hand a system that is reluctant to disclose prices He39s seen how hospitals charge uninsured people the full sticker rate while giving health insurance companies and the government big breaks off the listed price Because he owns his own business and says he is in the middle class Mr Selby usually doesn39t get offered the indigent discount programs that many hospitals have begun touting in response to criticism over their billing practices Mr Selby says he used to think he had to accept a hospital39s prices as set in stone Then around the time he had a heart attack 11 years ago he decided he had to manage his affairs as a patient in a more businesslike manner By being a tough negotiator and never accepting an offer as final quotI am in business and I try to survivequot he says quotI realize there is a difference between wholesale and retailquot He now approaches shopping for health care in much the same way he handles buying lumber for his cabinet shop His suppliers quotwant our business and offer special pricingquot he says He finds that he can almost make the same assumption with a hospital quotWhen I found out the hospitals offered special pricing if we could kind of shop with them that made sensequot he says Mr Selby has had ample dealings with the medical industry His latest ordeal began around Christmas in 2002 when he was diagnosed with prostate cancer He knew he needed to be seen at a large medical center His town in the foothills of the Sierra Nevada is in a rural area of thick woods and winding roads While there are two local hospitals Mr Selby went to the University of California San Francisco Medical Center a 3 12 hour drive from his home He was examined by Mack Roach a specialist on prostate cancer Dr Roach determined radiation would be the best treatment to halt Mr Selby39s cancer which he says was especially virulent The hospital said the treatment would cost between 80000 and 100000 UCSF39s renowned cancer center attracts a moneyed clientele from abroad says Dr Roach These VIPs are a lucrative business not only for UCSF but other world class institutions quotSome of these patients are very wealthyquot and quotthey are able to pay without much difficultyquot says Dr Roach When uninsured Americans get quoted similar prices some of them give up he says In the spring of 2003 Mr Selby his wife and the youngest of his six children made their way to UCSF They wore the traditional dress favored by the Brethren Mrs Selby in a handmade oor length dress and a white cap her husband wearing a broad brimmed hat pants with suspenders and a shirt and vest They were determined to get Mr Selby39s care there which made an impression on the doctor and staff But it quickly became apparent that Mr Selby uninsured and not independently wealthy wouldn39t be able to afford the full cost UCSF sometimes negotiates discounts for uninsured patients39 treatment but until recently it hadn39t always immediately volunteered that information Dr Roach says Mr Selby was unusual he says because quothe askedquot 108 The hospital scrutinized Mr Selby39s finances asking about his income expenses and the size of his family then weighing those factors against the expected cost of his cancer treatment They determined he would likely be eligible for a number of government programs including California39s Medicaid as well as Medicare Though he owned a business he was supporting his wife and three children still living at home But Mr Selby threw a monkey wrench into the hospital39s financial aid apparatus by refusing to apply for Medicaid or Medicare citing his religious principles While his church doesn39t forbid accepting Medicaid Mr Selby says that quotindividual convictions based on scripturesquot guide him and others on health care issues That was a big problem for UCSF According to the hospital39s policy UCSF can write off some medical care as charity but only if the person has been turned down for Medicaid or Medicare Mr Selby and his wife went to meet UCSF39s admissions director Myriam Cabello She decided to invoke a religious exception to the hospital39s policy She cited the fact that Mr Selby couldn39t apply to government health care programs because of his beliefs as a way to get around the rule She also dipped into a private philanthropic fund the hospital maintains to help cancer patients The fund now stands at 213000 Mr Selby wasn39t opposed to private charity The decision to decline health insurance is left to individuals says Kenneth Landes 72 a church elder The Old German Baptist Brethren isn39t a hierarchical organization The estimated 6000 to 7000 members have local councils and a standing committee of a dozen elders who meet once a year Mr Landes who has served on the standing committee says he has steered clear of commercial insurance out of a sense of community quotI felt that it is probably better that we would take care of ourselves and each otherquot he says In and around his community of Eldorado Ohio church members are assessed money each month for an quotassurancequot program to help pay medical bills of members who also haven39t bought into health plans or HMOs Some Brethren do purchase commercial insurance Mr Landes notes He and others accept Medicare he says because they have paid into the system with their taxes Others decline government health care Mr Selby says UCSF delicately tried to determine what he could afford to pay for his cancer treatment The figure 25000 was suggested by a staffer at the cancer center he says He thought that was fair He told them he would try to come up with that amount of cash At the same time he was checking out other options Months earlier he had contacted Loma Linda University Medical Center in Loma Linda Calif which is well known for its prostate cancer treatment The institution first quoted him an 80000 treatment plan he says After several phone discussions with officials at Loma Linda the price came down dramatically Mr Selby says to between 36000 and 38000 Cindy Schmidt executive director of the patient business office at Loma Linda said while they have a record of Mr Selby39s calls they don39t have records of any negotiations and can39t 39 comment She added quotWe make every effort to ensure that cash patients do not pay more than what an insurance company would pay Still Mr Selby was hoping that UCSF could work out a financial package for him It did agreeing to do the treatment for one fourth the cost of its initial estimate Ms Cabello approved the 25000 price tag in late June 2003 Mr Selby39s first radiation treatment began in July At times Mr Selby would lug bins of sweet corn tomatoes and other fresh fruits and vegetables to the hospital and distribute them to therapists the receptionist office secretaries and Dr Roach the physician recalls The UCSF hospital lost money treating Mr Selby says Ms Cabello Based on the hospital39s list prices his treatment cost 88652 He came up with 25000 and the philanthropic fund chipped in 34000 for a total of 59000 The rest will be written off as charity care Ms Cabello declined to say how much private insurers would have been charged for such treatment Insurance companies usually negotiate prices that are significantly lower than the full rate Medicare she estimates would have paid somewhat more than Mr Selby 34000 Medicaid would have paid less about 20000 Like other institutions UCSF provides charity care both out of a sense of mission and because that is important in order to keep its not for profit tax status There are no quotrigidquot requirements to maintain that status says Kenneth Jones the UCSF medical center39s chief financial officer He says UCSF provided 22 million in uncompensated care in the 2003 fiscal year about 2 of its revenue of 950 million In addition UCSF lost 47 million treating Medicaid patients Mr Jones says After completing cancer treatment in September 2003 Mr Selby became seriously ill a few weeks later this time with pancreatitis an in ammation of the pancreas Rushed to the local hospital Sonora Regional Medical Center he was admitted and treated He knew the routine from years of experience Uninsured patients can get as much as 30 off list prices but typically only if they pay at the time He brought his credit card and charged 5900 for his treatment representing a 30 discount off his full bill of 8400 While he was in the hospital doctors determined he would also need to soon have his gallbladder removed The price 12000 That meant it was time to go shopping again Mr Selby tried another tactic he has learned He asked a doctor friend to intervene on his behalf in hopes of getting him a better deal The doctor called an administrator at a different hospital As a favor to the doctor and sympathetic to Mr Selby39s plight the administrator agreed to do the operation for only 3000 Mr Selby went back to Sonora and was offered the standard 30 discount for prompt payment quotCould you do any better he recalls asking Dave Larsen a senior vice president for finance He told Mr Larsen about the 3000 offer he had from another hospital Mr Larsen says he agreed to knock the price for the gallbladder operation down to 3500 He also agreed to erase an additional bill of a few thousand dollars related to Mr Selby39s pancreatitis So Mr Selby had the operation there Sonora Regional Medical Center officials say they are prepared to offer discounts to anyone who comes and negotiates as Mr Selby did quotWe exist to serve the community says Mr Larsen quotWe gave Curtis a discount because he needed services and he came to us basically saying that he was paying out of pocket that he had choices39 but he would prefer to get the services here39 Mr Selby has been feeling better in recent months But when he went back to Sonora Regional for checkups and blood tests he was shocked at a bill about 400 for a couple of blood tests One was a PSA test which checks the level of prostate specific antigen a key indicator of prostate cancer It cost 170 at the hospital quotI am thinking this is ridiculous he says Mr Selby received a discount of about 30 on that bill the hospital says Months later at a health fair in his community Mr Selby took the PSA blood test again The charge was only 10 A spokeswoman for Sonora Regional said hospitals have to build labor and technology costs into the price of basic procedures It39s quotunfairquot Mr Larsen says to compare the price of a blood test at the hospital with one offered at a health fair The spokeswoman noted the fair was staffed by volunteers and the blood tests were processed in bulk She added that her hospital was one of the sponsors of the fair helping subsidize the tests and providing volunteers Mr Selby39s recent experiences have made him re ect about how the system treats the middle class uninsured a group that tends to get neglected even by health advocates who focus their energies on the needy and indigent quotI don39t have these big reserves Mr Selby says quotI have a family business I have machinery that I could liquidate I have a couple of vehicles that I can go out and pawn But it would seem that hospitals would be considerate A salesman did come by his shop trying to persuade him to buy health insurance last year So far the answer is still quotnoquot Some Brethren have taken a different path including members of Mr Selby39s own family Mr Selby39s eldest son Simon 29 bought a state subsidized Blue Cross of California policy for his wife when she became pregnant for the first time two years ago He is glad he did His daughter Sadie who was covered by the policy had pneumonia shortly after she was born She had to be transferred to Doctors Medical Center in Modesto a unit of Tenet Healthcare Corp a for profit system The bill for her care in the neo natal intensive care unit came to more than 100000 the younger Mr Selby says The insurance company settled with the hospital for about 2400 according to the paperwork he received Doctors Medical Center won39t comment on the gap between what it charges and what it accepts from insurance companies Catherine Larsen a spokeswoman for the hospital says it 111 would certainly have tried to work with Simon Selby if his family were uninsured Even so she adds quotI think that it was good he had insurance Simon Selby knows that he could have been stuck with the full bill had he been uninsured quotIt is totally unreal he says Now that his wife is pregnant again he has coverage for his wife and children but like his dad not for himself Without a Net The 45 million uninsured people in the US by household income level Less than 25000 34 25000 49999 33 75000 or more 17 50000 74999 16 Source US Census Bureau current population survey March 2004 112 Anatomy of a Hospital Bill By Lucette Lagnado 21 September 2004 The Wall Street Journal HOW MUCH does an overnight stay at a Virginia hospital cost If Medicaid is paying the answer is 6000 If Paul Shipman is paying it39s 29500 A year ago Mr Shipman a 43 year old former furniture salesman from Herndon Va experienced severe chest pains during the night An ambulance took him first to a community hospital emergency room and then to lnova Fairfax Hospital Fairfax Va Suspecting a heart attack doctors first performed a cardiac catheterization to examine and unblock the coronary arteries Then they inserted a stent a small metal device that props open a blocked artery so the blood ows better to the heart Lacking health insurance Mr Shipman says he was worried about the cost The next morning too anxious about his bill to stay Mr Shipman checked himself out of the hospital against medical advice Since then Mr Shipman and his wife Alina have received hospital bills totaling 29500 for what they say was a 21 hour hospital stay In addition there were other bills some 1000 for the ambulance trip 6800 from the cardiologist who performed the stent procedure and several thousand dollars for the local emergency room visit In all the two day health crisis left the Shipmans saddled with medical bills totaling nearly 40000 Once solidly middle class the couple says the debt triggered a gradual unraveling of their lives quotMiddle class or not when you have a bill of 37000 hanging over your head that39s all you think aboutquot says Ms Shipman 36 years old and until recently a secretary at George Washington University quotYou eat sleep and breathe that billquot Like many of the 45 million Americans who don39t have health insurance the Shipmans gambled unwisely it turns out that they could make do without it Among the many factors they didn39t take into account was the high markups hospitals tag onto care for uninsured patients charging them far more than what they charge big private or government plans for the same care Because Mr Shipman was given an itemized bill listing each charge his situation offers an unusually detailed view of the size and scope of markups in the medical care market With some lawmakers suggesting that consumers should be able to shop around for their own health care using health savings accounts the Shipmans39 experience shows just how difficult it can be to evaluate what medical procedures really cost not to mention the difficulties a person in medical distress would experience in trying to shop for health care Mr Shipman filed a lawsuit in August in federal district court for the Eastern District of Virginia in Alexandria naming lnova Health Care Services and the American Hospital Association His attorneys are seeking class action status for the suit in which he challenges the hospital39s tax exempt status as a not for profit charity based on its pricing and billing practices Uninsured patients have filed dozens of claims against major medical centers in HY recent months echoing Mr Shipman39s claim that lnova quotengaged in the pattern and practice of charging inordinate and in ated rates for medical carequot for uninsured patients The US hospital pricing system is quota Persian rug market of negotiationsquot where providers suppliers and insurers cut their own deals and only the uninsured pay full fair says Bryan Vroon an Atlanta lawyer representing Mr Shipman Also representing Mr Shipman is Don Barrett an Lexington Miss attorney lnova asked a Virginia judge to dismiss the suit this week quotNot everyone who lacks health insurance is poorquot hospital attorneys argued in court papers quotMr Shipman does not allege that he is or was indigent Nor does he allege that he was unable to obtain or afford health insurancequot So far the plaintiff has paid only 225 toward his bill Indeed at the time of Mr Shipman39s illness the Shipmans weren39t poor Mr Shipman was earning 80000 a year in salary and commissions selling furniture They were living in an attractive rented townhouse in suburban Virginia and driving a leased BMW In March 2002 the Shipmans say Ms Shipman left a job with benefits in order to return to college and the couple decided to go without health insurance They figured they were healthy and relatively young health coverage would have cost them several hundred dollars a month money they figured would be better spent on tuition The same package of care devices services and drugs for which lnova Fairfax charged Mr Shipman 29500 would have been paid at only 6000 by Virginia Medicaid a spokesman for the state agency says Medicare the federal insurance program for the elderly estimates it would have paid lnova approximately 15000 for the catheterization and stent procedure plus depending on the hospital39s location an extra differential Managed care and private insurers reimburse at a variety of rates and the hospital wouldn39t disclose what its average such reimbursement is A major factor contributing to the size of Mr Shipman39s bill is that each component of his care from the 7560 charge for the stent to the 3915 charge for saline solution was broken out as a line item on his bill in the manner of an a la carte restaurant bill Big government insurers and many big private insurers refuse to pay for items billed this way reimbursing instead according to the uniform system of diagnostic codes that have been long accepted in the industry lnova Fairfax declined to comment on its markups or any specific charges on Mr Shipman39s bill It says it offered the couple a 20 discount off the bill and sent the couple a financial aid application but it was never returned The Shipmans say they were prepared to pay thousands of dollars toward the bill and tried to negotiate but never were offered an amount they could handle or that seemed fair They say they never received a financial aid application and the discount they were offered was only 15 resulting in a bill they still couldn39t afford to pay Mr Shipman negotiated a discount from at least one physician involved in his care Joseph Kiernan a cardiologist who practices at lnova Fairfax billed Mr Shipman 6800 but when the Shipmans told him they couldn39t afford to pay that much he slashed some 3000 off the bill bringing it down to about 3800 That is still more than what big government payers such as Virginia Medicaid would have paid A spokesman for the state agency says it would 114 have reimbursed the doctor slightly over 1000 Medicare says it would have paid about 900 quotWe feel that patients should be somewhat responsible for the medical costs Dr Kiernan says For uninsured patients who are uninsured but not indigent quotwe come up with a compromise solution The stent put into Mr Shipman39s artery was the Cypher a top of the line drug emitting device made by Cordis a unit of Johnson amp Johnson lnova Fairfax billed Mr Shipman 7560 for the tiny piece of hardware Thomas Gunderson an analyst with Piper Jaffray amp Co Minneapolis says Cordis listed an undiscounted price of 3195 for the Cypher last year The device that helped open up Mr Shipman39s clogged arteries was a balloon PTCA or percutaneous transluminal coronary angioplasty lnova Fairfax billed Mr Shipman 2114 for two of them or more than 1000 each Hospital costs for such devices typically range from about 250 to 300 Mr Gunderson says quotLooking at an itemized bill does start to remind me of the furor over Defense Department costs of years ago Mr Gunderson says quotWhile I would never begrudge a hospital from making a profit one hopes there would be some semblance of fairness in charging uninsured patients for product costs Kathleen Thomas an lnova spokeswoman dismissed the comparison quotIt isn39t the same issue not for profit hospitals including lnova provide millions of dollars in uncompensated care every year We treat all patients regardless of their means to pay lnova39s charges are below the national median and fall in the quotmid to low end of the market among Virginia hospitals on cardiac care she says On its bill to the Shipmans the hospital charged 437 for VasoSeal a popular sealant that stops arterial bleeding following catheterization that is made by Datascope Corp of Montvale NJ Hospitals generally buy the product for 200 to 210 says Murray Pitkowsky senior vice president at Datascope A gold guide wire was billed to Mr Shipman at 523 Mr Gunderson and others estimate that guide wires generally cost from 80 to 100 Mr Shipman39s bill lists 1000 milliliters of saline solution at a price of 3915 Falk Pharmacy in New York says it sells saline solution for 12 to 15 a liter Dr Michael Mooney director of interventional cardiology at the Minneapolis Heart Institute says he gets the bottles in bulk for a couple of dollars each quotThere is no one who pays line items except the uninsured which makes no sense Dr Mooney says Another supply used to treat Mr Shipman was nonionic contrast a dye used to help imaging of the arteries lnova Fairfax charged Mr Shipman 53250 for three bottles of the dye a product called Optiray made by Mallinckrodt a unit of Tyco Healthcare Mallinckrodt sells the product to hospitals for 28 to 50 a bottle Then there was the ambulance ride from the community hospital in Reston to lnova Fairfax Mr Shipman was billed 1000 for the 16 mile ride by the private company that transported him Loudoun Fairfax Ambulance of Sterling Va Medicare says it would have paid only 115 247 for the ride Virginia Medicaid says it would have paid as little as 165 in some cases for the same trip Private payers generally pay along the lines of 70 to 80 of the charges says Jeff Laramie the company39s owner quotThe rules are completely crazyquot he says quotIt is not like you39re going to a store and you buy a loaf of bread for 150quot He says that charges are high to compensate for low reimbursements from the government and other big insurers Doug Cropper Inova Fairfax Hospital39s administrator said he can39t discuss specific allegations of in ated charges But he defended the hospital saying it couldn39t thrive or even survive if it only charged costs quotIf we only asked people to pay our costs absent government subsidies we would not have the funds for the indigent for Medicaid patients or for self pay patients Nor we would we have funds available for new equipment or technology nor would we have funds to invest in new facilities that our growing community needsquot quotWere the Shipmans treated unfairly I don39t knowquot says Rick Wade spokesman for the American Hospital Association quotThey made a personal decision to give up coverage and they want to say We want to pay whatever we choose to pay We want to negotiate whatever number we like39 quot The industry39s patchwork pricing system has come about in response to the patchwork reimbursement system A good question to ask he says is quotwhat is a fair charge over and above the cost of care and shouldn39t everyone pay it if it is fairquot Hal Cohen a health care consultant who has studied hospital markups in all 50 states says his studies indicate that in Virginia hospital charges generally run about twice their costs The gap is even greater he says in states such as New Jersey Nevada and Florida Mr Cohen says some US hospitals charge as much as 10 times their costs Maryland which continues to regulate charges has the lowest hospital markups he says quotI agree that hospitals have to charge more than costs but that is no defense for charging two three eight ten times morequot Mr Cohen says Many hospitals reacting to criticism of the way they bill and collect from the needy have rushed to implement discount programs for low income patients who lack insurance But few hospitals have figured out what to do with those uninsured patients who aren39t needy but still can39t afford to pay full freight quotIf you are going to give charity to one group I would give it to the middle class rather than the poorquot says Elizabeth Warren a professor of the law school at Harvard University Her research indicates medical bills are the second leading cause of personal bankruptcy quotThe people that get wiped out are in the middlequot Mr Cropper Inova Fairfax39s administrator says Inova is among the largest providers of uncompensated care of any hospital in Virginia Last year the facility incurred real costs not charges of more than 100 million in care to the uninsured In January the hospital began a program to slash 35 off the bills for self pay patients regardless of income he adds The program wasn39t offered to the Shipmans though H7 Mr Shipman recently lost his job at Oak Post furniture showroom a Virginia operator and Ms Shipman has resigned from her university job The couple was planning to board a ight to visit family in Romania today Ms Shipman39s mother helped pay for the tickets quotIt has been really really stressful and I need to get away for a while Ms Shipman says Did she regret not getting health insurance the first time around quotOf course she says quotObviously nobody wants to go through this But at the same time nobody should pay this kind of money for health insurance or care Free Market Paul Shipman who lacks health insurance incurred a multitude of bills for healthcare services and supplies in connection with an apparent heart attack Doctors drug companies and other industry experts say his bills showed large markups SERVICES SHIPMAN BILL MEDICAID MEDICARE Ambulance ride 1000 165 247 Hospital stay 29500 6000 15000 Doctor charge 6800 1000 875 SUPPLIES SHIPMAN BILL LIST PRICE Stent 7560 3195 N on Ionic contrast 17750 28 50 Saline 3915 1215 Balloon 1050 250400 VasoSeal 437 200210 Medicare and Medicaid reimburse hospitals for total treatment package not on a per item basis Doctor discounted price by about 3000 Retail price at a New York City drugstore The price hospitals typically pay with volume discounts Inova hospital would not reveal what it actually paid for supplies Sources Medicare Medicaid WSJ research 117 ToDo List Wrap Gifts Have Baby The New York Times December 20 2006 By DAVID LEONHARDT For decades and decades the busiest day of the year in the nation s maternity wards fell sometime in mid September Americans evidently do a lot of baby making during the cold dark days of December and once a baby has been made the die for its birth date has largely been cast Or at least that s the way it used to be In the last 15 years there has been a huge increase in the number of births that are induced with drugs or come by Caesarean section In either case parents or doctors can often schedule a baby s arrival on a day of their choosing Not surprisingly they tend to avoid weekends and holidays when doctors have other plans hospitals are short of staff and the possibility of an unfortunate birthday 7 Christmas Day anyone 7 looms During holiday weeks births have become increasingly crowded into the weekdays surrounding the holiday Over this same period 7 since the early 1990s 7 the federal government has been steadily increasing the tax breaks for having a child For parents to claim the full amount of any of these breaks in a given year a child must simply be born by 1159 pm on Dec 31 If the baby arrives a few minutes later the parents are often more than a thousand dollars poorer Unless you re a cynic or an economist I realize you might have trouble believing that the intricacies of the nation s tax code would impinge on something as sacred as the birth of a child But it appears that you would be wrong In the last decade September has lost its unchallenged status as the time for what we will call National Birth Day the day with more births than any other Instead the big day fell between Christmas and New Year s Day in four of the last seven years 7 1997 through 2003 7 for which the government has released birth statistics The day was in September during the other years conception still matters Based on this year s calendar there is a good chance that National Birth Day will take place a week from tomorrow on Thursday Dec 28 It s phenomenal what s happening in late December said Amitabh Chandra a Harvard economist who provided many of the numbers here December is not really a particularly busy time for babies to be born So to see a spike that s equal to September is astounding Obviously there are reasons beside taxes that someone might prefer having a baby in late December rather than early January Many people will be on vacation next week with extended family in town to see a new baby and help around the house The stress of having relatives visit may also be enough to send some expectant mothers into labor So to see if taxes were truly the culprit Mr Chandra and another economist Stacy Dickert Conlin of Michigan State devised some clever tests They found that people who stood to gain the most from the tax breaks were also the ones who gave birth in late December most 118 frequently When the gains were similar high income parents 7 who presumably are more likely to be paying for tax advice 7 produced more December babies than other parents It s also telling that the year s final week was not the first part of the calendar to replace September For a few years in the mid 1990s a day on either side of the long July 4 weekend was National Birth Day But July lost the honor as the tax code became ever kinder to families with children The child tax credit now worth up to 1000 made its debut in 1998 and the earned income tax credit an anti poverty policy that s more generous to families with at least two kids became much larger in the 90s The personal exemption for its part has risen along with in ation reaching 3300 this year By my calculations about 5000 babies of the 70000 or so who would otherwise be born during the first week in January may have their arrival dates accelerated partly for tax reasons When Mr Chandra interviewed one mother in central Kentucky she told him her doctor encouraged her to schedule a late December birth well in advance to be sure she got a delivery room Anecdotes aside Mr Chandra thinks my estimate of 5000 is conservative based on his own more sophisticated statistical analysis In addition to being an entertaining bit of trivia the end of the year baby boom also raises a legitimate policy question just because we have the medical ability to do something does that necessarily mean it s such a good idea Induced births and Caesarean sections are considerably more expensive than natural births on average There are clearly cases when labor needs to be induced for a baby s health or the mother s It s much less clear however that the health care system should be subsidizing parents desire for a smaller tax bill The health effects of scheduled births are also murky A big study led by a researcher at the Centers for Disease Control and Prevention found that voluntary Caesareans increase the risk of infant mortality Another study found that weekday births are slightly more risky than weekend ones all else equal suggesting that a drug induced birth can also cause health problems The differences are small but the stakes are big enough to take any change seriously When you induce labor you compress this long process into a few hours said Dr Emmet Hirsch the director for obstetrics at Evanston Northwestern Healthcare near Chicago When you do that you can run into all sorts of problems To minimize those problems the largest medical provider in Utah lntermountain Healthcare now discourages women from electively inducing labor before their 39th week of pregnancy This is what s best for moms and babies said Janie Wilson a nurse who helps run the newborn program at lntermountain It just seems like a no brainer Before the policy went into effect in 2001 lntermountain based in Salt Lake City had more December births than January births It doesn t anymore H l The solution to this situation seems simple enough to me and it comes back to the tax code If Congress changed the all or nothing aspect of the child tax breaks it would reduce the incentive to rush a fetus along in the final days of the year A child born in December could be eligible for one twelfth of a deduction or a credit rather than the whole thing But maybe I m just biased When my mother was getting ready to give birth to her first child she would tell friends and family that Jan 1 was the only day she didn t want the baby to arrive She figured the hospital would be dealing with the aftermath of New Year s Eve and she couldn t stand the idea of giving birth to New York s much publicized first baby of the year I suspect most people thought she didn t have much to fear given that the due date 7 my due date 7 was Dec 22 But she apparently knew what she was talking about I arrived late on the afternoon of Jan 1 The doctor complained about missing the Rose Bowl and my parents missed out on one of the few ways that a child can be a financial windfall 120 Women Buying Health Policies Pay a Penalty The New York Times October 30 2008 By ROBERT PEAR WASHINGTON 7 Striking new evidence has emerged of a widespread gap in the cost of health insurance as women pay much more than men of the same age for individual policies providing identical coverage according to new data from insurance companies and online brokers Some insurance executives expressed surprise at the size and prevalence of the disparities which can make a woman s insurance cost hundreds of dollars a year more than a man s Women s advocacy groups have raised concerns about the differences and members of Congress have begun to question the justification for them The new findings which are not easily explained away come amid anxiety about the declining economy More and more people are shopping for individual health insurance policies because they have lost jobs that provided coverage Politicians of both parties have offered proposals that would expand the role of the individual market giving people tax credits or other assistance to buy coverage on their own Women often fare worse than men in the individual insurance market said Senator Max Baucus Democrat of Montana and chairman of the Finance Committee Insurers say they have a sound reason for charging different premiums Women ages 19 to 55 tend to cost more than men because they typically use more health care especially in the childbearing years But women still pay more than men for insurance that does not cover maternity care In the individual market maternity coverage may be offered as an optional benefit or rider for a hefty additional premium Crystal D Kilpatrick a healthy 33 year old real estate agent in Austin Tex said I ve delayed having a baby because my insurance policy does not cover maternity care If I have a baby I ll have to pay at least 8000 out of pocket In general insurers say they charge women more than men of the same age because claims experience shows that women use more health care services They are more likely to visit doctors to get regular checkups to take prescription medications and to have certain chronic illnesses Marcia D Greenberger co president of the National Women s Law Center an advocacy group that has examined hundreds of individual policies said The wide variation in premiums could not possibly be justified by actuarial principles We should not tolerate women having to pay more for health insurance just as we do not tolerate the practice of using race as a factor in setting rates Tl Without substantial changes in the individual market Ms Greenberger said tax credits for the purchase of insurance will be worth less to women because they face higher premiums The disparities are evident in premiums charged by major insurers like Humana UnitedHealth Aetna and Anthem a unit of WellPoint in prices quoted by eHealth a leading online source of health insurance and in rate tables published by state high risk pools which offer coverage to people who cannot obtain private insurance Humana for example says its Portrait plan offers ideal coverage for people who want benefits like those provided by big employers For a Portrait plan with a 2500 deductible a 30 year old woman pays 31 percent more than a man of the same age in Denver or Chicago and 32 percent more in Tallahassee Fla In Columbus Ohio a 30 year old woman pays 49 percent more than a man of the same age for Anthem s Blue Access Economy plan The woman s monthly premium is 9287 while a man pays 6230 At age 40 the gap is somewhat smaller with Anthem charging women 38 percent more than men for that policy Todd A Siesky a spokesman for WellPoint declined to comment on the Anthem rates Thomas T Noland Jr a senior vice president of Humana said Premiums for our individual health insurance plans re ect claims experience 7 the use of medical services 7 which varies by gender and age Females use more medical services than males and this difference is most pronounced in young adults In addition Mr Noland said Bearing children increases other health risks later in life such as urinary incontinence which may require treatment with medication or surgery Most state insurance pools for high risk individuals also use sex as a factor in setting rates Thus for example in Dallas or Houston women ages 25 to 29 pay 39 percent more than men of the same age when they buy coverage from the Texas Health Insurance Risk Pool In Nebraska a 35 year old woman pays 32 percent more than a man of the same age for coverage from the state insurance pool Representative Xavier Becerra Democrat of California said that if men could have kids such disparities would probably not exist Elizabeth J Leif a health insurance actuary in Denver who helps calculate rates for Nebraska and other states said Under the age of 55 women tend to be higher utilizers of health care than men I am more conscious of my health than my husband who will avoid going to the doctor at all costs Many state insurance laws require insurance policies to cover complications of pregnancy even if they do not cover maternity care Ms Leif said Insurers say those complications generate significant costs WT Representative Lloyd Doggett Democrat of Texas asked How can insurers in the individual market claim to meet the needs of women if maternity coverage is so difficult to get so inadequate and expensive Cecil D Bykerk president of the Society of Actuaries a professional organization said that if male and female premiums were equalized women would pay less but rates for men would go up Mr Bykerk a former executive vice president of Mutual of Omaha said If maternity care is included as a benefit it drives up rates for everybody making the whole policy less affordable The individual insurance market is notoriously unstable Adults often find it difficult or impossible to get affordable coverage in this market In most states insurers can charge higher premiums or deny coverage to people with health problems In job based coverage civil rights laws prohibit sex discrimination The Equal Employment Opportunity Commission says employers cannot charge higher premiums to women than to men for the same benefits even if women as a class are more expensive Some states including Maine Montana and New York have also prohibited sex based rates in the individual insurance market Mila Kofman the insurance superintendent in Maine said There s a strong public policy reason to prohibit gender based rates Only women can bear children There s an expense to that But having babies benefits communities and society as a whole Women should not have to bear the entire expense And that expense can be substantial In Iowa a 30 year old woman pays 49 a month more than a man of the same age for one of Wellmark s Alliance Select Enhanced plans Her premium at 151 is 48 percent higher than the man s 123 The Way We Age Now Medicine has increased the ranks of the elderly Can it make old age any easier by Atul Gawande April 30 2007 New Yorker Magazine The hardest substance in the human body is the white enamel of the teeth With age it wears away nonetheless allowing the softer darker layers underneath to show through Meanwhile the blood supply to the pulp and the roots of the teeth atrophies and the ow of saliva diminishes the gums tend to become in amed and pull away from the teeth exposing the base making them unstable and elongating their appearance especially the lower ones Experts say they can gauge a person s age to within five years from the examination of a single toothiif the person has any teeth left to examine Scrupulous dental care can help avert tooth loss but growing old gets in the way Arthritis tremors and small strokes for example make it difficult to brush and oss and because nerves become less sensitive with age people may not realize that they have cavity and gum problems until it s too late In the course of a normal lifetime the muscles of the jaw lose about forty per cent of their mass and the bones of the mandible lose about twenty per cent becoming porous and weak The ability to chew declines and people shift to softer foods which are generally higher in fermentable carbohydrates and more likely to cause cavities By the age of sixty Americans have lost on average a third of their teeth After eighty five almost forty per cent have no teeth at all Even as our bones and teeth soften the rest of our body hardens Blood vessels joints the muscle and valves of the heart and even the lungs pick up substantial deposits of calcium and turn stiff Under a microscope the vessels and soft tissues display the same form of calcium that you find in bone When you reach inside an elderly patient during surgery the aorta and other major vessels often feel crunchy under your fingers A recent study has found that loss of bone density may be an even better predictor of death from atherosclerotic disease than cholesterol levels As we age it s as if the calcium ows out of our skeletons and into our tissues To maintain the same volume of blood ow through narrowed and stiffened blood vessels the heart has to generate increased pressure As a result more than half of us develop hypertension by the age of sixty five The heart becomes thicker walled from having to pump against the pressure and less able to respond to the demands of exertion The peak output of the heart decreases steadily from the age of thirty People become gradually less able to run as far or as fast as they used to or to climb a ight of stairs without becoming short of breath Why we age is the subject of vigorous debate The classical view is that aging happens because of random wear and tear A newer view holds that aging is more orderly and genetically driven Proponents of this view point out that animals of similar species and exposure to wear and tear have markedly different life spans The Canada goose has a longevity of 235 years the emperor goose only 63 years Perhaps animals are like plants with lives that are to a large extent internally governed Certain species of bamboo for instance form a dense stand that grows and ourishes for a hundred years owers all at once and then dies H39V The idea that living things shut down and not just wear down has received substantial support in the past decade Researchers working with the now famous worm C elegans two of the last five Nobel Prizes in medicine went to scientists doing work on the little nematode were able to produce worms that live more than twice as long and age more slowly by altering a single gene Scientists have since come up with single gene alterations that increase the life spans of Drosophila fruit ies mice and yeast These findings notwithstanding scientists do not believe that our life spans are actually programmed into us After all for most of our hundred thousand year existenceiall but the past couple of hundred years the average life span of human beings has been thirty years or less Research suggests that subjects of the Roman Empire had an average life expectancy of twenty eight years Today the average life span in developed countries is almost eighty years If human life spans depend on our genetics then medicine has got the upper hand We are in a way freaks living well beyond our appointed time So when we study aging what we are trying to understand is not so much a natural process as an unnatural one Inheritance has surprisingly little in uence on longevity James Vaupel of the Max Planck Institute for Demographic Research in Rostock Germany notes that only six per cent of how long you ll live compared with the average is explained by your parents longevity by contrast up to ninety per cent of how tall you are compared with the average is explained by your parents height Even genetically identical twins vary widely in life span the typical gap is more than fifteen years If our genes explain less than we imagined the wear and tear model may explain more than we knew Leonid Gavrilov a researcher at the University of Chicago argues that human beings fail the way all complex systems fail randomly and gradually As engineers have long recognized many simple devices do not age They function reliably until a critical component fails and the whole thing dies instantly A windup toy works smoothly until a gear rusts or a spring breaks and then it doesn t work at all But complex systemsipower plants sayihave to survive and function despite having thousands of critical components Engineers therefore design these machines with multiple layers of redundancy with backup systems and backup systems for the backup systems The backups may not be as efficient as the first line components but they allow the machine to keep going even as damage accumulates Gavrilov argues that within the parameters established by our genes that s exactly how human beings appear to work We have an extra kidney an extra lung an extra gonad extra teeth The DNA in our cells is frequently damaged under routine conditions but our cells have a number of DNA repair systems If a key gene is permanently damaged there are usually extra copies of the gene nearby And if the entire cell dies other cells can fill in Nonetheless as the defects in a complex system increase the time comes when just one more defect is enough to impair the whole resulting in the condition known as frailty It happens to power plants cars and large organizations And it happens to us eventually one too many joints are damaged one too many arteries calcify There are no more backups We wear down until we can t wear down anymore It happens in a bewildering array of ways Hair grows gray for instance simply because we run out of the pigment cells that give hair its color The natural life cycle of the scalp s pigment cells is just a few years We rely on stem cells under the surface to migrate in and 125 replace them Gradually however the stem cell reservoir is used up By the age of fifty as a result half of the average person s hairs have gone gray Inside skin cells the mechanisms that clear out waste products slowly break down and the muck coalesces into a clot of gooey yellow brown pigment known as lipofuscin These are the age spots we see in skin When lipofuscin accumulates in sweat glands the sweat glands cannot function which helps explain why we become so susceptible to heat stroke and heat exhaustion in old age The eyes go for different reasons The lens is made of crystallin proteins that are tremendously durable but they change chemically in ways that diminish their elasticity over timeihence the farsightedness that most people develop beginning in their fourth decade The process also gradually yellows the lens Even without cataracts the whitish clouding of the lens caused by excessive ultraviolet exposure high cholesterol diabetes cigarette smoking and other unhelpful conditions the amount of light reaching the retina of a healthy sixty year old is one third that of a twenty year old I spoke to Felix Silverstone who for twenty four years was the senior geriatrician at the Parker Jewish Institute in New York and has published more than a hundred studies on aging There is he said no single common cellular mechanism to the aging process Our bodies accumulate lipofuscin and oxygen free radical damage and random DNA mutations and numerous other microcellular problems The process is gradual and unrelenting We just fall apart he said This is not an appealing prospect and people naturally prefer to avoid the subject of their decrepitude There have been dozens of best selling books on aging but they tend to have titles like Younger Next Year The Fountain of Age Ageless The Sexy Years Still there are costs to averting our eyes from the realities For one thing we put off changes that we need to make as a society For another we deprive ourselves of opportunities to change the individual experience of aging for the better For nearly all of human existence people died young Life expectancy improved as we overcame early deathiin particular deaths from childbirth infection and traumatic injury By the nineteen seventies just four out of every hundred people born in industrialized countries died before the age of thirty It was an extraordinary achievement but one that seemed to leave little room for further gain even eliminating deaths before thirty would not raise over all life expectancy significantly Efforts shifted therefore to reducing deaths during middle and old age and in the decades since the average life span has continued upward Improvements in the treatment and prevention of heart disease respiratory illness stroke cancer and the like mean that the average sixty five year old can expect to live another nineteen yearsialmost four years longer than was the case in 1970 By contrast from the nineteenth century to 1970 sixty five year olds gained just three years of life expectancy The result has been called the rectangularization of survival Throughout most of human history a society s population formed a sort of pyramid young children represented the largest portionithe baseiand each successively older cohort represented a smaller and smaller group In 1950 children under the age of five were eleven per cent of the US 1quot population adults aged forty five to forty nine were six per cent and those over eighty were one per cent Today we have as many fifty year olds as five year olds In thirty years there will be as many people over eighty as there are under five Americans haven t come to grips with the new demography We cling to the notion of retirement at sixty fiveia reasonable notion when those over sixty five were a tiny percentage of the population but completely untenable as they approach twenty per cent People are putting aside less in savings for old age now than they have in any decade since the Great Depression More than half of the very old now live without a spouse and we have fewer children than ever beforeiyet we give virtually no thought to how we will live out our later years alone Equally worrying and far less recognized medicine has been slow to confront the very changes that it has been responsible forior to apply the knowledge we already have about how to make old age better Despite a rapidly growing elderly population the number of certified geriatricians fell by a third between 1998 and 2004 Applications to training programs in adult primary care medicine are plummeting while fields like plastic surgery and radiology receive applications in record numbers Partly this has to do with moneyiincomes in geriatrics and adult primary care are among the lowest in medicine And partly whether we admit it or not most doctors don t like taking care of the elderly Mainstream doctors are turned off by geriatrics and that s because they do not have the faculties to cope with the Old Crock Felix Silverstone the geriatrician explained to me The Old Crock is deaf The Old Crock has poor vision The Old Crock s memory might be somewhat impaired With the Old Crock you have to slow down because he asks you to repeat what you are saying or asking And the Old Crock doesn t just have a chief complaint ithe Old Crock has fifteen chief complaints How in the world are you going to cope with all of them You re overwhelmed Besides he s had a number of these things for fifty years or so You re not going to cure something he s had for fifty years He has high blood pressure He has diabetes He has arthritis There s nothing glamorous about taking care of any of those things There is however a skill to it a developed body of professional expertise And until I visited my hospital s geriatrics clinic and saw the work that geriatricians do I did not fully grasp the nature of that expertise or how important it could be for all of us The geriatrics clinicior as my hospital calls it the Center for Older Adult Healthiis only one oor below my surgery clinic I pass by it almost every day and I can t remember ever giving it a moment s thought One morning however I wandered downstairs and with the permission of the patients sat in on a few visits with Juergen Bludau the chief geriatrician What brings you here today the doctor asked Jean Gavrilles his first patient of the morning She was eighty five years old with short frizzy white hair oval glasses a lavender knit shirt and a sweet ready smile Small but sturdy in appearance she had come in walking steadily her purse and coat clutched under one arm her daughter trailing behind her no support required beyond her mauve orthopedic shoes She said that her internist had recommended that she come About anything in particular the doctor asked The answer it seemed was yes and no The first thing she mentioned was a lower back pain that she d had for months which shot down her leg and sometimes made it difficult to get out of bed or up from a chair She also had bad arthritis and she showed us her fingers which were swollen at the knuckles and bent out to the sides with what s called a swan neck deformity She d had both knees replaced a decade earlier She had high blood pressure from stress she said and handed him her list of medications She had glaucoma and needed to have eye exams every four months She never used to have bathroom problems but lately she admitted she d started wearing a pad She d also had surgery for colon cancer and by the way now had a lung nodule that the radiology report said could be a metastasisia biopsy was recommended Bludau asked her to tell him about her life She said that she lived alone except for her Yorkshire terrier in a single family house in the West Roxbury section of Boston Her husband died of lung cancer twenty three years ago She did not drive She had a son living in the area who did her shopping once a week and checked on her each dayi just to see if I m still alive she joked Another son and two daughters lived farther away but they helped as well Otherwise she took care of herself quite capably She did her own cooking and cleaning She managed her medicines and her bills I have a system she said She had a high school education and during the war she d worked as a riveter at the Charlestown Navy Yard She also worked for a time at the Jordan Marsh department store in downtown Boston But that was a long time ago She stuck to home now with her yard and her terrier and her family when they visited The doctor asked her about her day in great detail She usually woke around five or six o clock she saidishe didn t seem to need much sleep anymore She would get out of bed as the back pain allowed take a shower and get dressed Downstairs she d take her medicines feed the dog and eat breakfast Bludau asked what she had for breakfast Cereal and a banana She hated bananas she said but she d heard they were good for her potassium so she was afraid to stop After breakfast she d take her dog for a little walk in the yard She did chores flaundry cleaning and the like In the late morning she took a break to watch The Price Is Right At lunchtime she had a sandwich and orange juice If the weather was nice she d sit out in the yard afterward She d loved working in her garden but she couldn t do that anymore The afternoons were slow She might do some more chores She might nap or talk on the phone Eventually she would make dinneria salad and maybe a baked potato or a scrambled egg At night she watched the Red Sox or the Patriots or college basketballishe loved sports She usually went to bed at about midnight Bludau asked her to sit on the examining table As she struggled to climb up her balance teetering on the step the doctor held her arm He checked her blood pressure which was normal He examined her eyes and ears and had her open her mouth He listened to her heart and lungs briskly through his stethoscope He began to slow down only when he looked at her hands The nails were neatly trimmed Who cuts your nails he asked I do Gavrilles replied I tried to think what could be accomplished in this visit She was in good condition for her age but she faced everything from advancing arthritis and incontinence to what might be metastatic colon cancer It seemed to me that with just a forty minute visit Bludau needed to triage by zeroing in on either the most potentially life threatening problem the possible metastasis or the problem that bothered her the most the back pain But this was evidently not what he thought He asked almost nothing about either issue Instead he spent much of the exam looking at her feet Is that really necessary she asked when he instructed her to take off her shoes and socks Yes he said After she d left he told me You must always examine the feet He described a bow tied gentleman who seemed dapper and fit until his feet revealed the truth he couldn t bend down to reach them and they turned out not to have been cleaned in weeks suggesting neglect and real danger Gavrilles had difficulty taking her shoes off and after watching her struggle a bit Bludau leaned in to help When he got her socks off he took her feet in his hands one at a time He inspected them inch by inchithe soles the toes the web spaces Then he helped her get her socks and shoes back on and gave her and her daughter his assessment She was doing impressively well he said She was mentally sharp and physically strong The danger for her was losing what she had The single most serious threat she faced was not the lung nodule or the back pain It was falling Each year about three hundred and fifty thousand Americans fall and break a hip Of those forty per cent end up in a nursing home and twenty per cent are never able to walk again The three primary risk factors for falling are poor balance taking more than four prescription medications and muscle weakness Elderly people without these risk factors have a twelve per cent chance of falling in a year Those with all three risk factors have almost a hundred per cent chance Jean Gavrilles had at least two Her balance was poor Though she didn t need a walker he had noticed her splay footed gait as she came in Her feet were swollen The toenails were unclipped There were sores between the toes And the balls of her feet had thick rounded calluses She was also on five medications Each was undoubtedly useful but together the usual side effects would include dizziness In addition one of the blood pressure medications was a diuretic and she seemed to drink few liquids risking dehydration and a worsening of the dizziness Her tongue was bone dry when Bludau examined it She did not have significant muscle weakness and that was good When she got out of her chair he said he noted that she had not used her arms to push herself up She simply stood up 7a sign of well preserved muscle strength From the details of the day she described however she did not seem to be eating nearly enough calories to maintain that strength Bludau asked her whether her weight had changed recently She admitted that she had lost about seven pounds in the previous six months The job of any doctor Bludau later told me is to support quality of life by which he meant two things as much freedom from the ravages of disease as possible and the retention of enough function for active engagement in the world Most doctors treat disease and figure T l that the rest will take care of itself And if it doesn tiif a patient is becoming infirm and heading toward a nursing homeiwell that isn t really a medical problem is it To a geriatrician though it is a medical problem People can t stop the aging of their bodies and minds but there are ways to make it more manageable and to avert at least some of the worst effectsSo Bludau referred Gavrilles to a podiatrist whom he wanted her to visit once every four weeks for better care of her feet He didn t see medications that he could eliminate but he switched her diuretic to a blood pres sure medicine that wouldn t cause dehydration He recommended that she eat a snack during the day get all the low calorie and low cholesterol food out of the house and see whether family or friends could join her for more meals Eating alone is not very stimulating he said And he asked her to see him again in three months so that he could make sure the plan was working Nine months later I checked in with Gavrilles and her daughter She turned eighty six this past November She is eating better and has even gained a pound or two She still lives comfortably and independently in her own home And she has not had a single fall In the story of Jean Gavrilles and her geriatrician there s a lesson about frailty Decline remains our fate death will come But until that last backup system inside each of us fails decline can occur in two ways One is early and precipitately with an old age of enfeeblement and dependence sustained primarily by nursing homes and hospitals The other way is more gradual preserving for as long as possible your ability to control your own life Good medical care can in uence which direction a person s old age will take Most of us in medicine however don t know how to think about decline We re good at addressing specific individual problems colon cancer high blood pressure arthritic knees Give us a disease and we can do something about it But give us an elderly woman with colon cancer high blood pressure arthritic knees and various other ailments besidesian elderly woman at risk of losing the life she enjoysiand we are not sure what to do Several years ago researchers in St Paul Minnesota identified five hundred and sixty eight men and women over the age of seventy who were living independently but were at high risk of becoming disabled because of chronic health problems recent illness or cognitive changes With their permission the researchers randomly assigned half of them to see a team of geriatric specialists The others were asked to see their usual physician who was notified of their high risk status Within eighteen months ten per cent of the patients in both groups had died But the patients who had seen a geriatrics team were a third less likely to become disabled and half as likely to develop depression They were forty per cent less likely to require home health services Little of what the geriatricians had done was high tech medicine they didn t do lung biopsies or back surgery or PET scans Instead they simplified medications They saw that arthritis was controlled They made sure toenails were trimmed and meals were square They looked for worrisome signs of isolation and had a social worker check that the patient s home was safe 130 How do we reward this kind of work Chad Boult who was the lead investigator of the St Paul study and a geriatrician at the University of Minnesota can tell you A few months after he published his study demonstrating how much better people s lives were with specialized geriatric care the university closed the division of geriatrics The university said that it simply could not sustain the financial losses Boult said from Baltimore where he is now a professor at the Johns Hopkins Bloomberg School of Public Health On average in Boult s study the geriatric services cost the hospital 1350 more per person than the savings they produced and Medicare the insurer for the elderly does not cover that cost It s a strange double standard No one insists that a twenty five thousand dollar pacemaker or a coronary artery stent save money for insurers It just has to maybe do people some good Meanwhile the twenty plus members of the proven geriatrics team at the University of Minnesota had to find new jobs Scores of medical centers across the country have shrunk or closed their geriatrics units Several of Boult s colleagues no longer advertise their geriatric training for fear that they ll get too many elderly patients Economically it has become too difficult Boult said But the finances are only a symptom of a deeper reality people have not insisted on a change in priorities We all like new medical gizmos and demand that policymakers make sure they are paid for They feed our hope that the troubles of the body can be fixed for good But geriatricians Who clamors for geriatricians What geriatricians doibolster our resilience in old age our capacity to weather what comesiis both difficult and unappealingly limited It requires attention to the body and its alterations It requires vigilance over nutrition medications and living situations And it requires each of us to contemplate the course of our decline in order to make the small changes that can reshape it When the prevailing fantasy is that we can be ageless the geriatrician s uncomfortable demand is that we accept we are not For Felix Silverstone understanding human aging has been the work of a lifetime He was a national leader in geriatrics for five decades But he is now himself eighty seven years old He can feel his own mind and body wearing down and much of what he spent his career studying is no longer abstract to him Felix has been fortunate He didn t have to stop working even after he suffered a heart attack in his sixties which cost him half his heart function nor was he stopped by a near cardiac arrest at the age of seventy nine One evening sitting at home I suddenly became aware of palpitations he told me I was just reading and a few minutes later I became short of breath A little bit after that I began to feel heavy in the chest I took my pulse and it was over two hundred He is the sort of person who in the midst of chest pain would take the opportunity to examine his own pulse My wife and I had a little discussion about whether or not to call an ambulance We decided to call When Felix got to the hospital the doctors had to shock him to bring his heart back He d had ventricular fibrillation and an automatic defibrillator had to be installed in his chest Within a few weeks though he felt well again and his doctor cleared him to return to work full time He stayed in medical practice after the attack multiple hernia repairs gallbladder surgery arthritis that ended his avid piano playing compression fractures of his aging spine that stole three full inches of his once five foot seven inch height and hearing loss I switched to an electronic stethoscope he said They re a nuisance but they re very good 131 Finally at eighty two he had to retire The problem wasn t his health it was that of his wife Bella They d been married for more than sixty years Felix had met Bella when he was an intern and she was a dietitian at Kings County Hospital in Brooklyn They brought up two sons in Flatbush When the boys left home Bella got her teaching certification and began working with children who had learning disabilities In her seventies however retinal disease diminished her vision and she had to stop working A decade later she became almost completely blind Felix no longer felt safe leaving her at home alone and in 2001 he gave up his practice They moved to Orchard Cove a retirement community in Canton Massachusetts outside Boston where they could be closer to their sons I didn t think I would survive the change Felix said He d observed in his patients how difficult the transitions of age could be Examining his last patient packing up his home he felt that he was about to die I was taking apart my life as well as the house he recalled It was terrible We were sitting in a library off Orchard Cove s main lobby There was light streaming through a picture window tasteful art on the walls white upholstered Federal style armchairs It was like a nice hotel only with no one under seventy five walking around Felix and Bella have a two bedroom apartment with forest views and plenty of space In the living room he has his grand piano and at his desk piles of medical journals that he still subscribes to for my soul he said Theirs is an independent living unit It comes with housekeeping linen changes and dinner each evening When they need to they can upgrade to assisted living which provides three prepared meals and up to an hour with a personal care assistant each day This was not the average retirement community but even in an average one rent runs thirty two thousand dollars a year Entry fees are typically sixty thousand to a hundred and twenty thousand dollars on top of that Meanwhile the median income of people eighty and older is only about fifteen thousand dollars More than half of the elderly who live in long term care facilities go through their entire savings and have to go on Medicaidiwelfareiin order to afford it And ultimately the average American spends a year or more of his old age disabled and living in a nursing home at twice the cost which is a destination Felix desperately hopes to avoid He tries to note the changes he s experiencing objectively like a good geriatrician He notices that his skin has dried out His sense of smell has diminished His night vision has become poor He tires easily He has begun to lose teeth He takes measures where he can He uses lotion to avoid skin cracks he protects himself from the heat he gets on an exercise bike three times a week he sees a dentist twice a year He s most concerned about the changes in his brain I can t think as clearly as I used to he said I used to be able to read the Times in half an hour Now it takes me an hour and a half Even then he s not sure that he has understood as much as he did before and his memory gives him trouble If I go back and look at what I ve read I recognize that I went through it but sometimes I don t really remember it he said It s a matter of short term registration It s hard to get the signal in and have it stay put 132 He makes use of methods that he once taught his patients I try to deliberately focus on what I m doing rather than do it automatically he told me I haven t lost the automaticity of action but I can t rely on it the way I used to For example I can t think about something else and get dressed and be sure I ve gotten all the way dressed He recognizes that the strategy doesn t always work He sometimes told me the same story twice in a conversation The lines of thought in his mind would fall into well worn grooves and however hard he tried to put them onto a new path sometimes they resisted Felix s knowledge as a geriatrician has forced him to recognize his own decline but that hasn t made it easier to accept I get blue occasionally he said I think I have recurring episodes of depression They are not enough to disable me but they are He paused to find the right word They are uncomfortable What buoys him despite his limitations is having a purpose It s the same purpose he says that sustained him in medicine to be of service in some way to those around him He had been in Orchard Cove for only a few months before he was helping to steer a committee to improve the health care services there He tried to form a journal reading club for retired physicians He even guided a young geriatrician through her first independent research study 7a survey of the residents attitudes toward Do Not Resuscitate orders More important is the responsibility that he feels for his children and grandchildreniand most of all for Bella Her blindness and recent memory troubles have made her deeply dependent Without him I suspect she would probably be in a nursing home He helps her dress He administers her medicines He makes her breakfast and lunch He takes her on walks and to doctors appointments She is my purpose now he said Bella doesn t always like his way of doing things We argue constantlyiwe re at each other about a lot of things Felix said But we re also very forgiving He does not feel this responsibility to be a burden With the narrowing of his own life his ability to look after Bella has become his main source of self worth I am exclusively her caregiver he said I am glad to be And this role has heightened his sense that he must be attentive to the changes in his own capabilities he is no good to her if he isn t honest with himself about what he can and can t do One evening Felix invited me to dinner The formal dining hall was restaurant like with reserved seating table service and jackets required I was wearing my white hospital coat and had to borrow a navy blazer from the maitre d Felix in a brown suit and a stone colored oxford shirt gave his arm to Bella who wore a blue owered knee length dress that he d picked out for her and guided her to the table She was amiable and chatty and had youthful seeming eyes But once she d been seated she couldn t find the plate in front of her let alone the menu Felix ordered for her wild rice soup an omelette mashed potatoes and mashed cauli ower No salt he instructed the waiter she had high blood pres sure He ordered salmon and mashed potatoes for himself I had the soup and a London broil When the food arrived Felix told Bella where she could find the different items on her plate by the hands of a clock He put a fork in her hand Then he turned to his own meal 133 Both made a point of chewing slowly She was the first to choke It was the omelette Her eyes watered She began to cough Felix guided her water glass to her mouth She took a drink and managed to get the omelette down As you get older the lordosis of your spine tips your head forward he said to me So when you look straight ahead it s like looking up at the ceiling for anyone else Try to swallow while looking up you ll choke once in a while The problem is common in the elderly Listen I realized that I could hear someone in the dining room choking on his food every minute or so Felix turned to Bella You have to eat looking down sweetie he said A couple of bites later though he himself was choking It was the salmon He began coughing He turned red Finally he was able to cough up the bite It took a minute for him to catch his breath Didn t follow my own advice he said Felix Silverstone is without question up against the debilities of his years Once it would have been remarkable simply to have lived to see eighty seven Now what s remarkable is that he has the control over his life that he does When he started in geriatric practice it was almost inconceivable that an eighty seven year old with his history of health problems could live independently care for his disabled wife and continue to contribute to research Even today most people his age cannot live as he does Partly he has been lucky His memory for example has not deteriorated significantly But he has also managed his old age well His goal has been modest to have as decent a life as medical knowledge and the limits of his body will allow So he saved and did not retire early and therefore is not in financial straits He kept his social contacts and avoided isolation He monitored his bones and teeth and weight And he has made sure to find a doctor who had the geriatric skills to help him hold on to an independent life I asked Chad Boult the geriatrics professor now at Johns Hopkins what can be done to insure that there are enough geriatricians for our country s surging elderly population Nothing he said It s too late Creating geriatricians takes years and we already have far too few This year just three hundred doctors will complete geriatrics training not nearly enough to replace the geriatricians going into retirement let alone meet the needs of the next decade Yet Boult believes that we still have time for another strategy he would direct geriatricians toward training all primary care doctors in caring for the very old instead of providing the care themselves Even this is a tall orderininety seven per cent of medical students take no course in geriatrics and the strategy requires that the nation pay geriatricians to teach rather than to provide patient care But if the will is there Boult estimates that it would be possible to establish courses in every medical school and internal medicine training program within a decade We ve got to do something he said Life for older people can be better than it is today Boult and his colleagues have yet another strategy just in caseia strategy that they have called Guided Care and that doesn t depend on doctors at all They re recruiting local nurses for a highly compressed three week course in how to recognize specific problems in the elderly such as depression malnutrition isolation and danger of falling how to formulate a plan to remedy those problems and how to work with patients families and doctors to follow H l through on the plan In a test of the strategy the researchers are putting the nurses to work in primary care practices around Baltimore and Washington DC and studying the results It is a meagre solution for a huge problem but it is cheap which insurers demand and if it provides even a fraction of the benefit geriatricians have it could nudge medical care in the right direction I can still drive you know Felix Silverstone said to me I m a very good driver After our dinner together he had to go on an errand to refill Bella s prescriptions in Stoughton a few miles away and I asked if I could go along He had a gold 1998 Toyota Camry with automatic transmission and thirty nine thousand miles on the odometer It was pristine inside and out He backed out of a narrow parking space and zipped out of the garage His hands did not shake Taking the streets of Canton at dusk on a new moon night he brought the car to an even stop at the red lights signalled when he was supposed to took turns without a hitch I was I admit braced for disaster The risk of a fatal car crash with a driver who s eighty five or older is more than three times higher than it is with a driver between sixteen and twenty The very old are the highest risk drivers on the road This past fall in Los Angeles George Weller was convicted of manslaughter after he confused the accelerator with the brake pedal and plowed his Buick into a crowd of shoppers at the Santa Monica Farmers Market Ten people were killed and more than sixty were injured He was eighty six But Felix showed no difficulties At one point during our drive poorly marked road construction at an intersection channelled our line of cars almost directly into oncoming traffic Felix corrected course swiftly pulling over into the proper lane There is no saying how much longer he will be able to count on his driving ability The day may well come when he will have to give up his keys At the moment though he wasn t concerned he was glad simply to be on the road The evening traffic was thin as he turned onto Route 138 He brought the Camry to a tick over the forty five mile per hour speed limit He had his window rolled down and his elbow on the sash The air was clear and cool and we listened to the sound of the wheels on the pavement The night is lovely isn t it he said 135 An unhealthy burden Jun 28th 2007 From The Economist print edition America39s health care market is not as unfettered as it seems TO MANY outside the United States America39s health care system might seem an example of capitalism at its rawest Europeans and Canadians enjoy universal health care and cheap drugs thanks to government run systems the argument goes but the market based approach taken by the world39s richest nation leaves many millions uninsured and leads the rest to pay the highest drugs prices in the world Such doubts are sure to be reinforced by this week39s release of Michael Moore39s Sicko a much trumpeted new film on health care that bashes the free market Yankee model even as it praises the dirigiste alternative north of the border So is America39s health system really red in tooth and claw Hardly according to a growing body of academic evidence As a result of interference at the federal and state levels health care is one of America39s most heavily regulated industries Indeed its muddled approach to health care regulation may act as a massive drag on the American economyiwhat one expert has called a 169 billion hidden tax Costing an arm and a leg That figure comes from a path breaking study of a few years ago by Christopher Conover of Duke University It looked at the many ways in which the American legal and regulatory systems affect the provision of health services and lumped them into five categories medical torts the Food and Drug Administration FDA insurance regulation and the certification of both health professionals and health facilities His team concluded that the overall benefit to society of 170 billion per year delivered by this system of oversight was far outweighed by the 339 billion in annual costs that it imposed see chart Even ignoring the cost of big federal tax breaks for employer sponsored health insurance which Mr Conover left out his study estimated that the net cost of America39s health regulations resulted in perhaps 4000 extra deaths each year and was responsible for more than 7m Americans39 lacking health insurance Building on this point a forthcoming paperT by Michael Cannon of the Cato Institute a libertarian think tank in Washington DC investigates the biggest federal component of this regulatory burden the FDA39s oversight of pharmaceuticals lt notes that some 20 cents out of every dollar spent by consumers goes on purchases under the purview of the FDA which it calls one of the most pervasive federal agencies in the country Citing the best evidence to date on the costs and benefits of FDA regulation Mr Cannon argues that the agency is too slow and demands too much testing ultimately harming consumers He points out that drugs regulators can make two broad types of errors First they might approve a drug too quickly only to find out after its launch that it is dangerous or even deadly Second they could delay the launch of a highly innovative drug by demanding onerous or unnecessary trials and thereby deny many needy patients a new therapy Proper regulation requires balancing these two risks but the pitch may be queered by bureaucratic self interest If the regulator allows even one drug to slip through the approval process that later proves harmful to some people some of the time a hue and cry is sure to 136 followvla an lnoll er rm m were llnked to Vloxx a blockbuster parn remedy made by Merck Cannon pu l ho FDA h m pl V blgdmg agalnst newcomers wthout the cash or lobbth power to navlgate the FDA lac M n n r 50 states dea IS 0 rank maul ownershrp chan also shows The heavyrhandednesa he holes rncluoles goups of surgeons belng denled regulatlons protectlng thelr palch Meanwhrle enterprlslng hurserpractltloner are blocked supervlslon by doctors New quot her earlrer proposals for a governmentrmn health system whrch they dub HlllaryCare But L 9 man others 5er state us healuvcam manna hunevvvsnlmgumlou lpoz Shlv casls Mom mronsolmrrn mshm 300 ma 1 n lonl mrallsn m Ynsuvsncz anh Hralm Morer mahhe rv Locked Out Note to Medicaid Patients The Doctor Won39t See You By Vanessa Fuhrmans 19 July 2007 The Wall Street Journal BENTON HARBOR Mich Medicaid provides health care coverage for millions of Americans but a growing number of doctors won39t accept it In February Jada Garrett a 16 year old sophomore developed what seemed at first a mild case of strep throat Within a couple of weeks her joints ballooned Many afternoons her swollen ankles hurt too much to walk To get to the bottom of her symptoms Jada needed to see a rheumatologist But the local one listed in her Medicaid plan39s network wouldn39t see her in his office The wait to get into a clinic was more than three months By the time she found a rheumatologist in a nearby county to take her in mid April J ada39s debilitating pain had caused her to miss several weeks of school quotYou feel so helpless thinking something39s wrong with this child and I can39t even get her into a doctorquot says J ada39s mother Nicole Garrett who enrolled her three teenage daughters in Medicaid after they lost private coverage quotWhen we had real insurance we could call and come in at the drop of a hatquot On paper J ada39s Medicaid coverage is real insurance Funded jointly by states and the federal government the safety net program is intended to provide comprehensive healthcare coverage for more than 50 million Americans too poor or disabled to afford it elsewhere Like the majority of Medicaid recipients in Michigan Jada receives her benefits through a private health maintenance organization contracted by Medicaid to administer the program But when Medicaid patients seek care they often find themselves locked out of the medical system In a 2006 report from the Center for Studying Health System Change a nonprofit research group based in Washington nearly half of all doctors polled said they had stopped accepting or limited the number of new Medicaid patients That39s because many Medicaid programs straining under surging costs are balancing their budgets by freezing or reducing payments to doctors That in turn is driving many doctors particularly specialists out of the program The dwindling number of doctors who accept Medicaid is a large little discussed hurdle to some ambitious efforts to broaden health care coverage Expanding Medicaid eligibility or using the private Medicaid HMOs is a linchpin in universal coverage initiatives in Massachusetts and other states as well as some 2008 presidential candidates39 platforms In California a key component of Gov Arnold Schwarzenegger39s universal coverage proposal calls for a controversial 2 to 4 surcharge on doctors39 and hospitals39 revenues The money would be used to pay for higher Medicaid fees so that doctors will take in more enrollees About 51 of family physicians in California participate in Medicaid For a 138 number of specialties such as orthopedic surgery the percentage is much lower according to the California HealthCare Foundation Michigan39s governor Jennifer Granholm is also pushing a plan to extend coverage to more than 500000 of the state39s uninsured Because physician groups have balked at taking more people at Medicaid level reimbursements policy makers hope the new program will pay doctors rates similar to Medicare about two thirds higher than Medicaid But many people fear that will give doctors even less reason to accept people on Medicaid In Michigan the number of doctors who will see Medicaid patients has fallen from 88 in 1999 to 64 in 2005 Many of those doctors tightly cap how many they39ll see or refuse to take on new Medicaid patients At the same time enrollment in the program in Michigan has risen more than 50 to nearly 16 million since 1999 Paul Reinhart the state39s Medicaid director says he doesn39t believe difficulties finding specialists is a pervasive issue But he acknowledges that patients can run into access problems quotThat39s a problem that we39re working on and one that probably can only really be resolved with increased feesquot he says To safeguard against access problems his agency requires the plans to have at least one primary care physician for every 750 people in a given region The program also checks a few times a year whether the specialists listed in the plans39 networks are indeed available quotAt this point I have to pay money out of my own pocket to take care of that Medicaid patient and it39s only going to get worsequot says AppaRao Mukkamala president of the Michigan State Medical Society and a radiologist in Flint Mich There auto industry layoffs have helped push one in five people onto Medicaid or into the ranks of the uninsured For every chest X ray Dr Mukkamala performs for instance Medicaid pays him 20 Commercial insurers such as Blue Cross pay about 33 and Medicare pays 30 But with technicians film and other equipment his costs are about 29 per X ray he estimates Medicaid patients he sees at Hurley Medical Center in Flint make up 28 of his work there Like many states Michigan hires private Medicaid HMOs to administer benefits The state pays HMOs a monthly fee for each patient The HMOs then pay doctors usually amounts close to government set payments As in many states the managed care plans win Medicaid contracts based partly on how robust their networks of doctors and hospitals are The HMOs39 directories of network providers in Michigan seem full but phone calls to listed specialists in some places find big holes The three HMOs which operate in the county around Benton Harbor Community Choice Great Lakes Health Plan and Health Plan of Michigan post on their Web sites lists of local specialists participating in their network Of the 11 obstetrician gynecologists that Community Choice lists for Berrien County four doctors said they were listed in error and another one no longer practices in the area One took only Medicaid patients referred to her by doctors within her practice Three others were only seeing new Medicaid patients at a nearby clinic not in their offices And two more were taking patients at the same clinic 139 Many doctors on Health Plan of Michigan39s list which includes many of the same names had similar restrictions Great Lakes39 Web site noted that none of the six on its ob gyn list were accepting new patients All three HMOs39 listed gastroenterologists another high demand specialist area 7 only saw Medicaid patients at an offsite clinic where appointment waits can be three to nine months The health plans say they encourage members and their referring doctors to call them if they have trouble getting an appointment with a specialist quotWe can39t just rely on what39s in the directory it would be our obligation to help any memberquot says Pamela Morris president of CareSource Management Group which manages Community Choice39s health plan She adds that a wait of several months is quotunacceptablequot The company says that all of the doctors in its directory are indeed contracted with it It says sometimes staff at medical practices make mistakes about what plans they accept Health Plan of Michigan39s chief operating officer Shery Cotton says that in some places it will pay doctors bonuses to encourage them to see ob gyn patients It also periodically checks in with primary doctors to see if their Medicaid patients are being refused by specialists And it doesn39t require plan members to use just network doctors But Ms Cotton acknowledges that low reimbursements from the state sometimes make raising participation a struggle quotWe literally get on the phone with doctors and beg 39Will you see this patient39quot Steve Matthews a spokesman for AmeriChoice the Medicaid arm of UnitedHealth Group Inc which owns Great Lakes Health Plan said that the plan39s customer service records don39t show a doctor access problem in Benton Harbor He added that if a patient has difficulty the company will help set up an appointment quotanywhere in the state regardless of whether they39re in the networkquot Many primary care doctors however say they don39t have the time or resources to call the plans for all of the patients for whom they have trouble finding referrals Robert Ward 111 a neurologist in nearby St Joseph says the only new Medicaid patients his practice now sees are those who were admitted to the local hospital first Occasionally he will see a patient referred by a doctor he knows But all three of the local Medicaid HMOs have Dr Ward listed as a network provider only Great Lakes Health Plan39s Web site notes that he isn39t accepting new patients Dr Ward says his office has pointed this out to the Medicaid plans When he started his practice in the early 1990s Dr Ward says he placed no limits and Medicaid patients ocked to his practice Medicaid patients soon ballooned to 35 of his roster quotIt was a rookie mistakequot says Dr Ward one of only two full time neurologists in the tri county area Commercial health plans such as Blue Cross pay him between 72 and 85 for a typical neurological exam He receives about 31 from the Medicaid plans Now 12 of his patients are on Medicaid 140 Southwestern Medical Clinic a multispecialty group sees some Medicaid patients in its offices across the county because of its involvement in Christian based medical mission work That group now accounts for some 20 of the clinic39s patient mix Yet the clinic limits many appointments to Medicaid patients who live in the same or surrounding ZIP codes of its various branches quotWe don39t want people driving past their community provider to come see usquot says Kenneth O39Neill Southwestern39s medical director quotOtherwise the model of everyone doing their fair share starts to fall apartquot Delays in getting treatment can have serious consequences Jennifer Kinchen 47 enrolled in Medicaid in late 2005 after Hurricane Katrina forced her to leave her home in Louisiana and move near family in Benton Harbor Since late last year she has suffered from tremors severe enough to cause her to drop her coffee mug or sometimes fall liver problems and high levels of ammonia in her blood Her family doctor has searched and waited to get her an appointment with a neurologist or gastroenterologist In the meantime Ms Kinchen has gone to the emergency room a few times because of dehydration and blacking out In Benton Harbor more than 300 patients lost access to counseling services after the main provider of Medicaid mental health services Riverwood Center stopped accepting payments from Medicaid HMOs Riverwood says the reimbursements it was receiving from the Medicaid HMOs for outpatient sessions didn39t cover their costs Payment delays and other administrative hassles compounded the crunch says Riverwood39s president Allen Edlefson The center lost 350000 in 2003 the year before it decided to quit its Medicaid HMO contracts quotIt was a painful decision but we just couldn39t make it work financiallyquot he says The Medicaid HMOs helped slow costs by more tightly managing care such as reducing hospital admissions and assuring that recipients are at least assigned a primary care doctor The state estimates HMOs have saved Medicaid more than 300 million annually in recent years Nestled along Lake Michigan39s southeastern shore Benton Harbor has been hard hit by job losses Manufacturers have steadily cut or relocated elsewhere good paying union jobs with health benefits About a quarter of the community of 12000 poor and predominantly black are unemployed As the city39s middle class dwindled most doctors along with the hospital relocated in the late 1980s and early 1990s across the St Joseph River to its much more af uent twin St Joseph a picturesque lake resort town Most of those doctors are listed in HMO networks but many don39t accept Medicaid patients in their offices Instead many spend an afternoon every one or two weeks seeing Medicaid patients at a clinic set up in a building that once housed Benton Harbor39s hospital 141 v m r emce L rnanhanfrnhrv arrapp u h n n39T vn Dr Harbor T hr r Harbor hgh wheel 1 don t want to pull any punche taking care ofpeople ay Dry Tynex quotI m a pmtual man not a buxmexxman Inhi wamng room goxpel meme play round the clock on a DVD player and pauent can Sign up for hr wergauorr coadimg On a recent day 22 out of the 37 pauent were on MedroaroL and another 12had Medroare or nr vm Mn 4 0500 to 0750 a week to uppon hr ramrly of we chrldren the red Laxt year he cut hr of ce taff from even to four people quotWe prrmary care kxlledquot he ayxv Payment Disparity Average yermhmsemem m Mltmsan dmmrs ror some common proceduresr IMedwam IMe kare mummy aha Ems Wan 52m aarfl rir 39 W 57 vs 304 W mm 1224 ram mm m 22 Treatment af 1 n Wequot 31 335 in A pendenomy w an mzz szn w exam I 15 ynavi 50mm Mkmqanslalnmwkvsudalv A Dog39s Breakfast Note this is an editorial By DANIEL L MCFADDEN Wall Street Journal February 16 2007 Last year Medicare underwent a major expansion with the addition of Part D prescription drug coverage A controversial feature of this new program was its organization as a market in which consumers could choose among various plans offered competitively by different insurers and HMOs rather than the single payer single product model used elsewhere in the Medicare system Proponents of this design touted the choices it would offer consumers and the benefits of competition for product quality and cost opponents objected that consumers would be overwhelmed by the complexity of the market and that it was unnecessarily generous to pharmaceutical and insurance companies Part D is a massive social experiment on the ability of a privatized market to deliver social services effectively With the support of the National Institute on Aging my research group has monitored consumer choices and outcomes from the new Part D market I will summarize our findings but first I want to provide some perspective on the American health care system and the questions that study of Part D may help answer Most Americans are aware that our health care system is in deep trouble a dog39s breakfast of private providers and insurers that has weak and inconsistent incentives for quality control and cost containment Many consumers cannot obtain health insurance at reasonable cost and financing the system is stressing employers pension funds and the government39s Medicare and Medicaid programs In terms of health delivered per dollar of cost our system is grotesquely inefficient We spend 6102 per person on health care each year nearly 17 of GDP Our neighbor Canada39s single payer system costs 3165 per person per year about half our expenditure or 10 of their GDP The Canadian costs and health outcomes are typical of developed countries where government managed and financed systems predominate The extra cost of our system is not buying us better health The probability of dying between ages 15 and 60 a good indicator of failure of a health care system to prevent and treat disease is 81 for females in the US in Canada the same probability is 57 In the future things are going to get much worse If current trends continue health care in the US as a proportion of GDP will rise to 40 by 2050 a level that will break the current system of financing health through employers pension funds and MedicareMedicaid There are a number of reasons for this gathering storm First the US population is getting older and the old require more medical maintenance Second we are getting wealthier and staying alive is the ultimate luxury good Third we demand expensive medical innovations such as dialysis MRIs transplants stents and biotech About a third of all medical costs are incurred in the last year of life and are at best marginally effective The incentives in the system do not force hard choices To deal with this future three substantial reforms are needed First we need to wring out some of the inefficiencies Something like 30 of our health costs come from administrative 143 overhead legal costs and defensive medicine These could be largely eliminated in a comprehensive reform we just need to emulate best practice in other developed countries Second we need universal health insurance coverage with active emphasis on preventive medicine that is effective in reducing later medical events and costs Perhaps this can be accomplished by cobbling together existing sources of finance as in Gov Arnold Schwarzenegger39s current proposal for California However eventually we will have to go to a system that is not channeled through employers something like a tax financed medical voucher system Third we need incentives that match choice of expensive treatments with consumers39 willingness to pay for them a benefit cost analysis that places treatment choices and financial responsibility on the individual This brings us to Medicare Part D This experiment in privatizing the prescription drug insurance market and the interface between insurers and consumers gives the individual the right and responsibility to make insurance plan choices that are in his or her self interest If consumers are up to this task then their choices will ensure that the plans and insurers that succeed in the market are ones that meet their needs However if many are confused or confounded the market will not get the signals it needs to work satisfactorily The success or failure of the Part D market is a bellwether for proposals to spread consumer directed health care across the system putting health and financial choices in the hands of consumers and utilizing the forces of market competition to rationalize the system So how well has the Part D market worked We now have one year of experience including a second open enrollment period in which consumers could switch plans or enroll if they had not done so earlier We can ask whether consumers were satisfied with this market whether their choices were consistent with their interests and whether Part D insurance has had a positive effect on health outcomes To do this my group is tracking about 2200 consumers age 65 and up from opening of the initial enrollment period in mid November 2005 We interviewed them just before enrollment began and again just after the initial enrollment period ended on May 15 2006 Here are some of the things we have found Consumers were quite confused about the Part D program before enrollment began with 40 knowing little or nothing about what the program offered and 17 indicating that they were unlikely to enroll Start up problems widely publicized further clouded the program39s future However when the initial enrollment period closed only 74 of the age 65 plus eligible population of 358 million were not enrolled in Part D or comparable prescription drug coverage It helped that monthly premiums predicted to be about 37 were substantially lower averaging around 24 with some plans available for premiums as low as 6 to 10 It helped that about 68 of the population was automatically enrolled either through employer or union based plans or through Medicaid VA or federal employee coverage It also helped that Part D incorporates an annual subsidy of about 1200 per enrollee so that most potential enrollees benefit immediately Failure to enroll turned out to be a minor problem but making Part D voluntary rather than mandatory did have some consequences About 12 million seniors who use enough prescription drugs so that they would immediately benefit from enrolling failed to do so Mostly these were not the very poor who were picked up by Medicaid and by outreach programs but poorly educated people above the poverty line General opinions elicited after the close of the initial enrollment period give Part D a mixed report card Seventy seven percent liked having a choice of plans but 58 thought the program was not well designed 77 say they would have preferred to have prescription drugs provided automatically as part of Medicare Part A 58 are less satisfied with Medicare as a result of Part D and large majorities dislike formulary restrictions and the gap a range of out of pocket costs where the Part D standard plan offers no benefits However when one looks at plan choices made one finds that consumers were relatively consistent in recognizing their self interest Most consumers selected among the lowest cost plans available in their area Consumers with significant drug needs enrolled early while those with no immediate needs mostly enrolled later to preserve their option value of obtaining insurance at non penalized rates There is some evidence that consumers did not fully appreciate the consequences of the gap and enhanced policies that covered the gap were not heavily demanded even though the additional coverage they offered was close to actuarially fair The picture that emerges is that elderly consumers were mostly able to navigate the Part D market and reach reasonable choices despite its novelty and complexity Two concerns with insurance markets that also arise for the Part D market are adverse selection in which only the sickest seek insurance and insurers respond by cherry picking refusing coverage for individuals and conditions likely to increase claims and moral hazard in which insurance coverage encourages additional treatments by reducing the incremental costs of these treatments Adverse selection has so far been avoided in the Part D market because the voluntary enrollment rate is high including a high proportion of healthy seniors who currently are net contributors to the system Further adverse selection is not a problem for plan switchers because participating insurers must take all comers and are reimbursed by Medicare based on each individual39s experience rating There is moral hazard in the sense that prescription drug use is increasing for seniors newly insured under part D to 44 from 33 prescriptions on average per month according to our survey This increase must be assessed in terms of its health consequences Dana Goldman at RAND Corporation has found that making at least some drugs available to seniors at lower cost more than pays for itself in decreased incidence and cost of health problems For example reducing the copay on statins to 10 from 45 for a 30 day supply increased plan prescription drug payments but the increased adherence of patients to the therapy at the lower copayment reduced cardiovascular incidents and attendant hospitalization costs so that total annual health costs per patient in his study fell to 5180 from 5470 A recent study of the VA population indicates that statins increase adult life expectancy by nearly two years apparently because they act as anti in amatories as well as reducing cholesterol Anecdotal evidence indicates that Part D coverage will reduce medical problems and hospitalization costs enough to offset a significant portion of its cost However reduced adherence to therapies by consumers who hit the gap will probably have a significant adverse 145 effect on health outcomes that we will begin to see in 2007 A humorous proposal is that employers could lower their total health care bills by putting statins and anti hypertensives in the water cooler What is clear is that an integrated approach is needed to evaluating health care costs and programs like Part D that can deliver effective preventative drugs may pay for themselves My overall conclusion is that so far the Part D program has succeeded in getting affordable prescription drugs to the senior population Its privatized structure has not been a significant impediment to delivery of these services Competition among insurers seems to have been effective in keeping a lid on costs and assuring reasonable quality control We do not have an experiment in which we can determine whether a single product system could have done as well or better along these dimensions but I think it is reasonable to say that the Part D market has performed as well as its partisans hoped and far better than its detractors expected Does this mean that Part D proves that privatization will be effective in other segments of the health care market Here Ithink caution is advised First the success of Part D depends substantially on thoughtful and muscular management of the market The former head of Medicare Mark McClellan and a dynamic no nonsense 75 year old government bureaucrat Abby Block bullied insurers to make sure there were in her words quotno bad choices It is unclear whether their successors will be as successful in standing toe to toe with the industry and making sure consumers39 interests are protected A health insurance market like Part D probably requires this level of active management to work well after the fact oversight in the style of the SEC or FTC is inadequate If privatization is going to work elsewhere in health care active market management will be needed Finally consumer directed health care works only if consumers can understand the consequences of their choices In much of medicine providers are the agents that guide consumers through these choices If consumer directed health care is to be effective these providers must give sound advice on both the health and financial consequences of alternative choices This is possible if the incentives to providers and consumers are right but the design of such markets should not be left to chance Mr McFadden the E Morris Cox professor of economics and director of the Econometrics Laboratory at Berkeley is a 2000 Nobel laureate in economics URL for this article httponlinewsjcomarticleSBl17159975453110920html H Treating the Awkward Years The New York Times April 24 2007 By JAN HOFFMAN Robert T Brown s patients may be obese or anorexic sexual innocents or infected with chlamydia male or female jocks or goths abusers of alcohol Ecstasy or over the counter drugs tattooed pierced pimpled surly and stressed or just mortified by their molting rebelling bodies Diverse and challenging they share at least one common factor which brings them to the attention of Dr Brown and his colleagues They are all adolescents We do dermatology sports medicine psychology gynecology orthopedic issues psychosocial issues substance abuse and address problems of developing sexuality said Dr Brown a specialist in adolescent medicine who is chairman of pediatrics at Crozer Chester Medical Center in Upland Pa We re highly trained generalists for a specific population 7 like gerontologists he said But either we ve done a poor job of marketing ourselves or there is something about the field Adolescent medicine might be expected to be booming The nation has about 40 million people ages 10 to 19 a patient population that experts say is vulnerable to a growing array of behavior related health problems But a decade after adolescent medicine became board certified as a subspecialty it is in little demand by doctors seeking to advance their careers Small wonder the public is generally unaware of the field according to the American Board of Medical Specialties only 466 certificates in adolescent medicine were issued from 1996 to 2005 In the same period 2839 were issued in geriatric medicine Most major teaching hospitals have adolescent clinics pediatric residents have to spend a month in an adolescent rotation A few health maintenance organizations have stand alone adolescent clinics Occasionally a pediatrician in a group practice or in a community may have a special affinity for teenagers and be the go to doctor for them But the availability of doctors and nurse practitioners dedicated exclusively to adolescent care is still the exception Their numbers are so limited that many cannot take on adolescents as primary care patients the patients see them on a temporary referral basis Of those teenagers who are insured and who continue to see a primary care doctor a vast majority remain with the pediatricians or family doctors who have cared for them since diaperhood That job has become more time consuming and complex Adolescents are not big children and they re also not little adults said Dr Walter D Rosenfeld an adolescent medicine specialist and chairman of pediatrics at the Goryeb Children s Hospital in Morristown NJ They are not just a bridge population he and many others maintain but their own stop in the road During adolescence people need to learn how to take responsibility for their health and eventually to become health care consumers independent of their parents At programs that are sensitive to adolescents this changing dynamic is negotiated deftly but firmly Recently at an eating disorder clinic at the Goryeb Children s Center at Overlook Hospital in Summit NJ a nutritionist beckoned to a teenager in the waiting area The girl s mother stood to follow But after the girl slipped into the exam room the nutritionist closed the door Oh I thought I was going in with her the mother said to no one in particular Guess not she added with a small laugh of embarrassment Organizations like the American Academy of Pediatrics and the Society for Adolescent Medicine recommend that primary care physicians monitor teenagers for drug and alcohol use smoking sexual activity including disease prevention and use of birth control physical activity nutrition depression school behavior and social pressures Yet various studies have shown that many pediatricians feel inadequately prepared to address most of these issues A father in Indianapolis who did not want to identify himself to protect the privacy of his shy 12 year old daughter said Our pediatrician is a great guy around everyday things but he s not adolescent focused He won t ask her about sex or alcohol or drugs It s just not in his repertoire He s a baby doctor oriented toward the quickie office visit Because teenagers seek out doctors infrequently pediatricians have to grab at any opportunity to reach them said Dr Susan R Brill director of adolescent medicine at the Children s Hospital at St Peter s University Hospital in New Brunswick N I could see a boy with strep throat and he ll grunt at me and we ll be done in five minutes she said Or I could take a little more time to talk to him 7 I might find out about sexuality issues that way If a kid is coming in for bronchitis I ll get the parent out of the room and ask the kid if he s smoking If a kid is on a sports team and comes in with an injury is the pediatrician talking about weight and eating and steroid abuse With so many doctors feeling underprepared to treat teenagers and the need so critical why no rush to those advanced degrees In conventional terms the explanations for adolescent medicine s remaining the wall ower at the subspecialty ball are sensible enough The fellowship is demanding two years of additional study for internists and family practitioners three for pediatricians Yet after completing the adolescent fellowship a doctor s income does not markedly improve Insurance companies still view teenagers as large children Though the annual checkup of a 16 year old should take at least twice as long as that of a 6 year old doctors say the typical reimbursement is about the same Moreover the field does not get much respect at least from other doctors parents can be weepy with gratitude In the thriving world of high tech medicine doctors who treat 148 adolescents are determinedly low tech They listen They observe They do some subtle teaching a fair amount of diagnosing and on the good days intervention amelioration even outright prevention And then there are the patients themselves American society is not particularly fond of its teenagers said Dr John Santelli a professor of pediatrics and public health at Columbia University The 2 year olds everyone fawns over them But the guy with the pin through his nose is not cute A 1999 American Academy of Pediatrics study revealed that while 22 percent of the patients seen by pediatricians were ages 12 to 18 75 percent of the doctors surveyed did not want more adolescents in their practice The meager reimbursement rates directly affect pediatricians and family doctors Dr Elizabeth Panzner a pediatrician in Union NJ who speaks joyfully about watching a patient grow over many years said adolescents were nonetheless a challenge for a busy practice Say there s a gynecological issue she said Putting the time factor aside there s a financial burden which the pediatrician would never recoup because gynecological visits are bundled into a general pediatric office visit A relatively tiny hardy occasionally eccentric and fervent group adolescent medicine specialists understand that theirs will probably never become a much sought after position Many have come to see their mission not only in taking care of patients but also in researching public policy questions that affect adolescents And because many choose to become affiliated with hospital programs rather than setting up fee for service practices they also teach pediatric residents and local practitioners how to exchange critical information with teenage patients We can t do it alone Dr Rosenfeld the specialist in Morristown said We need to deputize pediatricians and family practitioners and make them our partners Since October specialists in adolescent medicine in his department have given a half dozen lectures including one for the professionals at a local pediatric practice as well as those for pediatric residents on dating violence and eating disorders They have also tried direct outreach to adolescents last year their blunt Web site wwwteenhealthfxcom which has an advisory board of teenagers averaged nearly a quarter million hits a month Dr Kenneth R Ginsburg an adolescent medicine specialist at Children s Hospital of Philadelphia who trains doctors in treating teenagers said that when the child is 11 to 13 the doctor should explain to both patient and parent that the visit will change the doctor will now spend some of it alone with the patient 149 Parents need to be assured Dr Ginsburg said that although they will now be left in the dark about some of what is said in the exam room the doctor s goal is still the health and well being of their child The challenge then he and other experts say is how to speak with teenage patients using language that is nonjudgmental and does not make them feel ashamed Dr Leslie Sanders an adolescent medicine specialist at Overlook recently gave a lecture to pediatric residents about interviewing teenage boys Many pediatricians know they should be asking but don t know how she said They might say You know how to put on a condom don t you or After you drink you don t get behind the wheel right When Dr Ginsburg sits down with teenagers he lays out the deal They ll have a choice they can say they don t want to talk about this subject They can lie to me but if they do I can t help them Then I emphasize the importance of honesty When the young person tells me something I wish they weren t doing like drugs Dr Ginsburg said I won t praise the behavior but I ll respect the fact that they re talking to me and looking for guidance The kid needs to know that my office is a place where they can get out of trouble but not in trouble Doctors who choose to treat teenagers exclusively have a special affection for them Dr Ginsburg s patients include the children of intellectuals and the privileged as well as those living in shelters and foster homes In a recent phone interview he spoke so glowingly that his speech ramped up and his words rushed out I get so excited about this work he said I m standing on my desk now For many of these doctors the work has both a tinge of personal identification and a call to social conscience Dr Santelli who is also a family planning expert remarked We all have our adolescence to live down It was an important time to me personally So I resonate when I talk to teenagers Adolescence is at the intersection of fundamental issues for society if you make it through successfully you re set up for life Dr Santelli said If you don t you could go to prison or end up in the underclass These doctors are also clear eyed about their patients This is after all a patient population whose three leading causes of death 7 accidents homicide and suicide 7 are often related to psychosocial problems rather than traditional medical diagnoses That is why a doctor patient relationship with the teenager based on trust and confidentiality is so crucial Dr Ginsburg said Adolescents are incredibly thoughtful creative and absolutely challenging he said They get when you re insincere really quickly The tough kids are not used to adults not fearing them But if you just love being with them they melt The attitude goes away because it s just a pained defensive posture 150 Becky Hirsch a 15 year old high school sophomore in Montclair NJ was mystified and embarrassed by her changing body She dreaded the annual checkup with her pediatrician this fall The sounds of crying vaccinated infants the sight of toddler chairs and the doctor s hurried manner as she barreled through a due diligence list that included sex and alcohol made Becky so uncomfortable that she just shut down It was the talking part she recalled later I d rather put off telling her stuff than say something But Becky was lucky Her pediatrician took stock of the impasse and referred her to an adolescent medicine clinic Becky and her mother Deborah went to Girl Street 7 The name is so stupid Becky moaned 7 a program at Overlook Hospital with adolescent medicine doctors nutritionists and a therapist Visits with new patients last at least an hour The waiting area was lined with adult size chairs Teenage patients were busily text messaging while their mothers smiled tentatively at one another as if seeking solidarity I was really nervous but then the nurse kept telling me how much she liked my shoes Becky said after a recent follow up visit Here they know you re uncomfortable so they make it so you re not The doctor didn t talk about scientific stuff Becky added She asked me about myself which was really nice 7 about school my family my friends I was surprised because I thought we were just going to talk about body stuff So I told her everything It took a while I was crying a lot I didn t know much about a woman s body before and she told me about some STD s and why I needed that new vaccine Becky continued referring to a vaccine approved for girls as young as 9 to prevent a cervical cancer linked to a sexually transmitted disease The doctor isn t warm and fuzzy but she makes you feel really normal And she takes everything seriously A few days later Becky called the clinic about another problem To her amazement she said The doctor called me back on my cellphone m How the Amish Drive Down Medical Costs By Joel Millman 21 February 2006 The Wall Street Journal Lititz Pennsylvania WHEN Health Management Associates Inc opened a regional hospital in Pennsylvania Dutch Country in 2004 it got an unexpected welcome from a group of men wearing broad brimmed hats and beards The delegation of Amish and Mennonite elders came to the Heart of Lancaster Regional Medical Center to haggle with executives there over rates They wanted discounts for their fellow worshipers who collectively spend about 5 million a year in Lancaster County for health services all of it in cash Like uninsured patients everywhere the Amish and Mennonites often are billed a hospital39s full retail price for medical procedures and pharmaceuticals mainly because they don39t have a large institution such as an employer or insurer to negotiate discounts on their behalf But unlike many of the uninsured they were able to organize and drive down the price of medical care in Pennsylvania The quotPlain Peoplequot as Amish and Mennonites call themselves choose to go without insurance or Medicare as part of their rejection of the secular world They do without electricity and automobiles in their daily lives And they rarely sue for malpractice believing that the outcome of surgery is in God39s hands What helped make the Amish effective negotiators was the experience many of them have had in getting cut rate medical treatment in Mexico They were able to use prices south of the border along with their willingness to pay upfront in cash as leverage to bargain for lower prices at home No deal no patients they told the Heart of Lancaster executives And the medical center proved willing to bend quotWe felt we needed to grow the business of this hospital We also need to be part of a communityquot says Kimberley Steward who helped negotiate a deal as the medical center39s chief financial officer and now works at Health Management Associates39 Mesquite Community Hospital in Texas The German speaking Mennonites and Amish are Anabaptists a religious denomination that traces its history back to the Protestant Reformation of the 16th century quotAnabaptistquot refers to the practice of rejecting infant baptism only adults are permitted to pledge themselves into the church They object to medical technology that they believe challenges God39s plan such as organ transplants and in vitro fertilization but they don39t reject all medical care outright as some other religious denominations do Heart of Lancaster is a small hospital and its case load is fairly conventional But the Anabaptists weren39t looking for anything exotic They wanted discounts on services such as orthopedic surgery biopsies and childbirth The hospital agreed to discounts of up to 40 off its top rates resulting in prices that would still be slightly higher than Medicare reimbursements the level most hospitals consider a minimum Not satisfied the Anabaptists 152 pushed the executives to go lower But the hospital said if it dropped prices to levels below Medicare reimbursements it could be charged for fraud for charging Medicare patients more The Anabaptists accepted the hospital39s offer and now pay at rates such as 1657760 for a hip replacement 3200 for knee arthroscopy and 7542 for a mastectomy The rates include the hospital stay as well as fees for surgery anesthesia medication testing medical supplies and occasionally outside specialists To qualify for these discounts the Anabaptists pay 50 of the fees upon admission to the hospital The Anabaptists39 rates are still more than what a Medicare patient might expect to be billed but as little as half the full retail rate other uninsured patients are likely to be charged For decades Anabaptist communities have pooled resources to pay for medical care But as the cost of a modern day hospital stay has skyrocketed cost sharing has often fallen short quotA man39s barn burns down you can replace it with donated labor in an afternoon You can39t do that with a hospital billquot says Sam Stoltzfus who farms near Gordonville Pa About a third of Anabaptist community resources go to cover health care costs he estimates Many Pennsylvania Anabaptists who are stretched financially take trains to Tijuana where private hospitals and clinics usually charge far less than the top rates at Pennsylvania hospitals After the Anabaptists39 busy November wedding season travel usually picks up in early December Even though travel expenses can run to 4000 a person Anabaptist patients say they save money quotGoing to Mexico also provides a little diversionquot says Donald Kraybill a sociologist at Pennsylvania39s Elizabethtown College who specializes in Anabaptists quotPeople who spend their lives in rural settings like to go to a motel sometimes watch cable TV and eat in a restaurantquot The Oasis Clinic operated by an oncologist Adan Ernesto Contreras is a favorite of the Anabaptists At a seaside hostel Anabaptist men stroll along a plaza with their wives who wear starched white bonnets A small plaque on a footbridge reads quotMy Hobby ls Driving My Buggyquot A bale of fan mail from former patients arrives daily quotGreetings Christiansquot begins one letter from Paoli Ind Dr Contreras who speaks uent English says he is conversant in the archaic Rhineland German many of his Anabaptist patients speak at home quotWe treat them body mind and spiritquot he says cheerfully quotBefore any procedure I pray with themquot In the lobby and corridors of the hospital the Amish rub elbows with sheikhs and tanned Californians who also come to Tijuana for treatment but stay in more expensive quarters Back in Pennsylvania testimonials about cancer and arthritis treatments in Tijuana spread quickly through tight knit Amish and Mennonite communities Tijuana39s Oasis clinic ran ads this summer in Die Botschaft an Amish newspaper promising medicine with quota caring environment prayer laughter faith hope and lovequot Visits from sales representatives of clinics in Tijuana Ciudad Juarez and Mexicali have become a form of folk entertainment in the rural communities where Plain People live an evening of charts on easels testimonials and refreshments for people who avoid most forms of modern media 153 E quotL thoughthe 39 4 r wlth Hean of m o L h n Mk9 many n Hmpv L w u v Full knee r39 W A 0 39 knee renla PWN costs 105001ncludmg a lwoday say u 1 u you ll hunt forbargarns says Lee Chnstenson chlefexeomve of Hean of Lancaster who kooM R HVH L r don t need m 4 3941 mwho m 14 r r e r r Moreover the hospltal knew that as a praoreal matter vmually every unrnsured patlent wlthm mlles ls a member of elther an Armsh or Mennomte chum w r only after berng referred by local doctors wlth largely Anabaptlst pmctloes As a legal matter L 4 L r And Larr a r malprale F clng rowr Deals me mm quotmm er a Lancaslev hosmalr campaled mm mm urnrrmmgrzmu I Nunllalzu m m lithiuman 19557 I 5 52 my my was one saw mm mm m m MM my wimp ysmrr New Formula A Hospital Races To Learn Lessons Of Ferrari Pit Stop By GAUTAM NAIK November 14 2006 Page A1 LONDON After surgeons completed a six hour operation to fix the hole in a boy39s heart Angus McEwan supervised one of the more dangerous phases of the procedure transferring the fragile three year old from surgery to the intensive care unit Thousands of such quothandoffsquot occur in hospitals every day and devastating mistakes can happen during them This one went off without a hitch thanks to pit stop techniques of the Ferrari race car team quotIt was smooth We didn39t miss anythingquot said Dr McEwan a senior anesthesiologist at Great Ormond Street Hospital for Children His role as leader of the handoff was partly modeled after Ferrari39s quotlollipop manquot who uses a large paddle to direct drivers to the pit In one of the more unlikely collaborations of modern medicine Britain39s largest children39s hospital has revamped its patient handoff techniques by copying the choreographed pit stops of Italy39s Formula One Ferrari racing team The hospital project has been in place for two years and has already helped reduce the number of mishaps The challenge of moving a patient to another unit or to a new team during a shift change is an old one In 1995 one man in Florida had the wrong leg amputated after a ubbed handoff quotIf you transfer a patient to the ICU after surgery and the ventilator isn39t ready you39re really riding on the edgequot of patient safety says Allan Goldman head of the pediatric intensive care unit at Great Ormond Street Hospital and a chief architect of the hospital39s collaboration with Ferrari A 2005 study found that nearly 70 of preventable hospital mishaps occurred because of communication problems and other studies have shown that at least half of such breakdowns occur during handoffs American hospitals are starting to improve the way they transfer patients As in Britain they are borrowing ideas from fields more skilled in the art of high risk handoffs including aviation space ight and the military Last week the Royal College of Surgeons of England and Dr Goldman39s hospital held an international conference on the subject One of the speakers was a British submarine commander who spoke about lessons from the Kursk the Russian submarine that sank in 2000 Kaiser Permanente of California a health system with 37 medical centers and 86 million members has a handoff method based on a change of command system developed for nuclear submarines At Trinity Medical Center in Rock Island 111 nurses and doctors actually quotpass the batonquot They place documents with key patient information inside a plastic baton and pass it on during a patient handoff A facility in St Joseph39s Health System in Orange Calif uses a method it calls quotTicket to Ridequot a series of questions about the patient39s medications infections and other medical issues that have to be asked of a person transferring the patient between departments Blount 155 Memorial Hospital in Maryville Tenn encourages its staff to quotJust Go NUTSquot an acronym for a four step handoff routine it recommends Name Unique issues Tubes Safety Recent trends have increased the risk during handoffs A nurse shortage means more hospitals are hiring temporary staff Because of new rules medical interns are also working fewer hours which makes shift changes and therefore handoffs more frequent At the same time some surgeons work in larger teams and connect patients to an ever growing tangle of wires and tubes Earlier this year the Joint Commission on Accreditation of Healthcare Organizations began requiring US hospitals to standardize their approach for handoff communications or risk losing their accreditations Without accreditation hospitals can find it harder to get reimbursed by Medicare and private insurers Founded in 1852 the Great Ormond Street Hospital was one of the first children39s hospitals in the English speaking world In 1929 JM Barrie gave the hospital full copyright and royalties of his children39s classic Peter Pan The facility treats 100000 children each year and is known for its expertise in infant heart surgery a field where a lot can go wrong Two decades ago a lot did go wrong Between 1987 and 1993 surgeon Marc de Leval performed 104 quotarterial switchesquot at Great Ormond Street Hospital The operation corrects a congenital heart defect and is often done within the first two weeks of a newborn39s life At one stage seven of Dr de Leval39s patients died in quick succession Horrified he decided to retrain at another institution before returning to Great Ormond Street Hospital He didn39t have such an alarming run of failures again Soon after in 1994 Dr de Leval published an unusually forthright paper about what had gone wrong His key insight was that the infant deaths couldn39t entirely be explained by the riskiness of the procedure or blatant failures such as a machine breaking down Instead he pointed to general quotsuboptimal performancequot by himself and his team Dr de Leval then persuaded 21 surgeons across Britain to allow quothuman factorquot specialists to observe their arterial switch operations The specialists use scientific techniques to study how people interact in a particular environment including areas where technology is heavily used The study found not surprisingly that big mistakes can lead to bad outcomes Its unexpected finding was about small mistakes The study revealed that they often went unnoticed and unrectified What39s more quotif you added them up they correlated stronglyquot with bad outcomes says Dr de Leval The paper caused a stir when it appeared in the Journal of Thoracic and Cardiovascular Surgery in 2000 At Great Ormond Street Hospital it prompted doctors to take a harder look at how their teams were working together and transferring patients quotOur handovers were haphazardquot says Dr Goldman the pediatric ICU chief 156 Sometimes a patient still in a precarious condition after an operation was moved before the ventilator in the ICU had been properly setup Or a key component of the blood pressure monitor went missing and a nurse had to scramble to find it a loss of valuable minutes One Sunday in 2003 after a particularly tough day in the operating theater Dr Goldman and surgeon Martin Elliot slumped before a TV set and watched a Formula One race unfold Both were racing fans and they noticed striking similarities between patient handovers at their hospital and the interchange of tasks at a racing pit stop But while a 20 member crew could switch a car39s tires adjust its front wing clean the air vents and send the car roaring off in seven seconds hospital handovers seemed downright clunky by comparison The duo invited members of McLaren a British team that fields race cars in Formula One contests to provide insights into pit stop maneuvers Armed with videos and slides the racing team described how they used a human factors expert to study the way their pit crews performed They also explained how their system for recording errors stressed the small ones that might go unnoticed not the big ones that everyone knew about That point struck a chord with Dr de Leval He immediately saw that pit stop handovers were successful precisely because of an obsession with tiny mistakes a conclusion similar to the one he had reached in his 2000 paper about arterial switch operations Dr de Leval then hired Ken Catchpole a human factors expert to do a more detailed study of patient safety in the hospital39s cardiac surgery unit The hospital also got in touch with Ferrari which invited a team of doctors from the hospital to attend practice sessions at the British Grand Prix in order to get a closer look at pit stops The Ferrari Formula One team is operated by the same company Ferrari SpA that makes sports cars for the general public There were skeptics quotI did think that the whole idea was a bit kookyquot says Dr McEwan the anesthesiologist In early 2005 Dr Elliot Dr Goldman and Mr Catchpole traveled to Ferrari39s headquarters in Maranello Italy and sat down with Nigel Stepney the racing team39s technical director As a test car roared around a nearby track the visitors played a video of a hospital handover and described the process in pictures The Ferrari man wasn39t impressed quotIn fact he was amazedquot at how clumsy and informal the hospital handover process appeared to be recalls Mr Catchpole now a researcher at Oxford University In that meeting Mr Stepney described how each member of the Ferrari crew is required to do a specific job in a specific sequence and usually in silence By contrast he noted the hospital handover was often chaotic Several conversations between nurses and doctors went on at once Meanwhile different members of the team disconnected or reconnected equipment to a patient but in no particular order In a Formula One race the quotlollipop manquot with a paddle ushers the car in and signals the driver when it39s safe to go But in the hospital setting it wasn39t always clear who was in 157 charge Though the anesthesiologist had nominal responsibility to take the lead during a handover sometimes the surgeon assumed that role or no one at all The crew at Ferrari trained for the worst contingencies quotIf Michael Schumacher comes in five laps early because it39s raining and he wants wet weather tires they39re preparedquot says Mr Catchpole referring to the Ferrari driver and seven time world champion who recently retired The hospital team dealt with problems as they came up Back in London Dr Goldman and his colleagues began to incorporate Ferrari39s lessons along with advice from two jumbo jet pilots into the hospital handover process They wrote up a seven page protocol describing every step in the procedure Between December 2003 and December 2005 they also did a careful study to see if those changes made any real difference to patient safety Dr Goldman and his colleagues recently submitted a paper to a peer reviewed journal that describes 50 patient handovers at Great Ormond Street Hospital over that two year period The study looked at 23 handovers before the Ferrari inspired changes were put in place and 27 after After the changes the average number of technical errors per handover fell 42 and quotinformation handover omissionsquot fell 49 It also took slightly less time to execute each handover though unlike the Ferrari team the doctors weren39t trying to speed up their process The study didn39t attempt to measure whether the changes reduced deaths Not everything has gone smoothly Mr Catchpole says that some cardiac doctors at Great Ormond Street Hospital chose not to adopt the new handover process arguing that there was nothing wrong with the old method At one point Drs Goldman and Elliot considered having their surgical team stand in prearranged places around the patient just as Ferrari organizes technicians around a pit stop quotBut I thought it was a step too farquot says Dr McEwan The idea was dropped Nonetheless cardiac surgery handovers at the hospital are now systematic One recent afternoon three year old Faizaan Hussain lay sedated on an operating table his chest open and his tiny heart pumping solidly The six hour operation to save his life was coming to a close Faizaan suffered from tetralogy of Fallot a congenital condition that includes a hole in the heart and thickened heart muscle that reduces the normal ow of blood Such infants are often blue Each year in the US about 3000 babies are born with the condition If untreated about 25 of patients die within the first year of life and about 40 by age 10 As a pair of surgeons closed the boy39s chest Dr McEwan took the lead role in preparing for the handover mimicking the job done by Ferrari39s lollipop man Dr McEwan dispatched a member of the team to the ICU with a document describing the state of the patient and what equipment was needed at the ICU end a contingency planning idea learned from the Italian racing team The patient was then moved from the operating table to a mobile bed Dr McEwan and his colleagues systematically disconnected a mess of tubes and wires from a 158 large refrigerator size unit in the operating room and replugged them into smaller devices on the mobile bed quotWe call it the spaghetti effectquot said Dr McEwan as he untangled a pair of tubes draining blood and uid from the boy39s chest Other wires led to monitors measuring the boy39s blood pressure heart rate oxygen saturation level temperature and respiration The process lasted several minutes it was completed in near silence At the ICU where a new group of doctors and nurses awaited the patient the surgical team went through a three step procedure to complete the handover First key instruments were replugged into the ICU39s wall units Dr McEwan noticed that the boy39s blood pres sure had jumped so he asked a nurse to increase the anesthetic Because of the efficient transfer quotwe could pick that up immediately instead of 10 minutes laterquot said Dr McEwan Next the anesthesiologist went through a two page handover checklist including the patient39s name age weight and medical history quotBefore he came to us he was very bluequot he said When a pair of doctors at the back of the room started up a conversation Dr McEwan shushed them The senior ICU doctor listened carefully while an ICU nurse wrote down everything Finally a surgeon described the operation Only 15 minutes had elapsed since Faizaan was wheeled in Even so the new ICU team now knew almost as much about the boy39s medical condition as did the surgeons who had been with him for six hours The surgical team39s work was done Faizaan made a quick recovery and less than a week later his parents took him home httponlinewsjcomarticleSBl16346916169622261html 159


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