Archive for the ‘Health Care Reform’ Category

Physician Burnout: The Next Public Health Crisis

August 20, 2017

Healthcare reform has led to an alarming prevalence of physician burnout in the United States. The increased workload, productivity demands, reduced autonomy, and overburdening administrative tasks for physicians have led to feelings of emotional exhaustion, depersonalization, reduced personal achievement, and decreased effectiveness. As a result, there are higher rates of job dissatisfaction, cynicism/apathy, absenteeism, depression, suicide, and substance abuse. A recent Mayo Clinic study revealed that 54.4% of physicians, spanning all specialties, reported burnout in 2014, compared with 45.5% in 2011.

Physician burnout has negative impacts on the healthcare system. It leads to reduced quality of care, poor patient satisfaction ratings, increased medical errors, decreased patient safety, decreased productivity, and increased healthcare costs. This decline profoundly impacts the doctor-patient relationship.

Since demand for physicians is outpacing supply, AMA estimates a shortage of up to 90,000 physicians by 2025. The viability of the healthcare system is at stake when physicians retire early, reduce clinical work, or leave the profession, thereby further reducing the workforce. The cost to replace a physician leaving clinical practice is up to $1 million, depending on specialty.

In pursuing improved population health, enhanced patient care experiences and reduced costs, institutions neglected the front-line people who bear these burdens. Despite being crucial to the health care industry, physicians are the forgotten patients. Physician burnout is becoming a public health crisis. Given the scope of the problem, national, state, and local healthcare organization leaders must focus on addressing this problem now, before it’s too late. Physician burnout equates to physician abuse. It is imperative that the healthcare industry culture change to value physician well-being over profits. To achieve high quality and affordable health care, a symbiotic relationship must exist between those who provide and those who seek care. Everyone must help to stop this impending train wreck from becoming a national health crisis.

 

We’re Doing it Wrong: Chronic Care in America

August 20, 2017

Graph - Chronic Conditions

Americans are chronically ill.  The prevalence of chronic conditions in America is trending to be 1 in every 2 persons by 2030. We all know people with chronic conditions and it is safe to say that they suffer from worse quality of life. Unfortunately, our healthcare system is ill-equipped to meet the needs of those with chronic diseases. But there are ways to change that.

The majority of Americans on Medicare are chronically ill and they have to pay a co-pay every time they interact with their physician. Every. Single. Time. It’s annoying enough to pay for that yearly physical (which we should all do and by the way; Medicare pays for it). How about paying every month for hypertension management? Or being required to schedule a timely face-to-face visit with your provider to discuss the blood pressures you’ve been checking yourself? Still have to pay. And the reality is many of us can’t.

Is it all down to the greedy physicians? Unfortunately, it’s not that simple. Providing care to medically complex, chronically ill adults is burdensome and time-consuming. Primary care providers are already under-compensated for the work they do – and the lack of incentive for a team based approach is causing physician burn-out.

So what’s the solution? One might be to invest in Comprehensive Primary Care programs that promote chronic care management. These programs can provide special services to patients that give them more access to their provider’s health team. By eliminating patient co-pays, CPC programs actually improve patient satisfaction and lower the cost of healthcare.

For providers, funding for these programs allows for investment in the infrastructure needed to provide a team based approach to chronic care. Oh yeah – and the fee schedule adjustments allow them to be fairly compensated for all their labors.

Here’s the kicker – the CPC models actually costs Medicare less than traditional fee-for-service models. So you know the drill – call your congressperson and tell him/her that you support funding for Comprehensive Primary Care programs.

Regulation by Florida of Cancer Treatment Costs for Medicare Beneficiaries

August 20, 2017

Cancer comes with one of the costliest medical expenses. Doctors often diagnose individuals 65+ years old with new cancers, so Medicare and its beneficiaries must pay for the high treatment costs. Medicare requires high-cost sharing among its beneficiaries, which leads to financial distress for example bankruptcy. Florida has one of the largest populations of senior citizens (19.9%), two million of which are Medicare beneficiaries. The high out-of-pocket burden from cancer treatment costs leads Medicare beneficiaries towards decreased medication adherence or medical care postponement. Overall, beneficiaries have poorer cancer treatment outcomes compared to privately insured individuals.

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Photo from: NCI Visuals Online

The Florida Department of Health, along with Gov. Rick Scott, should negotiate cancer treatment costs at quality cancer centers in Florida, such as Moffitt Cancer Center, and with pharmaceutical companies like Bristol-Myers Squibb to reduce out-of-pocket expenses for Medicare beneficiaries. The Florida Department of Health should place caps on cancer treatment costs to maintain them at reasonable prices. This political action would test whether cancer treatment cost negotiations at the state level are more effective than federal level negotiations. Biomedical companies can flexibly negotiate cancer treatment prices based on prevalences and morbidities in distinct states.

Florida’s House will not expand Medicaid health insurance coverage, and pharmaceutical companies refuse to negotiate drug prices for Medicare beneficiaries. Placing treatment cost negotiations and caps in the state’s health department’s hands may reduce Medicare beneficiaries’ substantial out-of-pocket cancer treatment expenses. Cancer incidence and morbidity has declined. However, cancer treatment costs and Medicare spending have only risen and are expected to continue growing.

Besides other factors that affect cancer treatment like transportation costs, psychosocial stressors, and reduced quality of life, add stress to a patient’s cancer care experience despite the financial resources provided by organizations like the American Cancer Society.

Expanding Medicare’s Immunosuppressive Drug Coverage to All Kidney Transplant Recipients

August 20, 2017
The high cost of necessary transplant medicines can lead to some kidney transplant recipients losing their new kidneys.

The high cost of necessary transplant medicines can lead to some kidney transplant recipients losing their new kidneys.

As of January 2016, about 660,000 individuals in the United States are being treated for kidney failure. While dialysis can be an effective solution for some individuals, the current best care for renal failure is a kidney transplant, which offers better health outcomes and is less expensive long term than dialysis. While the initial transplant costs about $90,000 and required post-transplant medicines cost $16,000 per year, dialysis costs about $44,000 per year; most transplants pay for themselves and become cheaper than dialysis after 2 to 3 years. Kidney transplant recipients must take expensive immunosuppressive medications to keep their transplants healthy and working. Medicare currently pays for dialysis and kidney transplants as needed for everyone in the United States. However, while Medicare will cover the cost of transplant medications indefinitely for those 65 and older or disabled, Medicare will only cover transplant medications for 36 months for those under 65. After 36 months, many transplant recipients are not able to afford their medication and stop taking it; many then lose their transplant and have to go back on dialysis.

A doctor preparing a donated kidney for transport.

A doctor preparing a donated kidney for transport.

Multiple professional, patient-centered, and nonprofit groups support changing the law to expand Medicare’s indefinite immunosuppressive drug coverage to anyone in the United States with a kidney transplant. While bills have been introduced multiple times in Congress to address this issue, none have yet passed. A proposal put forward in 2009 was blocked by a major industry coalition who opposed plans to generate cost-savings from dialysis care to pay for the new coverage.  Subsequent proposals have failed to make it to a vote, due both to a Congress unwilling to address more health legislation in the wake of the Affordable Care Act and to real concerns about continued funding for Medicare. While the long term savings will be high, initial funding for such a measure may be difficult to find. Nevertheless, expanding post-transplant drug coverage in this way has substantial advantages both in increased quality of life for patients and in long-term savings for Medicare. Patients, health care professionals, and kidney-focused nonprofit groups should continue to contact their legislators through both private communication and public statements to urge them to expand transplant drug coverage.

 

Policy Proposal: Performing Mental Health Screenings for Deaf College Students on College Campuses in the DMV (District of Columbia, Maryland & Virginia) – A Surveillance Tool

August 20, 2017

Mental health effects one in four college students but there is no statistical data about how many Deaf college students face mental health issues because it is often coupled with other forms of disability. Lack of effective communication, competent mental health providers/counselors who are either Deaf or knowledgeable about the Deaf and Hard-of-Hearing (DHOH) community is scarce, and not enough qualified mental health interpreters are available for the Deaf client seeking mental health services.

College is a crucial time in a young adult’s life and 73% of mental health episodes occur on college campuses and the Deaf are likely to suffer more from mental health episodes. Mandatory screening efforts needs to be established for all incoming Deaf college students. Currently there is no such health policy that exists. This is a proposal to require incoming Deaf college students on various college campuses in the District of Columbia, Maryland, and Virginia (DMV), to undergo a mental health screening with their primary healthcare provider or with their respective college counseling center before enrolling (they can accept/deny services but must be presented with the opportunity for data collection purposes; the information will be disseminated to the state’s respective public health office for analysis and interpretation). Efforts will effectively obtain a more accurate account of what mental health disorders Deaf college students face and how to provide semantically/linguistically equivalent services.

Source: YouTube – Gallaudet Counseling and Psychological Services

As an advocate for the DHOH community, I am for this position on the issue. This effort would increase mental health awareness among the DHOH community, increase access to services, and identify their unique needs while making the evidence/data more widely available. Other stakeholders such as the NAD, NCMHDI, and RID are organizations that strongly believe in revamped policy development for DHOH people in public mental health.

Give Thailand’s Migrants their Health Insurance (MHI)

August 20, 2017

In 2011, Thailand was estimated to have 3.7 million migrant workers. They form 5% of the total labour workforce and are estimated to contribute to 6.2% of the Thai national gross domestic product (GDP), or US $ 2 billion dollars in 2005. The majority of these migrants may be displaced, illegal or undocumented. Hence, they do not enjoy health protection through the Social Health Insurance (SHI) private employees provide to workers with a permit. In 2013, the MHI was expanded to include coverage for undocumented workers and other services for a yearly fee of 2100 baht (approximately US $60). Human rights groups applauded Thailand as it became a global leader in universal healthcare for non-citizens. However, reports have surfaced on the refusal of hospitals to register undocumented workers under the MHI, especially in the greater Bangkok metropolitan area.

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Figure 1. Proportion of Non-Thai Citizens in 2011 (adapted from the International Health Policy Program Foundation)

Migrants smuggled to Thailand UN

Figure 2. The UN Office of Drugs and Crime reports Thailand as a destination country for migrant smuggling and labour trafficking

Displaced people due to civil war or poor economic conditions in neighbouring countries, the trafficked, smuggled and asylum seekers all need the MHI to have access to healthcare. Yet, hospitals are given discretion in their interpretation of the policy and face no penalty for refusing migrant workers. A hospital’s refusal to allow a migrant healthcare because they do not have documentation is a violation of the policy and the human right to a standard of living adequate for health and the well-being of a person and his family according to the Universal Declaration of Human Rights 1948 Article 25. Sadly, they are motivated to do so for fiscal survival in fear of the migrant workers over-burdening their resources.

Cambodian migrant worker

Figure 3. Yum, 29, was sold from Cambodia to a Thai fishing boat. He sailed for days at sea before knowing he was sold. After nine months at sea, he escaped. Now with a wife and newborn baby, he is hoping to find work in Thailand again. – The Guardian.

The health ministry must enforce the MHI for undocumented migrants to protect the community against communicable disease and increase pooled funds. It is a moral imperative to allow the people who make significant contributions to the nation’s economy access to healthcare.

The Negative impact of the American Health Care Act of 2017, in the Care of Epilepsy Patients

August 19, 2017

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Background: Worldwide movement of care for epilepsy patients

While more than 50 million people worldwide have epilepsy, 80% live in developing countries. With optimal treatment, seizure-free can be attained in 70%. Therefore, access and availability of health care is crucial in the treatment of epilepsy. As such, the Global Campaign against Epilepsy: Out of the Shadows have been established in 1997 as joint projects of the WHO, ILAE, and IBE. In 2012, WHO Programme on Reducing the Epilepsy Treatment Gap has been proposed, and further in 2015, the Epilepsy Resolution was endorsed by the World Health Assembly. All of these efforts strengthen to address the specific needs in the management of epilepsy, and make resources available; making actions toward national health care plans.

American Health Care Act (AHCA)

The AHCA was a Republican health care bill proposed and passed in May, 2017 to repeal the existing Patient Protection and Affordable Care Act (ACA), in scope of the federal budget. Although recently in July 28th, the US Senate closed the debate on repealing the ACA, major changes in provisions would have occurred if AHCA had replaced ACA:

  • End Individual mandate: ACA mandated that all people be covered by health insurance.
  • Let states waive out ACA’s “Essential health benefit requirement”: This was the set of medical services that was required for all insurers to cover; included maternity care and mental health.
  • Let states waive out ACA’s “community rating”: It results in charging sicker people with higher premiums.
  • Tax credits based on age rather than income: It results in benefitting high-income people. (ACA helped the low-income group)
  • Lower health insurance coverage: Estimated 24 million fewer coverage by 2026
  • Falling short on High-risk pools: Estimated 2 to 4 million less for those w/pre-existing chronic conditions.

Public Opinion of the ACA

Recently in the New England Journal of Medicine, a publication regarding public opinion of the ACA was reported. While it revealed different views and attitudes about repeal-and-replace legislation between the Republican and Democrats, there seemed to be an agreement that the number of people covered by Medicaid should not be reduced in any replacement bill. Medicaid is a health insurance program in which people can be qualified for it based on income level or disability. Many Medicaid programs consider epilepsy as a qualifying disabling condition, if having uncontrollable seizures. It provides access and affordable basic health services, and supports millions of Americans, including those with epilepsy.

health insurance coverage

Conclusion

After AHCA was proposed, there has been many objections toward the act. Epilepsy Foundation was one that showed a definite opposition to this. As a result, there were no passage of any act, but I believe that when things like this happen, medical organization should speak up like how Epilepsy Foundation did. This is especially true when movements worldwide have been taking place to reduce the treatment gap, and some act tries to lessen the health care coverage and access. Specific stakeholders that could have taken the role, in terms of relation to the care of epilepsy patients, include ILAE (International League Against Epilepsy), AES (American Epilepsy Society), and NAEC (National Association of Epilepsy Centers).

Improved Access to Naloxone in Ontario’s Fight against Opioid Overdoses:

August 11, 2017

LEGAL + AVAILABLE ≠ ACCESSIBLE

Naloxone

Over the past decade Ontario has seen a steady rise in the number of opioid related deaths and narcotic misuse across all socioeconomic groups in the province. Of particular concern is that despite ongoing provincial initiatives little has been accomplished to prevent the rampant abuse and misuse of narcotic pain medications. The opioid epidemic is a public health crisis of epic proportions. Recently it has been estimated that 1 in 8 deaths in Ontario is related to opioid abuse.

The government has rolled out a variety of initiatives to combat the problem. They have stopped paying for higher-strength narcotic pain medications through the provincial drug benefit payment plan in an effort to reduce the abuse of these agents. The provincial government has also increased funding for addiction services, and set out new guidelines for opioid use in chronic pain. (http://nationalpaincentre.mcmaster.ca/guidelines.html)

These recent policy initiatives from the provincial government to combat the provinces growing opioid crisis are welcome news. The problem represents a complex health issue with potentially devastating consequences for individuals, families and the communities they live in. Unfortunately the crisis continues to grow and these efforts do not go far enough to help prevent the senseless deaths that are occurring every day on the streets of our cities from accidental overdoses.

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Ontario opioid toxicity deaths, by drug – 2002-13. Data from Ontario Coroner.

Historically the use of the lifesaving antidote for an opioid overdose, Naloxone was only available to a select group of healthcare providers like physicians and paramedics. Most recently this past year the provincial government reduced the restrictions on this lifesaving medication making it available in local pharmacies to consumers without requiring a prescription.

This is a welcome policy change that will save lives….unless you live in Grassy Narrows, Attawapiskat, Pikangikum, White Dog, or any of the other remote Northern Ontario First Nation reserves where there are no pharmacies or publicly available free Naloxone kits. You may not find these communities listed on the provincial government website ‘Where to get a free naloxone kit’ but deaths from overdoses are happening here at alarming rates.first nation grassy

While there is strong support for this new policy change, simply removing the legal barriers and improving the availability of this life saving intervention may not equal improved accessibility for some residents of Ontario.

LEGAL + AVAILABLE ≠ ACCESSIBLE

Major health disparities exist amongst remote First Nations communities living in Northern Ontario. These populations are socially marginalized and medically underserviced. Access to healthcare for these populations is limited as is the quality, equity and timeliness of the healthcare they do receive. This results in disproportionately high burdens of disease and poor health outcomes. First Nations youth have higher rates of suicide and an increase prevalence of risk taking behaviours which can all lead to higher rates of alcohol and drug abuse and ultimately death from overdose.

Attawapiskat

The government’s expansion of initiatives and services which take aim at combating the opioid epidemic in Canada need to target all Canadians and not just those living in urban centers. If the government is serious about broadening access to initiatives like free Naloxone it needs to couple that with initiatives to ensure these initiatives reach the most vulnerable and disadvantaged members of society like the remote First Nation reserves of Northern Ontario. There needs to be a global expansion of healthcare funding for Aboriginal populations that aims to reduce the health disparities that currently exist in these populations.  Otherwise available does not equal accessible.

 

No More Labs in Public Hospitals in China?

March 12, 2017
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A Typical Day in a Chinese Hospital; Source: sixth tone

Prior to the 2009 health system reform, in the face of dwindling governmental health spending, Chinese public hospitals relied primarily on drugs with high mark-up and expensive laboratory tests as their sources of revenue. In fact, according to earlier estimation, lab testing expenditure alone costs the system 751.9 billion RMB in 2015. Unlike in the U.S. where lab tests are conducted in both hospital lab settings (62%) and independent laboratories, lab tests are completed almost exclusively within public hospital laboratories (99.3%) in China.

In the effort to improve healthcare quality and cost-effectiveness, the Chinese central MOH has recently published policy recommendations that call for labs within public hospitals to register as independent legal entity. In addition, the development of independent medical laboratory companies is also encouraged. However, actual implementation of such policy recommendations (not mandate) is at the discretion of individual provincial MOH, whose opinion is largely influenced by large public hospitals. In this case, public hospitals are unlikely to support such policy in fear that they will lose another source of revenue (in light of the recent “zero drug mark-up” policy). General publics have also voiced concerns related to whether all hospital laboratory services will be removed and how that might affect their care-seeking experience.

To maintain healthcare quality and mitigate the risk of national health insurance fund deficit , the central government of China should enforce such policy with no delay. However, in order to generate buy-in and reconcile the conflicts between different stakeholders, the CMOH should:

  1. Change the “policy recommendation” to “policy mandate”, set pilot cities, start from small-scale implementation to national roll-out;
  2. Subsidize public hospitals to help them go through the transition period;
  3. Emphasize to the public that frequently used lab services will be available at public hospitals, only to be financially separated from the public hospitals’ revenue streams;
  4. Set high quality control standard for independent lab services.

Group member: Ai Liu, Zhengchun Jiang, Shanshan Wang

The Global Gag Rule, a harmful human rights violation

March 12, 2017

The Global Gag Rule (GGR) is harmful to women and families and violates human rights. Originally known as the “Mexico City Policy” because it was enacted by Ronald Reagan in 1984 at a conference in Mexico City, the policy is more commonly known as the Global Gag Rule because of how it silences NGOs and health care workers. Specifically, the original policy dictated that no USAID family planning funds could be awarded to organizations that performed or promoted abortion and therefore prohibited them from even speaking about abortion.

The GGR is highly partisan- every Democrat president since Reagan has rescinded the policy and every Republican has reinstated it. The current administration, however, has not only reinstated the GGR but has dramatically expanded the funds that are affected.

Reagan’s version applied to USAID family planning funds; G.W. Bush’s version limited the GGR by exempting USAID HIV/AIDs related work. The latest iteration, however, greatly expands the affected funds to cover all foreign aid arising from any agency or department. The current version restricts up to $9.5 billion in aid, or 16x the amount of funds that would have been affected by previous versions.

Worse yet, beyond being a clear example of religious overreach in US politics and a violation of human rights, evidence suggests that the policy reduces sex education and contraception use while increasing both abortions and the proportion of abortions that result in health complications- maternal, family, and child health all suffer. There is a large coalition of organizations that oppose the GGR. You can take action today by learning more information about the GGR and volunteering or donating to organizations like IPPF, PAI, and the Bill and Melinda Gates Foundation who, together with UN member countries, are attempting to counteract the extreme funding deficit.