The Moral Healthcare Blog

Book Review – Churchill’s Empire – By Richard Toye – NYTimes.com

Winston Churchill is remembered for leading Britain through her finest hour
— but what if he also led the country through her most shameful one? What if, in
addition to rousing a nation to save the world from the Nazis, he fought for a
raw white supremacy and a concentration camp network of his own? This question
burns through Richard Toye’s superb, unsettling new history, “Churchill’s
Empire” — and is even seeping into the Oval Office.

The Book Review is titled “The Two Churchills,” and makes the point that for all the things we admire Churchill for, he was not always right.

AMA Morning Rounds on NEJM Palliative Care Article

Early palliative care may prolong survival, enhance quality of life in patients with advanced lung cancer.

The New York Times (8/19, A15, McNeil) reports that a trial “paid for by the American Society of Clinical Oncology and private philanthropy” appears to “shed new light on the effects of end-of-life care.” In fact, it “confirmed what…specialists had long suspected,” that is, patients with “terminal lung cancer who began receiving palliative care immediately upon diagnosis not only were happier, more mobile, and in less pain as the end neared, but they also lived nearly three months longer.” The paper appears in the New England Journal of Medicine.

Notably, “palliative care specialists lament that their image as the medical world’s grim reaper deprives patients and their families of care and support that can ease the burden of serious illnesses that exact a steep physical, psychological, and social toll,” the Boston Globe (8/19, A1, Smith) reports on its front page. “All too often, they said, patients and doctors outside their field equate palliative medicine with hospice care, even though hospice is the refuge for people who have stopped aggressive treatment and whose death is imminent.” But, “palliative care…is available at any juncture during a life-threatening illness and, at its core, is designed to make living with a serious ailment more comfortable, incorporating everything from exercise to counseling to pain medication.”

The current study illustrates that and is “one of the best tests yet of palliative care,” the AP (8/19, Marchione) reports. It should also “ease many fears about starting it soon after diagnosis, doctors say.” Researchers at the Massachusetts General Hospital (MGH) began their study by looking at “151 people newly diagnosed with cancer that had spread beyond the lung.”

Seventy-seven of the “newly diagnosed patients were assigned to receive palliative care along with the standard treatment for the cancer,” while the “other 74 patients received the standard treatment without palliative care,” the Los Angeles Times “Booster Shots” (8/18, Roan) blog reported. The team eventually discovered that “patients receiving palliative care…scored higher on measures of quality of life and enjoying the time they had left. They also were more likely to express their wishes regarding resuscitation at the end of life.”

What’s more, those “who received palliative care in addition to standard care had…a 50 percent lower rate of depression and they lived 2.5 months longer than patients not receiving palliative care early,” HealthDay (8/18, Doheny) reported.

MGH’s Jennifer S. Temel, MD, told WebMD (8/18, Mann), “We were surprised by the magnitude of impact that palliative care had on quality of life, which normally decreases over time in these cancer patients, and the magnitude of the impact it had on depression.” And, “the survival benefit was the most surprising thing,” she added. “Cancer care and palliative care are not mutually exclusive.” Bloomberg News (8/19, Cortez), the Wall Street Journal (8/18, Hobson) “Health Blog” and MedPage Today (8/18, Bankhead) also covered the study

Key Provisions That Take Effect Immediately

Health Law Provisions Kicking In; States Prepare For High-Risk Insurance Pool Implementation – Kaiser Health News

A piece from Kaiser health news on the status of the Health insurance High-risk Pools.

Wealthcare

An analysis by Jonathan Chait of the philosophy of Ayn Rand and its influence on modern conservative thought. It is based upon 2 books about Rand Published in 2009.

Well worth reading, especially with the rise of Randian thought amongst the Tea Party crowd.

New Law Could Help Hospice Patients Continue Aggressive Medical Treatments – Kaiser Health News

But the new health law could lead to a major change in Medicare policy that allows patients to get treatment and hospice care simultaneously.

Experts say this dual approach, known as “concurrent care,” may be especially useful for people using dialysis to extend their lives, and those waiting for organ transplants that may not come in time. More broadly, advocates say, the change may encourage people with any kind of terminal illness to take advantage of hospice care earlier.

“Having personally had to explain what’s good about hospice to families that think I’m about to shove them onto an iceberg, I know it’s a very difficult decision,” says Diane Meier, director of the Center to Advance Palliative Care at the Mount Sinai School of Medicine in New York City.

It will be easier to get the terminally ill to accept hospice care, she says, “if you can say to
families, you don’t have to make this terrible choice here — it’s more, not less.”

Medicaid Change

The new law instructs Medicaid, the state-federal program for the poor, to cover simultaneous hospice and curative care for children with terminal illnesses immediately. And it directs the federal Medicare program, which covers seniors and disabled people, to launch up to 15 pilot projects around the country to test the concept. If the experiment is deemed successful and doesn’t increase costs, then Medicare could make the benefit available to everyone in hospice.
Someone with heart disease, for example, could get cardiac drugs that improve blood circulation and at the same time receive hospice’s palliative services. Those include a team of doctors and nurses devoted to easing physical pain and symptoms, and social workers and
clergy who help patients and their families accept death. Hospice staff typically come to a dying person’s house or nursing home a few times a week.

Myths of the Supply Side – Ross Douthat Blog – NYTimes.com

For an example of what I did have in mind, though, read Kevin Williamson’s fine piece on supply-side economics from the last National Review, in which he goes after the panglossian misinterpretation of supply-side theory that’s become dogma among too many Republican politicians and activists — namely, that tax cuts generate so much economic growth (and with it, increased government revenue) that they more than pay for themselves. As Williamson notes, the most prominent supply-side theorists themselves don’t believe this, but they’re tolerant of politicians who do:

What If Summers and Romer Are Wrong Again?

I hope this gets passed around the White House like an Atul Gawande article!

Watching PBS NOVA last night, I am still amazed that there are still defenders of the efficient market hypothesis in a pure form. I am 50 years old and remember stagfaltion, the crash of 87, the S&L debacle, the internet boom/bust and our current fiasco. Who is so out of touch that they do not recognize these events for what they were and are: disastrous macroeconomic and microeconomic events casued by oh so ‘inefficient’ humans?

I an still dumbfounded to hear that conservatives still think that the business leeches will act in the best interests of their companies. They will act in their own best interests, period. And if that means earning $100 million as they ride their company into the ground? Hey, they still have their $100 million.

Greenspan, still such an Ayn Rand dupe, that he still seems to think, exclusive of his mea culpa last year, that we can count on people to act in the ultimate interest of themselves and all will be well. Voltaire’s “Best of all possible worlds,” for the uber-capitalist set.

Read the Article at HuffingtonPost

Much Cheaper, Almost as Good: Decrementally Cost-Effective Medical Innovation — Ann Intern Med

Under conditions of constrained resources, cost-saving innovations may improve overall outcomes, even when they are slightly less effective than available options, by permitting more efficient reallocation of resources. The authors systematically reviewed all MEDLINE-cited cost–utility analyses written in English from 2002 to 2007 to identify and describe cost- and quality-decreasing medical innovations that might offer favorable “decrementally” cost-effective tradeoffs—defined as saving at least $100 000 per quality-adjusted life-year lost. Of 2128 cost-effectiveness ratios from 887 publications, only 9 comparisons (0.4% of total) described 8 innovations that were deemed to be decrementally cost-effective. Examples included percutaneous coronary intervention (instead of coronary artery bypass graft) for multivessel coronary disease, repetitive transcranial magnetic stimulation (instead of electroconvulsive therapy) for drug-resistant major depression, watchful waiting for inguinal hernias, and hemodialyzer sterilization and reuse. On a per-patient basis, these innovations yielded savings from $122 to almost $12 000 but losses of 0.001 to 0.021 quality-adjusted life-years (approximately 8 hours to 1 week). These findings demonstrate the rarity of decrementally cost-effective innovations in the medical literature.

From Drs. Nelson, Cohen, Greenburg and Kent in Annals of Internal Medicine.

Interesting article explicitly making the argument for more research to figure out where we reach diminshing marginal returns in specific treatments for specific conditions.

Health Care Cost Increase Is Projected for New Law – NYTimes.com

But Mr. Foster said, “Overall national health expenditures under the health reform act would increase by a total of $311 billion,” or nine-tenths of 1 percent, compared with the amounts that would otherwise be spent from 2010 to 2019.

In his report, sent to Congress Thursday night, Mr. Foster said that some provisions of the law, including cutbacks in Medicare payments to health care providers and a tax on high-cost employer-sponsored coverage, would slow the growth of health costs. But he said the savings “would be more than offset through 2019 by the higher health expenditures resulting from the coverage expansions.”

The report says that 34 million uninsured people will gain coverage under the law, but that 23 million people, including 5 million illegal immigrants, will still be uninsured in 2019.

Sounds like success to me. Uwe Reinhardt used to estimate it would cost an additional $100 billion a year to cover everyone. This doesn’t seem to far off from that estimate.